Gomantak Times – Weekender, 18 July 2010

Advances in the field of medicine have made the detection and treatment of illness so much simpler. Yet, one feature is sorely lacking — the human touch. Meena Parulekar examines the need for this human element

Kuldeep Mishra, aged 54 years was diagnosed with a block in his right coronary artery a few days back in Mumbai and is advised to go ahead for a beating heart surgery by his cardiac surgeon after considering the severity of the block. Beating heart surgery is a special kind of by-pass surgery in which the heart is fully functional, use of heart-lung machine is not resorted to. Having undergone an angiography and angioplasty a few months earlier in January 2010, he is not sure of what he is heading for this time and needs reassurance from his doctor. The doctor advises him to choose between by-pass surgery or radiation therapy as there is not much time to lose.

For Mishra, however, there are other concerns like his feeling of discomfort with the stent post angioplasty and the nature and risk of bypass surgery. Is it asking for too much to have his doctor brief him about the nature and technique of medical intervention? Can his fears be allayed in some ways to prepare him physically, mentally and emotionally for the operation ahead?

HUMAN SIDE OF MEDICINE

Science and technology together have created wonders for mankind. Drugs and treatments that were thought impossible have today been discovered, tried and successfully implemented. The future is bright for molecular diagnostics, pharmacogenomics, stem cell engineering and the like. Medicine in itself is considered to be a noble profession and requires a certain amount of human touch to make the patient feel better. What, then, is human touch in medicine?

According to Dr Shobha Patkar, a practicing psychiatrist from Mumbai, the practice of medicine is both an art and a science. In the field of medicine, this very art is exhibited from the medical team in the form of empathy which goes much beyond mere words of sympathy.

Eg, “I feel sorry for you” – Sympathy.

“I feel your sorrow” – Empathy

This is precisely known as human touch and is displayed through the behavior of the physician.

Eg: 1) Attentively listening to the patient.

2) Trying to understand his feelings and attitudes.

3) Explaining the plan of action.

4) Allowing him to make choices if rational.

5) Creating an atmosphere of comfort, confidence and involvement to the extent required.

In short, human touch is nothing but genuinely being with the patient throughout his journey of sickness.

Earlier, the practice of history taking and complete clinical examination allowed the physician to know the patient and not merely know the disease. These days, after a quick initial dialogue, the patient is made to run to multiple numbers of experts, investigations and treatment modalities. In the process, the patient loses the primary anchor — the physician with whom he would have preferred to discuss the issues, clear the doubts and make decisions together. No wonder then, he feels not only exhausted, but rejected and helpless, too.

Advanced technology has not spared the doctors who rightfully expect the ‘humane’ approach from patients and relatives.

The so-called aware patient community who acquires information through advanced e-technology tends to doubt, disagree, and distress the doctor — forgetting that the doctor is a qualified and experienced person who has to be discrete and precise. In fact, many a time, a physician has to face legal consequences for not directing the patient to all possible and available diagnostic tools and treatment procedures, though medically not indicated in the opinion of the treating physician.

So, the patient and the doctor, both, have to be cautious and guarded just because mechanical culture is increasingly losing the human touch.

Dr Kalpana Chodankar at the NIO dispensary, Dona Paula, opines that advances in technology do serve as a boon in aiding the diagnosis, but should not stop the clinical examination of the patient, at large. A number of recent advances like mammography, CT scan are useful in terms of early diagnosis and assist in deciding the line of treatment for the physician. This is a huge benefit when one considers the severity of symptoms as manifested during a clinical presentation when it is too late.

IS HUMAN TOUCH NECESSARY?

It can be argued whether human touch is really required in medicine. In any civilized human society, we create, develop and nurture relationships as part of our social identity. In a virtual world, like today, where smileys take over real people in text messages, how much does the warmth of a real smile, a nice hug or a handshake matter?

Today, thanks to telemedicine, it is possible for a diagnosis to be made by a doctor while sitting in his plush cabin without actually having to go out and meet his patient in a remote village or a town in the country. It is technology that has made it possible to have a blood sugar test done in the convenience of our homes, or for that matter, the cardiac activity can be monitored by a simple device worn on the wrist of a patient. These are advances in the realm of technology that have surpassed our expectations.

For a healthcare professional, who has to deal with the human touch in such interventions, some issues that hold prime importance are: Nature of treatment or surgical intervention; availability of resources in the public or private setting; severity of symptoms/illness; co-ordination in terms of healthcare delivery with other services/service providers.

At the end of the day, a patient-centric approach is most desired for all interventions; however every situation/case has its own set of demands and constraints faced by the hospital administrators/doctors who handle their patients in a hospital.

For Kuldeep Mishra, the decision to go in for the beating heart surgery may be tough, but it may actually be the only best possible way to save his life.

The writer is faculty at the Marian Institute of Health Care Management, Panjim, and can be contacted at meena.sahib@marianinstitute.in

Meena Parulekar – Gomantak Times – Weekender, 20 June 2010

Self-medication is quick and convenient, making it an appealing alternative to consulting a doctor. Meena Parulekar finds out if there are any bitter pills to swallow when it comes to self-medication

Shreya has had a splitting headache for the past two days. Unable to concentrate on her work, she pops tablets of aspirin every two hours to make her feel better. The headache does subside mildly, but she now complains of acidity and stomach pain.

Shreya is among those many of us who, at some point or the other, have indulged in self-medication.

An ambiguous phenomenon, self-medication has attracted the attention of the medical fraternity worldwide. Heard synonymously with over-the-counter products, self-medication has been debated on both its benefits and risk fronts. Self-medication is possible with non-prescription or over-the-counter medicines simply because there is no medical intervention required. In certain ways, the customer – in this case, the patient — has a choice to be exercised like many other consumer products.

An effort to streamline the products that can be successfully self-medicated has been compiled in a WSMI (World Self-Medication Industry) forum that brings together self-medication guidelines for developed countries of the world.

WHY SELF-MEDICATE?

What, then, is self-medication? It is the treatment of common health problems with medicines especially designed and labelled for use without medical supervision and approved as safe and effective for such use.

The objective of self-medication is primarily to enable an individual to understand his/her own health requirements and work as a tool in providing responsible self-care. This becomes even more important in the current state of affairs where the focus has shifted towards prevention of disease rather than cure. Both the level of information available to a health-conscious consumer and the options to promote healthy living have increased manifold in the last decade.

RESPONSIBLE SELF-MEDICATION

Can self-medication really help? If so what is responsible self-medication?

Responsible self-medication: where a patient is able to correctly diagnose his minor ailment, and has sufficient information available about the medicine/s he needs to use so as to make a “responsible” decision whether to use a medicine, which, how much, when, etc and also knows when to stop self-treatment and go to a doctor. The benefits are many, since for every little ailment, one need not rush to a medical practitioner.

Also, considering the fact that these drugs have a well established safety profile and are being used in

low doses makes the patient feel comfortable using them.

However, there is a thin dividing line separating self–medication from abuse of drugs. In a country like ours, this has grown to become a problem of serious nature. From cough and cold remedies to antibiotics and CNS acting agents, a number of drugs have been misused. One of the most important issues highlighted is the ease of availability of these medicines at pharmacies.

According to Raj Vaidya, a Panjim-based community pharmacist, it is common knowledge across the country that, unfortunately, many times one can easily get almost any prescription medicine without producing a prescription – and this includes habit forming medicines and medicines of abuse. So in India, self-medication is not restricted to OTC medicines, it very largely extends to prescription medicine self-medication, which of course is dangerous.

Some of the associated variables with self medication that could be highlighted are:

• Availability of drugs over the counter
• Counselling by the pharmacist
• Level of literacy of the patient/customer
• Information availability of over-the-counter drugs
• Demographic profile of the patient/customer
• Nature of relationship/rapport with the retail pharmacist
• Urgency of need for the patient

BEFORE SELF-MEDICATING

The concept of responsible self-medication has a major deterrent in the form of insufficient information available along with products that can be successfully self-medicated in India. Neither the advertisements nor the labels of the medicine or package inserts provide complete information to the patient in an easy to understand language.

In developed countries, self-medication is more like a social phenomenon. Accepted and practiced by many, products that can be easily self-medicated come with a host of related information, packaging and other benefits. The patient thus, at any point in time is able to comprehend and understand the role of the non-prescription medicine in promoting his health.

As consumers of the medicine, before we choose to self-medicate, it is important that we are aware about simple, but important, facts like:

• Interactions among drugs used for treating different conditions
• Possibility of individual allergies/sensitivities
• Misuse of medication
• Incomplete dosage regimen and its effects
• Storage of the medicine

For Shreya, it implies either to go through some pain and opt for home remedies or take another antiacidity pill for fast relief. There are always options available, but the onus is on us to decide. Shreya could still choose to call her doctor before popping up the next pill!

[The writer is faculty at the Marian Institute of Healthcare Management and can be contacted at meena.sahib@marianinstitute.in]

Meena Parulekar and Sarita D’Souza - Gomantak Times – Weekender, 6 June 2010

As shocking as it may sound, blood test reports can sometimes be erroneous, the reasons for which are many.

Seeing his son with a high fever, Rahul took the boy to the doctor. On examining the boy, the doctor asked Rahul to get a blood test done to check for possible causes of the fever. Since it was late evening and he had to travel on work the next day, Rahul took his two-year-old son for a blood test to a laboratory attached to a hospital. The next day, his wife Gauri took the results to the doctor.

The doctor was shocked to see the blood test show the possibility of leukaemia. He waited till Rahul returned and asked him to take his son for another blood test — the results indicated an infection. One can only imagine the angst and turmoil that the parents would have experienced on seeing the initial test results.

As we can see from the above incident, a pathological laboratory plays a key role in diagnosing a health condition. Pathology is understood as the study and diagnosis of disease through examination of organs, tissues, body fluids. Decisions about diagnosis and treatment, hospital admission and discharge largely rest on these test results.

For a lab manager, a wrong blood report signals the need to review the lab’s working. He would do well to examine the process followed at the lab including:

• Entry of the patient and recording of his details
• Checking the tests to be conducted with the doctor’s written recommendation
• Conduct of the test and handling of the blood sample collected
• Labeling of the blood sample collected and storage conditions
• Processing of the blood sample
• Documentation of the blood report
• Handing over of the report to the patient and maintaining a copy for the record
• Timelines involved for all the above

INCORRECT REPORTS

A wrong report could be the result of the following reasons: insufficient blood for testing, wrong details on sample tube and form, wrong sample taken, no signatures, wrong type of tube, mismatch with information on lab records, tube compromised, clotting, ability of processing technician, lab equipment and so on. The lab manager could conduct a root cause analysis to find out the reason/s for the error in the report and then put in place processes to eliminate the cause of the error.

Dr P N Velingkar, who runs a lab in the heart of the city, cites quality of the reagent used, process followed and a possible error in test kit as possible reasons for errors. He suggests that labs examine standards of previous reagents used and track their performance, perform an EQAS (External Quality Assurance Services) regularly. He also opines that while sometimes a patient wants the results urgently, it is important that the lab ensures adequate time for confirmation of results.

This helps review decisions on which tests the lab can conduct, lab layout planning, quality and maintenance of equipment, putting in place proper standard operating procedure for consistent processes, proper storage facilities, training personnel and providing proper working conditions.

REDUCING ERRORS

Continuous improvement cannot rely on a single approach. An error could arise out of several individual causes working together with each other. In addition to putting in place barriers to reduce errors in test results, training initiatives create a sharp awareness of the impact and potential risk of errors in the entire process.

Pathological laboratories face issues like access to patients, availability of trained lab technicians, managing working capital and investment for equipment. Also, according to Dr J P Agarwal, director of a diagnostic centre in Hyderabad, “Some onus also rests on the doctor who does the initial diagnosis. Only when the initial diagnosis is in the right direction, the lab report will also be on the right path.” Thus, there are several operating constraints faced by path labs.

Despite having to deal with several constraints, laboratories would do well to review their working to enable consistent and accurate reports. This would form the basis for better diagnosis and effective treatment so that parents like Rahul and Gauri can rest assured about their son’s diagnosis and treatment.

The Navhind Times – Zest, 15 May 2010

The focus is shifting and healthcare delivery has moved from the domain of physician care to the domain of the healthcare delivery organization. While new insights continue to be gained from professional practice in the field of health care, one also needs to look at practical aspects of delivering healthcare.

[The author, Meena Parulekar, is faculty at the Marian Institute of Healthcare Management]

The health sector encompasses various services that aim primarily towards affordable care and preventive medicine. Availability of skilled medical personnel, access to healthcare and insurance for the poor, freedom from preventable diseases like malaria and pneumonia are a few issues that are faced in delivery of healthcare.

While these continue to be challenges for the public health system in India, the last decade has seen changes like growth of organized healthcare with players like the Apollo group, Ranbaxy, Max India, Wockhardt and Fortis entering the healthcare market and opening up of the insurance market to the private sector.

With competition setting in, the emphasis is on value and greater transparency about quality, services and prices. One of the most important reasons cited is the changing expectations of the patient who wants to be actively involved in the ‘care’ delivery process. A paradigm shift of hospitals towards service lines in this changing scenario would hence become inevitable. In a well established clinical service line, physicians and administrators can exchange views more easily and share best practices with colleagues elsewhere in the system. If we look at the existing systems of knowledge exchange in the healthcare domain , it appears to be a one way flow from research which is funded by external agencies to the delivery stage (doctors, nurses ) and then to the patient. This meant that the doctor is the main caregiver.

The focus is shifting and healthcare delivery has moved from the domain of physician care to the domain of the healthcare delivery organization. While new insights continue to be gained from professional practice in the field of healthcare, one also needs to look at practical aspects of delivering healthcare, e.g. In the materials management department of a large tertiary hospital, who will do what, when, where and how? How will they hand over tasks, decision rights and accountability to the next person? These are issues that require managerial intervention. In a hospital where patient handling is critical, focus on managing patient waiting times becomes important. Similarly, considering the work environment of health care workers like nurses in a hospital, understanding their social and job related needs becomes a critical issue.

The McKinsey report of December 2008 on healthcare spending in the US re-affirms the need for healthcare reform while highlighting the importance of its stakeholders-doctors, payers and hospitals- involvement. Despite having among the better facilities in terms of hospitals and innovations in technology, it has been found that the cost of spending on healthcare for the common man in the US is perhaps the highest.

Thus, there is a felt need to narrow the gap between clinical practice and management practice in healthcare delivery organizations in order to ensure effectiveness and efficiency of ‘care’ delivery.

Management is a science that is based on observation and facts. The role of a healthcare manager would be to plan, organize and manage care and management of institutions in which care takes place. Put simply a healthcare manager would be in a position to guide these centers of healthcare delivery in making effective decisions that benefit the patient while also serving the organization interest . Any new intervention of designing processes and operating systems for the organization would require an understanding of the nature of clinical processes and the relationship between the medical knowledge, care processes, organizations and practitioners. Thus, healthcare as a domain, is fast emerging to be an integrated discipline. There is a component of industry intervention (pharmaceuticals, biopharmaceuticals and insurance) and patient focus that guides the efforts of skilled professionals in this sector.

A healthcare management program can be objectively designed keeping the above requirements in consideration. What a student is able to achieve through a healthcare MBA program is this objective of (a) Understanding the working of the organizations in the health sector,

(b) Drawing on management knowledge and competencies to deal with the specific issues faced in managing healthcare, and

(c) Gathering an integrated view of the entire system of healthcare delivery

Given the emerging trends in scale and needs of healthcare in India, a focused management approach to the specific issues faced in healthcare would serve the needs of the sector and also help the individual to contribute to achievement of better standards and in turn enhance the quality of overall healthcare delivery.