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Dawn n dusk In the life of a physician
1. Dawn and Dusk in the life of
a physician
Dr Vijay Sardana
MD,DM ( Neurology)
Professor & Head
Deptt. Of Neurology
Govt .Medical College,
Kota
2. The Noble Profession of
Medicine
“There is no career nobler than that of the
physician. The Progress and welfare of
society is more intimately bound up with
the prevailing tone and influence of the
medical profession that with the status of
any other class…”
Elisabeth Blackwell, MD, 1889
3. Health care sector: problems
Shortage of skilled labour
Increasing cost & complexity of
technology
Patient population more demanding
Increasing orientation towards consumers
4. Doctors: Problems
Struggle to attract patients
Rampant prevalence of unethical malpractice
Declining social status
Threat of litigation
5. Doctor : Have to answer
Patients
Hospital Trustees
courts
6. Doctors : Definition of success
Having lots of patients
New car/plot Every year/lots of
money
Publishing papers in journals
Teaching students
7. Doctor : Facts
One of the every three dissatisfied due to lack of
time for themselves or their families
Average life 10 year less
Depression 4 times higher than general
population
US- Physician suicide 3 time than general
population
10% - Develop drug addiction
8. Stages of career
Entry
Establishment
Exploration
Specialization
Mastery
9. Sta ges of Professional
life
No work, No money, lots of time
Some work, some money, some time
Plenty of work, Plenty of money, no
time
10. Success
Know – How.
Know - W ho.
W ho you know.
W ho knows you.
11. Today's successful doctor
Clinician
Academician
Manager
Financial Expert
CEO
Family care Provider
Self care taker
12. Indian Doctor –Talented but less
Recognized
Research – no motivation
Infrastructure
Lack of working hands, lack of time
Commercialization
No evidence based medicine approach
13. Component of a good Job
• Economic – Salary & facilities
• Job security
• Good working condition
• Status
• Growth Opportunities
• Recognition of work done
• Challenges of work
14. Judge your alignment with your job
• Am i passionate about what I am doing ?
• Am i using my talent and strength ?
• Am i happy in my work ?
• Does it bring joy & fulfillment ?
• Am I Earning what I deserve ?
Improve & change
15. Job satisfaction among Doctors
69.5% –satisfied (AIIMS)
Medical doctor in Armed Force – 40%
Choudhary et al MIAFI 2004;60:329-32
Initial satisfaction high , falls > 35 years,
again rise later
Madan N. job satisfaction among doctor in a Tertiary Care Hospital jk science:2008,10(2)81-83
16. Stress among Resident doctors
32.8% had stress-17.7%- mild,13.2%-
moderate,2.9%-severely
Reason- long duty hours, departmental academic
activities, Financial constraints, family &
emotional problem.
Predictors – year of Residency, giving time to
family & friends, job satisfaction, existence of
children, place of graduation.
Saini NK et al Iindian j public health. 2010;54(4):219-23
18. Physician motivators
Intrinsic
Serving people
Work interest
Career growth
Ability to support oneself & family
Autonomy
Empowerment
Socio-cultural
Respect
Social rewards
19. Physician motivators
organizational
Opportunities for higher education
Good working & hygienic conditions
Personal safety
Good professional experience
Good pay
Financial incentives other than pay
23. Medical pr ofessionalism :
deprofessionalism- causes
Technology – Depersonarlise medicine &
deprofessionlise a physician
Corporatization of Medicine
Specialization – Most patients identified by
disease rather than human beings who
happens to have disease
Patients knowing limitation of modern
medicine
Greed
26. Doctor s’ Expectations
Administration should punish the
guilty
Media –
- publish both views, avoid
sensationalism, seek an expert
opinion preferably from another city
- more positive
Violence Against Doctors
27. Doctor-Patient relationship:
Politicians
Political mileage.
Instigating patient to raise voice
against doctor, at times unjustified.
28. Display of War nings & Other
infor mation
Display warning in hospital premises
mentioning the consequences of violence
against doctors in hospital
Display flow chart/plan in Emergency Room
Display information on boards, counters etc.
Try not to escalate costs later or change pla
frequently
29. Improving Relationship
Teaching of ethics & communication
skills in UG curriculum.
Teaching of sociology aimed at
creating cultural sensivity,empathy &
respect for patients’ dignity.
Teaching legal aspect of practice.
Physician has to enter patients world-
to see illness through patient’s eye
30. Resident Evaluation checklist on
Professionalism
Marking 01234 5678 9 10
Unsatisfactory Satisfactory
exemplary
(4) Empathy in patient care.
(5) Appropriate fund of knowledge.
(6) Soundness of clinical judgment.
(7) Technical expertise with diagnostic and therapeutic
procedures.
(8) Communication with patients, families and staff.
(9) Sensitivity and responsiveness to individual patient
differences in economic status,ethinicity,age,gender and
disabilities.
(10) Honesty in dealing with patients and colleagues.
(11) Accountability for action.
(12) Conflict-resolution skills.
(13) Adherence to regulatory, institutional and departmental
norms.
31. Pressures
Ministers
Bureaucrats
Ex ministers
PAs
Political party office bearers
Other parties
Regional parties
Media
others
33. Communication skills in clinical
pr actice- Intr oduction
“Its an art to talk medicine in the
language of a non medical men”
not an option but a necessity
separates successful doctors from
unsuccessful ones
include ability to engage with patients
at emotional level, to listen, to convey
information with clarity & sympathy
34. What do patients want
- Patient dissatisfaction with doctors relate
to problems of communication rather than
clinical competence
- They want
- quality information about their problems
- risks & benefits of treatment
- relief of emotional distress
- to be active participate in medical
decision making
35. Benefits of doctor patient
communication
- communication with personal touch
provides treatment beyond drugs
- Patients more likely to comply
- The overall quality of care & patient
satisfaction improved
36. Answering skills
weakest communication skills among
Indian Medical Professionals
In Indian context patient satisfaction is
largely decided by the quality of answers &
explanation given by doctors
Understand the question clearly, answer
fully, & clearly but briefly
Avoid major technical terms
37. Barriers to communication
Wor k over load on doctor s
Shor ta ge of man power- less time for
individual patient
Lack of tr aining in communication
skills during medical education
Individual attitude & per sonality traits
Under utilization of par amedical staf f
38. Communication
7% - Spoken words
38% - Voice quality like Tone,
Tempo, intonation
55% - Body language
39. How to perfect non verbal
signal
Smile
Open Posture
Forward lean
Touch
Eye contact
Nod
40. Information sharing & decision making
Most important when there is life threatening illness
When different management options exist with varying
costs, benefits & when outcome is unpredictable
Discuss risks & benefits of each option
It not only increases patient satisfaction but also reduces
the chance of litigation if any adverse outcome results
While prescribing any drug with life threatening side
effects- informed consent to be taken
41. Communicating prognosis, hope & risk
Misunderstandings in these areas can lead to
patient dissatisfaction & litigation
Prognostication is like weather forecasting
uncertain but based on sound scientific principles
St of ilness atpr
age l esent ion of pat
at ient
Cur it of disease
abil y
In face of uncertainty there is nothing wrong with
providing hope
Provide evidence based risks
Never create guilt for negligence on part of patient
42. Dealing with relatives during
resuscitation
Routinely relatives are excluded
Studieshave found no adverse
psychological effects if some mature
person observes the process
One of the doctors of team should explain
the procedure being done to relatives- it
builds better rapport & communication
regarding adverse outcome easy
Remember that bereaved relatives are
also your patients- counsel them & give
medical help
43. Anticipate & handle common reactions
Disbelief- Is he really gone- for their
satisfaction show them proof- eg. ECG
Guilt- by giving logical & rational
explanation & saying that he tried his
best
Offer help to manage transport
In case of Violence & Aggression-
Remain calm & show sympathy
Talk to some elder & mature person
Call police if situation is out of control
44. Do’s
If too many anxious attendants, send them one
or another job. eg. Bringing medicines, arranging
blood- Energy utilization
Never argue with attendants
Argument will trigger them, at the same time
your calmness and promptness will even calm
down a triggered person.
If patient is sick, attend patient periodically and
talk to attendants.
Check emergency tray for drugs.
Try to solve/resolve crisis immediately
45. Do’s
Patients should be attended promptly:
- Error in Decision making is Excusable but
not attending patients timely is not.
Identify a Prominent Person:
- Important person/relative and explain
initial assessment of patient immediately.
- Explain them management has started.
Ask if they have any questions
Call senior consultant as per requirement,
talk to them telephonically if possible delay
in arrival.
46. Don’ts
Never argue with attendants. this
situation teaches you how to remain
calm in provocative circumstances.
No book in the world can teach this.
Never overlook a call, especially if
call is by a attendant.
52. Attitude formation of a Physician
Medical student
Altruism
Role models behavior
Prevailing commercialism
Work environment
Social and political environment
53. Positive Mindset
• Look for Positive in every person.
• Develop an immunity to negative criticism.
• Learn to find pleasure in every little things.
• Remamber ups and downs are part of life.
• Keep yourself continuously occupied. Spend so
much time improving yourself that no time left to
criticize others
• Be equally enthusiastic about other success
• forgive yourself & others.
57. Positive Negative
• Part of the answer • Part of the problem
• Has Program • Has excuse
• Let me do it for you • Its not my job
• Difficult but possible • Possible but to difficult
• I must do something • Something must be
done
• See the gain • See the pain
• See possibilities. • See problem.
• Hard arguments, • Soft arguments, Hard
Soft words words
58. Positive Negative
• Firm on values, • Firm on petty things,
Compromise on Compromise on values
petty things
• Don’t do it to • Do it to others
others what you before they do it to
would not want to you
do to you
• Make it happen • Let it happen
60. Knowledge Vs Wisdom
• Common sense – 6th sense
- Ability to see things as they
are and do them as ought to
be done.
• Abundance of Common sense - Wisdom
61. Knowledge Vs Wisdom
• Knowledge - Piling up facts
Wisdom - Simplifying it
•Knowledge - Potential power
Wisdom - Real power
• To attain knowledge - Add things everyday
To attain Wisdom - delete things everyday
63. Reasoning
• Cognitive process of looking for reason,
Beliefs, conclusion, actions & feeling
• Why reasoning – What we should believe
- What we should do
64. Critical Thinking
• Involve determining the meaning & significance
of what is observed & expressed
•If adequate justification to accept argument,
inference and conclusion as true
65. Lord Buddha : 6 centaury B.C.
Rely not a teacher/person, but on the teaching
Rely not on the words of teaching but on spirit
of words
Don’t believe in any thing simply b’cos you have
heard it
Don’t believe in traditions because they have
been handed over for many generations
66. Lord Buddha : 6 centaury B.C.
Don’t believe anything because it is spoken &
rumored by many
Don’t believe in anything because it is written in
religious books
Analyze & observe -apply reasons, if any thing is
good & beneficial to one &all agree to it.
67. Emotional Intelligence (EQ)
Def – “The ability to monitor one’s own &
other feelings & emotion to discriminate
among them, and to use this information to
guide one’s thinking and action”
IQ Average citizen - 100
Doctor - 120
EQ Average citizen - 100
Doctor - 90
68. EQ Components
Knowing your own emotions (Self awareness)
Managing your own emotion (Self regulation)
Motivating yourself
Recognizing and understand other people’s
emotion ( Empathy)
Managing relationships or social skills-
Skills in managing emotions in others
determines popularity, leadership &
interpersonal effectiveness.
69. EQ
Physician cannot perform his job without
understanding his emotion & those of
patients
IQ - Technical Competence
EQ - People’s Competence
IQ - Gets you job
EQ - Gets you promoted
IQ - Gets you higher marks
EQ - Makes you happy & Productive
70. Keeping updated : Managing
knowledge
Medical books -- Become outdated fast
Medical journals -- Costly
Conference
Medical representative
Internet
Medical knowledge problem – Mammoth size
- Short half life
71. Keeping updated
Imitation
Structure your knowledge around
patients
Learn from your past mistakes
Master clinical protocols & Flow
charts
Concentrate on carry home massages
72. “ The education of the doctor which
goes on after he has his degree is
the most important part of his
education”
John Shaw Billings
77. Vulner able times for
mistakes
Tired, lazy, sleepy
Angry
Overconfident
Patient irritating
Complex medical Problem
78. Mistake : Response
Blaming the system
Blaming the colleagues, even patients
Disconnecting of importance ( No
Clinical effectiveness)
Emotionally Distancing (Everyone makes
mistakes)
79. Dealing with mistake
Accept responsibility for the mistake
Discuss with trusted friend, colleague or
spouse
Disclose & Apologize to the patients
Error analysis
Measures to reduce similar mistake in
future
80. Mar keting in medicine
“Marketing is Practice building
not advertising”
81. Pr actice
building/Mar keting
Satisfied patients
Volunteering at community medical
service.
Organizing an event – like conference
Attracting Media attention
Contributing article on health to magazine
Public lecture
News letter
Website
Marketing to referral base
86. Mar riages
Perfectionism, compulsiveness &
wor k holism – good doctor but
problematic spouse
Many mar ried to Profession – no time
to cultivate intimacy with spouse
87. Mar riages
Stage 1 -- Romance – you are
perfect
Stage 2 -- Fault finding
Stage 3 -- Blaming
Stage 4 -- Acceptance
Transfor mation – Growing
together
89. Mar ria ges
Spend time together
Respect each other
Have fun together
Treat your spouse as your most
impor tant VIP patient
-- A loved spouse is also
loving spouse
90. childr en and jealous
mistress
A meal together ever yday
Fun together once a week
One holiday ever y year together
Make sure children meet grand
parents, relatives periodically
Help childr en honor family traditions
92. Doctor : Personal crisis
Illness
Divorce
Financial Loss
Being Sued
Bereavement
93. Doctor: Personal crisis
Qualities make you better equipped to handle
Self confidence
Optimism
Sense of humor
Resilience
Faith in God
94. Litigation
Patient dissatisfaction
Mistrust
Medical litigation
95. Litigation
Professional failure in diagnosis or
treatment
Lack of communication
Some form of insensitivity by the doctor
to upset them emotionally – insult adding
to injury.
96. Litigations
Reasons related to clinical competence
Failure to perform adeq clinical
assessment
Omission of necessary tests
Improper diagnosis
Failure to treat
98. Legal battle
Single law suit doesn’t mean you are a bad doctor.
Usually results from unavoidable bad outcome,
communication gap, misunderstanding with
patients/attendants, anger rather than actual
negligence.
99. Legal battle
Patients has to prove 4 things
Duty
Breach of standard care
Injury
Proximal Cause
100. Legal battle
Inform your professional indemnity insurance
company
Discuss with your spouse
Don’t discuss with colleagues, staff, & reporters
Ask for the details, if you don’t remember the
detail of the patient.
101. How to reduce chances of litigation
Be a nice person
Be honest
Be open
Be accessible
Keep up to date professionally
Insurance
104. Doctor - Burnout
Personality Traits
Perfectionists
Want to do anything themselves
Often act as if infallible
105. Burnout : Symptoms
Behavioral – Angry/Depressed, poor
concentration,
Chronically late or psychologically
absent, work avoidance
Excessive drinking/Drugs
Tiredness, lethargy, sleep disorders
106. Burnout – Things to do
Learn to take care of yourself
– learn to rest
- learn to Exercise
Learn to say No
Have fulfilling life outside of clinic-develop your
hobbies & activities
Learn to cut routine work
Develop strong support system
110. Physician : lets take lead
Leadership – genes, charisma, education, wealth,
luck, training, experience
Ethics
do right
Reality Greatness vision
Have no think big & new
Illusion
Courage
act with sustained initiation
111. Physician – lets take a lead
physicians well groomed to be good leaders
Educated
Articulated
Affluential
Respected
Deal with human emotion daily
Deal with cross section of society
think scientifically.
112. Physician : Lets take a lead
Lets make a professional bodies strong
More representation of Professionals in policy
making team e.g. Secy. Medical Education
Chandigarh a Doctor
113. Patients spirituality
Soft definition – “The way you find meaning, hope,
comfort & inner peace in your life’’
Spirituality Vs Religion
one may be spiritual without being religious
illness triggers – spiritual distress in patients &
family members.
114. It pays to address spiritual belief of
patients
Religion belongs to spiritual needs are
common among patient
Religion belief sometimes influence decision
making
Spirituality is related to positive health in
some areas
Better patient doctor relationship
115. Patients & Spirituality
Spirituality concept not scientific
Few physician are hard core
religious/spiritual
Spiritual concepts are thought private not
worth discussion.
116. Doctor & Spirituality
HOPE
Hope
Organized religion
Personal spirituality & practices
Effect or medical care issues
119. Impaired Physician
“ one who is unable to practice medicine with
reasonable skill and safety of patients”
Physical or mental illness.
Ageing process
Loss of motor skill
Drugs/alcohol abuse
120. Impaired physician
Denial
Physician Health Programme
Peer assistance committee- early identification,
treatment & rehabilitations of physicians.
122. Preparing to retire
What would you do if you didn’t have to work for
living
Where do you want to live
How will you use your time so that you remain
productive & inspired
Want to be close to children or away
What role the family will play
Arrangement for possible decline in health
123. Retirement
Don’t retire unless you have enough financial
security
Studies-Retirement has Predominantly positive
impact on emotional state
Explore you hobbies
Explore your spirituality
Serve other selflessly-do charity work/volunteer
work
Physical activity/light exercise
125. Preparing to retire
What would you do if you didn’t have to work for
living
Where do you want to live
How will you use your time so that you remain
productive & inspired
Want to be close to children or away
What role the family will play
Arrangement for possible decline in health
126. Retirement
First year is difficult, adjustment subsequently
Old spouse is the best friend around
Grand children keep you busy & happy
Reduce the workload to the extent of enjoying it.
127. Take home
Let us enjoy being a doctor/physician, let us work
for joy of working, nor for a home, car or vacation
Don’t find faults in medicine, Identify happy doctor
& follow their secrets
Lets love what we do, and do what we love
Watching dying patients should remind us about
our own mortality enabling us to live each day
well.
128. Take Home
Social capital is more important than financial
capital at end of the day.
Work & practice with Medical professionalism
Use common sense. Identify local socio-cultural
practices & integrate in your working style
People prefer those doctors with average clinical
skills but good communication skills rather than
those with excellent clinical but poor
communication skills
129. Visualised your self
Visualize your funeral with these
speakers – A family Member, a Friend,
a colleague & a patient.