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A leading Family physician views :
Consultation practice - almost a mockery

A leading family physician in the country who also headed the Sri Lanka Medical Association, the OPA, the Sri Lanka College of paediatrics, the College of General Practitioners and presently a visiting lecturer in the Postgraduate Institute of Medicine - Dr. Dennis J. Aloysius last week observed that consultation practice as it is being done today has lost its real meaning and value and become almost a mockery in our health care system.

He was delivering the Dr. M.P.M. Cooray Memorial oration for this year, on the topic - a doctor's dilemma on difficult role of a doctor, at a meeting of the Catholic Doctors guild held at the SLMA auditorium in Colombo.

Consultation is central to medical practice. Consultation is central to the practice of medicine and is the bedrock of curative as well as preventive medicine.

Sir James Spence has best described the consultation as "The real work of a doctor is not an affair of the health centres or public clinics or operating theatres or laboratories or hospital beds. Techniques have their place in medicine but they are not medicine.

The essential unit of medical practice is the occasion when in the intimacy of the consultation room or a sick room, a person who is ill or believes himself to be ill, seeks the advice of a doctor whom he trusts. This is a consultation and all else in the practice of medicine, derives from it".

Patients complain - doctors are in a hurry

In a proper consultation the doctor should talk to the patients and more importantly listen to them. The patients often complain that the doctor is in a hurry and this is often true.

The mockery

Unfortunately due to constraints on time and perhaps incorrect training and bad example, some in medical profession make a mockery of this sacred event in their daily practice. This often happens in the Out Patients Departments where there is often a shocking 2-minute consultation. It also happens in some private practice consultations where some medical professionals deal with 20 to 30 patients in an hour. Even worse some of them conduct two to three simultaneous consultations in the same room.

The clinical process of consultations is comprised the following steps:

* Taking a history
* Examing a patient
* Selecting the investigations
* Making a plan of management/diagnosis
* Stating the prognosis
* Treatment
* Follow-up

There are numerous problems faced in a consultation. There are several questions that arise. These include -

"Should I listen or interrupt?
Do I examine? Do I investigate?
Do I prescribe?
Should I refer?
Should I admit?"

The complaints made against doctors about consultations include

* Doctors do not talk to their patients or even listen to them

* Doctors seem uncomfortable, uneasy and even irritable when patients ask questions about the nature of the disease, the prognosis, the rationale for certain items of treatment

* Doctors appear to be reluctant to obtain a second opinion or to refer their patients

* Doctors keep patients waiting long hours and show lack of concern for other peoples time

* Doctors do not keep appointments

Doctors consultation fees are high and unaffordable

Doctors seem to forget that the word 'patient' is from "Patior"

"I am suffering"
The word "patient" has several meanings such as
"Long suffering"
"Forbearing"

"Enduring evil with composure"

"Possessing patience"

But this does not give the person consulted to focus on the other meanings and do a poor quality job.Even though the persons who consult are suffering, they often do it silently and patiently. Doctors by their attitude and conduct often confirm what William Osler said.

"Half of us are blind
Few of us feel and
We are all deaf"

Doctors must recognise that it is the patients who grant the medical privileges we continue to enjoy no matter how difficult it is they should manage their time effectively.

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What determines consultation length?

Patients are satisfied with the care they receive from general practice, but often say that consultations are too short. A study in this week's BMJ finds that characteristics of patients have as much effect on consultation length as the characteristics of the doctor and the doctor's country. Researchers selected 190 general practitioners from six European countries with different healthcare systems. They videotaped and analysed consultations with 3,674 patients.

The average length of consultation was 10.7 minutes. Belgium and Switzerland had the longest consultation times, Germany and Spain had the shortest consultation times, and consultation times for the Netherlands and the United Kingdom were in between. Consultations in city practices lasted 1.5 minutes longer than those in rural practices, those with women patients lasted about 1 minute longer than those with men, and those about at least one new problem lasted 51 seconds longer than those about known problems. Consultations were also longer when the doctor or patient felt that psychological problems were important.

As the patient's age increased by one year, the consultation time increased by 1.2 seconds, while the consultation time decreased as the doctor's workload increased. The doctor's sex or age and patient's level of education were not related to the length of consultation.

Based on these findings, women consulting general practitioners in urban practices about problems perceived as psychosocial by doctor and patient have longer consultations than other patients, conclude the authors.

: Picked for the Health Watch from BMJ news by Dr. Dennis J. Aloysius in our Medical Advisory Panel.

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Stressed out? Just forget about it

Ignoring trauma may be healthier than pouring out your heart about it, Israeli researchers reported on Tuesday.

Report after report has detailed the post-traumatic stress suffered by the U.S. population after the Sept. 11 attacks on New York and Washington, but a study published in the journal Psychosomatic Medicine suggests it may be better to suppress those feelings.

"The findings of this study suggest that a repressive coping style may promote adjustment to traumatic stress, both in the short and longer term," Karni Ginzburg of the Bob Shapell School of Social Work at Tel Aviv University in Israel, who led the study, said in a statement.

Ginzburg and colleagues studied 116 patients who were hospitalized for a heart attack and suffering from anxiety over their near-miss with death. They compared them to 72 people who had not suffered heart attacks.

"The damage to the heart, with its symbolic meaning as the essence of the human being, may shatter the patient's sense of wholeness and safety," Ginzburg said.

The patients took standardized tests for acute stress disorder, which check for symptoms such as distress, trauma flashbacks, difficulty carrying out everyday tasks, insomnia, and poor concentration.

This syndrome is called post-traumatic stress disorder if the symptoms last or occur more than a month later, and the patients were re-tested after seven months.

They were also asked questions about coping style - whether they ignored their anxiety or tended to dwell on it.

People who tended to repress their anxiety had the lowest levels of PTSD, the researchers reported.

Many people have done studies on how to cope with stress, and results are mixed. But Ginzburg and colleagues cited studies that suggest that if the patient does not go too far into denial, repression may work well.

"Prior studies report that repressors tend to perceive themselves as competent, self-controlled and having adequate coping skills," Ginzburg said.

(Reuters)

It is all about food : 
Should we over follow our health teachers

A lawyer from Dehiwela has sent this cutting from the July 2002 issue of BASL news for use

Unlike our counterparts in most other countries who are used to ready-made food without sticking to rigid, specific times like breakfast, lunch and dinner-for us Sri Lankans, preparation of food plays a great role in our lives.

Most Sri Lankans believe in what is written in western medical books regarding food. For example, such books advice diabetics to eat less, do more work and take medication too! They are told to eat more leaves like a cow and eat lots of fruit, which only fill the stomach but do not give energy.

A port worker is advised to eat only one saucer full of rice, a lot of vegetables and fruits and take anti diabetic pills. If they adhere to this regimen, they can fall dead due to lack of energy in our terribly warm country. I know of a person who is a diabetic and listened to the doctor's advice very loyally. He ate half a papaw in the morning, drank a cup of plain tea at 10'O clock without sugar, and had two slices of bread and an apple for lunch, tea in the evening and a little rice for dinner with vegetables. He was very happy about his regimen since he did not consume any sugar or cholesterol and expected to live 100 years.

One day, when this man did some strenuous work he developed a generalised fit. When he was taken to the doctor his condition was misdiagnosed as epilepsy and treated as such. The treatment gave rise to disastrous results. The real cause was only hypoglycaemia which was entirely due to him following this absurd regimen that is suitable only for a vegetable.

Energy is an absolute requirement for life, and it is related to the type of life that you got to lead. Everybody must remember that functioning of the organs of the body, even if you are seated all the time, requires energy. Fruits and vegetables alone are not enough.

The next myth in our country is about Cholesterol. We doctors have given so much publicity to this word that people run a mile away when they see food with fat - cholesterol. Some people do not give food even to their children. Fat - cholesterol is an essential item to our body for the functioning of the brain and nerves, and for the maintenance of all the organs".

We should note how the westerners eat - the very people who preach us not to eat items containing fat. We are told to eat green leaves, which our people follow to the atom, and thus think that even eating Jak leaves is nourishing. We are told to eat unrefined items like Red rice, Kurakkan, Juggary etc. We do not understand how the impurities in them can cause severe reactions. Our body systems are not like that of animals that can digest and tolerate any food item.

In most other countries they analyse the food items and avoid the items that have injurious constituents, however palatable and nourishing they appear to be. They don't eat Mukunuwanna, Gotukola, Sprats, Karawala and all kinds of Alawarga.

Our teachers of health only stress on whatever beneficial items that are present in the food, but do not teach or understand the bad effects of other inclusions in the items. For example, dried fish and half digested, partly decomposed protein are good only for animals. Sprats and other small fish have very bad items that produce severe reactions in humans. We think of only the calcium in them and eat belly full till we fall sick. But never relate the illness to the food item. Pumpkin has atropine which can give rise to severe bad effects. But we are told that it is a very nourishing food item. Maldive fish is the same, which is decomposed tuna. Westerners never eat this stuff.

The Sri Lankan hypochondriacs never touch an egg, do not eat butter or eggs and do not drink milk ever in their tea. The above are first class nutrients with adequate vitamins, minerals and proteins. The lack of these cause eye problems - which are very common now, brain degeneration, bone thinning and diseases. Diabetics are of the opinion that potatoes are very bad because it contains a little starch and therefore, shun it like the plague. But potatoes are full of nourishment and contain iron.

The teaching is that, all fat people develop high blood pressure, diabetes, heart conditions and die early. Please remember that I am not talking about the hefty, greedy, sluggish, alcoholic humans who develop various ailments and die early. I am talking about normal human beings who have a certain amount of fat deposited in the required places. Such people are pleasant to look at, contented, have enough energy to manage their day to day matters and live a normal life span. Those people who run away from fat and normal nutrients are a sore to the eyes and have all kinds of illnesses, and lie on various tablets prescribed by our teachers of health.

With regard to meat of course, I have my reservations. Though it is considered to be full of nourishment, I think meat is only an animal food unsuitable for the human digestive system, unless he or she has an animal mentality.

What I am trying to explain is that we should not over follow the teachings of our health teachers and misunderstanding the real meaning in such statements. We must always follow the middle path even regarding food. There was a time when our Passion fruit juice was exported to a western country. After some time they stopped importing this item because their analysis of the juice revealed that it has something that causes irritation of the human body. However, our experience is that this is a natural product and encourages everybody to drink it and even eat the leaves in the form of a 'mallum'.

Anyway, you are the best judge of what is suitable and not suitable regarding food items. Do not ever consume items that cause bad effects even if your teacher recommends it. Avoid over indulgence. Do not think longevity is given by eating the so called cholesterol free diet. As in the case in other things in life, an intelligent human being should always resort to self assessment regarding his food to live a healthy life.

Dr. (Mrs) C. R. Weeratunge, 
Doctor-on-Duty, BASL Medical Centre

A letter from Vavuniya

Since we started this medical page two years ago, and following the cessation of hostilities by the LTTE with the signing of the MoU with the Government nine months ago last week we received a letter to the Health Watch from R.M. Kunaratnam, a resident in Vavuniya seeking advice from Dr. D.P. Atukorale, Consultant Cardiologist in the Health Watch Medical Advisory Panel for a heart condition he is affected with.

Health Watch Medical Advisory Panel and the 'Daily News are pleased to receive this letter coming from Vavuniya - No. 245, Iyanar Kovil Road, Thirunavatkulam, Vavuniya, as it indicates that the 'Daily News' is now reaching these areas and are being read by the public there, clearly reflecting the very positive results emanating from the peace process now under way.

While thanking you for writing to us we wish to inform you that Dr. Atukorale will directly write to you on the advice you sought, for your condition.

You are certainly welcome to meet Dr. Atukorale at his clinic on a week day. He will be writing to you all about it.

- Health Watch

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Dr. D.P. Atukorale joins debate on chelation therapy
Is chelation therapy legal?

Absolutely. There is no legal prohibition against a licensed physician (M.D or D.O) using chelation therapy in USA for whatever condition he deems it to be correct. FDA has approved marketing, labelling and advertising of EDTA.

On the question of legality, it is now possible for a physician with holding information about availability of other treatment choices such as chelation therapy prior to performing vascular surgery such as by-pass surgery to be found legally liable. With holding information about a different form of recognised treatment may be tantamount to medical mal practice, if as a result a patient is deprived of possible benefits.

I am very grateful to the "concerned knowledgeable physician" for his article on chelation therapy in the media last week as it has created a number of misconceptions in the minds of the reading public regarding the value of chelation therapy (C.T) it is my duty to correct some of the inaccurate statements made by him probably in reply to my article in the Health Watch earlier.

He has quoted a research article written by Olzewer et al to prove that C.T. is not useful, but has missed the most important research paper written by above authors namely a retrospective study of 2870 patients where Olzewer et al have found that there is "marked" or "good" improvement in 94% of patients with ischaemic heart disease and in 98% of patients with peripheral vascular disease and intermittent claudication following chelation therapy. (J. Ad. Med. 1987:2,197-211).

He says that numerous chelation clinics have sprung up in Europe and USA. It is surprising that this knowledgeable physician appears to be ignorant of the large number of C.T. clinics in Australia, Canada, New Zealand and Asia including Sri Lanka. Does he know that over 400 patients have been successfully treated in Colombo C.T. clinic alone; without any untoward side effects.

Does he know that "physicians in USA have been chelating with EDTA for almost five decades and that the occurrence of serious side-effects have been minimal. An estimated 6,00000 C.T. treatments have been given each year in USA alone and more than six million treatments have been given in USA in last 10 years. These numbers indicate clearly that the number of untoward reactions is less than any other therapeutic modality' ("Scientific Basis Of EDTA Chelation Therapy (2nd edition) edited by Halstead MD and Rozema, MD, page 129. T.R.C. publishers Landrum S.C.).

He says that C.T. causes serious side effects including renal failure. Can he quote a single instance of any untoward side effect like renal failure following C.T. during the last 10 years?

In a meta-analysis of 17 studies involving 22765 patients who had undergone EDTA chelation therapy Dr. Terry Chappel and Dr. John Stah I have shown a correlation between EDTA chelation therapy and improvement in cardiovascular function. Above meta-analysis has revealed a correlation coefficient of 0.88 which indicated a high positive relationship between EDTA CT and improvement in cardiovascular function.

According to this meta-analysis, 87% of patients demonstrated clinical improvement by objective testing (Journal of Advancement in Medicine Vol.6, No.3, 1993).

Dr. Norman E. Clark in an editorial written in American Journal of Cardiology August 1980 says "In summary the treatment of atherosclerotic vascular complications with EDTA chelation is supported by a large volume of information concerning the development of atherosclerotic plaque. EDTA chelation therapy helps in restoration or repair of vascular injuries and the demonstration of unusual improvement in patients who had advanced states of various forms of occlusive vascular disease."

Those who are specialized in cardiology will agree with me that "Cardiovascular Drug Therapy (2nd edition) by Franz H. Messerts M.D., (W.B. Saunders Comp.) is one of the most recognised textbooks published on cardiovascular drug therapy. This famous textbook has devoted one full chapter (chapter 175) to EDTA chelation therapy.

In this book Dr. Martin Rubin who is the author of this chapter on C.T., says "there is functional improvement of the damaged vascular areas by repetitive intravenous infusion of Na Mg EDTA".

Above textbook quotes 65 references from highly recognised journals to show how C.T. helps patients with vascular disease. I thank who ever wrote the article for the opportunity given to explain things and give the correct picture to the readers.

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Engonona gets solar electricity : 

She is 'Mother Lanka' to me - Pradeep Jayewardene

Sri Lankans oldest, and worlds second oldest living Centenarian Engonona at 114 years, still up and getting about, though frail in body, weak yet healthy, with a near perfect memory is like "Mother Lanka" to me.

Talking to her one really feels whether there is anything greater on this earth than human life.

Why people should fight over man made differences, kill each other and yet call ourselves living in an advanced society in a space age is incomprehensible.

All these things come to mind when one talks to this centenarian, who has done the impossible in living and still running the humanity's living race flying the Sri Lankas flag.

Pradeep Jayewardene - grandson of late President J.R. Jayewardene, so described the living achievement of Engonona to the Health Watch, when he visited her in her one roomed hut in Galle last week to which he provided solar electricity, fulfilling one of the wishes of this Lankas living human treasure - to enjoy electricity in her hut before her death.

Health Watch carried her wish in this page last month, and one of the first to respond to the call was Mrs. Penny Jayewardene, who has got Pradeep to get the thing done through Shell Solar Lanka Ltd, a company initiated by Pradeep who has borne the entire cost of installation and is grateful to the Health Watch and Prof. Colvin Gooneratne head of the centenarian study for highlighting Engonona's cause.

Engonona was honoured by Sri Lankas highest professionals body OPA, at their annual sessions held at the BMICH last month (September 17) for her unique achievement in living.

She though poor and uneducated was invited as a special guest of honour to the inauguration of the sessions garlanded and honoured by its president elect and sessions organising committee chairman Architect V.N.C. Gunasekera. Both the chief guest and guest of honour at the occasion Power and Energy Minister Karu Jayasuriya and Opposition Leader Mahinda Rajapakse came down the stage and honoured Engonona for her living achievement.

She thanked and blessed all those connected with the centenarian study, Daily News for helping her.

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