Clini --Chorea CLINICAL SECTION
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Index 4 7 9
I don't want to do my MD but what else can I do? Dr. Saranya Sridhar
Biomedical Waste Management
Dr. D.K. Mendiratta
WHAT HEART HAS TO SAY!!! Neha Pandey
10
The Fear of rejection in a Doctor-Patient Relationship
12
The Good Death
14
Hypnosis and Crime
Dr. Rajnish Joshi
Dr. Amit Bhatt
Dr. Vishwajit, Dr.Aloke, Dr.Sandip
Medico's Love Letter Manish Kumar Singh
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HOSPITALS - A BREEDING GROUND FOR DISEASES Anupriya Singh
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MICROBIOLOGY OF MEDICOS Neha Pandey
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No Longer Gage!!! Nayan Chaudhari
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Ig Nobel Prize Pawan Kandhari
19
Blunders Par Excellance!!! Aditi Jain
19 20
Why did I choose Medical Career Option? P. Keerthi Kundana
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Clini--Chorea Six months back when we chose to accept this responsibility, our hearts were filled with a feeling of fear, which today has been completely taken over by one of accomplishment and victory as we successfully present before you the Clinical section of Sushruta 2008-09. After a lot of mind pestering, we chose to name it CLINI-CHOREA which actually denotes “A dance to play in a clinical way” as our motto. This year we have tried to give this supposedly monotonous and serious section a “make-over”. Therefore though we had articles pouring in on a plethora of issues, we carefully excluded plain information-based ones for which we believe there is no dearth of medical books and journals. Our aim has been not to burden your minds but to lighten your moods by presenting information in an interesting manner but how far we have succeeded in our attempt is for you all to judge. Hope you read and enjoy this special part of the magazine. We promise you that these new ideas and facts are really going to woo your minds. We thank our beloved teachers and dear friends for their generous contribution. Our special thanks to Dr. Anshu madam for her indispensable guidance and Mr. Nayan Laxman Chaudhari for his co-operation. Hope you read and enjoy this special part of the magazine. We promise you that these new ideas and facts are really going to woo your minds. Wishing you all a pleasant time going though Clini-chorea. -
Editors Neha Pandey Aditi Jain (2005 batch)
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I don't want to do my MD but what else can I do?”
“
About ten years ago, I entered MGIMS to start my MBBS degree fixated on becoming one of the many doctors and surgeons whose heroic lifesaving efforts in Reader's Digest inspired me to pursue this career. But over the five years of lectures and clinics, I wondered whether an MBBS automatically meant that my next career step is an MD. I continued to half-heartedly study and write my post-graduate entrance exams, hesitatingly venturing to find options beyond MS and MD. In hindsight, my vacillation to break the mould and shackles of expectation (my father still believes that I should have become a practicing physician) lay rooted in limited knowledge of my options beyond the MD and MS. I am uncertain that make lifedefining decisions aged 17 is the best time to decide your career. Unfortunately, I realised this when I was close to finishing my MBBS, which was not necessarily the best time for career enlightenment. I am currently on a different path to the traditional MBBS- MD-MCh route, having done a PhD, finishing a Masters and headed for an academic research career. Last summer, I spent some time with a few students back in MGIMS. It was suggested that my experiences might help some others like me who weren't entirely persuaded by the MBBS-MD route, although closer to 30 than I wish and currently unemployed, you might be careful of following my lead. Most of this article is a distillation of my interaction last summer and I hope that by reaching a wider audience it encourages people to think a little bit more about their future by relating the variety of options that I explored after finishing my MBBS. I can only hope this article does not deter you from continuing to be a doctor, for I wish to read about you someday in Reader's Digest, but rather I do hope it deters you from asking “what else can I do after MBBS but my MD?” My first steps on moving away from pursuing my MD can be traced to the rather hot summer of 2000 when I spent many a days with my batch mate Chandan scootering to the Government TB clinic in Wardha. We were collecting sputum samples, which we brought back to grow on the greenish-blue LJ media. It was the first time I was in a position to ask a question the answer to which didn't exist in a textbook or professors' lectures. The
SARANYA SRIDHAR, 1997 Batch saranya.sridhar@gmail.com
idea that I might be doing something new was a little heady and intoxicating. I got hooked to asking questions, which was fuelled by the next summer spent in the Biochemistry labs doing ELISAs, measuring responses to isolated candidate vaccine antigens and mulling existential and scientific questions with PhD students. I was intrigued by the idea of research, although I continued to concentrate on learning the sideeffects of calcium channel blockers and the treatment of pancreatic cancer. Internship made me realise that I wanted a break from the clinic and ward and I decided to apply for some research PhD positions. I applied to the National Institute of Immunology (they like having MBBS students!) for a PhD program and wrote my GRE's to apply for Masters Programs in the US. I also applied for a scholarship during the last few months of my internship for a PhD at the University of Oxford (D.Phil as it is called in Oxford) which I was lucky enough to get. The option of going to Oxford University to do a PhD and have someone else pay for it seemed like an opportunity too good to miss. I still harboured aims of continuing my medical career after the PhD after all, what else was I good for? For the scholarship application, I had to identify a professor that I would like to work with and a research area of interest. I had to make a decision about what aspect of scientific research interested me and whether I would prefer to work in a lab or pursue clinical area of research. I chatted with a few seniors, realised that the options were endless and there wasn't really a right choice, just the best one. My options included most areas of research open to MBBS graduates whether they seek a research career abroad or in India. I was keen to work on vaccines, so I had a choice of departments and areas to choose from. My options included being part of designing and conducting clinical trials of malaria vaccines in Africa and the UK, a career that would have allowed me to continue my medical training a little bit and use my medical training. This career option might have resulted in pursuit of a medical career in the UK, so if you wish to continue clinical work and academic research early after MBBS, this is not a bad option. The other option was to undertake laboratory work in immunology primarily working on
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samples from the human clinical trials or doing basic molecular biology work designing vaccines. Another area of interest was genetics, understanding genetic susceptibility to disease. However, most of these were laboratory work. I did meet doctors doing many different things, just to give you an idea that if you are interested in something there are ways to pursue that stream. I met surgeons who worked on improving transplant uptake, someone interested in drug development and working in a chemistry lab developing new drugs, doctors working to combine nano-technology with drug delivery, another doctor who was a hiker and interested in altitude hypoxia and physiology and a few who ventured into the field of behavioral psychology and psychiatry. Most of these are research based careers, which either meant that you pursued a PhD and a research career or you incorporate research as part of your clinical career. If you are keen to be part of medical research, choosing MDs in Biochemistr y, Microbiology and the other basic sciences is an option. A large part of your medical career is spent pursuing research in their field along with the added advantage of teaching and being affiliated to a medical college. There are other options that I briefly thought about which is especially good for those interested in doing something different with their medical training. Bioinformatics is a developing field that requires people interested in computing with a biology background. This is an excellent area to work in and is slowly coming to play an important role in medical technologies and pharmacology. The field has mainly been populated by computer scientists but is now looking for medical professionals who enjoy computing enough to understand the computational theory and techniques involved. The long term career option is not restricted to academic research but extends to working in pharmaceutical companies. The other exciting area is systems biology which also makes use of computing techniques to answer some very basic biological questions from a different theoretical perspective. An equally exciting career option is health policy, which I briefly explored by taking a course in the subject. The long term career options here are to either become an academic in this area or part of a think-tank NGOs, UN organizations or working in the public sector evaluating, designing and implementing different health policies. This is a great area to work in, often the domain of bureaucrats and experts from social and public policy and needs doctors who can contribute medical expertise to the health policy debates. This is ideally suited to doctors who says,“ I would really like to affect more people than to keep treating one individual at a time”. To work in this area, you might either pursue an MD in Community Medicine or an MPH specializing in health policy and systems. To give you an example,
one of my colleagues, an MBBS from India is undertaking a PhD project to investigate the rural health insurance system in Karnataka to see whether it works to improve health for people. T h e Masters in Public Health (MPH) is a n o t h e r increasingly popular career path that I briefly considered after MBBS and am currently pursuing. Ten to fifteen years ago, pursuing this career path necessitated going to the US or Europe, but increasingly institutes in India are offering this course. So, what happens after you do an MPH? Most MPH graduates might work in either government departments, academic institutions as researchers or global think tanks and health organizations like the WHO, UNAIDS, Gates Foundation as program managers and later program directors. As a doctor you are eligible for admission to the MPH program either after your Post-graduate degree (post MD) or immediately after MBBS. You could either do this after MBBS and then come back to doing a MD/MS or can do it after you finish your MD/MS which is an option taken by many consultants. If you decide to do an MPH after MBBS in India, it does make it a little difficult for you to write your PG entrance exams. On the other hand, if you plan to take a break to study for those exams, doing an MPH on the side is a useful qualification. There are a number of specializations in public health epidemiology, biostatistics, environmental health, occupational health, maternal and child health, nutrition, social behavior and health and the list is endless. I am currently doing a Masters in Epidemiology with a focus on infectious diseases at the University of California, Berkeley. The field of public health is too broad for me to talk about here, but one suggestion for many MBBS graduates is Clinical Epidemiology. This is especially suited for doctors especially those who wish to continue clinical practice and broadly speaking involves learning how to design and analyze research studies that improve clinical decision making and feeds into the broader area of Evidence based medicine. The other option for those who wish to do something different is called Clinical Research. The field of clinical research involves the design and conduct of clinical trials and is currently experiencing a boom in India. The influx of foreign pharmaceutical companies and the growth of the Indian R&D sector has increased the demands for trained workers in this
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field. This is a natural progression for many doctors who would like to be continued to be involved in some sort of clinical work while not spending everyday at the hospital or private clinic. Medical professionals tuned to the Indian regulatory set up are highly prized and compensated in accordance. Many companies, institutes and universities both in India and abroad offer training courses in clinical research as well as offering a Masters of Clinical research, which then allows you to either continue in this career as a researcher or work for pharmaceutical companies or set up your own Clinical Research Organization. I finally chose to undertake laboratory-based research in molecular biology and immunology working to develop a malaria vaccine. I was advised by my seniors that acquiring some laboratory skills might be extremely handy for a future research career. Four years in a laboratory and I decided I preferred human interaction as part of my job description rather than a close relationship to mice, which is why I shifted to doing epidemiology. Most of the options I have outlined above allow you in some way to keep in touch with the medical field, but there are other options for those who wish to make a drastic career change. The IAS has become a favored destination for MBBS graduates. However, in this discussion I would submit to my more experienced batch mate Karthik Adapa for advice on navigating this career path. I understand that he would be more than happy to talk to students interested in pursuing this career path. I wish to put forward another option that I wished I had considered when I was finishing my MBBS. This is the option of working for financial consulting services like McKinsey, Monitor, and Accenture. This is a favoured avenue for many MBA, economics and mathematics graduates. These companies which mainly advise other financial and business ventures also advise Pharmaceutical companies on their marketing, business and investment strategy and are therefore not averse to employing medical graduates. A few companies also have a global health component a department that is involved in working on issues concerning health. The competition is fierce for these positions, but it is a well-paying job, but involves working hours that would remind you of being back in the ward. An option that many PhD graduates with
advanced degrees in science are opting for is scientific and medical publishing and journalism. It does require command over the language, but medical professionals are naturally advantaged in understanding medical and scientific jargon. The BMJ, NEJM, Lancet all require junior editors and staff and positions of this sort while difficult to get while staying in India, are not impossible. One of the ways to explore whether you might like such a career is to write for the Student BMJ, Student Lancet editions and become a student editor. This should allow you both the experience when you apply for such positions and the extra qualification on your CV. A more recent career path is the combination of legal skills with medical expertise. The National Law School is Bangalore offer a Medical Law and Ethics distance learning course which is attracting a number of medical graduates. It is an interesting career for the future in the light of the consumer protection act extending to the medical profession and the growth of large medical corporations. There is also a very interesting research component to undertaking work in this area with issues o f m e d i c a l p r i v a c y, confidentiality and informed consent in India waiting to be explored academically. The above list that I thought of is neither exhaustive nor detailed for anyone to base their decisions on. Rather, it seeks to provide a taste of the different opportunities that exist today. The MBBS degree seems to have become like any other professional degree, equipping you with unique expertise but also with a set of transferable skills that is valuable in a non-medical marketplace. I hope that you make a more informed and careful decision about your future career, irrespective of where that decision leads. I have often been asked whether I planned my path to where I am today, and my unabashed reply is the negative. I am currently doing a Masters in Epidemiology after having spent four years working in a laboratory with mice getting a PhD and I assure you that I am still groping to find that rather elusive utopian job where every morning is not a chore but an exciting challenge. The only difference is that I have a better idea of what I want now than I did five years ago and that can only be a good thing. I hope this article allows you to make that decision earlier than I did.
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Biomedical Waste Management Biomedical Waste or Health-care waste (BMW / HCW) is a by product of health care and is the Waste generated by hospitals, healthcare establishments and research facilities during the diagnosis, treatment, immunization and associated research. BMW generation by region has been reported to be ranging from 7 - 10 kg / bed /day in N America to 1.4 to 2 kg / bed /day in Eastern Europe. Estimates of HCW in South East Asian countries has been reported to be 0.25 kg / bed / day in Bhutan , 0.36 kg / bed / day in Sri Lanka , 1.06 kg / bed / day in Pakistan , 1.16 kg / bed / day in Dhaka & 1.5 kg / bed / day in India. With respect to source it has been estimated to be 0 .05 - 2 kg / bed in PHC, 0.5 1.8 kg / bed in district hospital , 3.1 - 4.2 kg / bed in General hospital to 4.1- 8.7 kg / bed in University hospital . Between 75% and 90% of the HCW produced by health-care providers is non-risk or “general” health-care waste, comparable to domestic waste. This comes mostly from the administrative and housekeeping functions of health-care establishments and may also include waste generated during maintenance of health-care premises. The remaining 1025% of healthcare waste is regarded as hazardous / risk waste and may create a variety of health risks as it contains pathogens (bacteria, viruses, parasites, or fungi) in sufficient concentration or quantity to cause disease in susceptible hosts. The risk waste includes Sharps ( hypodermic needles, scalpels and other blades, knives, infusion sets, saws, broken glass, and nails), Pharmaceutical waste( expired, unused, spilt and contaminated pharmaceutical products, drugs, vaccines and sera that are no longer useful.) , Radioactive waste(solid,liquid,andgaseous materials contaminated with radionuclide) , Chemicals waste ( used in diagnostic and experimental work, and in cleaning, housekeeping and disinfecting procedures.) , Infectious waste ( Laboratory cultures , waste from isolation wards , tissues . items contaminated with blood & other body fluids etc), Pathological waste ( body parts , blood & other body fluids), Pressurized containers & Genotoxic waste (cytotoxic drugs, genotoxic chemicals). The risk waste is potentially hazardous to doctors & nurses, patients, hospital support staff ( attendants, laundry, CSSD, paramedical staff,
Dr D K MENDIRATTA Officer In charge, Student Council, Prof & Head, Microbiology.
sanitary) , waste collection & disposal staff & general public ( dumping in municipal dustbins , open spaces, water bodies etc.). This potentially hazardous waste may cause in humans beings : HIV, Hepatitis B & C , GIT , Respiratory tract, blood stream & skin infections , tetanus , intoxication and effects of radioactive substances etc, while in animals & birds it may lead to choking ( plastics) & injuries ( sharps) and chemicals such as dioxins & furans may result in serious health hazard. WHO estimates that a single needle stick injury from a contaminated source has the potential to case HBV infection in 30% , HCV in 1.8% & HIV in 0.3% exposed individuals. A National surveillance (1996) on occupational HIV infection revealed that among the medical personal 70% Nurses were affected and the commonest mode was needle stick injury. Another study from India in 2003 revealed Dioxin in the tissues of humans (170-1300 pg / gram fat: Normal- 1-4pg/Kg), fishes chicken, goats, birds and Ganges river dolphins. In India, concern for medical waste was an outcome of judicial and NGO interventions. Ministry of Environment and Forests came out with the first draft rules on bio-medical waste in 1998. The C e n t r a l G o v t. n o t i f i e d t h e management and handling of biomedical waste in exercise of the powers confirmed by section 6, 8, 25 of the Environment (Protection) Act 1986. Short title of this is “BioMedical Waste (Management & Handling) Rules, 1998 (envfor.nic.in/legis/hsm/biomed.html) . This document included thirteen (1-13) rules, five (I-V) Schedules, three (I-III) forms and two (I-II) annexures. The document was amended in 2000 & 2003. These rules are applicable on all persons who generate , collect , receive , store , transport , treat , dispose or handle waste and on all institutions generating BMW (Hospitals , PHC's , Nursing homes , Clinics , Dispensaries , Veterinary hospitals , Animal houses , Research & Pathological labs , Blood bank etc). The law essentially wants the above mentioned persons & institutions to segregate ( separate in designated types/groups ) waste at source , use designated color coded containers, transport the waste in designated authorized vehicles, treat infectious waste according to prescribed standards, avoid incinerating plastics & use safe incineration ( if must). The rule further states that non compliance of
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these rules may result in fine and / or imprisonment for as long as seven years. The schedules of the Government notification includes details on categories of biomedical waste, color coding , labels for hazardous waste, label for transport of BMW container/bags, standards for incineration , autoclaving, sewerage, deep burial and deadlines for implementation. A total of ten Categories (Schedule I) of BMW have been described. They are: Category 1: Human anatomical waste , Category 2: Animal wastes, Category 3: Microbiology and biotechnology waste, Category 4: Waste sharps: needles, syringes, scalpels, blades, glass, Category 5: Discarded medicines and cytotoxic drugs, Category 6: Solid Soiled waste: items contaminated with blood, body fluids including cotton dressings, soiled plaster castes, linen, beddings, Category 7: Solid wastes: waste generated from disposable items other than the waste sharps i.e. tubing's,
HCWM plan that should contain a National Action Plan (using for example the WHO/National guidance document), Consolidate the legal & regulatory frameworks, Standardize HCWM practices (edit National Guidelines), Strengthen the institutional capacities (human and financial resources; training, etc.), Set up waste management plans at all relevant levels and Establish a monitoring plan. For efficient management there has to be a team which should include Head of Hospital (chairperson: Occupier) , Heads of Hospital Departments , Infection Control Officer , Chief Pharmacist , Radiation Officer , Matron (or Senior Nursing Officer), Hospital Manager (Superintendent) , Hospital Engineer and Financial Controller . A Waste Management Officer (WMO) with overall responsibilities for the development of the hospital waste management plan and for the subsequent day-to-day operation
catheters, IV sets, Category 8: Liquid wastes, Category 9: Incineration ash, Category 10: Chemical waste Schedule II describes the color & type of containers / bags in which these categories of waste have to be separated, stored and transported along with methods of final disposal. In brief they are as given in Table.
and monitoring of the waste disposal system should be appointed. This person will often be the infection control officer / nurse. Effective HCWM includes waste minimization, waste segregation, collection, storage, transport, treatment and disposal. Waste minimization can be achieved through 3R's i.e. Reduce , Reuse , Recycle, however the key to waste management is segregation which means separating waste into various waste groups according to its final treatment & disposal for occupational safety and reducing cost of management by separating non hazardous & recyclable material from hazardous waste. It should be carried out by waste producer & as close to the site of production. Segregated waste should be collected daily (or as frequently as required) and transported to the designated central storage site which should have an impermeable floor with good drainage, easy to clean and disinfect, afford easy access and it should be possible to lock: the area to prevent entry of unauthorized person / animal. In temperate climate areas the waste could be stored for up to 72 hours in winter and 48 hours in summer,
Health care waste management (HCWM) is first of all a management issue before being a technical one and therefore completely depends on the commitment of both administrative and political authorities as well as the entire staff within HCF's( Health care facilities ) . The 10 steps for a HCWM plan are: Raise awareness of the problem, especially amongst policy makers, Define a policy (the rational for HCWM and what one wants to achieve), Set up a strategy (which is basically stating what steps must be taken to achieve the objectives that have been listed in the Policy), Conduct an assessment of the current situation (using for example the WHO Rapid Assessment Tool), Draft a
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while in warm climates, 48 hours during the cool season and 24 hours during the hot season. The aim of treatment and disposal is to limit public health & environment impacts by transforming HCW into non hazardous and containing it to avoid human exposure & dispersion in environment. The various treatment options recommended are Incineration, Chemical disinfection, Steam sterilization (autoclave / hydroclave / vapoclave) , Encapsulation , Micro waving etc while the Disposal options are municipal land fill, deep burial in premises and discharge in sewers. BMW is a universal problem. We must join together to form a united front powerful enough to tackle the problem. Today, with increasing number of health care institutions and careless attitude of health personal , the job has become more challenging.
· · · ·
Further reading: www.solutionexchange-un.net.in · www.csuchico.edu/ehs www.noharm.org/details.cfm www.envfor.nic.in/legis/hsm/biomed.html www.latrobe.edu.au/pc/ohs
WHAT HEART HAS TO SAY !!! Neha Pandey (2005)
Big 'P's, so plain for all to see Denote of course hypetrophy ? when the the waves are tall and thin, Cor pulmonale has set in, Broad and bifid then it is vital, to eliminate stenosis mitral. Ectopic foci may appear, abnormal 'p's will make them clear If 'T to P' is nil or dismal, take care it may be proximal, But don' t forget in nodal rhythm. inverted 'p's may then be hidden. with a 'P-R' of nought point two, everything will nicely do. But if it should be rather long. His or Kent is not too strong. When it is short then one should fear. Ectopic focus rather near, Now QRS is complicated, but following may be statedIf there exist a BBB,
it is rather mids and untidy. When infarction is severe A deepened 'Q' will appearif the heart size doeth grow a high 'R' one will surely show. But in a left super charge, then in both R5 and Rb are large. All points from 's' across to 'T' should ever isoelectric be If on the line they do not lie then querry first the blood supply, then there in much more the danger lies. Least distal cardiac muscle dies, moreover at a later date, An altered line an altered state, Then bear in mind those "drugs and ions", Forgetting not the endocrines
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Most of us fear rejection in our lives, an emotion which begins early in life, a n d probably continues life-long. Individual personalities determine the degree of such a fear,
and the initiatives we take to overcome such a fear. Traditionally a doctor-patient relationship has been of a provider (doctor), and a seeker (patient), where the former was on a higher pedestal and probably had to fear the least, while all the fears were for the latter. Increasingly the hierarchy in the doctorpatient relationship is getting diminished, making fear of rejection a greater concern for doctors as well. Often doctors encounter patients who are termed as “difficult patients”. These patients ask questions, demand results, and have often researched about their disease. Some of them would refuse clinical history or examination by a trainee medical student, as they very well understand the hierarchy in a teaching hospital, and are vocal in expressing their discomforts. In the clinical world, the term difficult is applied to a variety of patients: the noncompliant, the rude, abusive and manipulative, the malingering, the mentally ill, the skeptical. The antitheses of this minority are the docile and compliant patients, who are meek, compliant, agreeable, non-dissenting, and hardly ever seek a clarification from the doctor. Understandably, we the doctors like the latter, and tend to reject the former “difficult” patients. Difficult patients can be grouped in three categories1) Dependent clingers are excessively dependent on the doctor, desperate for reassurance but will return continually with a new array of symptoms. For example, "Thank you, my back's much better but I've got chest pain now." 2) Entitled demanders are also inexhaustibly needy, but rather than using thanks and flattery, will use intimidation, devaluation and guilt against the doctor, frequently complaining when every request
is not met. For example, "I must see a specialist for my ingrowing toenail right now!" 3) Manipulative help-rejectors continually return to the surgery to report that treatment failed. Where any symptom is relieved, it is rapidly replaced by another. For example, "None of the painkillers have helped my back, I'm allergic to those other pills. Pain Clinic did nothing. You've got to help me!" All these three “difficult” patient types inherently feel that they have been inadequately treated by the doctor, so would present with a new set of symptoms, demand results, or are vocal in expressing that previous treatments did not help. Doctors are never trained to handle such patients, and different personalities tend to handle such patients differently. Why do some patients
become difficult? A wonderful insight was provided by a physician, who was suffering from scleroderma and self confessed about being a difficult patient. The narrative from a physician explains1 and I quote: “ Why did I become difficult ? It wasn't my first choice. In the physician-patient relationship, trust on the part of the patient is a consequence of a number of factors, including perception of the provider's technical competence, interpersonal skills, and ability to act in the patient's best interests. In other words, the provider knows what he or she is doing, treats the patient what could be described as "nicely," and acts in a way that the patient would act, given access to the same knowledge and information. Being difficult was my natural response when my doctor was incompetent, rude, or domineering. I didn't need a physician to be my "perfect agent" (the phrase from health economics that the physician is the patient's agent). I needed a physician to be an additional source of information and insight to support my informed decision making. I wasn't interested in being told what to do, and I expected my doctors to respect my right to make truly informed choices that were consistent with the way in which I wanted to intervene in my disease and live my life…….. But being a difficult patient is a tricky proposition. By advocating for myself, I risk incensing the person on whom I depend for care. I tried being the "good" patient. I suppose like many young women, I was raised to please others. My natural inclination is to be pleasant, because, in all honesty, I want people to like me, and I believed that others, including doctorsboth male and femaleapproached interpersonal exchanges in the same way. In return for being a pleasant patient, I was misdiagnosed for fourteen
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months, given scientifically unsound advice about treatments, and warned against having children despite limited literature on scleroderma and pregnancy………..When I finally decided to become a difficult patient, terminate relationships with unhelpful physicians, and find like-minded providers willing to inform rather than dictate my treatment decisions, I started getting the care that I wanted and needed. Although some might label me as "difficult," others might callme "empowered." My empowerment allowed me to accommodate scleroderma into my life rather than surrender my life to the disease. It was the difference between becoming a patient with scleroderma instead of b e i n g a s c l e ro d e r m a patient: I came first, not my illness. I wish more providers treated me rather than my diagnosis.” Patients in general are weak players in the doctor-patient paradigm. Their fear of rejection begins even before they approach a doctor. This could result in a delay in seeking care, and often significant symptoms would be trivialized by patients themselves. This threshold of triviality differs according to patient personality types, but in general when a patient musters enough courage to partially overcome this fear, and approaches a provider the symptom is significant for the patient. When such symptoms do-not make sense to a treating doctor, they are termed as “non-specific” or “vague” or “miscellaneous”. Usually providers are uncomfortable with such symptoms or conditions, largely because they were never trained to deal with them. This discomfort manifests itself as patient-rejection, attitude patients realize soon. Some patients would persist with their symptoms none-the-less, and in the process would get labeled as “difficult”. An element of fear operates in a difficultpatient-doctor relationship. Patients feel inadequately treated or cared for, and ask questions. When these questions or demands are
unmet by the doctors they term such patients as difficult. Doctors fear difficult patients, and have a feeling of failure or rejection by the patient. This feeling is often difficult to digest or accept, so is expressed as a negative reaction. To overcome fear of rejection, doctors would ignore a patient, refer the patient to another provider, delay their appointment requests, or overwhelm the patient with triviality of their symptoms. Thus a fear of rejection in a provider manifests itself as a tendency to reject the patient by the provider, and this becomes a cyclic self-perpetuating phenomenon. What could be done about it? Foremost is the knowledge and understanding among doctors, about occurrence of this rejectionphenomenon. Secondly, realizing that the art of medicine is based on communication skills, something which in the forest of medical education is left for individuals to figure out. Lastly making internship as a more interactive process where art of medicine is emphasized, rather than learning of mundane clerical skills. Once we realize that 1) most patient-symptoms would not fit into textbook description of diseases, and 2) these symptoms need to be addressed time and again without abandoning the patient, would probably be the first step in breaking the rejection-cycle.
Reference: 1. Mayer ML. On being a difficult patient, difficult, I will tell you what is difficult. Health affairs 2008; 25(8) 1416-21.
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T H E Dr. AMIT BHATT
G Lecturer O Dept Of Medicine O My grandfather died long before. What killed him was not the D cancer that riddled his body and wormed its excruciating way up his spine. It was an overdose of morphine. My father, a doctor himself, had discussed the matter with the treating physician and the family knew exactly what was going on. When he passed away, the matter was also laid to rest. There is nothing unusual or controversial about his case; euthanasia was never even mentioned. He was merely given ample pain relief. That the required dose of painkiller became fatal was an unfortunate yet unavoidable side effect. Such practice still goes on today, discretely and regularly.
D E A T H
about a quick injection, an easy end. I love my daadi dearly, and that's why I might be prepared to do it. My parents are doctors. They know what's happening; they have watched many patients die. When I discussed the issue with Mum, she looked at me and said, "You realize that I believe you would ruin her chances of eternal happiness. I don't want you even to discuss it with daadi." She's right, of course. Suicide and murder are both grievous sins in our religion. If I were to give that painless, undetectable and lethal shot of potassium, daadi would be barred from Heaven. Heaven or otherwise, the suffering here on Earth would be very real. If losing a parent is hard, losing hope for them in the hereafter is intolerable. That could well ruin my mother, and our relationship. In times such as these, my solution is to curl up in a quiet room, take several deep breaths and meditate. I try to divest myself of all my preconceived notions of right and wrong, of loyalty and obligation, and the fetters of emotion and fear. I strive to see things in the clearest light possible, free of such hindrances. Then I hope for a solution ... Nothing. Alleviate suffering
Today my grandmother is also dying. This time there is no cancer, but a disease called multiple sclerosis, which has already left her virtually unable to talk or swallow. Communication between her and my father is almost impossible, something which has exacerbated existing, domestic difficulties. As the disease progresses, she can expect gradual paralysis. Her death will come when she is no longer physically able to breathe.
Currently I am a practicing medical physician myself. I had an elderly doctor with recurrent stroke and severe paralysis in my ward. With the recent controversy surrounding euthanasia, the topic came up easily. He paused a moment and rubbed his prickly chin before proffering judgment. "It is not a doctor's place to decide life and death. That is for God. It is simply our place to alleviate suffering. If, in the course of doing that, the patient dies, so be it. I believe a crime against God for anyone, particularly a doctor, to kill."
Unlike my grandfather, she is not in any great physical pain. Although her osteoporotic old back does cause some discomfort, it is nothing compared to her fear, her perpetual cloud of depression, and to the difficulties she faces at home. The anti-depressants she is on do little to hold back her tide of lament. As she becomes weaker and weaker, more and more immobile, she seems to sink lower and lower. Often she talks of wanting to die, of looking forward to her death, and of being ready to leave this world. Occasionally I have thought
Originally I was dissatisfied, but as I curled back up on the sofa I started to see his point. God does not feature in my decisionmaking, but that does not diminish the significance of what he said. For the terminally ill, alleviation of suffering is paramount. If an earlier death is the side-effect, that's acceptable, but one should never intend to kill. The next day, when I saw him at morning rounds, I asked about the current debate on euthanasia. He was unimpressed. "You can talk all you like about building safeguards into
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the law and having a panel with psychiatrists and such. It doesn't mean a thing. We went through these 25 years ago with the abortion debate. We were going to have at least two doctors who had to be able to verify that there was sufficient medical reason and all sorts of paraphernalia. Recently I read that 60 per cent of all abortions in India last year were for social reasons." Whatever your views on abortion, his point is to do with the hazards of legislation. Open the floodgates and the waters will come pouring out. It is not hard to imagine the situation where someone sick, old or an economic strain on the newly wed c h i l d re n , m i g h t f e e l compelled to request death. It is also not hard to make the next leap - to killing those unable to request, but whose relatives feel it is "for the best." Leaving the law as it stands does not mean that we prolong suffering - we should be frantically working to relieve it. It does mean that the focus is not placed on killing, but on supporting, and that a patient's death retains the gravity it deserves. I like to think I had learnt a little more about my role in life. Although I don't have a blind belief in God, I do have values. Love of life and happiness are what count for me. Upon these you can build the same moral and ethical structures that have been preached for millennia. Whether you see it as following God's rules, preserving the sanctity of life, or just helping others find their happiness, it comes to the same thing. Taking a life is unacceptable; accidentally losing a life in the process of bringing happiness into it is very different.
Again, I dragged my mind back to the question of Daadi. She was a tough case. There is no drug that is appropriate for her to overdose on inadvertently - antidepressants just don't work that way. However, the grieving and fear she is going through now is a natural process, and one that will pass. That requires no treatment other than family support, love and perhaps some therapy. Eating and speech will still be difficult, and in time she may even need to be fed through a tube. That is part of her condition, and she needs to work through that and come to terms with her fate. It is important, not only for her, but also for the grieving process of those who will survive h e r. U n f o r t u n a t e l y, Daadi's depression is only partly related to her illness. In some form or another, it has been lingering in the background for years, never really resolving, but never really treated aggressively. To my mind, this is perhaps one of our greatest transgressions. Not treating aggressively in these cases is a mistake. Everything possible should be done to make their remaining time comfortable. "When inevitable death is imminent... it is permitted in conscience to take the decision to refuse forms of treatment that would only secure a precarious and burdensome prolongation of life, so long as the normal care due to a sick person in similar cases is not interrupted.” 1980 Declaration on Euthanasia issued by the Sacred Congregation of the Doctrine of the Faith
HUMOURrrr…ours 1.Q. What are MEN? A. Multiple Endocrinal Neoplasia 2.MISS….. CONCEPT A doctor was examining a pretty young girl. “ You've got a-cute appendicitis”, He said at last. The girl sat up indignantly. “EXCUSE ME” she said. “I want to get examined, not admired”.
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Hypnosis and Crime Many of us may remember an incident occurred during the beginning of this year. A woman in Nagpur had some major personal problem for which she sought help of a guru who hypnotized her. Ultimately the lady lost a good amount of her precious ornaments in that incident under her hypnotized condition. All of us have heard of similar incidents. But what exactly is hypnosis? What is hypnosis? Hypnosis is a state in which a person is relaxed and drowsy and more suggestible than usual. Enhanced suggestibility leads to diminished sensitivity to pain, vivid mental imagery, hallucination etc. In fact this is a sleep-like condition brought on by artificial means. It is practice where a connection is made with the subconscious mind in order to alter a pattern of thinking or acting in order to improve a state of health, relieve pain and or improve one's personality and self esteem. It has generally been observed that the subject doesn't remember the activities of hypnotized state afterwards. Induction of hypnosis: Hypnosis can be induced in many ways, but the primary aspect is that the subject should be willing to be hypnotized and convinced that hypnosis will occur. This means the personality or state of mind of the subject should be in such a position so that it can be dominated by the hypnotizer. Most hypnotic procedures contain some combination of tasks to focus attention (such as watching a moving object, rhythmic monotonous instructions, and the use of a series of suggestions for e.g. - one limb of the subject will rise, like this). Slowly, a Trans state appears and the subconscious mind of the person is focused. Scientists have developed a hypothesis that hypnotism and hysteria are related because they found that 1. Phenomena observed in hysteria could be produced in normal subjects by, means of hypnosis 2. The same symptoms also could be removed by means of hypnosis. It is interesting to inform that many people today practice hypnosis on themselves by using the help of CDs and DVDs as well as books for guidance. Many
Dr VG PAWAR, Dr ALOKE MAZUMDAR, Dr SANDIP BHOWATE on-line sites are there to help in performing hypnosis. Hypnosis and crime: Although the infrequent use of hypnosis in psychiatry (medical hypnosis) is a known factgenerally in alleviating anxiety, depression and related disorders, the relation of hypnosis and crime is a real fact of consideration. Hypnotism as a defense to a criminal act is not generally recognized in courts. A person cannot be hypnotized against his will. Hence when he volunteers for hypnotism; he is expected to have the anticipation of the consequences of the act. A group of persons believe that crimes are possible by hypnosis. They do it by complex brainwashing in which the entire personality of the individual is shattered. In medical hypnosis, the personality of the subject is not hampered. But in brain washing, the subject is processed through severe mental pressure, often by confinement and regular stimulus of horror and emotional activities. It is told that today's suicidal terrorists are products of such type of hypnosis/brain washing. But as it is very hard to perform hypnosis on someone without his knowledge, it is not a common to create crime by hypnosis. But on the other hand, hypnosis is increasingly being utilized by police and investigators in solving crimes. Well, when practically all investigation leads have been exhausted there is certainly no harm in exploring hypnosis as potential solution. This part comes under “Forensic Hypnosis” Authorities use hypnosis to tap into victims and witnesses, subconscious and retrieve memories that can be utilized in solving the case. The first attempted use of hypnosis in the criminal justice system dates back to the mid 1800s and the second documented effort was in 1894. Tom Pert, a hypnotherapist said, “If we could use and access our subconscious minds like we should be able to, for would be amazed at what we have stored up there.” “Forensic hypnosis is nothing more than memory refreshing,” says detective (Dollar Police), B .J. Watkins. Hypnotically refreshed recall is admissible in Texas in both criminal and civil cases.
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There were approximately 800 law enforcement officers in Texas who had received training as the Forensic Application of Hypnosis by 1986. But although potentially handy, hypnosis cannot be relied upon for 100% truthfulness. It has several limitations like some people can mimic or simulate hypnosis and can lie willfully. Some may confabulate. During the induction of hypnosis there is a possibility of bias by the investigative hypnotizer, and also any existing preconception of any thought- may create pseudo-memories which may dominate the actual memory of any crime. All these did not allow hypnosis to be accepted in the court of law at all places. Conclusion:-OK, enough is enough. Thank you very much for being hypnotized by us. Hope you have been hypnotized by this article.
MEDICO'S LOVE LETTER -MANISH KUMAR SINGH (2005
Date : t
10 Cranial'08 Vagus day
Address : Graymatter/white mater Brain Stem Street, Near Cerebellum, Pontine Colony - Skull
My Love, You are the rhythm of my cardiac muscles. Do you remember, the first time we met? We were standing in anatomical position with my coronal suture exactly parallel to yours. You looked into my eyes and I looked into your glasses. Second time we met, you were standing in your balcony, your right lower limb was in mid flexion and left fore arm supine. You smiled at me, my eyes blinked, my heart rate increased to 200/min. and 4th heart sound became clearly audible. Third time we met, I had a cardiac arrest, you caught my wrist, it acted like DC shock. My ventricles revived, causing hypertension. My dear, whenever I look at you, I develope Isolated systolic hypertension. My love is as pure as distilled water, you can test it by adding hot CuSo4 powder. It will surely turn blue. I hope you will not forget me.
Clinically yours, S.A. Node
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We have turned doctors into Gods and worship this deity by offering up our bodies and souls not to mention our worldly Gods. And yet paradoxically, they are the most vulnerable of human beings. They are aptly called as “wounded healers”. This article tries to take a 'look' at one of the aspects of medicine which is often 'overlooked'. Long before the microbial nature of infection was known, hospitals were regarded as places where communicable diseases could be acquired as well as treated. The admission of a patient with a communicable disease into a hospital creates a potential source of infection in that hospital. Usually the risk is minimized by nursing the patient under isolation, but if the infectious nature of the illness is unrecognized, the danger is increased. The disease may be so rare as to serve an improbable diagnosis. For instance small pox in Britain in 1973 which spread from an undiagnosed patient to two visitors of a patient in the adjacent bed with viral hemorrhagic fever spread to nursing and medical attendants of the index case. Actually a communicable disease depends on the conjugation of many factors: presence of microorganisms which can cause the disease, presence of susceptible host and a mode of transmission. In the hospitals, the conjugation of these factors occurs and they are deemed to be the breading ground for resultant outbreaks. Hospitals in which antibiotics are heartily used are an environment where antibiotic resistant bacteria are in effect selected for survival, such threat is posed by Staphylococci and other gram negative bacteria as
Escherichia coli, Klebsiella spp and Enterobacter spp. (all penicillin resistant). Another recently discovered infection for which hospitals provide special conditions enabling the causative organisms to survive is Legionnaire's disease. Rarely the nursing and medical staff themselves are source of infection to patient, but streptococcal pharyngitis, influenza and other respiratory infections are examples where hospital staff should take to be immunized against communicable diseases to reduce their chances of acting as sources of direct infection to patient or to community indirect via laboratory staff to their families and friends has recurred in cases of tuberculosis and Hepatitis B. Medical drugs have occasionally been the vehicles of infection. Intravenous fluids contaminated by bacteria cause the most serious hazards, but are very uncommon. Eye drops have also been a problem when disposed from large containers which become contaminated after sterilization. Finally drugs such as pancreatic enzymes, have been known to transmit infections. Any discussion of the possibility that hospitals are breeding grounds for communicable diseases, risks appearing as a catalogue of hazards which portrays hospitals as hot-beds of infection. In developing counties like ours much of infection that is acquired in hospital is caused by patients own colonizing bacteria which take the opportunity of the illness or treatment to become invasive and cause infection. Nevertheless, the past history of hospitals as places, where once infection was rife should serve to warn us against becoming complacent.
The nurse went in to check her patient in the ICU who was wearing nasal prongs. The nurse tried to talk to him, but all she could get out of him was gasping and unintelligible talk. Finally, the nurse thrust a note pad and pencil at the patient and said, “I can't understand you, sir. Please write it down.” The patient weakly scribbled on the pad, “Get your dang foot off my oxygen tube!”
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MICROBIOLOGY OF MEDICOS NEHA PANDEY (2005) The microbiology of medicos is complicated and pleomorphic. Mutation is common phenomenon and requires careful study. Even after careful study the subject is difficult to be put in black and white. Here is also not an insincere attempt. HABITS AND HABITATSA large number of them are found in boys and girls hostel, though some are found scattered in city. They are particularly sensitive to the term ''DOCTOR SAHIB.'' MORPHOLOGYFor convenience of description they are classified into 2 main groups1.Male organisms 2.Female organisms The female are cocci, always arranged in groups and hence known as staphylococci contributing Brownian movements. They are multicolored, powder sprinkled and cream coated . The males are bacilli arranged in chains and called as streptobacilli. They are actively motile and highly virulent particularly to cocci. STAININGSome of them are ward positive while others are ward negative. Ward negative bacilli are exam resistant. They usually form spores during examinations and need intermittent autoclaving in order to get rid of them. By careful observation over a long period we have recently detected the most virulent organism which is ward negative, exam resistant and 100%.nurses fast .Morbidity is high and mortality is 100%.Other commonly used stains are theatre meta chromatin ,guncha blue and elite violet . CULTURE MEDIA Ordinary culture media for a male organism is the college corridor and for a female organism is the girls common room. Special selective media for both of them hospital canteen, reading room egg media and college gathering agar. When both are inoculated in same liquid media (theatre at Wardha) they give uniform turbidity.
BIOCHEMICAL REACTIONSAll are "parents money fermentors" and "knowledge liberators". Ward positive organisms liberate more knowledge than ward negative. DISINFECTANTScientists have been able to discover only a few disinfectants even after full sweat. These disinfectants only retard the growth of microorganisms. Some of them are anatomy stages pharmacology tutorials and ward attendance. Most effective disinfectants are final year classes and postings. TOXIN PRODUCTIONOnly the male type is found to produce an exotoxin which is very powerful and is called ''theatre phoron-toxin.' CHEMOTHERAPYRepeated failure in 1st year MBBS used to give a radical cure. But since this therapy has been abandoned, more and more resistant strains are encountered. Subsequent failures in other exams give a palliative cure. Other important drugs recently marketed are election fight tablet and leadership injection. COMPLICATIONS1.Acute, sub-acute or chronic boring fever. 2.Adhesion to college corridor. 3.Malignancy which metastasize to girls hostel. 4.Sarcomatous changes in reading room couples. 5.Prescriptions for bikes. 6.Particularly the ward negative may sometimes become patient killers.
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CASE STORY OF THE YEAR
No longer Gage! ! - Milestone of neurology Compiled by NAYAN CHAUDHARI (2005) Tyanv!!! Tyanv!!! Hear the first cry of the baby! Gradually- the baby walks… talks...plays with friends… argues with friends… fights with them… faces exams in full tension... falls in love… comes under emotions and that is what we call 'behavior'. Till the 19th century, scientists didn't know the biological basis of behavior till the accident with Phineus P. Gage happened. On September 13, 1848, Gage was foreman of a crew of railroad construction workers who were excavating rocks to make way for the railroad track. Gage was preparing for an explosion by compacting a bore with explosive powder using a tamping iron. While he was doing this, a spark from the tamping iron ignited the powder, causing the iron to be propelled at high speed straight through Gage's skull. It entered under the left cheek bone and exited through the top of the head, and was later recovered some 30 yards from the site of the accident. Amazingly, Gage spoke within a few minutes, walked with little or no assistance, and sat upright in a cart for the 3/4-mile ride to town. Though physicians Edward H. Williams and John Martyn Harlow found him weak from hemorrhage, he had a regular pulse and was alert and coherent. Within a few days of his accident, one of Gage's exposed brain became infected with a 'fungus', and he lapsed into a semi-comatose state. Harlow released 8 fluid ounces of pus from an abscess under Gage's scalp, which would otherwise have leaked into the brain, with fatal consequences. His family prepared a coffin for him, but Gage recovered. By 1st January 1849, Gage was leading an apparently normal life. Harlow goes on to describe how, while examining Gage, he determined that no bone fragments remained inside the skull: “in searching to ascertain if there were other foreign bodies there, I passed in the index finger its whole length, without the least resistance, in the direction of the sound [of the hemorrhaging?] in the cheek, which received the other finger in like manner.” After the accident, but his wife and other people close to him soon began to notice dramatic changes in his personality. It wasn't until 1868 that Harlow documented the “mental manifestations” of Gage's brain injuries. His contractors, who regarded him as the most efficient and capable foreman in their employ previous to his injury, considered the change in his mind so marked that they could not give him his place again. He is fitful, irreverent, indulging at times in the grossest profanity (which was not previously his custom), manifesting but little deference for his fellows, impatient of restraint of advice when it conflicts with his desires, at times pertinaciously obstinent, yet capricious and vacillating, devising many plans of future operation, which are no sooner arranged than they are abandoned in turn for others appearing more feasible. In this regard, his mind was radically changed, So decidedly that his friends and acquaintances said he was “No Longer Gage.” Thus, the damage to Gage's frontal cortex had resulted in a complete loss of social inhibitions, which often led to inappropriate behavior. In effect, the tamping iron had performed a frontal lobotomy on Gage. Ferrier, an early proponent of the localization of cerebral function, used Gage's case and told that there are certain regions in the cortex to which definite functions can be assigned; and that the phenomena of cortical lesions will vary according to their seat and also to their character…removal or destruction…of the antero-frontal lobes is not followed by any definite physiological results…And yet, notwithstanding this apparent absence of physiological symptoms. Gage's case, therefore, had confirmed Ferrier's findings that damage to the prefrontal cortex could result in personality changes while leaving other neurological functions intact. Gage's case is one of the very first which provides evidence that the frontal cortex is involved in personality. Today, the role of frontal cortex in social cognition and executive function is relatively well established; however, this area of research is yet to blossom, and neuroscientists know little more about the relationship between the mind and the brain than did the early neurologists of 19th century. [Clinical Section editors of this edition urge future editors of Clinical Section to continue the thread of CASE STORY OF YEAR.]
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Ig Nobel Prize
- PAWAN KANDHARI (2008)
The Ig Nobel Prizes are a parody of the Nobel Prizes and are given each year in early October for ten achievements that "first make people laugh, and then make them think." The first Ig Nobels were awarded in 1991, at that time for discoveries "that cannot, or should not, be reproduced." Ten prizes are awarded each year in many categories, including the Nobel Prize categories of physics, chemistry, physiology/medicine, literature, and peace, but also other categories such as public health, engineering, biology, and interdisciplinary research. Some of the Medicine Ig Nobel prize winning topics: 1991- Work with anti-gas liquids that prevent bloat, gassiness, discomfort and embarrassment. 1992- People who think they have foot odor do, and those who don't, don't. 1993- Acute Management of the Zipper-Entrapped Penis. 1995- The effects of unilateral forced nostril breathing on cognition. 1998- Presented to Patient Y and to his doctors for "A Man Who Pricked His Finger and Smelled Putrid for 5 Years." 1999- For carefully collecting, classifying, and contemplating which kinds of containers his patients chose when submitting urine samples. 2000- Magnetic Resonance Imaging of male and female genitals during coitus and female sexual arousal. 2001- Injuries due to falling coconuts. 2002- Scrotal asymmetry in man and in ancient sculpture. 2003- The hippocampi of London taxi drivers are more highly developed than those of their fellow citizens. 2004- The Effect of Country Music on Suicide. 2005- Artificial replacement testicles for dogs, which are available in three sizes, and three degrees of firmness. 2006- Termination of intractable hiccups with digital rectal massage. 2008- Expensive placebos are more effective than inexpensive placebos. At an exam, a student was asked causes of absent knee jerk. He replied, 'above knee amputation.’ There was a forensic exam in which a short note on STATUTORY RAPE was asked. One student wrote 'raping a statue…. Another one wrote 'threatening a girl into standing still like a statue and then raping her. A gynaecology viva going on.. Examiner- What will you do if a female cannot feel the thread neck of Copper-T? Student- Ma'am.. I mean Copper-T has been lost in the body and we'll give her copper chelating agents. Examiner to student in pharmacology viva ---What is therapeutic window of a drug? Student after thinking for sometime said “Sir, It is the window through which a chemist dispences his drugs.” Ma'am not satisfied asks further “If the patient is nulligravida and she wants a child in future, What will be your step? Student- “ADOPTION” Teacher Area to be biopsied for cervical dysplasia? Student- “The patient's neck.” In anatomy exam, a student was given a female pelvis section. Teacher- Wat's this? (pointing towards uterus. Student- TONGUE…
B L U N D E R S PA R EXC E L LA NC E ! ! ! Aditi Jain (2005)
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Why Did I Choose Medical Career Option? P.KEERTHI KUNDANA (2008) Every human being strives to become “something” in life- primarily for earning the livelihood and secondarily to satisfy his taste of interest and passion. The same is the case with me. I too wanted to create a distinct image of myself. But the BIG question that blocked me was- HOW and in which field should I sprout my talent? It was the result of all the entrance exams that made me enter the state of dilemma. I qualified almost all of them with good scores. On one side IIT and several NITs were calling me and on the other side many Govt. medical colleges were pulling me. I stood on a path from where two roads diverged and it was for me to decide as to travel on which road. Both the roads were equally attractive and boasted of providing safe and comfortable journey. Then my needle of interest turned towards the medical field and hence I decided to move my steps on the path of becoming a doctor. A number of factors led me take this tough decision. The professions in demand today like software engineering, law, chartered accountancy are based more or less on temporary subjects. If computers were to disappear today software engineers would become jobless and the new machines would replace the manual workers. But the doctors could at least never be out of work because their subjects human beings are to stay are to stay here permanently. No technology could ever replace the diagnosis and treatment done by a doctor. Thus it is one of the safest career options in today's transient world. Today half of the population is unaware of the correct lifestyle, eating habits and its nutritional values, importance of exercise etc. This invites a number of ailments and diseases and necessitates the intervention of a doctor. Thus it makes a doctor; the person must sought after today. The other white collar jobs are in for high craze and need just in big cities. Actually, the employees literally play in hands of MNCs and become the victims of their whims and fancies. They sell their freedom for mere packages of few lacs as they cannot exercise any right to retain their jobs and are fired as soon as their efficiency
declines, I can never tolerate my actions to be dictated like this by someone else. The long tenure of medical studies, struggle, and immense handwork cannot overshadow the sweet fruits that it would bore in the long run in the form of fame, money respect, responsibility with a degree. After all a common man is recognized only by his neighbours but a doctor is well known throughout his locality among all age groups. Who can deny the fact that with a stetho in neck, one is dealing with best creations of god, the jewels of nature- “Homo Sapiens” and gets an opportunity to appreciate the wits of God. In keeping view with the changing lifestyles of people, changing climate, increasing pollution and ascending population as well as irrelevance of outdated medical techniques- there crops up a need for quality specialists, and research scientists to innovate solutions to the prevailing problems, and when the society is craving for these people Why should I keep myself aloof from it? From birth till adolescence, when society has bestowed on me so many good things, its now my turn to pay the debt by providing services as a doctor. But for that I need to sweat out a little more and for a longer time than my counterparts of other professions but for those who wear khadiDoesn't matter at all. So I think I took the right path though it was the one less travelled by. I move my steps with an aim to leave a trace behind.
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