Uncertainties of Medicine

Dr. Dennis T. Aloysius visiting lecturer Post Graduate Institute of Medicine (PGIM) and member of the Healthwatch Medical Advisory panel, writing to the Healthwatch on - uncertainties of medicine says:

“Whatever form this uncertainty takes it can only be resolved if it is perceived as a problem. Yet much of our medical training serves to prevent us from disclosing our own uncertainty to ourselves and to others”.

Dr. Dennis T. Aloysius

The practice of medicine is an art and a science. Medicine is an applied science and an uncertain one, involving a considerable measure of subjectivity.

The medical profession has paternalistically projected into the minds of our practice population an image of being all-knowing. Most patients have complacently helped to foster this perception and seek solace and comfort in it, for who will ever seek advice or care from a person who admits, even honestly, to be unaware of the accurate answers to most questions.

Are we not just role-playing?

The pretence seems acceptable, because it is what the public and profession find mutually satisfying and are comfortable with. But I ask you the question are we in the medical profession deceiving those who place implicit trust in us?

On the one hand pretence seems acceptable, because it is what the public and profession find mutually satisfying and are comfortable with. On the other hand, in the case of a diagnosis that is elusive, would it not be wise to state that the diagnosis is uncertain but everything possible is being done to establish it.

The balance between inspiring confidence and trust, of mild deception and honesty is precarious and fragile, and needs to be handled with sensitivity with the interest of the patient at heart. So the practice of medicine often involves an element of play-acting.

Why not just one single book

If medicine had within its compass of knowledge and understanding, nearly everything there is to know about illness and health, why have we not published a few or better still, just one single book that encompasses our knowledge, such as the great religions have done? For example, we could have published a single book such as the Dhammapada or Bhagavad-Gita or Bible or Koran or Talmud. Instead, we are currently publishing several medical texts and over 5,000 medical journals and nearly 2,000,000 biomedical articles annually.

Some of the medical articles contradict the previous published, “proven” and universally accepted views. We are constantly revising our views. We pompously and patronizingly term this “the progress of science,” “match of science” the “evolution of knowledge”.

This is certainly true but how can we explain away to patients, basing our earlier advice on these disproved premises and thus having given wrong advice and made misleading statements over the years. This may have caused harm to our credulous patients.

The expectation

The expectation that a doctor should have all the answers is as bad for patients as it is for the doctors themselves.

There are several doctors do not admit to any uncertainty. They are very vocal at meetings and lectures assuring others that the correct path of clinical management is obvious. Their colleagues, feeling undermined, ask no questions and express no doubts, and are silent. Paradoxically these same doctors in private conversations freely admit that medicine is an uncertain science.

Underestimated

Whatever form uncertainty takes, it can only be resolved if it is perceived as a problem. Yet much of our medical training serves to prevent us from disclosing our own uncertainty, to ourselves and to others. As a result, the prevalence of uncertainty and the magnitude of its impact on doctors and patients are therefore underestimated.

Hiding the fact

In situations where clinicians face uncertainty, the use of practice guidelines may be of assistance. Some pompous doctors assert that guidelines are only necessary for the ignorant and that resorting to them is a sign of inadequacy.

Such hostility usually hides the fact that these same clinicians often work to their own set of private guidelines. Other common criticisms are that guidelines erode clinical freedom or lead to the practice of cookbook medicine’.

Clinical freedom is all very fine as long as it is used to benefit patients. When it is used to continue outmoded and harmful practices, or to prevent the adoption of more effective treatment, it becomes clinical anarchy. Research and experience demonstrate that this can happen all too often.

Why practice guidelines are there

Guidelines will not remove our freedom, or indeed our obligation, to think and to place our patients’ needs first. Even when working in areas where excellent guidelines exist, doctors will contravene them when patient preference or commonsense so dictate. Practice guidelines are there to help us, not to tyrannize us.

Where there is uncertainty doctors should tactfully tell the patient and carers the truth, pure and simple. But as Osca Wilde once said “Truth is rarely pure and never simple”.

1st International conference in Sri Lanka

Towards understanding psychology

The first international conference Towards Understanding Psychology will be held in Sri Lanka at the Peradeniya Medical Faculty next month November 7th and 8th.

The Department of Philosophy and Psychology of the Faculty in a release to the Healthwatch on the conference says:

The conference will bring together professionals from different psychology-related expertise, providing an opportunity for addressing some of the key practical challenges that psychologists face in developing as an separate academic and an applied field in contemporary Sri Lanka.

It will also serve to improve ties among psychologists by creating an environment conducive to a free exchange of ideas. As a whole, the conference will play a critical role in the development and professionalisation of psychology within the country.

The following panel discussions will take place at the sessions by expert professionals in the fields.

1. Culture and Psychology

2. The Application of Psychology to Improve Human well-being

3. The Application of Psychology in Work organisations including the Military

4. The Profession of Psychology

The aim, purpose, participants and background to the conference the organising committee says:

Background: An on-going civil war and after effects of the Asian tsunami (2004) has left Sri Lanka grappling with many psychology related issues but with few who are competently able to address them.

Despite a burning need for competent practitioners within this specialised field, only one department within the entire university system grants a degree in psychology which has resulted in a dearth of new psychologists.

The small number of existing Sri Lankan psychologists are then absorbed into various isolated academic departments and institutions around the country, depriving the psychology community of a collective voice to express their many common and pressing concern.

The absence of a recognised professional body to support, develop and control its practice, has placed Sri Lanka’s public and the few trained psychologists in a vulnerable predicament, as individuals without even basic qualifications in the subject are dawn to advice and direct government efforts in the name of psychology. Hence, the proposed conference aims to initiate a forum through which psychology related concerns in Sri Lanka will be addressed collectively.

Aim of conference: To initiate a proficient community of professionals engaged in psychology.

Participants: Psychologists in Sri Lanka, with a special emphasis on those working in the national university system.

Purpose: * Improve ties among psychologists, * Create an environment conducive to a free exchange of ideas, * Explore the role of psychology in Sri Lanka, * Develop and professionalise psychology in the country.

The main sponsors are the American and UK Psychological Associations.

Participating institutions -

University of Colombo: Department of Educational Psychology, and National Education Research and Evaluation Centre (NEREC), Department of Sociology, Department of Psychological Medicine, Faculty of Graduate Studies.

University of Peradeniya: Department of Agricultural Economics and Business Management, The Department of Philosophy and Psychology.

University of Kelaniya: Medical Education Centre.

Open University of Sri Lanka: Department of Early Childhood Education.

University of Ruhuna: Department of Psychiatry.

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Some stress relieving strategies

Dr. Kelum Pelpola

To get back in control when allergy symptoms have you reeling, consider the following stress-relief strategies:

1. Figure out what’s adding to your stressful feelings and remove or reduce the source. If your stress is from overwork, learn to delegate, especially during allergy season. If your stress is from overextending yourself, rethink your priorities.

2. Get plenty of sleep every night, not just on weekends. Getting in bed and resting can restore the body’s balance and help the allergic body heal.

3. Set priorities and budget your time to allow for a little relaxation. Having a more balanced life with moments of relaxation each day can help you deal with allergy symptoms more effectively.

4. Exercise daily. Even if you only have time to take a walk, exercise helps reduce stress hormones that may cause you to feel keyed up. And remember, exercise produces epinephrine, which acts as a natural decongestant, helping you breathe better.

5. Learn to meditate. Twenty minutes of meditation once or twice daily can help you reduce stress and feel more relaxed.

6. Keep taking your allergy medications. While that may not sound like a stress-relief strategy, it might surprise you. Stress may cause anxiety and depression, and depressed individuals are less compliant with their medications. So stay on track!

Folate (folic acid) helps prevent breast cancer and heart attacks

D. P. ATUKORALE

Folate and folacin (vitamin B9) are the names used to describe a group of substances which are chemically similar to folic acid. Its importance to growth and prevention of anaemia was established in 1946. The word folate comes from the Latin word “folium” meaning “leaf” which should tell us something about the best sources of the above vitamin.

Importance and functions

(a) Folate plays an essential part in the formation of D. N. A. and R. N. A;

(b) With vitamin B12 it plays an essential part in amino - acid synthesis;

(c) Folate is essential for formation of red blood cells (RBC) and white blood cells (WBC);

(d) Folate contributes to the formation of the iron constituent of haemoglobin.

Human beings need less than 5 mg (one tablet) of folic acid per day which - costs about 30 cents in the private sector.

Most meats are poor sources of folate and vegetarian diet is full of vit B9 (folate) and it is advisable for pregnant and lactating mothers to take vitamin supplements containing folate. Most of the common multivitamins available in our pharmacies contain folate but few very popular brands don’t contain folate.

Best vegetable sources of folate

These are spinach, cabbage, asparagus, soya bean and soya products, akra (“ladies fingers”), peanuts and cashew nuts, legumes (such as beans, lima bean (“mekaral”), lentils (dhal) and kidney bean, chickpeas), broccoli, bean sprouts, peas, avocado, papaya, and all dark green vegetables.

Folic acid deficiency anaemia

This type of megaloblastic anaemia was quite common in the poor pregnant mothers in our rural areas and when I was working as a house officer in 1965 in obstetric wards, we used to get severely anaemic pregnant mothers from rural areas such as Karawenella and we used to administer iron injections or iron tablets, folate, and anthelminthic drugs and the few cases investigated by us by doing peripheral blood picture, showed evidence suggestive of megaloblastic anaemia.

Majority of these pregnant mothers used to have haemoglobin levels below 5 grams percent and needed urgent blood transfusions. At that time we had no facilities to do serum B12 levels and serum folate levels.

It is noteworthy that B12 deficiency anaemia has not yet been reported among Sri Lankan vegetarians, as far as I am aware. I used to see a few cases of B12 deficiency (pernicious) anaemia in U.K. when I was following the teaching rounds with the haematologist, at Manchester Royal Infirmary, U.K. in 1971 - 1973 period but never seen one in Sri Lanka during my medical carrier.

Folate helps prevent breast cancer

Researchers evaluating folate intake in 11699 post menopausal women from the Malmo Diet and Cancer cohort found that the intake of folate correlated with the lower risk of invasive breast cancer in the post menopausal women (Ericson U. et al, Am I. Clin. Nutr, August 2007, 86 (2) 434 - 443).

In the above study women who consumed an average of 456 micrograms of folate per day had 44 per cent lower risk of breast cancer compared with women averaging 160 micrograms per day. As mentioned earlier, folate deficiency could impair DNA synthesis and repair, and evidence suggests that folate deficiency could lead to development of certain types of cancers.

Folate prevents neural tube defects

It is common knowledge among doctors, nursing staff and most of the laymen that administration of folate during the early months of pregnancy prevents occurrence of neural tube defect in the foetus. As such all the doctors prescribe folic acid to women during pregnancy.

Folate prevents heart attacks

Homocysteinaemia is a known coronary risk factor and I prescribe 5 mg (one tablet) of folic acid to all those patients with potential coronary heart disease and to all patients with coronary heart disease. Folic acid is an extremely cheap vitamin B tablet.

To conclude it is advisable to prescribe 5 mg (1 tablet) of folic acid to (a) all females over age of 40 with a view to prevent breast cancer (b) to all patients with coronary risk factors (c) to all pregnant women with a view to prevent neural tube anomalies in the foetus.

As far as I am aware physicians prescribe folic acid to most of the megaloblastic anaemia patients (after excluding B12 deficiency in which case folate should never be given before administering B12) other indications for folic acid administration such as chronic haemolytic anaemias, renal dialysis patients etc will not be discussed in this article.

Dr. Upali Mendis on Dr. Robert Emmanuel Selvarajah

A leading figure in the medical field - Dr. Robert Emmanuel Selvarajah, former Consultant Ophthalmologist of the Eye Hospital Colombo, after a brief illness, passed away peacefully on September 6.

It was at the Eye Hospital that I first met Selva when we were both trainees. Although he left London on a Commonwealth Scholarship, we were fortunate to meet once again since I too left to London a year later. I have fond memories of our time together at lectures as well as work in the clinics at Moorfields.

After completion of the Fellowship of the Royal College of Surgeons, Edinburgh, Selva returned to Sri Lanka and served as a Consultant Ophthalmologist in Trincomalee, Kandy and Colombo.

During this period of committed service in his homeland, he was an active member of the Ophthalmological Society of Sri Lanka and held several posts in the Society, ultimately becoming its President.

Regrettably, the ethnic violence of 1983 left Selva no choice but to emigrate to Canada and later to the USA for the sake of his children’s education. He practised as a Family Physician in the USA until May this year when he was diagnosed with a terminal illness.

At the Colombo Eye Hospital, Selva’s service was looked upon with gratitude and admiration by his patients, subordinate staff and colleagues.

He was, above all, an unassuming, simple and generous man, always willing to help anyone in need. I never saw him displaying any anger or talking disparagingly of others. Despite his position, he never looked down on others.

He was beloved as a gifted teacher who encouraged his trainees to learn and accomplish their goals. Whenever there was disagreement among his colleagues over administrative and academic issues, his intervention helped to settle them. In addition to these commendable and rare qualities, Selva had a good sense of humour and was invited as an after-dinner speaker on innumerable occasions.

I not only greatly valued his friendship, but also his advice on academic and administrative matters while I was the Director of the Eye Hospital Dr. Selvarajah’s exemplary life leaves much to learn from and gives each of us who knew him in various capacities much cause to celebrate the fact of having been associated with such an admirable man.

Problem-solving dreams

Dr. H. B. Jayasinghe (Consultant Clinical Hypnotist)

Daydream is a pleasant fantasy indulged in while awake whereas a dream constitutes a series of scenes occurring while asleep, may be in broad daylight or at night.

While daydreaming may lead to problems rather than solving them, a dream, irrespective of its time of occurrence can be usefully employed not only for problem solving but also for entertainment and creativity enhancement.

Although dreaming is a physiological condition experienced by every healthy human being, hallucinations, be auditory, visual, olfactory, gustatory or sensory are all pathological, and experienced only in psychiatric illnesses such as schizophrenia, delirium tremens etc, Hallucinations can either be abolished or modified but cannot be used for problem solving.

(Dr. Jayasinghe has sent this short note in reply to a letter sent by a Healthwatch reader Abdulla Ziard on daydreams and hallucinations)