Wednesday, March 27, 2013
Monday, August 20, 2012
A patient of acute popliteal artery occlusion and thoughts on the Lancet article: Transforming Education to strengthen Health Systems in an interdependent world
We run a patient centered network that receives patient information from
rural remote towns in India often with the intent of offering therapy
either in the form of information (even prescriptions) or procedural
interventions (for which they are encouraged to attend the nearest
feasible set up). Day before yesterday night i got a call from our
social worker in one remote town who related the story of a patient of
sudden popliteal arterial occlusion (a little on phone and mostly on
email along with the doppler reports etc) and a quick review of the
evidence based literature ( other than background knowledge) told me
this needed urgent popliteal arterial embolectomy as a current best
option if performed within hours.
The biggest problem was that he had been given an estimate of 1.25 lakh rupees from the fee-for-service facility in the nearest town/tier2 city that could do the procedure. The patient was a near unemployed young man (surviving on private tuition to school students) and we needed to find a govt facility where the procedure could be done for much less (if not free) and as time was of the utmost essence we activated our web based global network.
The nearest govt medical college was still a few hundred kilometers and we were not sure if it would have facilities for popliteal embolectomy so yesterday morning the patient set out for the nearest metropolitan city to meet one of our network members, an intern in another govt medical college (which had vascular surgery facilities) to find if this could be arranged there on an emergency basis.
One of our US based members skyped me yesterday night to contact another senior vascular surgery colleague who was supposedly in the same metro-city in a Govt Post Graduate institute. Today morning as the patient reached the metro-city i learned that the senior vascular surgeon had been transferred to the same nearest govt medical college the patient came from and also the facility required for a popliteal embolectomy was currently non existent in that govt medical college.
Even as i write the patient and his relative have already boarded the train for Bhopal ( 1,500 kms from their home) because even the health care system in the govt medical college in their nearest metropolitan city (as per available information from the social worker, patients and intern) was not designed to provide emergency popliteal embolectomy (although they had the facility for vascular surgery with even regular Mch courses, so it was perhaps just our inability to approach the correct people in power there).
Our private medical college charges 3000 rupees for any operation (a limb amputation is what this unfortunate patient may possibly now require) and a fee for service vascular surgery practitioner in Bhopal who i contacted said it would cost 30,000 for a popliteal artery embolectomy.This is still much less than the 125,000 estimate the patient was given in the tier 2 city near his hometown.
Now let us take a look at the key components of a health-education-system identified in this Lancet article:http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2810%2961854-5/fulltext?_eventId=login
(1) stewardship and governance, (2) financing, (3) resource generation
importantly faculty development and (4) service provision
From a bottom-up patient centered perspective we start with (4) and from this evolving case-story it is obvious that we have to equip our rural district hospitals and medical colleges with both equipment and (3) trained health care professionals to enable them to handle any emergency procedure.
Actually the Fogarty catheter http://www.edwards.com/
It is disappointing to see how so very often doctors are forced to overcharge their patients for a small piece of plastic equipment ( this is to highlight how locally designed low-cost technology can transform health care) and a procedure http://www.youtube.com/watch?
In-spite of the large volume of doctors graduating from the 300+ medical colleges in the country, training in procedures and clinical decision making is finally being provided to a much lesser percentage than the actual need.
In summary: There are issues that need to be addressed from a bottom-up individual patient perspective.on how to optimize our entire workflow (training and equipment to help our individual patients).
At the same time from a policy maker's top-down population-perspective (1) stewardship and governance and (2) financing can only be optimally implemented for the maximum benefit of a larger population.
Finally to integrate both the patient and population perspectives i leave you with these questions:
How do we ensure that such individual patient stories at the interface of health-science and suffering also have a happy ending?
Could awareness of these stories (collected in an online repository) that otherwise regularly go unsung from every corner of the country help our policy makers to decide better? Can converting district hospitals into 'functioning' medical colleges also address the above problems?
The biggest problem was that he had been given an estimate of 1.25 lakh rupees from the fee-for-service facility in the nearest town/tier2 city that could do the procedure. The patient was a near unemployed young man (surviving on private tuition to school students) and we needed to find a govt facility where the procedure could be done for much less (if not free) and as time was of the utmost essence we activated our web based global network.
The nearest govt medical college was still a few hundred kilometers and we were not sure if it would have facilities for popliteal embolectomy so yesterday morning the patient set out for the nearest metropolitan city to meet one of our network members, an intern in another govt medical college (which had vascular surgery facilities) to find if this could be arranged there on an emergency basis.
One of our US based members skyped me yesterday night to contact another senior vascular surgery colleague who was supposedly in the same metro-city in a Govt Post Graduate institute. Today morning as the patient reached the metro-city i learned that the senior vascular surgeon had been transferred to the same nearest govt medical college the patient came from and also the facility required for a popliteal embolectomy was currently non existent in that govt medical college.
Even as i write the patient and his relative have already boarded the train for Bhopal ( 1,500 kms from their home) because even the health care system in the govt medical college in their nearest metropolitan city (as per available information from the social worker, patients and intern) was not designed to provide emergency popliteal embolectomy (although they had the facility for vascular surgery with even regular Mch courses, so it was perhaps just our inability to approach the correct people in power there).
Our private medical college charges 3000 rupees for any operation (a limb amputation is what this unfortunate patient may possibly now require) and a fee for service vascular surgery practitioner in Bhopal who i contacted said it would cost 30,000 for a popliteal artery embolectomy.This is still much less than the 125,000 estimate the patient was given in the tier 2 city near his hometown.
Now let us take a look at the key components of a health-education-system identified in this Lancet article:http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2810%2961854-5/fulltext?_eventId=login
(1) stewardship and governance, (2) financing, (3) resource generation
importantly faculty development and (4) service provision
From a bottom-up patient centered perspective we start with (4) and from this evolving case-story it is obvious that we have to equip our rural district hospitals and medical colleges with both equipment and (3) trained health care professionals to enable them to handle any emergency procedure.
Actually the Fogarty catheter http://www.edwards.com/
It is disappointing to see how so very often doctors are forced to overcharge their patients for a small piece of plastic equipment ( this is to highlight how locally designed low-cost technology can transform health care) and a procedure http://www.youtube.com/watch?
In-spite of the large volume of doctors graduating from the 300+ medical colleges in the country, training in procedures and clinical decision making is finally being provided to a much lesser percentage than the actual need.
In summary: There are issues that need to be addressed from a bottom-up individual patient perspective.on how to optimize our entire workflow (training and equipment to help our individual patients).
At the same time from a policy maker's top-down population-perspective (1) stewardship and governance and (2) financing can only be optimally implemented for the maximum benefit of a larger population.
Finally to integrate both the patient and population perspectives i leave you with these questions:
How do we ensure that such individual patient stories at the interface of health-science and suffering also have a happy ending?
Could awareness of these stories (collected in an online repository) that otherwise regularly go unsung from every corner of the country help our policy makers to decide better? Can converting district hospitals into 'functioning' medical colleges also address the above problems?
Saturday, May 23, 2009
Meeting information needs: The role of clinical case reports
This was my response to queries posted on this topic in the forum HIFA2015.
"Would such a database be useful as a reference or learning tool to support the delivery of health care in low-resource settings?"
It would be the most useful database ever utilized in medical practice be it the developing or the developed world.
To quote Dr Smith's editorial in the same journal, 'GPs might, and will, use their experience - as they have done for centuries. Their experience might be supplemented with evidence from high quality databases that follow every one of a cohort of patients. But they might also search our journal and database to find a patient just like theirs and see how the patient was treated and what happened to him or her (follow up will be very important).'
"Who might use it - health professionals, researchers, policymakers? How might it be used?"
It would be utilized by multiple stakeholders in the patient's journey though his/her illness. These would include among others the patients, their relatives, their immediate primary care as well as their referral physicians.
"How might it be used?"
One way to better the usage would be to create portfolios of contributors be it patients contributing their own disease perspectives or health professionals reflecting on their day to day activity and then link these with web 2.0 tools commonly available in social networking sites such as Facebook. In this way patients and health professionals can remain in touch just by following their status updates (thus maintaining informational continuity or follow up which as Dr Smith pointed out is vital to positive health outcomes).
"What features would such a database require to provide maximum benefit for end-users in developing countries?"
Free to publish (I am sure it will be for those in HINARI countries but that leaves a lot of poor Indian academics in the lurch due to Indian's newfound non HINARI exalted status).
How would an Indian villager access it to share his stories? Well a villager could go to the nearest internet kiosk and his story could be uploaded by the kiosk operator (that would also create an employment opportunity).
Finally do we have a quicker and easier way of doing this instead of having to go through a lengthy peer review process (which could be better performed in the post publication rapid responses from those who happen to discover the story as it matches theirs)?
We have tried to create a similar model where we have health professionals and patients as group members with their individual portfolios and these health professionals and patients stay in touch with each other by just following each others status updates.
Many of the patients have chosen user names (one such is "English Patient" that you will find on the site) to protect their identity.
Feel free to join the group, add the patients or health professionals to your contacts and start following their status updates. I am sure you will find that just sharing your concern with these patients (with or even without sharing your expertise) may make this a different experience.
http://www.facebook.com/group.php?gid=77835023213
You could begin with by adding "English Patient" to your contacts, read her notes, (which are categorized into an unstructured one she created and the structured summary that her physician did) and finally do go through her status updates and the comments of the health professionals who responded to them.
We have another similar group for our medical students as well:
http://www.facebook.com/group.php?gid=102177045567
warm regards,
rakesh
http://peoplesgroup.academia.edu/RakeshBiswas
"Would such a database be useful as a reference or learning tool to support the delivery of health care in low-resource settings?"
It would be the most useful database ever utilized in medical practice be it the developing or the developed world.
To quote Dr Smith's editorial in the same journal, 'GPs might, and will, use their experience - as they have done for centuries. Their experience might be supplemented with evidence from high quality databases that follow every one of a cohort of patients. But they might also search our journal and database to find a patient just like theirs and see how the patient was treated and what happened to him or her (follow up will be very important).'
"Who might use it - health professionals, researchers, policymakers? How might it be used?"
It would be utilized by multiple stakeholders in the patient's journey though his/her illness. These would include among others the patients, their relatives, their immediate primary care as well as their referral physicians.
"How might it be used?"
One way to better the usage would be to create portfolios of contributors be it patients contributing their own disease perspectives or health professionals reflecting on their day to day activity and then link these with web 2.0 tools commonly available in social networking sites such as Facebook. In this way patients and health professionals can remain in touch just by following their status updates (thus maintaining informational continuity or follow up which as Dr Smith pointed out is vital to positive health outcomes).
"What features would such a database require to provide maximum benefit for end-users in developing countries?"
Free to publish (I am sure it will be for those in HINARI countries but that leaves a lot of poor Indian academics in the lurch due to Indian's newfound non HINARI exalted status).
How would an Indian villager access it to share his stories? Well a villager could go to the nearest internet kiosk and his story could be uploaded by the kiosk operator (that would also create an employment opportunity).
Finally do we have a quicker and easier way of doing this instead of having to go through a lengthy peer review process (which could be better performed in the post publication rapid responses from those who happen to discover the story as it matches theirs)?
We have tried to create a similar model where we have health professionals and patients as group members with their individual portfolios and these health professionals and patients stay in touch with each other by just following each others status updates.
Many of the patients have chosen user names (one such is "English Patient" that you will find on the site) to protect their identity.
Feel free to join the group, add the patients or health professionals to your contacts and start following their status updates. I am sure you will find that just sharing your concern with these patients (with or even without sharing your expertise) may make this a different experience.
http://www.facebook.com/group.php?gid=77835023213
You could begin with by adding "English Patient" to your contacts, read her notes, (which are categorized into an unstructured one she created and the structured summary that her physician did) and finally do go through her status updates and the comments of the health professionals who responded to them.
We have another similar group for our medical students as well:
http://www.facebook.com/group.php?gid=102177045567
warm regards,
rakesh
http://peoplesgroup.academia.edu/RakeshBiswas
Wednesday, February 18, 2009
Experiences on Medical Education networking
To share experiences on medical education networking I guess I won't have to go back further than when I was an undergrad medical student.
I always thought the best way to crack the assessments would be to know what our examiners knew. A bit of networking with them would have allowed me to know what was on their minds but then getting to get to know them was a major challenge in our college where even the internal examiners were actually from a different college (although from the same university).
So we had to restrict ourselves to knowing what was general knowledge ( I believe the MCI calls them "must know").
However a bit of networking with our hostel seniors did allow us a sneak peak into the previous assessment scenarios with interesting tit bits on the examiners as well.
Hostel life that way was a great place for networking.
I soon grew out of the assessment networking fever after having completed UG although I could never grow up from being a medical student: http://student.bmj.com/issues/03/02/reviews/41.php
In my clinical practice I realize that networking is essential to success and each and every new workplace offers its own challenges in setting up networks from scratch ( I have changed a good many places from Kolkata, Chandigarh, Nepal, Bangalore, Malaysia and finally Bhopal).
However online networking gives me an opportunity to maintain older networks with ease. My facebook contacts ( 250 and growing) are mostly people who I met on my previous institutions, many of them students sharing their life pictures ranging from holidaying in US or Borneo to getting married or having children etc etc.
Wish I could have kept in touch with my patients in the same manner.
Facebook gives me a hope that some day in the distant/near future we shall be able to network more meaningfully with our students and patients.
I always thought the best way to crack the assessments would be to know what our examiners knew. A bit of networking with them would have allowed me to know what was on their minds but then getting to get to know them was a major challenge in our college where even the internal examiners were actually from a different college (although from the same university).
So we had to restrict ourselves to knowing what was general knowledge ( I believe the MCI calls them "must know").
However a bit of networking with our hostel seniors did allow us a sneak peak into the previous assessment scenarios with interesting tit bits on the examiners as well.
Hostel life that way was a great place for networking.
I soon grew out of the assessment networking fever after having completed UG although I could never grow up from being a medical student: http://student.bmj.com/issues/03/02/reviews/41.php
In my clinical practice I realize that networking is essential to success and each and every new workplace offers its own challenges in setting up networks from scratch ( I have changed a good many places from Kolkata, Chandigarh, Nepal, Bangalore, Malaysia and finally Bhopal).
However online networking gives me an opportunity to maintain older networks with ease. My facebook contacts ( 250 and growing) are mostly people who I met on my previous institutions, many of them students sharing their life pictures ranging from holidaying in US or Borneo to getting married or having children etc etc.
Wish I could have kept in touch with my patients in the same manner.
Facebook gives me a hope that some day in the distant/near future we shall be able to network more meaningfully with our students and patients.
Saturday, February 7, 2009
Open health information management and user driven health care
What if we have user driven health records generated in the community by patients, relatives IT professionals (call them PHR, EMR whatever) and this was stored in an openly accessible platform (without patient identifying data) and this in turn was utilized effectively to upgrade stage 6 and 7 of Hospital records? (HIMSS says there are 7 stages of hospitals, most US hospitals on stage 3 and none on stage 7.The seven stages are : Stage1 Lab, Radiology and Pharmacy all networked, Stage 2 Clinical Data repository, Controlled medical Vocabulary, Clinical Data Support System, may have Document Imaging, Stage 3 Clinical Flow Sheets, CDSS, PACS, Stage 4 CPOE,CDSS , Stage 5 Closed Loop, Stage 6 Physician documentation complete, Stage 7 Medical record fully electronic)
.
http://www.igi-global.com/reference/details.asp?ID=33436&v=tableOfContents (chapter XVIII)
I know it sounds whacky but I feel this is actually what is happening today on paper (minus a lot of valuable data that goes unrecorded due to time and resource constraints thus making our present paper records useless...barring exceptions).
What is happening today is that the same PHR exists in an individual patient's and his/her relatives mind and a fracton of it is handed out to the busy clinician who records an even lesser fraction of it in his paper record. Thus a valuable opportunity to share patient and health professional driven experiential insights is lost.
openEHR platforms are changing for the better daily and the coming years will remain exciting for the clinical informatics community.
.
http://www.igi-global.com/reference/details.asp?ID=33436&v=tableOfContents (chapter XVIII)
I know it sounds whacky but I feel this is actually what is happening today on paper (minus a lot of valuable data that goes unrecorded due to time and resource constraints thus making our present paper records useless...barring exceptions).
What is happening today is that the same PHR exists in an individual patient's and his/her relatives mind and a fracton of it is handed out to the busy clinician who records an even lesser fraction of it in his paper record. Thus a valuable opportunity to share patient and health professional driven experiential insights is lost.
openEHR platforms are changing for the better daily and the coming years will remain exciting for the clinical informatics community.
Thursday, February 5, 2009
Sunday, January 25, 2009
user driven health care for plants
I guess the following discussion that I generated on a list serv may serve as an example:
We have noticed these leaf changes in our queen's crepe myrtle from a potted sapling since Jan 2008 (image apr 18 2008) as they persist even today although the plant continues to thrive. (Image Jan 25 2009).
Would be grateful for comments, suggestions regarding these peculiar changes and remedies.
rakesh
Response 1
I notice a couple of leaves having a sort of crumpled appearance. Itcould be the larvae of some insect on the rear side of the leaves.Sometimes, the moths lay their eggs on the rear portion of the leavesand the larvae build some kind of cocoon around themselves. If that isthe case, removing the cocoon should help.regards
Yazdy Palia.
Response 2
Rakesh-- Occasionally I've had an occasional deformed leaf, usually caused by either minor insect damage or drought stress as leaves are starting to expand. Again, I wouldn't worry about it at all. Enjoy the color of the new growth!
Regards--
Ken Greby,
Broward County,
Florida USA
Response 3
My own:
Thanks Ken.
Yes I guess this is a minor problem after all as long as they aren't failing to thrive.
rakesh
Thanks Yazdy.
I shall keep that in mind.
Meanwhile the discussion contiues to evolve:
Hi Yazdy,
Whenever u see the leaves are being eaten/crumpled in a potted plant, u tend to use the pesticides to remove the infection.
However, many a times it is a food plant of caterpillars of butterflies or moths. Although all the leaves are eaten and the the entire plant becomes leafless, dont worry. It is the natural process which u should not interfere into. After some days, these caterpillars will form a pupa/ cocoon and imrge into a butterfly or a moth. Eventually, the plant will grow new leaves again.
i have reared many butterflies and moths so far sucessfully.
please remember when u remove a cocoon from a leaf, u kill a butterfly or a moth before it is born.
cheers,
shubhada
Hope it continues...
Cheers to pluralism.
rakesh
We have noticed these leaf changes in our queen's crepe myrtle from a potted sapling since Jan 2008 (image apr 18 2008) as they persist even today although the plant continues to thrive. (Image Jan 25 2009).
Would be grateful for comments, suggestions regarding these peculiar changes and remedies.
rakesh
Response 1
I notice a couple of leaves having a sort of crumpled appearance. Itcould be the larvae of some insect on the rear side of the leaves.Sometimes, the moths lay their eggs on the rear portion of the leavesand the larvae build some kind of cocoon around themselves. If that isthe case, removing the cocoon should help.regards
Yazdy Palia.
Response 2
Rakesh-- Occasionally I've had an occasional deformed leaf, usually caused by either minor insect damage or drought stress as leaves are starting to expand. Again, I wouldn't worry about it at all. Enjoy the color of the new growth!
Regards--
Ken Greby,
Broward County,
Florida USA
Response 3
My own:
Thanks Ken.
Yes I guess this is a minor problem after all as long as they aren't failing to thrive.
rakesh
Thanks Yazdy.
I shall keep that in mind.
Meanwhile the discussion contiues to evolve:
Hi Yazdy,
Whenever u see the leaves are being eaten/crumpled in a potted plant, u tend to use the pesticides to remove the infection.
However, many a times it is a food plant of caterpillars of butterflies or moths. Although all the leaves are eaten and the the entire plant becomes leafless, dont worry. It is the natural process which u should not interfere into. After some days, these caterpillars will form a pupa/ cocoon and imrge into a butterfly or a moth. Eventually, the plant will grow new leaves again.
i have reared many butterflies and moths so far sucessfully.
please remember when u remove a cocoon from a leaf, u kill a butterfly or a moth before it is born.
cheers,
shubhada
Hope it continues...
Cheers to pluralism.
rakesh
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