CGPSL NEWSLETTER OF THE COLLEGE OF GENERAL PRACTITIONERS OF SRI LANKA No.6, “Wijerama House”, Wijerama Mawatha, Colombo 7. FEBRUARY 2008 Tele: 2698894 Fax: 2695188 E-mail: cgpsl@sltnet.lk / genprac@sltnet.lk Website: www.cgp.lk HELPING HIPPOCRATES, SUPPORTING SUSRUTHA Patient Safety and Safety in Practice 21st March 2008, 3.45pm – 5.15pm, Hall C, Cinnamon Grand Hotel, Colombo The College of General Practitioners of Sri Lanka will be conducting a symposium and consultative meeting on “Patient Safety and Safety in Practice” on 21st of March 2008 during the Academic Sessions of the SLMA. The programme will be as follows: • Introduction to patient safety Aruna Rabel • Preventing a death in the family Seneth Samaranayake • Learn ethics to practice safety Eugene Corea • Making mistakes apparent Jayantha Jayatissa • The safe prescription Prasanna Siriwardena • Promoting safety and learning from experience Christine Perera • A home based patient held record Dushyanthi Weerasekera • Safety in an institutional primary care setting Aruna Rabel • Followed by discussion on the roles of the community and professional bodies in improving safety • Music - Anushka Kothalawala, Ayanthi Perera, Amila Abeysekera This segment of the sessions will be chaired by Prof. Nandani de Silva, President of the College of General Practitioners of Sri Lanka. As in the past music will be an important feature. This time it will be live music featuring Anushka Kothalawala and Ayanthi Perera. Come. If you have registered for the SLMA sessions, you will not be required to register for this symposium. If you have not done so, a registration fee of Rs.500/- will be charged for the symposium by the SLMA. In This Issue Helping Hipocrates, Supporting Susrutha – P1 B(l)ack to Red – P2,3 Stopping Stemis – P6 The cost effective healthcare provider – P5 CPD in March & April – P8 1 !" B(L)ACK TO RED Projected Income & Expenditure Statement January 2008 – October 2008 INCOME Amount in current account (31st December 2007) Less: Amount allocated for photocopier Amount due to website developer 719,954.00 100,000.00 90,000.00 Amount receivable from Sponsors towards office rent (20,000/= x 10 ) Fixed deposits interest income from Jan.-Oct’08(Expected) HNB 37,485/= x 3 HNB 32,812/= x 3 Treasury Bill 45,696/= x 3 190,000.00 529,954.00 200,000.00 112,455.00 98,436.00 137,088.00 1,077,933.00 ========= EXPENSES Based on expenses in July, August, November and December 2007 (Average expenses per month 120,000.00) Total expenses that would be incurred from January to October 2008 Additional expense incurred due to salary increase to staff (Inclusive of EPF and ETF) Income over expenses (deficit) 1,200,000.00 51,750.00 1,251,750.00 ========== (173,817.00) Real Expenses incurred in the last six months June 2007 July 2007 Aug.2007 Sept2007 Oct.2007 Nov.2007 Dec.2007 - 340,660.53 173,079.94 205,660.44 266,017.33 738,041.54 191,236.44 133,025.73 Note: Additional Expenses (1) Ultimax – Website 1st (50,000.00) and 2nd (40,000.00) Installments (2) Homagama project is on, an average of Rs.15, 000.00 per month for lecturer fees (3) MCGP course is on, an average of Rs. 6,000.00 per month for lecturer fees (4) MRCGP lectures are on, an average of Rs. 4,000.00 per month for lecturer fees 2 !" Annexure 1 Monthly expenses SLMA Rent Electricity Salary 13,500.00 14,000.00 11,500.00 8,740.00 EPF / ETF SLT – Telephone 7,000.00 Internet/E-mail 2,012.50 Petty Cash Newsletter printing charges Avalon – photocopy papers Printer - Cartridge Toner 27,500.00 7,500.00 20,240.00 5,060.00 9,012.50 30,000.00 9,500.00 5,100.00 2,500.00 2,500.00 --------------118,912.50 ========= Amounts deposited in various financial institutions at present (Fixed Deposits) HNB Treasury bill Total amount Note: 450,000.00 300,000.00 782,735.88 961,170.00 ----------------2,493,905.88 ========== 1. From above deposits we will get approximately Rs.470, 160.00 per annum as interest. If we withdraw any of these amounts our interest income will come down. 2. The above deficit will increase further if the inflation goes up. Sekher YOUR PARLOUR IS READY Calling all Spiders It is with a great sense of satisfaction I share the good news with you that the work on the College Website is nearing completion. The website committee has decided to have the official launch of the site at a simple ceremony, at the Lionel Auditorium on the 20th of April 2008 at 5.00pm. Please inform the office before 31st March 2008 as to whether you wish to attend this event, so that the necessary arrangements could be made for your participation. 3 !" I am indebted to you, for having given us the courage to go ahead with the Website project, when there was confusion in our minds as to whether the members would support this. The 63 responses we received in the affirmative, was the launching pad for this project. We immediately started with the Weekly communiqué of E-Mail Club - “My College” on the 22nd of August 2007. I am proud to share with you that the 28th communiqué was sent on the 29th February, 2008.We have 72 members in the E-Mail Club at present. The following information is in the process of being uploaded into the Website • Member details – professional qualification Place of practice • Courses available at College and relevant details(examination/ course fee) • CME lectures- the resource person’s handouts. • Clinical problems in practice - questions to be posed and to be answered by any member • College Newsletter • College – latest news • News of members • Link to other websites You will be having a username (the name as it appears in the desktop directory) and a log in number (your membership no) to access the website as a member. You will be eligible to access the site fully if you are a member of the College only. You could change your log in number if you wish. Important website details 1) Website address is www.cgpsl.org – registered already. This will only come into use with the official launch. The temporary Website address is as follows - www.ultimax.lk/cgp till such time the final OK is given by the Website committee to upload it into the new website address 2) We have been successful in getting the principal sponsor-Telecom Pvt. Ltd. (Amount Charged Rs.100, 000.00 per annum) 3) Two more slots for advertising are available.-Assistance in this regard would be appreciated. The amounts to be charged are Rs.75, 000.00 and Rs.50, 000.00 per annum. Advertisements from Non Pharmaceutical sector are being explored. 4) It has been decided to make the site available for our members free of charge We are planning to have a trial run for about two weeks to sort out teething problems as well as to give the members an opportunity to check whether their personal information given are correct. The trial run will be on from the 15th of March to the 31st of March 2008. We are also planning to activate the discussion forum open to members, to discuss any medical problems they would want to talk about with their colleagues. This will be handled by our “teacher par excellence” Prof. Desmond Fernando who has kindly consented to do this for us. We need your cooperation to make our Website accurate and up to date by the 20th of April 2008. Your active participation is needed to make it a successful site which would help all of us to improve our knowledge and keep ourselves abreast with advances in our field. Please pass on the information to your fellow College members who too would like to benefit from the Website of OUR College. Sekher – Chairman, Website Committee 4 #"$ THE COST EFFECTIVE HEALTHCARE PROVIDER by Duncan Bujawansa The Sri Lankan family doctors seem to be unique in providing cost effective health care to the community. Paradoxically they are a tribe not adequately recognised by the State, and are on the way to extinction. The average age of the full time GPs in Sri Lanka is definitely in the mid fifties. The working pattern of the Sri Lankan GP may not be regarded as fashionable in the modern context. The majority of GP’s run solo dispensing practices. In the Sri Lankan context this is a most cost effective way of providing health care. The health burden of the Sri Lankan community consists of money spent on technology and pharmaceuticals. Comparatively little is spent on professional services of the doctors. General practice is an affordable compromise between expenditure on professional fees, laboratory tests and imaging technology. The patient patronizing the GP is not exposed to these risks and abuses. Therefore his or her health bill is definitely less. There is a disturbing awareness of a clan of GPs who are vending expensive investigations to their clients, for pecuniary gain. The dispensing GP nullifies all the harm from the generic Vs brand prescribing. The dispensing GPs policy has to be cost effective prescribing, as his business will become non viable if he does not exercise it. All dispensing GPs study the market and stock cost effective products. As for cost effectiveness of medicine is concerned the dispensing GPs patients enjoy it to the maximum. % It is a fact that laboratory investigations and imaging technology is forced on patients seeking out door treatment, in private secondary and tertiary care establishments. There is touting going on in favour of costly investigations. Patient gets little or no information about limitations and risks of these expensive investigations. For example few patients are aware of the high “false positive” rate in mammograms. In fact, not many know that the advent of mammography has not reduced the deaths from breast cancer. In private institutions offering secondary and tertiary care the place occupied by these expensive investigations is not quite rightful. Even expensive non indicated risky surgical procedures are touted to patients seeking out door treatment in these establishments. The fact that the caesarian rate is probably several times the 18 % recommended by WHO is proof for this. No work has been done on the Caesarian section rates in the private sector in Sri Lanka. Those who attempt to do it may well end up in an accident service. There are mushrooming house call services which are prohibitively expensive. Still many GPs do home visits for a nominal fee. GPs should not give up the policy of doing home visits. The old fashioned GP running a dispensing practice doing an occasional home visit, and even attending funerals of patients, is an asset to society. After all we are health care providers at grass root level and are not trend setters. The present generation of family doctors would do well to emulate the GPs of old while attending to the interests of their modern clients. & ' () !* ) ! OUR STORY Physical Healing - A Most Noble and Democratizing Profession by Nalin Swaris Most people regard the human being as a body, soul dichotomy. The soul is regarded as a non corporeal or ‘spiritual’ entity temporarily lodged in the body but destined for immortal life in another world. The after life is the preserve of religious ministers. Physicians as the very term implies are BODY and THIS LIFE specialists. And this life and this body are frail, fragile vulnerable and mortal. Birth, growth, sickness decay and death are necessities of the human condition, whatever one’s religion, ethnicity or social status may be. The most important existential question for physicians who are daily witnesses to these realities is this - Knowing that we must all die, how must we live? 5 % & ' () !* ) ! It is customary to speak of the doctor/patient relationship. A patient is one who suffers illness and suffers being subjected to the invasive scrutiny and intervention of physicians. This patient ‘thing’ - the ‘other’, is delivered into the hands of the doctor. However, it must become evident to any reflecting physician that the microbes, the viruses, the bacteria in the patient, may be in the doctor himself. The blood pressure, the blood count, the urine sample measured and read is no different to what is measured in the physician’s own body. The carcinoma, the weakened heart muscle or affected kidney or liver is no different to the organs of the physicians. Physicians do not have extra corporeal immunity. The patient’s story is also the physicians’ story. Perhaps the best place to start a movement for radical democracy is not the temple or the parliament, but the hospital ward and the clinic. Sickness does not discriminate. A physician’s very profession of healing – restoring wholeness - compels democracy – the democracy of the body – not spirit. Physicians need body wisdom. It is the mind which attaches ethnic labels and speaks of Sinhala, Tamil or Muslim’, of ‘high’ and ‘low’. Morphologically and physiologically human beings are the same. It is filthy lucre that often discriminates and decides how ‘clean’ the ‘bill of health’ is. The bodies of physicians are the same as those of their patients. The ailments they treat could actually or potentially be in their bodies too. There is indeed a doctor-patient distinction but the healing profession erases the subject/object opposition. Physicians have the potential to be noble men and women whose life-attitude is one of ‘com-passion’ – feeling with. Is it any wonder that the Hippocratic Oath includes the pledge, “With purity and with holiness I will pass my life and practice my Art?” If I may add my own direction to Nalin’s movement for a radical democracy in the hospital ward and the clinic can we start with the floor patients please? - Ed "+ STOPPING STEMIS Coronary Heart Disease Some Lines to Remember by Farouk Sikkander The process of infarction in STEMI takes 6 hours and is only50 percent complete by 90 minutes. It is possible to save the myocardium by prompt restoration of blood flow. The available reperfusion strategies are thrombolysis and coronary angioplasty. Irrespective of which is chosen the first goal of treatment must be to ensure that this life saving treatment is given to all appropriate patients. The largest reduction in mortality occurs in patients treated within one hour of symptom onset --the golden hour when upto 65 lives per 1000 patients treated, can be saved. The benefit subsequently decreases in non linear fashion, for each hour that thrombolysis is delayed. In recognition of the fact that time is muscle, the standard is a call to needle time of less than 60 minutes. Medical assessment by primary care physicians have no role to play Type setting, page setting & formatting – Tharanga in suspected MI. These patients may be in the process of losing cardiac muscle and could die suddenly. The first priority is to send them to a hospital where coronary reperfusion can be started. Giving asprin 300mg inserting a cannula and morphine if chest pain is severe is all that can be done in primary care. Editorial assistance – Preethi Wijegoonewardene Editor – Eugene Corea 6 ,) - THE PATIENT’S DILEMMA K P Piyasena Mr. W M, 60 years old retired bank officer, presented with recurrent dizziness. He had been suffering from this problem for the last few years with remissions in between. He was on Enalapril 5mg daily which had been prescribed by a consultant a few years ago. Now he was in charge of his hypertension and he himself adjusted the dose after getting his BP checked at home or sometimes by a doctor. He next asked me for the cost of each test and I gave him a rough estimate. A few days later he returned with the reports and the consultants notes. All the tests were within normal limits. The consultant had advised him that it was probably “benign vertigo” and to seek treatment whenever he was dizzy; exactly the same opinion given by the GP with no investigations done! I found no significant abnormality on examination. Gait – Normal No nystagmus Ear canal - clean and healthy Hearing – Normal Pulse, BP – Normal Rombergs sign – Normal The whole exercise had cost him a fortune, and luckily for him the bank would reimburse the bill. He was very angry about the whole affair and this was not the first time, it had happened to him, and that was the reason why he was attending to his hypertension himself. I explained to him, that there was nothing sinister that I could find, and given the duration of the symptoms it was most likely to be Benign Paroxysmal Vertigo and, since it had remained at the same intensity for the last few years, he had nothing to fear. I requested him to take symptomatic medication when he felt uneasy. He asked me whether it was possible for me to refer him to a Neurologist as he wanted to be sure that there was nothing wrong. On his request I referred him to a reputed Neurologist with a referral letter. A few days later he returned with a card with the Neurologist’s notes. Cinnerazine had been prescribed under a trade name together with Prochlorperazine (which I had also prescribed). He has ordered. CT skull, Thyroid profile, Audiogram, ECG, FBS / PPBS, Full blood count The patient wanted to know whether all these tests were relevant for diagnosis. I explained to him that I was not the best person to answer that question, as I was not the one who requested them. He should have asked this question from the consultant who ordered the tests. The patient replied that the consultant had dismissed him with a sarcastic grin, when he asked the question. Here was a dilemma. I had to protect the interests of my patient without letting down my senior colleague while maintaining my professional integrity! I tried to balance everyone’s interest and went the extra mile to answer his question to the best of my ability. I told him that the consultant had to make sure that there was nothing wrong with him, and that was what he wanted in the first place and that would be reason for ordering the tests. The patient then inquired from me whether he could ask me a very sensitive question. I replied in the affirmative. He wanted to know whether doctors get a commissions for ordering these unwarranted tests. I said that there were reports to that effect, but to the best of my knowledge the consultant he had seen was reputed to be of high professional intergrity. This brought back the memory of another incident when one of my young diabetic patient who was also suffering from a psychiatric condition had to say when I requested for a FBS. (It is easy for you to say. But I am the one who is going to pay for all these) I think the DFM trainees who were with me at that time had the best lesson they learned in my practice. It was easy for the psychiatric patient to come out with his opinion uninhibited unlike our usual patients who would dare not express their opinions freely for obvious reasons. Let me leave it for you to decide, whether we always have the best interests of our patients when we investigate indiscriminately and dictate terms to our patients, who are not as stupid as some of us believe, them to be. Your comments and opinion are mostly welcome. 7 - " CPD IN MARCH & APRIL In lieu of the 2008 Academic Sessions of the SLMA and the College’s symposium “Helping Hippocrates, Supporting Susrutha” on the 21st of March (lead story) during the sessions, the College will not be holding the monthly CPD in March. The website launch will be held on the 20th of April 2008 and this will constitute the CPD session for April. AGM ON 27.04.2008 The Annual General Meeting of the College of General Practitioners of Sri Lanka will be held at 6.00 pm in the Lionel Memorial Auditorium, “Wijerama House”, No.6, Wijerama Mawatha, Colombo 7. WRITE TO US. KEEP IN TOUCH. SHARE YOUR VIEWS. GIVE US YOUR ADVICE. BUT FOR GOD’S SAKE DON’T KEEP QUIET! If undelivered please return to: COLLEGE OF GENERAL PRACTITIONERS OF SRI LANKA No.6, Wijerama Mawatha, Colombo 7. 8 9