The Resident's Scolding

Dr. Dev (Fictional Name) went to meet his friend Dr. Jolting (Fictional Name) at his hospital. Dr. Jolting was taking the ward round at that time. When he saw the case sheet record of one patient he first frowned and then angrily scolded the junior resident doctor in-charge of that patient, ‘Why is the case sheet not complete?’

The patient was suffering from an infected wound on his leg. It had happened that the junior resident had done debridement i.e. surgical removal of the infected tissue, and dressing of the wound the previous day but had not written it down in the case sheet. So, even when the surgery had been done, the case sheet showed that the patient was just being treated with antibiotics and pain killers.

After Dr. Jolting reprimanded the resident for not maintaining the proper record, Dr. Dev noticed a strange thing. 

With a softening of his voice, Dr. Jolting suddenly changed his tune. He said to the resident, ‘You are such a hard-working person and take such good care of the patients. But all your hard work does not get reflected in your written record. Next time write down in the case sheet all the hard work you are doing for this patient!’

Once the ward round was over and Dr. Dev was alone with Dr. Jolting in his chamber/office, a curios Dr. Dev asked Dr. Jolting to explain his strange behavior of first scolding and then praising the resident within few seconds.

Dr. Jolting explained, ‘First I scolded the resident as negative conditioning, that he remembers in future that if his work is not up to the mark then he will be disciplined.’ 

‘I then praised the resident, as he had actually done the work as positive reinforcement. Also, the patient and his relatives were watching closely the entire time. If I stopped at the scolding stage then the patient and his relatives would have carried the impression that the patient is not receiving proper care in the hospital. You may think it is the resident who will be blamed, but the good name of the entire hospital will be besmirched along with me as his supervisor. They will say that the doctors of this hospital are not taking proper care of the patient. There will be collective infamy.’

Dr. Jolting continued, ‘By praising the resident for the work he had actually done in front of the patient and relatives, there is first positive conditioning, that the resident remembers that if he will do good work it will get appreciated. Then again by praising in front the patient, the reputation of the hospital gets a build-up and the patient understands that the resident had just done a clerical slip up and not done any actual error or mistake in the patient's care. This will help in preventing any litigation or charges of deficiency in the patient's care from him in the future.’

If your junior staff had done some error, avoiding bringing the matter in front of your patients/clients/customers. This will damage the reputation of the entire hospital/institution/organization.

If someone had done good work along with some error then be balanced in your feedback with praise for the good work and chastisement for the error. While penalizing for the error or deficiency do not overlook any good part of the work done by them. You will then earn the reputation of being a fair person who gives what the juniors actually deserve.

 (Based on an allegedly true incident)

— ND

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DISCLAIMER: This article is intended only for fun purpose. The author does not promote or recommend any behavior illustrated here or claim it to be useful. Use of the information herein is at you one's own risk. Before trying to emulate or follow anything the reader is well advised to take into account ethical, moral, legal and other considerations. The author recommends that Medical Practice should be of the highest ethical and moral level keeping in mind the interest of the patient as foremost. 

DISCLAIMER: This article is intended only for fun purpose. The author does not promote or recommend any behavior illustrated here or claim it to be useful. Use of the information herein is at you one's own risk. Before trying to emulate or follow anything the reader is well advised to take into account ethical, moral, legal and other considerations. The author recommends that Medical Education should be of the highest ethical and moral level keeping in mind the interest of the patient as foremost and according to MCI and other Board’s norm

The Operation Charges

Enough of the true incidences and life lessons; let me try to write some fiction for light Sunday reading.

The son of a famous surgeon completed his Mastery of Surgery (MS) from AIMS, New Delhi, (Fictional Name) and came back to work with his father, in their small hospital in their home town. 

The father who was a very experienced surgeon imparted this wisdom to his son.

The father said, ‘Son, you may have learned how to operate and treat the patient in AIMS, Delhi, but the most important part of private practice in  surgery is to know how to charge your patients for the operation.’

The father explained, ‘Suppose you want to charge Rs 25,000 for an operation. If a patient comes and asks about the charges of that particular operation, say it is Rs 30,000 and closely observe the patient.’

‘If the patient appears shocked and upset’, continued the father, say, ‘If you belong to economically weaker section of the society, then as public service I will give you discount of Rs 5,000 and you can pay just Rs 25,000 for the operation’ ‘Everyone, including patients love a good bargain, and you can also act as if you are not money minded or greedy’ explained the father.

‘If the patient does not appear shocked on hearing the charges then add, ‘That is only the surgeon’s charges; it will be Rs 30,000 extra for the Operation Theatre (OT) charges.’ 

‘If the patient still does not appear surprised,’ the father continued, say; ‘there will be also Rs 30,000, charges for the anesthetist and operation theatre’s nursing and paramedical staff.’ 

‘If the patient still appears cool and unfazed, add; ‘there will Rs 30,000 ward bed and nursing charges in addition to these charges.’ (The total now is Rs 1,20,000/-).

‘If the patient still appears serene’ continued the father, say; ‘you will also have to get investigations (tests) done before the operation which will cost you Rs 30,000’ (The total now is Rs 1,50,000/-).

 ‘If the patient still appears unperturbed, then add; you will have to deposit Rs 30,000 for medicines and other consumables items, such as syringes and gloves, during the ward stay.’ (The total now is Rs 1,80,000/-).

‘What to do if the patient still appears calm and placid on hearing this as we appear to have used up all the methods to increase the bill?’ inquired the son.

‘If anyone reaches till this level and still remains cool and calm then we will use our reserve golden card’ replied the father, ‘And we will say;  ‘there will be also Rs 30,000 for the ICU charges, where you will have to be kept immediately after the operation.’ (The total now is Rs 2,10,000/-).

‘What do if the patient still appears unworried and composed even after hearing this?’ asked the son.

The father sagaciously replied, ‘Then drop everything and immediately call a press conference and announce to the world that Bill Gates has come to your hospital to get operated!’

 

 (Entirely Fictional)

— ND

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DISCLAIMER: This article is intended only for fun purpose. The author does not promote or recommend any behavior illustrated here or claim it to be useful. Use of the information herein is at you one's own risk. Before trying to emulate or follow anything the reader is well advised to take into account ethical, moral, legal and other considerations. The author recommends that Medical Practice should be of the highest ethical and moral level keeping in mind the interest of the patient as foremost. 

DISCLAIMER: This article is intended only for fun purpose. The author does not promote or recommend any behavior illustrated here or claim it to be useful. Use of the information herein is at you one's own risk. Before trying to emulate or follow anything the reader is well advised to take into account ethical, moral, legal and other considerations. The author recommends that Medical Education should be of the highest ethical and moral level keeping in mind the interest of the patient as foremost and according to MCI and other Board’s norm.

The Lymph Node Biopsy Lesson

A young boy came to AIIMS, New Delhi with complaints of fever and abdominal pain. On investigation, he was found to have multiple enlarged lymph nodes in the abdomen. 

For Non-Medicos: Lymph nodes are tiny bean-shaped organs found throughout the body. They may be 500 to 600 in number. They filter the lymph flowing in the body and are an important part of the body’s immune (defense) system against various germs. 

The lymph nodes are generally few mm in size with the largest being lymph nodes lying in the inguinal (groin) region where size up to 1 cm (10 mm) may be normal. They may become enlarged (increased) in size in a variety of disorders such as viral or bacterial infections, e.g. infectious mononucleosis, tuberculosis, skin infections, and even cancer.

He got admitted in the surgery department and a laparotomy, (opening the abdomen by making a surgical incision (cut) and examining the internal organs usually done under general anesthesia in the major operation theatre, and biopsy of enlarged lymph nodes was planned. This was the days before the spread of laparoscopic surgery.

For Non-Medicos: Lymph node biopsy is a surgical procedure where single or multiple lymph nodes are removed by operation and sent to the pathology department for histo-pathological examination to find if they are having any disease.

On routine check-up the junior resident found that he had minimally enlarged lymph nodes in the left inguinal (groin) region. This finding was discussed on the ward clinical round, and as tiny lymph nodes in the groin region are very common even in a normal person and the biopsy of these inguinal lymph nodes usually is not diagnostic, the original plan of laparotomy was followed.

On opening the abdomen the lymph nodes were found to be adherent to each other and to large blood vessels and covered with fibrous tissue. A small piece was taken for biopsy due to fear of causing any complications due to injury to the large blood vessel stuck to the lymph nodes mass.

The pathology report came back after a week. It was inconclusive, i.e. no clear opinion was possible and the pathologist advised to repeat the biopsy with a bigger piece.

The patient and his parents were upset when they learned that the patient will once again have to undergo the major laparotomy operation to get a fresh tissue sample for repeat pathological examination.

The junior resident looking after the patient noticed that those left groin lymph nodes which were initially tiny on admission had now grown to significant size since the patient had got admitted to the ward. This was discussed in the clinical ward round. Although biopsy from the groin lymph nodes are usually inconclusive, but after considering the risk-reward ratio, it was decided to do lymph node biopsy from the groin and wait for the result before doing a repeat abdominal operation.

The patient underwent the relatively minor operation of the lymph node biopsy from the groin region under local anesthesia in the minor operation theatre.

One week later the biopsy report came and there was the unequivocal diagnosis of lymphoma, a cancer of the lymphatic system. With the diagnosis made, the repeat laparotomy was canceled and the patient was referred to the oncology (cancer) department for further treatment such as chemotherapy.

During an ongoing treatment of a patient, a project, a journey, etc. the situation may change. As in this patient, there were only tiny lymph nodes on admission but they increased to a significant size during the hospital stay. Keep on continuously monitoring the situation and if something new occurs then you may change your plan accordingly.

Do not disregard the observation and suggestion of any member of the team, no matter how low in the hierarchy he/she is. This is especially true if the team member is closely involved in the day to day care/function of the patient/project. For example, the junior resident is junior most in a medical college unit, yet due to his keen observation, the patient was saved from undergoing another major surgery.

In real life, sometimes there may be an exception to general rules or guidelines, such as in this case. Biopsy from the groin lymph nodes is not usually done but in this patient, biopsy turned out to be diagnostic from the groin region. So be open to making exceptions to rules and guidelines according to the actual situation.

(Based on an allegedly true incident)

— ND

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DISCLAIMER: This article is intended only for fun purpose. The author does not promote or recommend any behavior illustrated here or claim it to be useful. Use of the information herein is at you one's own risk. Before trying to emulate or follow anything the reader is well advised to take into account ethical, moral, legal and other considerations. The author recommends that Medical Practice should be of the highest ethical and moral level keeping in mind the interest of the patient as foremost. 

DISCLAIMER: This article is intended only for fun purpose. The author does not promote or recommend any behavior illustrated here or claim it to be useful. Use of the information herein is at you one's own risk. Before trying to emulate or follow anything the reader is well advised to take into account ethical, moral, legal and other considerations. The author recommends that Medical Education should be of the highest ethical and moral level keeping in mind the interest of the patient as foremost and according to MCI and other Board’s norm.

The SR to JR Reversal

Dr. Ravi (Fictional Name) was a junior resident in the Department of surgery in AIIMS, New Delhi. Dr. Ajay (Fictional Name) was the senior resident in the unit in which Dr. Ravi was posted. Both were preparing for the AIIMS Urology Mch entrance exam. 

Mch is a 3-year super-specialization course done after passing the Master of Surgery (MS) exam in general surgery. Urology is the super-specialized branch dealing with surgery of the genito-urinary system, e.g. kidney, prostate, testis, etc.

Being a brilliant student, Dr. Ravi got selected in the first attempt to the Mch Urology course and joined it while his senior resident, Dr. Ajay, did not get selected. 

Dr. Ajay kept on working as a senior resident and studying and preparing for the Mch exam. Dr. Ajay got lucky the third time and finally got selected to the Mch Urology course in AIIMS, New Delhi. By this time, his junior resident, Dr. Ravi had become the 3^rd year resident in the Urology department. 

So the senior resident now became the first-year resident and his ex-junior resident became his senior resident.

A similar incidence occurred in Rajasthan (India) police department. A constable who was preparing for the Rajasthan Civil Services got selected to the Police branch and got posted as Deputy Superintendent of Police (Dy SP) with the police station where he was serving as constable coming under his jurisdiction. Now he had become a senior officer to the same inspector under who he was serving in the past.

Life is filled with ups and downs. Keep in mind that those who are junior to you now may become your senior and those who are senior to you may become your junior. Temper your behavior with people around your suitably. 

As someone had so well said, be kind to people who you pass when you are climbing the ladder of success as you may meet them as you slide/fall down the same ladder.

Education and hard work can work wonders for you and make you jump up in life. So if you are not satisfied with your career/job or your supervisor/boss/officer, make these the tool to rise above them.

The opposite case of a JR becoming SR is illustrated in 'The JR to SR Promotion'

(Based on allegedly true incidents)

— ND

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DISCLAIMER: This article is intended only for fun purpose. The author does not promote or recommend any behavior illustrated here or claim it to be useful. Use of the information herein is at you one's own risk. Before trying to emulate or follow anything the reader is well advised to take into account ethical, moral, legal and other considerations. The author recommends that Medical Practice should be of the highest ethical and moral level keeping in mind the interest of the patient as foremost. 

DISCLAIMER: This article is intended only for fun purpose. The author does not promote or recommend any behavior illustrated here or claim it to be useful. Use of the information herein is at you one's own risk. Before trying to emulate or follow anything the reader is well advised to take into account ethical, moral, legal and other considerations. The author recommends that Medical Education should be of the highest ethical and moral level keeping in mind the interest of the patient as foremost and according to MCI and other Board’s norm.

The JR to SR Promotion

Dr. MK (Fictional Name) was a final year junior resident (JR) in Surgery Department in AIIMS, New Delhi. As expected in the very hectic and busy work schedule of the junior residents in AIIMS, many times Dr. MK work used to be incomplete and he used to be reprimanded by the senior resident in the unit. 

Dr. MK passed his MS exam (Mastery of Surgery) and got selected for the post of senior resident (SR) in AIIMS itself. By chance, he got posted as a senior resident in the same unit in which he was junior resident. 

Those junior residents with whom he used to behave like friends and colleagues had now become his juniors. By virtue of his post, he was entrusted to control them and discipline them if they were found lacking in their work. He now had to point out and discipline the junior residents in the unit for the same mistakes he used to commit as a junior resident in the past.

Once a junior resident pointed out, ‘MK you are getting angry at us for the same mistakes that you used to commit when you were junior resident like us.’ 

Dr. MK sagely replied, ‘When I used to commit these mistakes as a junior resident then I was lacking in my duties in the past. But if I let you commit the same mistakes then I am not fulfilling my duties as a senior resident in the present. Just because I had made some mistakes in my past is no excuse to let you also commit the same mistakes in the present.’

A similar problem is faced by many when they get promoted and become the officer/boss/in-charge/supervisor of the people of the same unit/division/ office in which they used to work. The juniors, who were their colleagues in the past, do not take them seriously. Many times the junior tries to raise the point that even you were committing the same mistakes when you were in their post. 

First, show strictness and firmness from the moment you assume your new post. Give a clear message that even if you were lacking in your work in the past, you will not tolerate them as their officer/supervisor. 

If possible, it is better to get transferred and start fresh in a new unit/branch/ division when you get promoted that such a problem be avoided altogether. Some companies follow this policy of mandatory transfer to some other office when a person gets promoted for the same reason.

With the passage of time, the memory of your shortcomings during your junior post will fade from everyone memories. You can, later on, get transferred to the same unit/division/branch after some times when your new identity as the superior officer has become well established that you will not face any problem in controlling your present juniors.

 (Based on an allegedly true incident)

— ND

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DISCLAIMER: This article is intended only for fun purpose. The author does not promote or recommend any behavior illustrated here or claim it to be useful. Use of the information herein is at you one's own risk. Before trying to emulate or follow anything the reader is well advised to take into account ethical, moral, legal and other considerations. The author recommends that Medical Practice should be of the highest ethical and moral level keeping in mind the interest of the patient as foremost. 

DISCLAIMER: This article is intended only for fun purpose. The author does not promote or recommend any behavior illustrated here or claim it to be useful. Use of the information herein is at you one's own risk. Before trying to emulate or follow anything the reader is well advised to take into account ethical, moral, legal and other considerations. The author recommends that Medical Education should be of the highest ethical and moral level keeping in mind the interest of the patient as foremost and according to MCI and other Board’s norm.

The Fracture Reduction

Forget the ancient period when the knowledge was shared only among a few select persons, often in a secretive society or cult; even just a few years ago, there were many who were secretive about their knowledge or techniques. 

Dr. Ashok Tiwari, senior professor of orthopaedics, in Kota Medical College, recalled the scenario just a few years ago giving the example of treatment of fracture. 

After fracture of the bone of the limbs, depending on the bones involved and exact place they are broken the distal or lower part of the limb may become deformed. In health, there is a complex system of muscle surrounding the bones, fulfilling their function and balancing the action of each other. With fracture, this coordinated action of the muscle becomes unbalanced, causing the distal/lower part of the arm or leg to take a deformed position. Just putting a simple plaster cast or splinting the fractured limb may result in the bones joining in a deformed position, causing cosmetic and functional problem to the patient. 

The distal / lower part of the limb has to be manipulated in a precise sequential manner, depending on the site and type of fracture to bring the limb in normal position, known technically as 'reduction of facture' before applying a plaster cast. Some orthopedicians used to practice great secrecy about their technique to bring the fractured limb in proper position. They did not want other to learn their methods so that they can have a monopoly. 

Some orthopedicians used to ask other doctors and staff members to leave the room when they would do this manipulation to bring the fracture in the proper place. One orthopedician used to throw a heavy cloth or blanket over the fractures arm or leg then manipulate it blindly covered with the blanket so that others including the nursing staff assisting him do not learn how to bring the fractured part in proper position.

In contrast, now when Dr. A. K. Tiwari goes to medical conferences, he notices that the best orthopedicians from India and abroad, freely talk about their methods and techniques to various orthopedic problems, and demonstrate them by an on-screen presentation.

As Dr. Tiwari had so aptly said, ‘In old times surgery used to done behind the screen. Now it is done on the screen!’ or ‘पहले सर्जरी परदे के पीछे करते थे अब सर्जरी परदे के ऊपर करते है!’

This is true in almost all fields now. There are many workshops, courses, classes, seminars, etc. available nowadays in almost all subjects. With the advent of internet, YouTube, bloggers, Wikipedia like sites, there has been a tremendous change in the knowledge and information available to any person with desire to learn something new. There are lots of educational resources available on internet such as video lectures and online courses both in orthopaedics and diverse subjects from medical and engineering science, arts, craft, technical and vocational subjects and what not.

The present students should be thankful that they live in such an open society. Please use wisely the available resources to increase your knowledge and expertise to enrich your life and better serve humanity.

(Based on allegedly true incidents)

— ND

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DISCLAIMER: This article is intended only for fun purpose. The author does not promote or recommend any behavior illustrated here or claim it to be useful. Use of the information herein is at you one's own risk. Before trying to emulate or follow anything the reader is well advised to take into account ethical, moral, legal and other considerations. The author recommends that Medical Practice should be of the highest ethical and moral level keeping in mind the interest of the patient as foremost. 

DISCLAIMER: This article is intended only for fun purpose. The author does not promote or recommend any behavior illustrated here or claim it to be useful. Use of the information herein is at you one's own risk. Before trying to emulate or follow anything the reader is well advised to take into account ethical, moral, legal and other considerations. The author recommends that Medical Education should be of the highest ethical and moral level keeping in mind the interest of the patient as foremost and according to MCI and other Board’s norm.