Rural female primary care physician- By choice?

 

Dr Smruti Mandar Haval

           Many people ask me how and why you become a rural primary care physician? Is it by choice or a circumstantial decision? So to get answers to these questions let me share little bit of background of mine. I Dr. Smruti Subhash Nikumbh now known as Dr. Smruti Mandar Haval is a daughter of Dr. Subhash K. Nikumbh & Dr. Usha Nikumbh. My parents are specialist in their own subjects (Obstetrics Gynaecology & Ophthalmology) respectively. They are practising in area named Chalisgaon, Dist Jalgaon a town with population of 1 lakh to 2 lakh now with a good rural area surrounding it. When my parents started their practice 32 years back the population was round 40000 and most of the patients used to be farmers, poor daily wagers with not so good paying capacity. Most of the consultations used to be charity service. The connectivity was also poor then to the town. Patients used to come on bullock cart, cycle, walking. Ambulance service was a fancy thing. Maternal and child mortality was a regular thing. Laboratory facilities were in very primitive stage.

          With so many challenges my parents started their practice and with their good clinical judgement they managed to improve overall mortality and morbidity of patients from that area. Health promotion and awareness was always a part of their consultations. Since childhood I have observed their moves - conservative approach, no unnecessary surgeries, IV fluids, antibiotics abuse as that of today’s era.

                This entire thing nurtured a family physician in me and I learnt to live with people of golden heart. This journey with my parents generate a kind of liking in me for rural health, it’s up liftment, challenges. 

              With God’s grace and wish I got family medicine as my post graduate course and carrier. Also I got married to a man who has his work place in a small developing town of population 50000 -60000. For me this new work place is like my own home town                15-20 years back. After looking back at my 2 years of journey of rural physician I feel my challenges are same as of my parents but I love my job as patients I deal here are same as of my childhood pure mind, golden heart with lots of faith in me. They do feel I have healing hands. Their trust act as placebo in my treatment plan.

                For my residency & undergraduate training I have stayed in urban and metro areas. Those 10 years taught me how urbanisation changing human psychology. There I mate various types of patients like Google masters, self-diagnosis specialists, doctor shopping freak etc. This work culture was just not suitable for me. May be I was still a country side gal. Hence as soon as I finished my studies I decided to come back to my routes the rural practice. 

              Here I diagnose patients with minimal investigations, cost effective medicines, no much branding of pharmacy companies. This job gives me lots of satisfaction of work and my dues are getting clear slowly towards community I live. I also run few projects to improve treatment compliance of my patients to their long term treatment.

These projects are

1. Project Kamal -Early screening of Hypothyroidism and Treatment
2. Ajol -Myecha Olava - Dedicated Geriatric Care Clinic
3. Diabetic Mitra- Live Healthy with Diabetes
4. Asha - Dedicated Diabetic Foot Care Clinic
5. SurekhUsha Kavach- Early Screening of Cardiovascular Diseases and Treatment
6. Dwarika Movement- Early Screening & Prevention Osteoporosis
7. SubhaNand initiative – Patient Education Material

              In these activities we make sure that they will receive best treatment with each visit, investigations done by me. Slowly & steadily I am working on up liftment of health of my community.

                 Being a female I can relate well with both male and female patients. Female patients open up about their problems much better & clear so with that I can help them in best way.

   I am thankful now that I got connected to various rural GP networks all over world via rural café, rural health stories etc initiatives. Learning a lot from these activities.  I am a proud # Rural Female GP by choice and I am loving it. Thank you Almighty for all guidance & strength.

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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.

Neither burden nor feather

André Silva

This post was originally wrote for the Brazilian Blog of General Practice: “Causos Clínicos”

Attention: The following personal essay is based on a real case, but all names are fictitious. Further, all the story elements occurred in different situations. I saw main story with a wire of my life story. In this patchwork some details are older, some newer. But all are thea background of memories and heart.

As a suggestion please listen this soundtrack to read this story, this is the playlist that I listened when I wrote it. They are songs that made me smile, cry and touch as human in my vulnerability. Good reading!

AppleMusic

Spotify

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 -   You're kidding me! I do not believe in you !! This is absurd !!

I heard the shouts at reception, a woman's voice. All while I was talking to two undergraduate students in their final year of medicine. They were preparing to meet the last person in the morning at that Thursday autumn. It had up a music of Enya which the resident had said that she was fed up of listening it.

I'm going to the front desk, and I come across a lady I had met three weeks ago, Mrs. Matilde. Skinny, black, with hands punished by time and hard work in the fields and at home in their seventies. So slight that it was hard to imagine that she had four children.

-          Doctor, why are you doing this to me? - She said almost in tears.

As she screamed, a short film went through my head: the diagnosis of HIV for more than month and she denying it. The case discussion with the nurse and the difficulty to make her understand. And those cold data on paper: 14000 and few viruses per mL of blood, 350 leukocytes type CD4, numbers that leave no doubt, but Matilde only increased her anguish.

I almost as a reflex, call her to the office, the same that had Enya as background music.

-          Doctor, I couldn’t have AIDS, I am with no man for over 30 years since I husband had died, I did not take blood... what will I become? How much life do I have?

       I ended up stopping the music. I thought it was worse, because it was possible to hear the strained breaths of both students, Bruna, Pamela, and my own.

-          Mrs. Matilde, let's talk calmly. I'm here to clarify all your doubts.

-          Doctor, I'm not with a man for over thirty years, my life was taking care of four children, and just now I met my first granddaughter. Look, you need to wash the chair where I sat, so people will not be contaminated when sit here! – She was sobbing, already standing.

"Hard to believe that today there are still people who think that HIV is transmitted like this." - I thought in my smallness. "I need to act fast, accurately and undressing of my prejudices and my fears."

I turn on the music again. I ask Mrs. Matilde to sit and breathe deeply with me. The students in the corner observing were seedlings.

-          Mrs. Matilde, the main point now is not where this virus came from. What matters is that today we have treatment and we will always be here to care you.

-          But doctor, people will not be able to get closer to me and ...

-          Mrs. Matilde, please give me your hands.

-          But but...

-          Mrs. Matilde, give me your hands. Let's go. - I speak with her more firmly.

I welcome those skinny little hands, and look at that old lady with a scarf on the head.

-          You see? We don’t get HIV like this? Can you see thaat you don’t need to be afraid? You still could play with your grandoughter.. You just need to slow down. You will be able to take the medicine and live quite yet.

-          Doctor, you have the age of my grandson. Aren’t you lying to me, right? I'll even be able to continue to come here, sit in this chair and be cared by everyone here at the Health Basic Unit?

-          For sure, Mrs. Matilde.

-               And I can get my granddaughter on my lap?

-               Of course.

-               And could I hug anyone?

-               You can even hug me, Mrs. Matilde.

Them, the lady opens her arms and wraps me in a hug, weeping. "Thank you," she said. And a new film goes through my head, my poor childhood, the youngest of eight children, the causes and conditions that led me to medicine, family medicine, for living the distance of five thousand kilometers of the city where I was born and raised. The miss of my mother, that great friend the lives over thirty years with HIV, that another friend who has been diagnosed recently, the fragility and richness of this phenomenon called life. And drops a tear inside my being, while I hug that little person.

-          Doctor, so I'm going, much more peaceful. I do not want to take you time. I can come tomorrow with my daughter for you to explain to her how it will work from here on?  The exams... medicines...

-          Please Mrs. Matilde. We will be waiting for you.

  And Mrs. Matilde leaves the surgery, light as a feather. I observe Bruna and Pamela thrilled.

-          Professor, how beautiful was this! But we have a question: a doctor at the hospital told us once that we should never hug patients, neither in private practice, because "gives a lot of freedom" for the patient to ask for more and more things, and it becomes a burden. Do this mean that we can hug?

"I need to be careful with the words," I think as I remember the zeal I learned to have when I do ikebana, those Japanese floral arrangements.

-          But even ICU doctors say that touch helps, what about us, family physicians, doctors of people, of lives, stories and emotions? Hug is therapeutic for patients and for us. And I imagine you have had a good example just now.

-          Undoubtedly teacher. We will bring it to life. Thank you - tell the students at the same time.

So I say goodbye to the students and I'm thinking about it at the office. The clock mark midday, lunch time. I look at the picture of “Lord”, my dog that died few months after 14 years of affection, and I am there, absorbed in my thoughts, in my longing, in my tears, in a vacuum. Moreover, remember Master Dogen, an ancient Japanese Zen master, who said that our practice in life should be "no gain". I think it is. Only family doctor, of people, of lives, stories, emotions. Without any gain or burden, nor feather.

Several months later, after comings and goings of Mrs. Matilde she is "very well". When I was doing another ikebana before dinner during a retreat as I finished the floral arrangement, I remembered Mrs. Matilde and what it means life: a breath, a flower that blooms and withers, a force, the bird flight that leaves no trace, a moment. And ikebana was like this picture. I am grateful to you, Mrs. Matilde. And I found myself not burden nor feather.

_________

André Silva is a Family physician in Brazil and works in a Rururban area located at Porto Alegre within rural characteristics with local creation of animals but the influence of urban problems like drug dealing.

Non indigenous "disease" x Indigenous "disease"

Video with the testimony of Lucíola Inácio Belfort the first Brazilian Indigenous Kaingang to be graduated at medical school she is woking at SESAI (Special Indigenous Health Secretariat) with indigenous communities. She also is a nurse and she is working  on the ground. This video was recorded during the "1st State Seminar of Health of Traditional Communities: indigenous and Maroon - Rio Grande - Brazil‏" ("I Seminário Estadual de Saúde das Comunidades Tradicionais - Indígenas e Quilombolas " - http://www.sinsc.furg.br/site/isesct/ ).

Struggle for health

 

Samir Lopchan

58 years old male from Khung-1, Pyuthan came to our OPD with complains of fever for 2-3 weeks, pain in right side of chest with productive cough. He also had loss of appetite and loss of weight. On examination his temperature was 99° F, pulse rate 92/min and BP 110/70mmHg. On chest examination there were decreased breath sounds on right side of chest. Other examination was within normal limit.

Blood investigations, chest X-ray and Sputum for AFB (for PTB) were ordered. TLC 15,500/mm3 (N73L26E1), Platelet 3,70,000/mm3. Chest X-ray showed opacity in right lung with air-fluid level suggestive of hydropneumothorax/ pyopneumothorax. 

To make sure what is inside I aspirated with a syringe and got thick pus, so the diagnosis was made Pyo-pneumothorax (collection of pus and air inside the lung). For definite treatment the pus should be drained with a pipe inside the chest, it’s called chest tube insertion and drainage and intravenous antibiotics. We all know that ideally money shouldn’t be the issue between the patient and the health worker. But he had only 1-2 thousand rupees with him. This is how most of our patient comes to the district hospital. It is the scenario of every government hospital in rural areas. He even didn’t have any family member to accompany. He had come to hospital thinking he will get some tablets and cough syrup and he will return back. We told him about his condition, what needs to be done and asked him to call his wife to come to hospital. He said, “She has to stay home to look after home and the cattle.”

After taking informed written consent, we gave him Inj. Cefuroxime, Inj. Metronidazole and under local anesthesia, we inserted a 32 no. chest tube in his right chest. A gush of thick pus came, about 550ml of pus was drained and it was attached with a bag with water seal. He was admitted under Inj. Cefuroxime, Inj. Metronidazole, Tab. Levofloxacin, Analgesics, Aciloc. Later his sputum report came which showed positive for pulmonary tuberculosis, so Anti-tubercular drugs were started. 

He couldn’t afford the treatment so we did all for free. If we have had relied only on government free supply we wouldn’t be able to manage this case in a district hospital. Chest tubes aren’t available in most district hospitals. Many antibiotics don’t come under free supply. And if we had referred him outside the district either he would have returned back home or he had to sell his property to arrange money for his treatment. I had bought chest tubes, water seal bags from the NSI (Nick Simons Institute) GP fund, few medicines, tapes, sutures from my ‘Poor patient treatment fund’ (for which I collect donations from various kind-hearted donors) and got some medicines from NCCDF (Nepal Critical care development Foundation).

After 3 weeks of treatment, he improved a lot, most of the pus was drained but the entire lesion was not clear. CECT chest was the best option to see the extent and detail of the lesion and obviously a cardiothoracic consultation. But for that he had to go out from the district and he didn’t have money for that and he was not ready for that. So we discussed the situation, explained him and took out the tube and discharged him on Anti-tubercular drugs and other medicines. I know this isn’t the world’s best treatment what he got. People may say why you didn’t do pus culture, why you didn’t do CECT chest to see lesion, why didn’t you send him for the CTVS consultation, what if he develops some complications and many things. But what I am confident about is what I did is the best in this situation, what I did is the best any doctor can do in this settings. We knew that we had limited resources; we knew that we were less specialized. But everything was well explained to him and it was a joint decision to do the best in that situation. This is how we are giving our service; yes definitely compromised, may not be according to the international guidelines, may not be satisfactory to the super-specialized doctors but it is definitely stuffed with lot of warmth, devotion, dedication and right to the situation and settings.

Sometimes we have to act out of our profession and do something extra to provide health service in rural areas. I want to thank NSI, NCCDF and all the donors who believed in me and my work and helped me and my entire team.

 

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Name of the author- Dr. Samir Lama
Brief Description about the author- MD General Practice, working at Pyuthan District Hospital, Nepal
Area of practice- MD General Practice, I see all general cases and do surgeries mostly LSCS, appendectomy, hernia, hydrocele.
epidemiology of your area in brief- Mid-western region of Nepal, hilly area, difficult in transport, nearest referral center is 4-6hrs long drive through the hilly roads.
Introduction of your rural health story
Conclusion
Suggestions for strengthening rural healthcare and Role of WoRSA

Newer technologies and rural health

 Dr.Smruti Mandar Nikumbh-Haval

With new updates in world of bioengineering many firms are introducing various patient friendly gadgets which help them in monitoring of health issues. But in most of the rural areas these techniques are beyond reach. Reasons could be cost, literacy rate, education level to monitor them, maintainace, service centers, easy availability etc. 

 But a primary care physician can judge the need of such techniques well for community. These can bring a welcome change in community health services. He/she should try to search and use them for improvement of rural health. Urban or rural good patient health care should be the aim of every primary care physician. 

Today I will share my experience of one such technology came across few months back. It’s named as Continuous Glucose Monitoring System (CGMS).This is a new technology in market for monitoring of glycemic control of patient over period of 14 days continuously without causing much discomfort to patient. 

I got introduce to this during one of the workshop I attended. One of my colleague there who was type I diabetic using it smoothly to control his glycemic variables. I quite liked that so I searched for the company that provided that in India. My main hurdle was my rural back group .To convince marketing fellow was a task as he was bit reluctant to come to our place, share a demo and training. I assured him that I will personally take him to the venue and arrange transport. Then with lot of yes/no he agreed. One more (?) Bribe I offered him was discovery of an undiscovered market place which will help him in his promotion. That clicked well to him I guess. :-P. 

 We got our demo and I soon mastered the skill. We now have used it on more than 7 patients and it really helped them in their treatment plan modification. My patient range was also variable /we used it in post CABG, post angioplasty, uncontrolled diabetic patients and brittle diabetes cases. We got excellent details from that monitoring. We also ask patient to keep a food consumption chart to correlate readings of glucose levels. 

 We document hypoglycemia unawareness, false alarms of hypoglycemia/ Hyperglycemia, Dawn’s phenomenon. With these variables we could modify there treatment plan and make their life bit stress free as symptoms are gone or in control. This time we know a concrete reason. The patient satisfaction was immense. 

 CGMS really document it better and helps in monitoring of glycemic control. We even saved one patient who was having recurrent severe hypoglycemia and need of Insulinoma workup. With careful history, glucose monitoring and treatment adjustments things are in control, major operative or multiple investigations and psychological stress got saved. 

The only factor that hampers its routine use in rural population of India is cost of device. But I am hopeful in near future it will come down. In primary care one should learn to balance technology and its need as treatment option. We should not depend too much on them. Clinical judgment is a priority. Additional tools like these should be used to improve clinical outcome. 

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Brief Description about the author
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.