Sunday 26 June 2016

Fieldwork in indigenous communities of Vale do Ribeira


Fábio Junqueira

"It was a really nice experience being part of this action with the Guaranis, we left a bit of ourselves and learned a lot. It was remarkable! After the activities, conversation circles with the communities and the health team, we put a lot of thought to a broader concept of health, and also social, cultural and environmental determinants.
How can we ask for a healthy life in a sick plane? The natives Guarani inspired us and showed us we need to discuss the creation of societies truly sustainable, we must resume the harmony between humankind and nature and value the social diversity and the different ways of life, for instance, those from native peoples and from different indigenous nationalities.
We believe that putting thought to these issues is essential in the current formation of the health professionals. We would like to thank the indigenous leaders who welcomed us so warmly and also thank the indigenous health team from Miracatu, the Prof. Paulo Abati and the medical students. As a complementary reading I suggest the book: "O Bem Viver" by Alberto Costa!"

Contact: fjunqueira@pucsp.br

Sunday 19 June 2016

The Humours of General Practice

Amber Wheatley

Early on in my medical training I was introduced to the term ‘GP Land’. Coming from an island where there was only ever two doctors working, the concept of a hierarchy within the medical profession was very strange to me. I quickly grasped that the division between hospital doctors and general practitioners rested on the assumption that GPs worked an idealistic 9-5 with weekends off and no on-calls while hospital doctors were overburden with far more intellectually challenging medical dilemmas. The impression I got prior to starting my GP placement was that hospital doctors, in the eyes of the public, were the real doctors. GPs were just bad impersonators living in ‘GP Land’.

One thing that stayed with me the most was a conversation I had with a classmate while on our clinical placement. One of the junior doctors was planning on becoming a GP and it sparked a conversation about those in our class who wanted to be GPs. I remember my classmate saying that the junior doctor was too smart to be a GP. Wanting to be a GP was a ‘waste of talent’. But my experience from GP placement made me think otherwise. We are told over and over again in lectures that medicine is both a science and an art. You can know all the pathophysiology behind a disease, all the treatments possible, all the mechanisms of action but being able to recognise the clinical signs and take a good history is where the artistry becomes crucial. What I learned from observing GPs on placement was that what separated a good doctor from a great doctor was how well they managed the peculiar combination of science and art in medicine. To me, GPs are the true artists of medicine. Unfortunately, like most great artists, their art is both under-appreciated and often goes on unrecognised.

The artistry of General Practice lies in what I call the humours of General Practice. In ancient Greek medicine it was thought that the body consisted of four humours; yellow bile, black bile, phlegm and blood. The composition of these humours was thought to determine the disposition and the health of patients and so ancient medicine focused on balancing these humours. This led to a system of individualised treatment where patients were treated holistically, considering both mental and physical health. Today’s GPs have the advantage of seeing patients from the cradle to the grave, seeing whole families and most importantly getting to know their patients. This allows them to understand the temperament of their patients and so tailor their consultations to suit whoever is in front of them. Even among GPs, rural GPs have an even deeper understanding of their patients.

One moment were I experienced this was when I saw a lady complaining of neck pain. She had worked in the past as a carer before the implementation of hoists and lifts and so had experienced a lot of wear and tear. In the past she had had a scan that showed the damage to her cervical vertebrae and so I had determined the best plan for her would be to have a repeat scan and see if the damage had gotten worse. I looked expectantly at the GP that was observing me to confirm that this was the right decision and she responded, “No, but I will tell you why”. It turned out that the lady had a history of depression and anxiety and sending her for a scan would just have made her feel worse. She had used acupuncture for the pain in her neck and that had worked marvellously for her. The GP later explained to me that the pain in her neck was most likely due to muscle stiffness probably affected by her anxiety and all she needed was to relax. She was put in a quiet room with classical music playing in the background, had her acupuncture and left the practice beaming. This experience forced me to learn that deciding what happens next with a patient is determined solely by protocol or what I think is their main worry, it’s about the disposition of the person in front of you. It’s understanding what the next step means for them, their daily life, their occupation, and their family.

My attachment in general practice has given me some of the most enriching experiences of my medical education. It has helped me put a face to the massive amounts of information I need to learn. It has forced me out of my comfort zone and on to the frontline, seated across from a real life patient. It’s safe to say that my greatest achievement from my GP placement, although still a work in progress, is in the development of my clinical judgement and communication skills. Being able to read and understand the expressions and body language of a patient as well as I can read and understand the medication lists and patient notes. My GP placements have helped me to maintain, and even grow, my love and passion for medicine. In an age where medical careers are taking the form of narrower and narrower sub-specialities, I hope that the value of the artistry of medicine, perfectly demonstrated by General Practice, does not get lost or forgotten.

“Science and art share a common mandate—to find surprise in the ordinary by seeing it from an unexpected point of view.”

— Howard Bloom
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Brief Description about the author: Amber is a third year medical student at Swansea University. Originally from the British Virgin Islands, Amber has been active in the area of rural family medicine and hopes to return to the Virgin Islands to practice medicine. Amber is a participant in the Rural Family Medicine Cafe and Swansea University's Rural and Remote Health in Medical Education (RRHIME) program. Amber is also the Caribbean student representative for WONCA Polaris.

Area of practice: medical student

Epidemiology of your area in brief: Wales has a mixed demographic of rural practices in predominantly farming areas and also more urban practices near the city centre. This reflection was inspired by an experience comparing urban GPs to rural medical practice

Saturday 11 June 2016

The Dual Challenge Pregnancy with Hypothyroidism and GDM



About a young lady and her journey with hypothyroidism and GDM
Dr Smruti Mandar Haval  (Dr. Smruti Subhash Nikumbh)

This story I have pen down today is about Mrs.P a young lady of mid-twenties age. She is a known case as hypothyroidism and on regular treatment. In fact her hypothyroidism got diagnosed during her work up of infertility. With meticulous follow up and treatment she managed to conceive.(It is a painful journey so far as she meet me every month with blood report - poor lady is tired of same).But now she is a pioneer member of Project Kamal and inspiring many more for a good fight against hypothyroidism).


All was good till one fine day her husband called me and asked for an appointment .Her 7 th month was running and she was suffering from sore throat, joint pain, fever with chills, pedal edema etc. The joint pain was so severe that it was refraining her from doing her day to day activity. I ask him to see me earliest. It’s been an slightly emotional call as I know this couple last 18 months and have seen their struggle quit closely. They are very humble, obedient and compliant with whatever treatment has been offered to them.


As per schedule she came to my OPD and I did her assessment. Clinically she was suffering from acute pharyngitis with viral fever. She told me these symptoms are there from 4-6 days and she seek treatment for same from a nearby doctor who gave her two injections (?) followed by which she had dark colored urine for 2 days with little relief. We advise her few basic investigations to work up fever cause.


She came back after 2 hours with them and to our surprise her urine was showing 3 + glucose, her RBS was 348 mg/dl, Hb has dropped and urine was showing few pus cells. This was a big news as all her last investigations were absolutely normal. To confirm the findings we probed her more on family details and we got to know that her father was a diabetic and died few years back because of diabetic complications. Her paternal aunt and elder sister are diabetic. So a strong history of diabetes support current results.


She got nervous, anxious, emotional all at same time and started crying as she smell that something is wrong with her investigations. The husband and I somehow counseled her that no need to worry lets fight the battle. I told her that she is on verge of a disease name Gestational diabetes mellitus a type of diabetes appears during pregnancy and there is treatment for it if she cooperates as she always do. She somehow manage to balance her emotions and told me please go ahead and confirm whether it’s really there in her as she was really tired of fighting this pricking & draw blood business!


I did her Hba1c in my OPD and that reading too came 8.4 %.I was not so convinced with that result as her Hb was also low so there were higher chances of bias or increased reading. We also cross check her urine sample for glycosuria as on dip stick we got 3 + glucose but on Benedict's test also the urine colour came brick red the same colour I have seen in my biochemistry classes!


We admit her control her sugars with MNT and insulin therapy. Her infection has been controlled with intravenous antibiotics. Throughout the process pedal edema remains with fluctuations but her BP was normal and no investigations suggesting HELLP syndrome. Now things are under control, she underwent caesarian section and delivered healthy girl child Macrosomic but cute.





Conclusion

The lesson I learnt from this case is importance of detail history taking, screening high risk pregnancy and MOGTT in second trimester. Tests like MOGTT are bit costly, time consuming hence not so popular test or investigation in most of the parts of rural India.

But the primary care physician and obstetricians can use simple tests like 50 gm oral glucose challenge test which is less time consuming and good screening tool along with random RBS. This may help to pick up the DM early in pregnancy as India is one of the capital of diabetes and diabetes is fast treading disease.

Many guidelines have shown that South Asian females are more at risk of developing GDM hence there early screening is very important. HbA1c can also act as a good tool but in Indian rural scenario under lying Anaemia is a hurdle. Through Diabetic Mitra project we are trying to improve this situation and hopeful that Almighty will give us healing hands. Thank you.

Suggestions for strengthening rural healthcare and Role of WoRSA

To create database or educational materials this will help primary care physician in rural area all over the world in awareness about GDM. Some researches papers can be done and published which can later be used as reference or guidelines suitable to need of south Asia.

_________
Dr Smruti Mandar Haval (Dr. Smruti Subhash Nikumbh)
M.B.B.S.D.N.B. (Family Med),M.N.A.M.S.,P.G.D. Diabetology & Geriatric Med.
Certified International Diabetic Educator by Project Hope & International Diabetes Federation (IDF) USA
Consulting Physician in Family medicine, Diabetology, Preventive Cardiology, Thyroid disorders & Geriatric Medicine
C.E.O. Sukarmayogi Publishers, Sankeshwar Dist: Belgaum, Karnataka
Assistant Professor, Department Family Medicine, USM-KLE IMP,Belgaum
Blog: drsmrutihaval@blogspot.com
drsmrutimhaval.blogspot.com
Area of practice- Sankeshwar, Dist – Belgaum ,Karnataka

Epidemiology of your area in brief:
It’s an semi rural area covering more than 50 km radius including many villages. Its USP is it’s an border area connecting borders of Maharashtra and Karnataka which makes it an multiethnic area. Common chronic health diseases are diabetes,hypertension,asthma ,hypothyroidism etc.

Sunday 5 June 2016

The silence of tired tongues

 
Brazilian "mate" at an Irish background

Mayara Floss

* Thoughts about one of my experiences as a Brazilian medical student in the countryside of Ireland

When I was leaving an elder’s home care in a rural area of Ireland, a doctor told me: "you know, one of the last things a person with dementia loses is the sensation of the touch on the skin, and this is the reason that touching your patients is so important in this stage of their lives."

 With these few words I started to realize how much this explains to us. One of our first sensations is the tact, and in the end everything is the same sensation. The knowledge to feel before speak. But, as we grow up, the tact becomes rarer. Sometimes the symbol of a friendship becomes a simple handshake. And we start to get used of how not to feel. We leave our parents’ laps and start “learning” that too much proximity often is invasive or not common. 

 However, the sensation of the touch continues to be important, even in our unconscious. People with dementia do not lose the capacity of having emotions or the recognition of a caress. Probably this is one of the sensations the doctors need to revive in their practicing. The tact is essential, even if just feeling the pulse. In the song “Casa no campo” (house at countryside), by Zé Rodrix, he speaks about “the silence of the tired tongues”, something not so common in our society nowadays. However, when the dementia process starts, this silence makes more sense. 

The care also changes its form, the silence of tired tongues makes us try to approach people in other ways. Sometimes, words lose their meaning, as well as communication (which seems to be many times attached to concept of speaking) with the patient becomes in body language. Although the person with dementia is most of times isolated from the conversation and loses the reference of the listening, what we learn is the importance of smiling, of giving hands and hug each other – be human without talking. Sometimes I think that words left the world more distant. Probably, the importance of the touch continues to everybody since his/her childhood, but masked by words. By finding a patient in the process of dementia, we have the chance to rediscover ourselves and our own tact. Due to this, tired tongues or not we still could say a lot of things touching.




The song about the house on the countryside and the "tired tongues"

Originally written in Portuguese: http://balsa10.blogspot.com.br/2014/05/silencio-das-linguas-cansadas.html?q=sil%C3%AAncio