How to Get the Best Medical Care by Aniruddha Malpani

HOW TO GET THE BEST MEDICAL CARE – FOR LESS ! Dr Aniruddha Malpani, MD Dr Anjali Malpani, MD www.thebestmedicalcare.com

Preface Effective health care depends on self-care. Ivan Illich. Whenever someone falls sick, they hope to get the best medical care from their doctor. In a perfect world you'd have the perfect doctor who would have plenty of time, infinite wisdom, low fees, be totally honest yet compassionate, have a conveniently located clinic and understand your emotional as well as medical problems â&#x20AC;&#x201C; in short, one who treats you as a VIP ! Since it's unlikely you are going to find this doctor, you're going to have to take active charge of your own medical care ! Medicine, as both a science and art, often requires choices and there are no "right" answers - you need to make your own decisions - after all, it's your life ! While you obviously have a vital interest in treatment decisions and outcomes , unfortunately you lack the medical knowledge and skill to be able to decide alone. This is where the concept of a team , which consists of you and your doctor , is so important. Your role on the medical team is multifaceted - remember that you need to wear many hats when you are a patient ! Medical Information Researcher: The more knowledgeable you are about your problem and its treatment, the better are your chances of getting the right treatment. Educate yourself - you need to become an informed participant in your medical care in order to ask the right questions and to participate in making decisions about your treatment. Medical Team Manager: You will have to find, evaluate, select, hire and sometimes fire - members of your medical team. As an enlightened patient, you need to remember that you are the one in charge of your body !

Treatment Decision Maker: You will have to decide which treatment to choose. Sometimes the choices are straightforward , but sometimes they can be very confusing. A good doctor will offer you all the options and help you to decide - but it is finally your right (and responsibility ! ) to select which is right for you. You cannot afford to leave everything upto God - or upto the doctor either ! Medical Record Keeper. You must keep all your records - this can be very helpful if you need to change doctors or get a second opinion. Financial Manager: Medical treatment can be very expensive these days - and you must be aware of the costs involved . Many patients are hesitant to talk to their doctor about money matters - but this reluctance can prove to be very expensive ! Communicator: It is important that you be open and honest with your doctor. Ask questions, listen to the answers and take notes. Remember, the only stupid question is the one you don't ask - so don't hesitate to ask ! And if you don't understand, the fault is not yours - it just means your doctor is not explaining well! This book will help you during your medical journey – right from choosing your doctor; making the best use of his expertise; researching your options; understanding medical jargon; to taking care of yourself in hospital and during surgery. It answers all your common questions about medical care, medical tests and medicines – right from birth to death, so you can get the best medical care for yourself – and for your family ! All the information in the world will never replace a personal conversation with your own doctor. But it can be a starting point in helping you to take control over your own medical situation ; to find the doctor who can best treat it; to have effective conversations with that doctor; and to help you to be a partner in your treatment. A VIP patient is a very well Informed Patient - and that's the best kind of patient to be if you want to get VIP care ! Dr Aniruddha Malpani, MD Dr Anjali Malpani, MD Medical Director

HELP - Health Education Library for People Om Chambers Kemps Corner Bombay 400 036. India Email: malpani@vsnl.com

Contents Preface I Your Health And How To Keep It Chapter 1 Going Beyond An Apple a Day: How to Remain Healthy Chapter 2 Health Headlines: Making Sense of Medical Stories in the News Chapter 3 How You Can Give Your Baby a Head Start in Life Chapter 4 Medical Care for Your Offspring: No Child’s Play Chapter 5 Growing Old, But Keeping Fit Chapter 6 Caregiving: Taking Care of Elders Chapter 7 Learning to Live well with a chronic illness Chapter 8 Self-Care: Handling Common Medical Problems at Home Chapter 9 How to Keep Fit While Travelling Chapter 10 How Not to Get ‘Quacked’ Chapter 11 Alternative Medicine: Exploring Your Options Chapter 12 The Healthy Community: One for All, All for One II You and Your Doctor Chapter 13 Looking for Dr Right Chapter 14 How to Make the Most of Your Doctor Chapter 15 How to Talk Intelligently to Your Doctor Chapter 16 How to Use the Telephone Wisely

Chapter 17 Making Friends with the Clinic Staff Chapter 18 A Second Opinion: A Prime Necessity Chapter 19 Specialist: A Class Apart Chapter 20 The Ideal Doctor's Code of Practice III Becoming An Empowered Patient: Making the Doctor-Patient Partnership Work Chapter 21 The Responsibilities of a Patient: Quite a Load! Chapter 22 Your Rights as a Patient Chapter 23 Your Medical Records: Vital Statistics Chapter 24 Beware of Medical Care! Chapter 25 Checking up the Medical Check-up Chapter 26 Medspeak: Making Sense of Medical Jargon Chapter 27 Support Groups: Self-Help Is the Best Help Chapter 28 Sources of Information: How to Research Your Medical Problem Chapter 29 New Technology in Medicine: Handle with Care Chapter 30 How to Prevent â&#x20AC;&#x2DC;Testitisâ&#x20AC;&#x2122; Chapter 31 Making Decisions about Treatment Chapter 32 Medical Insurance Chapter 33 Healthy, Wealthy and Wise: How to Balance the Medical Budget Chapter 34 Informed Consent: A Crucial Factor Chapter 35 How to Complain Effectively: The Legal Options IV You And Your Medicines

Chapter 36 Medicines : Boon or Bane? Chapter 37 Over-the-Counter Drugs: How to Use them Wisely Chapter 38 Coping with Side-Effects Chapter 39 Preventing Medication Errors: A Vital Precaution Chapter 40 ‘Prescription’ for a Healthy Medicine Cabinet V A User-Friendly Guide to the Hospital Chapter 41 On the Way to the Operation Theatre: What You Should Ask Your Doctor Before Undergoing Surgery Chapter 42 The Kinder Cut: Surgery Made Easy Chapter 43 The Importance of Emergency care Chapter 44 How to Make a Hospital Hospitable Chapter 45 Intensive Care or Insensitive Care? Chapter 46 Death with Dignity VI Appendixes Appendix 1 Your Personal Health History Appendix 2 Key Questions to Ask Your Doctor Appendix 3 Detailed Information About Your Medical Problem : Delivered at Your Doorstep

Chapter 1 Going Beyond An Apple a Day: How to Remain Healthy Those who think they have no time for exercise will sooner or later have to find time for illness. Edward Stanley An ounce of prevention is worth a pound of cure is a cliché, but very true, nevertheless ! All said and done, no matter how efficient medical technology is, and no matter how competent your doctor is, the best course would be to adopt such a lifestyle that you never need to see a doctor in the first place ! Unfortunately, we have become increasingly dependent upon technology, with the result that we have lost sight of the sagacity of the ages; which was so designed that human beings could live in harmony with nature, and use nature’s healing powers and the body’s intrinsic wisdom to remain well. Fortunately, preventive health and wellness have once again become fashionable ideas for the 1990s — after all, the best medicine is prevention! Do we really need a doctor to keep us healthy ? The dismal fact is that most doctors know a lot about treating ailments, but they know precious little about how to remain healthy ! (Unfortunately, medical colleges do not teach doctors how to specialize in keeping people healthy !) In fact, since doctors are so used to treating patients who are ill, many of them really wouldn’t be of much use in teaching you how to remain healthy! Fortunately, you do have a remarkable teacher, who can help you to remain healthy — the wisdom of your own body ! Many people are now realizing the value of going back to nature. None of the steps involved in such a process is difficult, complex or expensive, but you need a firm resolve to implement them.

Fortunately, India can boast of a rich tradition of folklore and wisdom ( including yoga and ayurveda) to fall back on, and we should tap this resource before we lose it entirely. All sensible doctors realize that healing finally occurs from within, and thus we can make beneficial use of the innate wisdom of the body to remain healthy ! Traditional wisdom recognizes that it is the body which heals itself; in other words, the power to cure a disease lies within the body itself and not in the hands of the doctor. A majority of people will admit that they have fallen victim to several bad habits. However, most of us are still not willing to change, and that’s odd, because most people still believe that being healthy is far more important than having lots is money or driving a fabulous car. So why don’t we change ? One reason is that we feel it’s too much trouble to hoist ourselves out of our comfortable ruts, in which we are deeply entrenched. This is especially true when we’re under stress. Unhealthy behavior proves easier and more convenient than doing what we know is right ! One factor which galvanizes many people to get serious about living healthily is confronting a serious illness, either afflicting them, or a friend or a relative. This realization usually acts like a kick in the pants, and makes them reform quickly! Many patients, after having been through the rigours of a heart attack, for example, are so thankful to be alive that they’re very willing to make serious changes in lifestyle. However, a smart person learns from others, and you don’t have to wait for an agonizing incident to jumpstart a change in your life! The most important question is: How do you get started? For one, start out by trying to make small changes before going in for big ones. Also, begin by adopting a new behaviour pattern rather than giving up an old one, because the former is easier. For example, it’s hard to stop smoking, but it’s pretty easy to add fruit to your diet every day. If you’re successful in introducing small changes, the resulting benefit will motivate you to undertake the required big changes. Do things that make you feel good instantly, such as spending more time with understanding friends. If they let you talk out your problems and are warm and caring, even if they aren’t in the best shape themselves, such a sympathetic attitude will reduce your stress and make it easier for you to follow other healthy strategies. Prayer, worship and belief in God are an important part of life for many people, and spiritual beliefs and practices can actually enhance your health and well-being as well.

Keeping a pet is also a beneficial activity, and has been shown to improve life expectancy according to many studies. It would be worthwhile to be realistic and specific when setting goals for yourself – don’t try to run a marathon if so you’re out of shape that you cannot even walk one kilometre! Start by promising yourself to walk for five minutes every day; then increase the duration gradually each week. If you find yourself gobbling sweets or junk food at certain times of the day, try to figure out what triggers the desire. If you find that you keep on munching chips while watching TV, put a bowl of fruit next to you instead; or else don’t watch TV. It’s very important not to let temporary setbacks obstruct your overall progress. We are all normally prone to relapse; just don’t treat it as a monumental problem. Promise yourself that you’ll start again and get back on track right away. It’s simple to live healthily — and it’s not expensive either ! There are only seven major ingredients in a plan for good health: 1. Exercise: Work up to a regular aerobic ( endurance) exercise programme 2. Diet and nutrition: Everything in moderation – and cut down on the fat. 3. Weight Control: Maintain a healthy weight, avoid gaining and losing it. 4. No smoking: Consider smoking as enemy number one. 5. Alcohol moderation: Abstinence would be ideal. 6. Avoiding injury: Use your common sense (for example, by using seat belts, or opting only for safe sex). 7. Disease prevention: This can be achieved through periodic checkups, immunizations and health risk appraisals. Your future health is largely determined by what you do at present; your lifestyle and dietary habits will determine how much time you’ll spend in hospitals and how rapidly you’ll age. Techniques have been developed for estimating mathematically your future health risks. These techniques are collectively termed ‘health risk appraisal’ or ‘health assessment’. Here, you have to fill a questionnaire about your lifestyle and health habits and your responses are computed to evaluate the likelihood of your developing major medical problems, such as heart disease and cancer. These techniques are an important part of comprehensive health education programmes, and can help you shape your own personal health maintenance regimen. Remember

that a health risk assessment is virtually useless unless it motivates you to change your behaviour. You should constantly remind yourself that you can reduce your health risks by changing your lifestyle! Any person on the street knows that to live longer you need to eat properly, exercise regularly and reduce stress to the extent possible! What you need to do is to get off your backside and start doing what you know will help you feel better and lead a longer and healthier life. Just do it, like the Nike ads exhort! Teach your children as well, so that our next generation can look forward to a healthier future !

Chapter 2 Health Headlines: Making Sense of Medical Stories in the News It’s all story telling, you know. about.

That’s what journalism is all Tom Brokaw

All of us rely on the media (TV, radio, newspapers, magazines) to remain updated with the latest news. While making sense of the share prices in the financial section is straightforward, how does one interpret or understand the medical stories? We are now awash in a flood of health information, and barely a day goes by without a report of a spectacular new cure for a formerly incurable illness. However, many people find themselves increasingly frustrated in the face of the media barrage of confusing and contradictory health advice. One day, drinking alcohol is bad for your health; the next day it is reported to help prevent heart disease. One day, margarine is healthier than butter; the next day it's not. One day fish prevents heart disease, then it doesn't! You may be exasperated enough to ask: Why can't researchers get their facts right the first time? And how are you supposed to make sense of what you read, if the experts themselves can't make up their minds? In order to maintain a balanced perspective, it's important to remember that news, by its very definition, implies something new and unusual. This is why medical stories in the media often seem to be at loggerheads with what common sense tells us. After all, the hundredth study showing a relationship between high cholesterol and heart disease is hardly news, but the one study that shows that eating fat helps prevent heart disease is likely to become a headline — no matter how flawed it may be! The media is often guilty of oversimplifying or exaggerating results. Moreover, headline writers may focus on an angle that gives a distorted impression, which often means that facts are sacrificed at the altar of readability or circulation figures. Many reasons can be attributed to the somewhat shoddy standard of reporting in the lay press with respect to medical matters. Editors crave for stuff which is ‘new’ and doctors and hospitals are only to

happy to tom-tom their latest gadgets and gizmos. Reporters are often not specialized enough to understand the medical technical background. Often, they do not do their homework properly, which results in misreporting, which is, unfortunately, a common occurrence in India. It is a sad fact that although most newspapers and magazines have a battery of expert financial reporters, few have full-time knowledgeable health medical reporters. The outcome of the foregoing drawbacks is that patients are often confused and are not sure how the latest advances apply to them. They often flood their doctor’s clinics with ‘false alarms’. As a result, the media loses credibility, so that they often end up performing a disservice to patients and their doctors. Because the public is eager, for any scrap of medical news, the media often reports individual studies out of context, as if each study could stand alone. However, single studies rarely yield a simple ‘yes’ or ‘no’ answer to a medical question. One ought to realize that scientific discovery is a process that often takes years to unfold. In a sense, medical researchers are weaving a large tapestry that will eventually tell a complex story when one stands back to look at the whole picture. An individual medical study can only contribute a small strand to the overall fabric. While the findings of individual studies may even seem to contradict one another, evidence accumulates gradually from scores of such studies. A coherent picture emerges slowly over time, and only then can we make definitive recommendations. One way of solving the problem arising due to misleading, inaccurate or piecemeal reporting on the medical front would be for newspapers or magazines to appoint medical doctors as consultants on their editorial panel, who can be used as a sounding board to assess the reliability and validity of a medical story. Also, as the media realizes the importance of health stories, hopefully, we will soon have full-time reporters who specialize in covering health stories exclusively. Till then, what can you do to separate the wheat from the chaff ? First of all, identify the source. Does the information come from a reputed publication (such as The Lancet) or a leading medical professional organisation (such as the American Heart Association)? Not that such identification can guarantee its reliability or trustworthiness either, but it helps to know that the information is coming from a respected and respectable source. At the other extreme of unreliability is information from a commercial source, or from an Internet newsgroup!

Second, look beyond the statistics. When reports hurl at you statistics like ‘a 30 per cent increase’ or phrases such as ‘a 50 per cent higher risk ,’ take a closer look at the exact numbers. Many of us get ‘turned off’ by numbers, but this attitude can prove dangerous: you need to ask yourself what the numbers really mean and how they apply to you? Benjamin Disraeli once remarked that there are three kinds of lies: lies, damned lies and statistics. Remember that statistical methods are simply tools, and they can produce blatantly wrong conclusions unless sensibly used. One common way in which statistics can be misleading pertains to reporting of relative and absolute risk. A headline that screams ‘X Doubles the Risk of Y’ is way off target if your chance of contracting ‘Y’ is one in a million to begin with. Doubling the risk of ‘Y’ only makes it two in a million! The relative risk (doubled) is nothing to worry about if the absolute risk (an increase from one to two in a million) is tiny. Third, scrutinize the results. Does this information reveal a direct cause-and-effect relation between two factors? Or is it merely an association? For example, someone could argue there’s an association between matches and lung cancer because matches light the tobacco that causes lung cancer. But common sense would tell you that lighted matches don’t cause lung cancer. Typically, years of consecutive studies are required to prove a cause-and-effect relation and the results of one study usually don’t provide enough proof. If just one medical study has documented an unusual or peculiar finding, and if the results have never been replicated by any other study, then this situation suggests that the study is not reliable! None of us wants to become a medical researcher, but it does help to know a little bit about the various types of medical research as well as their limits. Basically, medical studies can belong to three categories: (1) Laboratory experiments; (2) epidemiological research; and (3) clinical trials. Laboratory experiments can be carried out in test tubes or on animals such as mice, rabbits or guinea pigs. Results obtained from animal trials should never be applied directly to humans for several reasons. For starters, of course, people are not lab animals. Also, mice and other small creatures are not naturally subject to many of the common ailments that afflict humans; therefore, scientists have to alter them genetically or physiologically to create animal ‘models’ for human diseases. The results of such studies are interesting and useful

to scientists, and often pave the way for important advances, but they donâ&#x20AC;&#x2122;t tell doctors which medicines to prescribe for people. In epidemiological research; scientists closely study a large group of people and then collate their findings. Next, they extrapolate these findings to the general population . Because such a study is observational, it is a fairly useful method to uncover possible risk factors but it can never actually prove a cause-and-effect relation, because the interactions between humans and the environment are extremely complex. In contrast to epidemiological studies, which scrutinize the complexity of real-life cases, clinical trials provide a systematic way of testing the effects of one particular factor, such as a drug, under tightly controlled circumstances. Clinical trials, which are experiments performed on people, are thus the most reliable of the three categories, because they compare two carefully controlled groups of people. However, remember that these trials have their own limitations as well. Often, the process of reading the original research study in a medical journal can be an intimidating task. However, editorials in the journal help place things in proper perspective. Also, review articles can help provide a broad overview of the research and its importance. Consumer health magazines also help demystify some of the research by providing understandable commentary. One important safeguard against imperfect or flawed scientific reporting is peer review; i.e., scientists scrutinize each other's work in advance. Almost all well-respected scientific journals rely on peer review to select papers for publication. Any study that has not undergone peer review should be regarded with the utmost scepticism. For example, one should be wary of findings announced at a press conference that are not accompanied by publication in a journal or by a presentation at a scientific forum. At the same time, it's also true that peer review is no guarantee by itself that a study is reliable. For example, expert reviewers have no way of knowing if an investigator has falsified the data in an article. And even if a study is well-designed and scientifically valid, it may have absolutely no relevance to most people. The next crucial question is: how do you apply what you have learnt? Let's imagine for a moment that you've read a report about a new clinical trial and all the signs appear encouraging: its results confirm conclusions drawn from similar trials and the experts seem to agree that it has been well designed and has generated valid

information. Now comes the difficult part: how can you use these new findings to improve your own health? Initially, ask some basic questions: How likely am I to get this disease in the first place? Were the symptoms of the participants in the study at all similar to mine? Because perspective on depth is so often missing from news reports, some people focus on the latest details at the expense of the big picture. You should ideally follow the dictum: Be quick to question, but slow to change. Moreover, if the ‘new’ information is in conflict with ‘conventional wisdom’, you should regard it warily. Trying to heed all the advice all the time can prove overwhelming and disconcerting. You should evaluate your individual risk profile, based On your lifestyle and family history, and then make appropriate changes that will give you the highest returns for your effort. If a news report raises nagging doubts in your mind about your treatment , diet or lifestyle, make it a point to ask your doctor whether or not the report applies to you. However, most of the time you simply need to rely on your common sense. After all, it's rather silly to worry about having missed one's daily quota of beta- carotene supplement while smoking the twentieth cigarette of the day !

Chapter 3 How You Can Give Your Baby a Head Start in Life Take care to be born well. George Bernard Shaw We are all familiar with the adage: ‘Be good to your baby before it is born’. This aphorism serves to emphasis the importance of medical care during pregnancy (known as antenatal care). However, in reality, the best time to start taking care of your unborn baby is even before you conceive! Such care is called pre-pregnancy or preconception care. Why is this care so important? Remember, that the foetal organs are actively developing during first 12 weeks of pregnancy (this crucial period is called ‘organogenesis’.) The embryo is highly susceptible to external insults during this time, so that any damage can lead to crippling birth defects. The beauty about pre-pregnancy care is that it is so simple: all that is involved is visiting your doctor before you are planning to get pregnant, rather than after you've missed your menstrual period! The doctor normally undertakes the following procedures: (1) takes a medical history; (2) carries out a physical examination; and (3) performs some simple laboratory tests. These procedures are inexpensive and easy to conduct and signify examples of preventive medicine at its best! Pre-pregnancy care also leads to other benefits. For instance, it allows the doctor (duly assisted by you) to identify problems and rectify them. If, on the other hand, these problems were to be spotted only after you became pregnant, detailed testing can become very difficult, because the very presence of the delicate embryo, can impede testing. The harsh reality is that not all problems are preventable, but you can, nevertheless, increase your chances of having a healthy baby by identifying the risks you face and trying to eliminate them, if possible. After all, most doctors go in for a battery of tests before performing major surgery, to make sure that the patient is healthy enough to withstand the stress generated by the operation and the anesthesia. Pregnancy can also stress the body, and it is important

to screen the woman for potential problems before she embarks on one of the most important journeys she will ever make! The most important precaution to be taken is to ensure a regular intake of a vitamin called folic acid. Folic acid greatly reduces the chances of your baby being born with spina bifida (a developmental anomaly affecting the spinal cord) or anencephaly (without a brain) if taken before you become pregnant and during the first six weeks of pregnancy. This vitamin is now routinely prescribed in many countries in the West to prevent many birth defects. Most women are aware of the importance of regular medical care during pregnancy and you should plan to register with a reliable obstetrician as soon as you find out that you are pregnant. This ensuing pre-natal care will then simply be an extension of your prepregnancy care. While modern obstetric care can ensure that pregnancy and childbirth are very safe for both mother and baby, unfortunately, today doctors have ‘medicalized’ pregnancy to such an extent that what is otherwise a normal event has been converted to one which needs rigorous and frequent medical assistance. Every mother naturally wants a normal baby, and technology can be very useful in reassuring her that all is well. However, it's easy to misuse technology. One particularly disturbing trend stems from the fact that many obstetricians nowadays overuse medical technology; such overuse can often prove detrimental to both the mother and the baby. Common tests which are misused include: blood tests for TORCH (Toxoplasmosis, Rubella, Cytomegalovirus; Herpes) infections; ultrasound scans; and foetal monitoring. Another area of misuse relates to the tests available for screening the baby for a possible birth defect. Many doctors routinely subject their patients to a ‘triple test’ during the pregnancy to screen for birth defects. While this is an easy test (it’s a simple blood test which measures the levels of 3 hormones in the blood) to carry out unfortunately, it has still not been standardized for Indian women. Such a drawback leads to a large number of tests yielding abnormal results, even though the babies are completely normal. An ‘abnormal’ result creates a lot of anxiety - and then the doctor needs to perform a battery of other tests to confirm that the baby is, in fact, normal to reassure the mother. The second tier of tests can be expensive, and risky as well, because some of them can cause the mother to miscarry. Thus, it is not uncommon for a mother to lose a healthy baby because of a test which was not really required in the first place!

The foetal monitoring procedure has also been overused over the past few years. While this procedure was initially designed to serve as a tool to monitor the well-being of the foetus and to help reduce the need for medical intervention, today it is often used to justify an LSCS (Caesarean section) in order to forcibly take out a baby ‘in foetal distress’! A much simpler alternative would be to opt for ‘kick counts’, a procedure in which the mother simply keeps track of how often her baby moves in a given time period — a baby which moves actively is sure to be healthy! Antenatal classes conducted by medical or paramedical professionals can be very helpful. Here, you not only to learn a lot about pregnancy and childbirth, but also you get an opportunity to interact with other women in various stages of their pregnancy. The friendships developed during this period can be very supportive and helpful! Despite tremendous advances in medical science, labour and childbirth are still events which many women dread. Moreover, the rituals associated with childbirth in hospitals have unfortunately been designed for the doctor's convenience, rather than the patients'! In this context, the harmful practises include: forced induction of labour; routine use of enemas and intravenous drips, foetal monitoring, making the patient lie down (rather than allowing her to walk about) — it's a long list! Don't let the hospital/clinic staff patronize you — you need to assert your rights! It's very useful to draw up a birth plan (which includes things you will allow and those you won't ) and make sure your doctor agrees with the procedures. The presence of a doula (birth assistant) has been proven to be you very helpful for women in labour. Also, should encourage your husband to participate in this adventure as actively as possible ! Yet another minus point pertains to the application of anaesthesia for pain relief, which has become the norm nowadays. We have mindlessly aped this Western ‘advance’, much to the detriment of both the mother and the child. While techniques for pain relief a valuable resource, can be they should be used only when absolutely necessary. We are witnessing a virtual epidemic of Ceasarean sections today. Whereas a CS once used to be the method of last resort to deliver the baby, it has at present, tragically, become the norm in some hospitals, accounting for 50 per cent of all births. The reason, of course, is obvious: a CS is financially much more lucrative to the doctor than a normal delivery. As a senior obstetrician wryly put it: ‘The only

indication for a normal delivery today seems to be if a patient delivers before the doctor reaches the hospital!’ The alarming spurt in CS has taken on the dimensions of a major scandal today, which needs to be tackled actively. What steps can you take if you don't want to end up as another statistic? It would be a prudent idea to find out the rates your doctor charges for a CS and for a normal birth. You can also ask him what proportion of his patients successfully delivers normally. Other patients in the clinic, as well as the hospital nursing staff, can prove to be valuable sources of information, which you should effectively tap to alert you to a “knifehappy” obstetrician, from whom you need to stay away! A significant recent development is that many women in the West are turning back to natural childbirth once again, often either at home or what are known as ‘birthing centres’. In other words, they would like to keep as far away from a hospital as possible! Despite the fact many doctors scare women into believing that the hospital is the safest place to deliver a baby, recent international studies have shown that the home is often much safer and much more congenial for normal births. For example, Holland, where over 60 per cent of births occur at home, under the supervision of midwives, can justifiably boast of having one of the world's lowest neonatal mortality rates! The midwifery model seeks to remind women that childbirth is a natural process for healthy women and women need to learn (or rather, relearn!) to trust their bodies! There are several ‘dos’ and ‘don'ts during labour and birth; for instance: Do walk around. Do learn to manage your labour pains without resorting to unnecessary medication. Do ask to hold your baby as soon after birth as possible, so that you start immediate bonding. Do ask that your baby be allowed to remain with you. Do leave hospital as soon as possible (in 2-3 days). Do have your husband with you. Do have a doula (birth assistant) with you . Do use pain relief medications very sparingly. On the other hand:

Don't take an enema. Don't lie in bed constantly. Don't allow an episiotomy (i.e., surgical incision into the perineum and vagina). Don't allow the doctor or other medical staff to cut the umbilical cord, until it stops pulsating. Don't allow them to start an IV drip, routinely. Don't allow them to take your baby away. Don't allow them to give the baby top feeds (i.e., food other than motherâ&#x20AC;&#x2122;s milk). The last point needs a little elucidation. While everyone knows that breast milk is best for baby, unfortunately, many mothers still persist in giving their babies manufactured products. Why not give your baby â&#x20AC;&#x2DC;the real thingâ&#x20AC;&#x2122;, rather than a substitute ? It's a shame that most women who would never dream of wearing imitation jewellery don't mind feeding their babies an imitation substitute! TIPS FOR A HEALTHY PREGNANCY The following pointers would prove useful during your pregnancy. 1. Learn as much as possible about the wonderful ways in which your body is changing and about how your baby is growing. Talk to your mother, your friends, and other women about pregnancy, labour and birth. Attend pregnancy-related classes, read the relevant books, and watch videos about normal pregnancy and childbirth. 2. Eat a well-balanced diet and drink lots of water. 3. Avoid substances that may be dangerous for you and your baby such as cigarettes, alcohol and street drugs. Do not take any medications, even over-the-counter varieties, unless you have discussed them with your doctor and taken his approval. 4. Remain active! Continue with the exercise programmes that you were following before you became pregnant, modified, if needed, according to the recommendations of your doctor. If you were not exercising at all before becoming pregnant, consider going in for walking or swimming. Start with short periods of exercise, and gradually increase the amount of time.

5. Get plenty of rest. Listen to your body to determine if you need short breaks during the day as well as to determine how many hours of sleep you need at night. 6. Talk to your baby and enjoy your growing bond with him. Research now shows that babies can react to the sense of touch as early as ten weeks of pregnancy! A little later, they can react to light, your voice, music, and other sounds. 7. Try to minimize the stress in your life by practising stress management techniques such as slow and deep breathing, yoga and relaxing various muscle groups when you feel stressed. 8. Plan your baby's birth. For most women, the process is normal, natural, and healthy. 9. Enjoy this special time in your life! Your husband and, your family and friends can help you make the most of this wonderful transition. Have confidence in your body's ability to grow, nourish, and give birth to this baby just as women have done for centuries. 10. During pregnancy, many women are highly motivated to remain as healthy as possible, so that they can give their baby the best start in life. Pregnancy is an excellent opportunity to develop good health habits; you can use these habits to keep yourself healthy for the rest of your life!

Chapter 4 Medical Care for Your Offspring: No Childâ&#x20AC;&#x2122;s Play A smart mother often makes a better diagnosis than a poor doctor. August Bier Nowadays, many mothers prefer to select a childrenâ&#x20AC;&#x2122;s doctor (pediatrician) even before childbirth, in order to ensure that he is around when the child is born! Your pediatrician plays an important role in making sure that your baby remains healthy in the first year of his life, and will provide routine baby care, by examining your baby every few weeks, to make sure he is growing well and has taken his immunization shots on schedule. As your child grows older, it is a good idea to continue with the same pediatrician, with whom you can get in touch in case any worries assail you. There are going to be numerous occasions when uncertainties and anxieties grip you, especially if itâ&#x20AC;&#x2122;s your first baby, and having a doctor who is familiar with your child can be very reassuring when he develops a fever or a cough. Nevertheless, remember to trust your own common sense and instinct. As a mother, you are final expert as far your baby is concerned and you are much more likely to be able to sense when your child is ill (or when he is getting better) than a doctor. The trouble today is that many of us have become so dependent upon the doctor that we do not heed our own gut feelings. Most children dread going to the doctor with good reason; after all, most of us still associate the doctor with painful jabs and awful tasting medicines! When you are on the lookout for a pediatrician, remember that a good doctor can do a lot to put your child at ease. A pediatrician should be unhurried and be willing to spend plenty of time with you and your child (and often it is the mother who needs reassurance more than the child needs treatment!). A good doctor will talk and play with your infant or toddler when he is on your lap, before he even attempts to conduct an examination. After all, your baby is reluctant to leave the comfort of your arms, and will regard the examining table with puzzlement and fear. Therefore, many doctors will examine your baby

when he feels safe and secure in your lap. They also give out lollipops and speak to kids in baby talk to calm them down. A good doctor will always approach kids in such a manner that he is on the same eye level as the little patient, rather than standing over the child. Another strategy many doctors adopt is to let children play an active role in the examination. Whether it's looking into mummy's ears or listening to daddy's heart, being proactive allows them to understand they're at the doctor's clinic for help, not to get hurt. Some pediatricians even keep toy doctor kits on hand, complete with bandages and plastic stethoscopes. Others give away stickers ‘for being such a brave little girl’ at the end of a visit! Distractions such as toys are very helpful, and many pediatricians remark an entire corner in the waiting room for children’s rattles, minibeads and building blocks, so that they feel more at home! The unknown probably holds the biggest fear for most children. A lot of kids associate going to the doctor with a needle. A good doctor should be able to reassure the child (only when it is completely true , of course ! ) that there are not going to be any 'ouches' or anything that hurts. You can find out what it is that makes your child most relaxed by simply asking. For example, if he says he needs his favorite stuffed toy to make him feel brave, then bringing it to the doctor's office would be an enormous help. Remember that in the long run, your child's positive attitude toward his health can start with happy experiences at the doctor's. Sometimes, your child may be sick enough to need hospitalization. Remember that hospitalization can be a scary experience even for adults, so that it's likely to be even worse for children. If you think about it from a child's perspective, a stay at a hospital can be scary and confusing! "Is the stretcher going to stretch me?" "Is the IV like the plant that covers up buildings? "Some of your child's misunderstandings might seem humorous, but they probably indicate serious anxiety about entering the hospital. Children commonly wonder: Will it hurt? Will mom or dad be with me? Will I get better? Is it my fault? When can I go home? Why don't my friends have to go to the hospital? For many children, a hospital stay often represents their first night in an unfamiliar setting, away from the comfortable surroundings of home. Before arriving at the hospital, talk with your child about what to expect and why hospitalization is necessary. Be confident , honest and serene. Accurate information — given in a way that child a can

understand — is the best way to reassure and calm your child. If you tell him that a procedure will not hurt and then it does, you stand to lose credibility and he may not trust you again. It is unfortunately a fact of life that medical procedures can be painful. However, they are often necessary in order to help your child recover, and if your child can be reassured so that he cooperates in his care (rather than fights it), this can help to improve the care he receives, that would lead to optimum benefit as a result of for their medical care. Parents who remain calm help their children feel calm. If you don't know what is happening with regard your child's care, ask a doctor or nurse to explain the details to you. Remember that families are members of the health-care team, and that you, as a parent, are the expert on your child ! Try to understand your child's feelings — put yourself in his shoes! Younger children might need reassurance that hospitalization is not a form of punishment for something they did. It's not uncommon for children to act younger than their age (such as by wetting the bed or sucking their thumbs) before, during or after a hospital stay. Your child fears are often age – specific, and toddlers don't worry on this count; most children return to normal very soon. Worry about being separated from parents; school-going children are more concerned about being different from their peers, while teenagers have a greater need for privacy and independence. Admission to the hospital early in the morning, immediately before the planned procedure or surgery, is common, but this step affords little time for a child to adjust to the new environment. Ask the authorities if your child can visit the hospital a day or two before scheduled surgery to help him understand what will happen. All children should be told ahead of time what to expect, but very young children may not possess a clear concept of time, such as tomorrow or next week, so that a review of what is going to happen, just before it occurs, can help children overcome their fears. Children often demonstrate their understanding of the world through the medium of play. You may get an opportunity to reassure your child if you observe misconceptions about the hospital in his play. Many progressive hospitals offer children a playroom, so that they can relax, even when they are in hospital. Some hospitals even allow them to tour a ‘mock’ operation theatre; and wear nurses' uniforms and doctors’ masks, so that they are more comfortable in a hospital setting. After hospitalization, play can be a very beneficial way for young children to make sense of their experiences. Reading aloud children's

stories about hospitals before and after your child's stay also can be helpful. Most hospitals encourage parents or close relatives to stay overnight with their child. A parent or family member can provide security in the unfamiliar and somewhat disorienting world of the hospital. Stay with younger children, especially, as much as possible. If you need to leave, it is best to be factual with your child about where you will be, why you need to go, and when you plan to return. Remember that you can help doctors and nurses do their job more competently by observing and reporting your child's symptoms accurately. It helps to prepare in advance by writing down your questions and observations. A child in hospital can feel comforted if you bring along a few treasures such as favourite dolls, stuffed animals, security blankets or family pictures. These items provide a connection to home. School homework may not be a ‘treasure,’ but if your child is able to work on class assignments at the hospital, the process can ease the transition back to school. Hospitalized children are usually gripped by three main fears: (1) fear of pain; (2) fear of the unknown; and (3) fear of separation. While hospital personnel and the child's immediate family can help dispel the first two fears, visitors can help allay the fear of separation. For older children and, especially for teenagers, visits from their friends can be really important because, at that age, peers may be as important as family. Request visitors to behave the way they normally do with the child – there is no need for them to change their behavior just because he is in hospital. Don't discuss the child's situation with other adults in front of the child as if he or she weren't present — either include the child in the conversation, or go and talk elsewhere. Although a hospital stay can be frightening, well-prepared children often show remarkable courage. Remember that children are very resilient, and can bounce back to health rapidly!

Chapter 5 Growing Old, But Keeping Fit Growing old is a bad habit which a busy man has no time to form. Andre Maurois. Most people are scared, indeed, terrified of old age because they feel that aging is characterized by a progressive loss of essential body functions that they have learnt to take for granted over the years; for instance, loss of vision, hearing, teeth, memory, intelligence, sexual drive, muscle strength and vigour. However, it needs to be emphasized that you can become old healthily; remember that old age does not necessarily mean progressive deterioration or susceptibility to a plethora of ailments! The best way to live to a ripe old age entails possessing the right genes. In other words, if your parents and grandparents have led long lives, you are likely to do so too! However, the fact remains that while you cannot choose your parents, you can, nevertheless, increase the chances of your growing old healthily! Despite the advertised claims to the contrary, there is no fountain of youth or magic potion that can prevent the process of aging. And no one has still answered the key question: why do we grow old? According to a popular theory, free radicals damage cells, tissues and organs progressively and as we age the bodyâ&#x20AC;&#x2122;s ability to neutralize such damages wanes. In this context, it is useful to bear in mind that anti-oxidants are natural substances that fight these harmful free radicals. Some recent studies have indicated that anti-oxidants may help prevent heart disease, some cancers, cataracts, and other ailments that are more common among older people. Among the antioxidants available in food are vitamins C and E and beta-carotene which is why most experts recommend five servings of fruits and vegetables a day. Presently, research is being conducted to test the anti-aging effects of human growth hormones, DHEA (Dehydroepiandrosterone), and other hormones, such as testosterone and estrogen. However, itâ&#x20AC;&#x2122;s too early to ascertain whether or not any of these hormones will be effective. The fact remains that there is still no known drug, pill, or

treatment that has been proven to reverse the aging process or to extend life. However, the good news is that there is solid evidence to prove that adopting a healthy lifestyle can both lengthen and improve the quality of an individualâ&#x20AC;&#x2122;s later years. TIPS FOR HEALTHY AGING The following points should be borne in mind: 1. Ensure a balanced diet, including five helpings of fruits and vegetables a day. 2. Exercise regularly. However, check with your doctor before starting an exercise programme. 3. Go in for regular health check-ups. 4. Donâ&#x20AC;&#x2122;t ever smoke. If you have picked up the habit, itâ&#x20AC;&#x2122;s never too late to stop. 5. Practice safety habits at home to prevent falls and fractures. Always wear your seatbelt while driving a vehicle. 6. Stay in touch with family and friends. Remain active through work and play and interact regularly with other members of the community. 7. If you drink alcohol, moderation is the keyword. Let someone else drive the vehicle after each of your drinking bouts! 8. Adopt and maintain a positive attitude towards life. Do things that make you happy. Since it's extremely difficult to change the habits of a lifetime overnight, it would be highly beneficial to develop good habits right from childhood. Such habits are likely to pay you rich dividends in the future, so that you can be playing golf while your contemporaries are ailing in hospital beds! Fortunately, aging doesn't have to be a downhill slides and gaining adequate knowledge about changing body patterns over time can help you age the healthy way. Older people have the reputation of being more mature, experienced and thoughtful. Whether or not you become wiser as you grow older, you are likely to become farsighted for sure ! Farsightedness ( presbyopia ) is a change in vision that's a normal part of aging. Presbyopia is caused by a gradual hardening of the eye's lens, which impairs your ability to see up close. Your optometrist may recommend a pair of non-prescription reading glasses or prescribe bifocals for you.

Staying active is a terrific way to stave off the negative effects of aging because it helps your body maintain, improve and even repair itself. Physical activity increases flexibility, lowers blood pressure, strengthens bones, slows down the process of osteoporosis, and promotes weight loss. The remarkable aspect about getting fit is that it's never too late to start. Fifteen to 30 minutes of exercise, with a warm-up and a cool-down, three or four times a week, would be ideal. Remember to start out slowly, exercising for about five to ten minutes twice a week, and gradually build up to a higher level of activity. Choose an activity that you'll enjoy, and try to get a friend to accompany you. Brisk walking, swimming and yoga are just a few of the options. Before starting your regular exercise regimen, please check with your doctor about possible complications or risks. Ensuring a healthy diet pattern is also very important. Middle-aged individuals need to increase their intake of certain vitamins, such as D and B6, while also simultaneously reducing the number of calories they consume. Bodily changes caused by aging, combined with reduced physical activity, could lead to a situation when you may gain weight more easily in your 50s than you did in your younger years. Be that as it may, that excess weight contributes to health problems more often in older people, including diabetes, heart disease and high blood pressure. Contrary to popular opinion, most senior citizens want to enjoy active, and satisfying sex lives. The natural process of aging does entail physical changes that can sometimes adversely affect sexual intimacy and your capabilities during intercourse. Women may experience discomfort during sex because their vagina becomes drier and more fragile. As they get older, men often notice differences in their erection patterns, and it may take them longer to achieve an erection and to sustain it. Also, the erection may not be as firm or as large as during their younger years. Anxiety and depression, which often accompany a chronic illness can also interfere with your libido. A strong support system is an important aspect of good health, and seniors can benefit greatly by being socially active. Community organisations, clubs and religious places such as churches and temples are ideal meeting points for elderly people to socialize and to make friends. Continue to remain productive, whatever be your field of activity; this is good for your self-esteem. Even if you have retired from your job, you can contribute your time and skills in many ways: for example,

by volunteering for social service organisations; or teaching part-time in any educational institution. You could also learn new skills (such as a painting or becoming computer literate). The ultimate objective is to keep your brain active ! The twilight years are also likely to lead to an unfortunate increase in illnesses, accompanied by the additional burden of unwelcome medical bills and the fear of dying and death. As the body ages, biological systems start failing gradually, and one starts developing an assortment of medical problems. Consequently, older patients often have special health care needs. It is not uncommon for many older patients to suffer from multiple medical complications: for example, diabetes, hypertension and ischaemic heart disease often go hand in hand. Such a situation also means that they will need to be subjected to multiple medications; and perhaps consult many different doctors as well! Thus, while their care pattern becomes more complex, it also becomes more fragmented! In fact, geriatric medicine has attained the status of a specialty in its own right in many parts of the world, in order to take care of the medical needs of an aging population. Most old people face a lot of difficulty in taking care of their own needs, because of persistent problems such as deteriorating hearing, failing vision, and decreasing memory. Many of them tend to be afraid of becoming dependent on others as they lose control over their bodily functions. Others dread becoming disabled and being confined to a wheelchair or bed. Instances of abuse and neglect of old people are becoming increasingly prevalent, as the joint family structure is breaking down in urban India. As a result, homes for the aged are becoming increasingly popular in India, so that older people can live together and support each other, when their own families are no longer willing to do so. Remember that illness and aging need not go hand in hand. If you take good care of your body in the ‘morning’, it will take good care of you in the ‘evening’ of your life.

Chapter 6 Caregiving: Taking Care of Elders We need to learn to take as good care of our parents in their second childhood as they took of us in our parents in their second childhood as they took of us in our first childhood. Thanks to the rapid advances in the field of medicine, more and more people live to a ripe old age, it is increasingly likely that you will be taking care of older relatives at home. While this has always been a traditional practice in the joint Indian family, caregiving can prove to be quite a burden in the modern Indian city. Caregiving refers to a wide range of involvement â&#x20AC;&#x201D; everything, from checking in on your relatives every day at their places of residence to providing round-theclock care for your parents in your own home. Entering into a caregiving relationship offers a valuable chance to reconnect with someone for whom you care deeply. But as this person ages and becomes more infirm and demanding with each passing day the relationship can become increasingly stressful and, at times, acrimonious. Also, ambivalent or unhappy feelings from the past can re-emerge and cause pain and bitterness, unless you work through them positively. If youâ&#x20AC;&#x2122;re trying to shoulder the burden all alone, the frustrations may overwhelm you. An amicable situation can turn sour and, in some cases, mistreatment or abuse of the older person could be the tragic result. As testimony to this disquieting but indisputable reality, the media is reporting more and more cases of abuse and neglect of the elderly in India. Many parents have even been forced to commit suicide when they have got fed up of the ill-treatment they have received. To sidestep an unpleasant situation and to ensure that you handle caregiving as successfully as possible, you should go in for a little thought, education and preplanning. To start with, hold a family session when your parents are well. Talk about the future, and what they would like you to do for them in case they fall stick. Involve your brothers and sisters in the discussion and hold it in a positive atmosphere. Although talking about old age and

impending debility can be uncomfortable, and disconcerting, this could be the most positive approach in the long run. Consider covering the following areas: 1. Division of labour: Decide who will do what — in an unambiguous manner — when your parents need help. If one relative lives close by and decides to be the primary caregiver, it’s crucial that the other siblings play a supportive role. One should also find answers to the following important queries: Who will give the primary caregiver a break when he or she needs it? Who will help financially? Who will lend a sympathetic ear when the primary caregiver feels overwhelmed? 2. Money: To plan for the years ahead, you should know your parents’ financial resources. Such information helps you avoid the pitfalls of arranging for your parents to live beyond or below their means. If you’re the main caregiver, decide well ahead of time if you want financial compensation for your efforts. This attitude might seem very commercial , but may actually help in the long run! 3. Insurance: Make sure your parents have taken adequate medical insurance to cover their medical expenses. 4. Living will: This document puts into writing what medical measures your family member does and doesn’t want to be taken in the event of a terminal illness or condition. 5. Power of attorney: This legal document allows a designated person to make specified legal and financial decisions if your parent or elderly relative becomes unable to manage his or her affairs. Try to make your caregiving relationship as positive as possible, while, at the same time, being realistic. The relationship you had with your parent as a child doesn’t disappear, and if you had a friendly, easygoing rapport with your mother or father when you were younger, it’s likely to continue. However, if the relationship was subject to stresses, they may re-emerge. Also remember that prominent personality traits tend to become exaggerated as both of you grow older. Caring for an older adult is very different from caring for a child. With the passage of time older persons become more dependent on others, not less. On some days, the experience may feel like an emotional roller-coaster ride: you quickly move from pity and guilt to love and on to anger and frustration.

The following suggestions can help make you a better and more considerate caregiver: 1. Encourage independence: If it takes your father 10 minutes to button his shirt, so be it. The ‘I’ll-do-it-for-you’ attitude leads to work overload (for you) as well as increasing dependence and low selfesteem on the older person’s part. 2. Set limits: A highly dependent parent can be demanding. You should know your limits and learn how to refuse requests politely but firmly. You could say: ‘No, I’m too tired to go to the store today. We’ll go tomorrow.’ A failure on this count can lead to resentment and a feeling of being ill-treated on the part of the caregiver. 3. Make time for fun: Break the routine occasionally by inviting friends and other family members over to watch a funny movie or play cards. A little laughter and a bit of socialising can lift everyone’s spirits. 4. Encourage your parents to remain active: Also, motivate them to take part in community activities so that they have additional sources of support, and are not totally dependent on you. 5. Share the care: When your friends or relatives offer to help, accept it gladly and gratefully. 6. Take a break: This aspect is critical. You could risk your own health if you persevere for long periods without a break. Get someone to fill in for you as often and as long as needed. 7. Cancel guilt trips: You’re bound to experience anger and frustration, but don’t let these feelings make you feel guilty, they are normal. Your parents most probably felt the same way about you when you used to give them a hard time as a child ! 8. Stay active: Even though you may feel limited as far as time and freedom are concerned, do your best to keep your interests in a club or hobby alive. These activities will continue to enrich your life when your caregiving responsibilities are over. Being a caregiver does not mean that you have to give up your own rights! The following are included in a Caregiver’s Bill of Rights, as formulated by Dr. Virginia Flagg. A caregiver has the right to: 1. 2.

Honest communication with the patient, his/her friends, family, and other caregivers. Express opinions and suggestions when appropriate.

3. 4. 5. 6. 7. 8. 9.

Expect the patient to make as many decisions and put affairs in order as much as possible. Make reasonable requests of the patient. Take care of his/her own needs without guilt. Express emotions in front of the patient. Acknowledge his/her limitations and obtain assistance from outside resources. Continue maintaining relationships and activities outside the caregiving role. Not take responsibility for decisions and actions made by the patient.

With pragmatic planning, acquiring help from others and adhering to a commitment to devote time to yourself, you can emerge as a successful and happy caregiver. And don’t forget that you’ll be setting an example for your children, so that when it’s time for them to take care of you when you become old, they’ll do a good job too !

Chapter 7 Learning to Live well with a Chronic illness Illness is the night side of life. Sontag In some ways, living with chronic illness is very much like being trapped in a maze - you’re never quite certain what lies ahead of you; so, it’s easy to lose your perspective. You wander the same path over and over again - totally lost and bewildered. You appear to be alone with no one to show you the way out. There are many questions, but few answers. Which is the most effective treatment ? Who are the best doctors ? What options can be utilized so that the way out can be found ? You need to find your own path, and confronting your illness is a process that must be worked through . This process takes time and effort. If you live with a chronic condition, how you view the path you’re on and decide to manage your day-to-day situations can greatly affect your quality of your life. Acute vs. Chronic Most people are familiar with acute illness, such as appendicitis, typhoid fever or pneumonia, which comes on suddenly and often has an identifiable cause. Generally, such an illness is treatable. Often the individual regains normal health, and usually does not remain sick very long. On the other hand, a chronic illness often begins gradually and may have several causes. Also, rarely is a chronic illness cured, and it usually persists for an indefinite period of time. Diabetes, heart disease and arthritis are examples of chronic illness. Many factors can affect the course of a chronic illness, including heredity, lifestyle (e.g., stress, diet, exercise) and even environment. As a result, it’s difficult to predict how you may feel from one day to another. Restoring a sense of control

Many factors can affect the course of a chronic illness, including heredity, lifestyle (e.g., stress, diet, exercise) and even environment. As a result, it’s difficult to predict how you may feel from one day to another. The process of living well despite suffering from a chronic illness begins with understanding your illness. What you know about your condition can make a vast difference to how you approach each day. You can start by collecting information about our illness – and remember that there is a wealth of information out there ! (See Chapter 28). Another useful information tool both for you and your doctor is a medical diary. In this diary, keep track of your visits to the doctor, noting down meticulously when and why. In addition, maintain a list of treatments undertaken, along with the following details: side effects; copies of your test results; and a record of symptoms, their severity and possible triggers. This diary will not only serve as a useful record of your illness, but will also provide your doctor with valuable diagnostic clues, which may help him to tailoring your treatment appropriately. Many people also find that the very act of recording their feelings and emotions in a different section of the diary can be therapeutic as well, as it allows them to ventilate your feelings! Attitude by itself cannot cure a chronic illness, but cultivating a positive outlook and learning self-management techniques can make it much easier to live with. No matter what the ailment, confidence and determination will help you to maximize your health. Living well with a chronic illness often involves making important lifestyle adjustments. One of the first decisions to be taken is to consider how you should pace yourself. Adopting a moderate pace, maintaining a regular schedule and getting adequate rest and exercise can help you in managing your illness more effectively. Be wary of overextending yourself. Learn how to say “no.” It’s especially important to pace yourself properly on days when you feel energetic and may be tempted to overdo things. Other precautions or adjustments include the following : Taking medications regularly : Follow your doctor’s instructions carefully on how and when to take your medications. Stay in close contact with your doctor, especially when you start taking a new medicine, so that you can let him know how your symptoms are affected ; and what side effects you experience.

Eating properly : Depending on your illness, you may need to avoid some types of food and incorporate others in your diet. In addition, consult your doctor about determining a healthful weight and ways to achieve that objective. Exercising regularly : Appropriate exercise, as prescribed by your doctor, is a vital tool in managing chronic illness. Regular exercise can improve your strength and energy levels, as well as self-confidence. Such activity can also play a role in lessening the anxiety and depression, which is often associated with a chronic illness. Emotional ups and downs Living with chronic illness can give rise to a roller-coaster of emotions. There are several ways in which you can help even out the ups and downs: Maintain normal daily activities as best as you can. Stay in touch with friends and family. Continue to pursue the hobbies you enjoy without overexerting yourself. If your illness impairs your ability to perform activities that you enjoy, check with your doctor about possible ways to get around the obstacles. Keep in mind that your physical health can directly impact your mental health. Men may feel guilty about not being able to work, perform sexually, or provide for the family, while women may feel guilty about not being able to care for children or the husband. Negative emotions such as denial, anger and frustration are not uncommon when you learn life has dealt you something painful and unexpected. In addition, many chronic illness are associated with an increased risk of depression. Such a state of affairs does not mean a ‘failure to cope’ but may indicate a disruption in the body’s neurochemistry. Such as disruption can be rectified by appropriate medical treatment. At times, you may need more “tools” to deal with these negative emotions. Professionals, such as psychotherapists or psychologists, can

help you put things in perspective. They can also teach you coping skills, including relaxation techniques, that may be helpful. Sometimes, a support group is the best answer. Again. your doctor is the ideal person to suggest the best course in your specific case. Living with someone who’s chronically ill Nowadays, with longer life expectancy, chances are greater than ever that you will need to help in caring for someone who’s chronically ill. Remember that chronic illness affects whole families as well as the patient, especially if the illness is terminal. Family members may find themselves in unfamiliar or undesired roles, and providing 24-hour nursing care can prove to be a major burden. They can become isolated from social networks as they struggle to care for a sick loved one. Stress can break down close relationships, and a patient’s inability to take care of himself often causes guilt, shame or irritation. Indian society expects the spouse and children of the chronically ill to always be patient, kind, supportive and understanding – a tall order indeed! Interestingly, researchers have found that a spouse’s attitude affects the suffering of someone with a chronic illness. When the spouse is supportive, it is easier for the sufferer to be positive and optimistic. By contrast, those with critical spouses are more likely to feel hopelessly victimized by their illness. A families’ efforts to downplay the severity of an illness is likely to make the sick member worse, whereas openness, acceptance, and compassion have a positive effect. Here are some aspects on which you can focus as a caregiver to help make your role more manageable: Accept the reality that the chronic illness may not go away. Focus on the signs of well-being – such as activities and the person’s feelings rather than on just physical health. Be readily available and listen, emphasizing positive changes. Get involved together in productive, fun-filled activities to distract the patient from the illness. Encourage independence while maintaining as “normal” a family life as possible. Take care of yourself, and seek help when needed. Look for organizations that offer support for caregivers.

If you are a victim of a chronic illness, there’s no denying the fact that it affects your life adversely. But how much you allow it to determine the quality of your life depends, to some extent, on the way you choose to live one day to the next. It’s true that a chronic illness does not ‘go away’, but you can learn to cope with it and lead satisfying and a happy life!

Chapter 8 Self-Care: Handling Common Medical Problems at Home The aim of medicine is to prevent disease and prolong life; the ideal of medicine is to eliminate the need of a physician. William Mayo Not every medical problem that affects you should make you rush to your doctor. After all, most medical problems are minor and self-limited, and experts estimate that more than 80 per cent of them can be safely managed at home. You should constantly remember that your body possesses remarkable healing powers, and given enough time and tender loving care, it can ‘repair’ most ailments on its own! Home remedies, many of which have stood the test of time, have proved to be effective and helpful. Simple measures such as massage and compresses are helpful as well – use to learn them judiciously! Here are some practical and useful steps you can use in order to take care of common problems which affect most of us at some point of time or the other. These are based on guidelines suggested by the American Institute for preventive medicine. Note: When your symptoms fall under the “Call your Doctor “ heading, you should do just that: call your doctor for with. State the problem precisely and you can get relevant instructions. When your symptoms fall under the “Get Immediate Care For” heading, you should get help fast – the situation may be a medical emergency! COLDS Symptoms: Sneezing, runny or stuffy nose, sore throat, dry cough, low-grade fever. Self-Care Measures -

Take adequate rest if you have a fever. Drink lots of liquids.

Take an over- the 窶田ounter medicine (paracetamol and/ or aspirin) for relieving pain and/or fever. Use salt water drops for nasal decongestion. The procedure is as follows: Dissolve half a teaspoon of salt in one cup of warm water and put three to four drops into each nostril several times a day, using a clean medicine dropper. Use a vaporizer or a humidifier, if possible. Eat hot and spicy foods, which help in draining the mucus.

Call Your Doctor for -

Quick breathing, troubled breathing or wheezing A feeling of weakness or with loss of energy along with delirium A bad earache or swollen, painful neck glands Fever lasting more than three to four days or over 102ﾂｰ F. A sore throat that looks red or has white spots. A cough that brings up sputum of any color. Pain or swelling over your sinuses. COUGHS

Cough can be of two kinds: a dry cough, or one that brings up sputum ( productive) Self-Care Measures For coughs that bring up sputum: -

Drink plenty of liquids. Use a vaporizer. Take a shower. Take an over-the 窶田ounter guaiphenisen.

cough

medicine

that

contains

For coughs that are dry: -

Drink plenty of liquids, essentially hot beverages such as tea, milk or soup.

Suck on cough lozenges. Take an over-the-counter dextromethorphan.

cough

medicine

that

contains

Call Your Doctor For -

A cough that has started suddenly and lasts for one hour or more without stopping A cough afflicting a baby or small child that sounds like a whoop or sealâ&#x20AC;&#x2122;s bark (high pitched like a whistle), and if the baby or child develops a fever of 102Â° F or higher. Weight loss (for no apparent reason), feeling tired, and sweating a lot at night. Wheezing, shortness of breath, rapid breathing, and swelling of the abdomen, legs, and ankles. A cough with sputum of any colour. A cough lasting for more than two weeks.

Get Immediate Care for -

Very hard time breathing or if lips become purple. Chest pain that spreads to the neck, arm, or jaw. Fainting. Coughing up blood. Diarrhea

Watery, loose bowel movements passed many times a day. Measures for Self-Care -

Drink plenty of liquids; for example, lime juice, lassi (whipped up curds or buttermilk with salt or sugar), fruit juice and soft drinks (after releasing the fizz). Try an over-the-counter medication, such as Imodium or Lomotil, if your condition does not improve even after 12 hours. You may need to take a tablet after each bowel movement.

Once the diarrhea has subsided, you can eat small amounts of soft foods, such as cooked potatoes, yogurt (curds) and rice. If a small child (less than three years old) has diarrhoea, then start him on oral rehydration therapy. You can use rice kanji, the ORS solution available at the chemist’s, or make it up at home yourself (by adding eight teaspoons of sugar and a half a teaspoon of salt to a litre of water). Continue breastfeeding (or his regular food) – don’t starve him!

Call Your Doctor for -

Diarrhea that has lasted 48 hours or more. Diarrhea which entails bowel movements more than eight times a day in an infant or a chronically ill person. Diarrhea that has started only after taking medication (s).

Get Immediate Care for -

Dehydration (symptoms: passing very little or no urine, being very thirsty and lightheaded, dry skin that doesn’t spring back after being pinched, sunken eyes, and disorientation). Severe abdominal or rectal pain or blood in the stool. Fever

Elevated body temperature, usually over 100° F (by way of mouth) or over 101° F (by way of rectum). Measures for Self-Care -

Consume plenty of fluids. Take a sponge bath with warm water. Take an over-the-counter medicine (paracetamol) to reduce the fever. Don’t wear too many clothes or cover yourself with too many blankets.

Call Your Doctor for

Fever that is accompanied by: ear pain; sore throat; vomiting; diarrhea; abdominal pain; burning urinary pain, skin rashes or skin that has turned red and swollen or developed areas of pus. Fever that occurs in a baby less than six months old.

Get Immediate Care for -

Fever that occurs with rapid heartbeat, confusion, disorientation and loss of consciousness. Fever with stiff neck, headache, lethargy, nausea and vomiting. Fever accompanied by lightheadedness and shortness of breath Headaches

Tension headache: Pain or pressure in scalp, temples or back of the head; and tightness in neck and shoulders. Sinus headache: Pain behind the forehead and eyes; sinus congestion; and fever. Migraine headache: Severe throbbing pain which usually starts on one side of the head and may lead to nausea, vomiting; dizziness, increased sensitivity to light and noise and problems with vision, such as blind spots or flashing lights.

Measures for Self-care -

Take an over-the-counter medicine for reducing the pain as soon as possible. Donâ&#x20AC;&#x2122;t wait for the pain to become worse! Rest in a quiet, dark room with your eyes closed. Massage the base of your head with your thumbs. Take a warm bath or shower. Place a cold or warm washcloth, whichever feels better, over the area that aches. Or else, place an ice pack on the back or the top of the head. Try to relax. Meditation and yoga can help.

Call Your Doctor for -

Headaches that occur at the same time of day, week, or mouth.

A headache that starts after taking a newly prescribed medicine or an over-the-counter medicine.

Get Immediate Care for -

A serious head injury or loss of consciousness. A headache accompanied by pain in one eye, blurred vision, double vision, slurring of speech, mental confusion, personality change, or difficulty in moving arms or legs. A headache along with a stiff neck, fever, lethargy nausea and vomiting. Heartburn

Symptoms Pain or a burning in the chest after eating and/or after bending over or lying down. Also, belching and a burning feeling in the throat.

Measures for Self-Care -

Sit straight while eating. Sit up, stand up or walk after you have eaten. Don’t lie down! If heartburn bothers you at night, raise the head of the bed by 6 inches. Shed some kilos if are overweight. Don’t wear tight-fitting clothes. Eat small quantities. Limit your intake of alcohol. Limit the consumption of foods and beverages that contain gas, such as potatoes and such as soft drinks. Don’t eat or drink anything two to three hours before bedtime. Antacids, such as Tums, can help relieve heartburn. Don’t smoke at all. If you have to take medicines such as aspirin, ibuprofen, naproxen sodium, or medicines for arthritis, take them along with food.

Call your doctor for

Stools that are tar-like and black in colours. Pain that goes through to your back or gripping pain in the upper abdomen. Difficulty in swallowing. Heartburn that occurs frequently.

Get Immediate Care for -

Heartburn accompanied by a tightness or pain in the chest which spreads to the neck, jaw, or arm; a feeling of discomfort in the chest with sweating or shortness of breath, nausea and/or vomiting or uneven pulse or heartbeart. Heartburn leading to vomiting blood or what looks like coffee grounds. Low Back Pain

Symptoms Back pain can be sharp, dull, acute, or chronic.

Measures for Self-Care -

Take an over-the-counter medicine for relieving the pain, if needed. For the first 48 hours, apply a cold pack to the pain-afflicted area. Do this for five to ten minutes at a time, several times a day. After 48 hours, apply heat (e.g., hot water bottle, hot shower), several times a day. Continue your regular activities to the extent possible. Rest your back if you must, but donâ&#x20AC;&#x2122;t remain in bed for more than 2 to 3 days, even if your back hurts a lot.

Call Your Doctor for -

Pain that spreads down the legs and below the knee. Pain that is very intense, or has lasted five days or more.

Increased pain when you move, cough, sneeze, lift something, or strain. Loss of control over bladder or bowel. Sensation of pain, burning, or itching when you pass urine, or if urine turns bloody or cloudy. Fever or vomiting.

Get Immediate Care for -

Any serious injury affecting the neck, spine, or back. The onset of pain being sudden and starting with a “cracking” sound. Back pain accompanied by difficulty in breathing and lightheadedness.

Sore Throats Symptoms Mild to severe throat pain, with or without swollen neck glands. The inside of the throat and/or tonsils could turn bright red or could be marked by white spots. Measures for Self-Care -

Mix one-fourth teaspoon of salt in half a cup of warm water. Gargle every few hours with this mixture, preparing it afresh each time. Drink plenty of warm liquids, such as tea and soup. Don’t smoke at all. Avoid eating spicy or hot foods. Suck on a medicated lozenge frequently. Take an over-the-counter medicine for relieving the pain and/or fever.

Call Your Doctor for

Sore throat that occurs along with: fever; swollen, enlarged neck glands; headache; chest, or ear pain; bad breath; skin rashes; abdominal pain; vomiting; or discharge of dark urine. The back of the throat turning very red or developing white spots. A mild sore throat that lasts for more than two weeks.

Get Immediate Care for -

Extreme difficulty while breathing or if the lips turn purple. Inability to swallow your own saliva. Vomiting

Measures for Self-Care -

Don’t eat solid foods; don’t drink milk. Drink only clear liquids (such as clear soups or coconut water). Take small sips; i.e., drink only one to two ounces at a time. Suck on ice chips if nothing else will stay down. After you stop vomiting, continue with clear liquids. Gradually return to regular diet, but wait about 8 hours from the last time you vomited to eat solid foods. Start with foods that are easy to digest. Don’t smoke, don’t drink alcohol, and don’t take aspirin.

Call Your Doctor for -

Very severe stomach pain, which lasts for more than two hours. Yellow looking skin or if the whites or the eyes appear yellow. Vomiting which lasts for more than 12 hours (two to six hours for a small child) without subsiding.

Get Immediate Care for -

Vomiting caused by a serious head injury. Vomiting accompanied a stiff neck, fever, headache, and lethargy. Vomiting which is black or bloody.

Dehydration (symptoms: very little or no urine, extreme thirst; and lightheadedness; dry skin that doesnâ&#x20AC;&#x2122;t spring back after being pinched; sunken eyes; and confusion). Vomiting occurring after a mild blow or injury to the head. -

Sprains A sprain is an injury that causes a stretch or a tear in a ligament. Ligaments are strong bands of tissue that connect bones at the joint. Sprains may be classified as mild, moderate, or severe. Measures for Self-Care The general rule for treating sprains is R-I-C-E: R for rest. Rest the joint! Avoid activities that cause pain. If you have an ankle sprain or knee sprain you may need crutches. I for ice. Apply ice and cool the injury to avoid swelling and every 3 to 4 hours. Do this for 2 to 3 days or until the swelling goes away. The ice will help to numb the pain. C for compression. Tie an elastic crepe bandage around the injured joint to reduce the swelling and inflammation. E for elevation. The injured part should be elevated so that gravity helps the circulatory system to reduce the swelling. You can also take pain-killers to reduce the pain. Call Your Doctor For Symptoms of a severe sprain. If a mild sprain persists longer than 2 weeks. Pain, swelling or bruising worsens despite treatment. Get Immediate Care for Inability to move the limb or joint.

Chapter 9 How to Keep Fit While Travelling

Men travel faster now, but I do not know if they go to better things. Willa Cather Even healthy people may find that travelling can precipitate illness. Differences in food, climate and schedule, in addition to the possible stress of travel can make you more susceptible to illness. Here are some tips to help you stay healthy when you travel. BEFORE THE TRIP First of all, plan ahead. Get your medical and dental checkups done before your trip, so that any problems can be detected, and to relevant medicines can be taken along. Find out what your health insurance company will pay for if you need to consult a doctor while you're away. In case you are travelling abroad, you may need to obtain a special health insurance policy called an Overseas Mediclaim Insurance Policy. Carry adequate quantities of your regular medicines in their original containers, along with extra prescriptions for them. It would also be a good idea to carry a doctor's note, listing your medical diagnoses and the medicines you need to take. If you are going abroad, get this translated into local language (for example, French or German), if possible. Carry a spare pair of spectacles and an extra set of contact lenses, if needed. If you have medical disorders such as diabetes or epilepsy, wearing a medical information bracelet can provide lifesaving information in an emergency in a foreign country. Prepare and pack a simple first-aid kit in your suitcase. This kit should contain the following items: Your prescription medicines, in their original containers. Medicines for diarrhoea and an upset stomach. Obtain from your doctor a prescription for an antibiotic you can take in case you are struck by diarrhoea. Ensure that you have packed medicines such as loperamide and antacids. Cough and cold medicines, such as pseudoephedrine tablets and cough syrups. Pain-relieving medicines, such as acetaminophen, ibuprofen and aspirin. Decongestants and antihistamines for treating allergies. Go in for the varieties that donâ&#x20AC;&#x2122;t cause sleepiness or drowsiness.

Antibiotic ointments, adhesive bandages and hydrocortisone cream. Medicines for preventing motion sickness, such as dimenhydrinate and an anti-nausea drug such as promethazine. Scissores, tweezers, nail clippers, pocket knife, thermometer, torch and mirror. If you are travelling abroad, remember that medicines can be very expensive in the West! Also, many medicines are available only on prescription, which means you will need to spend additional money on a doctor’s consultation. Therefore, it’s far more prudent and much less expensive to carry all your medicines with you! If you are travelling with children or elders, you will need to take extra supplies to be able to meet their needs as well. WHILE YOU’RE TRAVELING The first precaution: Eat carefully! Traveler's diarrhoea can easily ruin a holiday! Steaming-hot, well-cooked food is usually the safest. Avoid eating foods from street vendors, unpasteurised dairy products, and raw or uncooked seafood. Peel the fruits yourself. Drink water only from commercially sealed bottles or else go in for carbonated beverages. Avoid using ice. Brush your teeth with bottled water. If you're going to a place where you could face an increased risk of mosquito-borne diseases, protect yourself well. Insect repellents that contain DEET(N, N-diethyl-metatoluamide) work the best. If possible, wear permethrin-coated clothing and use nets while you sleep. Sunburn can be hazard if you plan to spend a lot of time in the hot sun. Use a sun block with a sun protection factor (SPF) greater than 15 and reapply this lotion after swimming or sweating. If you are going trekking in the mountains, you should be aware of the risk of developing acute mountain sickness, which is caused by a lack of oxygen when travelling to higher elevations. This form of sickness usually occurs at an altitude: headache, fatigue, shortness of breath, nausea, poor appetite and inability to sleep. It can be prevented by gradually ascending over several days to give your body a chance to acclimatize to the higher altitudes. Jet lag is a major bane for air travellers. Adjusting to a new time zone can take up to a week and the more time zones you cross, the longer the adjustment period. Symptoms include daytime fatigue,

nighttime insomnia, headache and disorientation. Lengthy travel may upset your circadian rhythm which controls various body cycles, including the production of a hormone involved in sleep patterns (melatonin). One strategy to prevent jet-lag is to change your sleep time closer to the new time zone over a period of several days; adjust go-to-bed and get-up times appropriately, so that you will be only slightly out of sync when you arrive at your destination. Being forced to sit for long periods in an uncomfortable airplane seat just adds to your woes (unless you are flying executive class!). Simple tips to help you cope with the travails of intercontinental flight are as follows: Try to get good nightâ&#x20AC;&#x2122;s sleep just prior to departure. The dry air in aircraft causes dehydration. Therefore, drink plenty of fluids (non-alcoholic only!) to counter water loss. Water is better than coffee, tea or fruit juices. Alcohol is not only useless in combating dehydration, but also brings about a markedly greater intoxicating effect when consumed in the rarefield atmosphere of an airliner than it does at ground level. Blindfolds, earplugs, neck rests and blow-up pillows are all used in helping you get quality sleep while flying. Get as much exercise as you can in the plane; for instance, by walking up and down the aisle, standing for spells and performing small twisting and stretching exercises in your seat. All of these help reduce discomfort, especially the swelling of legs and feet. If possible, get off the plane at stopovers, and perform some exercises or take a walk. Motion sickness can pose a major problem for some people, especially on a ship, or on long car journeys. There are many effective products available to prevent and treat this problem (including prescription drugs such as cinnarizine and promethazine) and you should start taking them at least one hour before starting your journey. Recent studies have shown that ginger root may be as effective as drug treatment, and is associated with fewer sideeffects. AFTER YOUR TRIP

In case you do fall ill during your trip, or after you come back, donâ&#x20AC;&#x2122;t forget to let your doctor know about your journey, as this information can help him in making the correct diagnosis.

Chapter 9 How Not to Get “Quacked” He who asks is a fool for five minutes, but he who does not ask remains a fool forever. Chinese proverb All of us would like to become younger, sexier and thinner, and to live longer! Given these universal needs, it is hardly surprising that quackery flourishes all over the world. ‘Quackery’ is derived from the word quacksalver (a throwback to the days when travelling salesmen would boast about the healing powers of their salves). Since quacks quack, quackery’s paramount characteristic is hype and promotion rather than simply fraud, greed, or misinformation — though these qualities often go hand in hand ! Much quackery is involved in informing people that something is bad for them (such as food additives) and selling a substitute (such as ‘organic’ or ‘natural’ food). Quackery is also involved in misleading advertising of dietary supplements, homoeopathic products, ayurvedic medicines and some non-prescription drugs. In many such instances no individual ‘quack’ is involved — just deception by manufacturers and their advertising agencies. Remember that quackery is not an all-or-nothing phenomenon. Some products can be useful for some purposes, but worthless for others. For example, vitamin B 12 shots can be life-saving in cases of pernicious anemia, but giving them to ‘pep you up’ is a form of medical fraud. Similarly, while certain ayurvedic herbs can be very useful, often the mass-manufactured ayurvedic medicines available in chemists’ shops are completely useless, because they do not contain what they are supposed to! While there is no doubt that homoeopathic medicines can be helpful, the concept of a standard homoeopathic remedy for common illnesses such as headaches and colds flouts a basic homoeopathic principle, which states that remedies need to be tailor made for a particular person and only a skilled homoeopathic physician can identify the required medicines properly. Unproven methods are not necessarily quackery. Those consistent with scientific concepts may be considered to be experimental, but

legitimate practitioners do not go around promoting unproven procedures in the marketplace. Instead, they engage in responsible, properly designed research studies to prove or disprove their claims. Methods not compatible with established scientific concepts should be classified as nonsensical or disproven rather than experimental: for example, ‘fish cure’ for asthma which draws huge crowds to Hyderabad. Quackery can harm individuals in many ways. First, is the loss of a tremendous amount of money which patients invest in pursuing this treatment, and many unscrupulous practitioners can bleed patients and their relatives dry — a little at a time. (There is an old saying: “The highwayman demands ‘your money OR your life’, but quacks demand “your money AND your life!”) Also, many of the quack therapies can cause direct harm. It is a common misconception that ‘natural medicines’ have no harmful side- effects — but anything which can have an effect, by definition, also has the potential to cause harmful effects (after all, the desired effects of a medicine are what we call its therapeutic action and undesirable effects are labeled ‘side-effects’!). The indirect harm they cause can also be enormous: for example, patients may pursue ‘alternative medicine’ for treating their cancers and may deprive themselves of the opportunity of getting effective state-of-the-art medical treatment. Quackery flourishes even in the USA where people are much more sophisticated, and the US Food and Drug Administration (FDA) provides effective policing. Therefore, it is hardly surprising that in India this menace is rampant, and there are far more quacks than regular medical practitioners. Faith healing, for example, is an integral part of Indian traditions, especially in villages where educated priests take advantage of people’s ignorance and blind faith. Many of us believe that we are far more sophisticated than the illiterate villager, and are above falling prey to quacks, but we need to realise that modern health quacks are supersalesmen, who play on fear and cater to hope. Who amongst us has not clipped at least one ad or bought at least one product which promises to either make you grow more hair, make you a better lover, remove your wrinkles, make you lose flab, or improve your memory? While the cold scientific fact remains that there is not a single effective way of fulfilling the aforementioned claims, the fact that ads for these products are so prevalent obviously means they have a ready audience and are pulling in the bucks for their manufacturers!

How can you save yourself from being quacked? Here are some useful pointers by Dr. Stephen Barrett from his Quackwatch Web site (at http://www.quackwatch.com.) 1. Forget about ‘secret cures’. True scientists share their knowledge as part of the process of scientific development. Quacks often keep their methods secret to prevent others from decisively demonstrating that they don’t work. No one who actually discovered a cure would have reason to keep it secret. If a method works — specially for a serious disease — the discoverer would gain enormous fame, fortune and personal satisfaction by sharing the discovery with others. 2. Remember that quackery often garbs itself in a cloak of pseudoscientific respectability and its promoters often use scientific terms and quote (or misquote) from scientific references. Be equally wary of pseudo-medical jargon. Instead of offering to treat your disease, some quacks will promise to ‘detoxify’ your body, ‘balance’ its chemistry, release its ‘nerve energy’ or ‘bring it in harmony with nature’. The use of concepts that are impossible to measure or quantify enables success to be claimed even though nothing has actually been accomplished. 3. Ignore any practitioner who says that most diseases are caused by faulty nutrition or can be remedied by taking supplements. Although some diseases are related to diet, most are not. Moreover, in most cases where diet actually is a factor in a person’s health problem, the solution is not to take vitamins but to alter the diet. 4. Be wary of catchy anecdotes and testimonials. If someone claims to have been helped by an unorthodox remedy there is often a rational explanation. Most single episodes of disease which affect patients lead to recovery with the passage of time, and most chronic ailments (such as arthritis and psoriasis) are marked by symptomfree periods. Many people who give testimonials about recovery from cancer have undergone effective treatment as well as unorthodox treatment, but give credit to the latter. Some testimonials, of course, are complete fabrications! 5. Be skeptical of any product which claims to be effective against a wide range of unrelated diseases, particularly serious diseases. There is no such thing as a panacea or ‘cure-all’. 6. Ignore appeals to your vanity. One of quackery’s most powerful appeals is the suggestion to ‘think for yourself’ instead of following the collective wisdom of the scientific community. A similar appeal

is the idea that although a remedy has not been proven to work for other people, it still might work for you. Remember that all humans have the same anatomy and physiology, and scientific rules apply to all of us. 7. Don’t let desperation cloud your judgement! If you feel that your doctor isn’t doing enough to help you, or if you have been told that your condition is incurable and don’t wish to accept this fate without a struggle, don’t stray from scientific health care in a desperate attempt to find a solution. Instead, discuss your feelings with your doctor and consider a consultation with a recognized expert. The best way you can protect yourself from being taken for a ride, is to make sure you are well informed about your own body. The ‘take-home message’ is simple: if it sounds too good to be true, it probably isn’t !

Chapter 11 Alternative Medicine: Exploring Your Options The art of medicine consists of amusing the patient While nature cures the disease. Voltaire Modern medicine often inspires awe. The huge gleaming hospitals, expensive computerized equipment and sophisticated scanning machines appear very impressive and reassuring when you are afflicted by a disease. However, paradoxically, even though the effectiveness of medical technology has improved dramatically, more patients than ever before have become dissatisfied with their medical care today. This situation has resulted in a move towards 'alternative' medicine, which has become increasingly popular all over the world. Even in the United States of America (the bastion of high-tech scientific medicine), more than 50 per cent of the patients have consulted an alternative medicine practitioner, mainly because they were unhappy with modern medical care. There are many reasons for this unhappiness with modern medicine. Patients increasingly feel that medicine has become too commercial and that doctors are too busy to spend time with them. They are unhappy with the impersonal nature of modern medicine, especially when the doctor spends more time looking at their reports and scans, rather than with them. While it is true that patients need technology, they also need tender, loving care; after all, doctors need to look after not only their medical problems, but also their emotional needs! Moreover, while modern medicine excels in certain areas (such as complex surgery for the repair of birth defects and the use of antibiotics for serious infections), it has failed miserably in the areas of disease prevention and the management of the myriad chronic illness (such as diabetes, hypertension and heart disease) to which modern human beings are prone to, because of their lifestyle.

Alternative medicine, on the other hand, offers a markedly different perspective. Rather than focussing on a person’s medical problems in isolation, alternative medicine treats the patient as a whole; hence the popular term, holistic medicine. Doctors practicing alternative medicine sit down and talk to the patient; they touch and feel him and ask many questions. And such attention feels good, in refreshing contrast to the modern doctor who rarely has even 15 minutes to spend with the patient. (Often, tender loving care and personal attention are all that alternative medicine practitioners have to offer, but they offer it very well indeed !) There is no doubt of the efficacy of the placebo effect, and many ailments will get better when the patient has someone he can talk to. Also, the simple act of touching the patient, can have a therapeutic effect. Alternative medicine doctors are very good at reassuring patients, as contrasted with the coldly scientific approach of western medicine. Modern medicine treats illness using science and technology; it focuses narrowly how the doctor can solve the problem when the patient is ill. Alternative medicine, in a radically different approach, emphasis’s the importance of staying healthy and requires individuals to take more responsibility for their own health. Traditional medical wisdom (for example, ayurveda in India) linked health to a state of harmony and disease to a state of imbalance, and focussed on wellbeing and remaining well, and not on just ‘fixing’ the problem after one fell ill! At this stage, we need to differentiate between alternative and complementary therapies. Since alternative treatments are used instead of conventional regimens, they can be medically dangerous and can delay standard medical care. Complementary therapies, on the other hand, are used in conjunction with mainstream treatment and are much more commoner. Complementary therapies become alternative only when promoted as ‘stand-alone’ remedies for serious illnesses. It is not the therapy itself, but its goal or the intention behind its use, that defines a regimen as alternative versus complementary. Unfortunately, the practice of alternative medicine in India today leaves a lot to be desired. For one, such medicine does not have a universally accepted scientific basis; hence, it is difficult to rigorously analyze its claims. Since there is no need for formal publication or peer review in alternative systems of medicine, there is little scientific documentation available about their efficacy or side-effects, so that it becomes difficult to confirm claims or dispute them. Consequently, one has to blindly trust the doctor . Authoritative journals or texts are

difficult to find; and most publications use little scientific rigour, being based mostly on anecdotal case reports, with little documentation or proof. Moreover, since there is no official monitoring of the practitioners of alternative medicine, anyone can make tall claims and get away with them ! Also, since there are few formal training requirements, anyone can practice alternative medicine, with minimal skills or qualifications. Unfortunately, unscrupulous practitioners have mushroomed, who are out to make a quick buck, and malpractice’s and quackery flourish. Alternative medicine practitioners need to be made accountable for their actions to ensure that they are up to date with their education. Also, some type of peer review mechanism needs to be put in place to ensure the safety of the public. Otherwise, the danger is that medicine can become a ‘bastardised’ system (for example, homeopathic practitioners in India who prescribe allopathic antibiotics for coughs and colds) which can harm patients considerably. One of the reasons for this sorry state of affairs is that alternative medical systems receive little official support and minimal funding. The situation often deteriorates into a conventional versus alternative medicine confrontation, with each system belittling the other, and this is a real tragedy. By ignoring alternative systems, doctors may be depriving patients of better medical treatment options. We need to remember that all doctors are on the same side – all of us want our patients to get better, no matter what system of medicine we practice ! Diverse modalities such as massage, Reiki, yoga, ayurveda, acupressure, hypnosis, homeopathy, naturopathy and many others can work in conjunction with each other as part of a unified team rather than in competition. We need to learn to combine the best of both worlds – high technology with high touch – and this is called integrative medicine, as pioneered by Dr Andrew Weil of the USA. Integrative medicine neither rejects conventional medicine nor embraces alternative medicine uncritically – just because most alternative medicine systems are ‘natural’ does not automatically make them better ! For example, for emergency care in the case of acute medical problems such as a fracture, Western medicine is still the best bet. However, for chronic diseases such as arthritis, asthma, angina and hypertension, alternative medicine may offer a better choice for some patients. The most important requirement is that you need to find a good doctor, no matter what system of medicine you choose to follow. It is equally important that you understand the limits and the rationale

of the system, so that you are not taken for a ride. Thus, if an ayurvedic doctor prescribes antibiotics, you should begin worrying! The combined knowledge of both old and new healing modalities is ultimately superior than a single-model approach to health and wellbeing. After all, no system of medicine can claim to have a monopoly on knowledge! What is needed today is a clinically responsible balance between the science of modern medicine and the comfort of alternative medicine. We need to combine the best of both worlds, much like fusion music does, and physicians from both sides can learn from each other! If Indian doctors are willing to blend an open mind with the scientific discipline which is needed for rigorous research, given our immense patient population and rich traditional medical knowledge base, they can become world leaders in providing the best medical care to their patients.

Chapter 12 The Healthy Community: One for All, All for One Any manâ&#x20AC;&#x2122;s death diminishes me, because I am involved in Mankind; And therefore never send to know for whom the bell tolls: it tolls for thee. John Donne No man is an island, and just keeping oneself healthy is not enough. We all live in society, but most of us still neglect the importance of ensuring healthy surroundings, so that it's common to find a house which is clean and sparkling inside, with all the garbage tossed outside the door or window! However, all of us pay the price for dirty and unhygienic surroundings, as pernicious diseases such as cholera, malaria , typhoid fever and asthma flourish under filthy conditions. Ultimately, every locality needs to take action to keep its environment clean, and people need to realize that garbage and filth in the neighborhood threatens them directly in their own homes, through a proliferation of files, cockroaches and mice. The need for preventive action outside the home (using garbage bins, keeping public toilets clean and keeping drains clear) is as important as preventive action inside the home (washing hands and feet thoroughly, washing vegetables properly, storing food safely, sweeping and swabbing the floor). It may be very difficult to organize the community, but if you do not, you may have to pay the price in the long run, by falling prey to a variety of diseases. The connection between health and cleanliness had been recognized and respected even in ancient India. In order to remain healthy, a community must ensure the following: A regular supply of clean drinking water. Enough water for cleaning , bathing and washing clothes as well as for flushing toilets. Safe garbage disposal.

Safe sanitation facilities. Clean pure air to breathe. Unfortunately, virtually all over India, especially in the cities, the foregoing basic requirements are becoming the exception rather than the norm. While political action is needed to ensure that the government supply these basic amenities, there is little concerted action taken by most citizens, with the result that the situation is likely to deteriorate from bad to worse. Taking care of the environment is a key part of remaining healthy, and if the community is not healthy, it is difficult for an individual to remain healthy. A promising recent development is the fact that builders are realizing the importance of providing a healthy environment and many of them are now developing self-contained mini-townships, which provide all basic amenities within their four walls. These townships can be healthy places to live and bring up a family in, since they provide several essential features such as: (1) lots of open space to play in; (2) clubs and gymnasiums to remain fit and healthy; (3) shopping arcades; (4) food markets; (5) chemistsâ&#x20AC;&#x2122; shops; and (6) clinics and hospitals. However, while the quality of life is excellent for the residents of these townships, who form a privileged minority, what about the rest of the citizens? After all, if your domestic help and his/her family are going to live amidst filth, it's likely they will be afflicted by infectious diseases such as tuberculosis and typhoid, which they could then transmit to you and your family. In the final analysis, this is a problem which affects all of us and we simply cannot afford to turn a blind eye to it! However, since it is a public health problem, we are usually content to let the government tackle it â&#x20AC;&#x201D; which it fails to do in its usual characteristic fashion! By contrast, citizens in developed countries of the world, have realized the menace of the problems created by unhygienic conditions and have collected together to lobby for change, in order to ensure healthy living conditions for themselves and their families. For example, environmental pollution affects the health of everyone, and you cannot afford to neglect the fact that the air you breathe is going to contain more and more toxic matter as the days roll by. Similarly, while it is the municipal corporation's responsibility to provide us with clean drinking water and to dispose off garbage hygienically, we should also ensure that this job gets done!

The number of environmental health hazards is increasing daily. All of us are paying the price for industrial pollution. The ‘litany of woes’ is a long one! For instance: pesticides in our food; pollutants in the water; toxic fumes in the atmosphere; and harmful hormones in the milk we give our children to drink. We are bombarded by noise pollution daily which can cause numerous health hazards, including headaches, insomnia and hearing loss. People living in cities spend over 80 per cent of their time indoors, and indoor air pollutants can pose many health risks, including an illness called the ‘sick building syndrome’! Occupational exposure to toxic chemicals is also becoming increasingly common. However, the risk of exposure to these chemicals is no longer restricted to factory workers alone. The 1984 Bhopal gas tragedy is an outstanding example of how thousands were adversely affected because of the failure to implement simple precautions, even though the factory from which the deadly fumes emanated was dealing with toxic chemicals. The Bhopal tragedy is replayed almost daily on a much smaller scale in cities all over India; for instance, when a tanker carrying toxic chemicals overturns and releases its poisonous load into the environment, or when manufacturing units operating from residential areas spew out toxic waste products. Effects of other toxins may be more subtle and hormone disrupters (such as industrial estrogenic chemicals) have been shown to decrease sperm counts in men all over the world ! Living safely in a polluted world is no easy task, and is likely to become increasingly difficult for our children, as these toxic accumulate agents can in the environment over decades. The prevalence of illness is increasing rapidly in metropolises such as Mumbai and Delhi. This increase can be attributed primarily to overpopulation, poor sanitation and excessive pollution. Water- and food-borne diseases are endemic, and these diarrhoeal diseases have been the major killers, especially of children. Also, respiratory diseases (such as asthma and bronchitis) are beginning to pose an equally serious threat to life because of increasing levels of air pollution. Keeping in mind all the foregoing factors, we simply cannot afford to continue to live in our own shells! In the final analysis, health is a political matter, and the types of illnesses found in society are reflection of the nature of that society. Illnesses do not hit all groups in society randomly and equally, and just as wealth is unequally distributed in Indian society, so is ill health. One of the best predictors of a person’s life expectancy is his annual income and extensive

research has proven that many illnesses have their origins in social conditions. The difference starts right from childhood, and poor nutrition means that the children of the poor are shorter, weaker, sicker and thinner than those of the rich --- even at birth. Although an individual’s life expectancy has increased, the gap in life expectancy between the poor and the rich has also continued to increase all over the world. According to a survey of global health by the World Health Organization, poverty was the greatest underlying cause of disease, leaving many with inadequate access to nutrition, drugs and basic health care. Those living in poverty must focus on survival priorities and often don’t have the time or the energy to prevent or treat illnesses, until they are forced to . Leading a hand-tomouth existence means falling ill is a luxury they really cannot afford! Unfortunately, many doctors and hospitals fail to treat the poor as well as they would treat the rich, so that many simply avoid doctors and hospitals completely because of inferior care. Political problems need political solutions, but governments in India have done precious little for providing health care for the common man. They make grandiose plans for a primary health centre in each village, but typically these PHCs have no medicines or supplies, because they have been siphoned off. They build expensive super speciality hospitals in cities, but most of these just end up as a palace of diseases, while the poor continue to die without food and shelter. In fact, the entire health care system is ill! It concentrates on treating the sick, but does little to prevent them from becoming so. In fact, the term ‘health care’ system, which takes care only of the sick. It treats only individuals, but does not attack the basic causes of illnesses, such as poverty and illiteracy. Far from encouraging people to lead healthy lives, our society encourages them to harm themselves, and a prime example is cigarette smoking. Unfortunately, profits come before people --- and there are too many people making too much money from tobacco, so that the tobacco industry continues to spend billions a year encouraging people to smoke, and the government allows them to do so. The question is: what sort of society lets a small group of people persuade the masses to engage in behavior which might kill them --- and then provides medical care to try to save them? We still continue to take a piecemeal approach to treating disease on a case-by-case basis, but this approach is doomed to fail in the long run. Let’s take the example of bronchitis. At present, we treat only those individuals who are suffering from the disease. However, a social approach to treating bronchitis would focus on removing those factors

in the environment which are known to cause or aggravate bronchitis, such as air pollution, poor working conditions, industrial pollution and cigarette smoking. While the modern medical system is designed to look after ill patients, we cannot improve the health of our community without taking concerted political action! All political action, however, starts with an individual’s initiative. Doctors in India constantly complain about the shortage of safe blood banks. Isn’t this state of affairs tragic in an overpopulated country like India (where one would imagine that there would be no shortage of people willing to donate blood). When was the last time you donated blood? If we do not develop a social conscience, we will not be able to improve our community’s health, and we will all pay the price sooner than later. A healthy community looks after the health of all its members, including the underprivileged. It protects the rights of the disabled and treats them respectfully as individuals who are ‘differently abled’, and also develops active programs for preventing and treating drug abuse and alcohol abuse. Progressive community also provide hotlines for suicide prevention as well as counseling, so that people have someone to reach out to and talk to. So much for a vision of what a healthy society should be. As an individual, what you can do to improve your community's health is to participate actively and to volunteer your services in various fields: for example, as a guide in hospitals; to lobby against polluting industries; or to care for older citizens. Improving a community’s health can be the entry point for improving the quality of life for the entire community! Remember, that by helping to improve the health of the community, you are helping yourself and your children!

Chapter 13 Looking for Dr Right A physician is judged by the three As: Ability, Availability and Affability. Paul Rezniknoff All of us hope never to fall ill, but this would be wishful thinking. When we do fall ill, we expect our doctor to be able to help us to tide over the crisis. However, it is a sad fact of life that most of us spend more time selecting a hairstylist than we do in choosing a doctor! Such an anomalous situation often results in our being unhappy with the medical care we receive. Invariably, patients stick to one doctor, even when they are not very happy with him, simply because their family has been going to him for years; or because "he knows my case". Others select a doctor on the bases of capricious reasons; for instance, because "he treated my cousin's friend's case successfully" ; or because " he is supposed to be the best " . However, such reasons do not lead to efficient ways of finding a good doctor. The perfect doctor would treat you as an intelligent person, have plenty of time, as well as infinite wisdom, charge low fees, be totally honest yet compassionate, have a conveniently located clinic and understand your emotional as well as medical problems. While you may never find such a doctor, you need to keep your picture of your ideal doctor in your mind when you are looking for the physician of your choice. First of all, you need to find a primary-care doctor; i.e., someone who will provide medical care for your whole family; carry out regular checkups; and treat common illnesses. Such a doctor is a usually a general practitioner ( also known as a family physician in today's trendy world) , or a general physician . Women may prefer a gynecologist, and for your children you may choose to go to a pediatrician. A primary care doctor is trained to recognize common health problems in the patient as a whole; in other words, his "specialty" is comprehensive care of a patient, either on a short or long-term basis. Choosing a good primary care doctor is perhaps the most important step you can take to insure that you get good medical care.

A primary care doctor is much more than a quick fix ‘craftsman’ for an acute illness; he can become your healthcare partner in the long haul...helping you to establish your health goals and periodically evaluating how you're doing while treating any illnesses that come up along the way. Ideally, a primary care doctor can offer you the following benefits: * A good starting point in the healthcare system. Whatever your concern or problem may be, your primary care doctor will either be able to either treat it or determine precisely when and where to send you for specialized help. In either case, you have the distinct advantage of a physician's expertise, and any trips through the medical ‘maze’ will be less confusing for you...and less of a hassle. * Preventive healthcare. Your primary care doctor can help you with disease prevention, as well as prompt intervention during any illness. * Continuity of care. You and your doctor can develop and sustain an on going health partnership. He will get to know your concerns, and you won't have to repeat your history each time you fall ill or need treatment. Your primary care doctor will know you as well as any chronic problems or potential troubles you may be facing. He well also be familiar with your family history. * One stop shopping. You can consult the same doctor for a variety of conditions, and often, he can treat both you and your family. Your family doctor can take you and your family through pregnancy, childbirth and childcare; instilling the concept of good health at an early age. * Lower cost and convenience. Primary care doctors generally serve large populations of patients, so they encounter and become familiar with managing the most common medical maladies. They have been trained to diagnose and treat a wide range of conditions costeffectively. And, in most cases, it's easier to gain asses to a primary care doctor than a specialist, since general practices are usually geared up for maximum efficiency. An assurance of continued health may be the most valuable benefit of teaming up with a good primary care physician. Your lifestyle plays a major role in shaping your health and well being in the long run. You, in tandem with your doctor, can define your health goals, analyze your habits and get started on the basics to maintain or improve your health, now and in the future. Your working relationship with your doctor can help prevent serious illness from developing down the line

apart from enhancing your well-being, the quality of your life, and your independence for years to come - the biggest benefit of all. Your primary-care physician should be someone who will coordinate and oversee your overall medical care, referring you to a specialist only if needed. It is not usually a good idea to consult the "top" specialist for every problem, though this seems to be have become fashionable these days- for example, rushing to a neurologist for a headache such a step can actually lead to your getting poor care ! Specialists often order unnecessary tests (which could be expensive and painful) to rule out rare diseases (after all, they are specialists, and they cannot afford to overlook any possibility, however, remote it may be, while making a diagnosis !). The best time to find a doctor is when you don't need one! This statement may seem paradoxical, but finding the right doctor when you are ill becomes much more difficult, because of the stress of the illness - as well as the pressure of time. Ask your friends for recommendations. A good source of referrals can be nurses and other paramedical staff. If you have a friend who is a doctor, seek his advice as well. The yellow pages can also serve as a useful source of possible names if you need to make a comprehensive list. You can phone the doctors on your list. Although it may appear unorthodox, "telephone shopping" can provide you with a lot of useful information about individual doctors practice, including details of clinic timings, fees, qualifications, hospital attachments, special interests. After all, if you are willing to research which travel agent will give you the best deal on a holiday trip, then isn't it worthwhile researching into whose hands you are going to put your life in ? You can learn a good deal about the doctor and his practice, even before you actually meet him , by merely telephoning and asking the right questions. While it is true that many mediocre doctors flaunt posh clinics, the setting in which the doctor functions can reveal a lot about him. Is the clinic located in a decent building? Is public access easy? Has the doctor bothered to provide the basic amenities you need ( e.g., drinking water, comfortable seating )? What kind of reading material is kept in the waiting area? (Old and torn magazines should qualify as a negative mark . Patient educational literature and current issues of health magazines indicate that the doctor respects your waiting time and wants to use it to educate you). Are the office staff member helpful? How do they answer the telephone? How do they treat other

patients ? you can learn a lot about a doctor and his practice from the personality of his employees: remember that efficient, caring physicians tend to hire competent, friendly personnel! During the first consultation, not only should the doctor get to know you and your medical problems by examining you, but you should also get to know a lot about him. Such a initial assessment is important in answering the following vital questions: Are you comfortable with him? Does he explain the details properly? Does he use relevant teaching aids? Does he ask for your views? Does he listen to you carefully? A concerned doctor will organize the clinic and its functioning so as to minimize your visits- for example, blood samples can be collected in the clinic itself, to be forwarded to a reliable laboratory, so that you don't need to go there yourself. Similarly, many obstetricians provide the facility for ultrasound scans in the clinic itself, so that patients need not run around from one place to another. While looking for the ideal doctor beware of quacks! While many of us tend to be overawed by a long list of alphabets behind the doctor's name, you need to remember that not all of them are legitimate degrees. For example, many doctor's will use the â&#x20AC;&#x2DC;embellishmentsâ&#x20AC;&#x2122; FICA (USA) and FRSH (London) to give the impression that they have been trained abroad. These acronyms are not qualifications- they merely indicate memberships in a society abroad, which are open to anyone- even a barber- on payment of a nominal fee, can acquire such memberships! Useful criteria to consider while selecting a doctor are as follows: Is the location of the doctor's clinic important? (in other words, How far do I have to travel to see the doctor? Is it convenient for me? Is there parking space?) Is the hospital to which the doctor admits patients important to me? Are factors such as the age, sex, race, and religion of the doctor important? Do I prefer a solo consultation or a group practice? Do I have to choose a doctor who is covered by my insurance plan? Is the doctor duly qualified and in which field? For example, a patient with a heart problem may prefer to see a cardiologist, rather than a general physician.

What days/hours does the doctor see patients? Are the timings convenient to me ? Does the doctor ever make house calls? How much in advance do I have to make appointments? What is the length of an average visit? In case of an emergency, how fast can I see the doctor? Who takes care of patients after hours or when the doctor is away? At this stage, one may well pose the question: what are the attributes of a perfect doctor? In my opinion, a perfect doctor is one who: is respectful and treats you with dignity; makes you feel welcome; treats more than the symptoms; recognizes the expertise of the patient; listens to you, explains the relevant facts, asks you questions and answers your questions; makes home visits if you require them, or arranges for another doctor to visit you after hours; uses pictures and diagrams to explain complex medical terms; explains everything, including diagnosis, procedures, treatment and what you can expect in the future; is easy to talk to and gives you clear â&#x20AC;&#x201C; cut information; is open to discussion about alternative systems and is willing to refer you to say, a natural therapist; is interested in you, is down-to-earth and treats you as an equal; prescribes medication that you can afford; fits you in if you are really sick despite a tight schedule ; is up-to-date with the relevant information; refers to various sources (e.g., books, journals, internet )to clarify information; refers you to an appropriate specialist when required; refers you to other support services or self-help groups; phones back when additional information or tests results are obtained; and gives adequate consultation time.

In contrast, a bad doctor is one who: Does not value your time, and makes you wait interminably on a routine basis Is more interested in treating your reports than in treating you Does not spend enough time with you Seems to be too busy and rushed all the time Orders tests whether or not they are needed Does not explain your options to you Discourages questions or refuses to answer them Promises too much. Makes remarks like "that's my secret." Doesn't explain clearly what he is doing during treatment. Sometimes, if you are a victim of a rare or complex problem, you may need to find a “ Doctor's Doctor “ i.e. the best doctor in the city, country , or the world for your particular problem. How do you go about locating such a doctor? The best way of beginning the search is by asking your doctor. To start with, your doctor knows you and your situation better than any other physician, also since most doctors are aware of the accomplishments of "super-specialists" who practise at large university hospitals or research based facilities . your doctor can help you identify there experts. If you can find a book relating to your problem, then the author (if he is a doctor) is likely to be a good choice. The other option is to find the name of a doctor or the head of a clinic or department which is actively publishing their medical research in this field ( you can easily do this by doing a Medline search). This doctor ( or the head of the clinic) is likely to be an authority in the subject, and will be wellinformed of the latest advances in the field. Many patients naively assume that all they need to do to get good medical care is to make a beeline for the west. However, do not automatically assume that just because you go to the USA, the UK or Germany, you will find a competent doctor – you need to do your homework thoroughly before making the trip!

In order to feel good about your medical care, you should feel good about your doctor, too. In this context, ask yourself the following questions in order to evaluate your physician: Does your doctor listen to you and answer all your questions about the causes and treatment of your medical problems, or is he vague, impatient or unwilling to answer them? Are you comfortable with your doctor? Can you openly discuss your inner most feelings and talk about intimate personal matters , including sexual and emotional problems? Does your doctor take a thorough history, asking for relevant factors about past physical and emotional problems, family medical history, medications you are taking and other matters affecting your health? Does your doctor address the root causes of your medical problems or does he merely prescribe medicine to treat the symptoms? Is your doctor well-groomed ? A doctor who cannot be bothered to take care of how he looks may not look after you carefully either ! Does your doctor smoke? ( if yes, this should be a black mark against him !) Are you satisfied with the doctor's stand-in when he or she is unavailable? Do you feel at ease while asking your doctor questions that may sound "silly"? Does your doctor explain complex medical jargon in simple terms? Are the office staff members friendly? Do they listen to you patiently? Does your doctor answer your telephone calls promptly? Are you usually kept waiting for a long time even if you have fixed an appointment before hand? Does the doctor have hospital privileges at a respected medical institution? If you are not satisfied with the answers to the proceeding questions, discuss your concerns with your doctor. Even after this discussion if you are still not satisfied, you should consider looking for another doctor.

Changing doctors is never easy, because, over a period of time you do build up a personal relationship with your doctor. However, you should consider changing doctors if you strongly feel that : the doctor is incompetent ( i.e., he has ignored obvious symptoms, missed a diagnosis, prescribed the wrong drug, or can't get to the bottom of your problem); the doctor does not communicate with you effectively ( i.e., his explanations are not in lay person's language or no time is given to you to ask questions and bring up related problems); the doctor does not pay attention to your needs and concern you have lost confidence in the doctor's skill and ability. you find the doctor is too inconsiderate ( i.e., he makes you wait a long time for an appointment, he fails to return your phone calls, he does not provide clinic time during evening or weekend hours ); and your doctor is too expensive. There is no single who is Dr. Right for everyone, and you may need to hunt patiently and persistently for the doctor who is right for you, depending upon your temperament, personality, and perhaps age and sex. Different patients have different expectations- some need to be told what to do while others want all their questions answered. Obviously, they will need different types of doctors. Most people invest a lot of brain power and analytical skills deciding which shares or stocks to buy, but doing in - depth research for finding the right doctor is likely to pay much better dividends for you and your family ! In the final analysis, remember that the most reliable test for a doctorâ&#x20AC;&#x2122;s suitability for you is your own gut instinct - after all, if you donâ&#x20AC;&#x2122;t feel comfortable with your doctor, you are not likely to be able to work well together in your health care partnership with him ! On the other hand, if you have faith in his abilities and can trust him that he will do his best for you, you are likely to get excellent medical care !

Chapter 14 How to Make the Most of Your Doctor The treatment of a disease may be entirely impersonal; the care of a patient must be completely personal. Francis Peabody No one likes to fall ill, and as a logical extension, most of us don't like going to the doctor. A visit to the doctor also brings back childhood fears of painful injections and unpleasant blood tests. Thus, it is no surprise that a medical clinic is second to unpopularity only to a dentist's chair! Consequently, most of us do not make the best use of our doctors; we tend to use them as crutches only when we fall ill. However, one should never forget that the doctor-patient relationship is unique; since it is the ultimate one-to-one relationship, in which you confide fully in your doctor and entrust him with your life, you must learn to work as a partner with your doctor ! In order to foster and nurture the relationship with your doctor treat it with great care and respect. Don't forget to say â&#x20AC;&#x2DC;thank youâ&#x20AC;&#x2122; to your doctor when you get better . He gets fed up of attending to droves of patients with complaints all day long and would be delighted to hear a patient appreciate his efforts! Unfortunately, this common courtesy is something we often forget; patients tend to remember the doctor only when afflicted by an ailment. This simple expression of gratitude by you will help the doctor to remember you as a person , rather than as just another case. He is likely to then treat you as a special patient and getting VIP attention from him helps improve your medical care a good deal! As in a marriage, the doctor-patient relationship depends on good communication and trust built up over time and it is definitely worth spending time and taking trouble to maintain a beneficial relationship. Remember that the doctor's staff plays a key role in your medical care , and you need to learn how the clinic functions. It's very helpful to build up a rapport with a special staff-member (who can be a receptionist, a nurse or an assistant), and this can prove to be very useful when you need to talk to the doctor on a priority basis. The

simple rule is that if you treat the staff well, you will be treated well too! A small ‘thank-you’ gift for the staff can help ensure that you get personalized attention. It's useful to learn which days are the busiest and what times are the best to consult the doctor. You should also find out what steps to take if there is an emergency, or when the clinic is closed. Your visits to the doctor can be expensive, despite the fact that the actual time you get to spend with your doctor is very short ! Many doctors have perfected the technique of flying into the examination room, shooting off questions, and rattling off advice. And, before you know it, you're shoved out of the door, worrying about those crucial matters you forgot to ask and the directions you forgot to write down. So, what's the solution? Is there really a secret to getting your money's worth from a doctor's visit? Yes, there is, and it's a simple one: Do your ‘homework’ thoroughly before visiting the doctor! In order to make the best use of your doctor's time, you need to ‘prepare’ for your visit, very much like you prepare for an examination. Time spent in getting organized before you go to the doctor can help immensely! A well-organized patient not only makes efficient use of the doctor's time but he is also likely to get better medical care, as he is helping the doctor a great deal in making an accurate diagnosis. A conscientious patient makes sure that he has all his medical records with him , as well as the vital questions to which he needs answers (preferably, in writing). Patients who value the doctor's time will do their best to get answers to their queries by tapping external sources such as books, libraries and the Internet, before going to the doctor’s clinic. This procedure will allow them and their doctor to focus on what is important to them, so that they can make the best use of the limited ‘quality time’ that they have with the doctor. Remember to inform your doctor about all the symptoms you have noted. List them in a chronological order, starting from the time when you first noted that something was amiss. It's extremely useful to record the factors that make your symptoms better, and those that make them worse. This information provides very useful medical clues. Also, let your doctor know what remedies you have tried earlier, and whether they have helped or not. Do not play games with your doctor. If you have consulted another earlier or have undergone relevant tests, please share this information with your present doctor. It's helpful to prepare a short one-page summary of your medical history; not only does this summary help the doctor, but it also ensures you do not forget to convey to him information which could be vitally important in

your treatment. Computer programs are available today, which can help you record and organize your medical history, as well as that of your family members. Make a list of all the medications you are taking, both prescription and non-prescription. As an alternative, you can collect all your medicines in a brown paper bag and show them to your doctor. Moreover, list all the specialists you are consulting for specific disorders/conditions. Ultimately, you obviously want to know what the diagnosis is, so do not shirk from asking your doctor what he thinks is wrong with you. Surprisingly, many doctors are reluctant to give a name to a patient’s problems, so that if you do not ask specifically, you may not get an answer. If you do not agree with the doctor’s diagnosis, tell him so, because if you do not agree with it, you are unlikely to follow his advise and treatment. Often, your doctor may reply he does not know the diagnosis as yet. This response does not indicate that he is an incompetent physician; it may simply mean you have a difficult problem, for which more tests are needed. It could also mean that your doctor would like to ‘wait and watch’ to see how the problem evolves, or that he may need to refer you for a second opinion. Remember that doctors do not always have all the answers. You should be aware that reaching a diagnosis can be hard and sometimes it can take a long time to find out exactly what is wrong. Ask your doctor to explain your diagnosis and how it might affect you and your family. Useful questions include: What is the diagnosis ? Find out the complete medical name – and what it means in plain English ! What is my prognosis (outlook for the future)? What changes, if any, will I need to make in my daily life? Is there a chance that someone else in my family might get the same condition? Will I need special help at home for my condition? If so, what type of help? Your doctor is definitely not a mind-reader and you must tell him everything you know, think, and feel about your problem if you want an accurate diagnosis and the best treatment plan. There is no need to be shy or embarrassed about sensitive subjects such as sexual

problems or sexually transmitted diseases as far as your doctor is concerned. Rest assured that doctors have ‘seen it all’ and ‘heard it all’ - they're not there to pass moral or ethical judgement on your conduct. Do not hesitate to share your thoughts with your doctor. If you think what he is recommending does not make sense, say so, and specify your reasons. If you're worried, do express your anxieties and find out how you can get more information and support to dispel them. If you just sit on your chair and listen meekly, your doctor will either assume that you are uninterested in a full explanation of your illness and its treatment – or that you are too stupid to understand ! Remember – the more you ask, the more you will be told ! Do keep in mind that doctors are also human, and they are badgered by their own share of problems. On certain days they may seem rude or curt; on such days, give them a little leeway and a lot of understanding! Since it is your ‘head on the block,’ so to say, you are entitled to raise all relevant questions and seek satisfactory answers to them. If you cannot understand your doctor's explanations, ask him to repeat everything in simpler language. Ask him to show you illustrations; also, ask for written material that explains the medical issues in greater detail, so that you can study this later at leisure. The following terms can be very helpful when you talk to your doctor: Please tell me more about that. What does that mean in simple English? Could you explain that to me again? Could you write that down for me? Where can I find more information about this subject? You seem rushed. When can I call you to talk about this in more detail? Try to schedule your next visit at the end of the consultation. If the succeeding question-answer session is something which can be managed on the telephone, then try to do so. You could save both time and money by avoiding an unnecessary follow-up visit to the doctor’s clinic. Another important point to be borne in mind is to carry written checklists with you during every visit. Normally, you can think up a wide range of questions to ask the doctor, but as a result of the stress generated by the consultation you invariably forget most of them. Such

a situation is very frustrating, and you kick yourself when you get home. To prevent this from happening, write down all the questions you need to ask in order of priority. It is also helpful to write down the doctor's answers. Studies have shown that patients forget about 50 per cent of what the doctor tells them during a visit! Writing down the doctor’s answers will prevent such a ‘disaster’! Moreover, your doctor also stands to benefit because you need not pester him with your queries all over again! Try to find a friend or relative to accompany you for the consultation, as his or her presence can be very useful. He or she can help reduce your anxiety, give you courage to ask the relevant questions, and also help you to interpret the doctor’s statements. As mentioned earlier, do not hesitate to ask questions (and more questions); never mind how many other patients are waiting outside the doctor's clinic, or how stupid the questions may seem to you. When you are with the doctor, his only focus of interest should be you, and it's his job to provide answers. Remember, the only stupid question is the one you didn't ask. Be courteous but assertive while asking questions and obtaining information, but don't turn aggressive or antagonistic. Listen carefully to what your doctor says, and in case of doubt and ambiguity, do not leave till these have been dispelled. Remember, the word doctor is derived from the Latin root docere, which means 'to teach'. Therefore, look for a doctor who is willing to share his knowledge with you! What happens if you and your doctor differ about a treatment option? Let me point out that there's a right way of approaching your doctor and a wrong way. It's simply a matter of mutual respect; you wouldn't want your doctor to assume the worst about you, so, on a reciprocal basis, don't assume the worst about him! Often, if you can put across your feelings and apprehensions in the right way, you can get your doctor to help you. Explain your needs to the physician in a polite way, without any belligerence or hostility. Remember that you are both on the same side — yours! The most common complaint of patients is that they are made to wait for ages before the doctor can see them! It is only because patients put up with such a situation that doctors get away with this unpardonable behavior. After all, no doctor would remain very busy if all his patients decide to refuse to wait for him! Some patients seem to believe that the longer they have to wait outside the doctor's clinic, the better he must be, since he has so many patients clamoring for his attention. This is simply not true! No matter how hard-pressed a doctor

may be, he can always space out his appointments, so that you never have to wait for more than an hour to see him. In order to ensure that you don't lose your patience while waiting in the clinic, it would be a prudent idea to carry a paperback novel or a Walkman. Nowadays, many doctors keep patient educational leaflets and brochures in their clinics and you could read these and thus use your waiting time constructively! Some clinics are also blessed with TV sets, so that patients do not get totally fed up. While an occasional delay is unavoidable (since a medical emergency could require your doctor's immediate attention), if you are made to wait for an eternity each time, something is seriously wrong with the doctor's attitude towards patients. For any inordinate delay, the clinic staff should be courteous enough to provide an explanation, and, if needed, an alternative appointment. As an example of efficient patient management, if a doctor at the famous Mayo Clinic in the USA makes you wait for more than 30 minutes without an explanation, you can complain to the hospital manager who will rectify matters. Make sure you carry photocopies of all your medical records and tests. You can give them to the doctor for his files, if needed – but keep your originals with you – they are your property ! Also, make sure that you have clearly understood the contents of your medical records so that you can explain the details to another doctor if needed. Certain categories of patients can be particularly irksome or tiresome. For instance, doctors dislike patients who : Expect to be treated on a priority basis. Are always late. Waste time needlessly. Ask the same questions endlessly. Think they know all the answers. Do not value the doctor's privacy or personal time. Do not follow instructions. Go ‘doctor shopping’ i.e., change doctors all the time. Don't pay their fees on time. It's always helpful to put yourself in the other person's shoes; i.e., to see things from your doctor's point of view! The ideal patient would be one who: Comes to appointments on time, or is thoughtful enough to phone to cancel them.

Tries to explain exactly what's bothering him; i.e., he can express his anxieties and apprehensions clearly. Answers questions honestly. Volunteers any important information that the doctor may not specifically ask about, including family history. Lets the doctor know if cannot follow his directions and specifies the reasons why. Takes medications as directed, strictly adhering to the dose schedule. Expresses his dissatisfaction in a courteous manner Try to do your best to become an ideal patient, and learn to take an active interest in your medical care. After all, this is the only body you have! It's a simple fact of life that patients who know how to make the most of their doctor get better medical care. Therefore, it's very important that you learn how to do so !

Chapter 15 How to Talk Intelligently to Your Doctor A doctor who cannot take a good history and a patient who cannot give one are in danger of giving and receiving bad treatment. Paul Dudley White The simple fact that in over 80 per cent of cases the diagnosis of the illness can be made purely on the basis of what the patient tells the doctor (what is called a medical history) should emphasize the importance of oneâ&#x20AC;&#x2122;s ability to talk intelligently to oneâ&#x20AC;&#x2122;s doctor! While the capability of absorbing the relevant details of an individualâ&#x20AC;&#x2122;s medical history is one of the key skills of a competent physician, being able to provide a lucid history is a key skill on the part of a good patient. You need to be able to describe your problem as accurately as possible. For example, if your problem is a headache, you should be able to provide all the details! For instance: Where does it hurt? Has the pain spread elsewhere ? How severe is the pain? What does the pain feel like? Is it a sharp, dull, or throbbing pain? When does it occur? What makes it better? What makes it worse? Have you noticed any other symptoms or signs recently, such as fever, shortness of breath or blood in the urine? When did the problem start? Has it changed since then? Have you felt like this before? If so, when? What made the pain better then? Is it affecting your daily activities such as sleeping or eating ? In this context, a useful aide memoir includes the following details: Site: Location (e.g., pain is in the chest and then spreads to the left arm). Quantity: Bringing up a cupful of sputum when coughing. Quality: It feels like an elephant is sitting on my chest! Setting: I usually develop such aches after fighting with my wife. Aggravating factors: Stomachache becomes worse after eating. Alleviating factors: Breathlessness becomes better after resting. Associated Symptoms: Other related complaints.

If you remember to categorize all your problems systematically, not only can you make better use of your time with your doctor but you can also help him arrive at a correct diagnosis more quickly! You could rehearse the details you are going to provide to your doctor with a friend or a relative. You could also summarize them on a single sheet of paper, just to make sure you don't forget any vital aspect. It is a medical truism that if the doctor listens to the patient intelligently, he will be able to make the diagnosis correctly. However, just like learning to take in a good history is a skill the doctor needs to master, providing an intelligent history is a skill the patient needs to learn. Patients are often slipshod while recounting their medical history so that the doctor needs to methodically extract the facts from them: and this exercise can be a painful for both! The common gaffes patients make include: Getting bogged down in irrelevant details. Not providing all the facts. Not furnishing the information in a chronological sequence. Jumbling up the details, so that they jump from one problem to another completely unrelated one. Remember to tell your doctor what you think the reason for your problem is! This â&#x20AC;&#x2DC;revelationâ&#x20AC;&#x2122; can often provide the doctor with a useful clue. Ultimately, do not forget that you are the expert on yourself ! You should also be able to provide relevant information about your health status, both past and present. The following aspects need to be highlighted: Your medical history (including instances of surgery and hospitalization). Your family's medical history. Allergies you are prone to. Medications you have taken (and are still taking). Your daily routine. Your work schedule. Pressures you have been subject to (and are still subject to). To sum up, the following suggestions will help you communicate effectively with your doctor:

(1)Plan well ahead of time what you intend discussing with your doctor about your problem. Your own observations about your health problem can prove invaluable in helping the doctor make an accurate diagnosis. Carry written lists to make sure you don't forget any crucial aspects! (2)If you are confused by complex medical terms, ask for simple definitions. There is no need to be embarrassed; after all, your doctor does want you to understand what is happening to you! Remember that your doctor’s objectives and yours are the same to help you to get better as soon as possible! (3)Repeat in your own words what you think the doctor meant and also ask: ‘Is my version correct?’ Such a clarification will ensure that you understand clearly what the doctor is saying and will also allow him to present the information to you again, if required, in a manner which you can comprehend. (4)Share your point of view with your doctor since he needs to know what's working and what's not. He or she obviously can't read your mind, so it is important for you to put across your thoughts and observations. If you feel rushed, worried, or uncomfortable, do convey your apprehensions to the doctor. Try to voice your feelings in a positive and courteous manner. For example: “I know you have many patients to see, but I’m really worried about my condition. I’d feel much better if we could talk about it a little more.’ If necessary, you can offer to return for a second visit to discuss your concerns. (5)Take notes on what the doctor’s analysis of your problem is and what you need to do to rectify the situation. (6)Discuss frankly with your doctor if any part of the visit has been annoying or dissatisfactory, such as a lengthy waiting time or discourteous staff. Your approach ought to be tactful, but honest. (7)Don't hesitate to voice your apprehensions about what you may have heard from well-meaning but ill-informed friends or relatives regarding your condition. The doctor may be able to dispel any misconceptions. (8)Discuss any self-medication practices you've used which have relieved symptoms. (9)Don't waste your doctor's time by asking irrelevant questions (for example, about your brother-in-law's medical problem ). Such a digression is likely to upset the doctor! Also, try to do as much homework as possible, so that you can ask your doctor questions specific to your particular problem. After all, if you can find the answers to your questions from another source, say, a book or by

asking the nurse or receptionist, you can save your doctor's precious time, something which he will deeply appreciate. You can, nevertheless, ask your doctor to confirm that the knowledge you have acquired is accurate! Even though most patients realize the need to ask their doctor certain important questions, many of them get tongue-tied when they actually come face to face with their doctor. Not only can they not think straight, but they also often forget what questions to ask! But remember that you will only get answers if you ask the right questions! Rudyard Kipling's five best friends — What? When? Why? Where? How? — should help guide you as to what to ask! A simple example would be asking: ‘What is wrong with me? When did the disorder originate? Why? What can you do about it?’ A clear understanding of what precisely your doctor has told you is crucial if you're going to work together as a team. At the end of your visit, you should be able to: (1)Describe your condition fairly accurately. (2)Know what additional tests are needed and why. (3)Explain your treatment, including the use of medications. (4)State if and when you need to return. If you can't fulfil the preceding objectives, you're not communicating properly with your doctor! Remember that communication between a doctor and a patient is a two-way process. Both the doctor and the patient must work together on activities such as listening as well as speaking to one another. Honesty and openness with each other are also important factors. The more honest you are, the better your doctor can help you. Much of the communication between the doctor and the patient is personal, as well as confidential. In order to obtain optimum results, you may need to be open about sensitive subjects such as sex, sexually transmitted diseases and death even if you feel embarrassed or uncomfortable. Doctors are accustomed to talking about personal matters and will try to ease your discomfort to the maximum extent possible. It would definitely be advantageous to take a family member or a friend with you while visiting the doctor's clinic. You will feel more confident if someone accompanies you. Also, a friend or relative can help you remember what you planned to tell or ask the doctor. He or she can also help you remember the doctor’s advice. But don't let

your companion play too prominent a role; after all, the communication is between you and your doctor. Also, you may want to spend some time alone with the doctor to discuss personal matters. Therefore, let your companion know in advance the extent to which he or she can be helpful. If a relative or a friend has been taking care of you at home, taking that person along when you visit the doctor could prove beneficial. In addition to the questions you have in mind, your caregiver may have certain concerns he or she could like to discuss with the doctor. Even if a family member or a friend can't accompany you to the clinic, he or she can still help. For example, such a person can serve as your sounding board, helping you to practice what you want to say to the doctor before the visit. And, after the visit, talking with that person about what the doctor said can remind you about certain important points and help you come up with fresh questions to ask the next time. Most capable doctors will agree that they learn from their patients all the time, just as a good teacher learns from his students ! A skillful doctor treats the patient as the captain of the ship and himself as the navigator, and a balance of respect between the doctor and the patient can foster a partnership in which both learn all the time! However, remember that playing an active role in your own health care places the responsibility for reliable communication with your doctor squarely on you!

Chapter 16 How to Use the Telephone Wisely The person most often appointment is the doctor himself.

late

for

doctorâ&#x20AC;&#x2122;s

Often times, you can save yourself a long wait for the doctor at the clinic by getting timely advice on the telephone. Such a trend is becoming increasingly important today, when time is at a premium and commuting is so arduous, thanks to frequent traffic jams! You need to learn to make intelligent use of the phone to get appropriate help from the doctor. However, when youâ&#x20AC;&#x2122;re sick or hurt, it becomes difficult to think clearly and the following routine may help you to help the doctor give you the care you need over the telephone: Keep a pen and paper ready so that you can write down the relevant instructions.

Make sure all your medical records are at hand, so that you can answer questions about your medical problem intelligently and accurately. Identify yourself properly, giving your full name as well as your diagnosis ( try not to tax your doctor's memory!). Ask if you can take a few minutes of the doctor's time now, or whether you should call back again — this is common courtesy! Report specific symptoms. For example, rather than just saying, ‘I don't feel well, or I've got the flu,’ which can be interpreted in different ways, be prepared to describe your symptoms precisely; for instance, fever, sore throat, cough, and/or bodyache. Similarly, instead of just saying, ‘my baby has a fever’, specify the exact temperature and the duration of the fever as well as other signs or symptoms. When you don't know what you need (for example, you may not be sure how serious the illness is, i.e., if you require a visit to the clinic), tell the staff you're uncertain and request that you speak to a nurse or the doctor's assistant over the phone. Don't be hesitant; if you're feeling concerned or anxious, let the clinic staff know. Don't insist on talking only to the doctor every time you call. For example, if you just need to make an appointment, or merely clarify a doubt, the nursing staff or receptionist may be able to help you. To put it differently: respect your doctor's time! Don't misuse the phone by trying to wangle a free consultation. Not only is this act unfair to the doctor, but also such a consultation is likely to be very unreliable! Today, many physicians make themselves, an assistant or other staff member available to their patients over the phone. Previsit questions and routine follow-up on the phone can save you — and your doctor — both time and money. Before making a call, you need to certain relevant information in advance: When is the best time to call? What is the doctor's rule for returning calls? Whom should you speak with (e.g., assistant, nurse) if the doctor can't come to the phone? What is the phone number for making emergency calls or for calls when the office is closed?

Whom can you call if your doctor is out of town? When you reach your doctor or his assistant over the phone, be prepared to : Identify yourself. Get to the nitty-gritty quickly, especially if you've phoned after hours. (Have someone else call the doctor for you if you are unable to talk.) Define your problems and symptoms accurately but swiftly. Write them down and keep them near the telephone so you can report them quickly and completely. Report results of self-tests and other symptoms you have been keeping track of, such as a temperature of 101Â°F for two days, diarrhea that has lasted for 48 hours, and so on. Ask the doctor what you should do and write down his instructions carefully. Ask the doctor to spell out any word if you are unsure about it. Ask if and when you should call back, or if you should come to the clinic. Ascertain what complications could occur that may require you to hurry to the emergency room. Don't forget to thank the doctor for talking to you on the telephone! Sometimes, you may have to call a doctor after the clinic has been closed. Remember when you call a doctor after hours, he is trying to help you solve your immediate problem, not provide advice about your entire medical situation. Try to be specific in your complaint; you should know what medications you are currently taking and which of them has proved successful in the past. If you are not happy with the physician's advice or if you feel you are getting worse, go to the nearest emergency room at once. Let me give an example of a precise and useful telephone call: â&#x20AC;&#x2DC;I am an asthma patient and have had increasing wheezing today. I am not coughing up any mucus. I am using my albuterol inhaler every three hours but it doesn't seem to work. Last year when I suffered a similar episode, the doctor gave me prednisone and it worked, but the prescription is a year old. What should I do now?

On the contrary, here is an example of a bad telephone call: ‘I don't feel good. The doctor treats me for breathing problem. I take three breathing pills, one is green, one is white and one is real, and I ran out of the red one last week. While I have you on the phone, I think I have a fungus on my feet, can you suggest a prescription for something for that as well….’ Making effective use of the telephone can help to save both you and your doctor considerable time, effort and money! learn to use this instrument wisely and well.

Chapter 17 Making Friends with the Clinic Staff To cure sometimes, to relieve often, to comfort always. Hippocrates The clinic staff members are the first hurdle you need to cross in order to contact your doctor --- which is why they are often referred to as ‘gatekeepers’. Your relationship with the staff will often determine how easily you have access to your doctor, which is why it’s well worth spending a little time and energy making sure the staff members are on your side! Choosing the right doctor is a little like choosing the right life partner! Although it's true you're marrying only one person, all the inlaws come along as part of the package. Similarly, when you select a primary care physician, you automatically select his staff as well , so make sure you like them, as they will play an important role in your interactions with the doctor! The personality of the staff is often very similar to that of the doctor, and friendly, caring and competent physicians tend to hire friendly, caring and competent employees. Remember that being a ‘gatekeeper’ for a busy practice isn't easy. Pressurized by patients on the one hand, and the doctor on the other a ‘gatekeeper’s job can be tough. For instance, whenever the doctor is ‘running behind’ it's usually the gatekeeper who (undeservedly) receives the nasty stares, and side remarks complaints. Thoughtful patients should therefore, make it a point to express appreciation to the doctor's gatekeeper, as well as to the doctor. Acknowledge that they have demanding jobs. Not only will this brighten their day (which is, in large part, filled with ‘unrewarding’ tasks), it will also increase the likelihood of their going the ‘extra mile’ for you when you need their services. HOW TO MAKE YOUR DOCTOR’S RECEPTIONIST THINK YOU’RE TERRIFIC If you’re well organizes and well prepared when you phone or visit your doctor’s clinic, you’ll win the respect and appreciation of the

receptionist, which will make him that much more helpful in helping you get the best medical care. For example, when you telephone with regard to a medical problem, the following guidelines can be very useful: 1. Introduce yourself. State briefly (in one sentence) why you’re calling. (‘I’ve had fever of 101° for three days and I was wondering if there’s something else I should be doing about it apart from taking Crocin). If you don’t think your problem is serious enough to merit a visit to the doctor, say so. 2. Be prepared to answer the following questions (use prepared notes!): What are the specific symptoms? When (what day/what time) did the symptoms start? What have you done for relief, if anything? (Refer to notes for names of any prescribed medication or over-the-counter medication you may have taken). What is the main cause of your anxiety? How would you like to be helped? 3. Keep a pencil or pen and paper handy to take notes. Similarly, when you plan a visit to the clinic, the following points should be kept in mind. 1. Make sure you fix an appointment. Try to schedule it well in advance and call again to confirm it. 2. Try to reach the clinic on time, since the doctor’s time (and yours!) is precious. 3. Make sure you have brought along all your records and documents. 4. Try to cooperate with the staff. For example, if the doctor is running late, rather than pepper them persistently with questions, read a book or magazine while waiting. 5. Try to learn the names of the staff members. If you treat them like VIPs, you'll be treated like one as well!

Chapter 18 A Second Opinion: A Prime Necessity Who shall decide when doctors disagree? Alexander Pope

At present, getting a second opinion has become a common practice among doctors; in fact, the American Medical Association advises that â&#x20AC;&#x2DC;physicians should seek consultation upon request; and in doubtful or difficult casesâ&#x20AC;&#x2122;. That is why family physicians often consult with specialists, and specialists, in turn, consult other specialists â&#x20AC;&#x201D; and superspecialists. (Sometimes, though, the process could be misused, and the patient may feel that he is stuck on a non-stop merry-go-round of consulting a wide variety of specialists!) Often, many patients tend to become sceptical or dissatisfied if their doctor suggests that they seek a second opinion, because they feel that such a suggestion indicates that their doctor is not competent. However, one should not forget that medicine is a highly complex science in which rapid advances are the order of the day and it is not humanly possible for one doctor to keep abreast of all developments in all fields. Consequently, a second opinion proves very useful for those patients afflicted with rare or complex problems. Unfortunately, some doctors tend to refer patients unnecessarily to other members of their fraternity. Also, doctors will often cross refer patients to each other for personal financial gain. In hospitals, especially, specialist consultation is often automatic and mandatory, and this process is inevitably overused. The upshot is that the patients bill shoots up! Thus, a hospitalized patient should ask the family physician (who should act as your medical manager) to intervene if the number of specialists involved in the treatment seems excessive. It may be difficult to get an unbiased opinion from a second doctor who is a member of the staff in the same hospital as your doctor. If at all possible, you should consult an independent doctor in another hospital for a second opinion. Most medical insurance policies that cover consultation fees will pay for this. In case of disagreement

between two specialists, a third opinion could prove helpful. In the present age of the telecommunication revolution, the ‘magic’ of telemedicine enables one to get a second opinion from a leading medical authority in any part of the world. The procedure usually consists of sending such an authority your clinical findings and medical reports through the Internet, so that you can get an unbiased opinion usually in as short a period as two days. Many clinics in India now offer this service in collaboration with leading hospitals from all over the world. I always encourage my patients to get a second opinion. As I explain to them: If two different doctors happen to reach the same conclusion, at least you know you are on the right track! However, don’t always assume that just because the opinions of both doctors are identical, you are safe . For example, if you have angina and you consult a cardiac surgeon, there is a high likelihood that he will advise you to undergo bypass surgery. A second cardiac surgeon is also likely to recommend the same; after all, it’s just simple financial common sense from the surgeons’ viewpoint! Therefore, getting a second opinion from a non-surgical specialist (in this case, a cardiologist) can be helpful in preventing unnecessary surgery. What course of action should the patient adopt if the second opinion differs from the first? Such a situation can be very confusing. Consequently, the patient needs to do a good deal more homework before making a decision. It would be worthwhile to get a family physician (preferably one who has no vested interest in the matter) to advise you. It would also be prudent to discuss the differences in the two opinions with the concerned doctors, so that they can explain and justify the reasons for the discrepancies in their diagnoses or plan of treatment. Remember that it’s your body which has to bear the consequences and you need to make your own decisions intelligently. It would be highly sensible to ascertain your options in advance, rather than to burn your fingers and then regret your actions later on ! Many patients also worry about getting a second opinion on their own accord. For one, they are apprehensive that if their first doctor were to find out that they have gone in for a second opinion, he may be offended. Another source of anxiety is the confusion that would result if they get differing opinions; they are worried they would not know what to do when confronted with such a situation. Most patients are quite passive and they tacitly feel that it much easier to trust their doctor and do whatever he suggests, rather than go through the trouble of getting a second opinion. However, by getting a second

opinion, patients should realize that they are not casting aspersions on a doctor’s competence or judgment, but are rather adopting a responsible attitude towards their own health and well-being. All patients have a right to seek a second opinion, and certain circumstances may arise in which it would be appropriate, if not mandatory, for them to exercise this right. They can even ask the doctor (whom they are consulting) himself to refer them to a second or even a third doctor for further consultation. No competent doctor will feel threatened if a patient wants a second opinion ! However, many doctors in India do have reservations about referring a patient seeking a second opinion to someone else, as they are worried that the new consultant may ‘snatch’ their patient away. To solve this problem, some countries abroad have set up specialized second opinion clinics , which consist of senior experts who have retired from active practice, but who use their experience wisely to provide unbiased second opinions ! Many doctors are happy to refer their patients to such clinics, because they are confident that they will not lose their patients in the process ! Keeping all the foregoing factors in mind, the question then arises: From whom should you get a second opinion? You should seek a second opinion from an expert who has the courage to give you an unbiased independent conclusion. Such an expert would, obviously be difficult to find, but it’s well worth searching for him! Another crucial question is: Should you let the expert know your first doctor’s opinion ? Many patients do not tell the specialist that they have already consulted another doctor, because they want an unbiased opinion. However, most doctors do not appreciate patients who play games with them. It’s far better to be forthright and explain to the expert that you are looking for a second opinion, so that he can explain the pros and cons of all the available options. An excellent source for getting an objective second opinion is the medical faculty of public hospitals — government or municipal. This source, unfortunately, has been grossly underused. The staff members here are basically academicians. Since they teach medical students and residents, they are usually well read and well informed. Moreover, since they do not have a financial stake in providing you with advice, their information is likely to be reliable and accurate. Of course, this procedure does involve the bother of waiting for a long time to get to see the doctor, but this wait is often well worth the effort! Remember that it is also possible to get a second opinion from a doctor who practises alternative medicine , for example, homoeopathy or ayurveda. Such an opinion will provide a completely different

perspective of looking at a problem, and you may prefer this alternative. You should also keep in mind that there are other ways of getting a ‘second opinion’ apart from going to another doctor. Presently, many sources of information can be tapped to verify and countercheck your doctor’s opinion; for instance, health books and encyclopaedias (all of which are available free at the Health Education Library for People, Bombay) as well as the Internet! For example, you can “Ask the Doctor” at http://www.flora.org/ask-doctor/, a free site which forwards your medical queries to specialists from all over the world, who then give their respective opinions on your problem. An important point to be noted is that a second opinion should be sought under certain circumstances: 1.

3. 4.

If surgery is recommended. About 80 per cent of all surgery is elective (i.e., performed on a non-emergency basis). Recent studies have shown that one out of five operations is not really required -what is considered ‘unnecessary surgery.’ A second opinion can definitely prevent you from becoming an unsuspecting victim of an overenthusiastic surgeon’s knife! If the diagnosis reveals a rare, potentially fatal, or disabling disease. The original diagnosis could be incorrect and may need to be revised. Or, even if it is correct, there may be new or experimental treatments available at an institution specializing in the treatment of such a disease. If your symptoms persist unrelieved and the doctor can provide no satisfactory explanation for them. If the risks and benefits of the proposed procedures are not satisfactorily explained. The patient has a right to know the details about risks and the cost involved and the potential benefits of any procedure, test or surgery. It is preferable to get the relevant details in writing, so that you can digest them at leisure. If the diagnostic procedures seem unnecessarily complex or expensive, or both. Some doctors are prone to making excessive use of technology in borderline situations, either due to insecurity or to protect themselves against malpractice litigation. If the patient lacks confidence in the doctor’s ability to do all that can reasonably be done. Effective treatment demands trust, and a lack of trust is as valid a reason as any other for getting a second opinion.

Remember you have only one life, and you may not get a second chance to rectify a medical mishap. Many patients (or their relatives) who are victims of adverse medical outcomes, later regret not consulting another doctor, but by then the damage has already been done! The best method is to avoid a problem in the first place â&#x20AC;&#x201D; by getting a second opinion !

Chapter 19 Specialist: A Class Apart An internist is someone who knows everything and does nothing. A surgeon is someone who does everything and knows nothing. A psychiatrist is someone who knows nothing and does nothing. A pathologist is someone who knows everything and does everything too late. Anonymous If you have a medical problem, it helps to know what kind of specialist your family doctor may refer you to. The most common varieties of specialists and their functions are as follows: Allergist – A doctor who specializes in preventing, diagnosing and treating allergies and asthma. Anesthesiologist – A doctor who specializes in administering anesthetics, drugs or agents that produce a complete or partial loss of feeling to relieve pain, commonly, but not always, during surgery. Cardiologist – A physician who specializes in disorders of the heart. Dermatologist – A doctor who specializes in diseases and problems of the skin. Emergency Medicine doctor: A doctor who specializes in the rapid recognition and treatment of trauma or acute illnesses. Endocrinologist: A doctor who specializes in disorders of the hormonal system, including diabetes mellitus. Family practitioner: A doctor who specializes in family medicine. Gastroenterologist: A doctor who specializes in disorders of the stomach, esophagus, intestines and liver.

Geneticist: A professional who specializes in the study or application of genetics, the science that examines the principles and mechanics of heredity. Geriatrician: A medical specialist in the field of geriatrics, i.e., the branch of medicine dealing with the physiology of aging and the diagnosis and treatment of diseases affecting the elderly. Gynecologist: A doctor who specializes in disorders of the female reproductive system. Haematologist: A doctor who specializes in the field of haematology, i.e., the study of blood and blood-forming tissues. Infectious disease specialist: A doctor who specializes in the prevention, diagnosis and treatment of infectious or communicable diseases. Internist: A doctor who specializes in internal medicine, i.e., the branch of medicine concerned with the physiology and pathology of the internal organs and with the medical diagnosis and treatment of disorder of the internal organs. Neonatologist: A doctor who specializes in the care of an infant from birth to four weeks and in the diagnosis and treatment of disorders of the newborn. Nephrologist: A physician who specializes diagnosis, and treatment of the kidneys.

the

prevention,

Neurologist: A physician who specializes in disorders and treatment of the brain and the nervous system. Obstetrician: A doctor who specializes in pregnancy and childbirth. Oncologist: A surgeon who specializes in the diagnoses and treatment of cancer . Ophthalmologist: A surgeon who specializes in the comprehensive care of the eyes and in the prevention of eye diseases and injuries.

Orthopedic surgeon: A doctor who specializes in disorders and diseases of the skeletal system. Otolaryngologist: A doctor who specializes in diseases and disorders of the ear, nose and throat. Also known as a head and neck. Pediatrician: A doctor who specializes in the care of infants and children. Pathologist: A doctor who studies and analyses tissues, samples and body fluids in the laboratory. Pharmacologist: A specialist who studies the preparation, properties, uses and actions of drugs or medications. Plastic surgeon: A doctor who performs surgery to repair bodily defects. He also performs cosmetic or aesthetic surgery, i.e., the alteration of visible parts of the body to improve the external appearance. Proctologist: A doctor who specializes in the prevention, diagnosis and treatment of disorders of the colon, rectum and anus. Psychiatrist: A doctor who specializes in the prevention, causes diagnosis and treatment of mental, emotional and behavioral disorders. Psychiatrists differ from other types of mental health professionals, (such as psychologists and psychoanalysts) in that they have earned a medical degree and specially training. As such, they are the only mental health specialists who are authorized to prescribe medication. Pulmonologist: A doctor who specializes in disorders of the lung. Radiologist: A doctor who specializes in radiology, i.e., the branch of medicine concerned with imaging the human body, using X-rays and scans. Rheumatologist: A doctor who specializes in disorders of connective tissue and related structures; largely, they diagnose and treat inflamed and diseased joints and arthritis.

Surgeon: A doctor who specializes in diseases and trauma that require operative procedures. Surgeons can be general surgeons as well as specialized surgeons in specific branches of medicine: for example, cardiovascular surgeons, neurosurgeons and pediatric surgeons. Thoracic surgeon: A doctor who performs chest and lung surgery. Urologist: A doctor who specializes in the diagnoses and treatment of diseases of the urinary tract in males and females, and those of the genital tract in males, including prostate problems. Vascular surgeon: A doctor who specializes in the surgical treatment of arteries or veins. One should remember that often a specialist is an expert who knows more and more about less and less. Therefore, it is your primary care doctor who should guide your medical care! Given the increasing complexity of modern medical care, there are likely to be many other varieties of health-care workers you will encounter, and you should be aware of their functions as well: Audiologist: A health professional who diagnoses and treats hearing problems and helps provide rehabilitation to individuals with hearing loss. Dietitian: A person trained in the nutritional care of group and individuals. Emergency medical technician (EMT): A person trained in, and responsible for, the administration of specialized emergency care and transporting acutely ill or injured individuals to a medical facility. EMTs are yet to become popular in India. Nutritionist: A person who studies and applies the principles and science of nutrition. Occupational therapist (OT): A health professional who evaluates and treats individuals who are limited in their ability to function fully, due to physical injury or illness. Ots encourage â&#x20AC;&#x2DC;purposeful activityâ&#x20AC;&#x2122; (for example, teaching how to cook a meal or use public transportation) in

their ‘clients’ to maximize independence, prevent disability and maintain overall health. Paramedic: A person who is trained in certain emergency medical procedures and assists a doctor during such procedures. Pharmacist: A qualified professional who formulates (prepares) and dispenses medications. Licensed pharmacists must procure at least a Bachelor’s degree in pharmaceutical science (B Pharm). Phlebotomist: A technician trained in drawing blood and starting intravenous lines. Physical therapist (PT): A health professional who examines and treats individuals with physical limitations or disabilities. PTs must obtain a Bachelor’s degree as a minimum requirement. Psychologist: A person who studies animal and human behavior. A clinical psychologist must hold a graduate degree in psychology. A psychologist provides testing facilities and counseling to people with mental or emotional disorders. Social worker: A professional with advanced education, generally a Master’s degree in social work, or MSW, who tackles social, emotional and environmental problems in association with illness or disability. Social workers about counsel individuals and families community resources, and depending on their area of specialization and training, on coping with mental illness or disorders. They also often assist in providing financial assistance to poor patients. Speech therapist: A practitioner trained in speech pathology who treats people with disorders that affect speech. X-ray Technician: Also called a radiologic technologist, an X-ray technician is a person who operates radiologic equipment and assists radiologists. Remember that if you know who does what in the world of medicine, you are likely to be able find the right person to help you in resolving your problems!

Chapter 20 The Ideal Doctor's Code of Practice ..the secret of the care of the patient is in caring for the patient. Francis W. Peabody The People's Medical Society in the USA encourages doctors to display the following code of practice in their clinics. This code comprises are excellent guidelines for all doctors to follow, and you might consider sharing it with your doctor! The code runs as follows: I will assist you in finding information resources, support groups and health care providers to help you maintain and improve your health. When you seek care for specific problems, I will abide by the following code of practice: 1. I will post or provide a printed schedule of my fees for office visits, procedures, testing and surgery, and provide itemized bills. 2. I will provide certain hours each week when I will be available for non-emergency telephone consultations. 3. I will schedule appointments to allow the necessary time to see you with minimal waiting. I will promptly return your phone calls and inform you if your test results. 4. I will allow and encourage you to bring a friend or relative into the examining room with you. 5. I will facilitate your getting your medical and hospital records, and will provide you with copies of your test results. 6. I will let you know your prognosis, including whether your condition is terminal or will cause disability or pain, and will explain why I believe further diagnostic activity or treatment is necessary. 7. I will discuss diagnostic, treatment and medication options for your particular problem with you (including the option of no treatment) and describe in understandable terms the risk of each alternative, the chances of success, the possibility of pain, the effect on your

functioning, the number of visits each would entail and the cost of each alternative. 8. I will describe my qualifications to perform the proposed diagnostic measures or treatments. 9. I will let you know of organizations, support groups, and medical and lay publications that can assist you in understanding, monitoring and treating your problem. 10. I will not proceed until you are satisfied that you understand the benefits and risks of each alternative and I have your agreement on a particular course of action.

21 The Responsibilities of a Patient: Quite a Load! Doctors know only what you tell them. Don Harold As a patient, you have to shoulder a wide variety of responsibilities, some of which are as follows: 1. You should provide your doctor with accurate and complete information about your medical history, past illnesses, allergies, hospitalizations and medications. 2. You should report changes in your condition (however minor they may seem to you) to your doctor â&#x20AC;&#x201D; don't keep him in the dark! 3. If you do not understand what your doctor says or wants you to do, you should let him know without any hesitation! 4. You should strictly follow your doctor's treatment plan. 5. You should keep your appointments on schedule, and if you cannot do so for any reason, let your doctor know well in advance. 6. You should pay your medical bills promptly! 7. You should follow hospital rules and regulations without fail. 8. You should have realistic expectations of what the doctor can do for you. Everyone would like to get well completely, but one should always bear in mind that the doctor is not a miracle worker. 9. You should help your doctor to help you! If you cannot stick to a particular treatment plan, let your doctor know, so that he can formulate an alternative plan. 10. You should maintain good health habits. 11. You should participate actively in your medical care. Patients who are highly motivated get better faster: in other words, help your body to heal itself! 12. You should ask questions to clarify any doubts or dispel any misconceptions in your mind. A doctor or nurse may not know when you're confused, uncertain or just want more information. Therefore, do not refrain from asking questions.

13. You should respect the doctors and the nurses. The medical staff deserve your respect and courtesy: treat them the way you would like to be treated by them! 14. You should not ask for false medical certificates or padded medical bills (in order to get additional reimbursement). While you obviously have a vital interest in your medical treatment, unfortunately, you lack the specialized medical knowledge and skills to be able to take decisions in this context alone. This is why the concept of a team — which consists of you and your doctor becomes very important. As a patient, your responsibilities are wide and varied. And you’ll need to play several “roles” at various times. Medical Information Researcher The more knowledgeable you are about your problem and its treatment, the better are your chances of getting the right treatment. Educate yourself: you need to become an informed participant in your medical care in order to ask the right questions and to participate in making decisions about your treatment. This step will also help you to critically assess media reports about ‘new breakthroughs in medical treatment’, and whether these ‘breakthroughs’ are relevant to your problem or not. Medical Team Manager You will have to find, evaluate, select, hire — and sometimes fire — members of your medical team. As an enlightened patient, you need to remember that you are the one in charge of your body --- and that it’s your medical team you are managing! Treatment Decision Maker You will have to decide which treatment to choose among the alternatives. Sometimes the choices are straightforward, but sometimes they can be very confusing. A good doctor will offer you all the options and help you to decide, but ultimately, you have to exercise your right (and responsibility!) to select a course of treatment. You cannot afford to leave everything to god, or to the doctor either! Medical Record Keeper

You must keep all your records safely, and this can be very helpful especially if you have a complex problem a chronic disease, or need to change doctors or get a second opinion. File all your records in reverse chronological order; and number all your documents in sequences. Also prepare a one-page summary sheet of your medical experiences. Software packages are available nowadays, which help you document all medical details very efficiently. Financial Manager Medical treatment, can be very expensive these days, and you must make it a point to know the costs involved. Many patients are hesitant to talk to their doctor about money matters, but this reluctance can prove to be very costly! Also, if you are claiming reimbursement (either from an insurance company or from your employer) you must make sure that you have complete records of payments made along with their receipts. Communicator It is vitally important that you be open and honest with your doctor. When in doubt, ask questions, listen to the answers carefully and take notes. A prudent measure would be to write down your questions before your appointment, so that you do not forget important matters during the stress of consultation. Remember, the only stupid question is the one you don't ask! So, to re-emphasize, don't hesitate to ask questions! And if you don't understand the answers, the fault is not all yours; it could be that your doctor is not explaining the facts well! There is no doubt that the one person who will look after his own interests the best is the patient himself. You need to do your homework thoroughly, find out more about your problem , and then discuss the results of your research with your doctor. This is your right, and your responsibility as well! Every honest doctor will agree that his patients are his best teachers!

Chapter 22 Your Rights as a Patient When men say they have rights, they generally mean that they are suffering wrongs. J.A.Spender The Patient's Bill of Rights, has been popularized in the USA by the American Hospital Association and all these rights should apply to all patients, all over the world! Patients in India are so used to being at the “receiving end” of medical care, that they sometimes forget that they do have rights! All patients have the right to: Respectful Care Medical staff should respect your dignity and be sensitive to your needs. Treatment must be provided regardless of your race, religion, national origin, or, in emergencies, your ability to pay. Complete Information You must be given complete, up-to-date information about your condition, treatment and chances for recovery. You also have the right to review your medical records — after all, they are your property! Informed Consent You must give written permission for any procedure, test or treatment. Before you can do this, your physician must explain to you, in language you understand the following: The advantages and risks of the procedure. Any possible side-effects. The consequences of not receiving treatment. How long recovery can be expected to take. Privacy

Personal or medical details of your condition and treatment may not be needlessly disclosed to others at any time. In most cases, you must give permission before anyone not directly involved in your case is given information about you. Confidentiality All communications and medical records (messages between you and your physician, hospital charts, test results, X-rays, etc.) must be kept private. You must give permission for the release of your records for specific purposes in most cases. Acceptance for Treatment If you request treatment at a hospital, you shouldn't be refused or sent to another hospital without a good reason. The decision should be based on: Whether Whether Whether Whether Whether

the hospital is qualified to treat your condition. the necessary equipment is available. treating you could potentially endanger others. your condition requires immediate treatment. treatment will be of value to you.

Information about Affiliation You have the right to know about any financial links your hospital and physician may have with other institutions. For example, if your physician recommends treatment at a specific institution, you have a right to ask if he or she is affiliated with that institution. Acceptance or Refusal of Treatment As a legally competent adult, you have the right to accept or refuse any medical treatment. Refusal of Experimental Treatment In some cases, physicians may recommend experimental therapies, medication or other courses of treatment. You must be told if your proposed treatment is experimental and what the potential results and

risks are. You may refuse to participate in any research if you do not wish to â&#x20AC;&#x201D; it's your choice! Knowledge of Hospital Regulations You should be told about the rules which govern conduct in the hospital - for example, regulations about visitors, smoking, meals, movement in the hospital, etc. Information about Continuing Care Before scheduling any treatment, you should be told when and where a physician will be available. This may save you the trouble and expense of long waits or long trips for treatment. You must also be told what treatment may be needed after discharge from the hospital. Information about Your Medical Fees You have a right to receive a copy of your bill and to know the charges for each service you receive. Remember, that you can demand your rights, only if you are aware of them!

Chapter 23 Your Medical Records: Vital Statistics ‘The horror of that moment,’ the King went on, ‘I shall never, never forget!’ ‘You will, though,’ the Queen said, ‘if you don’t make a memorandum of it.’ Lewis Carroll It’s a sad fact of life that most people devote more time and energy on organizing their bank statements, than they do on their medical records. They simply club together their prescriptions, chemists’ bills, lab reports and doctor’s findings, leading to an unwieldy and disorganized hodgepodge of papers, from which it is difficult for them (and their doctor!) to retrieve any useful information without wasting precious time. This state of affairs is very unfortunate, because only accurate medical records can help you to get the best medical care. Remember that maintaining a personal health record at home is one of the best ways of ensuring that you will have upto date information about your health at all times Since a doctor's diagnosis is based primarily on your medical history, your ability to provide complete and accurate information is crucial in ensuring you get good medical care. That is why you need to devote adequate time to organizing your medical records before you consult a doctor, so that you can answer his questions completely and accurately. This first step is to file all your papers in reverse chronological order i.e., the oldest ones last, and the newest ones first. It is a good idea to number the documents, to make sure they are all in order. Large-sized reports such as, X-rays and scans need to be carefully stored in a separate oversize file. Keep bills and envelopes separately if needed; these items need not be part of your medical record! If you have ever undergone surgery or hospitalization, make sure you get a complete discharge summary from the doctor, as this is information could prove vital in the future. If you do not get this information soon after discharge, it may be irretrievably lost and this loss can prove to be rather expensive to you! Make sure you understand fully the condense of the discharge summary; if you don’t, please ask your doctor to explain it to you! While it is the doctor’s responsibility to provide you with this information on a routine basis, it’s important that

you ask for it after all, itâ&#x20AC;&#x2122;s your record! If you change doctors, your present doctor should give you all your medical details, so that you can provide them to your new doctor. You may find your present doctor is reluctant to part with the information (after all, he may not want you to go elsewhere), but you need to assert your rights. If your file becomes very thick (as it may if you have a chronic illness), it is a good idea to summarize your medical history on a single sheet of paper, and to update it on a regular basis, as needed. Your doctor can help you to prepare this summary to make sure it is accurate and contains all the relevant information. A sample of a form which you can use to track your medical history is given in Appendix 1. Your medical record must also contain information about the following: Allergies. List all your allergies and sensitivities, especially to medicines, foods, and chemicals. Medications. Make a list of all drugs that you are presently taking. Don't overlook oral contraceptives, nonprescription medications (such as allergy pills, vitamin and mineral supplements), and alternative remedies such as herbal preparations. Include appropriate details on dosages and brand names. Previous adverse reactions to drug or side-effects. This knowledge is very important because many medications are chemically related to each other. Pacemaker or any other implanted device. This information is important because some examinations, such as magnetic resonance imaging, should not be done on patients who have certain electronic or metal devices in their body. Any forms of treatment you are now undergoing. In addition to describing other medical treatments, be sure to include any home remedies or alternative therapies, such as dietary remedies, enemas, herbal or natural medicines and homeopathy. In addition to your own personal medical history, pay particular attention to your family tree. In order to construct a family medical tree, carry out research on your parents, siblings and children. Then add information about grandparents, aunts uncles, cousins, nieces and nephews. The more relatives you include, the better. Be prepared to do a bit of detective work when filling in the relevant details in your family tree. Most families so have an unofficial family historian who can provide information about the health and longevity of previous

generations. The family tree should ideally depict all the relatives , the diseases they had, the age at which these developed, when they died, and what they died . Make copies of this family tree and distribute them to other family members ; theyâ&#x20AC;&#x2122;ll appreciate your gesture! This information can be invaluable in developing a preventive approach towards health maintenance. A family history of heart disease, high blood pressure, and other common killers that appear to have a hereditary component can alerts you and your doctor to your increased vulnerability, so that you can tailor your lifestyle to minimize your risk. You may also be advised to undergo more frequent medical checkups. If, for example, you detect a family history of colon cancer, you may be advised to undergo periodic colonoscopy or other screening examinations for this disease, even if you are free of symptoms. Many inexpensive computer programs are now available, which can help you to record your medical history. Not only do they ensure that your record is complete and legible, but they also allow you to update it easily. Such a programs are well worth investing in, if you own a computer ! You should keep all your medical records in one safe, and easily accessible place, along with the following information ( this can save your life in a medical emergency !): * Person to notify in an emergency. * Name and phone numbers of your doctor, dentist, optometrist and chemist. * Current medications you are taking. * Organ donor authorization details. * Health insurance information Understanding your hospital medical record. What about your hospital medical records ? These can be voluminous documents, and it may find it difficult to make sense of all the papers , reports, forms and charts in them. However, once understand the structure of the records, you can comprehend the details more easily. Documents Common to Most Health Records

The Identification Sheet is a form that originates at the time of admission. This form lists your name, address and telephone number. The document on History and Physical/Clinical findings describes factors such as: (1) any major illnesses and surgeries you have had; (2) any significant family history of disease; (3) your health habits; and (4) current medications. In addition, it usually specifies your height, weight, blood pressure, pulse, respiration rate, any particular symptoms you may have described, and details of your physical examination. Progress notes are notes made by the doctors, nurses, and therapists caring for you that reflect your response to treatment and their observations and plans for continued treatment. Consultation is an opinion about your condition made by a physician other than your primary care physician. Sometimes, a consultation is performed because your physician would like the advice and counsel of another physician. At other times, a consultation occurs when you yourself request a second opinion. Physician's Orders are contained in a document which records your physician's directions regarding your medications, tests, diet and treatments. Imaging and X-ray Reports are documents describing x-ray results, mammograms, ultrasounds, or scans. The actual films are usually stored in the radiology or imaging departments. Electrocardiogram (ECG, EKG) reports. Lab Reports describe the results of tests conducted on blood, sputum, urine and other body fluids. Common examples would include a urinalysis, complete blood count (CBC), cholesterol level and throat culture. Authorization Forms include copies of consents for admission, treatment and surgery. The Operative Report is a document describing the surgery performed and gives the names of the surgeons and assistants involved. The Anesthesia Report is a form documenting the pre-operative medication, anesthesia given, and the response to anesthesia during surgery. The Pathology Report describes tissue removed during an operation (if any) and gives a diagnosis based on the examination of that tissue.

The Graphic Sheet is generally a graph used to plot your temperature, pulse, respiration, and blood pressure over a particular period of time The Discharge Summary presents a concise account of your stay, which includes the following information: the reason for admission; the significant findings from tests; the procedures performed; the therapies provided; the response to treatment; the condition during discharge; and instructions for medications, activity, diet, and follow-up care. Some nurses and doctors still do not know that patients have the right to see their own medical records. To avoid the being victim of a misinformed medical professional, it is vital that you know your rights. In fact, some consumer advocates argue that it is a good idea for patients in a hospital to take a look at their own medical charts routinely, to make sure that the doctors and nurses have written down everything accurately; after all, medical notes can be inaccurate or incomplete, leading to confusion in the future! How do you go about getting copies of your records? Simple: just a your doctor! Remember that you have a legal right to your medical record, and, while technically, the documents belong to the hospital, in most cases, the information about you belongs to you. Of course, the hospital may charge you for making copies, and you will need to pay the required amount. While your records are very helpful in improving the quality of your medical care, do not forget that they can also prove extremely important in case you are unhappy with your medical care, and need to complain about your doctor or hospital, since these records can be used to support your claim. They are also vital when you need to claim reimbursement for expenses for medical treatment from your insurance company. To put the importance of your medical records into perspective, remember that records serve many purposes. For instance, these records provide: 1. The basis for planning your care and treatment. 2. A means of communication amongst the many health professionals who contribute to your care .

3. Basic data for health research and planning. 4. Verification of services and treatment covered by your insurance. 5. A legal document describing the care you received. Make sure you take extremely good care of your medical records â&#x20AC;&#x201C; they can help you to get good medical care in return!

Chapter 24 Beware of Medical Care ! Most people think that medical care is good for you. The fact is that some medical care is good for you, a great deal is irrelevant, and unfortunately, some of it is harmful. Lester Breslow Iatrogenic illnesses are those dirty little secrets of the medical world which no one likes to talk about. An iatrogenic (Iatros = physician and gen = producing) illness is one which is caused by medical treatment. It is defined as an adverse effect caused by a physician's actions, including reactions from prescribed drugs or from medical procedures. Some iatrogenic problems, such as multiple pregnancy after in vitro fertilization, may be unavoidable, and are considered as part of the risk-benefit ratio of the treatment. However, many iagtrogenic complications occur as a result of clinical errors, either of omission or of commission. Errors of omission occur when a doctor neglects to take certain precautions (for example, he does not check whether a patient is allergic to a drug before prescribing it, or does not check the blood group label on the bag before transfusion). Errors of commission occur when a doctor misinterprets a situation and carries out an action which he should not have (for example, he misdiagnoses a benign abnormality on an ECG as indicative of heart disease and starts unnecessary treatment). Some iatrogenic problems (such as not giving an injection on time), are minor, self-limited, and of little importance. However, some problems may be major (for example, operating on the wrong leg) and can lead to disastrous consequences ! However, do bear in mind that not every bad medical outcome is a result of an error; sometimes the condition of a patient may take a turn for the worse or he may even die, although the medical care has been superb ! According to a recent estimate, 13 per cent of hospital admissions result from the adverse effects of medical diagnosis or treatment. At present, iatrogenic illness has come to be recognized as

a significant risk factor in medical care. The tragedy is that this is a relatively modern phenomenon; the price we pay for delivering medical technology to ailing patients concentrated in large hospitals. The reason why iatrogenic illness is such an uncomfortable topic to talk about is that all of us would like to pretend that doctors (and other health care professionals) are infallible; to put it differently, the notion that we are in safe hands can be very reassuring when we are ill! The ideal held by medical professionals has always been to do no harm – ‘premium non nocere’ being the doctor’s first maxim. However, shocking accounts of medical blunders resulting in debilitating sideeffects, permanent disability, and even death abound. Since almost 70 per cent of iatrogenic complications are preventable, what can you do to protect yourself from them? Most iatrogenic errors occur when patients are admitted to a hospital, because here they are virtually at the medical staff’s mercy! If you think that a stay in the hospital could endanger your health, you’re absolutely right! Recent studies show that errors or accidents may harm up to 20 per cent of all hospitalized patients. Iatrogenic illnesses may be divided into four broad categories. The first is the most obvious, which is damage that occurs as the direct result of an invasive procedure ( for example, a blood vessel being torn during laparoscopy). The second is an insult due to therapy with a medication (examples are aplastic anemia resulting from chloramphenicol therapy and immune suppression resulting from chemotherapeutic drugs). The third type of iatrogenic illness is a new disease caused by the treatment (for instance, leukemia resulting from radiotherapy). The fourth category is subtle and the most difficult to recognize: a disease which progressively leads to complications because it remains undiagnosed or is improperly managed by the physician. One should always bear the possibility in mind that an adverse situation might be a result of the medical care itself, rather than assuming it stems from the disease ! Until recently, the unintended mishaps that occur in a hospital were hardly ever mentioned. However, today many hospitals and doctors are addressing the problem seriously, and taking effective steps to improve safety. These steps include: openly acknowledging the potential for error in medicine; analyzing medical accidents more carefully; and targeting areas where patients face the highest risk in order to minimize the scope for errors. As a patient, however, you are at the receiving end of medical care. What can you do to make your hospital stay as safe as possible? The

best way of averting errors when you are admitted to the hospital can be summarized in two words: Speak up ! While most doctors and nurses put in their best efforts to provide excellent care, remember that hospitals are staffed by human beings who sometimes make human mistakes. Although serious errors are the exception, and not the rule, they can occur at any time, and at any hospital, with serious consequences. Unfortunately, most patients are so intimidated by complex hospital routines and the seemingly overworked personnel that they try to stay out of the way and create as little trouble as possible. But despite such a scenario, you should never forget that the hospital is one place where it definitely pays to be involved and assertive! During the period of hospitalization, do ask questions about anything you don't understand. Be polite and pleasant, but be persistent. Try to understand the purpose and the schedule of every medication you are given. If you are given a medicine that looks unfamiliar, ask for details about it. If you know you suffer from a drug allergy, make sure everyone else knows about it too. If you have not been given your dose of six o'clock pills till eight oâ&#x20AC;&#x2122;clock, do inform someone. If a person comes into your room and fails to identify himself, find out who he is and what he wants. If you are wheeled off for a test that you haven't been expecting, ascertain why it is necessary. Most of the time, you will find that everything is going exactly the way it is supposed to , and someone was just too forgetful or busy (or rude) to let you know. But every once in a while, you will identify a real problem. Which you will be able to resolve because of your alertness! Admittedly, being involved in your medical care can be difficult if you are feeling ill or run down; so try to recruit someone to be your advocate, i.e., a friend or a relative who will ask the relevant questions on your behalf. And a final precaution: Make sure that everyone who enters your room to examine you washes his or her hands before and afterwards. Medical personnel should actually thank you for reminding them about this activity: hand-washing is the single best proven method of minimizing hospital infections! Of course, iatrogenic illnesses are not restricted to hospitals only; any medical procedure could lead to potential problems. However, if you are aware of the possibility of these problems occurring, you can actively help prevent them.

What if an iatrogenic error does occur? Most patients would naturally like to be informed about this error. They would expect the doctor to provide an explanation or an apology, and to rectify the error. In fact, this is what the doctor's ethical obligation to the patient is. However, given the fear of a malpractice lawsuit being slapped on them, most doctors today react to iatrogenic errors by trying to cover them up and hiding them from the patient. Such a step is retrogressive, because it often makes a bad situation worse. Recent surveys have shown that most patients who finally end up pursuing litigation usually experience multiple complaints including (1) professional failure in diagnosis or treatment, (2) a lack of communication on the part of the doctor; and (3) some form of insensitivity on the part of the doctor that has emotionally upset them. This sorry state of affairs implies that insult has been added to injury. Such a development not only destroys the relationship of trust between doctor and patient but it also makes the patient more vengeful if he does find out about the medical botch-up through another source. All said and done, honesty is still the best policy !

Chapter 25 Checking up the Medical Check-up We shall have to refrain from doing things merely because we know how to do them. Sir Theodore Fox. The Lancet, 1965 Nowadays, most patients head for their doctors’ clinics (or hospitals) for check-ups more than for any other reason. The ostensible objective is to ward off disease. In fact, of late, the annual medical check-up has become a ritual in many companies for many executives. While most patients assume that this is a standardized routine, a debate still rages in the medical profession regarding what tests ought to be performed, on whom, beginning when and how often. Often, patients seem to fall into two extreme categories: those who get no routine medical care and those who excess medical care including screening tests, even though they do not really ‘need’ them. Periodic tests and examinations should not become routine or part of a standard ‘one-size-fits-all’ package. In order to be really effective, they need to be tailored according to a person’s age, sex , family history and personal risk factors. Unfortunately, due to the widespread fallacy that the human body is no better than a machine, we have been taught that the body needs ‘routine maintenance’ which should be performed by a doctor, much as your mechanic tunes up your car periodically. However, medical experts have debunked such an analogy as being a gross oversimplification. They have emphatically stated that screenings and early detection are not a universal panacea to ward off all ills. At present, many people rather effusively gush: ‘Doctor, give me the works, I want a full check-up!’ Many clinics now readily pander to this demand by providing a wide range of ‘executive health check-up schemes,’ but often these ‘schemes’ can be more harmful than beneficial ! In fact, routine tests, such as electrocardiograms, chest Xrays and full blood screening, have been found to provide little overall benefit for the healthy individual. If such is the truth, then one may

well ask, why have these health check-up schemes have become so popular ? The answer is simple: they bring in the ‘moolah’! After all, much more money can be raked in by screening droves of healthy people, rather than by only taking care of sick patients. And then there is the additional lucrative bonus that the screening tests will ‘pick up’ abnormalities, thus converting a formerly healthy person into a patient who needs medical attention! While it is true that the concept of routine testing on a regular basis sounds attractive (after all, isn’t prevention much better than cure?), remember that your body is not a car! The major drawback of the tests conducted at present is that they are not very accurate. In other words, a large number of “false positives’ crop up; i.e., patients whose test results are abnormal but have no illness in reality! Not only does an abnormal test result create a lot of anxiety and stress but it also leads to a merry-go-round of further tests and consultations in order to determine whether or not the original result has any significance. In fact, the only routine tests that the US Preventive Services Task Force recommends are those for blood pressure, cholesterol, colorectal cancer, breast cancer and cervical cancer. This task force refused to recommend widespread screening against other diseases for two reasons: either the tests had been found to have no merit, or there was not enough evidence to prove their benefit (i.e., they did not help to improve either life expectancy or the quality of life). In fact, screening tests could have a major negative impact on one’s health, which is why they should be undertaken with a great deal of discretion and caution! The US Preventive Services Task Force soundly criticized physicians for frittering away their valuable time on screenings of questionable value instead of counseling people about the harmful effects of smoking, lack of exercise and other risks arising due to a faulty lifestyle. The only tests the task force recommended were: 1. Periodic check-ups for blood pressure for all adults. (High blood pressure is a leading risk factor for coronary heart disease, stroke, renal disease and heart attack.) 2. Total blood cholesterol measurement for men between the ages of 35 and 65 and women 45 to 65 (high cholesterol constitutes a risk factor for heart disease.) The frequency of testing was, however, not specified. 3. Screening for colorectal cancer for individuals over 50, by testing the stools for the presence of blood, or through sigmoidoscopy. Colorectal cancer is common in USA.

4. Mammogram (an X-ray to detect the early signs of breast cancer) for women between 50 and 69, every one or two years. 5. The PAP smear test , to screen for cervical cancer, for sexually active women once every three years. 6. Vision tests for children, before entering school, and for the elderly. 7. Tests for elderly people (or those with specific complaints) to assess hearing loss. Another simple but helpful test comprises measuring intraocular pressure to screen for glaucoma ( which may cause blindness). The role of (1) routine blood sugar testing (to screen for diabetes); (2) of thyroid hormones in the blood (to screen for thyroid disease); and (3) of bone densitometry in menopausal women ( to screen for osteoporosis) is still unclear. It is worth remembering that even the experts differ in their recommendations! For example, presently, a major controversy is raging as to whether mammograms should begin at the age of 40 or 50. The rate of false positive results has been higher among younger women, possibly because the women in the 40 to 50 age group have denser breasts than those over 50. Recent studies show that young women stand a 50 per cent chance of obtaining a false positive result over 10 years of annual mammograms. Such women endure intense anxiety and sometimes disfiguring biopsies before learning that they donâ&#x20AC;&#x2122;t have cancer after all ! Another controversy relates to the need to screen a prospective candidate for prostate cancer, either by rectal examination, or through a blood test for determining the presence of PSA (prostate-specific antigen). The PSA test measures the level of a specific protein in the blood that can indicate cancer and other prostate abnormalities. The drawback with this test, as with most screening tests, is that an elevated level of PSA is not diagnostic of prostate cancer. In fact, a number of patients who are normal will be found to have elevated PSA levels. Then, in order to prove that they are not suffering from prostate cancer, they will be subjected to a prostate biopsy, and sometimes even surgery to remove the prostate altogether. The adverse consequences of widespread screening include (1) a large number of false positive results, causing needless anxiety and concern; (2) unnecessary biopsies; and (3) harmful effects of aggressive treatments for slow growing cancers that may never have caused symptoms in a patientâ&#x20AC;&#x2122;s lifetime and could have been left well alone.

As for testing for the early detection of other hidden cancers and early heart disease, the Task Force believes that physicians’ time could be put to more productive use by discussing unhealthy behavior patterns with patients. After all, a doctor can do far more good for his patient by getting him to stop smoking than by subjecting him to a battery of tests or prescribing, a motley bunch of pills for him! Therefore, the vital question is: what can you do to get maximal benefit from a medical check-up? Remember that you do not need to go in for a check-up every year; individuals in their 20s and 30s, who have no symptoms, can safely undergo a physical once every 2 to 5 years. When you go for your periodic check-up, take all relevant medical records: for instance, your medical and family history; and all the medications you are taking (or have taken). Also, spell out clearly (to the doctor) the details about your lifestyle. Your doctor should talk to you and listen to you during your check-up, since disease prevention is as important as detection. People without any indicative symptoms do not need a chest X-ray, electrocardiogram or complete blood work. Since these do not provide the doctor with any clinically useful information. Therefore, you do not have to subject yourself to the ‘delights’ of such tests just because they are offered as part of the package! Many patients naïvely believe that the more the tests the better, the outcome. They are invariably enticed by expensive packages which offer more tests and, consequently, ‘better value for money’. However, such a belief is not true! A cost-effective check-up can be very simple, and should include the following: a physical examination; measuring height, weight, pulse and blood pressure; blood tests for cholesterol; and screening for colorectal cancer. For women, apart from the preceding tests, the physical should include a PAP smear test and screening for detecting breast cancer. Modern medicine has finally realized that simple common sense measures are much more effective than complex and exorbitant tests and scans for maintaining an individual’s health. The trouble is that these measures are greatly undervalued by patients due to their simplicity! Therefore, it would be rather futile to squander money on unnecessary tests during your check-ups. Remember that common sense is as important as a computerized report in preventive medicine!

Chapter 26 Medspeak: Making Sense of Medical Jargon When I use a word, Humpty Dumpty said in a rather scornful tone, it means just what I choose it to mean --- neither more nor less. Lewis Carroll Patients often complain that they can never understand anything their doctor says. This usually because doctors use medical jargon --but you should never get intimidated by this! You just need to remember that such jargon is simply a convenient shorthand which doctors ( and other health care professionals) use to communicate with each other. Since these words are often derived from the classic languages ( Greek and Latin), they may sound unfamiliar and difficult to understand, but if you devote enough time and take enough trouble, you can definitely do so. Remember that itâ&#x20AC;&#x2122;s not a secret code which is being used to keep you in the dark! If you have difficulty in understanding medical terms, you can ask your doctor to help you. Nurses, or family members in the medical profession, can also provide guidance. However, the easiest way to go about making sense of the jargon is to sit and decipher it with the help of a medical dictionary and a medical encyclopedia: the effort can prove very worthwhile! Spelling counts, and the first and most important step is to find out the proper medical terms and their spelling. Therefore, ask your physician (or the nurse or assistant) to write these down, as related to your specific case. The words - or terms - which make up the language of medicine are referred to as the terminology of the medical field, or medical terminology. Like every other language, medical terminology has changed considerably over time, but the majority of the terms are derived from Latin or Greek. As with all words, most medical terms can be broken down into one or more word parts. Basically, there are four possible parts, and any given medical term may contain one, some or all of these parts: 1. Roots,

2. Prefixes, 3. Suffixes, and 4. Linking or combining vowels. An example of a word with three of the foregoing parts is the medical term pericarditis. Pericarditis can be analysed for its meaning by dividing it into three parts: peri-card-itis. Once divided into its essential parts, pericarditis can be translated into ordinary English as follows: 1. The prefix ‘peri’ translates as surrounding (as in perimeter) 2. The root ‘card’ translates to heart ( as in cardiology). 3. The suffix ‘itis’ translates to inflammation. Thus, this analysis allows us to conclude that pericarditis means inflammation of the outer layer of the heart. Medical terms always consist of at least one root, although they may contain more. The root of a word is that part which contains its essential meaning: for example, in the term pericarditis, the root of the word is card, refers to the heart. By adding a prefix or suffix to the root (card), new medical terms are created. For example, let’s take the prefix brady, which means slow. If brady is added to the root card, the term bradycard, which roughly means slow heart, is created. Then, if the suffix ia - which means abnormal state - is added to "bradycard", the medical term bradycardia is formed. Thus, the translation of bradycardia (brady-card-ia) is: slow - heart - abnormal state, or the abnormal state of a slow heart rate. Let us move on to linking or combining vowels. As just discussed, a medical term must have at least one root, but need not have a prefix and/or a suffix. An example of the term sternocleidomastoid, which is a muscle that has attachments at the following bones: the sternum, the clavicle, and the mastoid. The term sternocleidomastoid can be divided into three parts (three roots, in this case): stern - o - cleid - o mastoid. Notice that there are vowels between the three roots which are linking or combining vowels, and these serve to make a term easier to pronounce. The vowel used most of the time is ‘o’, but other vowels such as ‘i’ and ‘a’ are also used. Combining vowels are often used between roots and suffixes or roots and other roots, but they are not used between prefixes and roots.

Here are more examples of how to “ translate “ medical jargon” into a layperson’s terms: Suffix

Definition

Example

algia(or dynia-) Pain Neuralgia blast – Early stage of a growth Cytotrophoblast ectomy – Surgical removal Appendectomy itis – Inflammation Bronchitis lysis – Freeing of Adhesiolysis oma – Tumor Melanoma oscopy – Viewing Laparoscopy osis – Process or condition Endometriosis pathy – Abnormality Myopathy plasty – To rebuild or restore Rhinoplasty pnea – Breathing Apnea rrhea – Flow Diarrhea scler(osis)Hardening Arteriosclerosis uria Pertaining to urine Glycosuria One other reason why medical jargon can be so hard to decipher is that doctors make liberal use of acronyms. Acromyms are nothing but abbreviations, which they use as convenient shorthand to help doctors and nurses to communicate with each other. These acromyms are virtually an alphabetic potpourri. For instance: ICU: intensive care unit AMI: acute myocardial infarction BPH: benign prostatic hypertrophy IVF: in vitro fertilization IOL: intraocular lens. If your doctor bombards you with acronyms or jargon, instead of being overwhelmed, please ask him to explain what the terms mean, so you can be are fully informed!

Chapter 27 Support Groups: Self-Help Is the Best Help Better to light a candle than to curse the darkness. Chinese proverb Any serious illness causes considerable personal distress and anguish. To add insult to injury, you often feel isolated and cut off from the rest of the world, since most ‘normal’ people cannot understand what you are going through. While your doctor can provide you with the medical care you need, you often need emotional support as well, which very few doctors can provide! While friends and family members usually provide such support, often this is not forthcoming in the case of certain sensitive problems such as AIDS, infertility or cancer, making patients even more miserable. This is where support groups come in. Such groups bring together people troubled by the same problem in order to share emotional and moral support, plus practical information. There are over a thousand support groups in the US itself, and these groups can range in size from the huge Alcoholics Anonymous, with thousands of chapters in 112 countries, to the handful of adults afflicted by infertility who meet in a clinic in Bombay. Support groups traditionally meet face to face, but now many meet over the internet as well! Also known as self-help, peer support, and mutual aid groups, these groups can be founded by several categories of people: for instance, health care professionals who believe that patients need to learn to help themselves: by individuals who are convinced that professionals alone can't meet all their needs: or by advocates for persons with specific diseases. Support groups act as a complement to medical care — they definitely do not replace your doctor! The very act of sharing the emotional side of an illness and exchanging helpful advice can encourage recovery or simply make it easier to cope with your problems. For example, if you've just been diagnosed as cancer, you may hide having a your anxiety and fear from your family and friends to avoid upsetting them. In turn, to avoid saying the wrong thing, they may say nothing at all. These barriers of silence tend to melt into refreshing candour when you

meet others who are coping with a similar burden. Similarly, if you're caring for someone with Alzheimer's disease, sharing your experiences with other caregivers can help you recognize that occasionally feeling resentful and sad is normal. Many group members can often offer pearls of practical advice, which help you to cope better with your illness. For example, infertile patients need to take daily injections when undergoing in vitro fertilization (IVF) treatment. One patient discovered that if she applied a ice cube to the site before the shot, the area would get numbed, and the injection wouldn't hurt as much. She shared her knowledge with others in the group so that they could also benefit from her experience. Support groups also allow you to gain more control over your life because you can learn from others who have already been through what you are going through now. An additional bonus is that they can help you to find the best doctor or hospital for your particular problem, because you can learn from other member's experiences with various doctors — both good and bad ! Besides offering moral support, a good support group may actually help you live longer! Researchers from Stanford University and the University of California at Berkeley studied 86 women with advanced breast cancer for 10 years. They found that the women who joined a support group outlived those who did not by an average of nearly 18 months. Support groups aim to achieve many goals. Primarily, they provide compassionate and informed help to people experiencing hardship and agony due to an illness. They can also help increase visibility about issues which concern them by educating the public and presenting their viewpoint through the media. In the US, many support groups act as powerful lobbies. For example, groups of parents of children with mental disability have been able to convince law-makers to pass legislation which prevents discrimination against disabled citizens. Many groups have also been successful in raising funds to help promote medical research into their disease. Others have published books and leaflets about the illness in order to disseminate information more widely, thus helping to dispel many myths and misconceptions about the disease among the general public. Support groups help primarily because they make you realize that ‘you are not alone’. An additional pleasant bonus many people discover is that by helping other people in their time of need, they learn to help themselves! The very process of being able to ventilate your feelings

and to get and provide emotional support can prove to be a healing experience. Try and identify a support group which contain a mix of veterans and newcomers at different stages of coping with an illness. People who have lived with health problems for years usually develop more insight and have more information to offer, while new â&#x20AC;&#x2DC;entrantsâ&#x20AC;&#x2122; offer another perspective. The group of your choice should consist of people with whom you feel comfortable, and leaders who empathize, by gently drawing out the shy members and keeping in check those trying to dominate. A good group should have a stable track record of meeting the needs of all members. Not all support groups are reliable. Don't be fooled by groups that put their interests before yours. Avoid groups that: (1) promise sure cures and quick solutions; (2) urge you to stop prescribed treatment and recommend a single solution to your problem; (3) insist that you reveal private or sensitive information; or (4) charge high fees or compel you to buy certain products. Most support groups are free, or support themselves by collecting voluntary donations or charging modest membership fees to cover expenses such as refreshments or production costs of leaflets/brochures. Many good doctors are happy to refer their patients to such groups. They realize that support groups provide valuable emotional support, which doctors, as busy professionals, simply cannot, because of time constraints. Unfortunately, misconceptions about support groups prevent many people from making use of this valuable source of help. Some patients become anxious that joining a support group might cause them to dwell even more on their problem, while others may feel that their illness is too private or personal or traumatic to share with a group of strangers. You may also believe that you can handle the crisis on your own. In reality, any serious illness is too traumatic not to share with others, and there is nothing wrong about reaching out for help. Such a step is definitely not a sign of weakness. A support group simply provides a safe, warm and supportive environment: you need never say a word if you don't want to. Fortunately, Indian patients are now realizing the importance of networking amongst themselves, and, presently, many support groups have sprung up all over India for illnesses ranging from Azheimer's disease, cancer, infertility, muscular dystrophy, multiple sclerosis to thalassemia. However, a major problem in India is that the culture of self-help is still very new. Most patients are passively dependent on their doctors, and they still expect their doctor to do everything for

them. Remember, however, that the more you help yourself, the easier it is for your doctor to help you! After all, if patients will not look after their own interests, then who will?

Chapter 28 Sources of Information: How to Research Your Medical Problem Information is the best prescription ! Health Education Library for People. While it is true that your doctor is your most valuable source of information, do not forget that there a number of other resources you need to tap before making crucial medical decisions which can affect the rest of your life! These resources include books, libraries, CDs and the Internet. It’s not always easy to get information, but patience and persistence can help you find precisely what you’re looking for! It’s mandatory that you trust your doctor, but it’s also a good idea to verify his advice. Thus, if your doctor recommends surgery and you confirm through an independent source that his judgement is right, you build up even more confidence in him. Remember that knowledge builds up trust! Doing your homework will also allow you to make more constructive use of your doctor’s valuable time, so that you can ask him focussed questions, relevant to your particular problem.

TAPPING OTHER SOURCES OF INFORMATION Do not forget to visit the prime ‘fount of knowledge’, i.e., the library — after all, librarians are professional information specialists! Next to an extensive and leisurely consultation with your doctor (which is next to impossible in this day and age for most of us!), the library is the best place to get your questions answered. Most public libraries (such as the British Council and the USIS) stock a fairly wide collection of medical reference books and journals. Also, India now has its first consumer health library, especially designed to help the layperson find information on any medical problem. This library, known as the Health Education Library for People (HELP), has a vast array of over 6000

books, 10,000 pamphlets and 500 videos — all meant for the layperson. This is a public library (address: Om Chambers, Kemps Corner, Mumbai 400 036) and is an excellent place to start your research ! It can be visited on the Internet as well at http://www.healthlibrary.com! HELP, also offers an innovative MISS-HELP (Medical Information Search Services from the Health Education Library for People) facility in which librarians compile customized information packages, tailored to your specific problem. This facility costs Rs. 300-500 (about the cost of a medical consultation!) and provides you with about 100-125 pages of intelligible information, pertaining to your particular problem, delivered to you at home! If you are unfamiliar with a particular topic, a medical encyclopaedia is probably the best choice for garnering information. For an excellent overview of just about any medical condition, the ideal guides include the following: The American Medical Association Encyclopedia of Medicine or the British Medical Association Family Guide. Penguin India has also brought out a Family Medicine Guide meant specifically for an Indian audience. A reliable medical dictionary, such as the Mosby Medical Encyclopedia or Merriam-Webster’s Medical Desk Dictionary, can help you make sense of seemingly convoluted terminology. Another publication, The Merck Manual (home edition), is a superb compendium of almost every known disorder and describes causes, symptoms, laboratory test, diagnosis, treatment and prognosis. Your local library may also be able to provide you with useful medical directories which can guide you to further sources of information. For instance, The Self-Help Source Book, which lists more than 700 organizations, can help you find a suitable support group. Also, The Consumer Health Information Source Book provides information on clearing houses, useful books, and other resources, while the three-volume Medical and Health Information Directory lists various organizations, publications, libraries and health services. If you possess a computer , you can use CDs effectively, to research your problem. Two worthwhile CD-ROMs are the American Medical Association Family Medical Guide and the Mayo Clinic Family Health Encyclopedia. One advantage of CDs over books is that they offer you with computer graphics and even video clips. The Internet is the ultimate information resource - it’s like a library which is open 24 hours and which provides a wealth of information on

any and all health and medical topics ! A lot of the medical information on the internet is specifically designed for the intelligent layperson, probably keeping in view Albert Einstein’s sagacious words: ‘Nothing is so difficult that it cannot be understood!’ The relevant question is: How does one go about finding this information? The Internet has made searching for information remarkably easy, so that you can locate the information for yourself. This exercise can also be a lot of fun — remember that you learn a lot by serendipity ! If you are looking for information on a specific topic, you need to use one of the Internet’s search engines, such as Hotbot (www.hotbot.com). Simply type in the terms (‘keywords’) you are looking for, and the engine will point you to the relevant information you need. (A warning for novices: You may also be inundated by a flood of garbage, so you will need to carefully sift through what you find!) There are many useful sites which provide consumer health information; for example, http://www.healthanswers.com has a superb collection of patient information leaflets on thousands of topics. The remarkable feature about locating a useful site is that it will often have a wide range of links, which will, in turn, point you to other helpful documents, from which you can retrieve even more information. The Internet offers a number of additional options for acquiring more information on specific topics. There are electronic mailing lists available on many diseases (for example, cancer-l deals with cancer) which allow you to network with people from all over the world, so that you can keep yourself updated. You can also send out e-mail to leading medical clinics and medical specialists from all over the world, many of whom will be happy to reply to you — free! There are also specialinterest Usenet news groups (for example, sci.med.aids deals with AIDS), so that you can ‘talk’ to thousands of people from all over the globe, who may be facing similar problems! Everything about the Internet is, however, not hunky-dory. One may very well ask: What are the drawbacks of using the Internet as a source of information? For one, please don’t have unrealistic expectations as to how the information can help you; after all, such information simply serves as an aid which can further guide you in your search for the best medical care! Also, you may not be able to find exactly what you need; you have to practice a good deal before you can hit the bull’s eye. You also need to be aware of the fact that not all the medical information available on the Net is reliable; you need to assess it critically (this is true for all information, whether it comes from a book, your neighbor, your stockbroker or your doctor!).

Once you have found as much information as you need about your problem, you then need to process it so that you can understand what treatment options are open to you. Your doctor (or a friend or relative who is in the medical profession) can be very helpful in explaining to you exactly which portions of the information you have unearthed are applicable to your particular problem. You then need to decide which treatment option is the best for you. For example, for patients with infertility, the options will include: adoption; child-free living; or taking medical treatment. Remember that there are always going to be choices - you need to be able to choose intelligently amongst them. You should keep the following factors in mind: (1) What would be the costs involved (for each option)? (2) What benefits would accrue? (3) What are the risks involved? (4) What are the alternatives available? Drawing upon management models, it is useful to construct a decision tree to analyse the various alternatives. In the USA, a new group of professionals, has come into being, called ‘medical information consultants’, who specialize in helping patients carry out this type of analysis. However, if you look upon this activity as a business exercise, it is really very similar intellectually to a SWOT (strengths, weaknesses, opportunities, threats) analysis. What is the possible downside of gathering such information? For one thing, you may come up with so many options that it becomes very difficult to make a decision. You may then be paralyzed into inactivity. Although it is difficult, it is absolutely critical that you actually do make a timely decision. If you don’t, you may end up without any treatment, rather than getting the best treatment! (You may also find that most of the options are equally promising. If this is the case, then just pick any one of them!) Too much information can also often leave you feeling confused. It’s obviously much easier to remain passive and to allow the doctor the freedom to do what he wants; ‘why break your head over something you will never fully understand anyway’ is a common rationalization many patients resort to. However, it is far better to be confused because you know too much, rather than because you don’t know enough. After all, there is little to be gained in complaining about shoddy medical care after a problem arises because of your ignorance! You may also be worried that your doctor may become upset if you ask too many questions: suppose he turns nasty and asks, ‘who is the doctor here?’ However, such a mindset reflects an archaic paternalistic attitude, and if your doctor refuses to help you find and analyse information about your medical problem, you should consider looking for another doctor !

Having a medical problem is bad enough, but the real tragedy is having a medical problem which can be treated, and not getting the right treatment! The ultimate rewards of doing your homework will be your peace of mind that you did the best you could! HOW TO RESEARCH THE MEDICAL LITERATURE How does one go about researching the medical literature ? Before starting your research, you need to obtain some basic information about your medical problem, particularly a complete diagnosis. Only your doctor can provide such a diagnosis, apart from explaining what alternative terms can be used to describe your condition so that you can gain the fundamental knowledge to begin your research. Make sure you get the spellings right — write them down! Of course, for some complex medical problems, it may not be possible to even come to a diagnosis, but such cases are rare. You should also spend a little time thinking about exactly what kind of questions you want answered: remember, GIGO (garbage in, garbage out). The more precise the nature of your questions, the easier it will be to find answers to them! Thus, it would be counterproductive to look for ‘everything about diabetes’. A more realistic query could be: ‘Is it possible for a diabetic to control his blood sugar levels without medications?’ You might also want to search for newer treatment options such as pancreatic transplants, or look for a world-renowned expert who specialize in treating diabetic complications affecting the eye. As your doctor can answer many of the questions connected with your problem, it would be sensible to ask him first and then start searching the medical literature. If you have a question about a specific symptom or a side-effect that you are experiencing, or about the interpretation of test results, your doctor certainly should be your first source of information. Again, if you want to know the precise success rate of a proposed treatment, or about the side-effects, you should first ask your doctor, although in these cases, it might also be reasonable to look into the issues yourself, especially if you aren’t satisfied with the answers you’re getting, or if you just need to know more details than what your doctor can provide due to lack of time. Researching medical literature is not like a single path that proceeds straight from the initial question to the final answer; it is actually more like a cycle. Initial questions lead to references which lead to other

papers, which, in turn, again, lead to more references, and more questions; and the process continues. Eventually, you will zero in on the information that is the most valuable to you. This process cannot usually be completed in a single day. The research cycle will probably take you to a wide range of medical databases, doctors, and medical libraries. It is helpful to pretend that that you are the ace defective Sherlock Holmes, looking for a vital clue! It is very important to understand the differences among references, abstracts, and papers. References are just what the world means: references to published journal articles and sometimes to books and conference proceedings. A reference normally contains the title and the authors of the work as well as the name of the journal, the year, the volume number, and page numbers as appropriate. Given a particular reference, you can look up the relevant paper in the medical library. (A paper could be an article published in a journal or proceedings of a seminar or conference.) An abstract is a short summary of a paper. Skimming through an abstract is usually sufficient to determine whether or not a paper is interesting enough to actually be worth looking up at the medical library. Almost all papers start with an abstract, and high- quality medical databases such as MedLine (an international database of the medical literature, collated by the National Library of Medicine, USA) contain abstracts for a majority of the references. The paper is the actual report of the work, and contains all of the details on the background, methods, results, and conclusions. Every paper also contains a list of references at the end. Please remember that all medical references, abstracts and papers are bound to be full of medical jargon as they are primarily meant for the medical fraternity. Many sources of references to medical papers can be tapped, such as: Other papers. Every paper in the medical literature contains a list of references at the end. Often this list is both lengthy and comprehensive. Your doctor. Many doctors are quite willing to give you references and even xeroxes of papers supporting their positions on treatment questions. All you have to do is ask!

Medical databases. Databases such as MedLine are by far the most effective way to find references, although some effort is required to learn how to use these resources intelligently. You can carry out MedLine searches free on the Internet (for example, at www.healthgate.com). The huge size of these databases with millions of references and abstracts from thousands of journals means that if the information you seek has been published, the references are there. The ability to focus your search on keywords that interest you allows you to extract the specific references that pertain to these words. The biggest drawback with regard to these databases is that you are swamped with too much information, not too little! It is important to determine beforehand how much information you actually need to make yourself comfortable with your diagnosis and treatment options. Some ‘insatiable gluttons’ need as much information as they can possibly gather! Others find that less information, or information with a specific focus, is the most appropriate for them. Some patients find it helpful to hear only the good news; others want the whole picture, including the negative possibilities. Again, let your doctor know what precisely your needs are. He or she can provide you with printed matter or other sources of information, as well as point you towards other potential resources that can help you gather whatever information you find necessary. Do not accept the contents of any single journal article or book as definitive. One should bear in mind that all scientific inquiry involves human fallibility, could be prone to errors. Also, many conclusions are false and many reports flawed. Even research conducted and reported over many years may eventually be proven to be false, which is why you need to seek your doctor’s help to make sense of the wealth of medical information available to you. He or she can explain to you how the information you have unearthed applies to you as an individual. In other words, you need to form a partnership with your doctor, but such a partnership should be one between wellinformed equals, which is why you need to do your homework thoroughly first !

Chapter 29 New Technology in Medicine: Handle with Care The medical establishment has become a major threat to health. Ivan Illich Most newspapers, magazines, as well as the electronic media these days regularly carry reports extolling the virtues of the newest technologic tools in medicine. The wide range of technological advances can leave many patients feeling completely confused. How is a patient to make sense of which technology may be useful for his particular illness? New technology can be dazzling, and undoubtedly, when medical technology is used properly, it can save many lives. However, technology can be a two-edged sword; and we need to remember that every rose has its thorns! For example, the introduction of antibiotics was very quickly followed by their misuse, leading to rampant antibiotic resistance amongst bacteria and an ever-increasing rate of hospital-acquired infections. We need to remember that new does not always mean better, and that time-tested medical procedures are often better than the latest gadget on the market ! It is very easy (and very tempting) to misuse medical technology. For example, MRI (Magnetic Resonance Imaging) scanners represent the latest advance in technology and these machines can undoubtedly provide very useful information about the human body ! However, MRI scanners are very expensive and need to be used to do at least 10 scans a day to be made cost-effective. Private hospitals buy them because they represent the â&#x20AC;&#x2DC;latest technology â&#x20AC;&#x2122; and are in vogue; for example, eight units have already sprung up in the city of Mumbai! Ironically, there are not enough patients to satisfy the needs of eight units, even in such a large metropolis, with the result that many patients are subjected to unnecessary scans, simply to keep the machines financially viable. Paradoxically, patients also pressurize doctors to misuse the new technology. Many of them go â&#x20AC;&#x2DC;doctor

shopping’, and demand that the ‘latest whole body scan’ be done to prove that they are healthy! You need to be aware of the following inappropriate uses of medical technology. 1. Excessive use of technology, even when it is not required. A prime example of this ‘folly’ is ultrasound scanning during pregnancy. While no one will dispute the fact that ultrasound scanning has provided an extremely useful window to the foetus and can yield invaluable information, ‘cosmetic’ ultrasound scans to provide ‘pictures’ for the baby's ‘first album’ are hardly appropriate. 2. Unethical use of technology. While pre-natal diagnosis (using ultrasound scanning) has been a very important tool for reducing the risk of birth defects, using this inappropriately has become a major scandal in India, especially when it is misused for foetal sex selection, by performing female foeticide. 3. Use of technology which is not suitable for a particular patient. An example of this would be advising IVF ( in vitro fertilization) for all infertile patients, just because the equipment and expertise are available and because the procedure is technically feasible. However, for most infertile patients , there are many simpler treatment options available, which should be fully explored before considering IVF. 4. Misuse of technology by unqualified persons. A common example is the use of lasers or endoscopic equipment for complicated surgery. Just attending a two-day workshop and acquiring a certificate does not make a doctor sufficiently expert in using this technology; and a number of mishaps have been reported because of operator inexperience. 5. Use of technology as defensive medicine, i.e., to protect the doctor from being sued, rather than using it because it is needed for the patient’s welfare. This trend is becoming increasingly common in India now, with the passage of the Consumer Protection Act, which covers medical practice too. There are many reasons for the inappropriate use of medical technology. 1. The major factor, of course, is money or the need to generate income. Doctors need to justify the purchase of expensive capital equipment, and as hospitals have become profit-oriented

organizations, doctors are becoming increasingly answerable to the management regarding the profitability of their services. Nowadays, once a piece of equipment has been purchased, it needs to be ‘utilized’ to make it ‘cost-effective’. Woe betide the doctor who does not generate enough money through the latest gadgets! He may find that his contract is not renewed! 2. The glamour and the dazzle of the latest gizmos tend to lure most doctors, just like driving the latest model car! One gains prestige by being the first to adopt the latest technique; or by being the only one in the world/country/city with the latest and newest ‘toy’. 3. The pressure from manufacturers to buy the ‘latest and newest’. ‘New and improved’ versions prove attractive , not only to toothpaste consumers, but also to doctors, and the medical industry (both equipment manufacturers and pharmaceuticals) has developed powerful tactics and techniques to induce doctors to prescribe and use their newest products. The companies involved can afford to spend large amounts of money on advertising, and they use this very effectively to maximize their profits. Thus, the crucial question arises: what can you do to protect yourself from being a victim of medical technology misuse? The answer is: make sure you are well-informed, so that you can judge the technology and its relevance (as it relates to you) for yourself. For example, the National Institutes of Health, USA, produces consensus statements in which leading medical experts from all over the world are invited to discuss the pros and cons of all the technological options available for dealing with a particular medical problem, essentially in order to guide doctors as to the appropriateness of the latest technologies. Using the information gleaned from such statements, or obtained from other sources intelligently, in cooperation with your doctor, will ensure that medical technology is utilized appropriately to provide the best possible care for your problem!

Chapter 30 How to Prevent ‘Testitis’ The magic of modern medicine is often diluted by its misery. Dr. Oscar London Today, the practice of modern medicine is based to a large extent on laboratory tests. These tests form the scientific basis of present-day medical practice, and provide considerable and valuable information about what's wrong with the patient, thereby helping doctors to come to an accurate diagnosis. However, while it is true that lab tests can be very useful, they are often misused as well. With billions of medical tests being performed every year, modern physicians appear to be relying more on tests results rather than on their clinical skills to make a diagnosis. And testing means big bucks! Outpatient testing has tripled in the last 10 years; in fact, laboratory tests, X-rays and scans now account for over 25 per cent of hospital bills. Many doctors have also started practicing ‘defensive medicine’ in order to defend themselves in case they are sued by unhappy patients or their relatives. They often perform many unnecessary tests to protect themselves from possible charges of negligence. After all, few lawyers will find fault with a doctor who performed too many tests, but woe betide the doctor who fails to perform a test, if his patient falls victim to an unfavorable outcome! This is the main reason why many doctors go in for tests even when they are not required, and it is important for you to safeguard yourself against excessive testing, which can cause a number of problems. Not only is it a financial drain, but it can also lead to a domino effect of spiraling testing, if the initial results are abnormal! Consider the common example of an abnormality found in a “routine” ECG performed in the course of a routine health check-up for a man with no complaints. In order to determine the significance of this abnormality, the doctor may decide to ‘order’ further testing, including an exercise stress test and even an angiogram, both of which are expensive and painful. Most angiograms will reveal some degree of block in the coronary arteries for practically everyone, and the

significance of such a block is difficult to determine for the individual patient. But, once they come to know that they have a ‘block’ in their artery, many men become ‘cardiac cripples’, who worry about every twinge of pain in the chest. As a result of the testing, many men will also have to undergo unnecessary open heart surgery to open the blocks — blocks with which they could have lived happily for the rest of their lives! The unreliability of medical tests also poses a major problem in India today. The most obvious reason can be attributed to laboratories whose functioning is marked by factors such as poor quality control, unskilled manpower and obsolete equipment. There is little ‘policing’ or retesting, with the result that the needed standards are not maintained. After all, even a science graduate with a six-month diploma in laboratory technology can set up a medical lab, if he so desires. Most people tend to rush to the nearest laboratory to get their tests done, but such haste can be a big mistake. After all, if the laboratory is not reliable, how can you trust its report? You should try go to the best laboratory possible - your life can depend upon your test results! A problem with all medical tests, no matter how well they are performed, is that they may give rise to false positives and false negatives. Let me clarify. False positives are test results which are abnormal (‘positive’), even though the patient has no disease. A false positive result causes needless anxiety, and will often lead to a situation in which the patient will have to undergo even more tests to prove or disprove the previous results. Conversely, test results which are normal (‘negative’), even though the patient does have the disease are called ‘false negatives’. These results could also cause problems, because they may induce a false sense of security, thereby leading to a delayed or missed diagnosis. Most tests have a wide range of normality, and can only very rarely yield a simple ‘yes’ or ‘no’ answer as to whether a patient has a particular disease or not. Remember that if your doctor performs enough tests on you, the mathematical certainty is that he will find something wrong with you. And if he finds something wrong with you, he'll usually end up treating you — whether you need treatment or not! However, such diagnostic labeling may be harmful to you, because the ‘diagnosis’ has now transformed you from a person into a ‘patient’, even though the abnormality may be a ‘red herring’ which has no significance to your medical problem ! Many cynics call these abnormalities ‘incidentalomas’ (for example, a small fibroid in the uterus detected on

an ultrasound scan), and these often result in unnecessary surgery as well. The real irony is that today many patients demand that the doctor ‘order’ the latest ‘whole body scan’ to confirm that they are ‘healthy’! because they often have more faith in a computer-generated report than in a doctor’s skills! Health check-up schemes which perform a ‘comprehensive panel of tests’ have also become very popular, but you need to remember that your body is much more complex than a car which needs an annual ‘tune-up’! Tests need to be targeted for a particular problem, rather than subjecting all patients to a whole battery of tests, something which can be wasteful and expensive as well. After all, in medicine, ‘one size’ simply cannot fit everyone! The upshot of it all is that you don't need to panic if the result of the test is abnormal. A simple common sense rule is that if the result is abnormal it needs to be rechecked, preferably from an independent laboratory! Competent laboratories will store blood samples for a few days, so that the old sample can also be retested if needed. If the repeat test also proves abnormal, then you need to ask your doctor to interpret the significance of this result. Most people are overawed by impressive looking computer printouts, and medical tests are considered to be extremely reliable and objective. However, this is a popular misconception. Tests can be just as subjective as a symptom (which is what a patient complains of) or a sign (which is finding noted by the doctor on clinical examination) . In other words, merely conducting more tests does not ensure better medical care; after all, the value of a test to the patient depends not only on the skill in interpreting its result, but also on the clinical judgment exercised in ordering the test in the first place. When a test which is not needed is done, the result is often more misleading than helpful, and overused tests can lead to confusion, misdiagnosis and unnecessary treatment. You should begin feeling suspicious if tests are ordered before an adequate history has been taken or before a physical examination has been performed. Remember that more than 80 per cent of all diagnoses are made on the basis of a patient’s history alone! A competent doctor will go in for tests selectively, their primary use being to confirm a diagnosis . You should also make sure that your doctor examines your original scans and X-rays, and not just the reports, because his interpretation may be different from the radiologist's. If you have undergone a series of scans, they should be arranged in chronological order, so that the doctor can compare them easily.

All tests have their limitations, which patients need to understand. For example, when we carry out a semen analysis (sperm test) to check a man's fertility, the question to which we seek an answer is: are these sperm capable of ‘working’ or not, i.e., can they fertilize an egg? Unfortunately, present-day tests simply cannot answer that question! A semen analysis simply provides an accurate count of the total number of sperm and their ability to swim, but because there is such a wide range of normality, the result italicise cannot be used to predict a man's fertility. Similarly, a positive skin test for TB (the Mantoux test) simply means that the patient has been exposed to the tubercle bacillus in the past (as most of us in India have been!) Such a result does not mean that the patient is suffering from an active TB infection, an erroneous conclusion many patients (and their doctors) still jump to. Here's a checklist of questions you should ask your doctor when a test is recommended: Why is the test being ordered? Is it to screen for a disease that has no symptoms, such as diabetes? Is it because the doctor is pretty certain about a diagnosis but needs the test to confirm it? Is it because the doctor is really puzzled about the diagnosis and is trying to “rule out” as many possibilities as possible? How definitive is the test? Is it the ‘gold standard’ for making the diagnosis? Will it reveal for sure that a condition is present or not, or must it be repeated or followed by more sophisticated tests? What precisely will the doctor be looking for in the results of these tests? What does he hope to learn from the tests? How accurate are they? You can help improve the accuracy of certain tests by taking simple steps beforehand. Therefore, ask your doctor if you need to take any precautions before the test; for example, before a PAP smear, avoid douching, wearing a tampon or using birth control foams or jellies for five days before the test and avoid sex for two days before the test. Other tests require special preparations, and you must check that they have been carried out, to make sure the results are reliable. For example, certain X-rays, such as barium enemas and intravenous pyelograms, require a laxative before the X-ray. Not doing the ‘preparation’ properly can lead to inadequate

results, requiring a repeat ‘preparation’, a repeat X-ray and a repeat bill!

Other relevant questions are as follows: Is there any pain? What are the side-effects? What are the risks? Many common tests do not involve any risks at all. Invasive tests, that is, those that entail introducing instruments (such as endoscopes) or chemicals ( such as barium ) into the body, generally, involve some risks, which may include infection, allergic reaction, or injury to an internal organ. Sometimes, a test may lead to complications which are more dangerous than the benefit to be derived from the test results. While this is usually not the case, you need to consider the risk-benefit ratio of all tests, especially expensive and invasive ones! Is this the best test for your problem? Tests are big money spinners today, because of which many doctors have fallen victim to ‘testitis’; (a disorder in which doctors go in for all the tests available instead of the most appropriate one!) What is the risk of not having the test done, and what are the alternatives? How will the result of the test change the course of your treatment? This is the single most important question you must ask. And if the answer is that it really won't, then maybe you don't need the test at all! In the final analysis, remember that medical tests can be very helpful in pinpointing your problem, but they need to be used wisely and well; after all, doctors do not treat abnormal test results, they treat patients ! Here is a checklist which highlights the important factors you need to consider before in for a medical test.

Medical Test Checklist Test name _____________________________________________ Description ____________________________________________ Purpose ______________________________________________ To confirm diagnosis?___________ Diagnosis _______________ To exclude diagnosis? ___________ Diagnosis ______________ Where will the test be done? Clinic? _________ Independent lab?________ Hospital? _________ Cost of test in: Clinic _______ Independent lab ________ Hospital _______ Are there risks associated with the test (i.e., is the test invasive)? ___________ If yes, what risks? _____________________________________ Are there less invasive tests that might give the same information? ___________________________________________ If the test result is abnormal what will be done next? __________ If the rest result is normal what will be done? _______________ COMMENTS ______________________________________ ________________________________________________ __________________________________________________ You should fill out this checklist for every medical test suggested. The more invasive or expensive a test is, the more important this checklist becomes.

Chapter 31 Making Decisions about Treatment There is only one cardinal rule in medicine: One must always listen to the patient. Oliver Sacks Once you have discovered that you have a medical problem, the resulting tensions and anxieties can be difficult to cope with. In addition to the emotional and physical stress, you now find yourselves faced with making difficult decisions regarding treatment. The word ‘decide’ comes from a Latin root meaning ‘to cut away from’, which essentially means that decision making by its very nature involves loss; i.e., giving up one or more treatment options while grasping another. The very act of not making a decision maintains the dangerous illusion that you can have it both ways: that there is no loss, no risk. However, not making a decision is, in a sense the worst possible decision of all! Unfortunately, most patients do not know how to make their own decisions , and expect their doctor to tell them what to do – they expect to be spoonfed! A good doctor can and will guide you conscientiously, and you should trust him sufficiently to be confident that he will not let you make a wrong decision. However, the final responsibility is always yours — you cannot abdicate it to anyone else! The decision-making process is different for each patient and depends on individual situations and requirements. Some patients may opt for expensive, high-tech treatment, while others in the same situation may prefer to wait and watch. The all-important question would be: what kinds of treatment are available? You’ll often find that a variety of treatment options exist for instance: Medical therapy. Surgery. Physiotherapy. Radiation therapy (for some cancers).

Waiting and watching (also called “masterful inactivity”). Your doctor will be able to make several recommendations about treatment. However, there are a number of important questions that you should always ask your physician so that you can make the best choice for yourself. The following questions can help you build up a reservoir of medical information to assist you in your decision-making process regarding a particular treatment: How much will this treatment improve my chances of getting well (In other words, what are the benefits?) How much risk is involved in this treatment and what kind of risk is it? How long will the treatment take? How much will this treatment cost? Does undertaking this treatment eliminate other options? Are there other options if this treatment fails? Your physician is the ideal person who can help you in determining certain vital factors vis-à-vis your treatment. For example: The The The The The

time required. physical stress or discomfort expected. emotional pressures exerted. risk involved. money required.

Ultimately, it is you who will have to take decisions with respect to the foregoing factors. You will have to ascertain how much money you can spread; how much physical and emotional stress you can bear; and how much risk you are capable of undertaking. On the basis of these decisions, you will need to design your own medical treatment plan custom-made for yourself! Not only will this step help you maintain control over your life as you proceed with the treatment, but it will also help in ensuring that you get good quality medical care. Nowadays, there are various tools available to help you make your own decisions. For example, the Foundation for Informed Medical Decision Making, based in the USA, has developed ‘shared decisionmaking programs’ on videos and CD-ROMs for common medical problems (such as breast cancer and hormone replacement therapy) which enable you to make up your own mind.

The main factors which can influence your decision are as follows: Medical factors: Diagnosis (or lack of one). Quality and availability of medical care. Success rate of treatment. Level of technology required. Personal factors: Age. Time commitment needed for treatment. Feelings — physical and emotional. Job and career priorities. Financial resources. Ethical and religious concerns. Family’s and friends’ reactions. Other obligations and commitments. Willingness to change lifestyle. Aggressive or low-key approach to resolution. Each of us has a different personal decision-making style. It is for you to choose which one of the following best fits your own personal style for making medical decisions: I prefer to make the final selection of my treatment after seriously considering my doctor's opinion. I prefer that my doctor make the final decision with regard to which treatment should be resorted to, after seriously considering my opinion. I prefer to make the final selection about which treatment I will receive on my own. I prefer to leave all decisions regarding my treatment to my doctor. It is important to understand that there are no right or wrong styles, and that your style may change as you proceed through diagnosis and treatment. It is imperative that you find a doctor who respects and understands your personal decision-making style.

Just as there are no right or wrong styles, remember that there are no right or wrong decisions about your treatment, and as your options change with time, you may also change your priorities. Try to be as realistic and open-minded as possible. While the final outcome will always remain unknown at the time of making decisions, if you take the time and the trouble to make your own decisions, at least you will have the satisfaction of knowing that you tried your best! Here is a sample worksheet for making medical decisions about treatment:

Option 1Option 2Option 3Option 4

Benefits Success Risks Costs Time Decision (in the rank of choice)

Chapter 32 Medical Insurance God heals and the Doctor takes the fees. Benjamin Franklin In certain cases, medical care can be expensive and costs are zooming upwards day by day. You acquire medical insurance for the same reason as other kinds of insurance - to protect yourself financially. By going in for medical insurance, you can protect yourself and your family if struck by disease. While no one wants to fall ill, the last thing one wants to worry about when is whether one will be able to afford good medical care. On the other hand, if you have been prudent enough to obtain insurance, many of your costs can be covered by a third-party payer, namely, the insurance company, thus relieving you of considerable anxiety and concern. The traditional form of health insurance is called indemnity insurance (also known as fee-for-service ) , in which the insurer pays for the cost of covered health care services after they have been provided. In most indemnity insurance plans the patient is free to choose his own doctor or hospital. In India, the insurance business is still a monopoly, so that, for all practical purposes, the only medical insurance policy available for most of us is MediClaim, through the subsidiaries of the General Insurance Corporation (GIC). The government does have special schemes for its employees: the ESIS (Employee State Insurance Scheme) and the CGHS (Central Government Health Scheme). Many employers now provide medical insurance as a standard perquisite to many of their employees â&#x20AC;&#x201D; this is called group insurance â&#x20AC;&#x201D; and the premium is less than a stand-alone personal insurance policy. In many cases, the employer pays part of the cost or all of it. Not all employers, however, offer health insurance. Your employer may not subscribe to a health insurance scheme, especially if you work for a small business or work part-time. In such a situation, you might still be able to obtain group insurance (and thus save money) through a labor union, a professional association, club, or any other organization you belong to. However, if this is not possible, then you will need to obtain coverage

for yourself (and your family) on your own by taking out a personal policy. Given the fact that the insurance business in India is still a monopoly, the only decisions you will need to make are very simple: whom to insure (some or all the members of the family); and how much to insure for. This situation is in sharp contrast to that in the USA, where there are a wide variety of medical insurance schemes on offer --- and choosing between HMOs (health maintenance organizations) and PPOs (preferred provider organizations) can leave most patients very confused! While taking out a policy is a simple matter ( after all, the insurance company is happy to earn the premium you pay!) getting reimbursement for the expenses you incur can be a tedious process; the company does not want to part with their money! This is why it is important that you go in for an agent to take out your policy, so that he can help to get your claim sanctioned in case you fall ill. In the future, with increasing liberalization, as the insurance business in India is opened up to the private sector, many more options will become available for patients to choose from. However, not all the changes will be for the best --- and you will need to use your judgement when making a decision as to which policy to select for your family. Premiums are likely to increase sharply each year. Since the cost of medical treatment is rising faster than the rate of inflation. Also, as you get older, the likelihood of your making a claim increases, and premiums will jump, often dramatically. Read the fine print on your policy, and make sure you understand precisely what your policy does and does not cover, so that unpleasant surprises do not crop up later on ! Here's a checklist of some aspects to be clarified before taking out a policy. Is the cover for treatment and operations restricted? Policies will often exclude factors such as : treatment for alcohol and drug abuse; dental treatment; HIV/AIDSrelated illnesses; infertility treatment; normal pregnancy; cosmetic surgery (to solely enhance appearance). This list is not exhaustive and you should ask the insurer for details about your particular policy. The medical insurance document requires that you declare everything on the application form, even if you think it trivial and unimportant. This document needs to be accurate as it forms the basis of the contract you make. If certain information is inaccurate or has been left out, the insurer may refuse to pay your claim. Remember that insurance policies generally only cover you for disorders which have not affected you. Conditions that you are suffering from or have suffered from in the past are known as pre-

existing conditions, and most individual policies (and some group policies) will not cover pre-existing conditions. Some policies cover a pre-existing condition only after a specific period of time has lapsed since your last treatment or visit to a doctor for the same condition. You might have a waiting period of between six months and two years before coverage begins. Check your policy carefully to check if you can be denied coverage for a pre-existing condition. When you want to make a claim, it is best to contact the insurer before you actually receive treatment, if possible. The insurer can confirm the specifics of your cover, check that the treatment is within any relevant limits, and let you know whether you should pay first and then be reimbursed or whether the insurance company can make arrangements to pay the hospital direct. It is very important to ensure that your paperwork is complete and accurate when you submit a claim for reimbursement to the insurance company. Don't make false claims under any circumstances: not only are you likely to be â&#x20AC;&#x2DC;caughtâ&#x20AC;&#x2122;, but you will also create problems for yourself in the future when you do make a genuine claim ! Make sure that you have filled in all the insurance company's forms correctly; and that your doctor has entered all the required information. You will also need to submit your medical records, as well as the bills and receipts. Consequently, make sure you keep all these items carefully, and retain a photocopy of everything you submit! One particularly nagging question is: What action can you take if the insurance company rejects a claim that you feel is valid? If the company refuses your claim, insist on a reply in writing, so that you can appeal against such rejection, say, to the consumer forum. You need to know how to stand up for your rights! Resubmit your claim in writing and express your views as to why you feel it should not have been rejected. Ensure that your problem is stated in a clear, concise manner. Also, do forget to include all appropriate documentation with the letter, including the following details: your policy number, relevant test results, medical records and doctor's statements that back up your claim. Most importantly, clearly state what action you want your insurance company to take to solve the problem. Keep copies of all your correspondence ! Don't be afraid to ask your physician and your insurance agent to contact the insurance company on your behalf. If your problem is not solved by your initial letter, you should appeal to a higher level within the insurance company. Remember that you are dealing with a bureaucracy and you will need to be persistent! You can

fight for your rights, either by tackling the company itself, or through legal action, if need be.

Chapter 33 Healthy, Wealthy and Wise: How to Balance the Medical Budget Three shapes a doctor wears. At first we hail the angel; then the god, if he prevail. Last, when the cure complete, he asks his fee, a hideous demon he appears to be. Anonymous Being ill can prove to be expensive! Present-day medical tests and the subsequent treatment cost considerable money. In the face of spiraling health care costs, you may end up spending a small fortune on your medical care. Being unwell is bad enough, but having to shell out an enormous amount to get better is like adding insult to injury! Most of us are hesitant to talk about money with our doctor. There are many reasons for this discomfort. For one, we prefer to think of our doctor as being above mundane commercial matters; after all, we are entrusting our life to him, and mentally, most of us still put our doctor on a pedestal! Many doctors are also uncomfortable talking about money to their patients. Consequently, this topic is often not discussed at all! However, do remember that even though medicine is a profession, it is also a business; after all, the doctor does need to earn his living. Patients are often reluctant to discuss medical expenses with doctors. However, they must remember that it is their hard-earned money which is being spent; they just canâ&#x20AC;&#x2122;t afford to shy away from this topic. Doctors are also sometimes vague about money matters. Therefore, it becomes very important to obtain specific figures before undertaking any form of treatment. Often times, your doctor may not even know the precise costs of the tests and medicines he prescribes. Therefore, it is worthwhile bringing this aspect to his attention, if you discover that doctorâ&#x20AC;&#x2122;s methods of testing and treatment are exorbitant. He may be able to suggest less expensive alternatives.

Some hospitals and doctors are very ‘creative’ about their billing, and this ‘creativity’ could prove to be very ‘destructive’ to you! Some doctors bend the rules (and themselves) and take cash payments ‘under the table’; others demand large amounts right in the middle of the operation, claiming that the surgery has (suddenly) turned out to be much more complicated than they expected. Some hospitals gratuitously add an arbitrary ‘surcharge’ to your total bill. Individual patients can do little to fight such shady malpractice’s, but these few doctors end up tarnishing the entire profession. To avoid such pitfalls, you should refuse to be cowed down by pressure tactics and should get an accurate estimate of the total (all-inclusive!) medical expenses before going ahead! You should get the specific breakdown for each of the procedures, preferably in writing. For example, in the case of surgery, find out exactly what the quoted figure covers: does it include the surgeon’s fees, the assistant’s charges, anesthesia, operation theatre charges, hospitalization expenses, post-operative care, and follow-up visits? Often, what is deftly excluded can add up to a pretty tidy sum! One has to be especially alert during surgery and hospitalization, where ‘hidden expenses’ can lead to your coughing up much more than you had bargained for! You also need to calculate precisely your total expenses, not just the medical costs. You should remember to include travelling costs; lodging and boarding costs if you are from out-of-town; and the costs incurred due to time taken off from work. Despite galloping costs, medical care in India is still far cheaper than in the West. In India, doctors’ professional fees are much less, and medicines cost a small fraction of what they do in the West, thanks to present-day Indian patent laws. However, when compared to the annual income of an average middle-class citizen, medical expenses can be considerable, and a serious illness can easily wipe out an individual’s lifetime’s savings! The pertinent question in this context would be: What can you do to keep your medical expenses down? The sanest advise, of course, would be to keep yourself healthy, so that you never need to go to a doctor in the first place! Traditional Indian wisdom is replete with simple but extremely useful ‘therapies’ such as yoga, meditation and nature therapy, which can help you keep the doctor away far more efficiently than an apple a day can! Nevertheless, if you do need medical care, there is quite a lot you can do to make sure your bills do not become astronomical -- following

the guidelines in this book can help considerably! Some other useful tips are as follows: Become an intelligent, informed patient and ask all the relevant questions to make sure that the medical procedures that you are required to undertake are really necessary. Take out a medical insurance policy when you are healthy -- this precaution can be very helpful in case you do fall ill. Do insist on receipts whenever you pay your medical bills. Insist on an itemized bill, so you know exactly what you are being charged for. Scrutinize the bill carefully, to ensure it is accurate. Sometimes, hospital bills can be monumental, and they need to be carefully analyzed to spot the errors! Do not assume that just because the bill has been generated on a computer it is bound to be accurate. It is always worthwhile bearing in mind that billing errors are amazingly common, and you need to look out for them actively! Remember that it’s your precious money and you cannot afford to waste it! You may need to shop around to get a realistic estimate of treatment costs. Medical charges vary widely, and don’t automatically assume that the more expensive a doctor is, the better he is ! It would be prudent on your part to discuss your financial concerns with your doctor! Many doctors can and do reduce their fees for patients who face problems with regard to payments. Also, remember that you will get exactly the same quality of medical care in a first class deluxe room in a private hospital, as you will in the general ward, but you will end up paying about ten times more in the former case! Don’t forget that the government does provide highly subsidized medical care through its vast network of hospitals. While the queues are long and the wait can be interminable, the quality of medical care is usually very good, and, at that price, it’s a fantastic bargain!

Chapter 34 Informed Consent: A Crucial Factor Tell me and I will forget. Show me and I will remember. Involve me and I will understand. Chinese Proverb No doctor can treat a patient without his permission, which is why a patient needs to give his consent to the doctor, before treatment starts. In the early part of the twentieth century, the law also recognized that the purpose of obtaining a patient's consent, was also to ensure that decisions about medical treatment were consistent with patients' wishes. "Consent" became ‘informed consent’ as a result of a landmark case in 1957 in the USA. The verdict in this case declared that doctors have a duty to disclose "any facts which are necessary to form the basis of an intelligent consent by the patient to proposed treatment." These ‘necessary’ facts include information about risks and benefits of the proposed treatment, as well as existing alternatives. Only if the patient has had the opportunity to evaluate the available options and to weigh their attendant risks and benefits, the court held, can he make an informed and independent choice. Informed consent is required before surgery, before many diagnostic and therapeutic treatments and before a patient participates in any clinical study or research. A signed consent form stands as evidence that a patient has been informed about, and has given permission for, the treatment described on the form. Consent forms protect the rights of the patient, not those of the doctors, as is often believed , since by signing a consent form a patient does not waive the right to sue a doctor hospital/clinic for malpractice. For a patient to give, and a doctor to receive, properly informed consent, several requirements must be met: 1. The doctor must give the patient all relevant information about the nature and purpose of the procedure, along with its risks and benefits, and any alternatives (including the alternative of no treatment,) Although patients cannot expect to be told everything about the natural history of their disease (all the possible complications and remote risks involved in all alternative treatments), they are entitled to

the disclosure of all "material" information. To define the term "material," courts so far have used a "reasonable patient" standard, instructing doctors to give such information as a ‘reasonable person in the patient's position’ would want to have. Such an option clearly leaves a great deal to the doctor’s judgment. Of late, a new standard seems to be evolving in which ‘material’ information is defined as the information that a reasonable patient, in these circumstances, would want to know. 2. The patient must understand the information, whether it is given orally or written on a consent form. 3. The patient's consent must be given voluntarily, without coercion or undue influence from health care personnel or others. 4. The patient must be mentally competent to give consent. As a patient, you need to make sure your doctor covers the following five areas when getting your informed consent. 1. 2. 3. 4. 5.

Details of the medical treatment proposed. The benefits. The risks. The alternatives. The written documentation.

There are no guaranteed outcomes in medicine, but informed consent enables YOU to make a rational decision about your treatment and also promotes greater understanding between you and your doctor. It is your responsibility to read each and every word of the document, because, once you sign it, you acknowledge that you understand everything about the procedure(s) and the potential problems that may arise. With informed consent: You cannot demand services that are beyond what are considered ‘acceptable’ medical practice or that violate professional ethics. You must recognize that you may be faced with some uncertainties or unpleasantness.

You should, if competent, be responsible for your choices. Donâ&#x20AC;&#x2122;t have others make decisions for you. A good doctor will guide you --- you should have enough trust in your doctor to be confident that he will not let you make a wrong decision. However, the final responsibility is always yours â&#x20AC;&#x201C; make sure you are thoroughly and properly informed, before giving your consent!

Chapter 35 How to Complain Effectively: The Legal Options The blunders of a doctor are felt not by himself but by others. Ar-Rumi The vast majority of patients are usually completely satisfied with their medical care and are grateful to their doctor. However, in some cases, problems can occur, and you need to know what steps you can take if you are unhappy or dissatisfied with the outcome of your treatment. In the first instance, you should try to resolve the problem as quickly as possible. Talk to the doctor or the hospital administration to try and settle matters at the earliest, especially with regard to minor complaints ( such as rude staff, telephone calls not being returned or unpalatable hospital food). Most complaints originate due to seemingly trivial problems. If however, if you have a serious complaint about your medical care, and if you are convinced that your doctor has been negligent, you can take appropriate action. However, do remember that just because the outcome has not been satisfactory ( for example, a patient dies during surgery) , it does not necessarily mean that the doctor has been negligent or irresponsible! There are many reasons why patients do not do as well as expected; after all, medicine is an inexact science which deals with many biological variables that are beyond anyone's control. Consequently, in spite of the best care, a patient may die or his condition may become worse. There are many avenues open to you to get redressal, and you may choose any or all of them. For instance, you can make a complaint to the local professional medical body, usually the state medical council. The appropriate medical council can punish the doctor: for example, by removing his name from the medical register, if he has been found guilty of serious professional misconduct, either permanently, or for a specified period, so that he can no longer practice medicine. One should bear in mind that state medical councils are generally comprised of physicians. This factor implies that they are more likely to

be on your doctor's side rather than yours! Since they have a personal and professional kinship with other members of their fraternity, it should come as little surprise that these councils unfortunately have not developed a good reputation for policing doctors effectively! That is why, when complaining to medical councils, it would be prudent on your part to be represented by a skilful lawyer. In reality, the odds are extremely small that your complaint will result in a physician being disciplined. However, this eventuality does not mean that you should not file a complaint: you should! The most logical reason to file a complaint is that it might alert future patients of the ‘delinquent’ doctor to his ‘unhealthy’ practices. Also documenting your unsavory experience could prevent others from being victimized. Moreover, your action may help to keep the doctor more honest in the future! Remember that the ideal way of exposing shoddy and unprofessional doctors is through making a public disclosure and creating public awareness. If you have been unable to obtain a satisfactory response to your complaint, you may even need to turn to the courts to settle your dispute. Doctors are no different from other professionals, and, from a legal point of view, when a doctor treats a patient, the doctor and the patient ‘have entered into an implicit contract’. A doctor-patient contract requires that the doctor must carry out the following duties: (i) he should continue to treat a patient with reasonable care and reasonable skill; (ii) he should not undertake any procedure/ treatment beyond his skill; and (iii) he must not divulge professional secrets. In effect, what these legal ‘niceties’ really mean is that you can sue a doctor if he is negligent in the manner in which treats you. Negligence does not mean just carelessness – it is carelessness where there is a duty to take care, and where failure to do so results in some damage. Legally, medical negligence or malpractice is defined as ‘lack of reasonable care and skill or wilful negligence on the part of a doctor in the treatment of a patient whereby the health or life of a patient is endangered or damaged’. In order to achieve success in litigation for negligence, the patient (or consumer) must be able to establish to the satisfaction of the court the following conditions: (i) the doctor (defendant) owed him a duty to conform to a particular standard of medical care; (ii) the doctor was derelict and committed a breach of duty; (iii) the patient suffered actual damage; and (iv) the doctor's conduct was the direct or proximate cause of the damage. The burden of establishing all four conditions falls upon the patient, and failure on his part to provide substantive evidence on any one condition may

result in no compensation being paid. Proving medical negligence is, consequently, very difficult. The fundamental requirement for building up a convincing case rests on the availability of medical experts willing to testify on your behalf; and such experts can be difficult to find, because doctors are very reluctant to criticize other doctors. Before taking legal action, you should carefully consider all the implications and repercussions. The process can be a very long and expensive one. You must also ascertain precisely what you want to achieve by initiating litigation. Do you merely want an apology from the doctor? Are you angry with the doctor because you feel he was careless and you want to seek revenge? Do you want to expose the doctor's incompetence to the public to protect other patients? Do you want monetary compensation? While all or any of these objectives may provide sufficient reason to go to court, do remember that medical malpractice lawsuits are powerful double-edged weapons which should be used only as a last resort. Not only can such lawsuits damage a good doctor's reputation, they can also create a lot of tension between patients and doctors in general. Let me point out, in this context, that unnecessary and excessive medical litigation has led to the regrettable situation in which American medicine finds itself today, in which both doctors and patients have become losers. In order to help aggrieved patients get redressal more easily, in 1997, the Indian judiciary ruled that doctors would be covered under the Consumer Protection Act (CPA). This decision was hailed as a major step forward in protecting the patient's interests, since the process of approaching the Consumer Dispute Redressal Forum was designed to be much easier and less expensive than going to court. However, as is typical in India, this forum has also got bogged down by a huge backlog of cases. Consequently, patients continue to face an uphill task in getting justice! A serious fallout of the CPA is that doctors have now started feeling threatened by it. As a result, many of them have started practicing â&#x20AC;&#x2DC;defensive medicineâ&#x20AC;&#x2122; in order, to defend themselves from a potential lawsuit, in case things go wrong. Such a development has led to unnecessary tests being performed, most of which are not needed to improve your medical care, but for which you will, perforce, have to foot the bill! For example, while medical studies have repeatedly shown that skull X-rays offer little useful information in patients with uncomplicated head trauma, such X-rays are usually performed routinely in order to protect the physician from future lawsuits.

(Unfortunately, lawyers and judges still seem to think that testing is a sign of good and attentive care.) In the final analysis, in my opinion, the best way to resolve claims of medical malpractice and negligence are to prevent them from arising in the first place! And, as an active patient, you can, and should, take appropriate measures to protect yourself â&#x20AC;&#x201D; don't blindly depend on your doctor!

Chapter 36 Medicines : Boon or Bane? He’s the best physician that knows the worthlessness of most medicines. Benjamin Franklin The right drug for the right patient in the right dose by the right route at the right time: this golden rule sums up the ideal prescription. In order to make sure you get the right prescription you need to help your doctor by giving a complete medical history; and informing him of any previous allergic reactions you’ve suffered to drugs, foods, or dyes and specifying any other drugs you may be taking. If you are a woman, you should inform your doctor in case you are pregnant or breast-feeding an infant. However, before you leave your doctor’s clinic, prescription in hand, you have still much more to do as a responsible patient. Make certain that the following questions have been clearly answered before taking any medicines. 1. What is the name of the medicine? 2. Is it available under the brand name (e.g., Crocin) or the generic name (paracetamol)? If a brand name, can it be safely substituted with a generic drug? 3. Why is the medicine being prescribed or recommended? Is it for relief of symptoms? If so, which symptoms? Is it for cure of a medical problem? If so, which problem? 4. If the medicine is recommended for the cure of a disorder or disease, is it medically necessary for the cure? Will the problem subside or go away without the medicine? 5. Is the medicine readily available? If not, is there an over-the-counter alternative? 6. For how long, should you ‘stay on’ the medicine? 7. Does your physician have any relevant written information about the medicine which he can give you? 8. What is the precise dosage of the medicine? 9. What is the recommended frequency of dosage? Once a day? Four times a day? If more than once a day, is it important that the time between doses be approximately equal? (For example, for doses of

four or more times a day, will you need to wake yourself up some time during the night to take a dose, or can you wait until morning?) 10.When should the medicine be taken? Before meals? During meals? After meals? In the morning? Before bedtime? 11.How should the medicine be taken? With how much and what kind of fluid? On an empty stomach? On a full stomach? 12.What should you do if you miss a dose? Should you double the next dose? Should you take the medicine as soon as you remember that you’re missed, a dose? Should you stay on your recommended schedule or should you space your doses over a certain number of hours? 13.What should you do if you start feeling better or your symptoms disappear and you still have some medicine left? 14.Are there any foods, beverages or activities that should be avoided while taking the medicine? For instance, other medicines (prescription and/or over-the-counter varieties)? Alcohol? Driving a vehicle or operating machinery? 15.What should you do if you are taking other prescribed or over-thecounter medicines? Continue with them? Stop taking them? 16.How long has the medicine been ‘on the market’? 17.What are short- and long-term risks associated with the medicine? Can the use of the medicine increase your chance of developing other health problems? If so, what is the likelihood of such problems occurring? What effects, if any, will the medicine cause on other medicines you are currently taking or planning to take? If there are some effects, should the dosage of either medicine be adjusted? Do the benefits of using the medicine outweigh the risks associated with its use? Are there less risky alternatives? 18.What should you do if you experience any of the obvious sideeffects? 19.What are the less common side-effects associated with the medicine? What should you do if you experience any of them? 20.How much does the medicine cost? 21.Is there a less expensive alternative or brand? 22.Will your insurance cover the cost of the medicine? Unfortunately, most patients often don’t fully understand details of their therapy, with the result that they do not comply fully with their doctors’ instructions. They may stop taking the medicine too soon because it doesn’t seem to work, or because they feel better, or because it causes bothersome side-effects. They may take the

drug improperly or at the wrong time or too often. The end result could be that they do not get better; perhaps they may even get worse. Your first step should be to read what your doctor has written ( no matter how illegible the writing may be), and to clearly understand what the ‘hieroglyphics’ mean! Don’t leave with questions unanswered: ask your doctor or chemist for an explanation of any confusing terms on your prescription. A very useful reference book you should consider purchasing is the Indian Drug Review. This book is easily available at any medical bookshop and is an excellent compilation of details on all the prescription drugs available in India: for instance, their cost; dosage; therapeutic action; drug interactions; and their side-effects. Though this book has been written for doctors, it is easy enough for any layperson to use. Not only will this book help in making you much more knowledge about the medicines you are taking, but it may also help you to save money , as you can select a less expensive brand of medicine, after discussing the matter with your doctor. Your doctor can also help you save money by prescribing generic drugs. "Generic" means that the drug is not protected by trademark registration; and the generic name of a drug is usually a shortened form of its chemical name, so that any manufacturer can use it when marketing a drug. Usually, a manufacturer uses a trade name (or brand name) as well as a generic name for a drug, and you should be able to identify the generic name and the trade name of every drug you are taking. Generic drugs are generally priced lower than their trademarked equivalents, largely because the former are not as widely advertised as the latter. This means that you may be able to save as much as 40 per cent by purchasing a generic product. However, not every drug is available generically, and not every generic drug is significantly less expensive than its trademarked equivalent. Also, do keep in mind that for certain drugs it is not advisable to ‘shop around’ for an alternative, because differences can exist between brands of certain drugs. For instance, the tablets or capsules from different manufacturers may not dissolve in the stomach at the same rate or to the same extent, because of variations in the way they are made or because of the fillers (non-active ingredients) that are used. It is, therefore, important to discuss with your doctor or pharmacist the advantages or disadvantages of any particular generic product.

The amount of medicine you buy at a particular time depends on several factors, the most obvious ones being how much money you have, or how much the insurance company will pay for each purchase. Medicines to treat heart disease, high blood pressure, and diabetes may be purchased in bulk because you will need to take such medicines for prolonged periods. The chances are that you will pay less per tablet or capsule by purchasing large quantities of drugs, and save quite a bit of money: do ask the chemist for a bulk discount ! Many family doctors used to (and some still do) dispense medicines which they ( or their compounders) made up themselves ( in fact, this is how the name ‘dispensary’ was derived !); for example, cough mixtures . However, this practice is fast disappearing, because it is difficult to control the quality of these medicines. The doctors who still do dispense medicines for their patients basically buy them in bulk from the manufacturers and then sell them to their patients. Such a practice may be cheaper and more convenient for you, but often you tend to be unaware of what medicines you are taking, because they are unlabelled ! Consequently, it is safer to buy the required medicines from a chemist. In any case, you must insist on knowing the names of the medicines you are taking ! All medicines should be kept in their original containers. Different medicines should NOT be mixed in one container. This precaution is absolutely necessary in order to prevent confusion about which drug is being taken. Never remove the label from the medicine bottle. You can safely store most prescription drugs at room temperature and out of direct sunlight. Some drugs require storage in the refrigerator, whereas some other medicines should not be refrigerated. As mentioned earlier, you should be able to understand the details of your doctor’s prescription. If you can’t do so, even after deciphering his hand-writing, the abbreviations listed below can be helpful. Some doctors still use these abbreviations ( a hangover from the old days, when prescriptions were written in Latin, so as to deliberately prevent the patient from understanding what medicines he was being given !) Abbreviation ad lib

Meaning Freely, as needed

b.i.d caps h.s P.O p.r.n q.4.h q.i.d q.d t.i.d

Twice a day Capsule At bedtime Orally As needed Every 4 hours Four times a day Daily Three times a day

While it’s still as difficult as ever to decipher the doctor’s handwriting, fortunately many doctors now computer printouts for their prescriptions, to ensure legibility ! One should never misuse medicines. While medicines are useful in the treatment of certain illness, the overuse of drugs has taken its toll, not only in the form of unnecessary expenses but also in the form of sickness, and even death, as a result of an adverse reaction to the medicine. Patients still believe that there is a pill for every ill – and this desire for instant relief translates into billions of rupees for millions of pills, potions, ointments and powders. ( The pharmaceutical industry in the second-most profitable in the world – right after illegal drug trafficking !) Most people take one medicine at least weekly, and more than 25% of the worlds population consume drugs on a daily basis. Most patients are not happy unless the doctor prescribes a medicine for them – whether or not they really need it. Often, doctors too will contribute to this “overmedication syndrome”, and the huge advertising budgets as well as the largesse of pharmaceutical companies lure them to do so on a regular basis. You must, however, understand that no drug is without sideeffects – after all, anything which has the potential to do good also has the potential to do harm. A ‘therapeutic effect’ is a desired effect, and a ‘side effect’ is an undesired effect – but both are simply effects of the same drug on the body, and go hand in hand ! Remember that 80 per cent of all illness are self-limiting and require no treatment . Therefore, think carefully about the costs and risks as well as the benefits before taking any medicine. You should be especially careful when your doctor prescribes the “latest” and newest drug. For one, such as drug is likely to be much more expensive than its ‘older’ counterparts. Drug companies nowadays spend large amounts of money in order to induce doctors

to prescribe there newest products, because they are much more profitable for them. Also, remember that newer does not always mean better – in fact, new drugs may be more dangerous! since they have not been used for long enough, as a result of which some of their harmful effects may not become apparent until many patients consume them over a long period of time. Older medicines, which have been tried and tested over many years, are a safer bet, because doctors have considerable experience with them, and are aware of their risks and benefits. For example, Duract, a new nonsteroidal anti-inflammatory drug (painkiller), was withdrawn from the market just a year after being approved for use in the USA (after having undergone rigorous testing), because it was linked with a dozen cases of liver failure, four of them fatal ! There's really no such thing as a safe drug, in the sense that the term means a drug completely free from harm or risk to everyone. The best drugs are simply those whose benefits far outweigh their hazards. Aspirin, for example, is an excellent painkiller and has been proven to prevent heart attacks. But it isn't totally benign either, and can sometimes causes serious gastrointestinal bleeding or, in rare cases, leads to Reye's syndrome in children. Surprisingly, no one knows how many deaths, injuries, and side effects prescription drugs cause each year – there is no agency which monitors these effects! Who's responsible for this modern epidemic of drug – induced disease? The answer is: all of us! Pharmaceutical companies, for a less than rigorous study of their approved drugs, physicians, who incorrectly prescribe drugs, or over prescribe the ‘latest’ drug; patients who don't follow their directions or don't tell their physicians about the other drugs they are taking; and even government agencies for not monitoring drug safety more carefully. As a patient you can help to protect yourself form a therapeutic misadventure by not opting for a newly approved drug unless there aren't any other, well-established alternatives : old is still gold ! Also, if you think a prescription medicine is causing a serious side – effect, inform your physician at the earliest. If the problem is drug related, encourage him to report it to the relevant government agency. Older people are especially prone to the problem of unnecessary drugging. It is astonishing how often neither the patient nor the family knows vital facts such as the name of the pills, what they are supposed to do, their correct dosage, and what possible

side-effects they could produce! Often, once a doctor starts a patient on a medicine, the latter continues taking it, whether or not he needs it any more. And each specialist adds his mite to the drug overload, invariably without having a clue what else the patient is taking . Not uncommonly, it turns out that only one or two of the assortment of drugs are really needed and, once the unnecessary medicines are eliminated, the patient starts feeling much better ! A good doctor is one who knows about all drugs, but who prescribes as few drugs as possible - someone who believes in ‘therapeutic minimalism’. In contrast to today's enthusiasm for drugs , it is wiser for you to be a "therapeutic nihilist" as well, in order to let the body heal itself whenever possible. The following factors should always be borne in mind: Avoid medicines to the extent possible. Pregnant women, for example, generally get along fine without drugs (or with very few drugs), and we can all learn a lesson from their experience. If you must take medicines, follow the time-honored rule: Start low and go slow. Periodically bring all your medicines, including over-the-counter drugs, to your doctor for review. Use reference books, or journals or the internet to check for drug side effects and interactions. Be especially careful not to establish a pattern of frequent medicine use for your children. Be skeptical of patently extravagant claims made by pharmaceutical advertisers. Remember that "big guns" are not needed to treat self-limiting or non-dangerous diseases, and that side-effects of medicines may well create more problems than the original illness. Take oral medicines as far as possible. Such medicines are usually equivalent to injections , and are both cheaper and safer. Many patients still naively believe that injections are more “ powerful”, but this is purely a myth ! If medicine is to be used for long periods, explore the possibility of buying it in bulk. You can often get a price discount when purchasing drugs in quantities of 100, 500 and 1000. For certain chronic conditions such as hypertension and arthritis, there may be several drugs that serve the purpose, and their prices

can vary tremendously. Ask your physician what medicines are equivalent so that you can compare prices. Bring a list of all the medicines you are presently taking during every visit to the clinic/Hospital. This step will ensure that your physician knows exactly what you are taking, and he will not duplicate a prescription, nor will he give you drugs that might interact with each other. Beware of physicians who prescribe new medicines at each visit without modifying or discontinuing previously prescribed drugs. Many patients are not happy unless the doctor gives them a medicine for their problem, even if this is not required â&#x20AC;&#x201C; and many doctors are happy to pander to their patientâ&#x20AC;&#x2122;s fancy! In fact, many patients still judge the calibre of the doctor by the length of his prescription and by the cost of the medicines he prescribes ! Taking two or more drugs at a time can complicate matters considerably, because they can interact with each other, resulting in either adverse effects, or a reduction in their efficacy. Drug interactions represent one of the most common complications of medicinal therapy, and it is estimated that when more than three drugs are taken together, an interaction will occur 25% of the time. While some of these interactions may not be important, others are of major significance. The best way of minimizing this problem is to minimize the number of drugs you take : take only what you need, for as short a time as possible ! Request your physician to discuss non-medicinal therapy even if he gives you a prescription. Always carry a card in your wallet listing all the medicines you are taking, with the precise dosages. This precaution could prove lifesaving in an emergency. It is vitally important that you continue to keep track of your medicines even while you are in hospital. (if you are unable to do so, request a relative or a friend to help out.) Donâ&#x20AC;&#x2122;t automatically assume that the nurse will give you the right medicine at the right time; after all they are human too! You must know what medicines you are supposed to be getting, and when , so that you ( or a relative) can check that no errors are being made. Ask your physician (or physicians) daily what drugs (or they) is (are) ordering and why. Ask the nurse what medicine you are getting each time you are given a pill or an IV is changed. Maintaining a list is helpful. Keep

in mind that over 20% of hospitalized patients have at least one serious reaction to a medication, often due to the wrong medicine or the wrong dose. Ask your physician daily if continued IV (intravenous) medicine is necessary. If the only reason you are in the hospital is to receive intravenous or intramuscular medicines, ask if your doctor if you can receive them at home with the help of special nurses, so that you can get out of hospital as soon as possible. Remember that medicines can help you get well, provided you know them well and use them well ! The following checklist can help you to learn more about your medicines : Drug Checklist Medicine _________________________ _____________________ (Brand name) (Generic Dosage ___ mg ___ cc

name)

1X___ 2X___ 3X___ 4X____ Daily

Should the drug be continued or stopped when symptoms are better? __ Should the drug be taken before, with or after meals? Should I avoid: Alcohol? Yes ___ No ___ . Should I avoid particular ______________________

food

other

drugs?

Pertinent diagnosis ________________________________________________ For symptoms only? Yes ___ No ___ Which symptom? ____________ Is drug necessary for cure? Yes ___ No ___

Will the condition resolve without treatment? Yes ___ No __ Is there an _________________________

over-the-counter

alternative?

Is a generic substitute acceptable? ______________________________ Is there any written __________________

information

about

this

Common side effects ___________________________

What to do if it occurs ____________________________

___________________________

____________________________

___________________________

____________________________

___________________________

____________________________

Rare side effects __________________________

What to do if it occurs ____________________________

___________________________

____________________________

___________________________

____________________________

COMMENTS ___________________________________________________ ___________________________________________________ ____________________________________________________

drug?

Chapter 37 Over-the-Counter Drugs: How to Use them Wisely A drug is a substance that when injected into a guinea pig produces a scientific paper. Anonymous Drugs that can be purchased without a prescription are referred to as over-the-counter (OTC) drugs, and these have become a worldwide phenomenon in the present era of globalization. Common OTC medicines include pain relievers, laxatives, cold-â&#x20AC;&#x153;relievingâ&#x20AC;? preparations and antacids. They are consumed rather indiscriminately by millions of people, but think carefully before purchasing an OTC drug. Do you really need a medicine in the first place? For example, rather than popping a sleeping pill into your mouth every night, a glass of warm milk may provide a better solution for your insomnia. Similarly, simple measures such as steam inhalation and salt water gargling can provide as effective relief from a sore throat as can medicines. Unfortunately, most people would rather take a pill for every ill. Consequently, more than 100 OTC drugs are available for treating the common cold â&#x20AC;&#x201C; none of which have been shown to be effective! We continue to spend huge amounts in buying OTC drugs despite the fact that many of these products are of doubtful value! Just because a medicine is available over the counter does not mean it is completely safe, and you should always check with your doctor before taking it. Moreover, sometimes OTC drugs can actually be harmful. For example, taking painkillers over many years can cause kidney failure and swallowing tablets to self-treat a fever may mask certain illnesses such as tuberculosis or malaria. Similarly, consumption of OTC medicines over a long period can create new problems: for example, total dependence on laxatives or sleeping pills. Self-medication can be sensible and beneficial, but only if done intelligently! Don't just depend on a friend's advice or on your chemist's suggestions: always discuss OTC drugs with your doctor!

In the USA, the Food and Drug Administration (FDA) determines whether medicines fall under the prescription or non-prescription categories. The term prescription (Rx) refers to medicines that can be dispensed by the chemist only under a doctor’s orders. In contrast, non-prescription (OTC) drugs are medicines that the FDA decides are safe and effective for use without a doctor’s prescription. In general, OTC drugs must be useful for an ailment which is mild and easily selfdiagnosable: the treatment should be of limited duration: the drug must be unlikely to produce hazardous side-effects or induce addiction: and the product’s labelling and instructions should be easy to follow. At present, non-prescription medicines offer greater opportunities for self-care. Nowadays, as we live longer and play a more active role in our own health care, the need to become better informed about selfmedication increases and the easiest way to do this is to read and understand the information on the OTC leaflet. The leaflet should carry the following information: The product name. Ingredients. Indications (what the medicine is for). The usual dosage and directions for use. Warnings (when to stop taking the medicine; when to see a doctor; possible side-effects). Expiry date (when to throw it out). Unfortunately, the leaflet will not tell you everything you need to know about using OTC drugs, in part because manufactures don’t want to scare people away. You can get complete information only by asking your doctor! Read the package insert or label before you leave the store, so that you can ask the pharmacist to clarify anything that you don’t understand. Here are some rules to follow when taking OTC drugs: 1. Take the least amount of drug possible to get the desired effect. 2. Use multisymptom medications (which contain a mixture of many drugs) only if you have all the symptoms that they treat. The more the active ingredients in the medicine, the higher the risk of adverse reactions and interactions.

3. Take most OTC drugs either one hour before or two hours after eating, to prevent food from reducing their absorption and effectiveness. 4. Never mix alcohol and medications. 5. If a problem doesn’t get better, worsens, or clears up and then returns, see a doctor. Some medications can make symptoms worse if take far too long. 6. Check label dates before buying or using medications. If you are pregnant, you need to be much more cautious regarding the medicines you take, since they can adversely affect the foetus. Similarly, if you are breast-feeding, remember that the drugs you take do enter the breast milk, so that you end up inadvertently passing them on to your baby as well ! Of course, this does not mean that women who are pregnant or who are breast-feeding cannot take medicines, it just means you should check with your doctor before taking them! Be especially careful when using OTC drugs for treating children they aren't just small adults. Therefore, don't estimate the dose based on their size: follow carefully all the directions on the leaflet. Don't play doctor and double the dose just because your child’s condition appears more serious than the last time and don't let children take medicines by themselves, just like you wouldn't let them play with fire. Never call a medicine ‘a sweet or a candy’ in order to induce your children to take it; if they come across the medicine on their own, they're likely to be tempted to try it, possibly with disastrous consequences! Therefore, you should store all medicines, including vitamins and supplements, in such a place where children can neither see nor reach them. One should be especially careful with iron-containing supplements: iron capsules are the leading cause of accidental fatal poisoning in children under the age of three. Certain OTC drugs may affect the way your body reacts to the prescription drugs you are taking. For instance, people taking tetracycline should avoid taking antacids at the same time because the latter interfere with the body's absorption of the former, thereby decreasing its effectiveness. Consequently, you must know precisely what OTC drugs you are taking, and let your doctor know as well! Nowadays, many homeopathic and ayurvedic medicines are also available over the counter as well. Don't automatically assume that because these medicines are ‘natural’ they are completely safe – remember that every medicine can have side-effects. You should

apply the same common-sense principles to OTC medicines hat you do to all other medicines!

Chapter 38 Coping with Side-Effects Doctors are men who prescribe medicines, of which they know little, to cure diseases, of which they know less, in human beings, of whom they know nothing. Voltaire Medicines have certain desirable effects (which is why the doctor prescribes them in the first place!) and these effects of a drug are known as the drug’s effects or therapeutic effects. Drugs, however, have undesirable effects as well, and these are broadly called sideeffects or adverse reactions. Some side-effects are expected and unavoidable, but others may surprise the doctor as well as the patient, and some of these unexpected reactions may be due to an individual’s specific response to the drug. Side-effects generally fall into one of two major groups — those that are obvious and those that cannot be detected without laboratory testing. A discussion between you and your doctor about your medicines should not be restricted to the most easily recognized sideeffects because other, less obvious, side-effects may also prove harmful. Some side-effects may signal a serious, perhaps dangerous, problem, and if such side-effects appear, you should consult your doctor immediately. If you know that a particular drug produces a particular sideeffect, you can afford to relax a little. Most expected side-effects are temporary and need not cause alarm. You’ll merely experience discomfort or inconvenience for a short time. For example, you may become drowsy after taking an antihistamine or develop a stuffy nose after taking certain drugs for treating high blood pressure. Of course, if you find certain minor side-effects especially bothersome, you should discuss them with your doctor, who may be able to prescribe another drug or at least assure you that the benefits of the drug (you are currently taking) far outweigh its somewhat irksome side-effects. Sometimes, side-effects can be minimized or eliminated by changing

your dosage schedule or taking the drug with meals, but you need to check this aspect with your doctor! Even if you experience minor side-effects, it is very important that you take your medicine exactly as it has been prescribed. Don’t stop taking a medicine just because you think that it does not ‘suit’ you ! You should take the full dose at the specified times for the length of time prescribed by your doctor. Taking a lesser amount of medicine to avoid side-effects or because your condition appears to be improving is NOT advisable. A smaller dose may not provide any benefit whatsoever; that is, half the dose may not provide half the therapeutic effects ! Some obvious side-effects of commonly used drugs include blurred vision, a dry mouth, heartburn, nausea, vomiting, diarrhoea, constipation, loss of appetite, drowsiness, dizziness, stuffy nose, skin rash, swelling, itching and sweating. Remember that these side-effects do not mean that you are ‘allergic’ to the drug, it may simply be one of the reactions of your body to the drug. Other side-effects may be subtle and more difficult to detect. You may not notice any symptoms at all, or you may notice only slight indications. Therefore, your doctor may advice you to go in for periodic blood tests or eye examinations to ensure that no subtle damage is occurring while you are on certain medicines. Such damage could affect your heart, kidney or liver; or cause anaemia or loss of hearing. USE OF DRUGS DURING PREGNANCY AND BREAST-FEEDING Before taking ANY medicine, it is very important to tell your doctor if you are pregnant (or planning to become pregnant) or are breastfeeding your baby. For most drugs, at present, complete information on safety during pregnancy and while breast-feeding is woefully lacking. This shortcoming cannot be attributed to negligence or lack of concern on the part of regulatory agencies, but to the fact that it would be unethical to conduct drug experiments on pregnant and nursing women. Keeping this aspect in mind, you should discuss in an unambiguous manner with your doctor the risks versus the benefits of taking any medicines during pregnancy or while nursing an infant. MANAGEMENT OF SIDE-EFFECTS

First of all, check your drug information leaflet or consult your doctor to determine whether, the side-effects you are experiencing are minor (relatively common and usually not serious) or major (symptoms that you should consult your doctor about). If your side-effects are minor, you may be able to compensate for them (see the following table for suggestions). However, consult your doctor if you find minor side-effects persistent or particularly bothersome.

Common Minor Side-Effects Side-effect

Management

Constipation

Increase the amount of fibre in your diet; drink plenty of fluids; exercise regularly Diarrhoea Drink lots of water to replace lost fluids; if symptoms last for longer than three days, consult your doctor Dizziness Avoid operating machinery or driving a car Drowsiness Avoid operating machinery or driving a car Dry mouth Suck on candy or ice chips Headache Remain tranquil; take aspirin or paracetamol Insomnia Take the last dose of the drug earlier in the day; drink a glass of warm milk at bedtime; request your doctor to draw up in exercise programme Itching Take frequent baths or showers, or use wet soaks; also calamine lotion or antihistamines may help Nasal congestion If necessary, use nose drops Upset stomach Take the drug with milk or food On the other hand, if you experience any major side-effects, contact your doctor immediately. Your dosage may need adjustment, or you may have developed an allergy to the drug. Consequently, your doctor may want you to switch over to a different medicine to treat your disorder. Never stop taking a prescribed medicine without first consulting your doctor!

Chapter 39 Preventing Medication Errors: A Vital Precaution I keep six honest serving men (They taught me all I know); Their names are What and Why and When, And How and Where and Who. Rudyard Kipling While no one can deny the fact that modern medicines have saved numerous lives, it is also true that medication errors have killed or harmed quite a few people. A medication error is a mistake made by a doctor, a nurse, a chemist, a caregiver, or a patient during the process of prescribing, administering, dispensing or using a medicine. Research has shown that the most common causes of medication errors are: similar drug names, similar packaging and labeling and illegible prescriptions. The crucial question is: what can you do to help prevent medication errors? The answer is simple learn to ask questions! Just because you haven't been trained as a doctor doesn't minimize the important role you play in preventing errors with regard to your medicines, or those for your family! As the patient (or the caregiver), you have a great deal at stake in the success of your drug therapy and should assert your right â&#x20AC;&#x201D; and your responsibility â&#x20AC;&#x201D; to ask relevant questions. By the very process of asking questions about your medicines, you understand why you are taking them, how to take them, and what to expect so that you can detect potential errors. After asking the questions, make sure you understand the answers clearly. Ensure that you can read your doctorâ&#x20AC;&#x2122;s prescription! If you can't, ask your doctor to print the name of the medicine and the directions for taking it. Fortunately, many doctors have now started using computers routinely to print out their prescriptions to ensure legibility! Ask your doctor, chemist or nurse questions about the medications. You should completely understand your health problem and what you can expect from the medicines. You should know the following facts:

How the medicines are supposed to work. What side-effects could occur and how long could they last. What to do if the medicine doesn't seem to be working. Discuss your medication with your chemist. Unfortunately, chemists still represent a very underutilized resource in India. Every chemist's shop must have a duly qualified and trained pharmacist. (Pharmacists are professionals who have done a four-year course in a pharmacy college and are knowledgeable about medicines and their effects.) If you have any doubts, seek out the pharmacist in the chemistâ&#x20AC;&#x2122;s shop; the clerk or the shopkeeper may not know anything about medicines! In addition to helping you take your medicine properly, talking with the pharmacist helps in pinpointing errors that may have occurred when reading a written prescription or transcribing an over-the-phone prescription. While taking medicines, you should strictly follow the doctorâ&#x20AC;&#x2122;s instructions. A medicine may not lead to the end result that you expect if it is not taken as instructed. If you are taking a medicine for a chronic condition, it is especially important that you understand certain vital facts such as: How is the medicine to be taken? How much? How often? For how long? What side-effects could occur? What do you do if you miss a dose. You should be able to identify your medicines properly. Many errors are made at home by taking a wrong tablet or capsule which appears similar to another family member's medication. The ability to recognize your medicines can help in preventing you from taking the wrong drug. Your doctor may decide to change your brand of medicine, and may substitute a brand name medicine for another, a brand name medicine for a generic, one generic for another, or a generic for a brand name medicine. In changing from one product to another, however, there is a chance of an error occurring. This is why you should always double check when your doctor changes your prescription. Knowing the generic names and the common brand names of your medicines can help prevent errors. You are as important as your doctor in helping to prevent medication error and using medicines wisely. If you believe an error has occurred, contact your doctor, pharmacist, or nurse as soon as possible. Do not take the medication until all your doubts have been dispelled.

Here are some simple steps you can take to reduce the risk of a medication error: Patronize the same chemist for prescriptions drugs as well as over-the-counter drugs. A complete record of your medications can be kept at the chemist’s shop, and some modern chemist have know installed computers which allow them to store the details of the medicines you are taking. This precaution is especially important if more than one physician has been prescribing medicines. A competent pharmacist can also spot hazardous combinations of medications, and help you avoid possible dangerous drug interactions. Your doctor should be aware of, and keep a record of, all the medicines you are taking. This record should include over-thecounter drugs (such as vitamins and aspirin) laxatives, as well as the medicines that another specialist may have prescribed. This precaution can help to avoid dangerous drug combinations in which drug can interact with each other to produce hazardous side-effects. Your doctor needs to know about your past reactions to certain drugs. However, tolerance levels may change with age and as some people grow order, they may show greater sensitivity to medications such as painkillers or tranquilizers. Always keep medications in their original containers. Many drugs look alike and this can cause an ‘identification crisis’. Never use another person’s medication; and never experiment with medicines just because a friend recommends them. Similarly don’t “play doctor” by lending your medicines to your friend or relatives! Throw away all medications once they have reached their expiry date. Try to reduce the need for potentially addictive drugs such as sleeping pills or laxatives. A glass of hot milk could help you sleep at night, while increasing the fiber intake by modifying your diet could replace the need for a laxative. Always check with your doctor for treatment alternatives which don’t need you to consume drugs. For example, if you have hyper tension, meditation, cutting down on salt and losing weight can help lower your blood pressure, there by avoiding the need for medication.

Don't break or chew any tablets or capsules unless you have been instructed to do so by your doctor or pharmacist. Such an action could interfere with a drug's potency because your system may absorb it too quickly, or not at all. Make a habit of reading the label every time you take your medication. so as to ensure that you are taking the right drug and following the instructions properly. Keep all medications in a locked cabinet where children can't reach them. Even though you may follow the preceding instructions carefully, accidents can still happen. One of the most serious medication errors is a drug overdose. Symptoms of an overdose include dizziness, shortness of breath, a slowdown in breathing, ringing in the ears, extreme sleepiness, nausea, clammy skin, difficulty in hearing, headache, sweating and even loss of consciousness. If you make a mistake and exceed the recommended dosage of your medication to the point of overdose, contact your doctor or hospital emergency room immediately. In case you are unable to do so, ask for help from relative or friend. Always remember that you are the one taking your medicines. Therefore, make sure you are well informed about them, so that you can take them safely!

Chapter 40 â&#x20AC;&#x2DC;Prescriptionâ&#x20AC;&#x2122; for a Healthy Medicine Cabinet A man too busy to take care of his health is like a mechanic too busy to take care of his tools. Spanish Proverb

Your medicine cabinet can serve as a very valuable resource center, keeping in mind the fact that more than 80 per cent of illnesses are minor and self-limiting, and can be easily managed at home. Unfortunately, most medicine cabinets tend to become a potpourri of pills, ointments, creams, tonics and out-of-date prescriptions! Here is some guidance on how to create a safe and effective medicine cabinet and first aid kit. First of all, clean out your medicine cabinet carefully, discarding all obsolete or unused prescriptions, over-the-counter drugs, ointments, and creams after checking all the labels on them, (to determine expiry dates). You should carry out this exercise at least once a year and replace the items as needed. Irrespective of the location of your medicine cabinet (in the bathroom or elsewhere in the house), make sure it's locked. The key should be kept far from the reach of kids, making due allowance for their climbing abilities! All medicines should be kept in one place - the locked medicine cabinet. This step is not only a wise precaution, against accidental poisoning it also makes finding a medicine much easier, especially when you need it in the middle of the night or in an emergency. What medications should your medicine cabinet contain, other than the prescription drugs you need to take? The following list can help to guiding you. Most of the medicines listed here are available “over-the-counter”, i.e., they do not need a doctor’s prescription. Ailment

Medicines for treatment

Example

Allergies

Antihistamines such as Astemizole cetrizine, chlorpheniramine

Ringworm, Athlete's foot,( fungal infection of the skin)

Antifungals such as miconazole

Candid cream

Minor cuts and scrapes

Antiseptics such as povidone iodine, polymer film spray

Betadine

Benadryl, Avil, Incidal

Healex spray

Constipation

Laxatives such as isabgol, bisacodyl, liquid paraffin

Cough (dry)

Cough suppressant such as codeine, dextromethorphan

Cough (wet) expectorant

Dulcolax

Linctus Codeine Tossex

Expectorant such as

Dristan

chlorpheniramine, guaiphenesin Stuffy nose

Decongestants such as Sudafed pseudoephedrine, phenylpropanolamine

Runny nose

Nose drops containing Otrivin nose drops locally effective decongestants

Skin rashes and itching

Creams containing steroids

Eumosone cream Betnovate

Colds

Tablets which contain a mixture of antihistamines and decongestants

Actifed

Diarrhea

Antidiarrheal such as loperamide, diphenoxylate

` Fever

Antipyretics such as paracetamol, aspirin

Pain due to gas

Antiflatulents such as dimethicone, methylpolysiloxane

Imodium, Lomotil

Crocin, Dispirin

Gellusil MPS

Headache and other aches

Analgesics such as aspirin,paracetamol, ibuprofen

Dispirin, Crocin, Brufen

Skin rashes

Lotion such as calamine

Calamine lotion,

Stomach upset

Antacids such as Gellusil, Tums alumunium hydroxide, calcium carbonate

Vitamin supplements

Vitamins

Becosules

This list includes only examples of the types of medications you could include; there are many other products available that may also be stored. Ask your doctor for specific instructions. Many people also keep homeopathic medicines and ayurvedic preparations in their medicine cabinet. THE FIRST AID KIT You should put together a first aid kit as well, in order to tackle minor medical emergencies at home. As with your medicine cabinet, check your first aid kit at least once a year. You must also check the kit before going on vacation or on a long trip to make sure you've got all the supplies needed. It would also be a good idea to go through the first aid kit after returning home from a vacation or trip and to replace those items you had to use while you were away. Your first aid kit should contain the following items: - One or two rolls of adhesive tape - One roll of gauze - A package of sterile gauze pads (separately wrapped) - A box of small adhesive strip bandages ( Bandaids) - One or two elastic wraps(Elastocrepe) - Cotton swabs - An antiseptic lotion or cream for minor cuts and burns and a bar of soap. - A thermometer

- A pair of scissors -Tongue depressors - A torch with extra sealed batteries - A backup supply of a prescription drug if someone in the family has a chronic condition that requires daily medication It’s also very helpful to tape a list of important names and telephone numbers, including your doctor and of nearest hospital emergency room, inside your medicine cabinet. Always remember the Scout’s motto: Be prepared! The last thing you want to do if you develop a hacking cough which is keeping you (and possibly your neighbors, not to mention your family members) awake at 2 a.m. is to phone your doctor, or hunt frantically for a chemist’s shop which is open!

Chapter 41 On the Way to the Operation Theatre: What You Should Ask Your Doctor Before Undergoing Surgery The greatest triumph of surgery todayâ&#x20AC;Ś lies in finding ways for avoiding surgery. Robert Tuttle Morris SURGERY: YES OR NO? The two most important questions to ask about planned surgery are: why is the procedure necessary for you, and what alternatives are there to surgery? If you do not need to undergo the operation, then you can safely avoid any risks that might result! Remember that all forms of surgery entail both risks and benefits; a surgery is worthwhile only if you can be reasonably assured that the benefits are greater than the risks. Your primary care doctor could be the one who suggests that you go in for surgery and he may recommend a surgeon. You may also want to identify another independent surgeon to get a second opinion. Your doctor should welcome relevant questions about the surgery and if you do not understand the answers, ask him to explain them clearly and unambiguously. Patients who are well informed about their surgery tend to be more satisfied with the results. 1. What operation are you recommending? During your session with the surgeon, request him to explain the surgical procedure. For example, if some organ has be repaired or removed, find out why it is necessary to do so. Your surgeon can use illustrations or models to explain to you the steps involved in the procedure. Today, there are often different ways of performing the same operation and one way may require more extensive surgery than another. For example, hysterectomy (surgery which involves removal

of the uterus) can be done through a large abdominal incision, through many tiny ones (using laparascopic technology) or through the vagina. You need to understand which method your surgeon will be adopting, and why your surgeon prefers one procedure over another. 2. Why do I need the operation? In response to the crucial question as to why surgery is necessary there can be many reasons. Some operations can relieve or prevent pain; others can reduce symptoms or improve some body function; yet others are performed to diagnose a problem. Make sure you understand how the proposed operation fits in with the diagnosis of your medical condition. 3. Are there alternatives to surgery? Often, surgery is not the only solution to a problem. Medical therapy or other non-surgical treatments, such as a change in diet or special exercises, might help you just as well as surgery, or even more. Ask your surgeon or primary care doctor about the benefits and risks involved in the other choices. You need to know as much as possible about these benefits and risks in order to make the most appropriate decision. One alternative may be ‘watchful waiting’, a process in which both you and your doctor check to see if your problem is getting better, so that you may be able to postpone surgery, perhaps indefinitely. Sometimes, a “tincture of time” provides a shield against the surgeon’s knife! 4. What are the benefits of undergoing the operation? Ask your surgeon what you will gain by undergoing the operation. For example, a hip joint replacement could mean that you can walk again with ease. Also, ask how long the benefits of surgery are likely to last. For some procedures, it is not unusual for the benefits to last for a short time only. A second operation may be needed at a later date. For other procedures, the benefits may last a lifetime. When identifying the benefits of the operation, one should be realistic. Sometimes, when patients expect too much, they can be disappointed with a perfectly satisfactory results!

5. What are the risks of undergoing the operation? All operations carry an element of risk, which is why you need to carefully weigh the benefits of the operation against the risks of complications or side-effects. Complications are unplanned events, such as infections, too much bleeding, adverse reactions to anaethesia, or accidental injury. Some people face an increased risk of complications because they have medical problem, such as diabetes or hypertension. In addition, certain side-effects may result after the operation, such as swelling and soreness at the site of the surgery. Ask your surgeon to specify the possible complications and side-effects of the operation. There is always some pain almost to after surgery. It would be prudent ascertain how much pain you may have to endure and what the doctors and nurses will do to reduce it. Controlling the pain will help you become more comfortable during recuperation, which will help you to recover faster. 6. What would happen if I don’t undergo this operation ? Based on the information you have collected about the benefits and risks of the operation, you may decide against it. However, you should definitely ask your surgeon what you will gain — or lose — by not undergoing the operation immediately. Could you develop more pain? Could your condition get worse? Could the problem go away? Getting a second opinion from another doctor is a very good way of making sure that undergoing the operation is the best alternative for you. If you are seeking a second opinion, make sure to get your records from the first doctor so that the second one does not have to repeat the tests. You may get a second opinion from another surgeon or from a medical specialist. CHOOSING THE RIGHT SURGEON One way of reducing the risks of surgery is to choose a surgeon who has been thoroughly trained to perform the procedure and has plenty of experience. You can ask your surgeon about his recent record of successes and complications, with the specific operation. If you feel it is necessary, you can discuss the topic of the surgeon's qualifications and experience with your family doctor.

THE OPERATION VENUE Most surgeons nowadays practice at one or more local hospitals. Find out the venue where your operation will be performed and ask your doctor about the success rate at that hospital. Research has shown that some operations, such as cardiac bypass surgery, have a better outcome if they are done in hospitals that perform many such procedures (perhaps because these hospitals have a heavy workload, which is why their surgical team has more experience). If the hospital has a low success rate for the operation in question, you should ask your surgeon to perform it at another hospital, which has a higher success rate. INPATIENT OR OUTPATIENT? Until recently, most surgery was performed on an inpatient basis; i.e., patients stayed in the hospital for one or more days. Today, a lot of surgery is done on an outpatient basis in a special surgical center, or a day surgery unit within a hospital. Outpatient surgery is less expensive because you do not have to pay for staying in a hospital room. Therefore, confirm whether your operation will be done in an inpatient setting or in an outpatient setting. One point should be borne in mind. If your doctor recommends inpatient surgery for a procedure that is usually done as outpatient surgery â&#x20AC;&#x201D; or vice versa, i.e., he recommends outpatient surgery that is usually done as inpatient surgery â&#x20AC;&#x201D; ask him for the reasons for his decisions. You should ensure that you are at the right place for your operation. THE IMPORTANCE OF ANAESTHESIA The purpose of using anesthesia is to ensure that surgery can be performed without unnecessary pain. Your surgeon can specify whether the operation calls for local, regional, or general anesthesia and also why this form of anesthesia is recommended for your procedure. Local anesthesia numbs only a part of your body for a short period of time; for example, a finger. In most cases, you will remain awake after being administered regional anesthesia. General anesthesia numbs your entire body for the entire duration of the surgery and you will be rendered unconscious. Anesthesia is quite safe for most patients and is usually administered by a specialized physician, called an anesthesiologist or

anesthetist. If you decide to undergo an operation, ask to meet the person who will give you anesthesia. Find out what his qualifications and experience are. Also, ask him about the side effects and the risks of going in for anesthesia in your case. Do not forget to tell him about medical problems you may have (including any allergies), or any medications you have been taking, since they may affect your response to the anesthesia. THE PERIOD OF RECOVERY Your surgeon is the ideal person who can tell you how you may feel and what you will be able to do — or not do — during the first few days, weeks, or months after surgery. Ask him how long you will need to remain in the hospital. Find out what kind of supplies, equipment and any other help you will need when you go home. Knowing what to expect can help you cope better with recovery. Ask when you can start regular exercise again and when you can go back to work. You should follow your surgeon's advice strictly to make sure that you recover fully as soon as possible. THE COST FACTOR You need to determine the total expenses you will incur in the entire process of surgery. First, find out what your surgeon's fees are, and what all they cover. Surgical fees often include the cost of follow-up visits after the operation, and may include the services of a surgical assistant as well. You will also be billed by the hospital for operation theatre time; inpatient or outpatient care; and the cost of consumables and disposables used. Additional costs are those of the anesthesiologist and other medical staff who provide services related to your operation. You need to find out what your total expense for the surgery will be – i.e., how much you will need to pay as a total figure. Many hospitals now also offer ‘all-inclusive’ package deals for certain operative. However, unforeseen complications can considerably add to the costs and you may need to budget for these as well. The health insurance coverage for surgery can vary, and there may be some costs which you will have to bear on your own. Before you undergo the operation, find out from your insurance company how much of these costs it will bear, and how much you will have to pay yourself. How to Avoid Unnecessary Surgery And Other Related Aspects

The following guidelines could prove helpful in avoiding unnecessary surgery: 1. Don't go directly to a surgeon for medical treatment. If at all possible, start out by going to your regular family doctor — a general practitioner or a physician — for the initial diagnosis or treatment. 2. Consider getting an independent consultation or a second opinion before subjecting yourself to surgery, even if your family doctor and surgeon agree that surgery is necessary. Consultations, according to some studies, reduce operations by as much as 20 to 60 per cent, and you may be lucky enough to fall into this category 3. Don't push a doctor to perform surgery on you. If you insist on surgery, even if it is actually unnecessary, you are likely to find a surgeon willing to perform it. There are enough ‘overtreaters’ who are willing to perform unnecessary surgery; so don't invite trouble for yourself. 4. Sometimes, the huge costs may compel you to discard the option of surgery. Discuss frankly the fee for surgery with your doctor. You should know what the surgery is going to cost so that you can make financial arrangements, if necessary. Any surgeon worth his scalpel will gladly discuss this aspect. 5. Check out the credentials of a surgeon by inquiring about him from those who know him or have been operated upon by him. This category includes other patients as well as colleagues of the surgeon. One good way of finding the ideal surgeon is to find out whom doctors go to when they need surgery for themselves or their families. The greatest compliment to a surgeon is paid when he is chosen by a doctor or his family. 6. Make sure the surgeon knows, and is willing to work with, your general practitioner or family doctor. To ensure complete, continuous and quality care, close contact between the surgeon and your doctor is vital. If they can't work coherently as a team, you may be the loser. 7. Select a surgeon who is not too busy to devote enough time and attention to his patients. Surgeons who handle too many cases are ‘bad news’ for the patient for obvious reasons. The reality is that the best surgeons are likely to be very busy. But the ‘best’ surgeon who must rush through an operation and zip past his patients is not likely to achieve worthwhile results.

Be on guard, especially if some of the operations which are most often unnecessarily performed, are proposed to you. These operations include hysterectomies, haemorrhoidectomies, and tonsillectomies. These operations have been referred to as ‘remunerectomies’ by some cynics ( derived from the word ‘remuneration’). 9. Listen carefully to the experts. But remember, the ultimate decision is yours. You're entitled to all the facts you need and you're entitled to decide whether or not to go ahead with the surgery. It is the patient, not the doctor or the surgeon, who is supposed to (and is entitled to) make the final decision on whether or not to undergo surgery. GETTING READY FOR SURGERY One inescapable reality is that surgery subjects your body to major stress, and could drain you of much of your energy which is essential for ‘post-surgery’ recuperation. However, going in for surgery does not mean that you leave everything in the hands of the surgeon! Just as the surgeon needs to prepare for the surgery, so do you! There is a lot you can do to help your body to heal better and recover more quickly from the effects of the surgery. Here are some practical pre-surgery measures to help build your stamina and improve your recovery: Get enough rest. Sleeping for eight hours or more every day is ideal for boosting your immune system and for optimizing the healing process after your operation. Discuss the intake of medications and alcohol with your physician. Inform your surgeon or anesthesiologist about any drugs that you may be using. This precaution is necessary because some substances can cause your body to react unpredictably to anesthetics and may contribute to adverse effects. For example, aspirin or ibuprofen can worsen bleeding, and you may be advised to stop these drugs prior to surgery. Another mandatory precaution: stop-smoking! Ensure that you get good nutrition. Certain vitamins and minerals are critical for healing and acquiring immunity. Choose foods high in vitamins C, E and A as well as in zinc and iron. You can start taking multivitamins and iron supplements if your doctor advises you to do so.

Exercise regularly, so that you can be as fit as possible for surgery. Learn mental relaxation techniques. For instance, meditation, breathing exercises, massage or other techniques can help ease your mind and calm your body. Studies have shown that patients who listen to their favorite music during surgery (even when under anesthesia) recover faster and experience less pain. Bank your blood. If your surgeon feels you may need a blood transfusion during surgery, Enquirer about banking your blood prior to surgery (autologous transfusion). This is the safest method of blood donation available, in which you store your blood a few weeks prior to surgery, so that it can be kept as a standby during your operation, if needed. However, if you need a larger amount of blood, you should get your friends and relatives to donate blood, or remain on call as needed. VARIOUS TYPES OF SURGERY Some wags have humorously defined surgery as ‘major‘ when it is done on them and ‘minor’ when it's being done on someone else! A more realistic definition would be to consider that surgery as ‘major’, which involves vital organs, requires a long time to perform entails a blood transfusion. Surgery can be classified under various categories. For or instance: Emergency: An immediate operation to save a life or maintain the functioning of a body part. Curative: An operation that rids the body of a problem or corrects a condition. Urgent: An operation that must be done within a matter of hours. Diagnostic: An operation that helps in making a diagnosis about a suspected problem. Planned or elective: Surgery planned well in advance of the actual operation date. Exploratory: This type explores a body organ or body area for a suspected disorder. Palliative: This type eases body pain, but doesn't cure the problem. WHAT TO EXPECT PRIOR TO SURGERY

Your doctor will most probably need to order a series of tests to make sure that you are fit for surgery as well as for withstanding the effects of anesthesia. These tests include: urine analysis, blood tests, chest X-ray and ECG, depending upon your age and the type of surgery required. Your anesthesiologist will visit you prior to surgery. He will review important information such as the timing and duration of surgery and what type of anaesthetic needs to be used. He will remind you not to consume any food or water for a specific period prior to the operation, such consumption can cause life- threatening vomiting during the course of surgery. The anesthesiologist will also need relevant data about any allergies or previous surgical experiences that you may have had. Surgical ‘preps’ are often necessary, depending on the kind of surgery scheduled. A ‘preparation’ can involve a variety of activities such as cleaning and shaving of the surgical area, a special preoperative diet of only liquid foods, placing a catheter in the bladder, administering, putting an enema, or drops in the eyes. A patient should feel free to ask the surgeon what to expect by way of surgical preparation. Knowing what to expect can ease preoperative stress to a great extent. The doctor or nurse will ask you to remove all valuables and possessions and hand them over to your relatives or friend or the hospital authorities. The items could include watches, jewelry and eyeglasses. The hospital authorities will need you to sign a surgical consent form. You must read this form carefully, especially the fine print, before affixing your signature on it. Usually, a sleeping pill will be offered the night prior to surgery. Most people tend to be anxious about the forthcoming surgery and find such medication helpful. Request your doctor to try and schedule your surgery as the first operation of the day. Not only does this mean that you will be starving for a shorter time, but it also means that the operation theatre staff is ‘fresh’; i.e., more alert and more efficient. AFTER THE SURGERY: AN ACTIVE ROLE CAN ASSIST YOUR RECOVERY Here is a list of ‘dos’ after surgery, which could prove helpful:

Do leave the hospital accompanied by a responsible adult. This person should ensure that you travel home safely; he should also provide immediate care at home. You should ensure that this adult stays with you for 24 hours after surgery. Do remain quietly at home for the day and take rest. You need rest both because you have received anesthesia and because you have undergone a surgical procedure, even one that is considered minor. If, after a day, you still do not feel that you have recovered, you should continue your rest for an additional day or two. Discuss your plans to return to work or normal routine with your doctor and obtain his approval. Do take liquids initially and slowly progress to a light meal (such as soup, dal, biscuits, toast, plain rice, or yogurt). Do call your doctor if you have any questions, even if they seem trifling. Moreover, if you feel your recovery is not progressing to your satisfaction, consult your doctor, rather than worry unnecessarily! Your doctor should make it a point to advise you about the warning signs of potential problems after surgery (such as excessive pain, fever or bleeding) and to whom you should report these symptoms. Your doctor may prescribe some medications after your surgery, such as painkillers or antibiotics. Take these medications without fail as advised. Your doctor will also advise you how to take care of the surgical wound (incision), so that it heals well. For example, he may advise you not to wet it for a few days; and will tell you when to return for your suture removal, if required. Your follow-up visit after surgery is extremely important. During this visit, your doctor can make sure that you are recovering as expected and that your wound is healing properly. He will inform you about his findings during the surgery, and also provide the details of your operation. Make sure that you have obtained or collected a complete record of your operation before you leave the hospital or clinic! You should insist that all the tissues removed from your body be sent for histopathologic examination and that a copy of the report be kept in your medical record, as it provides critically important information. Some varieties of surgery, such as endoscopic surgery, can be videotaped. Make sure that a copy of this video also becomes a part of your medical record! After the “dos”, here’s a list of ‘don’ts’ after surgery:

Don’t drive a car for at least 24 hours. After being subjected to anaesthesia, your reflexes, reactions and judgement may be impaired. Such impairment makes driving a car dangerous, not only for you, but also for others. Don’t take any important decisions or sign any legal documents for 24 hours. The potential for impairment relates not only to physical activities, but also to your mental state. Moreover, the anxiety that frequently accompanies the taking of important decisions should be avoided. The day should be spent resting. Don’t drink alcohol for at least 24 hours. Alcohol is also considered a drug, meaning that an alcoholic drink has the potential to react negatively with the anaesthetic present in your system after surgery. Alcohol includes hard liquor, beer and wine. Here’s a sample surgery checklist which can help you to critically think about surgery, if your doctor feels you need an operation.

Surgery Checklist Type of operation ________________________________________ Description _____________________________________________ Diagnosis _______________________________________________ Name of the surgeon _____________________________________ How often does the surgeon performs this surgery? ____________ Who will be the primary surgeon? __________________________ Risk of: Operative death? _____(%) Serious complications? ____% Possible complications _____ Possible complications chances of these occurring ________% Is this surgery only for symptom relief? ______________________ What symptom? _________________________________________ Is this surgery necessary to prevent death? ____________________ Likelihood of dying without surgery _______(%) in _______ years. What non-surgical treatment can be tried first? ________________ ________________________________________________________ Can surgery be done as an outpatient? _______________________

Can surgery be done with a local anaesthetic? ________________ If so, is anaesthetic standby necessary? _______________________ Does surgery require a surgical assistant? _____________________ If yes, of what caliber? ____________________________________ Name of anesthesiologist __________________________________ At what hospital is the surgery planned? ______________________

What other hospital could be used? _________________________ Expected duration of hospitalization? _________________________ Expected duration of recovery? ______________________________ How long will I tire easily? ________________________________ How soon can I go back to work? ___________________________ How soon can I resume normal exercise? ____________________ How long will I experience some pain or limitation of activity? ________________________________________________________ Surgical fee Rs. __________________________________________ Assistants fee Rs. __________________________________________ Anesthesiologist Fee Rs ___________________________________ Total Rs. ________________________________________________ What will insurance cover? Rs. _____________________________ COMMENTS _______________________________________ ___________________________________________________ ___________________________________________________ ____________________________________________________

Fill out this checklist when considering any surgery. Complete a separate checklist for each opinion you receive and each surgeon you consult.

Chapter 42 The Kinder Cut: Surgery Made Easy In a good surgeon, a hawk’s eye; a lion’s heart; and a Lady’s hand. Leonard Wright Most of us become petrified at the very thought of having to undergo surgery, and one of the major worries is the fact that hospitalization is needed. After all, hospitals can be terrifying places for patients! Fortunately, there is now a kinder option available for many patients who need to undergo surgery, namely, which does not need to spend time in hospital, and this is called day-care surgery (also known as ambulatory surgery or same-day surgery). Day-care surgery has become increasingly popular all over the world, for many reasons. First, thanks to tremendous advances in technology, many doctors have started performing minimally invasive surgical procedures. These procedures use endoscopes, and require very small incisions, so that the risks involved in conventional major surgery can be avoided. Secondly, the newer drugs used for anesthesia allow patients to recover consciousness very quickly, so that they can go home soon after the surgery is over. Finally, since modern painkillers are more powerful, patients have much less pain after the operation and they can successfully relieve the pain themselves by taking these medications at home. Ambulatory surgery allows patients to recuperate where they are most comfortable--in their own home ! This is now a global trend, and over 50% of elective surgery in the USA is now done on an ambulatory basis. This fact is not surprising, given the various benefits ambulatory surgery offers patients. Patients find day-care surgery much less stressful, as short recovery times allow anxious patients to be comforted soon after surgery, by their relatives and they don’t need to be isolated in a hospital room. Moreover, patients do not suffer from separation anxiety, as they do not need to be separated from their families overnight --- something which is especially helpful for children. Ambulatory surgery means less time away from home, less time off from work, and less disruption of the patient's schedule. Patients are happier, because they remain in a single unit which has been planned, and is operated, solely for their safety and comfort. Patients prefer

ambulatory surgery over hospital outpatient departments because the former involves less paperwork, little waiting and more organized and friendlier staff compared to crowded and uncomfortable hospital settings, where day care surgery patients get low priority, because their surgery is usually scheduled last, after the major operations. Studies worldwide have shown that ambulatory surgery delivers the same high-quality care as that given to hospital patients. The first ambulatory surgery center was setup in the USA in 1970. Today, almost five million surgeries are performed each year in the more than 2,400 surgery centers across the United States. While day-care surgery is still a very new concept in India, it is heartening to observe that is becoming increasingly popular day-by-day. Because the expenses incurred during a hospital stay are eliminated, ambulatory surgery usually costs less than the same type of surgery done for a hospital inpatient. This is a benefit that everyone --- insurance companies, business organizations, surgeons and patients --- greatly appreciate! Day-care surgery centers, provide high-quality health care at lower costs compared to hospitals because they maintain low overhead costs and also because they can focus only on aspect: treating ambulatory patients efficiently. On an average, procedures at ambulatory surgery centers cost 47 percent less than those at hospitals. (This figure is based on a study conducted by Blue Cross/Blue Shield of North Carolina). Some patients still prefer undergoing surgery in a large hospital, because they feel it is safer in view of the backup facilities the hospital can provide in case of an emergency, paradoxically, day care surgery centers are safer because they are dedicated to performing only ambulatory surgery, so that there are no â&#x20AC;&#x153;sickâ&#x20AC;? patients; and there is no risk of acquiring hospital - generated infections. In a surgery center, patients receive more individual personal care as compared to the impersonality of a large hospital. Ambulatory surgical units have achieved an excellent record throughout the world, with a very low incidence of complications, because of careful patient selection; and adequate back-up facilities to meet any emergency . Of late, patients and surgeons alike are increasingly, learning the benefits of outpatient surgery centers. Healthy patients find such centers much more comfortable than hospitals, which are primarily designed for the very ill. Family members also prefer day care surgery, because they can take care of the patients themselves, rather than leave them in an impersonal hospital room. Surgeons also find scheduling their outpatient activities much easier at an ambulatory

surgery center, because problems with hospital waiting lists or booking a hospital room do not exist. They also find that since the cost of a hospital stay is eliminated, they can provide quality care to their patients at a lower rate. Of course, day care surgery is not applicable to all patients. Thus, those patients who suffer from a serious medical illness; or those who need complex surgery; or those who do not have family members, will still need hospitalization for their surgery. The majority of procedures performed in ambulatory surgery centers fall into the following categories: (1) eye surgery, including removal of cataracts, eye muscle surgery and removal of foreign bodies; (2) gynecological procedures including dilation and curettage (D&C), laparoscopies and biopsies; (3) ear/nose/throat surgery such as removal of tonsils and adenoids; (4) bone surgery, such as biopsies , bone grafts, and arthoscopic surgery; (5) general surgery such as breast and muscle biopsies, hernia repair, hemorrhoid operations and laparoscopic cholecystectomies; and (6) cosmetic surgery such as scar revision, skin grafts and facial surgery . Many factors, including medical advances, patient awareness and economics are the primary â&#x20AC;&#x2DC;driving forceâ&#x20AC;&#x2122; behind the growth in ambulatory surgery centers. All aspects considered, ambulatory surgery is likely to become an increasingly popular option in the future!

Chapter 43 The Importance of Emergency Care Sickness comes on horseback, but goes away on foot. W. C. Hazlitt With rapid technological advances making the aggressive treatment of emergency conditions possible, a new medical specialty called ‘emergency medicine’ has come into existence. Almost every large hospital has an emergency room (known formerly as the casualty ward). The emergency room can prove to be an invaluable resource if properly used, as round-the-clock availability of trained staff, backed by state-of-the-art equipment, could mean the difference between life and death. However, many patients still misuse the emergency room; they land up there for the treatment of minor ailments in the middle of the night. One would be amazed to know that serious medical problems such as heart attacks, gunshot wounds, accidental poisonings, automobile accidents and other serious trauma account for only 10 per cent of the cases treated at emergency rooms; the other 90 per cent pertain to minor problems such as sore throats, cat scratches and diarrhea. Though emergency rooms serve as excellent places to receive care for real medical emergencies, they are unsuitable for individuals with non-emergency problems. First of all, they are expensive. Secondly, other than serious trauma, most medical problems are more easily diagnosed and treated when a close relationship between the patient and the physician exists. Lastly, if you visit the emergency room with a minor complaint you may be in for a long and frustrating wait -- after all, patients with more serious problems will need to be attended to first ! Emergencies require prompt, calm action. It would be helpful if one were to learn basic first aid and CPR (cardiopulmonary resuscitation) skills, which can be life-saving in a crisis. Whatever be the urgency, don’t lose your head ! Prepare yourself in advance by researching the emergency medical facilities available in your area. There is really very little a layperson can do once an emergency actually occurs, but you

can do your homework conscientiously and identify which ER is the nearest to you (usually in a large hospital). A major problem in India stems from the fact that some hospitals refuse to admit or treat emergencies because of the potential medicolegal complications associated with such patients. Because of antiquated laws, police formalities can be very time consuming, and most doctors would rather avoid them. That is why some of them may refuse to treat victims of, say, car accidents. Also, it is often not sensible to simply rush the patient to the nearest hospital or nursing home; some of them may simply not be equipped to cope with medical emergencies! Avoid using an ambulance except when absolutely necessary. If you can move (or be moved) by a car, use it. Usually, an ambulance is the slowest ( and the most expensive!) means of reaching an emergency room since it takes time to get to you before it can transport you to the ER . If the injury involves the neck, head or back, or if the illness is obviously grave, an ambulance is the best choice, particularly if it can offer paramedical services and has in-built life-saving equipment. While some ambulances are extremely well equipped, others are little better than large vans. When in doubt call your doctor or the emergency room to get the relevant details. If time permits, call your private physician before heading for the ER. If your situation is not life threatening, often, you can consult your private physician in his clinic; alternatively he can make more efficient and less expensive arrangements for you. If your physician advises you to proceed to the ER, he can call ahead and perhaps expedite matters relating to your admittance and subsequent treatment. If your condition requires a specialist’s care such as a surgeon or orthopaedist, your private physician may be able to arrange for a doctor of your choice, rather than the one who happens to be on call. It is very useful to arrange for an ‘emergency advocate’; in other words, take a relative or friend along. When afflicted by the trauma of emergency illness or accident you may be too overwhelmed to keep track of what type of care you are receiving. Consequently, assign a friend or relative to be your advocate and monitor your care. This person can serve as a ‘clear head’ for you. He or she can monitor what procedures are being undertaken, keep track of what kind of service you’re getting and speak up on your behalf if the treatment is too slow in coming or if it is not up to the mark. Such an individual’s timely assistance can help you manage your stress levels while being

confined in an emergency room. Don’t forget to carry important documents such as: your medical records and your insurance papers. Also, take along enough money ! Most hospitals will demand a large deposit ( usually in cash !) upfront before admitting you. If you are on medications, take them along with you to the emergency encounter ( if circumstances allow you to do so). Such a step will not only give a hard-pressed ER physician an idea of the extent of your other problems, but could also prevent dangerous drug interactions. If it becomes apparent to you that hospitalisation is likely, request the ER personnel to notify your physician as soon as possible, but definitely before an extensive work-up is begun. Write down the name of the emergency physician who has treated you. If things do not go as expected with respect to your treatment, it is helpful to be able to talk to this physician later if headed. Before you leave the ER, ask what follow-up care, if any, you will require. Ask what problems you can expect and what additional treatment will be necessary. Remember that not all conditions are really medical emergencies or matters of life and death. Therefore, don’t blindly rush to the nearest hospital ! Doctors find that patients will often misuse emergency care facilities, simply because they are open and easily available. For example, it is common to see a patient who has ignored an injury for three days walk into an ER at 1 a.m., because the wound has started “paining a lot”. For serious trauma, hemorrhage, chest pain and conditions that might require hospitalization, the hospital-based emergency room is the best bet. However, for minor trauma broken bones (without serious trauma), and minor medical emergencies (such as sore throat or bladder infections) the best place for getting treatment would be your doctor’s clinic. Here, the care would be more personalized, less expensive, and follow-up would be straightforward. After-hour emergencies can be best handled by calling your doctor and requesting him to see you at the clinic or hospital. While a medical emergency can be a scary situation, which can tax your resources to the utmost, the guidance of a family doctor can help you obtain timely, beneficial and quality medical care!

Chapter 44 How to Make a Hospital Hospitable Every hospital should have a plaque saying: There are some patients whom we cannot help; there are none whom we cannot harm. Arthur Bloomfield While hospitals can provide a secure refuge when you are seriously ill, remember that hospitals can be scary places! For one thing, the very fact that your doctor wants you to be admitted into hospital means that he thinks you are quite ill and this in itself can generate considerable anxiety! Even worse, hospitals can be very unfriendly places. Not only do hospitals strip you of all your dignity (having to wear a half-open hospital gown which barely covers your body properly does not do much good to your ego!), but also they subject you to painful routines and humiliating rituals performed by a retinue of strangers. Moreover, you could be woken up at any time of the day, (or night), deprived of your privacy, forced to eat unpalatable food, cut off from friends and family, and denied a lot of the independence which you take so much for granted in daily life. Also, remember that hospitals can be dangerous to your health as well! Hospital-acquired infections have become increasingly common ( since a number of sick patients are gathered together under one roof); and errors and mix-ups are not unusual at all, especially in India, where the paramedical staff is often poorly trained. The first rule, therefore, is try to stay out of hospital as far as possible! However, if there is no choice, there is a lot you can do to improve the quality of your hospital stay. The first step is selecting a hospital. Often, you may have no choice in this regard. For example, your surgeon may operate at only a particular institution. Or your employer may have entered into a contract with a particular hospital, so that if you want your hospital expenses to be covered by your company, you may have to be admitted only to this hospital. However, if a choice is available, then how do you select the best hospital? Basically, hospitals fall under the following categories: 1.

Private large hospitals. These are large (200-bed plus) institutes which offer all medical facilities (including pathology, radiology and

blood banking) under one roof. While such hospitals often attract the best medical specialists, and many have a developed a reputation for providing excellent medical care, they can be very expensive . Unfortunately, they are also usually very impersonal, and you are often just â&#x20AC;&#x153;the patient in bed number 423â&#x20AC;?. Also, the red tape in these places can be considerable. These hospitals tend to overuse medical technology, which can prove to be a major disadvantage while treating common problems. However, these hospitals should be your first choice if you are suffering from a complex or rare problem, or if you require major surgery. 2. Private small hospitals/nursing home. These are small facilities (containing 10-20 beds) which are usually run by a single doctor, or a small team of doctors, in order to provide care for their own patients. They are very popular, because they are relatively less expensive and provide patients with personalized care and attention. However, many of these places are poorly equipped (for example, a doctor may set up a cardiac monitor at the patientâ&#x20AC;&#x2122;s bedside, and call the bed an intensive cardiac care unit!) Also, the staff may also be poorly trained. Such places may not posses the infrastructure (e.g. blood bank facilities) to cope with complex problems. On the whole, well-run nursing homes are a good choice for treating simple problems (e.g., simple surgical procedures such as appendectomy or hernia repair). 3. Public (teaching) hospitals. These are large hospitals run by the government. While they may posses excellent medical staff, since they are often attached to medical colleges, their equipment, however sophisticated, often does not function, due to a paucity of funds. Often, basic standards of hygiene may be lacking in these places. Nevertheless, they can provide excellent medical care at highly subsidized rates and are a good choice for emergencies (since they are well-equipped to handle trauma and emergency cases, and will not turn patients away) and for certain complex problems, since some of the departments in these hospitals can be centers of excellence. Choosing Your Room During a stay in the hospital, several options are available as to room choice. Depending on insurance coverage or personal preference, a patient may stay in a private room, a semi-private room or a ward. Private rooms may be deluxe (with amenities comparable to

a five-star hotel in some hospitals) or first class, and offer the advantage of much needed peace and quiet. A major plus point is that your friends or relatives can stay with you; after all, you need to have someone who can look after your best interest when you in a hospital bed! In a semi-private room, curtains are put up around each bed that allow for some privacy, but the bathroom is usually common for the occupants. A ward is a hospital room that is large enough to accommodate several beds. Each bed may be curtained off during examination for privacy, but you are otherwise fully exposed to all passersby. However, the charges are much less than those of a private room. LOOKING AFTER YOURSELF Nobody likes to be in the hospital --- and it’s especially difficult if you have to be hospitalized for a long time. Some ideas which can help you to keep yourself from becoming bored, depressed or lonely if you have a long hospital stay include the following: keep a journal; write letters to family and friends; do activities such as needle point, sewing, knitting; listen to a radio; talk with other patients; read a book; do puzzles and word games; play computer games; and surf the Internet on a laptop. Hospitals can be dehumanizing places to be in, so try to personalize your surroundings as far as possible, by surrounding yourself with objects you enjoy, such as books, a radio, games and puzzles. Try to arrange for food from home, if at all possible --- hospital food has a deservedly bad reputation. It’s also a good idea for you to have your mobile/cellphone with you, in case an unforeseen emergency crops up during your hospital stay. It’s useful to ask for help from family and friends --- request them to come and visit you. Most people will be glad to oblige --- and remember to return the favour if someone you know is in hospital. If you like, you can ask them to bring food or fresh fruit that is not served in the hospital, so that you can look forward to eating something appetizing. And don’t forget to look at the upside --- you get served breakfast in bed! Medical Records: TO SEE OR NOT TO SEE?

Although your medical chart affixed to your bed is legally the property of the hospital, you should be aware of what kind of information is recorded on it. If you have any doubts, ask your doctor for an explanation. The chart should contain the following details: Your medical history (in the form of a synopsis). Results of all laboratory tests. Doctorâ&#x20AC;&#x2122;s order sheet: (1) daily list of medications to be taken, (2) special treatments or testing, (3) dietary restrictions, and (4) scheduled diagnostic procedures. Notes on surgery performed: (1) name of operation; (2) anesthetic used; (3) the names of the assisting staff; and (4) whether or not blood was transfused. Don't be surprised if you encounter resistance when you ask to see these records ! Many physicians and hospitals still don't believe that these records belong to you, or even that you should have access to them. As with any argument, there are two sides of this one too. The most commonly voiced concern is that patients may misinterpret the records, and become confused or unnecessarily frightened by the information they contain. Further, physicians and hospitals are concerned about their malpractice liability being increased if patients are granted unlimited access to their records,â&#x20AC;&#x2122; and some fear that records will not be kept with the same degree of honesty if patients were to have direct and unlimited access to them. Patients, on the other hand, want to know what is in their records --- after all, the records are about their body! They also believe quite correctly that they can store their x-rays and records more reliably than anyone else. The ideal situation is one where you and your physician go over the records together, with your physician explaining the information, and you knowing that you can ask any question and get a clear and honest answer. The Hospital Routine An average day in a hospital can be divided into five categories. They normally involve the following:

The patient’s activities such as lab tests (often done early in the morning), treatments or scheduled surgeries, visiting hours and rest periods. Nursing observations which include monitoring and charting your vital signs (pulse, blood pressure, temperature, urine output) on a frequent basis; as well as evaluating your physical and emotional needs. A good nurse is worth her weight in gold! Doctor’s visits such as the morning observations of patients by your doctor, his assistant or residents. Doctor’s rounds may occur at various times during the day. Medications which can begin before breakfast and continue throughout the day and night as prescribed by the doctor. Intravenous lines (V fluids) require more frequent nursing attention. Meals which are normally brought by orderlies three times daily. A night-time drink or snack may also be available. WHO’S WHO AT THE HOSPITAL

In a hospitals one finds so many people walking around in white uniforms that patients to become easily confused as to who does what! While it’s the normal procedure for all the staff to wear name tags that identify who they are and what their positions are, a understanding who does what in a hospital is beneficial.

Physicians Medical Students: They are found only in teaching hospitals (attached to a medical college), and are trying to learn as much as possible. They cannot actually treat patients by themselves, but a kind and understanding student can often spend a lot of time with you and explain what’s going on. 2. Residents : They are doctors who are receiving specialty training in a particular medical field such as surgery or medicine. 3. Doctor: The doctor who admitted you to the hospital. 4. Consultants: They are specialists, and your doctor may ask them to examine you to provide expert advise or a second opinion. 1.

Nurses Nurses are the ones who really take care of you when you are in hospital, and their responsibilities include: (1) taking and charting your vital signs (such as temperature, pulse and blood pressure); (2) taking care of your wound; (3) carrying out your doctor’s orders; (4) giving you your Nurses spend much more time with patients than doctors do, and will often be your primary contact with your medical caregivers. They can also teach you to care for yourself when you go home. Additional Hospital Staff Orderlies or nurse’s aides assist in moving patients to the xray room or to other specialized testing rooms and help in a nonmedical capacity. 2. Occupational Therapist assist disabled patients in performing their routine activities. 3. Physical Therapists assist patients in developing the strength and the ability to become and remain mobile through exercises, massage, and other treatments. 4. Respiratory Therapists help with the use of specialized equipment to treat breathing disorders. 1.

It is very helpful to know someone on the hospital medical staff (an ‘insider’) with whom you can really communicate. This individual may be a nurse, a technician or a social worker. Request this person to act as your advocate in order to help you get the medical care you need and want --- a medical ‘insider’ who is on your side can be very useful when you are in hospital! HOW TO BE A COST-CONSIOUS HOSPITAL PATIENT Hospital bills can add up to huge amounts very easily, and you need to be aware of what step, you can do to save your money! The basic rule is simple: avoid an unnecessary stay in the hospital! The

hospital should never be viewed as a place to get a good rest. Consider the following pointers: Consult your physician and, whenever possible, select outpatient services. By avoiding an overnight stay at a hospital, substantial savings can occur. Many routine laboratory tests and scans can be done for a lesser cost as an outpatient. As an inpatient, stay only for the prescribed time that is necessary. If it’s peace and quite you need in order to recuperate, a hotel may be a better bargain. If you need surgery, ask your doctor if this can be done on a daycare basis, so that you don’t need hospitalization. HOW TO KEEP YOUR HOSPITAL BILLS DOWN Be an intelligent and informed patient --- ask questions, to make sure that all the medical procedures you have been advised are truly necessary. Take out a medical insurance policy when you are healthy. This policy can be very helpful in case you do fall ill. Hospital bills can be huge, and they need to be carefully analysed to look for errors. Don’t assume that just because a bill is generated on a computer that it’s accurate --- billing errors are amazingly common, and you need to actively look out for them. Insist on a receipt whenever you pay your hospital bills. Beware of duplication of tests. Be sure to ask the doctor the kind and frequency of blood tests, x-rays and medical procedures you shall have to undergo. Check-out times should be strictly followed. Be sure you know when precisely you must leave and stick to your schedule; otherwise, you’re likely to be charged for an extra day’s stay. If your health problem isn’t an emergency, avoid being admitted to a hospital on a weekend. No one likes working on weekends, and testing will usually not take place until the following Monday. Discuss your financial concerns with your doctor. Many doctors and hospitals can and do reduce their fees for patients who have problems with payments. Also, remember that you will get exactly the same quality of medical care in a first class deluxe room in a private hospital, as you will in the general ward --- but you will end up paying about ten times more!

Remember that sooner or later, you or a family member will have to spend some time in a hospital. If you are well â&#x20AC;&#x201C; prepared, you can make sure you will survive your stay in style --- so that you can show off your surgical scar to all your friends at the next party! The following checklists can help you to retain control over your hospital care. Hospital Checklist Reason for admission (Diagnosis) ___________________ What procedures, tests or treatments cannot be done as an outpatient? ________________________________________________ What tests could be done prior to admission to shorten hospital stay? ______________________________________________ Expected length of stay (days) _____________________ Choice of hospitals: Hospital ______________

Average Daily Cost Rs _______

________________

Rs _______

________________

Rs _______

Can admission be arranged early in the morning ( rather than the previous night, thus helping to reduce your bill)? ____________________________________ Are consultations planned? _____________________ If yes, why, and who will perform them? ____________

Can the consultants be seen prior to admission? ____________________________________________ If diagnosis or treatment is unclear, has specialty consultation been considered? _________________ If not, why not?_______________________________ COMMENTS _____________________________________

Daily Hospital Checklist Reason for continued hospitalization? What procedures, tests, or treatments cannot be done as an outpatient? Tests ordered today: __________________________________ Tests needed before discharge: ________________________ Medications: Medications ordered today?

How often?

_______________________

___________ _____________

_______________________

___________ _____________

Why?

Can any medications be stopped? (Go over list) ___________ Can I eat (or eat more)? _______________________________ Can IV be removed? _________________________________ Can I walk around? __________________________________ What extra hospital equipment is presently in use?

Can any procedures the use of any or equipment be discontinued? ______________________________________ How many physicians continue to be involved with care? ____________________________________________ Who? ________________ ________________ ___________ Why? ________________ ________________ ___________

Discharge plans When? _______ Where? _______________ Will additional nursing care be needed at home ? Has this been arranged? ___________________________ Has transportation home been arranged? ______________ When do I see the doctor after being discharged ? Where ? Whom do I contact if I have a medical problem ? Whom do I contact if I have a problem with the hospital bill ?

Chapter 45 Intensive Care or Insensitive Care? Death is a punishment to some, to some a gift, and to many a favour. Seneca The technology of medicine has advanced to the point that aggressive intervention can prolong the lives of even the most seriously ill or injured persons. Almost every hospital has an intensive care unit ( ICU ) equipped with ultramodern instruments such as ventilators, dialysis machines, monitors, resuscitators, defibrillators and catheters to aggressively support patients whose life systems are failing. The equipment and the human resources needed to provide the heroic care in the ICU are very expensive and costs continue to soar. Yet only one out of every ten critically ill patients treated in the ICU survives. Clearly, there is a need to reconsider, from a compassionate viewpoint, how we choose to use this expensive, often painful and infrequently beneficial treatment option. In fact, countries such as the UK have decided to control ICU admissions so that doctors send only those patients with clearly treatable conditions there. Patients and their families must also begin to look objectively at intensive care treatment. While the ICU can, undoubtedly, provide the best of technological medicine and prolong life, the care is aggressive and potentially dangerous and should not be chosen lightly. Nor is expense the only consideration; the ICU can be a cruel, harsh and demeaning place to spend one's final days. It is not easy to make decisions involving life and death. The best time to make these decisions is when we are well and can think clearly, but few of us bother to do so! This tendency to procrastinate forces us to make crucial decisions during a crisis, and the decision-making process tends to be clouded by the disorientation or bewilderment caused by the sudden illness or by emotions of grief. The medical system, slanted towards aggressive intervention, may not provide the most balanced viewpoint ideal choice during this difficult time.

As you grow older or become more disease prone, you need to discuss openly how to approach your final days. You should be thinking about ‘living wills’ and ‘physician directives’ in order to guide your family members and physicians on how you wish them to act on your behalf when you can no longer make decisions for yourself. While you are in good health, decide what medical intervention you want undertaken on your behalf in case of serious illness or accident. Record your wishes unambiguously in a living will. Even though living wills and directives to physicians are not legally binding, they are helpful in guiding your physician in case you fall seriously ill. Reviewing these documents with your physician in advance has the added benefit of finding out his attitude towards the care of the terminally ill. The following tips could prove very helpful for the relatives and the loved ones of a critically ill person: If you do choose to proceed with aggressive, life- supporting measures for a family-member, you must constantly monitor your actions to ensure that you don't get carried away with the glamour and glitter of technology and, in the process, neglect the patient's basic human needs. Intensive care is almost always invasive. You must decide if your loved one's pain and suffering are ultimately worth the effort. Also, the following questions need to be kept in mind: Is the condition curable? What is the increased likelihood of recovery with intensive care? Is the ICU the appropriate place for treatment? Often the decisions regarding the care of the gravely ill are clouded by the intensity of the psychological grief that the family is experiencing. Guilt almost always plays a part in how family members feel when dealing with critically ill loved ones. It is natural to wonder what more we could have done and to blame ourselves for any past conflicts we may have had with a dying person. It is important to ensure that these feelings and emotions do not interfere with rational decision making about how aggressive one should be with regard to the prolongation of medical care. Keep track of who exactly is caring for your loved one. If a number of specialists are involved in the treatment, make sure that your family physician is acting as the ‘captain of the ship’. This physician should coordinate all aspects of the care process. The fragmented effect that can result when several specialists are involved could be inefficient, expensive and even dangerous. To avoid such possibilities the primary care physician should ensure that nothing is duplicated; he should give specific directions as to the care needed.

The coordinating physician should also take into consideration the humanistic aspects of the care process. He should continually evaluate factors such as the likelihood of survival, the patient's need for psychological support, as well as the needs of the family. While it is definitely important to have your primary care physician coordinate the various procedures, intensive care usually requires the expertise of specialists. Doctors who specialise in taking care of patients in intensive care units are called â&#x20AC;&#x2DC;intensivistsâ&#x20AC;&#x2122;. Depending upon the complexity of the problem, many consultants may be involved; for example, a heart specialist or a kidney specialist. However, remember that the bulk of the care in an ICU is really provided by the nursing staff. They usually work on shifts, so that you may encounter a new face each time, but try to get to know the nurses who are looking after your patient â&#x20AC;&#x201D; such meaningful contact can make a world of a difference to the care he gets! Visiting privileges are usually highly restricted in an ICU for medical reasons. Consequently, you cannot see or meet the patient, and it's often very difficult to find out how the patient is doing. Reliable information about your patient's condition is hard to get, and the medical staff often provides only very guarded replies, all of which tend to increase your anxiety levels considerably! Many relatives maintain all-night vigils, armed with cellular phones, often in shifts, outside the ICU, in case there is a sudden change in the patient's condition. However, while the conditions outside the ICU for relatives are miserable, the condition inside the ICU for the patient is often even worse ! The ICU is typically a large windowless room, sometimes with curtains between the beds, sometimes not. Men, women and children are usually clubbed together. There is a central nursing station from which all beds are visible. Bright lights are on day and night. The ICU tends to be noisy as monitors beep all the time. People are constantly dying. Sleep is usually impossible. Disorientation is common, not only because of illness or injury but also because of the constant din, bright illumination, hectic activity and lack of sleep. Small wonder that an ICU can be a terrible place to be in! Also, because ICU patients tend to be debilitated and gravely ill, the ICU is the most dangerous place in the hospital because one can easily catch a serious infection. The preceding reasons should provide you adequate motivation to try to get your patient discharged from the ICU as soon as possible! Each day, make it a point to ask the as to exactly why intensive care continues to be necessary. Sometimes round-the-clock special duty

nursing in a regular hospital bed can provide equally good medical care and that too at a fraction of the cost of an ICU bed. It can be scary a loved one in an ICU, with tubes and pipes coming out from all parts of the body. However, try to provide as much love and encouragement as possible --- remember that emotional support can make the difference between life and death! To help you in monitoring the usefulness of intensive care, the following can be helpful.

Intensive Care Checklist (1) Diagnosis ------------------------------------------------------(2) Reason for intensive care (what couldnâ&#x20AC;&#x2122;t be done in a regular hospital bed)? --------------------------------------------------------------------------------------------------------(3) If condition is critical, what is the chance of survival? (a) In an ICU ------------------------------------------------(b) In a regular hospital bed? ---------------------------(4) What are the current invasive procedures? ----------------------------------------------------------------------------------------------------------------------------------------(5)

Who are physicians involved? ----------------------------------------

Why? -------------------------

----------------------------------------- ----------------------------------------------------------------- -------------------------

(6) Primary physician (â&#x20AC;&#x2DC;captainâ&#x20AC;&#x2122;)? --------------------------------(7)Length of time expected to be spent in the ICU? _______________________________________________ (8)When are visitors allowed?------------------------------------By whom? ------------------------------------(9)Can the family be involved in the care? _______________________________________________ (10)Who is spokesperson for the family? _______________________________________________

Comments _____________________________________ _______________________________________________ _______________________________________________ The best person to complete this checklist would ideally be a loved one. The questions should be reviewed daily to ensure that the ongoing intensive care is both necessary and appropriate.

Chapter 46 Death with Dignity I am not going to fight against death but for life. Norbert Segard. Death is still a taboo topic — one most people don’t like to talk about — which is surprising, since it is one of life’s certainties. However, it is an extremely uncomfortable subject to discuss, which is why most of us continue to pretend that it doesn’t exist ! However, being prepared for death can help considerably in dealing with it from a pragmatic viewpoint. Most doctors, too, are uncomfortable with death, which is why they often cannot cope with a patient who is dying. Many doctors still look upon death as a ‘defeat’ since they are taught to treat death as the enemy. This is an unfortunate point of view and we need to change our attitudes! Death is simply a part of the cycle of life: it is not the opposite of life, it is the opposite of birth. When faced with our own mortality, all of us react in different ways. Most people, however, hope for a ‘good death,’ for a death with dignity, however they may define it. It’s therefore important for a person to express his or her preferences regarding the degree and the type of medical care he or she wishes to receive at the terminal stage of his or her life. Such preferences can be expressed through formal legal documents called ‘advance directives’. Such documents record legally your wish to choose or refuse certain forms of medical treatment. There are two types of advance directives: 1. Durable power of attorney for health care: This is a document that names a person (or persons) who would make treatment decisions for you if you are not able to make them yourself. Such a person (or persons) is authorized to make decisions you would have wanted whether or not you have written them down in advance. You should

remember that your condition does not have to be terminal or irreversible to have someone speak on your behalf. 2. A living will: This is a document that spells out, in writing, the medical treatment you would want or not want. A living will applies only when you can’t express your wishes on your own, and you suffer from a terminal illness or condition and aren’t expected to survive. Thus, by drawing up legal documents (advance directives) you may choose or refuse the following: 1. Measures to support life: Examples are cardiopulmonary resuscitation (CPR) and a respirator (a machine to breathe for you). 2. Measures to sustain life: Examples are tube feeding and dialysis ( where a machine performs the functions of where your kidneys) 3. Measures to enhance life: These measures keep you comfortable without prolonging your life. Examples are pain medications and hospice care. After you fill them out, discuss your advance directives with your family and close friends. Also, talk to your doctor and give him copies of the relevant documents. Keep these documents along with your medical records in safe custody. Death’s closest companion is grief, and the term ‘anticipatory grief’ refers to the feelings of loss and sadness which can arise during terminal care. It is helpful to remember that many people go through five stages of grieving when dealing with a terminal illness. As described by Elizabeth Kubler-Ross author of the famous book, on Death and Dying, these stages are as follows: 1. Denial: In this stage, the person needs to believe the illness is not real. Communication and decision making about the course of treatment often become very difficult in the denial stage. 2. Anger: In this stage, one accepts the illness but feels that it’s unfair. The anger is often misplaced, being directed at loved ones or, more commonly, at the hospital, the physician or the medical profession as a whole. 3. Bargaining: In this stage, in an attempt to postpone suffering and ultimate death, the person, in desperation, tries to ‘strike a bargain,’ usually through prayer. This short-lived stage marks the beginning of the final stages of grief.

4. Depression: When a person reaches this stage of grief, he or she requires support and, more importantly, honest and open communication to help the passage into the final stage of life. 5. Acceptance: In this stage, the patient accepts the illness and realistic decisions about the future can be made.

PALLIATIVE CARE There are different forms of caregiving available for the dying person. Many people who are terminally ill choose to remain at home or stay in a home-like place, such as a hospice, rather than a hospital. Many people fall victim to the anxiety that if they become seriously ill, modern medical technology will not restore health but simply prolong the agonising process of dying. Therefore, their decision to stay out of a hospital is closely connected with their desire to achieve death with dignity. A key objective in hospice and home care is to obtain highquality palliative care to control pain and preserve the highest possible quality of life as long as the patient is alive. Since it takes some time for hospice professionals to tailor palliative care and pain management to suit each individual, it is best to begin some level of professional care before a crisis actually arises. Palliative care, also called comfort care, is primarily directed at providing relief to a terminally ill person through symptom management and pain management. The objective is not to cure, but to provide maximum comfort to the patient and maintain the highest possible quality of life for as long as the patient is alive. Well-rounded palliative care programmes also address mental health requirements as well as spiritual needs. The focus is subtly shifted from death to compassionate specialized care for the living. Palliative care uses an interdisciplinary team model (consisting of doctors, nurses and priests) that provides support for the dying person and those who are companions in his journey. It cannot be stressed enough that top-quality palliative care can make the difference between a gentle death and one in which suffering is so terrible and prolonged that assisted suicide becomes an attractive alternative. Death care is an essential part of medical care, but it remains a neglected area today; we still donâ&#x20AC;&#x2122;t have â&#x20AC;&#x2DC;deathologistsâ&#x20AC;&#x2122;! Pain management is one of the most important aspects of care for terminally ill persons. Aggressive pain management forms a specialized topic of medicine, and a specialist opinion can be helpful if

the doctor treating a particular patient seems unable or unwilling to provide adequate pain management. Most doctors still use pain medication for dying patients very frugally. Such an approach is antiquated, and with the remarkable advance in medicine and technology, it should be possible to keep any patient comfortable during his final stages. The decision to end one’s life when death is approaching anyway is variously called self-deliverance, rational suicide, physician-assisted suicide (PAS), or voluntary euthanasia. An individual’s ‘right to die’ is presently the subject of controversial legal battles on an international scale. ‘LIVING’ AFTER DEATH At present, given the miraculous technique of organ transplant, death does not mark an end by itself; you can continue living even after your death! Merely filling out a donor card is not enough; the most important step is to convince your family members about your wishes. It is indeed a hard topic to bring up because most people don’t want to think about the deaths of their loved ones. However, it is important that you talk about your decision right away! If anything adverse happens to you, doctors will have to turn to your family for permission — even if you have signed a donor card — in order to use your organs to save another person’s life. If your family doesn’t approve of your decision, you can appoint a lawyer to put your request in writing. You should, nevertheless, remember that even with legal documents, doctors will honor your family’s wishes. The good news is that families which have discussed organ donation are more prepared to make a positive decision and are more likely to follow your wishes. THE ROLE OF RELATIVES AND FRIENDS Watching a loved one die can be a very painful process, and the deteriorating condition of the dying person also forces you to confront your own mortality. Families can become isolated from social networks as they struggle to care for a dying loved one, and stress can break down close relationships. A patient’s inability to take care of himself often causes guilt, shame or irritation, and physical changes also affect their self-esteem. Some families will find comfort in knowing that they are experiencing normal responses, and some may require counseling to help them cope.

Often times, in order to do everything humanly possible to prevent death from snatching away a loved one people sometimes resort to heroic and desperate medical measures. Such measures simply add to the patientâ&#x20AC;&#x2122;s burden, while providing little solace. At some point of time, you need to be able to let go â&#x20AC;&#x201D; and to respect the sinking personâ&#x20AC;&#x2122;s wishes to die with dignity. Often the familiar bed at home is a far better place to die than an impersonal and cold hospital room. After a person dies, often a number of formalities need to be taken care of. You will need to get a death certificate, or think of getting a postmortem (autopsy) done, in case doubts about the cause of death persist. Organ donation can be hard to think about at this time, but this is the only time to do so. You need to remember that your generosity can help another individual greatly. After the death of a love one, you need to allow yourself to grieve, so that you can continue to live, and there are many social support mechanisms to help you to do so. Remember that grief heals best when you share it with others !

Appendix 1

Your Personal Health History You can use the following chart to keep track of your health history. Remember to take it along with you to your doctor! 1.

I WAS IN THE HOSPITAL FOR (list Conditions):

Date

I HAVE HAD THESE SURGERIES:

Date

I HAVE HAD THESE INJURIES/CONDITIONS/ ILLNESSES:

Date

I HAVE THESE ALLERGIES (list type of allergy â&#x20AC;&#x201C; e.g., food, medicine --- and reaction):

I HAVE HAD THESE IMMUNIZATIONS (SHOTS): For children:

Date(s) received

Hepatitis B (HBV) Polio (IPV/OPV) Diphtheria, pertussis and tetanus (DPT) Measles, mumps and rubella (MMR) Chickenpox (varicella) (VZV) Tetanus

I TAKE THESE MEDICINES/SUPPLEMENTS: General Name

Brand Name

Dosage

MY FAMILY MEMBERS (PARENTS, BROTHERS, SISTERS, GRANDPARENTS) HAVE/HAD THESE MAJOR CONDITIONS: Relatives

Condition

I SEE THESE DOCTORS: Name

Why I see them

Appendix 2 Key Questions to Ask Your Doctor You need to learn to ask the right questions, if you want to get the right answers. Anonymous This appendix provides a list of the key questions that will assist you in making medical decisions when you visit your doctor. Photocopy these and check off the items you wish to discuss, as and when the need arises: 1.

Diagnosis: What is my diagnosis? Can you explain the diagnosis to me in detail? Is my condition chronic or acute? If it is chronic , how will it affect my life? Is my condition one that will be with me constantly or will it come and go in stages? If it will come and go in stages, how often would these stages occur? Is there anything I can do to help prevent this condition? Is my condition contagious? If yes, what should I do? Is my condition genetic? If yes, what should I do? How certain are you about this diagnosis? Do you have any literature about my condition? Is there a support group available? What effect will my condition have on my personal life and professional activities?

Tests:

What is the test called and how will it help identify what is wrong? Will it give us specific or general information? If the answer is general, where do we go from here? How accurate and reliable is the test? Is the test invasive or non-invasive? What will I have to do to prepare for the test? Where do I go for the test? How and when will I get the test results? Will more tests be necessary? How will this test change my treatment? 3.

Treatment: What is the recommended treatment plan? What results do you expect? When can I expect to see results?

4. Benefits What are the general benefits of the treatment? What will be the specific benefits if I go ahead with the treatment? To what extent will the treatment improve my condition? Is there documented evidence that the recommended treatment will have a positive outcome? 5. Risks: What are the potential risks of the treatment? Can you list the possible risks and complications? Do the benefits outweigh the risks or vice versa? Can you list the risks and benefits, rating each between one and five, to aid in your decision-making process (one being not very important and five being very important)? 6. Success What is the overall success rate for the treatment? What is the national success rate?

What is the success rate at the hospital or medical facility where my treatment is being planned? What is your (doctorâ&#x20AC;&#x2122;s) success rate and experience with the surgery? On how many procedures are the preceding success rates based? Are there any personal factors that will affect my odds either way? How long will the results of my surgery or treatment last? 7.

Timing: When should I begin the treatment? When is the best time to get started with the treatment plan? Do I have to undergo treatment right away? If not, how long can I safely wait? Alternatives: What are my options What will happen if I decide to do nothing? Can we (you and the doctor) investigate every option which you are considering as thoroughly as the original treatment plan?

What happens if you are not satisfied with your options? Discuss this with your doctor. If you are still not satisfied, consider consulting another physician. 9.

Cost: How much will the treatment cost? What is the cost of the recommended treatment plan? What related costs do I need to consider (e.g., time off from work, child care, transportation)?

Check with your insurance company to see what portion will be covered and whether you need to do anything to receive maximum coverage (e.g., seeking a second opinion and getting preauthorisation).

10.

Decision:

What do I decide to do? You are now in a better position to make an intelligent, informed decision? Remember, you are ultimately responsible for your own body and have the right to choose or refuse treatment. If you feel rushed or otherwise uncomfortable when discussing this information with your doctor, tell him or her how you feel.

Appendix 3 Detailed Information About Your Medical Problem : Delivered at Your Doorstep If you would like detailed information about your medical problem, a very starting place for your research is HELP, the Health Education Library for People, a free public library located in Mumbai. HELP is the world’s largest health library, with over 6000 books, 500 videos and 10,000 pamphlets. Here professional librarians help you find the information you need. HELP is also on the Internet at http://www.healthlibrary.com. For those unable to come to the library, an innovative service called MISS-HELP (Medical Information Search Services from HELP) allows the library to provide a package of customized information, tailored to your specific problem, to be delivered at your doorstep. Mode of payment: demand draft payable to the ‘Community Health Research Program’ at Mumbai. General Information Package For general information such as: an overview of the disease; how to cope with it; treatment choices; medications; and addresses of support groups, the charge is Rs. 300.00.* This overview has about 50-75 pages of information. Recent Advances and Research Package For recent trends in treatment/research, HELP searches the Internet and medical databses such as MedLine. The charges is Rs. 300.00.* This packet has about 50 pages of information containing abstracts of articles from medical journals and similar sources. This information can also be sent on a floppy disk. Comprehensive Package This ‘two-in-one’ combines both packages, and the charge is Rs. 500.00.*

This prices are subject to change.

The form to be filled and mailed is as follows:

Please fill in the details (CAPITALS ONLY PLEASE), and mail to: HELP (Health Education Library for People) ‘Om Chambers’, 5th Floor Kemps Corner Bombay 400 0036. Tel: 022 – 3683334, 022-3681014 email: helplib@bigfoot.com Website: http://www.healthlibrary.com I request the Health Education Library for People of the Community Health Research Program, Mumbai, to do a customized medical literature search on the following topic for me: Name: ------------------------------------------------------------------------Mailing address: ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Phone: -------------------------------------------------------------------------email: --------------------------------------------------------------------------Request for medical literature search on:

---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------(Please be as specific as possible and include as much detail as you can. What areas would you like more information on?) this is an example of an appropriate query: My mother is now 65 years old and has been diagnosed as having Parkinson'â&#x20AC;&#x2122; disease. Please send details on: surgical treatment; medical treatment; research centres; and support groups dealing with Parkinsonâ&#x20AC;&#x2122;s disease.