Dr Randeep Guleria, Chairman, Internal Medicine, Respiratory & Sleep Medicine, Medanta, says the health sector has improved a lot because there is a huge push by the government to open more hospitals and colleges. He, however, says there is a need to focus a lot on quality along with quantity. Excerpts:Shahid Faridi: How has medicine changed over the years?What was clinical medicine when I was training has now moved to what is known as investigative medicine. We were taught that you examine a patient in detail and do the least amount of investigation, reach a diagnosis and start the treatment. The focus now is to spend less time examining the patient and writing more investigations. It has added to the cost of medicine. How can we balance the art and science of medicine so that we are able to provide good patient care, which is affordable, of high quality, and train doctors in that respectWe are losing the art of medicine where you examine and talk to the patient. I think that’s important, because sometimes you can get a lot out of the patient just by listening to him. We have moved away from that and would order a battery of tests. Sometimes you are not sure whether a report is correct or not, but you go ahead. The focus is more on getting investigations done, which I think is not good in our country, because as you go to rural India, all these tests will not be available. The other thing that has driven this is defensive medicine. This is also adding to the cost of healthcare.The health sector has improved because there is a huge push by the government to open more and more hospitals and colleges. But I think we also need to focus a lot on quality along with quantity. We are seeing that government medical colleges have become less and the private ones are more. The NMC is trying to cap fees. But the cost of medical education has gone up tremendously. And that is impacting the thought process of students and the way they practice subsequently. So if we want to feel strongly that medicine should be a service rather than a business, then you have to train people from that point of view and with that mindset.Shahid Faridi: Do you think this is because of mushrooming of private hospitals?It is. The push from the private sector is driving investigative medicine, because it is looking at returns. And returns are more from the investigation and not from just examining. We need to balance it out. I’m not saying investigations are bad but it should not be at the expense of clinical medicine or the art of medicine. One has to see it from the patient point of view. If you’re in a remote area, you can’t say I can’t diagnose this unless I have an ultrasound machine. That is the wrong part of the training.Santwana Bhattacharya: There has been a sudden rise of incidence of heart attack deaths even among the young fitness freaks. What do you think is the reason that even as young as 17 year olds are dying of heart attacks?One myth is that it is related to COVID or vaccinations. There is no data to support any of the two. I don’t think we have enough evidence one way or the other to say that more deaths are occurring due to Long COVID because of clotting or vaccine side-effects.Secondly, we are becoming more aware because of social media. I think it’s also related to a change in our lifestyle. We have seen that heart diseases are occurring much earlier in our population than in the West. It is because of a genetic factor and also our lifestyle. Now, the type of diet that we have is not what we used to have earlier. The type of physical activity now is different.There is less activity among the younger generation, and more time is being spent on the Internet or on phone. The diet is becoming more synthetic rather than natural with fresh fruits, green leafy vegetables.Kavita Bajeli-Datt: Is Covid-19 over? Do you think new mutations will lead to another pandemic?Covid-19, as a pandemic, is over. But the virus has not gone away. Covid became a pandemic, and therefore, the viruses evolved and will stay with us. In the coronavirus family, a new virus is going to stay with us and cause illnesses. So we still have cases but not as many as we saw during the pandemic.During the early stage of the pandemic, the virus was evolving very rapidly. For the last two years, Omicron has stayed and the subsequent variants are sub-lineages of the variants. So the virus has stabilised for almost two years and if it stays like that, then we have a good amount of immunity. We will get Covid, but it will not cause that severe illness or that outbreak that we saw.Unless the virus changes dramatically, which it has not done, and becomes a novel new virus, we will probably not have another pandemic. However, we need to have active surveillance for newer outbreaks, not only for Covid, but for another virus known as H5N1 (Bird Flu). It has been there for many decades, but has now surfaced.Kavita Bajeli-Datt: Is Long Covid a real concern?It is. The number of cases has come down. If you look at data, more cases of Long Covid were there after the Delta wave. What one has found is that in most patients, after about nine months or so, many of them recovered from Long Covid, but some continue to have symptoms. I have a few patients who have Long Covid, who still have these symptoms of sweating, palpitation, not able to sleep, and panic attacks. In some patients, it stays on for a long time. I think we need to have more research on Long Covid.Parvez Sultan: What are the side-effects of Covid-19 vaccines and which one was better – Covishield and Covaxin?It depends on what you took. There was a debate on the advantage of taking a mixture of the two vaccines. There was a study, which showed that it is effective (taking the two vaccines) as it causes better immune reaction. In one state, the booster that was given by mistake was different from the original one. The study found that the antibody response was better. Most of the vaccines that were available in India were Covishield. So it is difficult to say which vaccine was more effective.Regarding side-effects, none of them really showed a lot of concern. There was some initial concern of a higher chance of clotting. But the efficacy was far better than the minimal side-effects. But then all drugs will have side-effects.Suchitra Kalyan Mohanty: Delhi has become a gas chamber, how does the long-term exposure to air pollution impact health?I think that air pollution is a medical emergency. We need to aggressively tackle this problem. We have done it in the past. We had this problem in the late 90s also when the pollution level was very high. The Supreme Court intervened and a lot of things were done and CNG came in. It really helped in achieving good AQI in the early 2000s. However, we lost out on all those benefits because we continued to have construction, and more diesel vehicles started coming into the city. Now, every year we are having this pollution problem.Pollution causes an acute respiratory problem, both in people who have underlying respiratory diseases like asthma, COPD (Chronic obstructive pulmonary disease), and even in the general population. It’s an acute problem which causes more admissions, and impacts the overall quality of life.You will see that there are very few good AQI days in a year in Delhi. It’s only during the monsoon months that the AQI comes down to an acceptable level. Some data show that long-term exposure can increase the chance of lung cancer and cardiac issues. One research paper showed that living in an environment with high air pollution is as big a risk factor for heart attacks as is high cholesterol or smoking. There are now studies which suggest that even Dementia and Alzheimer’s are higher in the population living in regions exposed to severe pollution.Other syndromes like metabolic disorders tend to be higher. Air pollution affects the immune system. Studies show it can contribute to autoimmune diseases.Kavita Bajeli-Datt: How do you think the governments, both at the Centre and the state, have tackled air pollution?We need to look at sustainable solutions and it’s not something that we are doing. There is a lot of knee-jerk reaction. If you look at the London smog in the late 50s, the pictures from that time would remind you of Delhi – dark and black. In December of 1952, there was a huge peak of bad AQI and almost 4,000 patients died in less than 10 days. They were able to bring in a lot of legislation. Now it is better in London, Los Angeles and New Mexico.Kavita Bajeli-Datt: Your suggestions to authorities in checking air pollution?I think there is a lot of legislation and plans in place. Implementation is the challenge. I think all citizens should actively participate. It has to become a movement. I remember, a long time back one journalist told me that unless an election is won or lost on air pollution, nothing is going to happen. Deaths caused by air pollution are like a silent killer. You can say that a certain number of people died from dengue or Covid, but it’s hard to quantify deaths from air pollution.Santwana Bhattacharya: Sleep disorder was a symptom among 65 plus, but do you see this among the young?Two things have happened to the younger generation. One, the work profile has changed. So the body’s circadian rhythm has gotten altered and that has led to sleep disorders. Secondly, overweight and obesity have led to obstructive sleep apnea in the younger age group. Young people who are overweight snore a lot, have daytime somnolence, and go off to sleep while talking or while doing something monotonous. It has also been linked to unexplained road accidents.Preetha Nair: Kerala is lauded for its robust healthcare system. But why do all these viral diseases get detected there first?When a shift from communicable to non-communicable diseases was going on in the country from 1990-2016, the first state which showed this change was Kerala. The state moved dramatically from infection control to non-communicable disease. This was a good thing. One thing that has to be seen is how good your surveillance mechanism is. If you have a good health set-up, you will pick up the outbreak earlier. Besides, Kerala has a lot of international connectivity. So infections from outside India are reported there first.Kavita Bajeli-Datt: Many young people are dying while gyming? How do you see this phenomenon of people dying of heart attacks in gyms?Two things happen in the gym. One is people do exercise, which sometimes they overdo it and it’s more related to muscle building rather than more of a cardiopulmonary exercise. Secondly, a lot of gyms promote a lot of protein supplements. A lot of people who go to the gym take a lot of protein supplements, which contain a lot of hormones and other things, which also have side effects.I have seen patients who take protein supplements and start developing early features of kidney failure because of not only gyming but the type of diet that they are advised to have. I think a combination of exercise should be done, but not to over-exercise. It depends on your own body structure and age. Based on that, you must develop an exercise schedule.Ashish Srivastava: A very horrific rape and murder of a PG trainee doctor was reported in August, following which the medical fraternity led a movement demanding for a Central Protection Act for Healthcare Workers. The case went to the Supreme Court, and NTF was appointed. But no separate legislation was announced, despite the unanimous demand from across the medical fraternity. What do you think?I personally feel that we should have some sort of actual legislation to protect doctors, especially the young resident doctors, who face violence every day. So unless there is a deterrent, it will not become less, and therefore, there has to be action. Unfortunately, that was not the recommendation given by the committee. I still feel that there is a need to develop that. It was put in place partially during COVID. But that is only as part of the Pandemic Act. It needs to be continued to some extent. I think we also need to look at how we develop as a society.We see a lot of it is related to change in thinking, and change in values. Society has also changed from being more value-based to more money-oriented. And that’s why professions which were really given a lot of importance or thought to be noble have become less noble whether it is teaching or whether it is medicine.The doctor-patient relationship has also changed because it is part of the problem of investigative medicine. Now the patient also thinks there’s an ulterior motive behind the investigation. Medicine was always a service. You joined medicine to serve rather than to earn. Now it has become the opposite. I think that’s why I said values have changed.Our own society has changed so much. Initially, you talk of someone becoming a professor and now we talk of so and so pay packages.Ashish Srivastava: NTF was formed, but there was criticism that there was no representation of resident doctors and nurses?I think you should at least take input or have representation from the affected people. You have to take their point of view, how safe they feel and what can be done from their point of view. What happens is that for the attendant, their patient is the most important patient. So their thought process is, I brought him to the emergency, he should be seen immediately. But for the resident, you have 10 patients, you have to prioritize seeing them. How do you communicate that to the attendants and how do you get that done?Sometimes it becomes a big challenge. Sometimes that leads to a lot of stress and issues happen. Some detrimental steps should be there.Kavita Bajeli-Datt: Do you think India will be able to eliminate TB by 2025?What do we mean by elimination? If we say it will be zero as per WHO targets in terms of deaths, and in terms of cases. I don’t think we’ll be able to reach that. We will be able to move in that direction. I think the main aim is to get everyone charged to try and move towards decreasing TB-related prevalence and incidence. But to eliminate TB in 2025 seems difficult.Kavita Bajeli-Datt: A lot of TB patients have highlighted the shortage of drugs. How would this impact the overall scenario of meeting the target?In certain states, that is a problem. The government is providing the TB drugs under DOTS (Directly Observed Therapy Short-course) but sometimes there is a supply issue. Due to certain factors, could be tendering or red tapism, the drug does not reach the centre on time.This delay is not good for TB patients as it can lead to the emergence of resistance. That is why you need a surplus of drugs. I do agree that certain times there is a shortage of drugs. In practical terms, some drugs don’t reach the patients on time.Paramita: Nowadays people are relying on wearable devices. How reliable is that for detecting BP for instance?A lot of wearable devices are coming in. But we need to really look at the data behind it and how accurate they are not only from the point of view of the device but are they applicable to our population.A lot of data which emerges sometimes is based on a different ethnic group where the colour of the skin may be different, the thickness of the arm may be different and therefore the utility may be compromised to some extent. There is a push in the market to develop more and more devices.If you look at your phone you have so many apps coming in. Some of them have not even been tested, they have been tested only in a handful of people and the app is launched. The same is happening with a lot of wearable devices.Ashish Srivastava: The NMC has dropped respiratory medicine and emergency medicine from the list of essential departments in the medical colleges? What do you think of this decision?The department of respiratory diseases is important. Not only because of the rise in respiratory diseases but also because we are moving towards the strategy of TB elimination in our country. Therefore having a department in all medical colleges will help actually in terms of better control of respiratory disorders and in terms of tuberculosis. I think that decision should be reconsidered. I think they (NMC) said they are trying to condense the syllabus as it was getting bigger.Ifrah Mufti: During air pollution, schools get closed, and children are asked to stay at home. Is there a difference in air quality inside homes compared to outside? Are children safe indoors?They are not necessarily safe indoors. This response is often a knee-jerk reaction. I mean you are actually then impacting their education. Online school doesn’t work and many of the underprivileged children are not able to access online education. This was a big debate during COVID also when there was a lockdown and the schools were shut. We are now doing the same thing and it’s not really of any use.
Source link
