Re: Rational Use of Investigations for Diagnosis

January 26, 2008

Hello All,

I am writing after a very long absence.But the topic was such that from the point of view of a patient , I could not stop myself from responding.

We had some decades ago, family physicians and not so many investigative tools to assist them with diagnosis.But their diagnosis was based on experience and observation.

The physicians now SOLELY depend on laboratory investigations for their diagnosis.And these tests are very costly. We all know about the links, the cuts that the laboratories have to pay to the the referring physicians. In all this racket, it is the patient who suffers monetarily. where is the rationality in this chain?

As a practising physician, a thought must be given to the economic health of the sufferer.

kunda

Hi,

The next discussion on NetRUM will run from 26 through 31 Jan 2008 on "Rational use of investigations for diagnosis" which will be moderated by young Dr. S. Ziaur Rahman, Senior Lecturer from Department of Pharmacology of Jawaharlal Nehru Medical College, AMU, Aligarh.

Dr Zia is requested to kindly introduce himself in the meantime to NetRUM members and take over NetRUM WEF eve of 25th Jan 2008.

New members are guided to view the moderator in photos option and see the topics in database.

Vijay

Groupie

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January 26, 2008

ï»¿

Dear Madam Kunda

Itâ€™s really a tragedy in both the sense. At one side, we are becoming totally dependent on these modern laboratory investigations for diagnosis and asking patients for each investigations be it right or wrong and at another side we are loosing our skill-based experience. Above all, the culture of "commission" to the referring physicians is corrupting our profession. Who is the culprit? Off course we the doctors! Itâ€™s ultimately the patient, who suffers. Physicians need to realize these things, which have an effect on patients directly and indirectly.

Zia

Re: Rational Use of Investigations for Diagnosis

Hello All,

I am writing after a very long absence.But the topic was such that from the point of view of a patient , I could not stop myself from responding.

We had some decades ago, family physicians and not so many investigative tools to assist them with diagnosis.But their diagnosis was based on experience and observation.

The physicians now SOLELY depend on laboratory investigations for their diagnosis.And these tests are very costly. We all know about the links, the cuts that the laboratories have to pay to the the referring physicians. In all this racket, it is the patient who suffers monetarily. where is the rationality in this chain?

As a practising physician, a thought must be given to the economic health of the sufferer.

kunda

Hi,

The next discussion on NetRUM will run from 26 through 31 Jan 2008 on "Rational use of investigations for diagnosis" which will be moderated by young Dr. S. Ziaur Rahman, Senior Lecturer from Department of Pharmacology of Jawaharlal Nehru Medical College, AMU, Aligarh.

Dr Zia is requested to kindly introduce himself in the meantime to NetRUM members and take over NetRUM WEF eve of 25th Jan 2008.

New members are guided to view the moderator in photos option and see the topics in database.

Vijay

Groupie

Looking for last minute shopping deals? Find them fast with Search.

Why delete messages? Unlimited storage is just a click away.

January 26, 2008

Dear friends,

this is being really interesting topic as far as the

patient's suffering is concerned. The suffering may be

economical or exposure to unnecessary hazardous

investigations like x rays and others.

If we talk about the irrational use of investigations

on the part of physician then to tackle this problem

the most appropriate way is to change the evaluation

method in exams for GRADUATES AND POST GRADUATES.

One pattern impressed me a lot is usually seen in exam

like USMLE AND PLAB. In these exams the questions are

clinical case based multiple choice type. Mostly the

correct mode of investigation and or treatments is

asked. This will help to develop an attitude of

correct and rational investigation suggestions.

Another important thing that can be done is to set SOP

LIKE STANDARD TREATMENT GUIDELINES for existing

ailments in particular area.

One important aspect of irrational investigation

suggestion is the competition in medical fields and

the malpractice of giving cut (known as cut-practice).

This stimulates unethical, deliberate, irrational

investigation suggestions by some of the physicians.

Sometimes the investigation are suggested to avoid the

act of omission where the diagnosis is confusing and

physician dont want to take a chance.

Regards,

dr kiran chaudhari

lecturer,pharmacology,

gmc nagpur.

--- ibnsinaacademy <ibnsinaacademy@...> wrote:

> Dear Madam Kunda

>

> Itâs really a tragedy in both the sense. At one

> side, we are becoming totally dependent on these

> modern laboratory investigations for diagnosis and

> asking patients for each investigations be it right

> or wrong and at another side we are loosing our

> skill-based experience. Above all, the culture of

> " commission " to the referring physicians is

> corrupting our profession. Who is the culprit? Off

> course we the doctors! Itâs ultimately the

> patient, who suffers. Physicians need to realize

> these things, which have an effect on patients

> directly and indirectly.

>

> Zia

>

> Re: Forthcoming

> discussion : announcement

>

> Dear NetRum Colleagues,

>

> The main and core objectives of rational

> use of investigations are:

> a.. Activities are wanted to trim down

> the frequently quite irrational overuse of

> diagnostic tests

> b.. Existing facts favors using

> mixtures of techniques to sway doctors' behavior

> c.. In routine practice doctors'

> judgments are often exaggerated by force from

> patients

> d.. General practitioners possibly

> need more assistance in putting across the

> justification for using, or not using, tests

> A patient who changed my practice

> Case Study

> was worried about three pea sized

> lumps on her anterior chest wall. She had noticed

> them about three weeks before and felt embarrassed

> about coming with something so trivial. As I

> examined her, we chatted about the children. She was

> six months younger than me, with a son six days

> younger than my daughter (aged 8) and a daughter two

> years older. Blond and vivacious,

> was always a pleasant patient to

> have on the morning list. Like any intelligent

> parent, she had her anxieties about her children,

> and I knew them well.

> The lumps she showed me was so small and

> insignificant that I reassured her confidently,

> adding my usual advice to âCome back if things

> change.â Three weeks later, the day the children

> went back to school after Christmas, came

> back. The lumps had grown, and I felt a horrible

> sense of dread. To âsave her worryingâ I removed

> one of the lumps at the end of the morning surgery.

> As I did so, I found the usual chitchat drying up.

> The specimen I held in the forceps was unmistakably

> jet black. I did not need the histologist' s report

> to tell me the diagnosis. Her future swam before

> meâthis was very nasty, she would be dead by

> Easter. How could I carry on discussing books we had

> both enjoyed and the tribulations of family life?

> In fact lived until May and died

> just before her 40th birthday. It was not an easy

> passing. She already had hepatic involvement, and

> the subcutaneous nodules spread over the whole of

> her trunk. Fortunately, before she had too many

> symptoms from her cerebral metastases, she was

> overwhelmed by sheer tumour load. At the funeral

> 's husband defiantly asked many of the friends

> and family to wear bright clothes, and their

> daughter played the flute superbly to a packed

> church.

> What did I learn from , and how has

> this changed my practice? Eighteen months earlier,

> she had had a 7 mmmole on her back. Seen by another

> doctor, she had been asked to come back in two

> months. The mole disappeared, and she did not

> return. I had not realised that spontaneous

> âresolutionâ is a well recognised feature of

> primary melanoma.

> I still confidently reassure the owners

> of undisputedly benign lesions, but when there is

> uncertainty I take steps to reach a definitive

> diagnosis. With guidance from the local

> dermatologist, I have bought a digital camera and a

> dermatoscope, which I am slowly learning to use. I

> do not tend to review patients with doubtful lesions

> but instead try to come to a decision there and then

> whether to refer or to excise so that I do not have

> patients default. My experience so far is limited,

> and my threshold for referral is low at present

> while I build up my knowledge. Above all, I am

> constantly suspicious and would far rather be safe

> than sorry.

> From a personal point of view, seeing

> someone my own age dying so quickly and so

> inevitably made me step back and look at my own

> family, reminding me that time spent together is

> very

=== message truncated ===

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January 26, 2008

Dear Dr. Kiran Chaudhari

You have given a good suggestion that the practice of irrational use of investigations on the part of physician can be tackled if we change the evaluation method in exams for graduates and post-graduates like USMLE AND PLAB. I agree that in these exams the questions are mostly clinical case based multiple-choice type with some answers related to correct mode of investigation and or treatments. This could further be improved if we teach our students on the basis of case-based learning or problem based learning (CBL / PBL). These steps will certainly be helpful in developing an attitude of correct, precise and rational investigations.

The existing culture that no physicians want to take risk in order to avoid act of omission is perhaps because of laws like CPA! Every physicians want to play safe. Isn't it?

Do you have any idea how can we develop SOPs for rational use of investigations in diagnosis? After having such guidelines, many a problems can then be minimized!!

Zia

Re: Forthcoming> discussion : announcement> > > > Dear NetRum Colleagues,> > > The main and core objectives of rational> use of investigations are:> a.. Activities are wanted to trim down> the frequently quite irrational overuse of> diagnostic tests > b.. Existing facts favors using> mixtures of techniques to sway doctors' behavior > c.. In routine practice doctors'> judgments are often exaggerated by force from> patients > d.. General practitioners possibly> need more assistance in putting across the> justification for using, or not using, tests> A patient who changed my practice> Case Study> was worried about three pea sized> lumps on her anterior chest wall. She had noticed> them about three weeks before and felt embarrassed> about coming with something so trivial. As I> examined her, we chatted about the children. She was> six months younger than me, with a son six days> younger than my daughter (aged 8) and a daughter two> years older. Blond and vivacious,> was always a pleasant patient to> have on the morning list. Like any intelligent> parent, she had her anxieties about her children,> and I knew them well.> The lumps she showed me was so small and> insignificant that I reassured her confidently,> adding my usual advice to âCome back if things> change.â Three weeks later, the day the children> went back to school after Christmas, came> back. The lumps had grown, and I felt a horrible> sense of dread. To âsave her worryingâ I removed> one of the lumps at the end of the morning surgery.> As I did so, I found the usual chitchat drying up.> The specimen I held in the forceps was unmistakably> jet black. I did not need the histologist' s report> to tell me the diagnosis. Her future swam before> meâthis was very nasty, she would be dead by> Easter. How could I carry on discussing books we had> both enjoyed and the tribulations of family life?> In fact lived until May and died> just before her 40th birthday. It was not an easy> passing. She already had hepatic involvement, and> the subcutaneous nodules spread over the whole of> her trunk. Fortunately, before she had too many> symptoms from her cerebral metastases, she was> overwhelmed by sheer tumour load. At the funeral> 's husband defiantly asked many of the friends> and family to wear bright clothes, and their> daughter played the flute superbly to a packed> church.> What did I learn from , and how has> this changed my practice? Eighteen months earlier,> she had had a 7 mmmole on her back. Seen by another> doctor, she had been asked to come back in two> months. The mole disappeared, and she did not> return. I had not realised that spontaneous> âresolutionâ is a well recognised feature of> primary melanoma.> I still confidently reassure the owners> of undisputedly benign lesions, but when there is> uncertainty I take steps to reach a definitive> diagnosis. With guidance from the local> dermatologist, I have bought a digital camera and a> dermatoscope, which I am slowly learning to use. I> do not tend to review patients with doubtful lesions> but instead try to come to a decision there and then> whether to refer or to excise so that I do not have> patients default. My experience so far is limited,> and my threshold for referral is low at present> while I build up my knowledge. Above all, I am> constantly suspicious and would far rather be safe> than sorry.> From a personal point of view, seeing> someone my own age dying so quickly and so> inevitably made me step back and look at my own> family, reminding me that time spent together is> very === message truncated ===Unlimited freedom, unlimited storage. Get it now, on http://help./l/in//mail/mail/tools/tools-08.html/

January 27, 2008

Dear Dr Zia, Currently I am not much aware about such SOPs but I came across about such possibilities in an article from BMJ. Attaching it here. Hope , it will be helpful. When ever we think of SOPs like guidelines for rational use of invetsigations, these shall be created by the hospitals (team of physician, pathologist, microbiologist and pharmacologist) with the help of current updates in the medical field. All the benefits and flaws of all possible investigations (confirmatory, supportive, ruling out etc.) for a particular ailment should be assessed and a grading in terms of positive and negative points be made for a diagnosis or presenting condition deciding further the choice of investigation which will be most appropriate to the medical condition, to the patient and finally to the area with availability/unavailability of

resources. I think this will be a little bit lenghty work but once done it will definately make miracle. regards, Dr Kiran Chaudhari Lecturer, Pharmacology, GMC, Nagpur.ibnsinaacademy <ibnsinaacademy@...> wrote: Dear Dr. Kiran Chaudhari You have given a good suggestion that the practice of irrational use of investigations on the part of physician can be tackled if we change the evaluation method in exams for graduates and post-graduates like USMLE AND PLAB. I agree that in these exams the questions are mostly clinical case based multiple-choice type with some answers related to correct mode of investigation and or treatments. This could further be improved if we teach our students on the basis of case-based learning or problem based learning (CBL / PBL). These steps will certainly be helpful in developing an attitude of correct, precise and rational

investigations. The existing culture that no physicians want to take risk in order to avoid act of omission is perhaps because of laws like CPA! Every physicians want to play safe. Isn't it? Do you have any idea how can we develop SOPs for rational use of investigations in diagnosis? After having such guidelines, many a problems can then be minimized!! Zia Re: Forthcoming> discussion : announcement> > > > Dear NetRum Colleagues,> > > The main and core objectives of rational> use of investigations are:> a.. Activities are wanted to trim down> the frequently quite irrational overuse of> diagnostic tests > b.. Existing facts favors using> mixtures of techniques to sway doctors' behavior > c.. In routine practice doctors'> judgments are often exaggerated by force from> patients > d.. General practitioners possibly> need more assistance in putting across the> justification for using, or not using, tests> A patient who changed my practice> Case Study> was worried about three pea sized> lumps on her anterior chest wall. She had noticed> them about three weeks before and felt embarrassed> about coming with

something so trivial. As I> examined her, we chatted about the children. She was> six months younger than me, with a son six days> younger than my daughter (aged 8) and a daughter two> years older. Blond and vivacious,> was always a pleasant patient to> have on the morning list. Like any intelligent> parent, she had her anxieties about her children,> and I knew them well.> The lumps she showed me was so small and> insignificant that I reassured her confidently,> adding my usual advice to âCome back if things> change.â Three weeks later, the day the children> went back to school after Christmas, came> back. The lumps had grown, and I felt a horrible> sense of dread. To âsave her worryingâ I removed> one of the lumps at the end of the morning surgery.> As I did so, I found the usual chitchat drying up.> The specimen I held in the forceps

was unmistakably> jet black. I did not need the histologist' s report> to tell me the diagnosis. Her future swam before> meâthis was very nasty, she would be dead by> Easter. How could I carry on discussing books we had> both enjoyed and the tribulations of family life?> In fact lived until May and died> just before her 40th birthday. It was not an easy> passing. She already had hepatic involvement, and> the subcutaneous nodules spread over the whole of> her trunk. Fortunately, before she had too many> symptoms from her cerebral metastases, she was> overwhelmed by sheer tumour load. At the funeral> 's husband defiantly asked many of the friends> and family to wear bright clothes, and their> daughter played the flute superbly to a packed> church.> What did I learn from , and how has> this changed my practice? Eighteen months

earlier,> she had had a 7 mmmole on her back. Seen by another> doctor, she had been asked to come back in two> months. The mole disappeared, and she did not> return. I had not realised that spontaneous> âresolutionâ is a well recognised feature of> primary melanoma.> I still confidently reassure the owners> of undisputedly benign lesions, but when there is> uncertainty I take steps to reach a definitive> diagnosis. With guidance from the local> dermatologist, I have bought a digital camera and a> dermatoscope, which I am slowly learning to use. I> do not tend to review patients with doubtful lesions> but instead try to come to a decision there and then> whether to refer or to excise so that I do not have> patients default. My experience so far is limited,> and my threshold for referral is low at present> while I build up my knowledge. Above all, I

am> constantly suspicious and would far rather be safe> than sorry.> From a personal point of view, seeing> someone my own age dying so quickly and so> inevitably made me step back and look at my own> family, reminding me that time spent together is> very === message truncated ===Unlimited freedom, unlimited storage. Get it now, on http://help./l/in//mail/mail/tools/tools-08.html/

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January 27, 2008

Dear Dr. Kiran and Zia, I am agree that pattern of examinations (AIPGME and other entrances)should be based on prevalance of common disease and clinical presentation and not the one liner question and rare syndroms. Second, We should conduct more and more researches to diagnose common illness based on symptoms or questionnaires. For example..Pneumonia can be excluded if Respiratory rate less than 28, fever lessthan 101 F, absence of tachycardia with sensitivity of 94% and specificity of 95%. This will help a lot in rural area particularly where there is no facilities. Dr. Viral shah, Physician, Jamanagar Dear Dr. Kiran Chaudhari You have given a good suggestion that the practice of irrational use of investigations on the part of physician can be tackled if we change the evaluation method in exams for

graduates and post-graduates like USMLE AND PLAB. I agree that in these exams the questions are mostly clinical case based multiple-choice type with some answers related to correct mode of investigation and or treatments. This could further be improved if we teach our students on the basis of case-based learning or problem based learning (CBL / PBL). These steps will certainly be helpful in developing an attitude of correct, precise and rational investigations. The existing culture that no physicians want to take risk in order to avoid act of omission is perhaps because of laws like CPA! Every physicians want to play safe. Isn't it? Do you have any idea how can we develop SOPs for rational use of investigations in diagnosis? After having such guidelines, many a problems can then be minimized!! Zia Re: Forthcoming> discussion : announcement> > > > Dear NetRum Colleagues,> > > The main and core objectives of rational> use of investigations are:> a.. Activities are wanted to trim down> the frequently quite irrational overuse of> diagnostic tests > b.. Existing facts favors using> mixtures of techniques to sway doctors' behavior > c.. In routine practice doctors'> judgments are often

exaggerated by force from> patients > d.. General practitioners possibly> need more assistance in putting across the> justification for using, or not using, tests> A patient who changed my practice> Case Study> was worried about three pea sized> lumps on her anterior chest wall. She had noticed> them about three weeks before and felt embarrassed> about coming with something so trivial. As I> examined her, we chatted about the children. She was> six months younger than me, with a son six days> younger than my daughter (aged 8) and a daughter two> years older. Blond and vivacious,> was always a pleasant patient to> have on the morning list. Like any intelligent> parent, she had her anxieties about her children,> and I knew them well.> The lumps she showed me was so small and> insignificant that I reassured her

confidently,> adding my usual advice to âCome back if things> change.â Three weeks later, the day the children> went back to school after Christmas, came> back. The lumps had grown, and I felt a horrible> sense of dread. To âsave her worryingâ I removed> one of the lumps at the end of the morning surgery.> As I did so, I found the usual chitchat drying up.> The specimen I held in the forceps was unmistakably> jet black. I did not need the histologist' s report> to tell me the diagnosis. Her future swam before> meâthis was very nasty, she would be dead by> Easter. How could I carry on discussing books we had> both enjoyed and the tribulations of family life?> In fact lived until May and died> just before her 40th birthday. It was not an easy> passing. She already had hepatic involvement, and> the subcutaneous nodules spread over the whole

of> her trunk. Fortunately, before she had too many> symptoms from her cerebral metastases, she was> overwhelmed by sheer tumour load. At the funeral> 's husband defiantly asked many of the friends> and family to wear bright clothes, and their> daughter played the flute superbly to a packed> church.> What did I learn from , and how has> this changed my practice? Eighteen months earlier,> she had had a 7 mmmole on her back. Seen by another> doctor, she had been asked to come back in two> months. The mole disappeared, and she did not> return. I had not realised that spontaneous> âresolutionâ is a well recognised feature of> primary melanoma.> I still confidently reassure the owners> of undisputedly benign lesions, but when there is> uncertainty I take steps to reach a definitive> diagnosis. With guidance from the local>

dermatologist, I have bought a digital camera and a> dermatoscope, which I am slowly learning to use. I> do not tend to review patients with doubtful lesions> but instead try to come to a decision there and then> whether to refer or to excise so that I do not have> patients default. My experience so far is limited,> and my threshold for referral is low at present> while I build up my knowledge. Above all, I am> constantly suspicious and would far rather be safe> than sorry.> From a personal point of view, seeing> someone my own age dying so quickly and so> inevitably made me step back and look at my own> family, reminding me that time spent together is> very === message truncated ===Unlimited freedom, unlimited storage. Get it now, on http://help./l/in//mail/mail/tools/tools-08.html/

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January 27, 2008

Hi, Why should investigations be used rationally? Because it takes: 1. Unnecessary burden on pockets of a patient 2. Using invasive type of investigations where non-invasive will work equally well. 3. Wastage of time and human resources. 4. Using expensive investigations like x-rays or CT chest for mild viral resp tract investigations. 4. To a nation with limited resources, unnecessary investigations add to the health budget. More in coming posts Anupama.ibnsinaacademy <ibnsinaacademy@...> wrote: After having fruitful information on Hathi Commission, lets start the new discussion on "rational use of investigations for diagnosis". Before I put some other remarks on this topic, I would first of all like to thank Dr. M. Bashaar who started this discussion so excitedly even before the due date. Nevertheless, I certainly agree with the 4 points that he brought up to our notice. The personal experience (an eye opener) that he mentioned is ‘food for thought’ by all medical scientists including physicians and surgeons. It’s a good idea if we discuss the topic under following headings: what are the points that led to irrational use of investigations what positive and negative impact (including adverse events of each investigations) it plays if we follow certain norms in deciding and prescribing investigations in routine practice and vice versa. how can we promote the culture of rationale use of various techniques and investigations in proper diagnosis what measures we can take to minimize “existing facts which favors using mixtures of techniques to sway doctors' behavior” Is there a need to have a guideline for rational use of investigations like guidelines available for rational use of medicines (I am not aware of any published guidelines on rational use of investigations for diagnosis!) S. Ziaur

Rahman Re: Forthcoming discussion : announcement Dear NetRum Colleagues, The main and core objectives of rational use of investigations are: Activities are wanted to trim down the frequently quite irrational overuse of diagnostic tests Existing facts favors using mixtures of techniques to sway doctors' behavior In routine practice doctors' judgments are often exaggerated by force from patients General practitioners possibly need more assistance in putting across the justification for using, or not using, tests A patient who changed my practice Case Study was worried about three pea sized lumps on her anterior chest wall. She had noticed them about three weeks before and felt

embarrassed about coming with something so trivial. As I examined her, we chatted about the children. She was six months younger than me, with a son six days younger than my daughter (aged 8) and a daughter two years older. Blond and vivacious, was always a pleasant patient to have on the morning list. Like any intelligent parent, she had her anxieties about her children, and I knew them well. The lumps she showed me was so small and insignificant that I reassured her confidently, adding my usual advice to “Come back if things

change.” Three weeks later, the day the children went back to school after Christmas, came back. The lumps had grown, and I felt a horrible sense of dread. To “save her worrying” I removed one of the lumps at the end of the morning surgery. As I did so, I found the usual chitchat drying up. The specimen I held in the forceps was unmistakably jet black. I did not need the histologist's report to tell me the diagnosis. Her future swam before me—this was very nasty, she would be dead by Easter. How could I carry on discussing books we had both enjoyed and the tribulations of family life? In fact lived until May and died just before her 40th birthday. It was not

an easy passing. She already had hepatic involvement, and the subcutaneous nodules spread over the whole of her trunk. Fortunately, before she had too many symptoms from her cerebral metastases, she was overwhelmed by sheer tumour load. At the funeral 's husband defiantly asked many of the friends and family to wear bright clothes, and their daughter played the flute superbly to a packed church. What did I learn from , and how has this changed my practice? Eighteen months earlier, she had had a 7 mmmole on her back. Seen by another doctor, she had been asked to come back in two months. The mole disappeared, and she did not return. I had not realised that spontaneous “resolution” is a well recognised feature of primary melanoma. I still confidently reassure the owners of undisputedly benign lesions, but when there is uncertainty I take steps to reach a definitive diagnosis. With guidance from the local dermatologist, I have bought a digital camera and a dermatoscope, which I am slowly learning to use. I do not tend to review patients with doubtful lesions but instead try to come to a decision there and then whether to refer or to excise so that I do not have patients default. My experience so far is limited, and my threshold for referral is low at present while I build up my knowledge. Above all, I am constantly suspicious and would far rather be safe than sorry. From a personal point of view, seeing someone my own age dying so quickly and so inevitably made me step back and look at my own family, reminding me that time spent together is very precious. Oliver Penney general practitioner,Weobley, Herefordshire Source: BMJ VOLUME 324 30 MARCH 2002, Page No 785 Thanks and best regards Mohammad Bashaar Ibn Sina Academy <ibnsinaacademygmail> wrote: Dear NetRUM Members Thanks Dr. Vijay for both the invitation and for allowing to moderate a new but very important topic "Rational use of investigations for diagnosis". I am right now sitting in Ludhiana. Two important members of NetRUM viz Dr. Chetna Desai and Dr. Anupama are also with me in Ludhiana. I will be back tomorrow to my place of work. Since I am going to moderate the forum first time, hence I would like to introduce myself first. I work as lecturer for the last 7 years at Jawaharlal Nehru Medical College, AMU, Aligarh and working basically on pharmacovigilance and indigenous drugs. As per advice of two active members here with me, I request all members to please post their valuable views and try to invite clinicians also so that we may have their views on the above topic as well. S. Ziaur Rahman Aligarh On 1/20/08, Vijay <drvijaythawani (DOT) co.in> wrote: Hi, The next discussion on NetRUM will run from 26 through 31 Jan 2008

on "Rational use of investigations for diagnosis" which will be moderated by young Dr. S. Ziaur Rahman, Senior Lecturer from Department of Pharmacology of Jawaharlal Nehru Medical College, AMU, Aligarh. Dr Zia is requested to kindly introduce himself in the meantime to NetRUM members and take over NetRUM WEF eve of 25th Jan 2008. New members are guided to view the moderator in photos option and see the topics in database. Vijay Groupie Looking for last minute shopping deals? Find them fast with Search.

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January 27, 2008

Dear Dr. Viral Shah

Again, there is a need to work on more and more researches in rational diagnosis of 'common diseaseas' based on skill-based experience rather than totaly dependent on clincial investigations. Proper with adequate and detailed history taking of patient is best criteria. The example which you have given is quite appropriate in making rational diagnosis on the basis of observing signs and symptoms.

Zia

On Jan 27, 2008 5:48 PM, Dr.viral shah <viralshah_rational@...> wrote:

Dear Dr. Kiran and Zia,

I am agree that pattern of examinations (AIPGME and other entrances)should be based on prevalance of common disease and clinical presentation and not the one liner question and rare syndroms.

Second, We should conduct more and more researches to diagnose common illness based on symptoms or questionnaires. For example..Pneumonia can be excluded if Respiratory rate less than 28, fever lessthan 101 F, absence of tachycardia with sensitivity of 94% and specificity of 95%.

This will help a lot in rural area particularly where there is no facilities.

Dr. Viral shah,

Physician,

Jamanagar

Dear Dr. Kiran Chaudhari

You have given a good suggestion that the practice of irrational use of investigations on the part of physician can be tackled if we change the evaluation method in exams for graduates and post-graduates like USMLE AND PLAB. I agree that in these exams the questions are mostly clinical case based multiple-choice type with some answers related to correct mode of investigation and or treatments. This could further be improved if we teach our students on the basis of case-based learning or problem based learning (CBL / PBL). These steps will certainly be helpful in developing an attitude of correct, precise and rational investigations.

The existing culture that no physicians want to take risk in order to avoid act of omission is perhaps because of laws like CPA! Every physicians want to play safe. Isn't it?

Do you have any idea how can we develop SOPs for rational use of investigations in diagnosis? After having such guidelines, many a problems can then be minimized!!

Zia

Re: Forthcoming> discussion : announcement> > > > Dear NetRum Colleagues,> > > The main and core objectives of rational> use of investigations are:

> a.. Activities are wanted to trim down> the frequently quite irrational overuse of> diagnostic tests > b.. Existing facts favors using> mixtures of techniques to sway doctors' behavior

> c.. In routine practice doctors'> judgments are often exaggerated by force from> patients > d.. General practitioners possibly> need more assistance in putting across the> justification for using, or not using, tests

> A patient who changed my practice> Case Study> was worried about three pea sized> lumps on her anterior chest wall. She had noticed> them about three weeks before and felt embarrassed

> about coming with something so trivial. As I> examined her, we chatted about the children. She was> six months younger than me, with a son six days> younger than my daughter (aged 8) and a daughter two

> years older. Blond and vivacious,> was always a pleasant patient to> have on the morning list. Like any intelligent> parent, she had her anxieties about her children,> and I knew them well.

> The lumps she showed me was so small and> insignificant that I reassured her confidently,> adding my usual advice to âCome back if things> change.â Three weeks later, the day the children> went back to school after Christmas, came

> back. The lumps had grown, and I felt a horrible> sense of dread. To âsave her worryingâ I removed> one of the lumps at the end of the morning surgery.> As I did so, I found the usual chitchat drying up.

> The specimen I held in the forceps was unmistakably> jet black. I did not need the histologist' s report> to tell me the diagnosis. Her future swam before> meâthis was very nasty, she would be dead by

> Easter. How could I carry on discussing books we had> both enjoyed and the tribulations of family life?> In fact lived until May and died> just before her 40th birthday. It was not an easy

> passing. She already had hepatic involvement, and> the subcutaneous nodules spread over the whole of> her trunk. Fortunately, before she had too many> symptoms from her cerebral metastases, she was

> overwhelmed by sheer tumour load. At the funeral> 's husband defiantly asked many of the friends> and family to wear bright clothes, and their> daughter played the flute superbly to a packed

> church.> What did I learn from , and how has> this changed my practice? Eighteen months earlier,> she had had a 7 mmmole on her back. Seen by another> doctor, she had been asked to come back in two

> months. The mole disappeared, and she did not> return. I had not realised that spontaneous> âresolutionâ is a well recognised feature of> primary melanoma.> I still confidently reassure the owners

> of undisputedly benign lesions, but when there is> uncertainty I take steps to reach a definitive> diagnosis. With guidance from the local> dermatologist, I have bought a digital camera and a

> dermatoscope, which I am slowly learning to use. I> do not tend to review patients with doubtful lesions> but instead try to come to a decision there and then> whether to refer or to excise so that I do not have

> patients default. My experience so far is limited,> and my threshold for referral is low at present> while I build up my knowledge. Above all, I am> constantly suspicious and would far rather be safe

> than sorry.> From a personal point of view, seeing> someone my own age dying so quickly and so> inevitably made me step back and look at my own> family, reminding me that time spent together is

> very === message truncated ===Unlimited freedom, unlimited storage. Get it now, on http://help./l/in//mail/mail/tools/tools-08.html/

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January 27, 2008

Thanks Anupama for posting your valuable points on negative impact of irrational use of investigations. Use of invasive type of investigations pose other sort of obserable problems.

Keep postings!

Zia

On Jan 28, 2008 10:18 AM, anupama sukhlecha <anupama_acad@...> wrote:

Hi,

Why should investigations be used rationally?

Because it takes:

1. Unnecessary burden on pockets of a patient

2. Using invasive type of investigations where non-invasive will work equally well.

3. Wastage of time and human resources.

4. Using expensive investigations like x-rays or CT chest for mild viral resp tract investigations.

4. To a nation with limited resources, unnecessary investigations add to the health budget.

More in coming posts

Anupama. ibnsinaacademy <ibnsinaacademy@...> wrote:

After having fruitful information on Hathi Commission, lets start the new discussion on " rational use of investigations for diagnosis " . Before I put some other remarks on this topic, I would first of all like to thank Dr. M. Bashaar who started this discussion so excitedly even before the due date. Nevertheless, I certainly agree with the 4 points that he brought up to our notice. The personal experience (an eye opener) that he mentioned is 'food for thought' by all medical scientists including physicians and surgeons.

It's a good idea if we discuss the topic under following headings:

what are the points that led to irrational use of investigations what positive and negative impact (including adverse events of each investigations) it plays if we follow certain norms in deciding and prescribing investigations in routine practice and vice versa. how can we promote the culture of rationale use of various techniques and investigations in proper diagnosis what measures we can take to minimize "existing facts which favors using mixtures of techniques to sway doctors' behavior" Is there a need to have a guideline for rational use of investigations like guidelines available for rational use of medicines (I am not aware of any published guidelines on rational use of investigations for diagnosis!)

S. Ziaur Rahman

Re: Forthcoming discussion : announcement

Dear NetRum Colleagues,

The main and core objectives of rational use of investigations are:

Activities are wanted to trim down the frequently quite irrational overuse of diagnostic tests Existing facts favors using mixtures of techniques to sway doctors' behavior In routine practice doctors' judgments are often exaggerated by force from patients General practitioners possibly need more assistance in putting across the justification for using, or not using, tests

A patient who changed my practice

Case Study

was worried about three pea sized lumps on her anterior chest wall. She had noticed them about three weeks before and felt embarrassed about coming with something so trivial. As I examined her, we chatted about the children. She was six months younger than me, with a son six days younger than my daughter (aged 8) and a daughter two years older. Blond and vivacious,

was always a pleasant patient to have on the morning list. Like any intelligent parent, she had her anxieties about her children, and I knew them well.

The lumps she showed me was so small and insignificant that I reassured her confidently, adding my usual advice to "Come back if things change." Three weeks later, the day the children went back to school after Christmas, came back. The lumps had grown, and I felt a horrible sense of dread. To "save her worrying" I removed one of the lumps at the end of the morning surgery. As I did so, I found the usual chitchat drying up. The specimen I held in the forceps was unmistakably jet black. I did not need the histologist's report to tell me the diagnosis. Her future swam before me—this was very nasty, she would be dead by Easter. How could I carry on discussing books we had both enjoyed and the tribulations of family life?

In fact lived until May and died just before her 40th birthday. It was not an easy passing. She already had hepatic involvement, and the subcutaneous nodules spread over the whole of her trunk. Fortunately, before she had too many symptoms from her cerebral metastases, she was overwhelmed by sheer tumour load. At the funeral 's husband defiantly asked many of the friends and family to wear bright clothes, and their daughter played the flute superbly to a packed church.

What did I learn from , and how has this changed my practice? Eighteen months earlier, she had had a 7 mmmole on her back. Seen by another doctor, she had been asked to come back in two months. The mole disappeared, and she did not return. I had not realised that spontaneous "resolution" is a well recognised feature of primary melanoma.

I still confidently reassure the owners of undisputedly benign lesions, but when there is uncertainty I take steps to reach a definitive diagnosis. With guidance from the local dermatologist, I have bought a digital camera and a dermatoscope, which I am slowly learning to use. I do not tend to review patients with doubtful lesions but instead try to come to a decision there and then whether to refer or to excise so that I do not have patients default. My experience so far is limited, and my threshold for referral is low at present while I build up my knowledge. Above all, I am constantly suspicious and would far rather be safe than sorry.

From a personal point of view, seeing someone my own age dying so quickly and so inevitably made me step back and look at my own family, reminding me that time spent together is very precious.

Oliver Penney general practitioner,Weobley, Herefordshire

Source: BMJ VOLUME 324 30 MARCH 2002, Page No 785

Thanks and best regards

Mohammad Bashaar

Ibn Sina Academy <ibnsinaacademy@...> wrote:

Dear NetRUM Members

Thanks Dr. Vijay for both the invitation and for allowing to moderate a new but very important topic " Rational use of investigations for diagnosis " . I am right now sitting in Ludhiana. Two important members of NetRUM viz Dr. Chetna Desai and Dr. Anupama are also with me in Ludhiana. I will be back tomorrow to my place of work. Since I am going to moderate the forum first time, hence I would like to introduce myself first. I work as lecturer for the last 7 years at Jawaharlal Nehru Medical College, AMU, Aligarh and working basically on pharmacovigilance and indigenous drugs. As per advice of two active members here with me, I request all members to please post their valuable views and try to invite clinicians also so that we may have their views on the above topic as well.

S. Ziaur Rahman

Aligarh

On 1/20/08, Vijay <drvijaythawani@...> wrote:

Hi,

The next discussion on NetRUM will run from 26 through 31 Jan 2008 on " Rational use of investigations for diagnosis " which will be moderated by young Dr. S. Ziaur Rahman, Senior Lecturer from Department of Pharmacology of Jawaharlal Nehru Medical College, AMU, Aligarh.

Dr Zia is requested to kindly introduce himself in the meantime to NetRUM members and take over NetRUM WEF eve of 25th Jan 2008.

New members are guided to view the moderator in photos option and see the topics in database.

Vijay

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January 27, 2008

Hi, I think if we have customer care centres to give unbiased information to patients regarding appropriateness of an investigation, they will not be forced to undergo inappropriate or invasive or expensive investigations. I remember this was taken up in discussion on "Is patient the king of his treatment" by Madam Kunda. Anupama.Ibn Sina Academy <ibnsinaacademy@...> wrote: Dear Dr. Viral Shah Again, there is a need to work on

more and more researches in rational diagnosis of 'common diseaseas' based on skill-based experience rather than totaly dependent on clincial investigations. Proper with adequate and detailed history taking of patient is best criteria. The example which you have given is quite appropriate in making rational diagnosis on the basis of observing signs and symptoms. Zia On Jan 27, 2008 5:48 PM, Dr.viral shah <viralshah_rational (DOT) co.in> wrote: Dear Dr. Kiran and Zia, I am agree that pattern of examinations (AIPGME and other entrances)should be based on prevalance of common disease and clinical presentation and not

the one liner question and rare syndroms. Second, We should conduct more and more researches to diagnose common illness based on symptoms or questionnaires. For example..Pneumonia can be excluded if Respiratory rate less than 28, fever lessthan 101 F, absence of tachycardia with sensitivity of 94% and specificity of 95%. This will help a lot in rural area particularly where there is no facilities. Dr. Viral shah, Physician, Jamanagar Dear Dr. Kiran Chaudhari You have given a good suggestion that the practice of irrational use of investigations on the part of physician can be tackled if we change the evaluation method in exams for graduates and post-graduates like USMLE AND PLAB. I agree that in these exams the questions are mostly clinical case based multiple-choice type with some answers related to correct mode of investigation and or treatments. This could further be improved if we teach our students on the basis of case-based learning or problem based learning (CBL / PBL). These steps will certainly be helpful in developing an attitude of correct, precise and rational investigations. The existing culture that no physicians want to take risk in order to avoid act of omission is perhaps because of laws like CPA! Every physicians want to play safe. Isn't it? Do you have any idea how can we develop SOPs for rational use of investigations in diagnosis? After having such guidelines, many a problems can then be minimized!! Zia Re: Forthcoming> discussion : announcement> > > > Dear NetRum Colleagues,> > > The

main and core objectives of rational> use of investigations are:> a.. Activities are wanted to trim down> the frequently quite irrational overuse of> diagnostic tests > b.. Existing facts favors using> mixtures of techniques to sway doctors' behavior > c.. In routine practice doctors'> judgments are often exaggerated by force from> patients > d.. General practitioners possibly> need more assistance in putting across the> justification for using, or not using, tests> A patient who changed my practice> Case Study> was worried about three pea sized> lumps on her anterior chest wall. She had noticed> them about three weeks before and felt embarrassed> about coming with something so trivial. As I> examined her, we chatted about the children. She was> six months younger than me, with a son six days> younger than my daughter

(aged 8) and a daughter two> years older. Blond and vivacious,> was always a pleasant patient to> have on the morning list. Like any intelligent> parent, she had her anxieties about her children,> and I knew them well.> The lumps she showed me was so small and> insignificant that I reassured her confidently,> adding my usual advice to âCome back if things> change.â Three weeks later, the day the children> went back to school after Christmas, came> back. The lumps had grown, and I felt a horrible> sense of dread. To âsave her worryingâ I removed> one of the lumps at the end of the morning surgery.> As I did so, I found the usual chitchat drying up.> The specimen I held in the forceps was unmistakably> jet black. I did not need the histologist' s report> to tell me the diagnosis. Her future swam before> meâthis was very nasty, she would be

dead by> Easter. How could I carry on discussing books we had> both enjoyed and the tribulations of family life?> In fact lived until May and died> just before her 40th birthday. It was not an easy> passing. She already had hepatic involvement, and> the subcutaneous nodules spread over the whole of> her trunk. Fortunately, before she had too many> symptoms from her cerebral metastases, she was> overwhelmed by sheer tumour load. At the funeral> 's husband defiantly asked many of the friends> and family to wear bright clothes, and their> daughter played the flute superbly to a packed> church.> What did I learn from , and how has> this changed my practice? Eighteen months earlier,> she had had a 7 mmmole on her back. Seen by another> doctor, she had been asked to come back in two> months. The mole disappeared, and she did not>

return. I had not realised that spontaneous> âresolutionâ is a well recognised feature of> primary melanoma.> I still confidently reassure the owners> of undisputedly benign lesions, but when there is> uncertainty I take steps to reach a definitive> diagnosis. With guidance from the local> dermatologist, I have bought a digital camera and a> dermatoscope, which I am slowly learning to use. I> do not tend to review patients with doubtful lesions> but instead try to come to a decision there and then> whether to refer or to excise so that I do not have> patients default. My experience so far is limited,> and my threshold for referral is low at present> while I build up my knowledge. Above all, I am> constantly suspicious and would far rather be safe> than sorry.> From a personal point of view, seeing> someone my own age dying so quickly and so>

inevitably made me step back and look at my own> family, reminding me that time spent together is> very === message truncated ===Unlimited freedom, unlimited storage. Get it now, on http://help./l/in//mail/mail/tools/tools-08.html/ Chat on a cool, new interface. No download required. Click here.

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January 27, 2008

Dear Dr. Ram Charitra Sah

Good to hear from you after a long time. Hearing experience from other countries is always enlightening. For every rational treatment, we should first of all define the patients's problem through rational ordering of investigations and then think of the main therapeutic objective(s). Medication should not be started before proper diagnosis.

Regards,

S. Ziaur Rahman

On Jan 28, 2008 10:39 AM, cephed org <cephed04@...> wrote:

Dear Kunda Mam and all

Greeting from Ram Charitra Sah, Nepal

It is necessary to have proper investigations for diagnose any kind of illness before it subjected to any kind of medication. It should be based on the doctors experience supported by the laboratory testing. Since we have seen an increasing number of medical negligence cases here in Nepal where doctors have prescribed high dose antibiotics which have resulted severe skin rashes to loss of eyesight of the patients. The second medical negelegence case we have dealt with is developing infection inside the hospital which considered to be a controlled environment under direct supervsion of the doctors and patient ended up with the death.

So, I am not in a position to suggestion medication without proper diagnose. There should be minimum criteria need to be setup which incourage rational use of investigations for diagnosis and up on which the prescribed medication will be effective enough to cure the illness.

However, people are oftenly victimised from subjecting unnecessary laboratory adn clinical diagnosis which some time seems to be unnecessary but at the same time it is hard to claim un necessary by a non medical professional and sometimes even by medical professionals.

The rational use of invetigation is also required to prescribe the proper drugs in proper dose. The use of pharmasist`s knowledge while prescribing the drugs by any doctor need to be made mandatory to avoide the sideefect as well as incease efficacy of the treatment practice.

So to control, medical neglegence cases and lossess of human health , there should be minimum in fact optimum level of rational investigation for diagnosis before medication.

Yours

Ram Charitra Sah

Executive Director

CEPHED

KAthmandu, Nepal kunda gharpure <gharpurekunda@...> wrote:

netrum From: kunda gharpure <gharpurekunda@...>

Date: Sat, 26 Jan 2008 15:44:59 +0530 (IST)Subject: Re: Rational Use of Investigations for Diagnosis

Hello All,

I am writing after a very long absence.But the topic was such that from the point of view of a patient , I could not stop myself from responding.

We had some decades ago, family physicians and not so many investigative tools to assist them with diagnosis.But their diagnosis was based on experience and observation.

The physicians now SOLELY depend on laboratory investigations for their diagnosis.And these tests are very costly. We all know about the links, the cuts that the laboratories have to pay to the the referring physicians. In all this racket, it is the patient who suffers monetarily. where is the rationality in this chain?

As a practising physician, a thought must be given to the economic health of the sufferer.

kunda

Hi,

The next discussion on NetRUM will run from 26 through 31 Jan 2008 on " Rational use of investigations for diagnosis " which will be moderated by young Dr. S. Ziaur Rahman, Senior Lecturer from Department of Pharmacology of Jawaharlal Nehru Medical College, AMU, Aligarh.

Dr Zia is requested to kindly introduce himself in the meantime to NetRUM members and take over NetRUM WEF eve of 25th Jan 2008.

New members are guided to view the moderator in photos option and see the topics in database.

Vijay

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January 27, 2008

I post my opinion after a very long time. Appologies for this.

This is indeed a very interesting discussion, and great to see the different angles to the same coin.

I recall my elders telling me that in yester-years, there was hardly any investigational procedures their doctors made them undergo. It was more like the doctor, who was at most times a GP/"family doctor", would sit with the patient, and ask many details, directly and indirectly (our patient counselling??), hold the arm to check for pulse / 'nadi' as in Ayurvedic medicine, and in most times, prescribe a simple remedy and they feel very well in 2-3 days.

I have, in my practice in India and Kenya, come across situations where, when there is a patient who comes to see his doctor, the first thing is to measure the essentials (BP, pulse, temp) and then remove the sophisticated investigations checklist, often supplied by a well known (expensive?) diagnosis centre and the clinician lets the pen guide his hand in ticking the most "needed" tests and investigational procedures.

On asking, what is the 'problem' by the patient, the doctor replies that looks like viral infection but "better we rule out everything" by the x-ray/CT scan, blood tests and urine tests he has prescribed!!!

In the interim, some injections are administered and some antibiotics prescribed. wow!

In another scenario, when a patient complains of a headache, the doctor immediately recommends a CT/MRI, with blood tests to "rule out everything". The doctor himself has graduated more than 50 years ago, hardly had any subsequent education/degrees, and wants to look at the CT/MRI scans. Do they really know how to interpret them?

They rely on the observations of the radiologist, who has not seen the patient and known the complaints, of course.

Any one come across such a trend?

Can we not:

- in the most basic way, go back to the yester-years and spend more time with the patient to truely learn what his complaints are?

- learn the rule to "rule out with our expertise" rather than investigations and

- learn NOT to "run out" the patient's finances?Jayesh

***************************************

Dr. Jayesh M. Pandit

Head- Department of Pharmacovigilance,

Pharmacy and Poisons Board,

Ministry of Health,

P.O. Box: 27663-00506

Nairobi, KENYA

: (+254-20)-2716905 / 6 Ext 114

: (+254)-(0)721 348 503 /(0)733 733 349

P Think about our environment!!!

Please do not print this e-mail unless you really need to.

-- Re: Rational Use of Investigations for Diagnosis

Dear Dr. Kiran and Zia,

I am agree that pattern of examinations (AIPGME and other entrances)should be based on prevalance of common disease and clinical presentation and not the one liner question and rare syndroms.

Second, We should conduct more and more researches to diagnose common illness based on symptoms or questionnaires. For example..Pneumonia can be excluded if Respiratory rate less than 28, fever lessthan 101 F, absence of tachycardia with sensitivity of 94% and specificity of 95%.

This will help a lot in rural area particularly where there is no facilities.

Dr. Viral shah,

Physician,

Jamanagar

Dear Dr. Kiran Chaudhari

You have given a good suggestion that the practice of irrational use of investigations on the part of physician can be tackled if we change the evaluation method in exams for graduates and post-graduates like USMLE AND PLAB. I agree that in these exams the questions are mostly clinical case based multiple-choice type with some answers related to correct mode of investigation and or treatments. This could further be improved if we teach our students on the basis of case-based learning or problem based learning (CBL / PBL). These steps will certainly be helpful in developing an attitude of correct, precise and rational investigations.

The existing culture that no physicians want to take risk in order to avoid act of omission is perhaps because of laws like CPA! Every physicians want to play safe. Isn't it?

Do you have any idea how can we develop SOPs for rational use of investigations in diagnosis? After having such guidelines, many a problems can then be minimized!!

Zia

Re: Forthcoming> discussion : announcement> > > > Dear NetRum Colleagues,> > > The main and core objectives of rational> use of investigations are:> a.. Activities are wanted to trim down> the frequently quite irrational overuse of> diagnostic tests > b.. Existing facts favors using> mixtures of techniques to sway doctors' behavior > c.. In routine practice doctors'> judgments are often exaggerated by force from> patients > d.. General practitioners possibly> need more assistance in putting across the> justification for using, or not using, tests> A patient who changed my practice> Case Study> was worried about three pea sized> lumps on her anterior chest wall. She had noticed> them about three weeks before and felt embarrassed> about coming with something so trivial. As I> examined her, we chatted about the children. She was> six months younger than me, with a son six days> younger than my daughter (aged 8) and a daughter two> years older. Blond and vivacious,> was always a pleasant patient to> have on the morning list. Like any intelligent> parent, she had her anxieties about her children,> and I knew them well.> The lumps she showed me was so small and> insignificant that I reassured her confidently,> adding my usual advice to âCome back if things> change.â Three weeks later, the day the children> went back to school after Christmas, came> back. The lumps had grown, and I felt a horrible> sense of dread. To âsave her worryingâ I removed> one of the lumps at the end of the morning surgery.> As I did so, I found the usual chitchat drying up.> The specimen I held in the forceps was unmistakably> jet black. I did not need the histologist' s report> to tell me the diagnosis. Her future swam before> meâthis was very nasty, she would be dead by> Easter. How could I carry on discussing books we had> both enjoyed and the tribulations of family life?> In fact lived until May and died> just before her 40th birthday. It was not an easy> passing. She already had hepatic involvement, and> the subcutaneous nodules spread over the whole of> her trunk. Fortunately, before she had too many> symptoms from her cerebral metastases, she was> overwhelmed by sheer tumour load. At the funeral> 's husband defiantly asked many of the friends> and family to wear bright clothes, and their> daughter played the flute superbly to a packed> church.> What did I learn from , and how has> this changed my practice? Eighteen months earlier,> she had had a 7 mmmole on her back. Seen by another> doctor, she had been asked to come back in two> months. The mole disappeared, and she did not> return. I had not realised that spontaneous> âresolutionâ is a well recognised feature of> primary melanoma.> I still confidently reassure the owners> of undisputedly benign lesions, but when there is> uncertainty I take steps to reach a definitive> diagnosis. With guidance from the local> dermatologist, I have bought a digital camera and a> dermatoscope, which I am slowly learning to use. I> do not tend to review patients with doubtful lesions> but instead try to come to a decision there and then> whether to refer or to excise so that I do not have> patients default. My experience so far is limited,> and my threshold for referral is low at present> while I build up my knowledge. Above all, I am> constantly suspicious and would far rather be safe> than sorry.> From a personal point of view, seeing> someone my own age dying so quickly and so> inevitably made me step back and look at my own> family, reminding me that time spent together is> very === message truncated ===Unlimited freedom, unlimited storage. Get it now, on http://help./l/in//mail/y! ahoomail/tools/tools-08.html/

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January 27, 2008

These " Customer Care Centre " could be a part of " Drug and Therapeutic Committee " of the hospital. But these concepts are being coming up more in corporate hospitals.

S. Ziaur Rahman

On Jan 28, 2008 12:03 PM, anupama sukhlecha <anupama_acad@...> wrote:

Hi,

I think if we have customer care centres to give unbiased information to patients regarding appropriateness of an investigation, they will not be forced to undergo inappropriate or invasive or expensive investigations.

I remember this was taken up in discussion on " Is patient the king of his treatment " by Madam Kunda.

Anupama.