Take appointment to discuss'- A clarification

 'Take appointment to discuss'- A clarification

Many times, patients message me to ask 'a quick question' or want to speak to me for a minute when 'free'. If your problem is short enough to be addressed in one minute, please type out the problem and send it. Whenever possible I will answer the query.

But sometimes I have to ask relevant details to give you a proper answer. This takes a bit of time and I need to refer to records to do so. In such cases I advise you to fix appointment- at least a teleconsultation appointment to discuss the matter and give correct answer. If matter requires time and expertise- I will charge you. Believe me- that I will not charge you unnecessarily.

Please do understand that by asking you to take appointment to discuss, I am only trying to make sure that my time is utilised properly as well as your concern is addressed with due care.

Pan mala golya ghyayachya nahi

 एक व्यक्ती म्हणून रुग्णाशी संपर्क साधणे आणि त्यांच्यासमोर असलेल्या समस्यांचे निराकरण करण्याचा प्रयत्न करणे हे माझे स्वतःचे उपचार तत्त्वज्ञान आहे. मी पूर्णपणे सहमत आहे की तणावाचे घटक, जीवनात होणारे बदल आणि व्यक्तीची त्यांना पूर्णपणे सामोरे जाण्याची असमर्थता, जमा होतात आणि या त्रासांना कारणीभूत असतात. रूग्णांना माझा पहिला सल्ला आहे की ही परिस्थिती निर्माण करणाऱ्या सवयी बदलण्याचा प्रयत्न करा किंवा बदला - हिप्पोक्रेट्सने दिलेला उत्कृष्ट सल्ला आहे. तथापि, रुग्ण माझ्यापर्यंत पोहचेपर्यंत- जे सहसा वर्षानुवर्षे वाट पाहिल्यानंतर आणि इतर प्रत्येक पद्धतीचा प्रयत्न केल्यानंतर- त्या व्यक्तीला मानसिक आजारासारखी वैद्यकीय समस्या असते. आता मानसिक आजाराच्या टप्प्यावर, व्यक्तीची क्षमता आणि आराम पूर्वस्थितीत आणण्यासाठी वैद्यकीय उपचार आवश्यक बनतात. या टप्प्यावर नुकसान झाले आहे आणि फक्त नुकसान भरून काढण्यासाठी किंवा भरपाई करण्यासाठी वैद्यकीय हस्तक्षेप आवश्यक आहे. रुग्ण मला सांगतात 'मला औषधे घ्यायची नाहीत'. ही परिस्थिती दोन प्रकारे त्रासदायक आहे.

प्रथम, जर तुम्हाला औषधे घ्यायची नसतील तर डॉक्टरांकडे का यावे? आधुनिक वैज्ञानिक वैद्यक परंपरेतून मानसोपचारात एमडी पदवी घेतलेल्या डॉक्टरांना, विशेषत: माझ्यासारख्यांना केवळ औषध देण्याचे प्रशिक्षण दिले जाते हे सर्वज्ञात सत्य आहे. जर तुम्हाला नैसर्गिक उपचारांची अपेक्षा असेल तर तुम्ही नैसर्गिक उपचाराकडे जावे, जर तुम्हाला योगासनाशी संपर्क साधण्याची गरज असेल तर योग प्रशिक्षकाकडे, आहार उपचार पोषण सल्लागार आणि व्यायाम उपचार फिजिओथेरपिस्ट/प्रशिक्षक देतात. मुख्य प्रवाहातील वैद्यकीय उपचारांना पूरक म्हणून मानसोपचारतज्ज्ञ याविषयी सल्ला देऊ शकतात. त्यामुळे जर तुम्हाला वरीलपैकी कोणतीही अपेक्षा असेल तर मानसोपचार तज्ज्ञांचा सल्ला घेणे हा तुमचा वेळ आणि पैसा वाया घालवणारा आहे. तुम्ही मानसोपचार तज्ज्ञाकडे आल्यास, लिहून दिलेली औषधोपचार करण्यास तयार रहा आणि तुम्ही तुमच्या भीती आणि चिंतांबद्दल चर्चा करू शकता. जर ते तुम्हाला औषधे वापरण्याचा आत्मविश्वास देत नसेल, तर तुम्ही ती न घेण्यास मोकळे आहात. मानसोपचार तज्ज्ञाची शिफारस अजिबात बंधनकारक नाही. (अनिवार्य मानसिक आरोग्य उपचारांच्या फार कमी परिस्थितींशिवाय). परंतू तुमचे उपचार पर्याय काय आहेत हे जाणून घेण्यासाठी मानसोपचार तज्ज्ञांचा सल्ला घेणे नक्कीच योग्य आहे. काही रूग्ण उपचार इतके भयावह नसतात आणि योग्य माहिती मिळवतात आणि पुढे जातात.

दुसरी अडचण म्हणजे एखाद्याला पर्याय आहे असा विश्वास. मी अगोदर सांगितल्याप्रमाणे; जोपर्यंत एखादी व्यक्ती मानसोपचारतज्ज्ञाकडे पोहोचते, तोपर्यंत बदलता येण्याजोग्या मानसिक अस्वस्थतेचा टप्पा खूप पूर्वीचा असतो आणि अपरिवर्तनीय मानसिक आजाराचा टप्पा आधीच गाठलेला असतो. या टप्प्यावर वैद्यकीय उपचार हा एकमेव प्रभावी पर्याय आहे. यावेळी, प्रत्यक्षात फक्त दोनच पर्याय आहेत- एकतर उपचारामुळे बरे होणे किंवा सतत प्रगतीशील मानसिक आजार. ज्याला स्वतःची खरी परिस्थिती स्वीकारता येत नाही त्याला समजावून सांगणे ही अवघड गोष्ट आहे. बहुतेक मानसोपचारतज्ञ 'काही काळ औषध घ्या', 'मी सौम्य डोस देत आहे' 'मी मानसिक जीवनसत्त्वे देत आहे' वगैरे सांगून पटवून देण्याचा प्रयत्न करतील. सत्य हे आहे की रुग्ण मानसिक नुकसानीच्या पातळीवर पोहोचला आहे ज्याला बरे होण्यासाठी औषधांची नितांत गरज आहे. . रुग्ण आणि कुटुंबीय हे सत्य जितक्या लवकर स्वीकारतील तितके दीर्घकालीन चांगले. उपचार सुरू केल्यावर रुग्ण बरा होतोच, पण पुढील नुकसानही थांबते. ज्याला औषधोपचार घ्यायचा नसेल त्यांनी दुसर्‍या मानसोपचार तज्ज्ञाचे मत घ्यावे. जर दोन किंवा अधिक मानसोपचारतज्ञ सहमत असतील की तुम्हाला वैद्यकीय उपचारांची गरज आहे, तर वैद्यकीय उपचार स्वीकारणे सर्वोत्तम आहे. ज्या मानसोपचारतज्ञांशी तुम्‍हाला सर्वात सोयीस्कर वाटले त्‍यांच्‍याकडे उपचार सुरू करा आणि जोपर्यंत मानसोपचार तज्ज्ञ तुम्‍हाला थांबण्‍याचा सल्ला देत नाहीत तोपर्यंत सुरू ठेवा.

BUT I DONT WANT TO TAKE MEDICINE!

 

My own philosophy of treatment is to approach the patient as a person and try to solve the problems they present with. I completely agree that stress factors, changes through life and the person's inability to completely deal with them, accumulates and cause these disturbances. My first advice to patients is to try and reverse or change the habits that have led to this situation- as is the classic advice given by HIPPOCRATES Himself. However, by the time the patient reaches me- which is usually after years of waiting and trying every other method- the person has a medical problem like a mental illness. Now at the stage of mental illness, medical treatment becomes essential to restore the person's ability and comfort. At this stage the damage is done and medical intervention is required to just cope or compensate the damage. Patients tell me 'I dont want to take medications'. This scenario is problemmatic in two ways.

Firstly, if you dont want to take medications, why come to a doctor at all? It is a well known fact that doctors, particularly those like myself who have an MD degree in Psychiatry from the Modern Scientific Medicine tradition are trained to give medicine only. If you expect natural treatments you should go to a Naturopath, if you need Yoga approach a Yoga Trainer, diet treatment is given by Nutrition consultant and Exercise treatment is give by Physiotherapists/ trainers. Psychiatrists can advise about these only as complementary to mainstream medical treatment. So it is really waste of your time and money to consult a Psychiatrist if you expect any of the above. If you come to a Psychiatrist, be prepared to be prescribed medication and you can discuss your fears and concerns. If that doesnt make you confident to try medications, you are free to not take them. A Psychiatrist's recommendation is not binding at all. (Unless in very few scenarios of mandatory mental health treatment). But surely it is worth consulting a Psychiatrist, to know what your treatment options are. Some patients discover treatment to be not so frightening and get the correct information and proceed with it.

The Second problem is the belief that one has the choice. As I mentioned earlier; by the time a person reaches a Psychiatrist, the stage of reversible mental turmoil is long past and the stage of irreversible mental illness has been already reached. At this stage medical treatment is the only effective option. At this time one has only two options actually- either treatment induced recovery or continued progressive mental illness. This is a difficult thing to explain to the person who cannot accept one's true situation. Most Psychiatrists will try to convince by saying 'take medicine for some time', 'I am giving mild doses' 'I am giving mental vitamins' etc. The truth is that patient has reached a level of mental damage that absolutely needs medication for recovery. The sooner the patient and family members accept this fact, the better it is in the longer term. When treatment is started the patient not only recovers, but further damage is also halted. Anyone who doesnt want to take medication, should seek opinion from another Psychiatrist. If two or more Psychiatrists agree that you need medical treatment, best is to accept medical treatment. Start treatment with the Psychiatrist whom you were most comfortable with and continue till the Psychiatrist advices you to stop.

GUDDU Sr and GUDDU Jr

I used to learn Carnatic Music from Rajeshwari Teacher between 2001 and 2003. I joined the class to learn music, but actually it turned out that being with Teacher for those few hours every week made me feel less lonely and I looked forward to the classes a lot. I wouldnt say I learnt a lot of Carnatic music, but there was much that I got from the experience. For one- entering teacher's house was like entering a temple- one could really feel the serene, safe, spiritual atmosphere there. This despite the fact that there would always be some guests etc milling around. After the class, teacher often treated us to goodies made by her- Gulab Jamun, etc. And Dassera times, Varamahalakmi were the best- it meant teacher would give a whole plate of snacks and plus the 'udi tumbo' ritual as I was married and qualified for this special 'muttaidi' felicitation. (North Kanada words, ok).

Our enthusiastic observer was Senior Guddu. As serene and mature as all other folks in the house, he lay down and quietly listened to the proceedings. Sometimes when I or my classmates went offkey, I did perceive him suddenly opening his eyes and looking around. Subsequently I used his reactions to judge if I was going the right way. The months after he passed away were painful for teacher, but she continued to take classes. I marvelled at her- it taught me first hand-- life must go on. Soon puppy- Junior Guddu arrived on the scene. Sometimes teacher called him 'Surya'. This fellow was the polar opposite of his predecessor- a bundle of energy and curiosity- always leaping up and wanting to park on my lap. As we began our class- he would amble in and lie down next to teacher and then the proceedings would go as follows-

Sa- open eyes and ears cocked up

Re- Head turned towards source of sound

G- Turn and stand up looking alternately at student and teacher

M- Start barking and leaping in place

Pa- Leap on the student (as if begging to stop)

.......Then teacher had to calmly say 'Guddu....' and catch him, pat him and again he would lie down

And the whole cycle would begin again. It was so cute to go to class with this puppy and all his antics and all the nice snacks and teacher's nice conversation. By the time Guddu Jr settled down enough to stay quiet through the class, I had to leave Bangalore and my classes with teacher concluded. I had the full intention of going back to Rajeshwari teacher, mainly to have her bless my son. But it was a shock to me to know, she was no more.

While I was reading Dr CRC's autobiography, I was constantly reminded of Rajeshwari teacher. She made such an impression on me and I had great affection and regard for her. 'Samadhana' Counseling centre is as much a result of her personality.

THE BANGALORE EXPERIENCE

This November, I was fortunate to attend Child and Adolescent Psychiatry (CAP) services under Supervision of Dr M V Ashok at St John's Hospital Bangalore. As a trainee Psychiatrist, I worked for 3 months in St John's and came to know that Dr Ashok was leaving for further training in CAP to the UK. Upon his return he set up this service, which now is approximately 20 years old.

I could see from the numbers and the great distance from which patients arrived, that this service is a great success.

Dr Ashok works with Dr Vijaya Raman (Senior Psychologist), Dr Suhas Chandran (Assistant Professor) and post-doctoral fellows. This core team is embedded in the 'Centre of Hope' which is the facility dedicated to serve children with special needs. The Centre of Hope is a huge building where Developmental pediatricians and other pediatric specialists like Orthopedicians, nephrologists, neurologists, Opthalmologists, ENT specialists and the full range of Specialists work. In addition, there are trained nurses, physiotherapists, speech and language therapists, occupational therapists, specialist psychologist and specialist medical social workers. A CommDeall centre is also included in this team. This the first time I have seen so many specialists work together, cordially, with common goal of giving the best life for children with special needs. St John's hospital also has very good gardens, security and traffic management, tuck shop and canteen with delicious food. Services are offered at very inexpensive rates. This is part of the general hospital and so the whole family can be served. I think this is a very good system for providing healthcare services.

CAP services treat children from infancy to adulthood. Thereafter, they are taken over by the adult Psychiatry services in a smooth transition. Patients are examined thoroughly and unhurriedly. Treatment is intensive and goal- oriented. Patients are seen in outpatient, inpatient and different therapies. Children with Intellectual challenges, autism, genetic disorders, behavior problems, emotional disorders, stress induced disorders and mental illness are treated in this service. Counseling, therapy, medication and ECT are available for children.

Work typically starts at 9am and extends upto 8pm daily. Everyone (including families) work really hard to give good outcomes to children. The CAP unit also liaises actively with special schools, tutors, shadow teachers, vocational centres and employers. I also visited clinic of Dr Yashaswini Kamraju, who is a private practitioner and practises Child and Adolescent Psychiatry in her clinic. In my free time, I also visited Dr C R Chandrasekhar's Samadhana Counseling and Guidance Centre (which will be covered in a later blog). Here too, children are examined and counseled- free of charge. Children requiring further help are referred to dedicated CAP services close to their homes or to NIMHANS.

All in all, I had a good experience during my stay at Bangalore. I was happy to see that every type of service for children with special needs is provided by Dr Ashok's team. I wish such comprehensive care, with easy access is available in all cities. I hope to emulate the method of doing as much as possible, as soon as possible, maintaining team approach and constantly expanding scope of services.

Repeat Prescription

 I have a pharmacist friend who runs a medicine shop. He often dispenses psychotropic medications. As he is very meticulous, he makes sure that the prescription is a valid one, records the required details, checks the patient's identity and then gives the medication. This means he has to turn away patients who come without a prescription or come with an outdated prescription. Patients tell him they do perfectly well on medication and so what is the harm in just giving it to them? And why should they pay the Psychiatrist an exorbitant amount to just have the same particulars copied down with a new date on it? I, too, face a situation where patients send me a text message with a picture of their old prescription and ask me to reply with a picture of a prescription with a 'new' date. I can fully understand that a patient who remains well on the same medication for several years feels that the process of follow up with a Psychiatrist is totally unnecessary. But for the patient's own safety, the matter has to be a bit different than what 'common' sense would suggest.

Psychotropic medications have to be taken on a long- term basis. During this time patient can have other disorders, start other medications, undergo surgery, have changes in weight, attain menopause or menarche (in female patients), develop new sources of stress, have old stress reduced down and so many other factors that will need a change in the dose of medication. Patient undergoes ageing process which changes the medication response. Some psychotropic drugs have to be monitored for side effects. A good number of mental illnesses will progress despite medication and the early signs of progress need to be picked up to prevent a full relapse. For all these reasons, regular follow up is absolutely essential. When the patient is feeling quite ok, there can be early signs of problem or risk factors for a problem- which can only be picked up during examination by a Psychaitrist. During routine follow up these are picked up and larger problems prevented. Psychiatrists also use the opportunity of follow up to educate the patient about proper diet, exercise, stress management and other important subjects relevant to maintaining good general and mental health. 

Legally, no medical advice can be given without adequate examination of the patient. Prescription is a written advice of the doctor. So, no prescription can be issued without proper examination of the patient. Even if the patient, their whole family or anyone gives full assurance that patient is doing well, and the current medication suits him/ her- such reassurance has no value. The only thing that can be the basis of writing a prescription is a thorough medical examination by the doctor writing the prescription.

And it is only reasonable that the doctor (Psychiatrist) who has worked to examine the patient, apply expertise to solve not only the present problems but to foresee and prevent the imminent ones and explained everything to you in detail and then written all that down in the form of a prescription- should be paid the consultation fee!

PS- If you feel the doctor is not giving enough time- change the doctor. Dont do the shortcut of avoiding consultation and continuing medications.

REPAIR A RUNNING CAR

I have often wondered if there is any time that a running car gets repaired? I have seen cars being serviced in record time during races, but they do stop for it to be done. But in mental health, we are expected to treat the patients while they are in action continuously.

A lot has been written about the loss of concept of 'convalescence'. But in psychiatry its worse- patients don't want to stop even when actively and severely ill. Particularly if the patient is a child or adolescent- the parents rarely allow any concessions in their packed schedule or attempt of various exams. Even celebrity sportsmen take a break when injured- but our patients- never do.

I often feel like I am continuously running to catch up with a running car and simultaneously trying to change its tires. When I do any intervention and expect result- instead patient has gone and stressed themselves out further- forget being over the initial problem- now there is a new problem to handle.

If only people would take it a bit easy and allow the body to heal- that would ensure they recover with minimum medication, minimum side effects and it will be a proper recovery. They should go back to work and life slowly and as advised.