Author: Dr Pankaj Kumar

I’m Dr Pankaj kumar, I entered medical school in 1984. postgraduate Int med 1994 and diploma Heath Management. presently a critical care specialist

Early civilizations Egypt: ancient Egyptian medicine


One of  the large, earliest and meaningful medical traditions were developed in Ancient Egypt.  Herodotus described the Egyptians as one of healthiest people because of possessing the notable public health system.  He found the practice of medicine very specialized. Although Egyptian medicine, to a considerable extent, dealt with the supernatural, it eventually developed into more practical use in the various  fields  of medicine.

Medical information in the Edwin Smith Papyrus may date to a time as early as 3000 BC. Imhotep  in the 3rd dynasty may be founder of ancient Egyptian medicine and with being the original author of the Edwin Smith Papyrus, detailing cures, ailments and anatomical observations. The Edwin Smith Papyrus is regarded as a copy of several earlier works and was written in 1600 BC, contains earliest recorded reference to brain. It is an ancient textbook on surgery almost completely devoid of magical thinking and describes in exquisite detail the examination, diagnosis, treatment, and prognosis of numerous ailments.

The Kahun Gynecological Papyrus treats women’s complaints, including problems with conception. Dating to 1800 BCE, it is the oldest surviving medical text of any kind.

Medical institutions, referred to as Houses of Life are known to have been established in ancient Egypt as early as 2200 BC.

Ancient Egypt also had one earliest known physician Hesy- Ra . He was Chief of Dentists and Physicians for King Djoser in the 27th century BCE. Also, the earliest known woman physician,  Peseshet, practiced in Ancient Egypt  at the time of the 4th dynasty . Her title was Lady Overseer of the Lady Physicians. In addition to her supervisory role, Peseshet trained midwives at an ancient Egyptian medical school in Sais.

 

 

Link    https://en.wikipedia.org/wiki/History_of_medicine

 

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Evolution of medical science


 

The   practice of medicine  by trained professionals has been ever evolving  in its approach to   illness and disease, from ancient times to the present.

Early medical traditions evolved in  Babylon, China, Egypt, and India. The Greeks  pioneered the art of   medical diagnosis, prognosis, and advanced medical ethics. The Hippocratic Oath, still taken  by doctors up to today, was written in Greece in the 5th century BCE. In the medieval age, advances in  surgical practices were made and  systematized in Rogerius’s,  The Practice of Surgery. Systematic training of physicians was  started in universities around the years 1220 in Italy.  During the Renaissance,  significant advances were made with invention of microscope and  better understanding of anatomy.   The germ theory of disease in the 19th century led to cures for many infectious diseases. Military doctors advanced the methods of trauma treatment and surgery. Systematic sanitary measures and public health measures  made significant improvement . Advanced research centers opened in the early 20th century, often connected with major hospitals.  Discovery of antibiotics  was major invention in the mid-20th century.. These advancements, along with developments in chemistry, genetics, and lab technology such as the X-ray, was recognized as   modern medicine. Medicine was heavily professionalized in the 20th century, and new careers opened to women as nurses from the 1870s.

 

Link    https://en.wikipedia.org/wiki/History_of_medicine

 

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Evolution of medical science:


 

The   practice of medicine  by trained professionals has been ever evolving  in its approach to illness and disease, from ancient times to the present.

Early medical traditions evolved in  Babylon, China, Egypt, and India. The Greeks  pioneered the art of   medical diagnosis, prognosis, and advanced medical ethics. The Hippocratic Oath, still taken  by doctors up to today, was written in Greece in the 5th century BCE. In the medieval age, advances in  surgical practices were made and  systematized in Rogerius’s,  The Practice of Surgery. Systematic training of physicians was  started in universities around the years 1220 in Italy.  During the Renaissance,  significant advances were made with invention of microscope and  better understanding of anatomy.   The germ theory of disease in the 19th century led to cures for many infectious diseases. Military doctors advanced the methods of trauma treatment and surgery. Systematic sanitary measures and public health measures  made significant improvement . Advanced research centers opened in the early 20th century, often connected with major hospitals.  Discovery of antibiotics  was major invention in the mid-20th century.. These advancements, along with developments in chemistry, genetics, and lab technology such as the X-ray, was recognized as   modern medicine. Medicine was heavily professionalized in the 20th century, and new careers opened to women as nurses (from the 1870s).

 

Link:

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Unfair prejudice against doctors distressing : shortage of docs and still delivering best, but punished and assaulted


Shortage of docs ails AIIMS emergency only one technician each for ventilator, ECG (link)

http://timesofindia.indiatimes.com/city/delhi/shortage-of-docs-ails-aiims-emergency/articleshow/58831115.cms

Times of India yesterday carried a news article which highlighted the problem of shortage of doctors and trained staff in AIIMS hospital emergency.  The number of doctors  available are less than half of those required. And if this is the scenario in a premier Institute, it does not need an Einstein brain to figure out how the problem at other places in remote areas would be.

Everybody desires to have themselves treated within few minutes of their arrival in a hospital to the best of standards, but there are many obstacles to it in the form of large patient overload and shortage of doctors. Despite shortage of staff, each and every doctor tries his best to see as many patients as possible while sacrificing his own personal life. In any civilized society, this kind of work should bring in appreciation and respect for those who deliver. But for some strange reason, possibly due to vicious campaign against doctors by media and even celebrities, the respect and appreciation for this profession is sadly lacking. Possibly it is due to inadequate root cause analysis of the real issues. News items like these will probably help public realize the problems doctors face.

Despite working in such conditions, they are still abused, assaulted, beaten and taken to court for reasons, which are not justifiable in a civilized society. With all such problems and heavy hearts, this wonderful community still continues doing their noble work day and night to give each patient the best possible treatment within a reasonable time frame.  As compared to other professions the amount of work is more and appreciation much less.

Let’s take an example of courts where people spend lot of money and time and their cases still drag on for years. Crores of cases are pending in courts and thousands die without getting justice in their life time.  In contrast, even if there is shortage of doctors, relief to uncountable patients is provided and the quality of work is much better than other professions. As nature of work of this saviour is very high in moral hierarchy as compared to any other profession, it is time our society realized about the constraints doctors face before blaming them for the loss of optimal health care provision. Surely society owes much more to this wonderful community, but sadly this realization is unlikely in present era.

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Ray of hope for doctors :Honourable President and Delhi high court show concern about violence against doctors


At last, Delhi high court has expressed concern  over growing instances of attacks on doctors by irate patients. It also identified lack of adequate number of medical experts in government hospitals, as a possible cause. It also made a note of  government’s  failure to increase the number of doctors despite multifold increase in patient load. And the next date for hearing is fixed for 10 days later, on 29th May.

Our Honourable President Mr Pranab Mukherjee too, has disapproved of the violence against doctors, thus giving hope to  doctors that their fundamental right  of safe working environment may be restored in near future.

Although good working conditions still remain a distant dream for doctors but this raises hope of getting atleast a safer environment which is absolute  necessary for a doctor to practise.

Although points raised by courts are well known and basic but are very important to begin with. But still until now, none of the government authorities had extended help to the doctor’s community. Isn’t it ironical that in 21st century, when sky is the limit for advances in majority of the professions, the most educated and a hard working community of the country is fighting for its basic and fundamental right of a safer workplace? It is just unthinkable that doctors still have to struggle for their basic  right in present era.

 

Honourable President Mr Pranab Mukherjee too, has disapproved of the violence against doctors(link)

Attacks on doctors by relatives of patients unacceptable: President Pranab Mukherjee

Delhi high court has expressed concern  over growing instances of attacks on doctors by irate patients.(Link)

http://timesofindia.indiatimes.com/city/delhi/hc-seeks-report-on-docs-safety/articleshow/58504721.cms

 

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Real story of a female doctor assault : Routine affair for uncivilized society


Few words here can’t describe the plight of a female doctor, who was brutally assaulted by a mob at her residence, for no fault of hers. This incidence happened few months back, about 200 KM away from Delhi.

It was an evening time and a boy had an accident with a bus. He was brought to a community health center.  Female medical officer who had her residence inside the hospital in staff quarters examined the patient and found that he was already dead. She explained the situation to the family members with due sensitivity, did all the paper work and returned to her residence in about an hour. Mob kept on gathering and after half an hour, they barged into the house of the lady medical officer.

They dragged her by hair in front of her teenage daughter. Mob started assaulting her with fists and legs along with a rod. Her daughter cried and shouted for help.   Mob even tried to set her on fire. This brutal and devilish assault continued till neighbours from other staff quarters saved her with great difficulty and took her away. Mob continued rampage in her house and hospital, trying to break everything.

She sustained severe head injuries and was admitted in a hospital for about ten days. What was her fault and why mob did this to her? Is being a doctor and working in remote area her fault? Everybody knew that the reason for death of the boy was what happened outside the hospital.  There was an errant bus driver, who was responsible.  Then why was she made a punching bag for venting out emotions of the bereaved relatives. Nothing and really nothing can justify this barbaric act. Emotions should not be allowed to take such a demonic form. This is simply jungle raj, goonism and  expression of a most  uncivilized kind of society, which simply cannot be excused by any sort of reasoning. The incident was protested by the professional bodies as is the routine and after few day things normalized for everybody else except that terrorised family. The said lady medical officer took posting elsewhere and as is usual, nothing much happened to the accused.

Woman doctor assault : Era worse than MAHABHARATA for female doctors

There was again same silence and little concern shown by our media, courts, prominent people, celebrities, human right commission, woman right activists and women commission. This again brings forth the hypocrisy of these people and organizations, who otherwise cry about woman rights and empowerment.  Whenever a female is assaulted, there is an outrage but the same support is not extended to a female if she is a doctor. Such bestiality should create havoc in minds of civilized people but this apathy to such incidents clearly indicates otherwise. Have we become so uncivilised that an incident such as this just remains as a small news item in a local paper? Can’t we see that such incidents are harbinger of many more in future? It is important to realise that this is the time to unify and condemn such episodes vehemently and prominently so that the miscreants realise that they cannot get away with it.

Beti bachao Beti padhao vs Violence against female doctors

Violence against female doctors: Silence of human and  woman right commissions

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How to survive medial lawsuit for central venous line insertion


 “ doctor- save the patient, but save yourself also”.

Consent must before invasive procedures: consumer panel  

National Consumer Disputes Redressal Commission has said that doctors must take consent of a patient or his family members for any invasive procedure during treatment. (11.5.2017 Times of India link below).

I really feel sad for the doctors, who sometimes due to overwork or zeal to do things  find themselves in a soup, because of lack of paperwork.  But they are learning the lessons the hard way. Law and media call them a mistake but I think the errors in documentation are due to lack of proper training and poor understanding of legal requirements of profession in consumer’s era. The ignorance is about necessity to save thou self, when we try to save the patient. These documentation have become all the more necessary in current scenario because of the non-acceptability of even common complications. If a complication occurs during treatment, prolonged retrospective analysis goes on at leisure by lawyers with an intention to find fault. They are driven by money as an incentive, and with the wisdom gained on the hindsight, they may find some fault almost always in some way. Thus, doctors are at great disadvantage on this issue. choosing medical career a disadvantage to doctors.

It is high time for doctors to learn how to save themselves. It is important to have a thorough documentation. I am mentioning certain aspects which should be taken care of, while putting a central line .

  1. As already in news “consent” is very important. Take care to write patient identity, age sex and all other relevant columns. Explain and write all benefits and possible complications of procedure. Get signature of patient, relative and a witness. Put doctor’s signature with date and time.
  1. Always try to use ultrasound to help you to locate lines. Patient can be obese, having short neck and it may be difficult anatomy. Ultrasound will help you in differentiation of artery and vein and avoid arterial puncture as in above case.
  1. Be sure before dilatation that you are in vein. Sometimes it is difficult to differentiate between artery and vein. Do everything to prove that you are in vein before dilatation.
  1. Take suitable precautions for to prevent sepsis, air embolism
  1. If it is not emergency always check coagulation profile.
  1. Make sure doctor who is doing the procedure is well trained for it.
  2. Upgrade quality assurance program by keeping record of adverse events during procedures.

These are simple steps, although documentation is cumbersome. But it is worth because it can help the doctor from future litigation, harassment and so many problems. This is need of the hour. Bottom line is “save the patient, but save yourself also”.

http://timesofindia.indiatimes.com/city/delhi/consent-must-before-invasive-procedures-consumer-panel/articles how/58618137.cms

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Generic vs. branded medicine: Doctor’s stake : just stringent check on quality of medicine.


Doctors should have no issues to what Honourable Prime Minister Mr Narender Modi himself has spoken, for putting in place a legal frame work to ensure that doctors prescribe only generic drugs. This practice can be easily followed if apprehensions about quality of medicines are allayed.

There have always been concerns regarding quality of generic drugs sold under various trade names since the control over their quality is not foolproof. Implementation has to come along with stringent laws regarding drug testing and quality assurance, otherwise it may be dangerous to patients and in turn to doctors, in the present scenario.

   Generic drug are low cost version of a formulation that should ideally be equivalent to a branded product as far as its production quality, dosage, strength, route of administration and efficacy is concerned. Most generic products are allowed to enter the market only after expiry of the patent protection duration granted to the drug’s original developer.

   Branded drugs are expensive and there is a huge price variation between different branded drugs containing same molecule which is inexplicable. How can doctors interpret the price variation which can be sometimes many times for the different brands of same molecule. Is this price variation because of some difference in efficacy? How to interpret this much price gap and how to keep track of newer names launched at lower prices? Doctors do not manufacture drugs nor are they responsible for printed high retail prices variation in drug prices. I feel the biggest problem is the lack of documentation on efficacy of different brands of same molecule, which if done could guide the doctor. Some regulatory agency needs to be responsible for guiding doctors and patients regarding relationship of quality of drugs and prices. Therefore it is actually not correct to hold doctors responsible for these cost variations.

Huge price variation:  But all said and done, none of the arguments can explain the huge price variation for the different brand of same molecule. This malpractice of pharmaceutical industry has gone on for years without any check and this needs a solution which cannot be found at the door of doctors alone.

The quality control mechanism need to be strengthened and made more stringent. Before using a generic drug, the doctor or patient has to be well assured about  consistent quality of various drugs of same molecule and their pharmacological properties and also the fact that they have been manufactured using the standard practices  and meet the quality controls as per the regulations laid down. Concerned agency should check, verify and certify each and every drug.

 Bioavailability equivalence: There has to be a stringent legal mechanism to guarantee the bio equivalency of the compound for the drug made available in the market. Even a bioequivalent drug can fail efficacy test because of factors like heat, humidity and stability issues. There should be a strict quality control with best manufacturing and packing practices followed for generic and branded medicines alike.

Quality assurance of every drug is a patient’s right and a doctor’s too. They both have a right to know about relationship of quality, efficacy and price. It is of paramount importance to the patient who is ultimately    the consumer.

 Doctors can be victim of this anomaly in a bigger way: They can be in big trouble if quality of the drug prescribed by them is lacking in its quality and efficacy. Major adverse effects and even deaths have been reported due to poor quality of drugs or contaminated drugs. For example deaths in a sterilization camp in Chhattisgarh (FIR 11.11.14) have been attributed to use of contaminated drugs. Think of the plight and suffering of the doctor who was then portrayed as a criminal. He was lucky that court ultimately found out about the poor quality drugs as the cause. But in a day to day routine practice, it is very difficult even to think of such possibilities and prove it and consequently doctor has to suffer the blame of being negligent. Most of the time, it is taken as incompetency and failure of the doctor while the actual problem lies with the drug. If a doctor makes a correct diagnosis and advises medicines correctly but the patient still does not get well, it is the doctor who is blamed for the lack of improvement. Sometimes, if patient does not get well or if a life is lost, doctor may be abused, assaulted or dragged to court. Consequently most doctors try to play safe and prescribe drugs of pharmaceutical companies of sound background. So doctor’s concern should be to ensure and demand strict quality control of medicines because it has a real bearing on the ultimate practice of the doctor. It is really unfortunate that for the lack of poor regulatory mechanisms and greed of pharmacy industry, doctors suffer.

 Doctors just need stringent quality control, law and mechanisms to guarantee effective medicine be it generic or branded. 

It is not a problem to a doctor whether patient gets a generic or branded medicine, as long as it is effective.  Nor does it concern them whether a drug company or chemist make 100% or 1000% of profit out of medicine. The latter should be regulated by government agencies.

It needs a sincere effort by the Government to maintain stringent quality of drugs so as to ensure that both generic as well as branded drugs have same quality and efficacy. The recent initiative by our prime minister can usher in a new era and can be path breaking if strict measure are in place for quality control and standard manufacturing practices are followed.

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NEET implementation vital and will decide quality of doctors in future


NEET, the common test for MBBS admission all over nation, is perceived as most basic step  towards uniformity of medical education. It is a welcome single most important step to transform the medical education. But its effective implementation is extremely vital for it to be successful and that is possible only if government takes strong measures to implement it in a true spirit. NEET can reform medical education, weed out corruption and in turn can radically transform healthcare. This new system should allow fair play, transparency and should set an example for promotion of merit in other arenas too. But it needs to be seen how NEET is finally implemented. It will be very unfortunate if it is diluted for any reason and merit becomes another casualty in accommodating other priorities, rather than having best doctors. It  is a now or never situation for the country to pick up best brains of country for  training as prospective doctors , decided purely on basis of merit.  By diluting the merit criterion, not only do less deserving people get ahead of deserving ones, but it breaks the faith and enthusiasm of the best and deserving people in the system, thereby generating a negativism in the whole system. Failure to implement NEET effectively and strictly should be interpreted as government’s inability to control vested interests in the system.

Enthusiasm and the zeal is what we need here in medical care. With the shortage of thousands of doctors, and our infant and maternal mortality rates matching sub-Saharan countries, it is not only the number of doctors which matters. The most important factor, I think, will be quality and enthusiasm of the people who are working for the system.

Besides Infant and maternal mortality rates, innumerable diseases like tuberculosis, heart and respiratory, cancer, neurological and mental ailments, accident and trauma etc need work on war footing.  But the medical system has to be built on the touchstone of merit and enthusiasm for a greater impact. Merely creating number of doctors is not the solution. The need of the hour is more but pure meaning on pure merit. If that does not happen sufferers will be poor genuine aspiring doctors and casualty will be medical profession and ultimately health system and its users.

Let merit not be made a casualty of the system. The ball is now in government’s court and they should ensure that NEET is implemented in its true spirit, to fulfil the dream for which it was envisioned and introduced which is to bring medical care in India to its most cherished peak.

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Nurses and Doctors, Altruistic professions not cherished in present era


Children from affluent, educated families are nowadays shunning from taking up professions like nurses and doctors. These professions, which at work naturally help others, are high in moral hierarchy. And the society and people are always benefitted by these altruistic professions but sadly these professions are no longer cherished and respected nor well paid. Although we are discussing here professions like that of a doctor and nurse which are involved with life and death, but other altruistic professions are also not much treasured. These include other noble professions like that of  soldier, teacher, scientist, fire-fighter etc. This emphasises a peculiar thought process of society wherein  only professions which earn handsome money are more respected. If we analyse and  compare different professions , we’ll realise that people in these noble professions are paid far less amount of money.   What does one pay to a doctor for saving one’s life  ( few hundred rupees/dollars)  or to a soldier, who is ready to  sacrifice his life for safety of fellow countrymen. Obviously the fact that these professionals are not much respected generally , neither well paid makes them less coveted by people as  career option. This highlights the misplaced priority and hypocrisy of society in present era.

Here we are discussing about the real hands that help. I am discussing about the doctor and nurses, who are awake at odd times, give a hand, really treats and saves life in real time(not as a investor in health). I am talking about a soldier in combat situation who really is fighting in a life and death situation.

A doctor  saves life and relieves pain while doing duty. Even a junior doctor while doing  duties deals with emergencies and saves uncountable people or relieves their pain. whatever  he is paid, it is no match to the amount and quality of work that he does. There are lot of problems and risk involved to doctors which I have already discussed before in “ doctor is a soldier” and “ doctor a wonderful global community”.

A nurse while doing duty, comforts the patient and  helps in all the work doctor does. It is really a skilled and hard  job. The sole purpose of their job is to benefit the patient and alleviate his suffering. There are only a few civilized societies in the world, where nurses get their due respect. But it is painful to see the how these comfort providers are taken as guaranteed and treated shabbily most of the time. Few lucky ones get decent placements but most are forced to do an underpaid thankless job.

These professions  make a living out of their noble work but money paid to them is not commensurate to the work, responsibility, accountability, risk involved to the provider and benefit they provide to other person and society. The money a doctor receives in lieu of saving a life is less than what people spend on a single good meal in restaurant. Reason for that is these altruistic professions are not monetized in a way other professions are. But strangely these professionals do not get rightful respect also and less treasured.

It will be interesting to note how many of our prominent leaders, actors and stars, elite and affluent society people, judges encourage their children to  become actual doctors and nurses . But they are ever proactive in sloganeering and blaming doctors for all malaise.

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