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Patient-doctor dialogue vital

by Dr. Remy Perumal, Consultant in Acute Medicine,East Surrey Hospital, Redhill, Surrey, UK

Therapeutic value of talking with patients has been well recognised since the time of Hippocrates. Because the physician's words can have a major impact on the patients experience of illness, much of the good or harm that is done in medical care, depends on the style and content of the physician's communication.

Good communication skills therefore, provide the cornerstone of a satisfying and fruitful consultation for both clinician and patient.

Medical Interview

To practise clinical medicine today, whether, in developing countries or in the developed world, clinicians need excellent communication skills and a correct attitude and the ability to relate to patients.

Good medicine is not only the practice of science, but also the practice of humanities; and central to the humanitarian practice of medicine is the development of good communication skills. Central to the development of good communication skills is the development of empathy. To emphasise, health professionals need to know how to deal with patients sympathetically and without condescension.

Medical interviewing is a core clinical skill. It is the mechanism of doctor-patient communication, the most single important source of diagnostic data, and the means through which we gain the patient's confidence and elicit the patient's participation in the process of care.

This core clinical skill has now become complex and important, as it influences communication effectiveness, data accuracy, clinical decision making, ethical decision making, compliance, patient satisfaction, clinician satisfaction and clinical outcomes.

Ethical issues

Even experienced clinicians will acknowledge that, there are clinical situations which require care, diplomacy and sensitivity - e.g. breaking bad news, whether, it be informing the patient of a terminal illness or explaining complex ethical issues e.g. end of life decisions.

Acceding to family requests, on withdrawing treatment and at the same time avoiding breaking the law, could present a challenge, even to the articulate clinician.

Problems of ethics and communication are intertwined. Ethical issues, such as informed consent, truth telling and confidentiality arise frequently in the doctor-patient relationship.

Successfully addressing these requires skills in ethical analysis and communication.

Physicians often justify making healthcare decisions for patients on the grounds that the physician is more qualified to decide which treatment plan best promotes the patient's health. However, patient participation in clinical decisions, rather than unbridled physician paternalism is justified in the ethical principle of Beneficence.

It means taking into account the patients view of their best interest as well as their medical best interest.

In the western world, growing medical litigation is a major cause for concern. In the United Kingdom, each year the Medical Protection Society receives about 20,000 requests for assistance from doctors, who are the subject of a complaint, an investigation or are involved in a claim or other medico legal advice.

Avoiding complaints

There is a growing body of international evidence that, the better doctors communicate with their patients, fewer the number of complaints and claims made against them. Conversely, doctors who relate poorly with their patients, attract higher than average claims and complaints regardless of their clinical/technical ability.

In conclusion, good communication skills are paramount in medical encounters, whether the goal is to obtain accurate information, convey a serious diagnosis, help a patient consider alternative treatment plans or provide reassurance to a frightened patient.

Communication skills is essential learning for all healthcare professionals. For the clinician practising medicine today, good communication skills are a required need, to create positive patient relationships, to facilitate patient centred treatment decisions and to achieve better treatment outcomes, through team work and increased patient participation.

It helps to create immediate rapport, trust and empathy with patients, leading to clearer understanding of patient's priorities. It can also help limit complaints against clinicians and may reduce medical negligence claims.

Medical schools, academic colleges and medical specialist societies must have mechanisms in place, for Undergraduates and Postgraduates to acquire and continue to improve their skills to communicate effectively with patients, in the well informed and demanding, modern society.

Fight the need to sleep, and sleep

Wouldn't it be nice to curl up and take a nap right now? About twenty million insomniacs pace the halls each night, but it's difficult to assess how many people suffer from excessive daytime sleepiness, known as hypersomnia.

The National Sleep Foundation estimates that up to 40 percent of Americans have at least some of the condition's symptoms some of the time. Its consequences are worse than decreased productivity: Fatigue causes at least 100,000 car accidents per year, estimates the U.S. National Highway Traffic Safety Administration.

Mass drowsiness can't be pinned on any one culprit. "Sleep lives at the nexus of our social life, biology, and behaviour," says James Wyatt, director of the Sleep Disorders Service and Research Centre at Rush University Medical Centre in Chicago.

Wyatt and his colleagues send patients an eight-page questionnaire and meet with them for an hour before arriving at even a preliminary diagnosis. "We're not looking for the smoking gun, we're looking for all the indicators... it could be a biological sleep disorder, it could be a medication you are taking, and it could also be that you live near an airport or sleep with a noisy pet.

Hypersomnia is not merely feeling tired after a late night out. It's a stronger, more consistent sleepiness that compels you to nap, even at inappropriate times. See your primary care physician if you have a particularly hard time waking up, if you are especially anxious and irritable, and/or if you've lost your appetite. Unsurprisingly, excessive daytime sleepiness can cloud your thinking and mar your memory or even spur hallucinations.

Sleepy sources

You can make yourself sleepy by repeatedly staying up. But narcolepsy, a neurological condition marked by uncontrollable urges to sleep, or sleep apnea, which causes interrupted breathing during sleep, are involuntary potential root causes.

Factors that bring on hypersomnia (separately or in combination) also include depression or bipolar disorder, the use of prescription medicines, drug or alcohol abuse, a head injury, and a genetic predisposition toward drowsiness.

Wake-up calls

Hypersomnia can indeed be treated. Once a doctor determines what is causing your sleepiness, he or she would treat a primary sleep disorder first. Sufferers of sleep apnea, for example, may be advised to use a CPAP (continuous positive airway pressure) device, a mask attached to a machine that blows air to keep nasal passages open during the night. Antidepressants could be prescribed if your doctor believes depression, anxiety, or bipolar disorder is causing your excessive sleepiness.

Stimulants are also a common treatment for hypersomnia?and new drugs such as modafinal are thought not to be habit-forming. Exposure to artificial bright light in the morning can help reset your body's internal clock. Your doctor may advise you to cut down on your drug, alcohol and caffeine, or may use cognitive-behavioral therapy techniques to help you establish a more consistent sleep routine.

Sweet dreams

You've heard some of these sleep hygiene tips before, no doubt, but incorporating them requires not just knowledge but self-discipline. Try keeping a sleep diary each day to hold yourself accountable as you develop better habits.

Most importantly, go to bed and wake up at set times. Try to exercise for at least 20 minutes, preferably five to six hours before bedtime. Establish a relaxing nighttime ritual such as taking a warm bath or reading, avoid watching TV or surfing the Internet too late as those images will get your mind racing when it should be settling down.

PsychologyToday.com

Vegetarians are not prone to anaemia

by D. P. Atukorale

Anaemia means "lack of blood" and in patients with anaemia there is a reduction in the oxygen-carrying capacity of the blood which can be caused in three main ways

(a) loss of blood eg. due to piles, heavy menstrual flow or gastric and duodenal ulcers or hook worms infection

(b) excess red cell destruction as in haemolytic anaemias; and

(c) defective red blood formation eg. iron deficiency anaemia.

There are many types of anaemia but the commonest type of anaemia we encounter in our clinical practice is iron deficiency anaemia which is mainly a nutritional problem.

There is a misconception among non-vegetarians that anaemia is common among vegetarians. You may be surprised to know that despite the meat industry propaganda, that a healthy vegetarian diet is an excellent way to get all the iron, and vitamins such as folic acid and vitamin C you need.

Iron deficiency anaemia is a common problem among Sri Lankans both among meat eaters and vegetarians. Iron deficiency anaemia is more widespread among women (before menopause) than among men, and excessive bleeding during menstrual periods is very common among women.

Other animals such as chimpanzees and monkeys (who eat vegetarian diet) don't get anaemia. Vegetarian and vegan (pure vegetarian) diet is well capable of providing normal iron requirements which are normally obtained from dark green leafy vegetables (such as Gotukola, Niwithi), soya products and whole grain.

Recent scientific evidence reveals that over-consumption of iron rich foods such as red meat may be a health hazard and people with high levels of serum iron and serum ferritin are prone to heart attacks.

There are a large number of research studies such as British Vegetarian Study, The British Vegan Report, studies done in Israel, Netherlands, Sweden, Canada and China comparing haemoglobin (Hb) levels of vegetarians and meat eaters to show that vegetarians are not prone to anaemia. The Chinese study which involved 6500 vegetarians showed that meat eating is by no means necessary to prevent iron deficiency anaemia.

The American Dietic Association has concluded that with vegetarian and non-vegetarian diet iron and folate supplements are usually necessary during pregnancy although vegetarians frequently have greater intake of those nutrients than do non-vegetarians. All the research studies disprove the fallacy that a meat-free diet can't provide enough iron. It certainly can.

Other dietary anaemias

Besides iron, folic acid (vitamin B9) and vitamin B12 play an essential part in the formation of haemoglobin in the blood. Folic acid deficiency is widespread globally and unlike iron and other vitamins such as B12, body does not store folic acid.

The good news for vegetarians is that folic acid is present in many common green leafy vegetables and folic acid is not present in most meat, fish, milk and root vegetables.

For all practical purposes folic acid deficiency anaemia does not occur in vegetarians although folic acid is given to both vegetarians and non-vegetarians during pregnancy to prevent neural tube defects in the foetus.

Lecto-vegetarians

Majority of Sri Lankan vegetarians consume milk, curd and milk products that contain vitamin B12. The amount of B12 needed in the diet is 1.0 micrograms (one million of a gram) per day. As far as I am aware B12 deficiency has not been documented in Sri Lankan vegetarians (both vegans and lacto-vegetarians).

B12 is almost always manufactured by bacteria in our gut, mouth (around gums) nasal passages and around tonsils which may produce B12.

But it is advisable for vegans to take a vitamin B-complex tablet containing B12 periodically. It is noteworthy that most of the vitamin B-complex capsules and tablets contain B12.

Majority of laymen, some doctors and dietitians both in Sri Lanka and abroad believe that vegetarians are likely to be anaemic and these fallacies, like other folklore are passed down from one generation of practitioners to another because they sound plausible because no one bothers to check or question the original research in the field and if they do, they would be in for quite a shock.

A computer search reveals that in the period 1966 to 1994 a total of 7,618,328 major medical journals (Medline database published in US National Library of Medicine) were published.

Of these just 62 mentioned the word anaemia in connection with the word vegetarian or vegan and most of the 62 reports dealt with iron deficiency anaemia due to poverty.

That is just under 0.000814 per cent of medical literature in 28 years. Not very much is it?

As mentioned earlier that vegetarians are prone to anaemia is a common myth among Sri Lankan (laymen, dietitians and doctors).

In any middle aged or elderly person with anaemia due to vegetarian diet an underlying disease such as cancer, haemorrhoids, peptic ulcer or hookworm infestation etc should be excluded.

Plant-based foods are superior to meat-based ones because they furnish us all the iron (and other vitamins) and protect us from health hazards associated with iron overload.