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SLMA goes-conversational

The Sri Lanka Medical Association (SLMA) is launching a workshop to develop conversational skills of doctors as it has found that this is an important area of medicine, which has hitherto not been properly addressed by the profession in the medical education programme.

A workshop on this topic is to be held on March 24 in Colombo, as part of the Association's Annual Academic Sessions, informs Prof. Nandani de Silva of the SLMA. In this workshop doctors themselves are to role-play the part of patients and their relatives conversing with doctors seeking medical advice on their predicaments, and how at some occasions the over worked doctors react unkindly towards the patients.

In her communication to doctors on this workshop Prof. Ms. Nandani de Silva says: "You will probably agree that skills in communication and counselling required in day to day clinical practice, have been a relatively neglected area in medical education until recently.Have you fond yourself in the following situations? ................

To break bad news such as the diagnosis of cancer to a patient
To convey to parents that their child is seriously ill
To counsel a patient who has a sexual problem or HIV
To counsel an alcohol dependent patient
To counsel a woman who is a victim of domestic violence

To talk to relatives about the dying patient Perhaps at the time, you felt that your training had not prepared you adequately, to deal with such difficult clinical encounters?

So, if you want to learn how to communicate well and counsel your patients, here is your chance. Register now for the post-congress workshop on communication skills and counselling skills to be held during the SLMA sessions on Sunday the 24th of March, 2002.

During the workshop you will get-together with colleagues and practice these skills, in a safe learning environment. You must be prepared to take part in role-plays in small groups of four, where you will take turns to act the role of the patient/relative, the doctor or the observer.

Simulated patients may also be available for the difficult roles.

You will receive constructive feedback on your performance as a doctor, and get the chance to give feedback to others. You can be assured of a satisfying and enjoyable learning experience.

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Alcoholism and drug abuse

Dr. H. B. Jayasinghe, MBBS Ceylon, MCGP Sri Lanka, MD CH London, MBS CH UK, C.HT USA in conversation with the Health Watch.

Suffering & Misery

The suffering and untold misery caused by alcohol and other addictive agents to the patient, his family members and the society as a whole, is only too widely known in Sri Lanka. Equally known is the difficulty in treatment as such many doctors are compelled to accept a compromise solution.

Patients may be encouraged to change from addictive drinking to social drinking and to permit perhaps a sherry instead of spirits. It must be emphasized, that although a social drinker can gradually get transformed into an addictive drinker, the reverse is not true.

An alcoholic can never become a social drinker. He will continue to be an addictive, unless and until he refrains completely and totally from alcohol consumption.

Chronic alcoholism is a symptom of a deep-seated personality disorder with hostility, insecurity, increased sensitivity, feelings of inadequacy and a low frustration tolerance.

Main Addiction Features

1. The psychological dependency, with an emotional craving for the addictive.

2. The physical dependency, with withdrawal symptoms as the effect of the addictive agent wears off.

A full medical, psychiatric and psychosocial assessment must be made prior to treatment.

In all cases of addiction, whatever the addictive agent may be, the following measures may have to be adopted.

1. Removal of the patient from the addictive environment and admission to a medical institution.

2. Adequate treatment of the physical condition with special emphasis on withdrawal symptoms and drug replacement.

3. Treatment of the psychological condition.

4. Mobilization of the services of health workers, social workers etc.

Whether sincerely motivated

It is an essential prerequisite to know whether the patient is sincerely motivated to overcome the problem of addiction. If the patient is not well motivated and the attendance is merely to satisfy the spouse or parents, then the likelihood of recovery is remote.

The patient's unconscious desire can be established by employing the Ideo Motor Response (IMR) under hypnotic trance. IMR is the involuntary capacity of muscles, and the nervous system to respond to thoughts, feelings, emotions and ideas. It is employed as a way of speaking to the unconscious mind of the patient and getting the patient to answer non-verbally.

Aversion Therapy

Aversion Therapy consists of administering an aversive stimulus to inhibit an unwanted (emotional) response, thereby diminishing the habit strength and is very effective in the treatment of addictions.

The aversion should be linked to the prodromal stimulus which initiates the unwanted behaviour and not to the behaviour itself.

1. A full case history should be taken, with special attention to the stimulus prior to the behavioral response. eg. Noticing a group of friends consuming liquor in a pub.

2. The hypnotist should clearly identify the most aversive, most repulsive, most disgusting, and most nauseating stimulus the patient has ever experienced, including a detailed account of his physical responses to that aversive stimulus.

3. Induce as deep a trance as possible.

4. Install IMR 'YES' finger.

5. Install Aversion Script.

'..... and as you drift ever deeper into the trance ... and your mind becomes so much more focused on your own inner experiences ...

I would like to you become aware of your problem behaviour ... and the situation in which you experience that response ... and when your unconscious mind is fully aware of that problem behaviour, it can indicate that to me by lifting the 'YES' finger.

...and NOWwww... I would like you to allow your mind to drift backwards in time to just before you started that problem behaviour... so that you can become fully aware of whatever thought... feeling... situation... appeared to triggered that inappropriate behaviour... and when your unconscious mind is fully aware of that thought, feeling or behaviour, (the hypnotist should direct the patient to make as clear an image as possible)

...it can indicate that to me by lifting the 'YES' finger. I would like you to put that thought... somewhere in the back of your mind so that you can recall it in a few moments time.

...and NOWwww... I would like you to begin to form a new image of the... (Aversive stimulus as ascertained from the case history)... And I would like you to make that experience so clear in your mind...

The hypnotist should direct the subject to make as clear an image as possible, including colour, texture, smell and any other senses that are appropriate... and no matter how unpleasant that experience may seem all of the while you think of it... that experience grows clearer and stronger... and as that experience grows clearer and stronger and more vivid... so your feelings of disgust... dislike of that noxious experience fill your mind and your body... becoming so strong and clear... you may even feel a little nauseous in your stomach... which will continue to become stronger... and stronger... as you think about that situation (aversive stimulus as ascertained from the case history)... and when you can experience those nauseating sensations clearly and fully your unconscious mind can indicate that to me by lifting the YES finger... well before you actually need to vomit.

Synthesis of stimulus and aversion (create as clear imagery as possible)

And NOWwww... I would like your unconscious mind to bring back that specific image of whatever triggered off that unwanted behaviour (specify accordingly)... and the moment that situation is clear in your mind... Instantly and immediately... I would like you to simultaneously... begin to experience that... repulsive... disgusting... nauseating (hypnotist should describe the aversive stimulus in great detail involving as many senses as possible)... and experiencing all of those nauseating... repellent... disgusting images, sensations and feelings spreading into that situation... and as you... continue to experience that situation or thought that triggered your unwanted behaviour... so those... disgusting... nauseating... sickening feelings... smells etc. grow stronger and stronger, clearer and clearer... spreading throughout your mind and body... and when you can experience those sensations and images clearly and fully in that situation... your unconscious mind can indicate that to me by lifting the YES finger... well before you actually need to vomit. Repeat synthesis of stimulus and aversion at least three times or until the subject automatically experiences the aversive stimulus and response when thinking of the unwanted behaviour stimulus.

And as a result of this treatment... from this moment on... if ever you think of that situation... or thought... or are actually in that situation... that in the past... triggered that unwanted behaviour... no matter where you are... how you are feeling... or who you are with... instantly and immediately you will fully experience that... (Hypnotist should describe the aversive stimulus)... which will grow stronger and stronger... more and more repulsive... more and more disgusting... more and more nauseating... so there will be absolutely no way you would be able to carry out that unwanted behaviour from the past... in fact... as a result of this treatment you may even decide to make a deliberate effort to avoid situations that might trigger that disgusting sickening response.

Awaken the subject with ego strengthening suggestions

Wolberg successfully employed symptom substitution in treating alcoholism. Eg. "Every time you crave a drink, you will reach for a glass of water and this will give you a sense of pleasure and relaxation."

Another effective method is to open a bottle of alcohol while the patient is hypnotised and to assure him that the bottle has not been tampered with or opened. He is offered a drink, and requested to hold it in his mouth for several minutes to get the full taste. Naturally, a burning sensation on his tongue is created.

After the patient has finally swallowed the drink, he is asked how he liked it. His usual reply is, "It tasted fine", whereupon the hypnotist informs the subject, "You have not been given alcohol but a mixture of lemon juice and salt". Under hypnosis, the patient will exhibit marked revulsion and disgust.

Before concluding the hypnotic session, the patient should be given a posthypnotic suggestion that any time he is offered a drink, these reactions will certainly occur. Even the thought or the smell of a drink will induce profound distaste.

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People's health rights

In another anniversary event doctors will hear of 'health rights of people' from Ms. Sunila Abeysekera.

This will be at the SLMA pre-congress symposium on Human Rights and The Sri Lanka Doctor, to be held on March 20th at Hotel Lanka Oberoi, Colombo. The panelists at the symposium include -

Judge C. G. Weeramanthry on Modern Technology Human Rights & Medical EducationProf. Carlo Fonseka on - A Socio-Biological Approach to Human Rights.

Prof. Chandrasiri Niriella on - Trials and Tribulations - The Medico Legal perspective.

Apart from the penalists the following are also expected to speak at the symposium - Dr. Rohan Edirisinghe, Dr. Nalin Suwaris, Dr. Ronald Higgins, Dr. Chris Nonis and Dr. Kamalini Silva.The SLMA Secretary Dr. Anura Weerasinghe lists the objectives of the symposium as creating awareness in the profession on

(1) Human rights in the profession

(2) Role of doctors in the human rights situation in the country

(3) Need for greater input on human rights in medical education.

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Question box

Dr. D. P. Atukorala answers patient from Kandy

64-years-old female patient from Kandy with mild hypertension and hyperlipidaemia (serum cholesterol 204mg%, serum triglyceride 184mg%, HDL 39mg% and LDL 128mg%) wishes to know about:

(1) food items that will increase her HDL cholesterol (good cholesterol)

(2) food items that will help her to decrease her LDL cholesterol (bad cholesterol) and

(3) as to whether it is safe for her to take exercises in the presence of mild hypertension which is under control

Answer

It is perfectly advisable and safe for you to take exercises such as brisk walking, swimming or cycling for about 45 minutes per day for at least five days of the week. Moderate exercises have been proved beneficial for hypertensive patients and exercises increase the level of HDL cholesterol (good cholesterol) and decreases the level of LDL cholesterol level (bad cholesterol).

Food items such as olive oil, cashew nuts and avocado which are rich in mono-unsaturated fats help to increase the level of HDL cholesterol and decrease the level of LDL cholesterol.

Oils containing polyunsaturated fats such as corn oil, soya oil, sunflower oil and gingerly oil when consumed in moderation results in decreasing the level of LDL cholesterol but excessive consumption of polyunsaturated fats has been shown to decrease the level of HDL cholesterol (good cholesterol).

It is not advisable for you to consume the so-called polyunsaturated margarines as the transfats contained in these margarines reduce the level of LDL cholesterol. Consumption of coconut oil and coconut kernel does not increase your LDL as coconut oil contains medium chain fatty acids.

You should avoid consumption of red meat and animal fats including butter, ghee and cheese as these increase your LDL cholesterol.

If you have been smoking, complete cessation of smoking results in elevating your HDL cholesterol. Fortunately majority of Sri Lankan ladies do not smoke.

Vegetarian diet has been shown to decrease the level of LDL cholesterol in view of the polyunsaturated fats and soluble fibre present in the vegetarian diet.

Lastly H.R.T. (Hormone replacement therapy) has been shown to increase the level of HDL and decrease the level of LDL cholesterol in some of the studies.

I.B.S. condition

Health Watch has received the letter sent by Mr. M. J. M. Fernando of Pannipitiya on I.B.S. condition. It will be replied next week. - Health Watch.

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Two year internship

Senior Family Physician, and PGIM visiting lecturer in Family Medicine Dr. Dennis J. Aloysius has called for the introduction of a 'two year' internship for medical graduates.

Writing in the last months issue of the IMPA journal Dr. Aloysius says: "If the present one year internship is increased to two years several important components can be introduced into the doctors training system.

This proposal has been discussed for the past several years, and I am sure when there is sufficient residential accommodation for the interns, it could be done.

Let us now look into the more general issues relating to medical education. Medicine is a healing profession. Healing begins with caring. Medical education should prepare and train the future doctor to play the caring role, sincerely and competently. A criticism has been made that medical education seems to erode the students sensitivity to a patient as a person and that unfortunately this seems to bring into the profession a large number of uncaring technocrats.

Paracelsus once said, "the most fundamental principle in medicine is love". I have been practising medicine over 44 years and I have had well over one million consultations during this period. I have come to realize that the most important thing that doctors can confidently offer those who seek their care, is a kind word and sharing with them and their loved ones, concern for what ails them. Does medical education as it is currently structured result in the production of a compassionate and caring doctor. There are several who think that it does not.

Let us briefly review the process of medical education. Most adolescents plan a career in medicine from the age 14 or even earlier. For then, from then onwards, their time for relaxation, reflection, reading, hobbies, sports, enjoying the arts, learning from the world around them and meeting people from all walks of life would be severely curtailed.

Should we not have an entry examination for medical school that does not demand so much time consuming accumulation of factual knowledge? Should not extra curricular activity also earn points for evaluating suitability for entry into medical school?

After entry, the medical student undergoes 5 years of intensive, exhausting and mind numbing training, followed sometimes by a long and strenuous period of post graduate training. These persons would surely tend to have very little interest outside the field of medicine.

They may surely ask themselves as Eliot did:

"Where is the life we have lost in living?

Where is the wisdom we have lost in knowledge?

Where is the knowledge we have lost in information?"

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Centenarian gets a wheelchair, Centenarian study team appreciates

Our centenarian study team headed by Prof. Colvin Goonaratna greatly appreciates the special consideration given by the Nawaloka Hospital Management (Deputy Chairman, Jayantha Dharmadasa, Medical Director Prof. Lal. Chandrasena and D. Chandima de Mel and Mr. P. Vithanage, Hospitals Marketing Manager in attending to Centenarian M. P. Mary Nona (102 +) from Kelaniya, in our study list.

Air Hostess offer wheel chair to centenarian

In response to the appeal we made in this page last week for the offer of a wheelchair to the above centenarian. We had three offers from social conscious readers in Ambalangoda, Matara and Kelaniya.

While we wish to thank all of them for the ready response, we have decided to accept the offer from Kelaniya - Mrs. P. Zepplin, 416/95, Old Kandy Road, as the centenarian concerned is also a resident in that area. We thank Mrs. Zepplin and her daughter Air Lanka Air hostess Miss Evangeline for the offer.

Dr. Dennis J. Aloysius of the Centenarian Study Team with a few team members will call on Mrs. Zepplin on Sunday to takeover the chair and hand it over to the centenarian.

New causes for new diseases
By Prof. John M. Last
We invite you to send your health problems on the above to:
Health Watch Coordinator

Edward Arambewala
Daily News
Lake House
Colombo 10
Fax: 429210
Email: [email protected]

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