Holistic Medicine: A Brief Intro

 One of the first duties of the physician is to educate the masses not to take medicine. — Sir William Osler

Holistic medicine simply means taking a broad view of the patient and disease. Treat the patient as a whole and not as a 'disease case'. In holistic medicine, the aim is the comprehensive care of the patient in all areas, such as physical, mental, emotional, spiritual, social, and economic aspects.

The word is derived from the Greek ‘holos’ which means entire, complete, whole. The word is not related to holy which means sacred or religious. It is not sacred or religious treatment, a common misunderstanding. I have seen an advertisement by a famous epilepsy clinic, which claims to cure epilepsy by 'pavitra' (holy) treatment.

It is not exclusive to any particular system of medicine but how a doctor practices his system. An allopath may practice with a holistic outlook, whereas a ‘vaidya’ (Ayurvedic medicine practitioner) may not.

For example, a person may come suffering from acid peptic ulcer disorder. The conventional practice may involve giving him a drug to inhibit the acid formation or to neutralize it, whether allopathic or of another system, such as Ayurveda. A holistic approach will be when along with drug treatment other factors are also considered and treated such as a change in lifestyle, diet, job, family or job counseling, stress management, etc.

A common confusion is with the term alternative or complementary medicine. These are medicine or therapy systems different from the accepted or conventional system. It may vary from country to country, e.g. Ayurveda is recognized by the government as one of the mainstream treatment systems in India but is classified as an alternative in other countries. Acupuncture is classified as an alternative or complementary therapy in most countries but in China, it is recognized as a mainstream therapy system.

The holistic approach is already enshrined in WHO definition of health given in as far back as 1948:

          "Health is a state of complete physical, mental, and social well-being and not merely the absence of disease and infirmity".

Therefore ideally we should pay attention to the mental, social and spiritual aspects of illness in addition to just the physical ones.

Although this definition of health by WHO is quite old, why is holistic medicine in so much limelight now? The answer lies in the increasing incidence of lifestyle-associated diseases. In them, even with the best possible medication, there is a ceiling on effect. We need to address the faulty lifestyle for optimum effect. For example, in hypertension or high blood pressure, diet, exercise, mental relaxation, abstaining from tobacco, etc., plays an important role along with medication to get optimum control of the raised blood pressure and prevention of future complications.

There are many problems being faced by doctors in practicing holistic medicine. The most important problem is the lack of time by Indian doctors burdened with caring for such a large population. Another problem is the lack of training. Medical education by and large places most emphasis on the physical aspect of disease and its treatment by drugs or medicines. Some training is imparted in PSM or Community Medicine classes, but there the emphasis is more on maternal-child health and diseases under the national health programs.

The practice of medicine in a Holistic manner should be the goal of all medical practitioners regardless of whether belonging to the allopathic or other medical systems. It does have some concrete benefits for the patient and is not just something exotic or fashionable.

— ND

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DISCLAIMER: This article is intended only for fun purposes. The author does not promote or recommend any behavior illustrated here or claim it to be useful. Use the information herein is at your 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 purposes. The author does not promote or recommend any behavior illustrated here or claim it to be useful. Use the information herein is at your 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 norms.

The Inexpert Senior Surgeon

 

Dr. Dev (Fictional Name) was sitting in the Surgical Outpatient Department (OPD) of the hospital. He saw a patient with a sebaceous cyst (a small skin swelling) and sent the patient to the adjoining minor operation theatre (OT) for operation (excision biopsy) under local anesthesia. Such minor operations were done almost exclusively by the interns and junior residents of the surgery department and were an integral part of their training to get the hands-on experience that was the foundation for their doing major operations in the later period.

When the patient reached the minor OT, he found that Dr. Sam (Fictional Name), the junior resident posted in the minor OT had to suddenly go to the indoor patient ward to attend to some emergency. The patient became angry and came back to Dr. Dev in OPD.

‘There is no doctor in the minor operation theatre where you had sent me,’ the patient complained. Dr. Dev replied, ‘The doctor had to go for an emergency in the ward to save the patient’s life. He will come back shortly and do the operation.’

The patient pondered Dr. Dev’s word for a few seconds and then countered, ‘If that doctor is busy in an emergency then why don’t you come and do the operation instead of sitting here?’

Dr. Dev carefully considered the patient’s words. As the senior-most doctor, he was needed in the OPD to discuss and guide the junior doctors. The training of the junior residents will also suffer if senior doctors start doing such minor operations. And it was only actually a few minutes since the patient had come to OPD and the junior resident will anyway come shortly and do the operation.

Dr. Dev replied, ‘Among us, Dr. Sam does the maximum number of this type of operation. I have not done even a single such operation in the last three months. You can confirm with the minor operation theatre staff. Even then if you want I can come and do the operation. Or if want you can wait for Dr. Sam who is the expert in this type of operation.’

The patient ruminated on  Dr. Dev’s explanation and then said, ‘Okay I will wait for Dr. Sam and get the operation done by him only’ and left peacefully to wait outside the minor OT.

When confronted by an angry patient/client/customer using logic to justify yourself is usually useless. Dr. Dev could have shown the patient the OPD slip with the timestamp on it to show that it was only a few minutes since he had made the OPD slip and therefore he can wait for some time, but he knew from experience this will not be accepted by an angry patient. Instead, he gave a justifiable reason for the junior doctor’s going to the ward, explicitly adding that it was necessary to save a patient’s life. For the matter, we don’t know if it was entirely true or just a fiction created to placate the patient.

Even if you are a senior person/head/supervisor/boss you can be asked by your patient/client/customer to do a task which is usually done by your juniors. If it is a true emergency then you should do the task without further thought. If it is not an emergency then things become tricky. If you refuse directly then you risk making your patients or customers angrier and face retaliation by them. In such a situation it is far better to use creativity like Dr. Dev to explain why it is in the patient/client/customer’s interest to wait for the designated person.

— ND

(Based on an allegedly true incident.)

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DISCLAIMER: This article is intended only for fun purposes. The author does not promote or recommend any behavior illustrated here or claim it to be useful. Use the information herein is at your 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 purposes. The author does not promote or recommend any behavior illustrated here or claim it to be useful. Use the information herein is at your 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 norms.

The Next Week Classes

 

Dr. Dev (Fictional Name) had joined as Professor in the Department of Surgery in Khota Medical College (Fictional Name). There were junior residents doing post-graduate specialization in surgery posted in his unit. The junior residents do the work of patient care and also study as they have to clear the MS (Master of Surgery) final exam at the end of their three years training period.

Once on a ward round, Dr. Dev asked an academic question to Dr. Vincent (Fictional Name), the second-year junior resident posted in his unit. Dr. Vincent did not give a proper answer. After some time Dr. Dev asked another academic question to Dr. Vincent. Again he was not able to give a satisfactory answer. 

Sometime later Dr. Dev asked another academic question to Dr. Vincent. With his poor performance in the previous questions, Dr. Dev asked him an easy question this time which could be answered well even by a good MBBS (Medical under-graduate) student. Surprisingly Dr. Vincent did not answer even this question completely.

As Dr. Vincent was in his second year of junior residency it was expected that he would have started studying and achieved at least some level of expertise in his subject by now. A disappointed Dr. Dev remarked, ‘Dr. Vincent, it is high time that you start studying something!’

Dr. Vincent promptly replied back, ‘Yes sir, I had already planned to start studying something. In fact, I am joining classes from next week.’

Dr. Dev was surprised on hearing this answer. With his poor academic standard up till now, he did not expect Dr. Vincent to start studying so expeditiously. Also, he was not aware of any classes teaching surgery outside of their Medical College in the city. A curious Dr. Dev asked, ‘Which classes are you joining from next week?

Dr. Vincent replied, ‘I am starting Guitar classes from next week.’

— ND

(Based on an allegedly true incident.)

© Author. All rights reserved. 

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DISCLAIMER: This article is intended only for fun purposes. The author does not promote or recommend any behavior illustrated here or claim it to be useful. Use the information herein is at your 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 purposes. The author does not promote or recommend any behavior illustrated here or claim it to be useful. Use the information herein is at your 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 norms. 

The First Tracheostomy

 

During their Master of Surgery (MS) in Surgery postgraduate course, the junior residents of the Surgery department of AIIMS, New Delhi are posted for few months in the department of neurosurgery. One of the things which the junior residents used to look forward to during their neurosurgery posting was doing a tracheostomy.

 With the Covid-19 era now everyone knows about the tracheal tube inserted from the mouth if a patient is not able to breathe on his own and artificial respiration given by ventilators. If a patient requires a tracheal tube and ventilator support for a long time, then the surgeon makes a direct hole (incision) in the front part of the neck, exposes the trachea (windpipe), and inserts a tube directly in the trachea through it known as tracheostomy or tracheotomy.

Due to prolonged coma, there used to be many patients in the Neurosurgery department who used to require tracheal tube and ventilator support for a long time. The operation of tracheostomy was usually entrusted to the Neurosurgery Mch senior residents, who in turn used to teach the general surgery junior residents to do it. After some experience, the junior residents starts doing it independently without supervision, so that the senior resident is free to do some other important work. Most general surgery junior residents used to do their first tracheostomy and later gain mastery of the operation in the neurosurgery department.

After few days of posting the senior resident on night duty called Dr. Dev (Fictional Name), who was on rotation posting during his MS (Surgery) course in AIIMS, New Delhi. He told Dr. Dev that the patient in Neurosurgery ICU A on Bed no 2 requires tracheostomy and he will demonstrate to Dr. Dev how to do a tracheostomy. He also told him that they will do the tracheostomy in the ICU itself as the neurosurgery operation theatre reserved for tracheostomy and other infected operations was closed for repair. The senior resident fixed the time at 4.30 am in the morning.

Usually, there are many patients coming to the emergency department till 2 to 3.00 am and the neurosurgery senior resident used to be busy attending to such patients. There were usually no calls between 3 to 5 am so he will be free to teach Dr. Dev to do the procedure. Also by 5.00 am the operation will be over and both of them can start their respective morning routine work after that.

At 4.30 am Dr. Dev was woken up by the pager calling him to the ICU. As Dev had slept at 2.00 am at night due to ward work, groggy with sleep, barely able to keep his eyes open and stay erect on his feet, he reached the ICU. The Neurosurgery senior resident was already there and so was the anesthetist.

It was the anesthetist's duty to remove the tracheal tube via mouth when the tracheostomy is made and monitor the patient's vital signs such as heart rate, breathing rate, and pattern, O2 saturation, etc. during the operation. The operation theatre (OT) nursing staff had also reached the ICU with their instruments.

Just as Dr. Dev and the senior resident after cleaning their hands and downing their sterile gloves and gowns got ready to do the operation that the senior resident received a call to reach urgently the emergency department. Due to the emergency, the senior resident asked Dr. Dev to start the preliminary part of the operation such as cleaning the skin with disinfection solution, laying sterile sheets around the operation site to avoid infection, and giving local anesthesia injection, while he attends the emergency call and comes back swiftly.

With an anxious heart, Dr. Dev started the initial part of the operation. Before this Dr. Dev had never even seen the tracheostomy operation let alone performed one. Remember, this was before the days of YouTube and internet videos. The only good thing was that as he knew that he will get the opportunity to do a tracheostomy during the neurosurgery posting so he had read in detail about the procedures from the books available in the AIIMS library.

The preliminary part of the operation was now complete but yet there was no sign of the senior resident. The anesthetist asked Dr. Dev, ‘Why are you waiting? Complete the operation fast as the patient is not in a good condition.’ The nursing staff also asked Dr. Dev to start as they had to go back to the operation theatre for their other work. With palpitation in his heart, Dr. Dev made the incision (cut in the skin). He asked for the cautery device to further cut the deeper tissues as there was much bleeding.

In their general surgery OT, they had a monopolar type of cautery device. This was a pen-like device. Using electric current the tip of the device gets heated which then cuts the body tissue at the same time stopping minor bleeding due to the heat. The neurosurgery nursing staff handed him a forceps-like instrument. A surprised Dr. Dev asked what this is as he had never seen such a device ever in his life.

The staff nurse informed Dev that this is a bipolar type of cautery forceps and only this was used in neurosurgery OT. Unlike the pen-like direct action of the monopolar device, here you have to cut the tissue first with a surgical knife or scissor, and then to control bleeding you pinch the bleeding site with these forceps then activate the machine to heat the tissues. So now, in addition to doing the operation of the tracheostomy first time alone, without assistance, Dr. Dev had to learn how to use the new gadget on his own.

So the sleepy, tired, Dr. Dev using unfamiliar instruments proceeded in the unfamiliar operation, till he reached the trachea/windpipe. Now there was no turning back. Dr. Dev made the hole in the trachea, asked the anesthetist to quickly remove the tracheal tube from the mouth and he swiftly inserted the direct tracheostomy tube in the new opening. With the crucial part of the operation now over, Dr. Dev found new energy and confidence and rapidly sutured the tissues and skin around the tube, and asked for the dressing to apply around the wound. As he handed over the patient back to the anesthetist and ICU nursing staff for further care, he prayed that the OT nurse and anesthetist had not noticed how tense and apprehensive he was when he started the operation.

Even when you are sure that you will be playing the part of just an assistant or of being guided in some new activity, it is better to be prepared to take over independently if the opportunity presents itself.

One should not assume about the facility or instruments one will be getting in a new place or situation but should find out in detail beforehand. Not just in an operation but even in a simple thing such as lecture or presentation, we see people struggling with an unfamiliar computer system, mike, pointer device, etc. So go beforehand and find out what exact tools or facility you will be getting in a new or unfamiliar setup or place.

— ND

(Based on allegedly true incidents.)

© Author. All rights reserved. 

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DISCLAIMER: This article is intended only for fun purposes. The author does not promote or recommend any behavior illustrated here or claim it to be useful. Use the information herein is at your 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 purposes. The author does not promote or recommend any behavior illustrated here or claim it to be useful. Use the information herein is at your 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 norms.