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VIOLENCE AGAINST DOCTORS: MISSING THE ELEPHANT IN THE ROOM

Counselling a patient and his attendants in India could be different. But the same degree of empathy and emotional connection needs to be present between the doctor and the patient.

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Every time we hear another doctor being assaulted in the hospital, a sliver of shock and disgust goes through people, the medical fraternity, and the media.

We have watched ad nauseam these scenes repeating all over the country. Doctors getting beaten up, hospital equipment being broken down, health workers being assaulted.

The scenes shown on media are deja vu.

The visuals are re-run, again and again.

They did not stop even during the pandemic.

Even for very sick patients with covid on a ventilator.

Why should the healers deserve so much hatred?

Why should such a noble profession become the epicenter for such violence?

Is something fundamentally wrong with medical training?

Or something that we are missing in our public?

Is this because of the gap between the expectations and the reality?

Are doctors soft targets for the institutions and hospitals not meeting up to what society requires?

Spending more than 30 years in this profession, we feel that this angst goes deeper.

Perhaps, we see only the tip of the iceberg.

It is essential to look at a problem pragmatically and concentrate on the solutions and not on the issue.

Everything in health is connected. The whole health infrastructure is one connected, seamless system.

Nothing in a health system is independent.

Fundamentally, the cogs of the wheel are the health personnel, the hospital, and the patient who make up this eco-system.

Each of these elements contributes towards health care both at the local and national levels.

At the local level, the doctors need to be trained personnel. We cannot have untrained professionals dealing with the lives of the patients. But it would also be necessary for doctors to be more trained explicitly in ethics and patient counseling. Unfortunately, there is no separate training for doctors in our profession, specifically on these subjects.

Health systems in some countries, including the United Kingdom, give a great emphasis on this. For example, students from India who wish to pursue a career in the UK need to undergo specific training in this area. The PLAB II examination, which qualifies an international medical graduate to practice in the UK, looks explicitly into these areas.

Coaching is provided to the students on how to speak, interact, and react and understand patients’ needs before the students appear for the PLAB II.

Interestingly, during the PLAB II examination, students interact with actors, and the examiners assess how good the student is in communication skills with the patient. For instance, if a patient is angry, the doctor would be expected to empathize and say, “I can see that you are angry” and not say “I can understand why are you angry” as the English language demands proper vocabulary from the doctor to convey their feelings.

Counselling a patient and his attendants in India could be different. But the same degree of empathy and emotional connection needs to be present between the doctor and the patient. In India, doctors are expected to learn this on the job.

So, how does a young intern who is hardly 22 years old handle the relatives, breaking the news of the death of their near one? How should they react when the relatives break down on hearing the news?

This may be too much for a young doctor to handle, hence the importance of training and including this in the medical curriculum.

Doctors need to have access to standardized operating protocols (SOP’s) and management algorithms at a national level. The National medical council (NMC) or similar apex body needs to create the availability of such material through mobile applications and websites.

We also need to urgently create a national database to store patient information (electronic medical records). So, if a patient goes to any hospital, that hospital should be able to access all the previous investigations and any pre-existing illness of the patient.

From the patient’s perspective, the dissipation of public knowledge over social media, newspapers, and television regarding correct behavior is important. Notice boards should be placed at several places indicating severe penalties for any uncivil behavior. Every hospital should invest adequately in the security and protection of health personnel. Education is very important. The patient and relatives must understand limitations for treatment for every disease. Education pamphlets regarding every disease must be distributed to patient attendants. The prognosis and outcome of the disease must be clearly understood by them. The caregivers cannot expect a cure in conditions which have a limited lifespan. Similarly, complications may arise from treatment of every disease. It is mandatory to record the informed consent properly in the medical records. In addition, it will be important to develop video recorded consent which should be stored by the hospital.

At a National level, alternate judiciary systems should be made available to tackle medical negligence. Senior doctors or even retired doctors should be made to preside over such legal hearings. It may not be a bad idea for senior doctors to undergo training for few years and take a whole career in medical jurisprudence, where doctors can occupy the same role as judges.  Such legal proceedings may occur in separate buildings and not the usual courts to allow expeditious settlement of such cases. This is important as the current legal systems may not cover enough knowledge base to understand and judge the negligence which arises from the complexity of medical pathologies. Hence the need for experts to preside and take such decisions.

One must understand the among all professions, the medical profession is among the longest and most difficult. It takes almost ten years to become a specialist and another decade to gain good experience. This involves years of personal sacrifice, several doctors marrying late, or some even not having children (many of our colleagues had adopted children as they were too old by the time they graduated). Among these, some sub-specialties like neurosurgery, neurology, and cardiac surgery have exceptionally long and grueling hours. By the time a doctor becomes a specialist, several professions are already preparing for their retirement! Hence, it becomes even more critical to make this profession attractive for future generations. Otherwise, we will end up having no one taking medicine or only the best brains and intelligentsia will take up other occupations and not be interested in medicine.

We should now consider the third component of the ecosystem- the hospital.

We, of course, need to increase our national GDP for health care.

But what prevents us from improving the current systems. Some nations spend much less on health care but have better-organized health care systems.

Indian currently has one of most advanced health systems globally. International medical ‘tourism’ is increasing exponentially. Indian doctors are recognized world over for their skills and expertise in view of their vast experience

However, It is imperative for us to understand that we are dealing with two extreme tertiary health care systems in India, both being on either end of the healthcare spectrum. On one hand, we have government institutions, where everything is subsidized or free. They are also places that handle large volumes and crowds. Doctors are usually overworked and have additional teaching and research responsibilities, all this with fixed pay and no incentives. Some medical colleges have their faculty private practicing at their clinics during the evenings. This creates a conflict of interest with their primary job. It is thus a little wonder that the quality of training in most medical colleges is going down.

The government institutions currently form the temples of learning. Therefore, they cannot be compromised as this will lead to a progressive deterioration of healthcare standards as the training of a future generation of doctors will be sub-optimal.

On the other end of the spectrum are the private medical colleges and hospitals. Large corporates usually run them. Most of the smaller hospitals are constructed with a very high debt-to-equity ratio. This places unnatural pressure on doctors to earn more money for the hospital.

So, the doctors joining such places at a young age of their career are faced with a challenge for which they have not been trained for- be part of the revenue generation for the hospital. Opening the medical profession to market forces is a clear and present danger to the profession.

Doctors are healers by profession. They should be given that job only to preserve their efficiency and dignity. Demanding that they should now become financial managers as well will be the last nail on the coffin.

It’s thus no wonder that all the young doctors, after having paid a large sum of  fees for their studies, now may have only one goal in their life- to have a payback time.

We think that it’s time to create a middle path. Something not significantly different from the UK has- a National health service but based on healthy public-private partnership.

So, if it wishes, every private hospital could become part of this health service for which they would get the benefit of joining hands with the government for better security and services without losing control over their hospital.

We have to understand that while health is a human right, no country may not afford to make it free and accessible for every citizen. It cannot be a business venture, but it could be made into a healthy, transparent, and compassionate business.

Every citizen needs access to a sound health system.

Even the richest in the country cannot deny that. And the pandemic has proven it.

Health care cannot happen in one day.

Nor does it mean creating luxurious hospitals with sparkling floors and “ultra-deluxe” rooms (and overpriced charges for treatment).

Hospitals are very different from hotels; the ecosystem is more complex.

It’s the people who are behind it that matter- the doctor, nurses, and paramedics.

If they are happy, the patients will be satisfied.

The happiness of doctors depends not just on financial remuneration.

It depends on the quality of training they receive, the continued medical education they will have, the hospital environment they work in, the sound ethics and principles that they are nurtured in, the bonding they develop with patients, and the contribution they make towards education and research to train the younger generation.

To move forwards after 75 years of independence, it’s time we stopped ignoring the elephant in the room.

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Medically Speaking

OVERWEIGHT CHILDREN CAN REDUCE CARDIOVASCULAR RISK BY FOLLOWING HEALTHY DIET

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Statistically overweight children who follow a healthy eating pattern significantly improve their weight and reduce a variety of cardiovascular disease risks suggests the findings of a Cleveland Clinic-led research team.

The study, which was published in the Journal of Clinical Pediatrics, paired parents and children together throughout the trial. According to the Center for Disease Control and Prevention, obesity now affects 1 in 5 children and adolescents in the United States. Children who are obese are more likely to have high blood pressure and high cholesterol which are risk factors for cardiovascular disease. Adult obesity is associated with an increased risk of several serious health conditions including heart disease, type 2 diabetes, and cancer.

For one year, researchers studied changing cardiovascular disease risk markers associated with three healthy eating patterns in 96 children between the ages of 9 and 18 years old with a body mass index (BMI) greater than 95 percent. BMI is calculated by dividing a person’s weight in kilograms by the square of height in meters, but for children and teens, BMI is age and sex-specific and is often referred to as BMI-for-age.

The three healthy eating patterns studied were the American Heart Association Diet, Mediterranean Diet, and Plant-based diet. All three emphasised whole foods, fruits and vegetables and limited added salt, red meat and processed foods. Parent and child pairs attended weekly educational sessions for four weeks which covered suggested foods to eat and avoid how to read package labels, proper portion sizes and shopping tips.

Fasting blood tests were used to access biomarkers of cardiovascular risk. All three diets were associated with improvements in weight, systolic and diastolic blood pressure, total cholesterol, and low-density lipoprotein.

“This study helps show the importance of starting healthy eating patterns as young as possible. We know that cardiovascular disease begins in childhood, and children’s eating patterns are easier to mold than adolescents and adults,” said lead author Michael Macknin, M.D., Professor Emeritus of Pediatrics of Cleveland Clinic Lerner College of Medicine.

The American Academy of Pediatrics Committee on Nutrition recommends that healthy children age 2 and older follow a diet low in fat (30 percent of calories from fat). These are the same recommendations for healthy adults. In the study, dietary compliance rates averaged 65 percent in week 4 and 55 percent in week 52 suggesting small improvements in diets can still be very beneficial.

“Because the process of heart disease begins in childhood, prevention should begin there as well,” said W.H. Wilson Tang, M.D., study author and research director in the section of heart failure and cardiac transplantation medicine in the Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute at Cleveland Clinic.

“A large majority of heart disease is due to modifiable or controllable risk factors, so it’s important for children to understand that they are in large part responsible for their health,” added Tang.

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INDIA’S COVID-19 VACCINATION COVERAGE EXCEEDS 81.85 CRORE

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With the administration of 96,46,778 vaccine doses in the last 24 hours, India’s Covid-19 vaccination coverage exceeded 81.85 crores (81,85,13,827) as per provisional reports till 7 am on Tuesday, informed the Ministry of Health and Family Welfare.

The ministry said that this has been achieved through 80,35,135 sessions. As per the data, as many as 1,03,69,386 healthcare workers have been inoculated with the first dose of the Covid vaccine while 87,50,107 have been inoculated with both doses. The number of frontline workers vaccinated stands at 1,83,46,016 (first dose) and 1,45,66,593 (two doses).

According to the health ministry, 33,12,97,757 vaccine doses were administered as the first dose and 6,26,66,347 vaccine doses were given as the second dose in the age group 18-44 years.

Also, in the age group of 45-59 years, 15,20,67,152 people have received the first dose and 7,00,70,609 have received the second dose whereas 9,74,87,849 vaccine doses were administered as first dose and 5,28,92,011 vaccine doses given as the second dose to the people over 60 years. Meanwhile, India reported 26,115 new Covid-19 cases in the last 24 hours.

Sustained and collaborative efforts by the Centre and the states, UTs continue the trend of less than 50,000 daily new cases that are being reported for 86 consecutive days now.

“The recovery of 34,469 patients in the last 24 hours has increased the cumulative tally of recovered patients (since the beginning of the pandemic) to 3,27,49,574,” the ministry said.

The active caseload is presently 3,09,575 which constitutes 0.92 percent of the country’s total positive cases while the recovery rate stands at 97.75 percent. The testing capacity across the country continues to be expanded. The last 24 hours saw a total of 14,13,951 tests being conducted. India has so far conducted over 55.50 crores (55,50,35,717) cumulative tests. The weekly positivity rate at 2.08 percent remains less than 3 percent for the last 88 days now. The daily positivity rate was reported to be 1.85 percent. The daily Positivity rate has remained below 3 percent for the last 22 days and below 5 percent for 105 consecutive days now.

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‘Robotic lab’ at AIIMS has capacity to conduct 2 lakh tests in a day

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Amidst the prevalence of the Covid-19 pandemic, the country’s renowned hospital, All India Institute of Medical Sciences (AIIMS) here has prepared a ‘robotic lab’ that has the capacity to conduct more than two lakh general tests in a single day.

AIIMS “robotic smart lab” has the capacity to conduct two lakhs tests in a single day. This hi-tech lab was started last year in July and inaugurated by Former Union Health Minister Dr Harsh Vardhan. Union Health Minister Mansukh Mandaviya on Monday also visited this lab and spent more than 20 minutes to see the working of this robotic lab which is fully IT and digitally enabled. Currently, this lab is conducting 3,000-4,000 tests per day but it has a capacity to conduct 8,000 tests per hour and two lakh tests in a single day.

“As of now, we are conducting 3,000-4,000 sample testings in a single day via this lab. The capacity is almost 8,000 tests per hour and 2 lakh tests in a day,” said Dr Tushar Sehgal, Assistant professor, Department of Medicine at AIIMS, Delhi.

This AIIMS smart lab is providing high-quality diagnostics and reduced time in producing lab reports here. The lab is doing more than 70- 270 advanced tests and some of them are free of cost for the patients, the official said.

Elaborating further, Dr Sehgal told ANI, “The testing involves a few stages. It primarily involves three main stages i.e. pre-analytical, analytical and post-analytical stage.” “We have three different types of sample testing methods as well. Haematology, Coagulation, Chemistry are the methods,” he added. AIIMS Hi-tech robotic lab is also providing some free-of-cost tests like the D-Dimer test that costs around Rs 1,000 in private labs. “There are some tests which we do free of cost. Our vision is to provide most of the tests free of cost like LFT, CBC, D-Dimer test etc.”

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Medically Speaking

VARIOUS INFECTIONS SURGE AMONG CHILDREN AS POST-COVID SYMPTOMS

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Respiratory syncytial virus (RSV) is emerging as the latest post-Covid symptom among infants and young children, said a paediatric expert on Tuesday.

According to Dr Dhiren Gupta, a senior paediatric pulmonologist at Sir Ganga Ram Hospital, the early phase of RSV infection in babies and young children is often mild, like a cold. However, in children younger than age three, the illness may move into the lungs and cause coughing and wheezing. In some children, the infection can also turn into severe respiratory disease. Dr Gupta told ANI, “Among 100 cases of post-covid complications, 80 percent patients are suffering from RSV, whereas among RSV cases 80 percent patients are infants.”

The expert also added that if a patient had prolonged fever as a post-Covid symptom, then about 1 percent to 20 percent chances are patient is suffering from Tuberculosis.

“Unfortunately there is no specific treatment for RSV infection and normally takes between seven and 10 days to settle,” said Dr Gupta. The doctor said though the Covid-19 infections have not increased in number, the severity of Covid infection was a little bit more than generally found.

“Also, children who were completely fit and healthy before Covid are suffering from tuberculosis and liver abscess along with RSV and they were not given immunosuppressant such as steroids,” he added.

A pyogenic liver abscess is the development of a pus-filled pocket of fluid within the liver. Pyogenic means producing pus. A liver abscess can develop from several different sources including a blood infection, an abdominal infection or an abdominal injury that was infected.

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Completing recommended sleeping hours could lead to smarter snacking choices, says a new study

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The findings of a new study suggest that people who miss the recommended seven or more hours of sleep per night might make poorer snacking choices than those who adhere to shut-eye guidelines.

The study abstract has been published in the Journal of the Academy of Nutrition and Dietetics and the research will be presented in a poster session on 18 October at the 2021 Food and Nutrition Conference and Expo. The analysis of data on almost 20,000 American adults showed a link between not meeting sleep recommendations and eating more snack-related carbohydrates, added sugar, fats and caffeine.

It turns out that the favoured non-meal food categories—salty snacks and sweets and non-alcoholic drinks—are the same among adults regardless of sleep habits, but those getting less sleep tend to eat more snack calories in a day overall.

The research also revealed what appears to be a popular American habit not influenced by how much we sleep: snacking at night. “At night, we’re drinking our calories and eating a lot of convenience foods,” said Christopher Taylor, professor of medical dietetics in the School of Health and Rehabilitation Sciences at The Ohio State University and senior author of the study.

“Not only are we not sleeping when we stay up late, but we’re doing all these obesity-related behaviours: lack of physical activity, increased screen time, food choices that we’re consuming as snacks and not as meals. So it creates this bigger impact of meeting or not meeting sleep recommendations,” added Taylor.

The American Academy of Sleep Medicine and Sleep Research Society recommends that adults should sleep seven hours or longer per night on a regular basis to promote optimal health. Getting less sleep than recommended is associated with a higher risk for a number of health problems, including weight gain, and obesity, diabetes, high blood pressure and heart disease.

“We know lack of sleep is linked to obesity from a broader scale, but it’s all these little behaviours that are anchored around how that happens,” said Taylor.

Researchers analysed data from 19,650 US adults between the ages of 20 and 60 who had participated from 2007 to 2018 in the National Health and Nutrition Examination Survey. The survey collected 24-hour dietary recalls from each participan—detailing not just what, but when, all food was consumed—and questions people about their average amount of nightly sleep during the workweek. The Ohio State team divided participants into those who either did or didn’t meet sleep recommendations based on whether they reported sleeping seven or more hours or fewer than seven hours each night. Using US Department of Agriculture databases, the researchers estimated participants’ snack-related nutrient intake and categorized all snacks into food groups. Three snacking time frames were established for the analysis: 2:00-11:59 a.m. for the morning, 12:00-5:59 p.m. for the afternoon, and 6 p.m.-1:59 a.m. for the evening.

Statistical analysis showed that almost everyone—95.5 percent—ate at least one snack a day, and over 50 percent of snacking calories among all participants came from two broad categories that included soda and energy drinks and chips, pretzels, cookies and pastries.

Compared to participants who slept seven or more hours a night, those who did not meet sleep recommendations were more likely to eat a morning snack and less likely to eat an afternoon snack and ate higher quantities of snacks with more calories and less nutritional value.

Though there are lots of physiological factors at play in sleep’s relationship to health, Taylor said changing behaviour by avoiding the nightly nosh, in particular, could help adults not only meet the sleep guidelines but also improve their diet.

“Meeting sleep recommendations helps us meet that specific need for sleep-related to our health, but is also tied to not doing the things that can harm health,” said Taylor, a registered dietitian.

“The longer we’re awake, the more opportunities we have to eat. And at night, those calories are coming from snacks and sweets. Every time we make those decisions, we’re introducing calories and items related to increased risk for chronic disease, and we’re not getting whole grains, fruits and vegetables,” added Taylor.

“Even if you’re in bed and trying to fall asleep, at least you’re not in the kitchen eating – so if you can get yourself to bed, that’s a starting point,” noted Taylor.

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INFANTS EXPOSED TO DOMESTIC VIOLENCE HAVE POOR COGNITIVE DEVELOPMENT: STUDY

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A new study has revealed that infants coming from homes with domestic violence often go on to have poor academic outcomes in school due to neurodevelopmental lags and a higher risk for a variety of health issues, including gastrointestinal distress, trouble eating, and sleeping, as well as stress and illness.

The findings of the study were published in the ‘Maternal and Child Health Journal’. While assessing a pregnant woman with premature labour in 1983, Linda Bullock noticed bruises on the woman. When she asked what happened, the woman told Bullock a refrigerator had fallen on her while cleaning the kitchen.

“Something didn’t seem right, but I didn’t know what to say at the time. I just went on to the next question of the assessment,” said Bullock, now a professor emerita at the University of Missouri Sinclair School of Nursing.

“We stopped her labour and sent her home, but I will bet my last dollar I sent her back to an abusive relationship, and it sparked my interest in helping other nurses assist battered women. What we didn’t know at the time was the impact violence had on the baby,” Bullock added.

Bullock helped implement the Domestic Violence Enhanced Perinatal Home Visits (DOVE) program in rural Missouri, which empowered safety planning and reduced domestic violence for hundreds of abused pregnant women.

After learning from home health visits that many of the abused women had up to nine different romantic partners during and following pregnancy, Bullock conducted a study to examine the impact of multiple father figures on the cognitive development of newborn infants.

After administering neurodevelopmental tests during home visits three, six and 12 months after birth, she was surprised to find the infants of women who had only one male partner who abused them had worse cognitive outcomes compared to infants of women with multiple male partners, only some of whom were abusive.

“The findings highlight the variety of ways the multiple father figures may have been helping the mom support her baby, whether it was providing food, housing, childcare or financial benefits,” Bullock said.

“For the women with only one partner who abused them, the infant’s father, the father may not have provided any physical or financial support or played an active role in the child’s life. It can be difficult for busy, single moms struggling to make ends meet to provide the toys and stimulation their infants need to reach crucial developmental milestones,” Bullock added.

Bullock added that infants coming from homes with domestic violence often go on to have worse academic outcomes in school due to neurodevelopmental lags and a higher risk for a variety of health issues, including gastrointestinal distress, trouble eating and sleeping, as well as stress and illness.

“When nurses are visiting homes to check in on pregnant women and their developing babies, we want them to be trained in recognising the warning signs of potential intimate partner violence,” Bullock said.

“I still think back to 1983 when I sent that lady back home into a terrible situation, and I am passionate about making sure I can help nurses today not make the same mistake I made,” Bullock continued.

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