Editor PK Sasidharan
Professor of Medicine Calicut Medical College Calicut-673 008 Kerala, India
Members
Rejith Valsalan
Aquil Kalanad
Sreejith Nair
Mukund A Prabhu
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Jaypee Brothers Medical Publishers (P) Ltd
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DOCTOR'S POCKET COMPANION
© 2006, PK Sasidharan
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the author and the publisher.
First Edition : 2006
9788180615856
Typeset at JPBMP typesetting unit
7Contributors
- RC Babu
- Associate Professor
- Institute of Chest Diseases
- Calicut Medical College
- Ramla Beegam
- Professor and Head Department of Community Medicine,
- Calicut Medical College (Retd)
- PV Bhargavan
- Professor of Medicine
- Calicut Medical College (Retd)
- V Udaya Bhaskaran
- Associate Professor of Medicine
- Calicut Medical College
- Binuraj
- MR Chandran
- Professor and Head
- Department of Forensic
- Medicine & Director of Medical Education (Retd)
- Narayana Das
- Associate Professor of Paediatrics
- Institute of Maternal and Child Health
- Calicut Medical College
- PC Easaw
- Professor of Medicine
- Calicut Medical College (Retd)
- CJ Francis
- Professor and Head
- Department of ENT
- Calicut Medical College (Retd)
- TS Gopalkumar
- Associate Professor
- Orthopedics
- Calicut Medical College
- Jeesha C Haran
- Professor and Head
- Department of Community Medicine
- PT James
- Professor
- Institute of Chest Diseases
- Calicut Medical College
- NV Jayachandran
- Assistant Professor of Medicine
- Calicut Medical College
- U Jayaprakash
- Professor of Orthopedics
- Pariyaram Medical College
- Kerala
- Jijith Krishnan
- Postgraduate Student
- Department of Medicine
- Calicut Medical College
- R Krishnan
- Professor and Head
- Department of Medicine
- Calicut Medical College (Retd)
- Sheela Mathew
- Assistant Professor
- Infectious Diseases
- Calicut Medical College
- Lulu Mathews
- Professor and Head
- Department of Paediatrics
- Institute of Maternal and Child Health
- Calicut Medical College
- KB Mohanan
- Professor of Medicine
- Medical College
- Calicut and Thrissur (Retd)
- VV Mohanachandran
- Professor and Head
- Department of Psychiatry
- Pariyaram Medical College
- Kerala
- V Rajashekharan Nair
- Professor and Head
- Obstetrics and Gynecology
- Medical College
- Trivandrum
- Binoy J Paul
- Associate Professor of Medicine
- Calicut Medical College
- K Pavithran
- Professor and Head
- Department of Dermatology
- Calicut Medical College (Retd)
- Anitha PM
- Assistant Professor
- Department of Microbiology
- Calicut Medical College
- MR Rajagopal
- Professor and Head
- Department of Anesthesiology
- P Rajan
- Professor and Head
- Department of Sugery
- Calicut Medical College
- PV Ramachandran
- Professor of Radiodiagnosis
- Calicut Medical College
- Ramakrishnan
- Former Professor and Head
- Department of Pedodontics
- Govt. Dental College Calicut
- G Ganapathy Rao
- Professor of Medicine
- Calicut Medical College
- presently at AIMS, Cochin
- A Riyaz
- Professor of Paediatrics and Paediatric Gastroenterology
- Institute of Maternal and Child Health
- Calicut Medical College
- CK Sasidharan
- Professor and Head
- Department of Paediatrics
- Institute of Maternal and Child Health, Calicut Medical College (Retd)
- Jyothi Sasidharan
- Assistant Professor
- Department of Ophthalmology, Calicut Medical College
- PK Sasidharan
- Professor of Medicine
- Calicut Medical College
- Akbar Sheriff
- Professor of Paediatric Surgery
- Institute of Maternal and Child Health
- Calicut Medical College
- MD Shyamkumar
- Senior Lecturer in Cardiology
- Calicut Medical College
- Calicut
- Thresiamma Thomas
- Professor and Head
- Department of Pharmacology, Medical College
- Kottayam, Kerala
- Varghese Thomas
- Professor
- Gastroenterology
- Calicut Medical College
- MG Usha
- Associate Professor
- Obstetrics and Gynecology
- Calicut Medical College
- M Vijayakumar
- Assistant Professor
- Department of Paediatrics
- Medical College
- Alappey
- Kerala
We are happy to bring out the third edition of the Doctor's Pocket Companion after the overwhelming response we received for the first two editions. It had a humble beginning in the nineties as a small book containing guidelines for rational medical practice, primarily aimed at the interns. But my desire was to make it a companion reference book for interns, general practitioners, family doctors, general physicians; and in fact, for anyone with a holistic attitude towards patient care. After the second edition was introduced; there was an increasing demand for the book among the doctors; and in fact, we started getting enquiries from every type of doctor and even undergraduate students who started buying the book from all over Kerala. As we started getting enquires from other states as well, we thought of publishing it all over the country and hence had entrusted Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, to publish it.
It is a common statement these days from every corner that medical knowledge is expanding rapidly and today's information becomes outdated or wrong tomorrow and, therefore, it is essential to keep updated. The fact is, all these changes are in relation to technology as applied to diagnosis and patient care. The basic skill required in diagnosis and management remains the same whatever may be the advances in technology, and without this skill the doctor becomes a burden on the society. It is unfortunate that in the mad race for acquiring a technological edge in diagnosis and treatment, the basic skill itself is not given the due consideration these days. The result is we produce doctors who do not see, or forget to learn, the Art of Medicine. This 12is as far as diagnosis and management of diseases are concerned. At the same time, one should not forget the fact that health care and disease care are two separate issues; we, the doctors, more often come in the picture only when disease strikes. Diseases are actually the result of failed health care. Each patient-each failure in health care should be enlightening us, as to what went wrong in health care and how he/she got the disease. This can be found out by keen observation of the lifestyle, diet and environment of each patient. We should be educating the society, only about problems and solutions in health care—not problems in disease care, as is done vigorously through the media nowadays. Due to the overemphasis on technology and the growing industrialisation of medical practice, which is only disease care, there is a neglect of basic health care issues these days. Even in disease care, what is required first is diagnosis without much investigations or without inflicting much trauma physically and mentally, and a humane attitude, to the patient. Then comes a cost effective plan and also a holistic approach to management. If one develops these qualities, then only one can be a useful doctor. The information required to acquire these qualities will never change no matter what developments take place in the field of Medicine. Most of the chapters in this book were written with an idea to enrich basic skills in diagnosis and management based on a problem-oriented approach.
Every chapter has been written with the wider spectrum of readers in mind and its growing popularity among family doctors. The topics are presented in a down to earth practical manner, as we are quite aware of the challenges before the primary doctor who has to depend heavily on clinical diagnosis and minimum investigations. The patients, as we know, come only with problems and not with diagnosis.13
I am deeply indebted to my young colleagues, Dr Rejith Valasalan, Dr Aquil Kalanad, Dr Sreejith Nair and Dr Mukund A Prabhu who helped me with the editorial work particularly Dr Rejith Valsalan who did the DTP work as well. The editorial board wishes to extend heart felt thanks to all the teachers who contributed their writings on time. We also extend our thanks to Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, for accepting to print the first national edition of this book.
PK Sasidharan
19About Doctors and Society
While treating diseases, every good doctor is expected to contribute to health care also by giving adequate preventive advices to his patient and his family members. Health is a well balanced, dynamic state of body and mind, which can be achieved only by the assembly of a nutritious diet, personal and environmental hygiene plus a life devoid of all vices and good social relations. All diseases, including genetic diseases are result of a failed health care noticed or unnoticed occurring in the past or present. This is obvious in the case of communicable diseases, like enteric fever, cholera, hepatitis, malaria, HIV and tuberculosis—which all can be prevented by proper health care. Diseases like ischaemic heart disease, diabetes and hypertension are the result of faulty living and eating habits with the diet which does not provide the protective elements. The so called degenerative diseases are due to similar problems hitherto unrecognised. The inherited disorders (genetics) are probably due to mutations occurring in the chromosomes, as a result of environmental insults like infections/radiation/chemicals, etc. which escape our attention. This is evident from the relation between sickle cell disease and malaria. Sickling in RBCs appear to be an adaptive mechanism developed by the nature to resist malaria, but they proved to be harmful to the human beings. Once the mutation develops, either it manifests in the same individual as a deadly disease like cancer/leukaemia, or if he lives on gets transmitted to the next generation—which we call as inherited disorders.20
Needless to say that, while treating diseases, doctors should have a holistic approach, as the state of ill-health in a person (as is the state of health) is closely linked to the entire body (and not just confined to organs like heart, liver or kidney) his mind, the environment and the society to which he belongs. We cannot improve the health of a person forgetting the health of the rest of the society and the environment, because such a state of health is unstable and will collapse sooner or later due to the health problems around him. Even the health of the health-care provider is at risk, unless he contributes his share of work to improve the health of the society to which he belongs—this is easily done by advocating preventive measures also whenever patients come for the treatment. This is the minimum of social commitment expected from health care (disease care) professionals. The degree of social commitment in any work can be assessed by the volume of the population “genuinely” benefited, directly or indirectly. In medical practice researchers and teachers can do a lot directly or indirectly by their dedicated work—the result of their work can reach the masses (both rich and poor) through their good inventions or good students.
Superiority of a doctor in practice is to be assessed only by the degree of social commitment and not by the length of his academic qualifications, material possessions and command over hi-tech investigations. Research becomes superior only when the expected results are aimed at benefiting the entire society, nation or the whole world—in a “cost-effective” manner. Researchers without social commitment are superfluous and need to be discouraged. We encourage hi-tech research, which are repititions of work done elsewhere and which usually do not benefit the society in a cost-effective manner. Research should be aimed at getting new ideas useful to the masses—to get something 21new and more cost effective or to refute an existing idea which is widely practiced. Among the practicing doctors, the general practitioners or the family doctors are more socially committed, and hence more superior, by the very nature of their work, and can do a lot more by concentrating on the public health activities. As one goes up (or down) the ladder of specialisation, what we see is the social commitment seems to become less and less as they often do not engage in socially important research work (which they are supposed to do). In fact, specialisation started as a means of enhancing research work, but it took a different turn and spoiled the family physician concept and almost killed clinical medicine and the holistic approach—specialisation as practised today led to escalation in cost of medical treatment, unhealthy competition among doctors and enormous scope for malpractice. The West has recognised these and started taking corrective steps: but we, with our meagre resources blindly encourage specialisation alone without sensing the health needs of our society. If only the specialist doctors had concentrated on “properly” referred cases and done dedicated research work, they could have become “super” by their actions.
Our major health problems are still malnutrition, lack of safe drinking water and sanitation facilities and poor personal and environmental hygiene which lead to diseases like cholera, typhoid, viral hepatitis, malaria, TB, HIV and the like. These can be prevented by cost-effective methods, but the stress is only on chemotherapy. Some quarters project IHD and cancer as our major health problems and cry for more Cancer Care Centres and centres for Coronary Bypass surgery. It is worth remembering that IHD and cancers are due to faulty living and eating habits plus exposure to various toxins combined with deficiency of protective elements in the diet. How many of us (Doctors) regularly eat a diet which 22provides us adequate amounts of Vit A, Vit C, Vit D, Vit E and other B complex Vitamins? Leave alone the poor who have no access to and the people who are unaware of these. This aspect in the diet has not become a popular practice and the advantage is taken by Pharmaceuticals selling antioxidant capsules.
The medical students and the young talented doctors are attracted towards training in bypass surgeries and cancer treatment—no one seems to be interested in the burning health problems of our society. We aim at control of communicable diseases with truck loads of costly antimicrobials for HIV by free supply of condoms and heart diseases by coronary bypass and heart transplantation. The priorities in health planning and utilisation of resources are upside-down. We have no health policy as such. Switzerland which has a very high per capita income as compared to India has decided not to spend public money in treatments which are not cost effective (like bone marrow transplantation). In our country, if we have the right contacts, any treatment can be done with the help of public money and we encourage superspeciality hospitals ignoring the basic amenities and PHCs. Can we ever make available superspeciality hospitals care within the reach of every poor patient? Is it the need of the hour? Who is the ultimate benificiary of this approach?
PK Sasidharan