dawn n dusk in the life of a physician

Dawn and Dusk in the life of a Dawn and Dusk in the life of a physicianphysician

Dr Vijay SardanaMD,DM ( Neurology)

Professor & HeadDeptt. Of Neurology

Govt .Medical College, Kota

The Noble Profession of MedicineThe Noble Profession of Medicine

“There is no career nobler than that of the physician. The Progress and welfare of society is more intimately bound up with the prevailing tone and influence of the medical profession that with the status of any other class…”

Elisabeth Blackwell, MD, 1889

Health care sector: problemsHealth care sector: problems

Shortage of skilled labour Increasing cost & complexity of technology Patient population more demanding Increasing orientation towards consumers

Doctors: ProblemsDoctors: Problems

Struggle to attract patients Rampant prevalence of unethical malpractice Declining social status Threat of litigation

Doctor : Have to answerDoctor : Have to answer

Patients Hospital Trustees courts

Doctors : Definition of successDoctors : Definition of success

Having lots of patientsNew car/plot Every year/lots of

moneyPublishing papers in journalsTeaching students

Doctor : FactsDoctor : Facts

One of the every three dissatisfied due to lack of time for themselves or their families

Average life 10 year less

Depression 4 times higher than general population

US- Physician suicide 3 time than general population

10% - Develop drug addiction

Stages of careerStages of career

Entry Establishment Exploration Specialization Mastery

Stages of Professional lifeStages of Professional life

No work, No money, lots of time

Some work, some money, some time

Plenty of work, Plenty of money, no time

SuccessSuccess

Know – How.Know - Who. Who you know. Who knows you.

Today's successful doctorToday's successful doctor

Clinician Academician Manager Financial Expert CEO Family care Provider Self care taker

Indian Doctor –Talented but less Indian Doctor –Talented but less RecognizedRecognized

Research – no motivation Infrastructure Lack of working hands, lack of time Commercialization No evidence based medicine approach

Component of a good Job

• Economic – Salary & facilities• Job security• Good working condition• Status• Growth Opportunities• Recognition of work done• Challenges of work

Judge your alignment with your job

• Am i passionate about what I am doing ?

• Am i using my talent and strength ?

• Am i happy in my work ?

• Does it bring joy & fulfillment ?

• Am I Earning what I deserve ?

Improve & change

Job satisfaction among DoctorsJob satisfaction among Doctors

69.5% –satisfied (AIIMS)

Medical doctor in Armed Force – 40% Choudhary et al MIAFI 2004;60:329-32

Initial satisfaction high , falls > 35 years, again rise later

Madan N. job satisfaction among doctor in a Tertiary Care Hospital jk science:2008,10(2)81-83

Stress among Resident doctorsStress among Resident doctors

32.8% had stress-17.7%- mild,13.2%-moderate,2.9%-severely

Reason- long duty hours, departmental academic activities, Financial constraints, family & emotional problem.

Predictors – year of Residency, giving time to family & friends, job satisfaction, existence of children, place of graduation.

Saini NK et al Iindian j public health. 2010;54(4):219-23

Physician motivationPhysician motivation

“determinants that drive performance of a task, independent of the resources and knowledge available”

Physician motivatorsPhysician motivators

Intrinsic Serving people Work interest Career growth Ability to support oneself & family Autonomy EmpowermentSocio-cultural Respect Social rewards

Physician motivatorsPhysician motivatorsorganizationalorganizational

Opportunities for higher education Good working & hygienic conditions Personal safety Good professional experience Good pay Financial incentives other than pay

Doctor-Patient RelationshipDoctor-Patient Relationship

Blind trust

Informed trust with skepticism

Patients satisfactionPatients satisfaction

Satisfied patient 3 other people

Dissatisfied patient 20 others

Satisfying unhappy patients 50 others

Medical ProfessionalismMedical Professionalism

“Contributing those attitude and behaviors that serves to maintain patients’ interest above Physicians’ self interest.”

Medical professionalism : Medical professionalism : deprofessionalism- causesdeprofessionalism- causes

Technology – Depersonarlise medicine & deprofessionlise a physician

Corporatization of Medicine Specialization – Most patients identified by

disease rather than human beings who happens to have disease

Patients knowing limitation of modern medicine Greed


Failure of referral system

Disproportionate work load

Unnecessary administrative responsibilities


Influence of drug & medical equipment manufacturer

Pardoned

Tolerated

norm

Violence Against Doctors

Doctors’ ExpectationsDoctors’ Expectations

Administration should punish the guilty

Media –

- publish both views, avoid sensationalism, seek an expert opinion preferably from another city

- more positive

Doctor-Patient relationship: Doctor-Patient relationship: PoliticiansPoliticians

Political mileage.

Instigating patient to raise voice against doctor, at times unjustified.

Display of Warnings & Other Display of Warnings & Other informationinformation

Display warning in hospital premises mentioning the consequences of violence against doctors in hospital

Display flow chart/plan in Emergency Room

Display information on boards, counters etc.

Try not to escalate costs later or change plans frequently

Improving RelationshipImproving Relationship

Teaching of ethics & communication skills in UG curriculum.

Teaching of sociology aimed at creating cultural sensivity,empathy & respect for patients’ dignity.

Teaching legal aspect of practice. Physician has to enter patients world- to

see illness through patient’s eye

Resident Evaluation checklist on Resident Evaluation checklist on ProfessionalismProfessionalism

Marking 0 1 2 3 4 5 6 7 8 9 10 Unsatisfactory Satisfactory exemplary

(1) Empathy in patient care.(2) Appropriate fund of knowledge.(3) Soundness of clinical judgment.(4) Technical expertise with diagnostic and therapeutic procedures.(5) Communication with patients, families and staff.(6) Sensitivity and responsiveness to individual patient differences in

economic status,ethinicity,age,gender and disabilities.(7) Honesty in dealing with patients and colleagues.(8) Accountability for action.(9) Conflict-resolution skills.(10) Adherence to regulatory, institutional and departmental norms.

Pressures

Ministers Bureaucrats Ex ministers PAs Political party office bearers Other parties Regional parties Media others

Communication skillsCommunication skills

“ Patients don’t care how much you know them, until they know how much you care”

Communication skills in clinical skills in clinical practice- Introductionpractice- Introduction

“Its an art to talk medicine in the language of a non medical men”

not an option but a necessity

separates successful doctors from

unsuccessful ones

include ability to engage with patients at

emotional level, to listen, to convey

information with clarity & sympathy

What do patients wantWhat do patients want

- Patient dissatisfaction with doctors relate to problems of communication rather than clinical competence

- They want - quality information about their problems - risks & benefits of treatment - relief of emotional distress - to be active participate in medical decision

making

Benefits of doctor patient communicationBenefits of doctor patient communication

- communication with personal touch provides treatment beyond drugs

- Patients more likely to comply

- The overall quality of care & patient satisfaction improved

Answering skillsAnswering skills

weakest communication skills among Indian Medical Professionals

In Indian context patient satisfaction is largely decided by the quality of answers & explanation given by doctors

Understand the question clearly, answer fully, & clearly but briefly

Avoid major technical terms

Barriers to communicationBarriers to communication

Work over load on doctors

Shortage of man power- less time for individual patient

Lack of training in communication skills during medical education

Individual attitude & personality traits

Under utilization of paramedical staff

CommunicationCommunication

7% - Spoken words

38% - Voice quality like Tone, Tempo, intonation

55% - Body language

How to perfect non verbal How to perfect non verbal signalsignal

Smile Open Posture Forward lean Touch Eye contact Nod

Information sharing & decision makingInformation sharing & decision making

Most important when there is life threatening illness

When different management options exist with varying costs, benefits & when outcome is unpredictable

Discuss risks & benefits of each option

It not only increases patient satisfaction but also reduces the chance of litigation if any adverse outcome results

While prescribing any drug with life threatening side effects- informed consent to be taken

Communicating prognosis, hope & riskCommunicating prognosis, hope & risk

Misunderstandings in these areas can lead to patient dissatisfaction & litigation

Prognostication is like weather forecasting uncertain but based on sound scientific principles

Stage of illness at presentation of patient Curability of disease

In face of uncertainty there is nothing wrong with providing hope

Provide evidence based risks

Never create guilt for negligence on part of patient

Dealing with relatives during Dealing with relatives during resuscitation resuscitation

Routinely relatives are excluded

Studies have found no adverse psychological effects if some mature person observes the process

One of the doctors of team should explain the procedure being done to relatives- it builds better rapport & communication regarding adverse outcome easy

Remember that bereaved relatives are also your patients- counsel them & give medical help

Anticipate & handle common reactionsAnticipate & handle common reactions

Disbelief- Is he really gone- for their satisfaction show them proof- eg. ECG

Guilt- by giving logical & rational explanation & saying that he tried his best

Offer help to manage transport

In case of Violence & Aggression- Remain calm & show sympathy Talk to some elder & mature person Call police if situation is out of control

If too many anxious attendants, send them one or another job. eg. Bringing medicines, arranging blood- Energy utilization

Never argue with attendants

Argument will trigger them, at the same time your calmness and promptness will even calm down a triggered person.

If patient is sick, attend patient periodically and talk to attendants.

Check emergency tray for drugs.

Try to solve/resolve crisis immediately

Do’sDo’s

Do’sDo’s

Patients should be attended promptly: - Error in Decision making is Excusable but not

attending patients timely is not.

Identify a Prominent Person: - Important person/relative and explain initial

assessment of patient immediately. - Explain them management has started.

Ask if they have any questions

Call senior consultant as per requirement, talk to them telephonically if possible delay in arrival.

Don’tsDon’ts

Never argue with attendants. this situation teaches you how to remain calm in provocative circumstances. No book in the world can teach this.

Never overlook a call, especially if call is by a attendant.

Have positive attitude

Attitude

• Way a person feels, thinks & behaves towards a particular issue.

- half full-hall empty

Positive Attitude - Benefits

• Pleasing personality

• Energizing

• Inspiring

• Problem Solving

• Increase work output

Attitude

Job/promotion/success

- 85% Attitude - 15 % Intelligence & knowledge of specific facts $ figures

• Education - Almost 100% teach facts & figure

12__suraj_ki_garmi_se.mp3

Elements of success

Attitude

SkillKnowledge

Attitude formation of a PhysicianAttitude formation of a Physician

Medical studentAltruismRole models behaviorPrevailing commercialismWork environmentSocial and political environment

Positive Mindset

• Look for Positive in every person.

• Develop an immunity to negative criticism.

• Learn to find pleasure in every little things.

• Remamber ups and downs are part of life.

• Keep yourself continuously occupied. Spend so much time improving yourself that no time left to criticize others

• Be equally enthusiastic about other success

• forgive yourself & others.

Identify & avoid negative people

How value system change

Intolerable

Acceptable

Involvement

Constant Exposure

Constant Exposure

Self justification

‘‘Frenemies’Frenemies’

Positive

• Part of the answer

• Has Program

• Let me do it for you

• Difficult but possible

• I must do something

• See the gain

• See possibilities.

• Hard arguments, Soft words

Negative

• Part of the problem

• Has excuse

• Its not my job

• Possible but to difficult

• Something must be done• See the pain

• See problem.

• Soft arguments, Hard words

Positive

• Firm on values, Compromise on petty things

• Don’t do it to others what you would not want to do to you

• Make it happen

Negative

• Firm on petty things, Compromise on values

• Do it to others before they do it to you

• Let it happen

Use common sense with knowledge

Knowledge Vs Wisdom

• Common sense – 6th sense - Ability to see things as they are and do them as ought to be done.

• Abundance of Common sense - Wisdom

Knowledge Vs Wisdom

• Knowledge - Piling up facts Wisdom - Simplifying it

•Knowledge - Potential power Wisdom - Real power

• To attain knowledge - Add things everyday To attain Wisdom - delete things everyday

Believe in reasoning & have critical thinking

Reasoning

• Cognitive process of looking for reason, Beliefs, conclusion, actions & feeling

• Why reasoning – What we should believe - What we should do

Critical Thinking

• Involve determining the meaning & significance of what is observed & expressed

•If adequate justification to accept argument, inference and conclusion as true

Lord Buddha : 6 centaury B.C.Lord Buddha : 6 centaury B.C.

Rely not a teacher/person, but on the teaching Rely not on the words of teaching but on spirit

of words Don’t believe in any thing simply b’cos you have

heard it Don’t believe in traditions because they have

been handed over for many generations

Lord Buddha : 6 centaury B.C.Lord Buddha : 6 centaury B.C.

Don’t believe anything because it is spoken & rumored by many

Don’t believe in anything because it is written in religious books

Analyze & observe -apply reasons, if any thing is good & beneficial to one &all agree to it.

Emotional Intelligence (EQ)Emotional Intelligence (EQ)

Def – “The ability to monitor one’s own & other feelings & emotion to discriminate among them, and to use this information to guide one’s thinking and action”

IQ Average citizen - 100 Doctor - 120

EQ Average citizen - 100 Doctor - 90

EQ ComponentsEQ Components

Knowing your own emotions (Self awareness) Managing your own emotion (Self regulation) Motivating yourself Recognizing and understand other people’s emotion (

Empathy) Managing relationships or social skills- Skills in managing emotions in others determines

popularity, leadership & interpersonal effectiveness.

EQEQ

Physician cannot perform his job without understanding his emotion & those of patients

IQ - Technical Competence EQ - People’s Competence

IQ - Gets you job EQ - Gets you promoted

IQ - Gets you higher marks EQ - Makes you happy & Productive

Keeping updated : Managing Keeping updated : Managing knowledgeknowledge

Medical books -- Become outdated fast Medical journals -- Costly Conference Medical representative Internet

Medical knowledge problem – Mammoth size - Short half life

Keeping updatedKeeping updated

Imitation

Structure your knowledge around patients

Learn from your past mistakes

Master clinical protocols & Flow charts

Concentrate on carry home massages

“ The education of the doctor which goes on after he has his degree is the most important part of his education”

John Shaw Billings

TRADITIONAL CME Vs CPDTRADITIONAL CME Vs CPD

73www.cpdindia.in

www.cpdindia.in 74

www.cpdindia.in 75

Develop friends & interest outside medicine

Vulnerable times for mistakesVulnerable times for mistakes

Tired, lazy, sleepyAngryOverconfidentPatient irritatingComplex medical Problem

Mistake : ResponseMistake : Response

Blaming the system Blaming the colleagues, even patients Disconnecting of importance ( No Clinical

effectiveness) Emotionally Distancing (Everyone makes

mistakes)

Dealing with mistakeDealing with mistake

Accept responsibility for the mistake Discuss with trusted friend, colleague or

spouse Disclose & Apologize to the patients Error analysis Measures to reduce similar mistake in future

Marketing in medicineMarketing in medicine

“Marketing is Practice building not advertising”

Practice Practice building/Marketingbuilding/Marketing

Satisfied patients Volunteering at community medical service. Organizing an event – like conference Attracting Media attention Contributing article on health to magazine Public lecture News letter Website Marketing to referral base

Informing patient in information Informing patient in information ageage

Printed material Broachers

Exercise has life transforming benefits

Regular exercise: benefitsRegular exercise: benefits

Improves cardio vascular fitness Improves mood Reduces stress Loses fat, not lean muscle Decrease back & joint pain Decrease loss of bone density Decrease chol., Ht, insulin senstivity,

incidence & mortality from CAD, risk of colonic cancer

Physicians: problematic spouse?Physicians: problematic spouse?

MarriagesMarriages

Perfectionism, compulsiveness & work holism – good doctor but problematic spouse

Many married to Profession – no time to cultivate intimacy with spouse

MarriagesMarriages

Stage 1 -- Romance – you are perfect Stage 2 -- Fault finding Stage 3 -- Blaming Stage 4 -- Acceptance Transformation – Growing together

Issues Threatening marriageIssues Threatening marriage

Money & Financial arrangements Infidelity Boredom Career crisis Empty nest syndrome Retirement.

MarriagesMarriages

Spend time together Respect each other Have fun together Treat your spouse as your most

important VIP patient -- A loved spouse is also loving

spouse

children and jealous mistresschildren and jealous mistress

A meal together everyday Fun together once a week One holiday every year together Make sure children meet grand parents,

relatives periodically Help children honor family traditions

Physicians: personal crisis

Doctor : Personal crisisDoctor : Personal crisis

Illness Divorce Financial Loss Being Sued Bereavement

Doctor: Personal crisisDoctor: Personal crisis

Qualities make you better equipped to handle

Self confidence Optimism Sense of humor Resilience Faith in God

LitigationLitigation

Patient dissatisfaction Mistrust Medical litigation

LitigationLitigation

Professional failure in diagnosis or treatment

Lack of communication

Some form of insensitivity by the doctor to upset them emotionally – insult adding to injury.

LitigationsLitigations Reasons related to clinical competenceReasons related to clinical competence

Failure to perform adeq clinical assessment

Omission of necessary tests Improper diagnosisFailure to treat

Legal battleLegal battle

Phases

Denial Anger Bargaining Depression Acceptance


Single law suit doesn’t mean you are a bad doctor.

Usually results from unavoidable bad outcome, communication gap, misunderstanding with patients/attendants, anger rather than actual negligence.


Patients has to prove 4 things

Duty Breach of standard care Injury Proximal Cause


Inform your professional indemnity insurance company

Discuss with your spouse

Don’t discuss with colleagues, staff, & reporters

Ask for the details, if you don’t remember the detail of the patient.

How to reduce chances of litigationHow to reduce chances of litigation

Be a nice person Be honest Be open Be accessible Keep up to date professionally Insurance

BurnoutBurnout

Loss of Physical, Emotional & Mental Energy

Doctor - BurnoutDoctor - Burnout

Personality Traits

Perfectionists Want to do anything themselves Often act as if infallible

Burnout : SymptomsBurnout : Symptoms

Behavioral – Angry/Depressed, poor concentration,

Chronically late or psychologically absent, work avoidance

Excessive drinking/Drugs

Tiredness, lethargy, sleep disorders

Burnout – Things to do Burnout – Things to do

Learn to take care of yourself – learn to rest - learn to Exercise Learn to say No

Have fulfilling life outside of clinic-develop your hobbies & activities

Learn to cut routine work

Develop strong support system

Doctors are not organized or united

Physicians: well equipped but don’t venture in leadership

Physician : lets take leadPhysician : lets take lead

Leadership – genes, charisma, education, wealth, luck, training, experience

Ethics do right

Reality Greatness vision Have no think big & new Illusion

Courage act with sustained initiation

Physician – lets take a leadPhysician – lets take a leadphysicians well groomed to be good leadersphysicians well groomed to be good leaders

Educated Articulated Affluential Respected Deal with human emotion daily Deal with cross section of society think scientifically.

Physician : Lets take a leadPhysician : Lets take a lead

Lets make a professional bodies strong

More representation of Professionals in policy making team e.g. Secy. Medical Education Chandigarh a Doctor

Patients spiritualityPatients spirituality

Soft definition – “The way you find meaning, hope, comfort & inner peace in your life’’

Spirituality Vs Religion one may be spiritual without being religious

illness triggers – spiritual distress in patients & family members.

It pays to address spiritual belief of It pays to address spiritual belief of patientspatients

Religion belongs to spiritual needs are common

among patient

Religion belief sometimes influence decision making

Spirituality is related to positive health in some areas

Better patient doctor relationship

Patients & SpiritualityPatients & Spirituality

Spirituality concept not scientific Few physician are hard core religious/spiritual Spiritual concepts are thought private not

worth discussion.

Doctor & SpiritualityDoctor & Spirituality HOPE HOPE

Hope Organized religion Personal spirituality & practices Effect or medical care issues

Doctor & SpiritualityDoctor & Spirituality

No Further Action Spirituality as adjuvant care

Impaired PhysicianImpaired Physician

“ one who is unable to practice medicine with reasonable skill and safety of patients”

Physical or mental illness. Ageing process Loss of motor skill Drugs/alcohol abuse

Impaired physicianImpaired physician

Denial

Physician Health Programme

Peer assistance committee- early identification, treatment & rehabilitations of physicians.

Think of retiring when you feel time is right

Preparing to retirePreparing to retire

What would you do if you didn’t have to work for living Where do you want to live How will you use your time so that you remain

productive & inspired Want to be close to children or away What role the family will play Arrangement for possible decline in health

RetirementRetirement

Don’t retire unless you have enough financial security Studies-Retirement has Predominantly positive impact

on emotional state Explore you hobbies Explore your spirituality Serve other selflessly-do charity work/volunteer work Physical activity/light exercise

Think of retiring when you feel time is right

Preparing to retirePreparing to retire

What would you do if you didn’t have to work for living Where do you want to live How will you use your time so that you remain

productive & inspired Want to be close to children or away What role the family will play Arrangement for possible decline in health

RetirementRetirement

First year is difficult, adjustment subsequently

Old spouse is the best friend around

Grand children keep you busy & happy

Reduce the workload to the extent of enjoying it.

Take homeTake home

Let us enjoy being a doctor/physician, let us work for joy of working, nor for a home, car or vacation

Don’t find faults in medicine, Identify happy doctor & follow their secrets

Lets love what we do, and do what we love

Watching dying patients should remind us about our own mortality enabling us to live each day well.

Take HomeTake Home

Social capital is more important than financial capital at end of the day.

Work & practice with Medical professionalism

Use common sense. Identify local socio-cultural practices & integrate in your working style

People prefer those doctors with average clinical skills but good communication skills rather than those with excellent clinical but poor communication skills

Visualised yourselfVisualised yourself

Visualize your funeral with these speakers – A family Member, a Friend, a colleague & a patient.

ThanksThanks

dawn n dusk in the life of a physician

Health & Medicine