Do you know how many Indian medical doctors who use the Internet blog? well, no one does. Neither do we know how many of us are students, how many are on twitter and how many talk about work online. We most definitely do not know if any of us follow professional guides to using social media written specifically for doctors. I want to find out, and I think irrespective of your profession, you would want to know more about your friendly neighbourhood doctor on the net. Without being creepy, of course.

This is a survey of Indian Medical folk on the web. By Indian I mean practising in India, and by Medical folk I mean allopathic doctors(medical students too). The reason for this “Discrimination” is convenience and because I can.

If you are a medical doctor, please take the survey, if you know one, mail her a link. Thank you very much.

If you are not a doctor, don’t take it, there are trick medical questions and I will know.

Here you go. Click here for the great Indian medical doctors on the web survey.

Feel free to re post this link on your site, or embed it. For convenience and tracking you can use this URL to email people: http://bit.ly/indsurvey

The survey will run for 14 days starting Monday September 12th. Email me with suggestions and feedback at Uberschizo at gmail

PS: There are no trick medical questions.

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Ten years inside hospitals gives you a great instinct to pick out criminals. Oh yes, there are a lot of them in the hospitals. Here are the greatest offenders and how to deal with them.

The Poor:

They can’t afford the services, yet they come. They never do what we ask them to, want multivitamins and “saline” and never come when we ask them to. They are dirty, and don’t pay even if they can afford it. Definitely deserve the long waiting times and getting sidelined for “paying” patients.

The old:

Slow, stubborn and forgetful, they can never come to the point. If they have bellyache, they start with the time they stubbed their toe back in 67 and the time they met a white doctor who gave them a red liquid for the belly ache. Definitely deserve the patronizing behaviour that we have perfected; don’t pay attention, just nod, agree and give them something for symptomatic relief. Talk loudly, most of them are deaf.

The very rich:

Scum of the earth, just the worst people in India. They walk around like they own the hospital and treat us like we are beggars. Clearly they deserve to be robbed. Such sense of entitlement, such low respect for the profession. Keep changing doctors, want results yesterday, stingy. Definitely deserve the over charging and the excessive tests, they ask for it.

Women:

90% of their problems are psycho somatic and they create such a fuss about the rest 10%. If you are a guy, they wont let you touch them, if you don’t, and get the diagnosis wrong, they curse you. In the labor room they wont push when they need to and scream like a banshee, as if it’s an elephant coming out. Never open their mouths if their husbands hit them, so we can’t do anything. Definitely deserve being given antidepressants for the vague symptoms and the slaps on the labor table.

Villager:

You can smell them from a mile away. Sure they work in the fields and have animals, but can’t they buy soap? or at least some chap perfume? many of them are rich but pretend to be poor, they don’t change their clothes and treat the women so bad. if you are a girl then you’ve had it, your old man wont spend a penny on you. Depending on the case, definitely educate them about taking bath and sending their girls to school.

Prostitutes and homosexuals:

Why can’t they just say it? how many times will I have to “guess” their tendencies and do the right test?  I mean I am a professional, trained to deal with them in a professional way, then why can’t they just open up? They hem and haw and beat around the bush and never tell you what’s really going on. As if they can fool anyone. Anyway, poor women, forced to live like this, sometimes I feel sad, but I have to do my job and I can’t care for emotions. For them always do STD panel, even if they complain of head ache, they actually mean something else, so no point in asking if you should do it, they will just say no.

Image by JohnMcNab

Surely, I am joking. Right? How can an educated, cultured professional hold such beliefs. These show the beliefs of a micro minority, right? No lessons to be learned here, just how some people can’t be cured by education. Correct?

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Dear fellow professional:

Did someone ever teach you how to ask someone their sexual history?

Did you get any systematic training  in handling sensitive issues?

Do you know if you sound judgemental while posing a question to a patient?

Do you know there are professional and standard methods in approaching sensitive issues?

Can you put a patient at ease when talking about their substance abuse issues?

Do you ask more than is relevant to the medical situation?

Do you explain to your patient why you need to ask such personal questions?

Do you say “you should not smoke”, after asking if she smokes?

I am a doctor, sometimes, that is my shame.

I studied at one of the best centres for medical education in India.

Yet

For every 100 lecture on what to ask, there was maybe, one lecture on how to ask.

“Get the patient’s sexual history”, I was instructed

The patient was a 20 something woman. I was a 20 something guy. Her mother was with her. There were 15 patients waiting. It was a disaster.

10 years in the medical system, multiple postings in gynaecology, yet not one workshop on “how to ask the awkward questions?”

It was assumed that I would know, or learn. That the patient would understand that I had to ask these questions. That it was the patient’s “duty” to answer.

“Do you smoke?” Can mean many things, do you know that?

Tell me, I am eager to know.

Inspired by a recent conversation on twitter

Featured Image by  jakebouma

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Rose George is a British journalist [wikipedia] and author whose book “The big nessecity [amazon]” addressed the issue of lack of sanitation as one of the greatest killers of the modern world.

This is her on Shit and India.

How/when did you get interested in sanitation?
It was a long story. I used to work at a magazine called COLORS, owned by but left alone by Benetton. The editor was Oliviero Toscani, famed for the scandalous Benetton ads. One day he decided to do a coffee-table picture book about shit called CACAS. I researched some of the very short texts that accompanied the pics and thought them fascinating. I was astonished that I could consider myself well-educated and not know, for example, that a quarter of the world’s population has no toilet. But I also learned that the topic of sanitation could be entertaining, and that urine can change the colour of your wallpaper, and that sewage in the streets probably led to the invention of high heels, and that kings used to defecate in public and eat in private. It is a rich, wide, deep and endlessly fascinating topic.

After the book, how do you keep being involved in the sanitation world-if you do
Yes, I do. I keep a blog about mostly sanitation matters at www.rosegeorge.com and still write op-eds here and there about sanitation.

I also do a lot of lectures about sanitation. In the last month, I gave a keynote speech to 2500 freshmen at the University of Pennsylvania, who had been assigned my book as part of the Penn Reading Project; then flew to Stockholm to hand out awards to journalists writing about sanitation and water; then to Hong Kong to talk at a conference of 1500 investors, to persuade them that shit is a scandalously underexploited resource, both as fertilizer and as energy.

What are, if there are, your most memorable experiences in India?

You don’t forget three days in a slum in a hurry. I originally intended to stay overnight in a slum but chickened out. I wouldn’t have been worried about the accommodation; all the houses I visited were pristine. But as soon as you step foot outside you are overwhelmed by filth. And of course, there are hardly any toilets. On the other hand, I met some fabulous people in India who I think of as sanitation footsoldiers. Milon Nag, who runs a plastics factory outside Pune and who has developed a low-cost plastic sanitation slab that is now regularly used in emergencies; Dr. Mapuskar, a doctor near Pune who arrived in his village – now a town – to find no toilets and became a sanitation evangelist, persuading 100% of people to install toilets and even human shit biogas digesters (a miracle in India); or the wonderful staff of Gram Vikas in Orissa, who are attempting to get villages to install 100% Total Sanitation. In one village they went to, it took 162 meetings for people to agree but they did and now disease has been dramatically diminished and the village school teacher told me 80% more girl children go to school. People think a toilet is a symptom of development but actually it can trigger it.
What are 3 easy-to-solve problems that governments and other agencies should tackle immediately?
1. Stop focusing on clean water at the expense of sanitation. There is no point installing one without the other.
2. Switch mindsets: Expensive wastewater utility systems are not always the solution. There is innovation in sanitation: use it.
3. Stop thinking that development has to cost a fortune. Invest in software like human behaviour change-makers. Persuasion doesn’t cost much but it can reap so much.

What are 2 of the knottier issues?
There is only one knotty issue: Diarrhoea. It is astonishing in 2010 that children die of something that is easily curable, and that they die at the rate of one every fifteen seconds. Astonishing and disgraceful.

How can the behavioural change be brought about rapidly- it happened within a generation in most of the world- why are some parts lagging behind so much?
Because often the investment goes to hardware and not to the software. Humans are complicated creatures. They can be persuaded but it takes marketing psychology. People have to want to use a toilet, and that is not always a straightforward thing to bring about, to someone who has been shitting in the bush quite happily for generations. There has to be investment in persuasion.

Some practical technological solutions?
Far too many to list. Practical Action does good fact-sheets on sanitation solutions. Akvopedia has a great database of technology.

We dont like talking about shit, its considered boorish and uncouth. But of all times now, we need to start talking about shit seriously. The sanitation challenge india faces is not going away anytime now, and is getting worse in some places like big cities.

I will be talking about shit in 1 or 2 more follow-up posts at the end of which I hope to have converted you into a fellow foot soldier for shit. In the mean time, do look through the Akovopedia portal on sanitaion for some great technologies that can radically reduce cost and improve outcome in implementing sanitation. Viva la revolution!

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The last date for submission of Application forms is 15th December, 2010.

For Application form and other details please visit www.cehat.org /

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• Science digest: Bronze age surgeons and psychedelic psychiatry
• Healthcare Innovation: How can Governments be an Engine?
• Nurses and Social Enterprise
• Partnership Celebration between CBCNEI and 4B Healthcare- Guwahati

The question of whether a hospital can be self sustaining, high quality, affordable, and poor centric all at once is a knotty one.

Will using a For-profit model cause the company to drift into a money hungry monster most of the present day corporate hospital chains are?

Is the philosophy transferable on to a realistic business plan?

Can the business plan actually work?

will creating such a hospital system actually help the poor in a long term, meaningful way?

Obviously, I dont have all the answers, and while I believe in the idea fiercely and the people behind it are personal heroes, some things only time can tell. Oh, dont worry, the business plan exisits, a good one that too, and so far, it seems to be working quiet well.

for now, to make better sense of what i have been saying, perhaps you should head over to the site to get a picture of the philosophy and workings of 4B healthcare

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I was shocked the first time I heard my then boss asking a PG if the patient was “salvageable”. Comparing sick people to shipwrecks didn’t seem respectful or right but before long I found myself asking the same question when dealing with a sick patient, particularity one who was very sick and needed expensive and intensive care.

If the patient was not “salvageable” and there was a “salvageable” patient waiting for that bed, then by unsaid rules, less time, effort and money would be spent on him/her, particularly if the patients relatives could not afford the treatment.

The truth about the god-like (read: Inhuman) choices that doctors working in resource-limited circumstances is rarely spoken about outside medical ethics seminars. On the rare occasion a news paper, a novel or even a sit-com decides to take up the topic, it receives nothing more than a few over the shoulder cliché’s about how real life is different from the books.

Chances are, no senior doc will sit a house surgeon down and explain tenderly that while all human life is sacred and deserves equal effort in saving, the ground realities force us to give preference to the young, the “salvageable” over the old or “un-salvageable” patients. That this does not make the old, terminally ill patient any less important or deserving of ones time and effort.

Yet day after day, thousands of “cases” are categorized and differentially treated. It is foolish to think that our actions do not affect us, the rare some learn to love humanity and do their best to bridge this unfair and gap while others learn to value life in terms of productivity and “salvagability” and are forever condemned to be less than human, for that is what you turn into, if you cannot see sanctity of life.

Someday, I hope there is reckoning and justice for the young lives scarred by the inhuman task they were given though we are not mere victims of our circumstances.

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Making the test compulsory raises hopes as well as questions. On the positive side is the fact that if the HIV status of the mother is known, the delivery can be made safer for the mother, the child and the health worker. Up to 40% mothers with HIV transmit the disease to their children without being aware of having HIV. A child has a 25-45% risk of contracting HIV during delivery from its mother, which can be brought down to under 2% if adequate precautions are taken and the mother is treated.

The most important question it raises is that of a woman’s right to autonomy. This is closely linked to the fact that in spite of the male partner being the source of HIV in majority of the cases, women are the ones who have to bear the brunt of the social stigma and abuse. Even though as per guidelines, the person getting tested for HIV has absolute rights about who gets to know about the result, in practice this rarely happens. Privacy and autonomy are alien to our culture, as a result of which chances are that if you are diagnosed with HIV in a typical Indian hospital, everyone from the ward-boy to the sweeper knows the results. There is no doubt that making this test compulsory breeches the fundamental dignity of women, and makes them vulnerable to the anger of their families.

It must be kept in mind that in many states in the south, all pregnancies followed up in government hospitals are already screened for HIV and Hepatitis B under the RCH scheme. But there is a big lacuna in this scheme and that is the home deliveries. Depending on the state and region of the state anywhere from 25-50 percent of children are born in homes, with no access to a doctor. The PFA has suggested that leaders at village level be involved in ensuring they are screened. This might be a good way of reaching health care to the most interior places, but it is obvious that this is going to expose women even more to hostile forces. Unless the forum comes up with a unique way of ensuring privacy while maximizing health care cover, such a drastic move is going to adversely affect lakhs of women.

While the intentions of the PFA are good, and their science is accurate, they fall short in keeping the ground realities in mind. One of the ways they can do better is by involving grass-route level organizations that work in the HIV/AIDS field. Also, there needs to be public debate about medical issues in the country. It is sad that the media and other sources are mostly silent, and even when this is a decision that will affect millions of our countrymen, there is a pitiable lack of public interest.

In the end the decisive question is whether protecting the unborn from a preventable disease outweighs the risk of ostracism and the moral duty of respecting women’s autonomy.

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