Lecture delivered at IMA CME Kota on 30th oct 2011

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

17. Physician motivation
“determinants that drive performance
of a task, independent of the
resources and knowledge available”

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

20. Doctor-Patient Relationship
Blind trust
Informed trust with skepticism

21. Patients satisfaction
 Satisfied patient 3 other people
 Dissatisfied patient 20 others
 Satisfying unhappy patients 50 others

22. Medical Professionalism
“Contributing those attitude and
behaviors that serves to maintain
patients’ interest above Physicians’
self interest.”

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

24. Doctor-Patient Relationship
 Failure of referral system
Disproportionate work load
 Unnecessary administrative
responsibilities

25. Doctor-Patient Relationship
Influence of drug &
medical equipment
manufacturer
Pardoned
Tolerated

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

32. Communication skills
“ Patients don’t care how much you
know them, until they know how
much you care”

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.

47. Have positive attitude

48. Attitude
• Way a person feels, thinks & behaves towards a
particular issue.
- half full-hall empty

49. Positive Attitude - Benefits
• Pleasing personality
• Energizing
• Inspiring
• Problem Solving
• Increase work output

50. Attitude
Job/promotion/success
- 85% Attitude
- 15 % Intelligence & knowledge of specific facts $ figures
12__suraj_ki_garmi_se.mp3
• Education
- Almost 100% teach facts & figure

51. Elements of success
Attitude
Knowledge Skill

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.

54. Identify & avoid negative
people

55. How value system change
Intolerable
Constant Exposure
Acceptable
Constant Exposure
Self justification
Involvement

56. ‘Fr enemies’

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

59. Use common sense with knowledge

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

62. Believe in reasoning & have critical thinking

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

73. TRADITIONAL CME Vs CPD
73
www.cpdindia.in

74. www.cpdindia.in 74

75. www.cpdindia.in 75

76. Develop friends & interest outside medicine

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

82. Informing patient in
information age
Printed material Broachers

83. Exercise has life transforming benefits

84. Regular exercise: benefits
 Improves cardio vascular fitness
 Improves mood
 Reduces stress
 Loses fat, not lean muscle
 Decrease back & joint pain
 Decrease loss of bone density
 Decrease chol., Ht, insulin senstivity,
incidence & mortality from CAD, risk of
colonic cancer

85. Physicians: problematic spouse?

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

88. Issues Threatening marriage
 Money & Financial arrangements
 Infidelity
 Boredom
 Career crisis
 Empty nest syndrome
 Retirement.

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

91. Physicians: personal crisis

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

97. Legal battle
Phases
 Denial
 Anger
 Bargaining
 Depression
 Acceptance

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

102. Burnout
Loss of Physical, Emotional & Mental Energy

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

108. Doctors are not organized or united

109. Physicians: well equipped but
don’t venture in leadership

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

117. Doctor & Spirituality
 No Further Action
 Spirituality as adjuvant care

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.

121. Think of retiring when you feel time is
right

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

124. Think of retiring when you feel time is
right

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.

130. T hanks