Explaining cardiac interventions: Using analogies to improve communication

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Dr KK Aggarwal

The doctor-patient relationship is the foundation of practice of medicine. And, communication is the key factor that decides the interaction between the doctor and his/her patient and influences outcomes.

Doctors are bound, both ethically and legally, to provide adequate information to the patient so that the patient can participate in the decision making process and are in a position to take an ‘informed’ decision.

Any information given to the patient should be in a language, using words or using terms he/she can understand.

But do patients really comprehend the information that is given to them during the process of informed consent? The science of medicine is abound with complex concepts. Medical terminology uses technical words and jargon that are unfamiliar to the patient and difficult to understand. This may hinder the effectiveness of communication.

One way to improve communication and enhance understanding of medical information is by using analogies. The dictionary meaning of an analogy is a ‘resemblance between two situations, people or objects that are otherwise unlike, especially when used as a basis for explanation’.

Analogies are situations that are familiar to the patient and so easily understood. The information is also better retained. Hence, using analogies to explain complex medical terms or concepts can improve doctor-patient communication.

This is how I explain cardiac interventions to my patients. I take the example of traffic management, a situation familiar to all.

For any traffic management, following are the options:

• Placing traffic signals can be equated to dos and don’ts of lifestyle management.
• Posting a traffic inspector on the crossing. This can be equated with a clinical cardiologist.
• Diverting the traffic from main road to side roads. This can be equated to opening collaterals by drugs and/or exercise.
• Hiring an architect to make maps. This can be equated to an angiographer (cardiologist) doing angiography.
• Looking for the possibility of widening the roads. This can be equated to balloon angioplasty.
• To prevent encroachment of widened roads to place railings around the widened roads can be equated to placement of metallic stent.
• To prevent mishandling of railing, safety grills are put. This can be equated to drug-eluting stents.
• When the roads cannot be widened, flyovers are made, which can be equated to bypass surgery.
• Flyovers can be made by stopping the traffic. This can be equated to open heart bypass surgery.
• Flyovers can be made without disturbing the traffic, this can be equated to heart bypass surgery.
(Disclaimer: The views expressed in this write up are entirely my own)

Privacy a fundamental right, rules Supreme Court of India

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In a landmark judgement delivered yesterday, the Supreme Court of India unanimously ruled that privacy is a fundamental right.

In its order, the nine-judge constitutional bench headed by Chief Justice of India said “The right to privacy is protected as an intrinsic part of the right to life and personal liberty under Article 21 and as a part of the freedoms guaranteed by Part III of the Constitution”.

Article 21 ensures protection of life and personal liberty.”No person shall be deprived of his life or personal liberty except according to procedure established by law.”

In doing so, the Bench overruled the two earlier judgements, also by the Apex Court, which had ruled against privacy as a fundamental right.

Right to privacy will be now find a place along with the other six fundamental rights recognized by the constitution of India.

1. Right to equality
2. Right to freedom
3. Right against exploitation
4. Cultural and educational rights
5. Right to constitutional remedies

Privacy and confidentiality are important tenets of ethical medical practice. They are the foundation of the doctor-patient relationship built on trust.

The terms, privacy and confidentiality have often been considered as synonyms. But, the two are not the same and it is important to know the difference between the two.

Privacy is the right of a person (patient) to keep his health information, including any other personal information, private and undisclosed. Doctors are often privy to private information shared by the patients during the course of history taking and treatment.

Confidentiality, on the other hand, is what we, as doctors (or other concerned persons) do with the information that has been entrusted to us. Confidentiality implies the duty of everyone entrusted with any information to keep that information private.

Health information is a part of personal information and includes information for example demographic data (name, address, phone no etc.), insurance information, identification data, medical history. Such information along with medical examination, clinical images during consultation and treatment is considered as information private to the patient.

Clinical images e.g. photos of a body part/skin lesion/injury, lab reports, x-rays/scan reports, audio/video recordings are also health information. They can be taken and shared only after consent of the patient.

Protecting the privacy of patient information is the ethical duty of the doctor as also mandated in the MCI Code of Ethics Regulations.

“2.2 Patience, Delicacy and Secrecy: Patience and delicacy should characterize the physician. Confidences concerning individual or domestic life entrusted by patients to a physician and defects in the disposition or character of patients observed during medical attendance should never be revealed unless their revelation is required by the laws of the State. Sometimes, however, a physician must determine whether his duty to society requires him to employ knowledge, obtained through confidence as a physician, to protect a healthy person against a communicable disease to which he is about to be exposed. In such instance, the physician should act as he would wish another to act toward one of his own family in like circumstances.

7.14 The registered medical practitioner shall not disclose the secrets of a patient that have been learnt in the exercise of his / her profession except –
• in a court of law under orders of the Presiding Judge;
• in circumstances where there is a serious and identified risk to a specific person and / or community; and
• notifiable diseases.
In case of communicable / notifiable diseases, concerned public health authorities should be informed immediately.

7.17 A registered medical practitioner shall not publish photographs or case reports of his / her patients without their permission, in any medical or other journal in a manner by which their identity could be made out. If the identity is not to be disclosed, the consent is not needed.”

Privacy and confidentiality has been included among the important principles of bioethics (Article 9) defined by UNESCO under its Universal Declaration on Bioethics and Human Rights that should be respected. “The privacy of the persons concerned and the confidentiality of their personal information should be respected. To the greatest extent possible, such information should not be used or disclosed for purposes other than those for which it was collected or consented to, consistent with international law, in particular international human rights law.”

Another very important aspect that should be understood and kept in mind is that while hospitals or healthcare establishments own the physical (or electronic) records, they are only “held in trust by them on behalf of the patient”. The information or data in the records are owned by the patient. This information is protected health information.

What constitutes protected health information? The Electronic Health Records Standards for India 2016 notified last year have elaborated on this.

“Protected Health Information (PHI) would refer to any individually identifiable information whether oral or recorded in any form or medium that (1) is created, or received by a stakeholder; and (2) relates to past, present, or future physical or mental health conditions of an individual; the provision of health care to the individual; or past, present, or future payment for health care to an individual.

Electronic Protected Health Information (ePHI) would refer to any protected health information (PHI) that is created, stored, transmitted, or received electronically. Electronic protected health information includes any medium used to store, transmit, or receive PHI electronically.

As per the Information Technology Act 2000, Data Privacy Rules, refers to ‘sensitive personal data or information’ (SPI) as the subject of protection, but also refers, with respect to certain obligations, to ‘personal information’ (PI). Sensitive personal information is defined as a subset of personal information. Followings are Sensitive personal information that relates to:

1. Passwords
2. Financial information such as bank account or credit card or debit card or other payment instrument details
3. Physical, psychological and mental health condition
4. Sexual orientation
5. Medical records and history
6. Biometric information
7. Any detail relating to (1) – (6) above received by the body corporate for provision of services
8. Any information relating to (1) – (7) that is received, stored or processed by the body corporate under a lawful contract or otherwise”

The patient is the supreme consent giver, and no action pertaining to his/her health information can be taken without consent from the patient. Any protected health information can be shared only after patient consent and that too only with the authorized person. Divulging this information to any unauthorized person without consent of the patient is breach of privacy and confidentiality.

This judgement will have huge implications on how information can be used.

In light of this judgement, privacy is no longer a common law right. And, it’s not just our ethical duty to respect the right to privacy of a patient simply because it is prescribed by the MCI Ethics Code or any other regulatory bodies.

Privacy is now a fundamental ‘inviolable’ right under the Constitution of India.

Disclaimer: The views expressed in this write up are entirely my own.

Dr KK Aggarwal

Triple talaq judgement may relieve stress in women

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Dr KK Aggarwal

Our Vedas tell us that every thought in our mind arises from the silent potential web of energized information or consciousness. This thought from the mind is then analyzed by the intellect and the personalized by the ego. It then leads to an action. Every action leads to a memory, which in turn leads to a desire and with this a cycle of action, memory and desire is set into motion.

If the desire is fulfilled, it leads to action again and then desire again. Repeated fulfillment of desires leads to habit formation, addictions and development of a particular personality. Unfulfilled desires, on the other hand, lead to irritability and then to anger.

Anger destroys peace of mind. It hampers the powers of discriminating between good and bad. Anger distorts intellect and fosters negative emotions. Loss of intellect leads to animal-like behavior and ultimately self-destruction.

Anger can be expressive anger or suppressive anger. Expressive anger or anger outbursts manifest as aggressive behavior, violence, hostility and cynicism. Emotionally stressful events, including anger, may trigger the onset of acute heart attack, asthma, anxiety. Cynical hostility has been recognized as major risk factor for coronary artery disease. While, suppressed anger or chronic anger in due course of time may cause depression, despondency, behavioral changes, anxiety, acidity and diarrhea.

However, anger is not always bad. Righteous or spiritual anger is a type of anger with good intentions. The classical example of righteous anger is when you become angry in a situation where you see a person doing something wrong to check that person.

Righteous anger can make people stand up for their rights and fight against what is wrong.

The story of a young Muslim woman who allegedly committed suicide after her son had been taken away from her, two weeks after being divorced through triple talaq was published earlier this year. Depression was reported to be the factor leading to this extreme step. (April 12, 2017. http://www.newindianexpress.com/nation/2017/apr/12/muslim-woman-divorced-through-triple-talaq-hangs-self-after-two-weeks-1592609.html).
Many such women in the country are living in a similar chronic stage of fear and apprehension of being discarded by their husbands. They are vulnerable to depression, anxiety, and various psychomotor disorders.

The historic verdict of the Supreme Court of India, abolishing the practice of triple talaq, will liberate women from such fears. Empowering them and giving women equal right in marriage will reduce the prevalence of acute and chronic mental disorders in them, most commonly depression.

Stressful events such as psychological trauma, etc. may also trigger development of depression.

According to the World Health Organization (WHO), depression is now the leading cause of ill health and disability worldwide. More than 300 million people are now living with depression, an increase of more than 18% between 2005 and 2015. A person with depression is typically depicted as sad, lonely, having no interest in activities that they earlier enjoyed, too much or too little sleep, low self-esteem, hopelessness. But, depression can also present as anger, irritability, addictions, eating too much or not eating enough, persistent aches and pains, memory problems, fatigue, or other behavioral changes.

Disclaimer: The views expressed in this write up are entirely my own.

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