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Wisdom of laymen on medical matters

The current year President of the Ceylon College of physicians, Dr. Sarath Gamini De Silva, at his induction address, calling upon the medical profession not to underestimate the wisdom of laymen on medical matters said we must not underestimate the wisdom of laymen on medical matters.

Dr. Sarath Gamini de Silva (left) being inducted in office as the President of the Ceylon College of Physicians.

"I still remember as a school boy I had recurrent polyrthritis of large joints. Looking back, it could not have been anything other than acute rheumatic fever. Yet none of the doctors I saw ever suggested that I should be admitted to hospital nor that I should have monthly penicillin. As I was doing my chemistry practicals with a bandaged elbow, my teacher asked me about my arthritis and just commented "be careful, that can affect your heart". Of course we ignored that advice. Fortunately my heart was spared. Yet during my first medical clerkship with Dr. Ernie Peiris, I thought I had a mid diastolic murmur on self auscultation. Dr. Peiris was kind enough to examine me and declare an all clear.

Overloading the labs

We have always complained about the poor quality of the laboratory and the other ancillary services. It is true that this is one area that has not kept pace with development elsewhere. Yet I feel the service is poor partly because we clinicians overload the labs with unnecessary work. Why should one do a urine Fr, ESR, CXR or an SGPT on a patient coming with fever for three days with no other symptoms? May be a WBC-DC or a platelet count in the presence of a Dengue epidemic is all that is necessary initially. Similarly a few days cough with no lung signs does not indicate a chest X-ray.

The irony is that we attempt to substitute a thorough clinical history and examination, for reasons of being too busy, with a whole heap of investigations. This defeats its own purpose as the overloaded laboratory produces unreliable results.

What the radiologists do

The fate of the ultra sound scan of the abdomen is the same. We find that at least half the patients in a ward get this done, often with negative findings. The radiologist, who had hardly any time to meet the demand, produces a preprinted report with some minor adjustments to suit the patient. How this helps the patient or the doctor is beyond my imagination. CT scans, echocardiograms, exercise ECGs and endoscopies are also similarly abused. Such overuse of the equipment leads to frequent breakdowns.

Then we find that even the most urgently needed investigations cannot be done for weeks until the machines are repaired often at exorbitant cost. We often find that lumbar punctures in cases with suspected meningitis or subarachnoid haemorrhage with no contraindications are postponed until a CT scan is done. We have had cases transferred to the National Hospital from far away for this purpose.

A word of caution is warranted here. The guidelines laid down in the West are necessarily coloured by their overriding desire to avoid litigation, the reason for defensive medicine. We should not slavishly follow them.

During the ward round, I always discourage the habit of my juniors showing me the X-rays or the ECG before giving me the clinical details. We are ourselves to be blamed to some extent. During the postgraduate discussions, too much attention is given to the investigative aspects and rare disorders. During X-ray discussion sessions, often no clinical detail is given before attempting to interpret the X-rays. Now that the fine needle aspiration biopsy has become a bedside procedure, many believe that it is the easiest way to diagnose the lump forgetting even to do a full blood count or the coagulation tests. No wonder the trainees carry away the wrong message. Once they get posted to smaller hospitals, they keep transferring most of their patients to larger hospitals for exotic investigations.

Luxuries free health service can Ill afford

These are luxuries this country's free health service can ill afford. We should prevent ourselves from requesting investigations without good reason, and there should be some one screening the requests before they are carried out. Let them learn that common things are common and most can be diagnosed with minimum investigation. Let them have a good base of theoretical knowledge but let them develop the wisdom and common sense to use that judiciously.

T3, T4, TSH when only TSH is required are some expensive mistakes we make often. FAT, SAT and even ASOT are done so often with no benefit whatsoever. Doing an HBA1C when the blood sugars have been repeatedly high or testing urine for microalbumin when the heat test is positive for albumin are common mistakes that cost the patient dearly. Likewise, fructosamine estimations though frequently done and included in most packages is of little use in the routine assessment of the control of diabetes.

The lipid profile has become a standard investigation now that we are preoccupied with risk factors for vascular disease. However we forget that in screening the total cholesterol or the serum triglyceride is all that is necessary. Also we forget that in the presence of an acute illness like a fever or uncontrolled diabetes the lipid profile can be altered drastically. Some of us have the habit of routinely repeating all the tests the patient has already had.

Many medical check up packages offered by the private sector have too many superfluous investigations as indicated above.

Overuse of tests

The fact that most tests, even the exotic ones, are available in the private sector is a blessing to both the doctors and the patients. Yet unfortunately this has led to the over use of such tests at a tremendous cost to the patients.

For example, recently in my unit I discovered that a doctor had ordered a c ANCA and p ANCA in a sixty year old patient with renal failure. He had no clinical features of vasculities. Such expensive confirmatory tests should not be used as screening procedures.

To entice the doctors, some well-known labs now have already made request forms where the doctor only has to tick the tests he wants. No doubt the laboratory knows that there will be more ticks than would have been possible otherwise! Let us keep the patients interest in mind, not that of the service provider.

The dilemma we face

I understand the dilemma we face here. The private sector invests a large amount of money buying modern equipment and other facilities.

Being primarily profit oriented the investor would naturally expect the doctor to see that the equipment is put to good use and not allowed to idle. This too would make the doctor under some obligation resulting in unnecessary procedures for which the patient pays the bill. This is specially so in the case of some finer specialists where the equipment is ear marked specially for them. Certainly the doctor cannot be solely blamed.

How limited resources are used becomes an issue in the use of renal replacement facilities. This has become a major ethical problem in the few hospitals with dialysis facilities. There is no prospect for a chronic dialysis programme in the foreseeable future. As our employers do not lay down policies in this regard it has become our burden to deny treatment to the majority of patients with chronic renal failure. Let us make an effort to sort this out among ourselves.

Re-thinking desirable

The use of newer drugs is another area where much rethinking is desirable.

The medical profession has to bear the onslaught of the pharmaceutical industry in this regard. It is true that our armamentarium of drugs is far from meeting all requirements. It is natural that new drugs are being introduced at a rapid pace.

The newer antihistamines, macrolides, 4 amino quinolines, the antidiabetic agents, angiotensin receptor blockers not to mention the anticancer drugs have certainly strengthened our hand in fighting disease. Yet to what extent these should replace the existing drugs will have to be decided judiciously.

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SLMC spells out doctors' obligations towards patients

The Sri Lanka Medical Council has identified fourteen obligations that the doctors registered with the SLMC should try to fulfill towards their patients as far as possible.

The council has notified these obligations to the profession at registration.

The council's President and Vice President Dr. H. H. R. Samarasinghe and Dr. Ananda Samarasekera requested the Health Watch to publish the list of obligations in this page which is widely read by the profession and the general public so that the general public in particular will come to know about them. Health Watch would like to know from the profession, and our readers their views and comments on the list, which we are publishing today.

Obligations of medical practitioners:

* Make the care of patients your first concern

* Treat every patient politely and considerately

* Respect patients' dignity and privacy

* Listen to patients and respect their views

* Give information to patients in a way they can understand

* Respect the rights of patients to be fully involved in decisions about their care

* Keep professional knowledge and skills up to date

* Recognize the limits of your professional competence

* Be honest and trustworthy

* Respect and protect confidential information

* Make sure that personal beliefs do not prejudice patients' care

* Act quickly to protect patients from risk if they have good reason to believe that you or a colleague may not be fit to practise

* Avoid abusing your position as a doctor

* Work with colleagues in the ways that best serve patients' interests

In all these matters, doctors must never discriminate unfairly against the patients or colleagues, and must always be prepared to justify their actions to them.

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Sugar can ruin your health

by Dr. D.P. Atukorale

Sugar is the generic term used to identify simple carbohydrates which includes monosaccharides such as fructose, glucose or galactose and disaccharides such as maltose and sucrose (white table sugar). When fructose is the primary monosaccharide in your diet the glycemic index registers as healthier since this simple sugar is slowly absorbed from the gut and then converted into glucose in the liver and helps to get a gradual rise and fall of blood glucose levels.

If glucose is the primary monosaccharide consumed, the glycemic index will be higher and less healthy for the individual as glucose is pumped across the intestinal wall directly into the blood stream. Glycemic index of foods such as pulses, oats pasta and granary bread is low as these are slowly absorbed and these achieve a better post prandial blood glucose. When the blood glucose level is too low, the person feels lethargic and can cause clinical hypoglycaemia. When the blood sugar levels are too high, this creates diabetic health problems.

In 1997, American Diabetic Association considered 126mg of glucose/dl or greater to be diabetic and less than 110mg/dl is considered normal. The Palaeolithic diet of small amounts of whole grains, nuts, seeds and fruit is said to have generated blood glucose levels between 60 and 90mg/dl. Obviously today high sugar diets are having unhealthy effects.

Excess blood glucose may initiate yeast overgrowth, blood vessel thickening (atherosclerosis), heart disease and other health problems.

As far as I am aware, majority of cancer patients in Sri Lanka do not get scientifically guided nutritional advice in view of (a) the large number of cancer patients in the cancer hospital and cancer clinics, (b) due to the shortage of medical personal and (c) due to severe shortage of dieticians in Sri Lanka. The cancer specialists have hardly any time to devote to these patients nutrition and they are told "just eat good foods".

Sugar feeds cancer

Cancer patients may have a better outcome if they control the cancer preferred fuel namely glucose. If the cancer growth can be slowed down, the patient can allow his immune system to reduce the bulk of the turmour mass to catch up to the disease. Controlling one's blood sugar levels through diet, supplement exercise, meditation and prescription of drugs when necessary can be one of the most crucial components to cancer recovery programme.

The 1931, Nobel prize winner in Medicine, German Otto Warburg PhD first discovered that cancer cells have a fundamentally different energy metabolism compared to healthy cells.

The crux of the Nobel thesis was that malignant tumours frequently exhibit an increase in anaerobic glycolysis whereby glucose is used as fuel by cancer cells with lactic acid as the by-product compared to normal tissues. Thus there is this acidic pH in cancer tissues and overall physical fatique from lactic acid build-up.

To be continued

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Medicalization of life : spiritual dimension of health in Sri Lanka

Continued from January 31

We know that if we take a walk when we are angry, the anger subsides. So this shows that a bodily or a physical activity can influence the mind. You may have experienced it yourself though you may not have thought of such an interaction. People who take regular physical activity have better concentration of mind and have better output of work. Research has established this fact. This brings us to an interesting point. Jogging and meditation have the same effect on mind - the concentration of mind.

How strange? This proves the interaction between body and mind again.

Link between body and mind

Newberg a neuroradiologist saw in the brain when he did a SPECT scan on a Tibetan Buddhist monk during meditation reduction in blood supply to the parietal lobe during intense meditation. So it is clear that neuro endocrine and immune systems provide the link between body and mind.

This is functional system that provides a scientific explanation to body mind interaction.

This system came into recognition only during the last two decades. If the interaction between body and mind is so close and so obvious why did we take such a long time to recognize this? It is because we haven't had a plausible objective mechanism to explain the connection between body and mind. As a result, we continued to follow the body mind dualism of 17th century preached by Descartes.

However, during last few decades medical scientists searched for a possible link between body and mind. Discovery of this system was not therefore an accident but the result of an intense search. In this system, Immune, Endocrine and Nervous systems act as the link between body and mind.

PNIE or PNI system is now well established. Recognition of this system allows us to accept the body mind interaction on a scientific basis. What we don't know yet is the exact mechanism or the neuroimmunochemistry or how this system works.

But we know for sure the system exists.

This brings us to a whole new dimension in health - Spiritual Health Spirit is something difficult to define, yet all of us can perceive it. Faith beliefs, emotions, aspirations all constitute the spirit of an individual. In fact some people believe that it is the spirit that distinguishes us from animals. Research has now established that people with deep religious commitments have better health and live longer. A study done in California showed that church goers live longer independent of other confounding factors.

Evidence Based Medicine Journal in Dec 2000 published a systematic review of trials on what is called distant healing practices such as prayer and religious activities. Conclusion was that such practices are effective in improving patient outcomes.

What we now need is to acknowledge the fact that patients have what is called inner resources of healings or inner healing capacity. This is the power of mind in healing. The challenge we face in the 21st century is to find ways and means of enhancing the healing powers of mind. As the evidence point out, spiritual practices certainly seem to be one way of promoting such powers of mind.

Recommendations

I wish to make the following recommendations for recognising the spiritual dimension in health in Sri Lanka -

1) We need to openly acknowledge the compelling evidence of the existence of the spiritual dimension of health.

2) We need to train doctors and other health professionals at undergraduate and post graduate levels to address this issue.

For this we need to make changes to the existing medical curriculum. I am pleased to note that Colombo and Kelaniya medical schools have already incorporated a module on behavioral medicine in their undergraduate curriculum. Behavioral Medicine is relatively a new speciality where there is an attempt to expand the traditional health model by incorporating aspects such as beliefs, emotions and behaviour in health. Eliciting spiritual history for example can be part of medical history taking as is already being done in some US medical schools.

3) Relaxation, meditation and spiritual involvement should be recognized as health promoting activities as much as physical activity promotes good health. Currently the health promoting activities are based on Ottawa charter of 1986 and there is no provision for a spiritual dimension in this. Therefore we need to appropriately modify this charter to include the health promoting effects of spiritual practices.

4) Patients should be educated on the healing powers of relaxation, meditation and other spiritual practices.

5) We should undertake more scientific research to define and quantify the effects of meditation on health. This should not be very difficult as we have a rich culture of Buddhist meditation in this country. This should be the responsibility of the medical profession and should not be confined only to religious leaders any more.

6) These practices are not to be regarded as an alternative to the orthodox medicine, rather to be considered as complementary to it

7) Spiritual dimension should be recognized as a universal issue in health and should not however be confined to any particular medical specialty.

8) Hospitals should be made an environment which promotes and nourishes patient's inner capacity for healing by providing appropriate spiritual support.

How to manipulate mind for better health should be the theme for a 21st century health model. We saw the ushering of the new millennium just two years ago. Now we should also see the ushering of a new health model to replace the 17th century Biomedical Health Model. I propose to name this new health model as Medicospiritual Health Model.

Let me conclude by quoting a famous Sinhalese poet Munidasa Kumarathunge "A nation with no innovative skills would never rise".

So let us be innovative and show the rest of the world a new direction in health by adopting this Medicospiritual Health Model in Sri Lanka.

From the induction speech by President SLMA Dr. Seneviratne Epa

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Music therapy for stress & depression

Health Watch last week met a young Sri Lankan Dr. L. P. S. Karunatilleke who has a doctorate (PhD) in Music Therapy from the Benaris University in India, and is practising sitar musical medicine as he calls it to relieve depression and stress in patients.

A German tourist (on right) relaxing listening to a stress relieving tune played on the Musical Health Sitar by Dr. L. P. Sisira Karunatilleke (PHD) in Music Therapy, Benaris University, India, on left is Mrs. Rukmani Fernando, Manager, Jetwing Ayurvedha Niwasa, Negombo, and 2nd from left Dr. Viraj Peramuna, Member, Prof. Colvin Gooneratne Centenarian Study Team, & M.O. Base Hospital Puttalam.

He told us that he was the first to qualify in music therapy from the Benaris University using the sitar, and the University has now set up a faculty for it.

He had spent 12 years in India getting his degree first in Eastern Music and then doing the PhD. in Music Therapy using the sitar. He had been so confident in developing a setup of special remedial tunes in sitar to treat stress and depression affected patients that his University had granted him a two-year scholarship to do it. At the end he had not only succeeded in proving his therapy but also had convinced the University Authorities of the feasibility of setting up a speciality in Music Therapy.

According to him he had selected 450 stress and depression affected patients who came for treatment at the University's Ayurvedha Faculty for the study.

Out of about 2000 Raga and Classic melodies in sitar music, he had selected, 20 melodies, which he thought was suitable for the treatment schedule and improved on them by playing them on the patients, to suit their individual mental structures. With every sitting he was able to draw the patient deeper and deeper into the melody, and ultimately was able to take away and free the mind of the depressive, or the stressful state.

Most of the patients over 30 per cent got well after about 10 to 15 sittings. Others the more difficult cases took about 21 sittings to get over their conditions. In all the total success rate was about 75 per cent. Dr. Karunatilleke who returned to Sri Lanka last year is now practising at the Jetwing Ayurvedha Niwasa, Negombo, where mostly foreigners come for resident treatment in Ayurvedha medicine.

He has also been picked by the Kelaniya University for a visiting lecturers post in music therapy at Heywood.

making undergraduate learning more rural orientated

Clinical experience in a rural-setting is an important factor associated with entering rural practice.

Early positive exposure to rural practice encourages more students to develop an interest in rural practice as a career option and fosters a better understanding of rural practice, even for those who choose not to work in a rural setting. All students need to be introduced to rural practice early in the medical course and have clinical rotations to rural hospitals and rural general practice later in the course.

Strategies

Rural practice should be included in the curriculum by:

Introducing rural health issue early in the curriculum, including specific rural communities for students early in the medical course and including further clinical rotations to rural hospitals and rural general practice later in the course.

Developing enhanced rural training experience for a selected group of students who indicate an early commitment to rural practice.

Ensuring that significant periods of undergraduate learning and teaching should be multi-professional and take place within the rural health team.

Encouraging multidisciplinary links in the training of medical students: The participation of nurses and other professionals in the education of undergraduates and junior doctors will improve the relationship between doctors and other health professionals facilitating a greater diversity of approaches. The inclusion of practising rural doctors in medical schools as educators and researchers is integral to the development of an improved understanding and a supportive attitude towards rural practice.

Dr. W. D. Ferdinands, President, IMPA.

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