Proper communication in medicine

Proper communication in medicine

Proper communication is vital in any field. There is ample scope for changing what we communicate and how we do it based on proper feedback. This effort may  appear to be thankless; however it will be truly rewarding in the long run. These conclusions are specially valid in the medical field. We often hear a  very disturbing trend. Wrong, inconsiderate communications land physicians in harrowing situations. Occasionally fisticuffs may follow.

Many years ago Christopher Martin, Associate Editor of  the British Medical Journal  wondered whether absence of feedback is one of the reasons why there are so many complaints about poor communication in medicine. You can access his article at:

http://www.bmj.com/content/341/bmj.c4490

The article received half a dozen rapid responses

http://www.bmj.com/content/341/bmj.c4490/rapid-responses

I could not resist writing the following rapid response to his article.

http://www.bmj.com/rapid-response/2011/11/02/challenges-physicians-communication.

Thus:

Challenges to Physicians’ Communication

                                             

Mr Christopher Martin convincingly argues in favour of collecting
appropriate feedback, a powerful source for improving communication.

It is not enough to receive feedback from representative group of
patients. A non representative patient may offer valuable inputs. A few
years ago, I distributed an article titled “Medical x-ray examinations: a
note of caution”, to many members of the administrative staff in a large
research organization.

Everyone appreciated the article. A few proposed the need to avoid
scientific jargon if that is possible. While describing the biological
effects of radiation, I explained the small potential for developing
cancer as a late effect of medical x-ray exposure. One of the respondents
was very upset. His niece had a few x-ray tests done a day before. He told
me that if he knew about the cancer-inducing potential of x-ray exposure,
he would not have agreed to the x-ray tests.

I modified the text substantially to assert that a patient should not
refuse a medically needed x-ray test. Feedback from a single respondent
influenced me because the adverse effect of avoiding a clinically
recommended x-ray may far exceed the tiny probability for induction of
cancer.

A physician has to be constantly alert. A wrong word or even the
slightest gesture indicating a mild degree of indifference may put off a
patient.

Once I took my five year old son to a well equipped hospital. He had
a fairly large boil in his eye lid. I described his condition to the
physician.

“We have to cut it”, the unsmiling, thoughtless physician who was
visibly impatient decreed. My son ran out of the room. He declared that he
will never again come with me to any hospital. The boil healed slowly;
some antibiotic cream helped.

Last week I suffered from severe earache. The consultant diagnosed
that it is due to impacted wax. The junior doctor who attended to me was
very considerate; may be a brief explanation on the procedure to be
followed may have been helpful and reassuring. One ear got cleared easily.
The wax in the other ear was stubborn. It was hurting badly.

Further procedure was postponed.” We will not hurt you”, a senior
doctor who was stern but considerate, assured me. The stubborn wax needs
some softening! I am yet to read the material on “ear wax removal”, I
collected from the website of the US National Institutes of Health.

The challenges to communication between physicians and patients may
be more demanding if the patients belonged to an elitist closed group.
Partly because of the patients’ expectations.Some of them may be more
knowledgeable than their physicians.

If a hospital is located in a township in which thousands of persons
serviced by the hospital stay, then all bad news will spread faster than
wildfire; good news seldom gets any coverage.

Communication under stress will be ineffective. If communication to a
patient has to be effective it has to be delivered with compassion. It
will be satisfactory only if the patients trust their physicians.

Advancement in technology particularly medical imaging technologies
is an instance in point. These technologies advance with unbelievably
astonishing speed; the clinical uses lag disappointingly behind. More
often, there is no scientific indication that these technologies are
beneficial. Under those conditions, specialist doctors with clear
conscience will find it very difficult to communicate with knowledgeable
patients.

K.S.Parthasarathy Ph.D

ksparth@yahoo.co.uk

Competing interests:
None declared

Competing interests: No competing interests

 

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How Researchers Found That Tourists Accidentally Carried a Superbug from India to Paris

39 tourists swabbed door handles in 136 airports around 59 countries, finding that a deadly bug resistant to antimicrobial drugs and known to exist in India also exists in Paris, where it is rare. Credit: limaoscarjuliet/Flickr, CC BY 2.0

The most difficult, thankless and uninteresting part of any research, particularly in a field like microbiology, is collecting the samples. Generally, this exercise is expensive, often tedious and at times amenable to justifiable criticism at the end of the study. Recently, researchers from University Hospital Münster and the Robert Koch Institute, both in Germany, used an ingenious method to collect samples for their project. They successfully persuaded 39 tourists (known to them) to collect swab samples from 400 bathroom door handles from 136 airports in 59 countries. And they discovered that a drug-resistant strain of bacteria from India has reached Paris.

The researchers were able to rightly guess that international travellers can acquire antimicrobial-resistant bacteria and carry these unwanted guests from their home countries to the countries they visit. Reporting online on September 23 in the journal Clinical Microbiology and Infection, the scientists noted that “internal toilet door handles are suitable to assess the spread of bacteria because they are the last contact of the hands before hand washing, (and) are frequently used by multiple people after potentially unhygienic activities (e.g. defecation, urination) and are mostly contaminated with the flora of the skin and the gut.”

They instructed the tourists who took part in the study to swab each door handle with special moistened environmental swabs between December 2012 and November 2015. They stored the samples before inoculating the bacteria in a nutrient broth. Finally, they processed each type of bacteria according to specified protocols, identified the species and analysed their genetic makeup.

In this study, the samplers collected most samples (60.5%) from men’s toilets. The median time between sampling and culture was one week. The contamination rates were highest for Staphylococcus aureus (5.5%), followed byStenotrophomonas maltophilia (2%) and Acinetobacter baumannii complex (1.3%). The most important finding was the contamination rate of S. aureus. After detailed genome mapping, the researchers found that one of the strains of methicillin-resistant S. aureus (MRSA) found in Paris was rare, and that it originated from India.

Before we analyse the implications, a caveat issued by the researchers is pertinent: “It is unknown if and how door handles were disinfected by cleaners before sampling. No information on the material of the handles was available. These sources of bias could explain both that we over- and underestimated the true rate of contamination,” they conceded.

Now, the MRSA is not a benign bug. According to WebMD, this bacterium causes infections in different parts of the body. It is tougher to treat than most strains of S. aureus because it is resistant to some commonly used antibiotics. At present, it is known to be resistant to amoxicillinpenicillin  and oxacillin. Evidently, the ability of the bug to resist these substances makes it a superbug. The researchers wrote: “… we detected low contamination rates of internal toilet door handles from airports with drug-resistant bacteria in our study. The detection of an emerging CA-MRSA from India in France shows that antimicrobial resistance could be spread through international travel hubs.”

MRSA develops resistance fast enough to keep specialists developing more effective antibiotics, and it is worrying that international travellers may be carrying the bacterium around. And sadly, only travellers need passports and visas; there are no export/import controls on MRSA, effectively vicious nano-assassins! At the same time, the claim that one of the strains of MRSA isolated in Paris originated from India is suspicious because quite a few papers (here, here and here) have been published showing that MRSA is present universally.

According to the documents,

  • Global surveillance show that  MRSA represents a problem in all continents and countries where researchers have carried out studies, determining an increase in mortality and the need to use last-resource antibiotics, which are also expensive
  • Researchers reviewed the literature on the occurrence of MRSA in hospitals and long-term care facilities in various countries in the Americas, Africa, Asia, Australia/New Zealand and Europe. Increasing prevalence of MRSA is a worldwide problem, they’ve concluded, affecting both affluent and poor countries. We also need better infection control guidelines.
  • Scientists observed very high rates of resistance in all WHO regions in common bacteria (for example,Escherichia coli, Klebsiella pneumoniae and S. aureus) that cause common healthcare-associated and community-acquired infections. These include pneumonia as well as infections of the urinary tract, wounds and the bloodstream.

So, if there is such a mass of evidence for the universal presence of MRSA, how are the German researchers so sure that the bug found in Paris is from India and not from any other country?

“Indeed, MRSA is spreading around the globe even in remote areas, for instance in Australia,” Frieder Schaumburg, a professor of infectious diseases at University Hospital Münster and one of the authors of the paper, told this correspondent via email. “Several MRSA clones are known and mainly circulate in particular geographic regions. However, this particular MRSA clone, sequence type ST672, is mainly reported from the Indian subcontinent and very rare in Europe. This suggests that this clone could have been imported from the Indian subcontinent to France through international travel.”

This minor controversy is of little relevance now as we realise the gravity of the problem. A WHO report from 2014 contained an ominous, first paragraph in its foreword that said it all.

Antimicrobial resistance (AMR) within a wide range of infectious agents is a growing public health threat of broad concern to countries and multiple sectors. Increasingly, governments around the world are beginning to pay attention to a problem so serious that it threatens the achievements of modern medicine. A post-antibiotic era—in which common infections and minor injuries can kill—far from being an apocalyptic fantasy, is instead a very real possibility for the 21st century.

The report also had this to say on the status of penicillin, probably the most commonly used drug:

Reduced susceptibility to penicillin was detected in S. pneumoniae in all WHO regions, and exceeded 50% in some reports. The extent of the problem and its impact on patients is not completely clear because of variation in how the reduced susceptibility or resistance to penicillin is reported, and limited comparability of laboratory standards. Because invasive pneumococcal disease (e.g. pneumonia and meningitis) is a common and serious disease in children and elderly people, better monitoring of this resistance is urgently needed.

It is particularly alarming to note antimicrobial resistance to antibiotics for diseases like tuberculosis, malaria and HIV-AIDS, which have been savaging India for the last decade. In fact, what is the status of India on antibiotic resistant superbugs such as MRSA?

A paper published by the Indian Network for Surveillance of Antimicrobial Resistance group in February 2013 gives some idea. It documents the results of a study in 15 Indian tertiary care centres by 17 researchers during a two-year period, from January 2008 to December 2009, to determine the prevalence of MRSA and susceptibility pattern of S. aureus isolates in India. The authors wrote:

The overall prevalence of methicillin resistance during the study period was 41 per cent. Isolation rates for MRSA from outpatients, ward inpatients and ICU were 28, 42 and 43 per cent, respectively in 2008 and 27, 49 and 47 per cent, respectively in 2009. The majority of S. aureus isolates was obtained from patients with skin and soft tissue infections followed by those suffering from blood stream infections and respiratory infections. Susceptibility to ciprofloxacin was low in both MSSA (53%) and MRSA (21%). MSSA isolates showed a higher susceptibility to gentamicin, co-trimoxazole, erythromycin and clindamycin as compared to MRSA isolates. No isolate was found resistant to vancomycin or linezolid.

The researchers also warned that the “study showed a high level of MRSA in our country. There is a need to study epidemiology of such infections. Robust antimicrobial stewardship and strengthened infection control measures are required to prevent spread and reduce emergence of resistance.”

The WHO also publishes a fortnightly newsletter on the implementation of the global action plan on antimicrobial resistance. According to the organisation,

Antimicrobial resistance threatens the very core of modern medicine and the sustainability of an effective, global public health response to the enduring threat from infectious diseases. Effective antimicrobial drugs are prerequisites for both preventive and curative measures, protecting patients from potentially fatal diseases and ensuring that complex procedures, such as surgery and chemotherapy, can be provided at low risk. Yet systematic misuse and overuse of these drugs in human medicine and food production have put every nation at risk. Few replacement products are in the pipeline. Without harmonized and immediate action on a global scale, the world is heading towards a post-antibiotic era in which common infections could once again kill.

Each stakeholder has an evolving role to play in preventing superbugs of the likes of MRSA from developing drug resistance. With this in mind, the US Centers for Disease Control and Prevention published a bookletThe WHO also updated its factsheet in September 2016.

K.S. Parthasarathy is a former Secretary of the Atomic Energy Regulatory Board.

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All about baking soda

For the past several days, I have abstained from reading any worthwhile article.I have voluntarily avoided using the internet.I was away in Kerala attending a wedding.I came back today to my favourite pastime. Yes,  I have an enormous amount of material to read.

One of the first items I noticed was a very informative  essay on baking soda. The very first paragraph itself was loaded with fascinating accounts of the use of baking soda:

” We here at Grist talk a lot about baking soda: how to clean our homes and laundryand hair and teeth and armpits with it, how to kill mold with it, and, naturally, how to cook up tasty treats with it.”

The article in grist.org  turned out to be a very useful resource on baking soda. It gave the following information among others:

  • People mine ninety percent of sodium carbonate using which baking soda or sodium bicarbonate is produced in USA from Wyoming’s Green River Basin.
  • According to the U.S. Geological Survey, Wyoming alone contains 56 billion tons of pure layered trona, plus 47 billion more tons mixed with other minerals. We’re only tapping trona at the rate of 15 million tons per year; the Wyoming Mining Association estimates that we have enough on hand to last more than 2,000 year

You may access the story  and enjoy the content at :

Where does baking soda come from, and is it really so eco-friendly?

 

 

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After all, antibacterial soaps may not be more beneficial than ordinary soap

 

The latest issue of the Scientific American (Sept 2, 2016) highlighted the recent decision of the  U.S. Food and Drug Administration  on banning 19 active ingredients in antibacterial soaps. It revealed that “the ruling, 40 years in the making, caps a decades-long debate over whether these germ-busting chemicals are safe and offer any advantage over ordinary soap.”

A major portion of the luggage of young parents of infants visiting India for the first time will be various antibacterial  tissues, toiletries, and  hand sanitizers. They may find the new findings and the follow-up action by the US FDA hard to stomach!

The development may not be new to  people who are aware of the history of soap use and personal hygiene. The evolution of Lifebuoy soap described here is an instance in point.

Lever brothers created Lifebuoy soap in 1894. One of the first things  they did was to start using vegetable oils instead of tallow to make soap. According to one source,  most soaps use beef tallow. This source asks us to look at the ingredients in the soap. Beef tallow may take a fancy name sodium tallowate! we got astray. let us go back to the new US-FDA action.

It is worthwhile to read the entire article in the Scientific American to appreciate the value of plain water and ordinary soap in personal hygiene.

The full article may be accessed at:

http://www.scientificamerican.com/article/u-s-bans-common-chemicals-in-antibacterial-soaps/?WT.mc_id=SA_HLTH_20160906#

Use of ordinary soap may prove to be  very inexpensive. It may not make bacteria resistant  to antibiotics is an additional bonus!

 

 

 

 

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Start eating healthy foods before processed-food -industry decides what you should eat

Twenty years ago, there  was no major processed-food- producing industry in India. Of late, the situation has changed drastically. Now since many upward mobile families have  husbands and wives working, all types of noodles and colas and drinks saturated with sugar  have become a major part of the foodstuffs  families consume. It has almost reached  a stage of no return. It may be very difficult to go back to healthy eating.  Advanced  countries have reached this perilous stage many years ago. It is now virtually impossible to reduce  consumption of salt or sugar by individuals as they have developed a taste for these ingredients.

Health agencies in those countries have started ‘requesting’  processed -food producers and restaurants to gradually reduce salt content. This way salt consumption may come to healthy levels after several years

http://www.eurekalert.org/pub_releases/2016-08/uoia-rpb080916.php

CHAMPAIGN, Ill. — An analysis of a nationally representative sample of U.S. adults reveals that access to healthy foods in a supermarket does not hinder Americans’ consumption of empty calories. In fact, the study found, U.S. adults buy the bulk of their sugar-sweetened beverages and nutrient-poor discretionary foods at supermarkets and grocery stores.

The new findings challenge the “food desert” hypothesis, which posits that a lack of access to supermarkets and grocery stores in some communities worsens the obesity crisis by restricting people’s access to healthy foods.

The study, described in the European Journal of Clinical Nutrition, looked at data from 4,204 adults who reported their daily food intake in two, nonconsecutive 24-hour periods in 2011 and 2012. The data came from the National Health and Nutrition Examination Survey. The analysis found that nearly half (46.3 percent) of U.S. adults consume sugar-sweetened beverages and 88.8 percent eat discretionary foods such as cookies, pastries, ice cream, cakes, popcorn and candy on any given day.

Sugar-sweetened beverages add an average 213 calories per day to the diet, the researchers found. Discretionary foods add, on average, 439 calories per day.

The largest portion of those products comes from supermarket shelves, the researchers report.

“More than half of the sugar-sweetened beverages and two-thirds of discretionary foods are purchased in supermarkets and grocery stores,” said University of Illinois kinesiology and community health professor Ruopeng An, who led the study.

“Supermarket purchases of these items are about two to four times as large as all the other sources – fast-food restaurants, full-service restaurants, convenience stores, vending machines and other locations – combined.”

The food desert hypothesis led the U.S. government to spend almost $500 million since 2011to improve access to supermarkets and grocery stores in underserved communities. States and municipalities also have made efforts to increase the supply of healthy foods, offering financial incentives to build new grocery stores or to increase the amount of fresh food available in convenience stores and gas stations, for example.

“It is true that supermarkets also are the largest source of healthy food,” An said. “But we can’t be naïve and think that people only purchase healthy food from supermarkets. They also buy all this junk food from supermarkets and grocery stores.”

Adding fruit and vegetables improves the diet, An said. “But from the standpoint of obesity prevention, it is only helpful if people replace junk food with healthy food,” he said. “We don’t see from our data that the presence of a supermarket has a preventive effect on people’s obesity or their junk-food intake.”

Indian health agencies must  start the public awareness move now. It is already late. A recent study revealed the usefulness  of  using mobile phones to carry health messages in India

 

 

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A fantastic news story on cockroach “milk”

“Structure of a heterogeneous, glycosylated, lipid-bound, in vivo-grown protein crystal at atomic resolution from the viviparous cockroach Diploptera punctata”. This is the title of a paper published in International Union of Crystallography  Journal (IUCrJ) Volume 3Part 4July 2016. Eleven authors from Canada, France, India, Japan and USA wrote this paper. I am sure that no one except a true specialist may have any interest in reading this paper, except when it is explained in simple jargon free language.

I read it for the first time from the following link:

http://www.zmescience.com/medicine/nutrition-medicine/cockroach-milk-superfood-future/

I could not imagine that such a lovely news story remains hidden in that original scientific paper. As on July 29, 2016, 10. 30 AM IST, different versions of the story appeared in over 250 news-outlets  including some of the major mainstream news papers and dispatches of news agencies.

You may be able to appreciate how various news outlets carried the story by using the following link:

https://www.google.com/?trackid=sp-006#q=cockroach+milk+superfood+of+the+future

No doubt this is likely to be a record of sorts seldom attained by any technical paper.

 

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Mercury poisoning linked to skin products cautions the USFDA

The United States Food and Drug Administration has just now cautioned people regarding cosmetic products which contain mercury. Some companies promote them as anti-aging skin creams and beauty and antiseptic soaps.

” How will you know if mercury is  in the cosmetic, especially one that’s marketed as “anti-aging” or “skin lightening”? US RDA asks.

It is simple.

“Check the label. If the words “mercurous chloride,” “calomel,” “mercuric,” “mercurio,” or “mercury” are listed on the label, mercury’s in it” the agency answered. ”  You should stop using the product immediately”.  FDA cautioned the consumer.

You may, if you so desire,  access the consumer note of July 2016  from the following link:

http://www.fda.gov/downloads/ForConsumers/ConsumerUpdates/UCM294876.pdf

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