October 16   2015, Friday
Dr KK AggarwalDr KK Aggarwal
IMA demands strengthening of primary health care/rural health service

A National sample survey, 2014 has shown that 40% of our population depends on single man clinic and small rural hospitals for their health needs. It is observed that these small and medium level hospitals are closing down due to financial non viability. IMA demands that the government to support these hospitals financially through a program of ‘aided hospitals’

To attract modern medicine practitioners to serve in rural areas, IMA suggests the following

• Government to identify difficult areas (primary health centers where doctors are not available for more than 3 years)

• To develop a package to attract doctors to these areas by offering higher salary, accommodation preferably at headquarters with transportation, weightage for PG admission for those serving in difficult rural areas (up to 30% weightage), admission of children to central schools

• To post minimum of three MBBS Doctors in PHCs instead of the present system of posting one MBBS doctor

• To utilize the service of private practitioners in the locality on a retainership/contract basis

• To utilize the services of foreign degree holders (Russia/China Indian graduates) as trainees under the supervision of PHC doctors up to 3 years or till they get registered

• Population covered by PHCs to be revised from existing 30,000 to 20,000; presently up to 1.5 lakhs population is covered by one PHC

• To get orientation of rural health problems, and to motivate them to work in rural areas at least both undergraduates and post graduates should spend 3 to 6 months in a rural set up, under graduates should get training in PHC during their Community medicine posting and also as part of vertical integration at clinical postings. The post graduates can work at least 3 to 6 months in CHCs along with or under the supervision of specialists. The period for preparation of thesis for this can be reduced to 6 months.
Breaking news
Routine thrombus aspiration for STEMI revascularization offers no advantage

Two separate trials presented at the Transcatheter Cardiovascular Therapeutics (TCT) meeting suggest that routine thrombus aspiration as part of revascularization for ST-segment elevation myocardial infarction (STEMI) does not improve outcomes, and might raise stroke risk.

• Sanjit Jolly, MD, from Hamilton Health Sciences in Hamilton, Canada, and colleagues reported their findings from the TOTAL trial that this strategy in acute STEMI still did not reduce the primary composite rate of cardiovascular death, MI, cardiogenic shock, or heart failure at 1-year follow-up, 7.8% with or without thrombectomy. The same stroke risk seen at 30 days also persisted at 1 year (cumulative rate 1.2% with thrombectomy vs 0.7% with percutaneous coronary intervention (PCI) alone).

• In the second trial, Steffen Desch, MD, of University Heart Center Lu¨beck, Germany, and colleagues reported that manual thrombus aspiration for patients presenting late after symptom onset did not reduce the primary endpoint of microvascular obstruction vs primary PCI alone (2.5% vs 3.1% of left ventricular mass). Other markers of reperfusion success such as infarct size, myocardial salvage, and left ventricular ejection fraction as well as angiographic and clinical endpoints also failed to show any advantage.

(Source: Medpage Today)
Dr Good Dr Bad
Specialty Updates
• A new study suggests that stress encountered by mothers during pregnancy could affect their child's motor development all the way through to adolescence. The study is published in the journal Child Development.

• Everolimus-eluting stent is a better choice for treating coronary artery disease in patients with type 2 diabetes than paclitaxel-eluting stent, reported the TUXEDO trial presented at the Transcatheter Cardiovascular Therapeutics (TCT) meeting and simultaneously published in the New England Journal of Medicine.

• Although obesity is a known risk factor for acute ischemic stroke, patients who are obese conversely show significantly lower rates of in-hospital mortality irrespective of whether they received thrombolysis, reported a new study presented at the American Neurological Association (ANA) 2015 Annual Meeting. The findings point to a trend similar to the "obesity paradox" reported in nephrology and some other chronic diseases.

• Odanacatib was effective for reducing the risk of fracture among postmenopausal women across a number of prespecified patient subgroups, suggested new research presented at the American Society for Bone and Mineral Research meeting.

• Modifying the dose and administration schedule for docetaxel, cisplatin, and fluorouracil (mDCF) reduces toxicity in advanced gastric or gastroesophageal junction adenocarcinoma, suggests a new study published in the Journal of Clinical Oncology.

• Implant-based hysteroscopic sterilization may lead to a significantly increased risk for reoperation, reported a new population-based cohort study published online October 13 in the BMJ.

• High intake of dietary components lutein and zeaxanthin is associated with a long-term reduced risk for advanced age-related macular degeneration, suggests new research published online in JAMA Ophthalmology.

• Early physical therapy for recent-onset low back pain resulted in statistically significant improvement in disability compared to usual care; however, the improvement was modest, suggested a study published in JAMA.

• Girls who suffer concussion in childhood could be at increased risk for abusing alcohol as adults, though the risk is reversible, suggested a new study published in the Journal of Neurotrauma.

• A new study suggests that a man's life behaviors may impact the health of his children as well as his grandchildren. The findings are published in the journal Science.
On the 4th Navratri, Be Happy In All Situations
Kushmanda is worshipped on the fourth day of Navratri. SHE shines brightly with a laughing face. In four of her eight hands (Ashtabhuja), she carries weapons like bow, arrow, discus and mace. In other three hands, she holds a lotus, a beaded rosary and a Kamandalu. In the remaining hand, she carries a jar of nectar.

SHE rides on a Lion. Rosary represents her power to bless her devotees with Ashtasiddhi (eight types of studies or wisdom sources) and Navanidhi (nine types of wealth). In Ayurveda, SHE represents the control over the air element. In Yoga Shastra, SHE represents the heart or Anhata Chakra with the Bija sound YAM.

Spiritual mantra on the 4th Navratri

One should continuously (beaded rosary) control the air (anahata plexus) within us by using our sharp intelligence (sword) and balancing the mind (Trishul) by focusing on one point (arrow and bow), practicing detached attachment (lotus), accepting things as they are (Kamandalu), keep smiling in both acceptable and difficult situations (smiling face) and killing the negative energies by using discus (power) when needed.
Legal Quote
Jacob Mathew v. State of Punjab SC / 0457 / 2005: (2005) 6 SCC 1 (iv)

“A professional may be held liable for negligence on one of the two findings: either he was not possessed of the requisite skill which he professed to have possessed, or, he did not exercise, with reasonable competence in the given case, the skill which he did possess. The standard to be applied for judging, whether the person charged has been negligent or not, would be that of an ordinary competent person exercising ordinary skill in that profession.”
Asset Protection

There is no magical asset protection strategy. Depending on the assets owned by the doctor, the aggressiveness of the plaintiff and certain other factors different structures will be used to protect a doctor’s assets. The timing of the planning is important as well. While it is always possible to engage in asset protection planning, even after a lawsuit has been filed, the planning will be a lot more effective and simpler when implemented before a malpractice claim arises.

(Source: IJCP)
Industry News
Acquisitions that signal India as a mature start-up ecosystem: The main reasons for a rush of venture capital into India over the last two years are a mushrooming smartphone market bringing hundreds of millions of people online, an improving environment for doing business and an abundance of start-ups with excellent tech talent. Exits have now become a strong pull factor. They keep the pot boiling with tangible returns which VCs can reinvest into new start-ups. Their risk appetite goes up too as exits mitigate worries over getting caught up in a valuation bubble (Business Standard- Malavika Velayanikal)

SRCC to set up a centre to promote startups: Shri Ram College of Commerce (SRCC) is planning to set up a centre for start-ups in its campus. And, it will become the first undergraduate commerce college in the country to do this. Niti Aayog and other government agencies will bear the operational cost of Centre for Innovation, Incubation and Entrepreneurship. Initial funding will come from the alumni network of the college. The centre will be opened on Friday at the campus in presence of global alumni and representatives of some successful startups. To begin with, the centre will fund 2-3 projects by current SRCC students. (The Times of India)

Common traits of successful entrepreneurs: Successful entrepreneurs like Bill Gates, Steve Jobs, Mark Zuckerberg and Richard Branson were not born with entrepreneurial DNA, but they cultivated traits that led them to greatness. Each had a unique success story, but certain common characteristics helped them build empires. The powerful habits that will make you a more productive entrepreneur and a better human being are rising early, never quitting, never-ending quest for knowledge, self-motivation, building a great team, risk taking and frugal living. (Yourstory Priyanka Desai)

FICCI urges centre to boost medical tourism: The Federation of Indian Chambers of Commerce and Industry (FICCI) wants the Centre to take new initiatives to increase medical tourism in India, including multiple-entry medical visa to enable easy follow-up treatment for foreigners. FICCI said in a statement that India needs to have a comprehensive, uniform and simplified check list for foreign medical travellers along with all relevant information for medical visas which should be displayed at the Indian embassy website across the globe. Abhay Soi, chairperson of FICCI working group on medical value tourism, stated that foreign patients travelling to India for high end treatment should not have problems in getting clearance for treatment when they arrive in India. India also needs to relax the fiscal laws for genuine foreign patients, allowing them to transfer money to India in case of additional requirements. (The Pioneer – IANS)
Cardiology - Yesterday, Today & Tomorrow - A CME was organized by IMA HQs on World Heart Day at IMA House, New Delhi
MTNL Perfect Health Mela 2015.

Pls click here for details
IMA Digital TV
Three Vampires Walk into a Bar

Three vampires walk into a bar and sit down at a table. The waitress comes over and asks the first vampire what he would like. The first vampire responds, "I vould like some blood." The waitress turns to the second vampire and asks what he would like. The vampire responds, "I vould like some blood." The waitress turns to the third vampire and asks what he would like. The vampire responds, "I vould like some plasma." The waitress looks up and says, "Let me see if I have this order correct. You want two bloods and a blood light?"
Bioethical issues in medical practice

A Physician’s right to privacy

Smita N Deshpande
Head, Dept. of Psychiatry, De-addiction Services
PGIMER-Dr. Ram Manohar Lohia Hospital
New Delhi

The case concerns a lady who underwent hysterectomy. The surgeon used to suffer from epilepsy, which was currently well under control. While the surgery went off well and the surgeon did not have any health issues during surgery, the patient died due to an inadvertent cystotomy during surgery.

a) Should the surgeon have disclosed his health information with the patient and allowed her to choose?

b) How much privacy should a physician enjoy in disclosing health issues to the patient?

c) When a surgeon suffers from periodic health issue such as epileptic seizures or unstable diabetes, should s/he discuss them with patients, especially if the health condition is under control? Should such a surgeon undertake surgeries without disclosing his health condition?

Adapted and shortened from: UNESCO, 2011. Casebook on Human Dignity and Human Rights, Bioethics Core Curriculum Casebook Series, No. 1, UNESCO: Paris, 144 pp.

Do write in with views and your solutions!

Here are some of the responses received

• Do pilots tell passengers what they're suffering from? It's for the competent authorities to make sure the professional is fit to deliver. No need for the client to know the details. Sheela Jaywant

• I believe this is not something that mandates disclosure, a conflict of interest would perhaps need disclosure, but epilepsy/diabetes really do not, until they impact the doctor’s daily living. An apparently healthy surgeon can have a heart attack in the middle of a case, a hospital building can collapse, a cautery can electrocute/cause burns –these are all out of the realm of ‘expected’ but they are possible –does it mean we should inform about all of those as well? Additionally there is personal/private information of a surgeon –that should not need to be shared. Doctors and surgeons are all humans and have all the limitations of being one. He should definitely inform of the inadvertent cystotomy and manage that to the best of his ability /refer. Dr Pooja Sharma, MD (Obs and Gynae), Senior Scientist Medanta - The Medicity, Cankids patient advocacy group leader (Hon)

• He should refrain from active surgeries as he can put the others life at risk. Satish Malik

• Let’s suppose the patient had a comorbidity, which was not initially declared, would the surgeon use the information to absolve himself/herself of all responsibility? We must consider whether this would have been the stand of the surgeon even if the comorbidities played no role in the patient's death. There are some more questions that this case study brings to the forefront. How many doctors declare substance abuse or dependence? Psychiatric disorders? Such as OCD or even other debilitating or minor disorders? Every patient has a right to know the qualifications of the doctor (MCI Code of Ethical Regulations), they also have a right to know the drawbacks of their doctor. I agree that the code is hardly followed in letter or spirit, but that is one of the reasons for the sorry state which medical practice finds itself in. I think both sides need to be open. In the hypothetical case you describe, a good lawyer would have a field day if the patient's relatives decide to sue. They should not only be open but be seen to be open too. I believe this debate could open a can of worms. Ravi Ghooi

• The case in example is not specific to only medical ethics, but ethics in public life in general. I remember some 2-3 years back, a neurologist colleague of mine discussed with me about one of her epilepsy cases, who was a school bus driver of a Public school in Delhi. She came to know about his profession after persistent inquiry. We discussed the possible consequences of such a school bus driver and on probing the case further, the driver admitted that he did not reveal his status to the school authorities. She took the pains of contacting the school and saw to it that the said driver was rehabilitated as a gardener, removing him from driving duties. Another similar case is the aircraft pilot of one of the recent air crashes, where the pilot was suspected to be a case of depression. So I consider this issue a more generic one. Coming to the case of the unfortunate surgeon, I reckon that such professionals need not discuss their health issues with individual patients they deal with. Instead they should disclose their health problems that might impinge their professional activities to their regulatory authorities. It is for the regulatory authorities (such as IMC or state medical council or NHS etc.) to consider the issue at length and advise the individual professional as deemed fit. If such a surgeon should disclose his health problem to his individual patients, then the questions such as consent form, its appropriateness, video recording of the consent etc. will compound the issue further. Dr V Sreenivas, Professor of Biostatistics, AIIMS, New Delhi

• By hiding information about themselves do physicians want to maintain a 'God like aura' and is this necessary to their practice and is this 'aura' beneficial for their patients? This could be permissible as long as the physician satisfies basic universal ethical and legal criteria of functioning and doesn't harm the patient? On the other hand, if the physician hides certain data about his/her own abilities (or disabilities as in this example) that may harm the patient (not very clear or definite from the given scenario, as also pointed out by others), I guess it would be unethical? Hiding information is a known mechanism of leveraging one's power base from time immemorial and primates too use it in jungles by not disclosing locations of trees where the figs have ripened (and hold the promise of better nutrition and subsequent power gains)? Apologies for posing more questions than offering answers. Dr Rakesh Biswas, Dept. of Medicine, LN Medical College, Bhopal

• If the symptoms were fully controlled for the duration which is used to decide on the competency of other professionals like drivers, the surgeon was not obliged to disclose his condition to the patient. The answer depends upon whether the health issue is likely to affect the medical judgment of the surgeon. If not, there is no need to disclose them. Do we disclose our current worries, stresses to the patient although we know they may affect our performance? Since surgery is always a team work, the surgeon may do well to let the other members know his health issues so that they can keep a watch and spot automatic behavior at the earliest moment. Sudhakar Bhat

• This is the simplest of a dilemma a doctor can answer (practically, theory is redundant here!): One tells the truth one faces the consequences; one doesn't tell it, one faces the consequences. This world is all about managing to survive. Ved Mahla

• When surgeon has a blade in hand during surgery and is also epileptic, it is really dangerous. Other medical illnesses in surgery or epilepsy in other medical branches are not dangerous to patient. Dr Rohit Bansal

• A relative of mine, a surgeon in UK was retired from active surgery after he developed scar epilepsy from a small superficial infarct. He was offered a teaching job. Vivek Kirpekar

• Most 'doctors' over the age of 40 have some illness or the other - heart disease, hypertension, diabetes, arthritis, cancers, GI diseases, renal disorders, Infections, UTIs, alcohol and other substance abuse/dependence disorders, mood disorders, anxiety disorders, other psychiatric disorders, other medical disorders, dental Problems etc. Most of them would be on medications and other necessary treatments.


o A 'doctor who is suffering from heart disease or other medical /psychiatric illness, while performing any surgery or invasive medical procedure or even performing ECT, has a myocardial infarction, hypoglycemic attack, epileptic seizure, blackouts, heart rhythm disturbances, delirium, other acute medical/surgical/psychiatric condition etc.

o Due to the side-effects of the medications the 'doctor' is taking, he could have sudden rhythm disturbances, hypotension, fainting spells, seizure, hypoglycemic attack etc.

The question is not whether the doctor is competent. The question is whether the doctor is currently suffering from the illness and is taking treatment and is he fit to practise or does he require rest till he is fit. A fitness certificate has to be provided/submitted by the concerned specialty treating doctor. The Hospital HR/administration is responsible for all these documentations. A doctor who is practicing in a hospital is deemed to be fit by any patient. If any procedure goes wrong due to the doctors illness and proven unfitness AND it is proven in the court of law, then the hospital is responsible for allowing the doctor to practise when not fit.

Fitness is taken for granted in India. In the US, according to recent statistics despite strict laws, their implementation, licensure exams and high quality care delivery, medical errors are leading to 400000 deaths (4 lakh deaths per year, YES 4 lakh deaths and innumerable increase in morbidity).

In India, with fake doctors flourishing, Homeopathy, Ayurveda, Allopathy, pharmacists, RMPs, Nurse practitioners, compounders and even health assistants practising however they like with scant regard to knowledge about standard care or Guidelines and no monitoring system, no accountability, it makes me believe, GOD is controlling India's population through these people. Dr Naresh Vadlamani, Hyderabad

• First of all, a surgery is a team effort led by a senior surgeon. Once you say epilepsy well under control, this means the hospital / organisation had accepted his capacity to operate. When the subject succumbs to some other cause (not because the surgeon having a PCS/GTCS at the time of surgery), the surgeon’s existing ailment which had been declared under control) the question of surgeons competence shall not arise. If you go by this yardstick, doctors with CAD /bronchial asthma etc. should declare themselves and tell the patients and the relatives that they suffer from these ailments which makes the disclosure ridiculous. That’s why the saying ‘go to an experienced physician, but to a young surgeon for treatment’. Probably in many elective procedures, our patients and caregivers are very clever as they choose who should perform it. Let’s not underestimate their selection. Probably you would remember about a senior surgeon in a prestigious institute who had a similar problem and it really happened. Unfortunately he himself was an administrator and the treating neurologist did not issue an advice about his ability to perform surgery. Dr Padma Sudhakar Thatikonda, Professor and head (Retd), Dept of Psychiatry, Sri Venkateswara Medical College, Tirupati.

• The balance to be struck is between the surgeon's autonomy (desire and will to operate and right to livelihood) and the greater public good. The greater public good will be served if he continued operating. Unless he had a seizure in the past few weeks when the odds of him having one while actually operating would be significant. A utilitarian perspective. The patient has no right to any personal information unless it is likely to harm him directly a la Tarasoff. Dr T Madhusudan
Breaking news
Government doctor's certificate now not required for tax benefits

The Finance Ministry has waived the requirement of producing a government specialist doctor's certificate to avail tax benefits on expenditure incurred on treatment of serious ailments. A notification was issued by the Central Board of Direct Taxes to amend rule 11DD pertaining to the matter on October 12. The official statement states, “As per the amended rule 11DD, the prescription can be issued by any specialist mentioned in the amended rule. Henceforth, it will not be mandatory to obtain a certificate from a specialist working in a government hospital. The amended rule relaxes the condition of obtaining the certificate for claiming expenditure under section 80DDB in respect of specified ailments from a specialist working in a government hospital.” Section 80DDB provides for deduction of Rs.40,000 for treatment of serious diseases, which is Rs.60,000 and Rs.80,000 for senior citizens and very senior citizens. Until now, only a government specialist in the fields of immunology, haematology, aurology, oncology, neurology and others had to issue a certificate in the prescribed format. But, now people with diseases like haemophilia, AIDS, cancer, thalassaemia and others can take a medical certificate from a specialist in the private sector also to avail tax benefits. (The Pioneer - IANS)
IMA Satyagraha, suggested slogans
• Writing prescription drugs by a non-MBBS is injurious to health of the community.

• Writing prescription drugs by unqualified people can be dangerous.

• Allow doctors to treat patients irrespective of patients’ income.(If compensation is not capped, we can't do this)

• When there is capping of Rs 2 lakh for a sterilization death, why not for other procedures?

• When there is a compensation of Rs 30,000/- for a sterilization failure, why not for other procedures?

• Allow us to treat poor and rich equally.

• Non pelvic ultrasound providers should be out of PCPNDT Act.

• Unless caught doing sex determination, no criminal offence shall be registered.

• If any prospective parent asks for sex determination, they should be booked under a non bailable offense.

• More patients will die if doctors are not provided protection during duty hours.

• Death does not mean negligence.

• Money spent does not mean you will get a cure.

• Including single clinic and small establishments under Clinical Establishment Act will make treatment costly.

• How can we treat patients using outdated standard treatment guidelines made by government?

• How can government decide the charges of a clinical establishment?
Restructured health insurance scheme to have wider coverage
The government is planning a restructure of the Rashtriya Swasthya Bima Yojana (RSBY) to widen its coverage and also make it intensive and IT driven. This restructuring will be coordinated by the Union Health Ministry and is likely to become operational shortly. Speaking at the ninth Health Insurance Summit organized by Confederation of Indian Industry (CII), the union Health Secretary B P Sharma said that the new scheme would have more benefits and beneficiaries. He also stated that a large database is being created that would detail facilities at every hospitals, disease profile and other details and would help immensely every stakeholder. Around 8 to 10 crore BPL people would be covered under the new scheme and cash limits for treatment would be enhanced. The scheme also envisages free medical check-ups once in every three years for the age group vulnerable to cardiac diseases and diabetes. (Economic Times - PTI)
NACO to increase access to health services for HIV-positive pregnant women
Plan International India and National AIDS Control Organisation (NACO) jointly launched a project to reduce parent-to-child transmission of HIV in 218 districts in nine states (Assam, Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Odisha, Rajasthan, Uttar Pradesh, and West Bengal). The target is to test 1.78 crore pregnant women for HIV, provide antiretroviral therapy (ART) to 14,500 HIV positive pregnant women and virological tests for 13,000 infants. R.S. Gupta, deputy director general of NACO, said, “Our focus was high prevalence states where we put more services and interventions and we achieved good results, but there are other states that are lagging behind because they did not receive those interventions. (Live Mint – Nikita Mehta)
Ebola virus fragments can persist in semen of some survivors for at least 9 months
The first results of a long-term study on persistence of Ebola virus in body fluids have been published in the New England Journal of Medicine. The study jointly conducted by the Sierra Leone Ministry of Health and Sanitation, Sierra Leone Ministry of Defence, the World Health Organization (WHO) and the US Centers for Disease Control and Prevention (CDC) focused on testing for Ebola virus in semen as previous evidence has shown persistence of the virus in that body fluid.

Ninety-three men over the age of 18 provided a semen sample that was tested to detect the presence of Ebola virus genetic material. The men enrolled in the study between two and 10 months after their illness began. All nine men who were tested in the first three months after the onset of illness tested positive (100%). More than half of men (26/40; 65%) who were tested between 4 to 6 months after their illness began were positive, while one quarter (11/43; 26%) of those tested between 7 to 9 months after the onset of illness also tested positive. The men were given their test results along with counseling and condoms. It is unclear why some study participants had cleared the fragments of Ebola virus from semen earlier than others. Further tests of the samples will be conducted to determine if the virus is live and potentially infectious.

Amara Jambai, M.D., M.Sc., Deputy Chief Medical Officer for the Sierra Leone Ministry of Health and Sanitation said, “Sierra Leone is committed to getting to zero cases and to taking care of our survivors, and part of that effort includes understanding how survivors may be affected after their initial recovery.”

“This study provides further evidence that survivors need continued, substantial support for the next 6 to 12 months to meet these challenges and to ensure their partners are not exposed to potential virus,” said Bruce Aylward, WHO Director-General’s Special Representative on the Ebola Response. The CDC Director Tom Frieden, M.D., M.P.H. said that study helps us make recommendations to survivors and their loved ones to help them stay healthy. (WHO Office for Africa).
IMA Digital TV
Choosing Wisely campaign yet to make an impact on most services

A study in JAMA Internal Medicine has found that of the seven treatment and testing services listed by the Choosing Wisely campaign as usually unnecessary, use of two had actually reduced, while use of the other five remained the same or had increased. The Choosing Wisely campaign was created in 2012 by the American Board of Internal Medicine Foundation and now involves more than 50 medical societies. The objective was to create awareness and cut down on the use of wasteful and unnecessary medical procedures and treatments. The authors state, “The relatively small use changes suggest that additional interventions are necessary for wider implementation of Choosing Wisely recommendations in general practice. Some of the additional interventions needed include data feedback, physician communication training, systems interventions (e.g., clinical decision support in electronic medical records), clinician scorecards, patient-focused strategies, and financial incentives.” (Source: Medpage Today)
ACP Issues Recommendations for Retail Clinics

A new policy position paper issued by the American College of Physicians (ACP) states that while retail health clinics provide patients with a backup for short-term illnesses or when their primary care providers are unavailable, they should not replace a long-term relationship with a regular physician. An executive summary of the position paper is published online October 13 in the Annals of Internal Medicine.

• All patients should establish a long-term relationship with a primary care physician, who then discusses situations in which fairly healthy patients with an uncomplicated medical history might appropriately seek care at a retail clinic for short-term needs.

• Retail clinics should use standardized medical protocols that rely on evidence-based practice guidelines, to clearly outline the limited scope of services their space and infrastructure can effectively allow, and to disclose to patients these clearly outlined services.

• It is inappropriate for retail clinics to refer patients directly to subspecialists without consulting a primary care physician, and they should promptly inform a patient's primary care physician about the patient's visit, including vaccines, prescriptions, tests, or other instructions the patients received. These clinics should also "have a structured referral system to primary care settings and encourage patients they see to establish a longitudinal relationship with a primary care physician if the patient does not have such an existing relationship," the authors write.

• The ACP discourages managing complex conditions at retail clinics because too little data exist to support the practice, but calls for more research "into the safety, efficacy, and cost effectiveness" of managing chronic conditions at such clinics.

Wayne J. Riley, MD, MPH, MBA, president of ACP said, "A balance must be struck between the convenience and easy access retail clinics provide with the importance of establishing relationships between patients and physicians, particularly for patients who have complex medical histories and/or multiple medical problems." (Source: Medscape)
MCI Code of Ethics Regulations, 2002

2.4 The Patient must not be neglected: A physician is free to choose whom he will serve. He should, however, respond to any request for his assistance in an emergency. Once having undertaken a case, the physician should not neglect the patient, nor should he withdraw from the case without giving adequate notice to the patient and his family. Provisionally or fully registered medical practitioner shall not willfully commit an act of negligence that may deprive his patient or patients from necessary medical care.
GP Tip: Cold shivering

The main sign of acute hypothermia is low temperature in absence of shivering
Inspirational Story
A beautiful way of looking at things

A Father was reading a magazine and his little daughter every now and then distracted him. To keep her busy, he tore one page on which was printed the map of the world. He tore it into pieces and asked her to go to her room and put them together to make the map again.

He was sure she would take the whole day to get it done. But the little one came back within minutes with perfect map……When he asked how she could do it so quickly, she said, “Oh…. Dad, there is a man’s face on the other side of the paper….. I made the face perfect to get the map right." She ran outside to play leaving the father surprised.

Moral of the story: There is always the other side to whatever you experience in this world. Whenever we come across a challenge or a puzzling situation, look at the other side…. You will be surprised to see an easy way to tackle the problem.
Why is My Nose Bleeding?

Nosebleed is a common problem and is often because of a respiratory illness or dry conditions. Nasal drying is common in the hot summer months because of the extreme temperature and dry air is due to use of air conditioners. Here are some typical reasons for nosebleeds:

• Nasal allergies
• Blowing your nose too hard or trying to remove something from inside the nose
• A result of “popping” the ear
• Nasal exposure to chemicals
• Frequent sneezing or having an upper respiratory infection
• Use of nasal spray or a blood-thinning drug, such as aspirin
• Inhaling air that is extremely dry or cold
• Having recent surgery on the nose or elsewhere on the face
• Breaking the nose or a similar injury
• Uncontrolled blood pressure

Bleeding can be controlled by direct pressure i.e. compression of the nostrils grasping the alae distally so all mucosal surfaces are opposed. Direct pressure should be applied continuously for at least 5 minutes, and for up to 20 minutes. The patient should be encouraged not to check for active bleeding. Patients who are properly instructed may control their bleeding while the evaluation gets underway.

Other maneuvers include bending forward at the waist while sitting up (to avoid swallowing blood), placing a plug of cotton wool or gauze into the bleeding nostril (sometimes coated with antibiotic ointment), expectorating out blood that accumulates in the pharynx and a cold compress applied to the bridge of the nose.

These maneuvers also should be taught to high-risk patients for use at home. Initial treatment with two puffs of oxymetazoline may hasten hemostasis.
The commonest variation in the arteries arising from the arch of aorta is:

1. Absence of brachiocephalic trunk.
2. Left vertebral artery arising from the arch.
3. Left common carotid artery arising from brachiocephalic trunk.
4. Presence of retroesophageal subclavian artery.

Yesterday’s Mind Teaser: Interscalene approach to brachial plexus block does not provide optimal surgical anaesthesia in the area of distribution of which of the following nerve:

1. Musculocutaneous.
2. Ulnar
3. Radial
4. Median.

Answer for Yesterday’s Mind Teaser: 2. Ulnar

Answers received from: Dr Bitaan Sen & Dr Jayashree Sen, Dr K V Sarma, Dr K Raju, Dr Avtar Krishan, Daivadheenam Jella.

Answer for 14th October Mind Teaser: 4. Pre-existing neurological deficits

Correct Answers received from: Dr poonam chablani, Dr Jainendra Upadhyay, Dr K V Sarma, Dr K Raju, Daivadheenam Jella, Dr Avtar Krishan.
Readers column
Dear Sir, Thanks for the updation. Regards: Dr Kavish
Digital IMA
Press Release
Seasonal flu causes more mortality than Swine Flu

There is no need to panic but prevention is essential

Respiratory hygiene can go a long way in preventing the disease from spreading.

With the second Swine Flu death being reported in the Capital, panic has grappled the residents of the city. Given this scenario, awareness generation is crucial. People must be made aware of the fact that there is no increased mortality in the case of Swine Flu patients as compared to normal flu cases. In fact, season flu has a death rate that is 10 times higher than that due to Swine Flu. Thus, if Swine flu kills one in 10 lakh people every year, one in 1 lakh die due to seasonal flu.

Swine Flu is akin to the ordinary flu, and has symptoms like fever, coryza (runny nose), cough, sore throat, bodyache, headache and malaise. Some patients may also have other symptoms like vomiting, diarrhea, nausea and rash on the body. These symptoms last for 1-2 weeks. If a patient reports severe breathlessness and blood on coughing, he or she should immediately be taken to a hospital for tests and admission. When a patient has temperature along with coryza and breathlessness, he or she should be attended to by a doctor and admitted to a hospital for customized medical assistance. These might be the warning signs of severe influenza flu (swine or otherwise).

Speaking on the issue, Padma Shri Awardees Dr A Marthanda Pillai National President Indian Medical Association and Dr KK Aggarwal Honorary Secretary General IMA and President Heart Care Foundation of India said, “To safeguard oneself, the foremost precaution that susceptible individuals can take is to get vaccinated. Influenza vaccines can prevent flu caused by human strains, and are recommended in children above 6 months of age, people older than 50 years, patients with pulmonary, cardiovascular, renal, hepatic, neurologic, hematologic disorders and diabetes mellitus; pregnant females and health care providers.”

Cough and respiratory hygiene can prevent Swine Flu. Some basic steps include:

• Do not cough in the hands or handkerchief; cough on the sleeves of the shirt or in a disposable tissue.

• Cover coughs and sneezes with disposable tissues and wash hands if they get soiled with respiratory secretions

• Wash hands frequently with soap and water to wash away the germs.

• Avoid touching face (mouth and nose) with your hands.

• Avoid touching or maintaining close proximity to any person who is coughing or is sneezing.

• Maintain a distance of 3-6 feet from a person who is coughing or sneezing.

• Avoid shaking hands with individuals during the flu season.

• Patients who have symptoms should stay indoors.

• Avoid going to office/schools or in crowded locations till the time their symptoms subside.

Many people do not know that most Swine Flu patients can be managed on an outpatient basis and do not require hospitalization.

Chemoprophylaxis is only recommended for symptomatic patients at the discretion of a doctor. These include pregnant women and those suffering from concomitant illnesses (like diabetes, heart or respiratory illnesses or end-organ failures). Antiviral medications are the first-line of treatment and most cases respond to Oseltamivir.