Sunday, 22 October 2017



Roshan Jacob

A simple omission can be disastrous is what I learned when Sateesh Reddy explained me how his brother in-in law got into coma stage. Past eight months, Prabhakar is lying in a coma stage in a hospital. Prior to his unconsciousness, he consulted three doctors complaining about neck pain radiating to shoulders. All the doctors prescribed him analgesics and some pain balms and could not find anything suspicious.  Prabhakar overlooked his fall from bike few months ago and never mentioned it to the doctors who he consulted.  Untreated cervical hairline fracture due to the fall resulted in the coma. The information (history of fall) was crucial for the doctors for further investigations, and this omission is in one way resulted in the mishap.   It is widely taught that diagnosis is revealed in the patient's history. Above mentioned scenario involving inadequate history taking leads to serious consequences illustrate the importance of medical histories in diagnosis and here Prabhakar’s case is the classic example of the value of history. 

Recently I interacted with three retired consultants, two physicians and a surgeon on the sidelines of a conference and when I broached the subject of the value of history taking, with no dissent, all of them expressed their dismay at their denigration of the importance of proper history taking in clinical practice. Modern day doctors, mostly nudged by managements give preference to ‘investigations’, and happy to go with figures rather facts. As champions of evidence based medicine can they produce evidence that taking a proper history is "unhelpful"?

Extracting a proper history means listening carefully to what the patient has to say, followed by relevant systematic and constructive questions. As examples of clinical situations in which this discipline yields rich rewards we would cite the elucidation of chest pain or the recognition of da Costa's syndrome, where a proper history could save expensive and anxiety-producing investigations.

The foundation of a true history is nothing but a smooth communication between doctor and patient. Here patient should not show any inhibitions and the doctor is a good listener. Listening is at the heart of good history taking. The patient may not be looking for a diagnosis when giving their history and may even have irrelevant aspects and the doctor's search for one under such circumstances is likely to be fruitless. The patient's problem, whether it has a medical diagnosis attached or not, needs to be identified. Without the patient's perspective, the history is likely to be much less revealing and less useful to the doctor who is attempting to help the patient.

There was a time not long ago; often the history alone does reveal a diagnosis. Sometimes it is all that is required to make the diagnosis. A classic example is with the complaint of headache where the diagnosis can be made from the narration of the headache and perhaps some further questions. For example, in cluster headache the history is very characteristic and reveals the diagnosis without the need for examination or investigations for an experienced consultant.

To acquire a plausible, representative account of what is troubling a patient and how it has evolved over time, is definitely not an easy task. It takes practice, patience, understanding and concentration. The history as told in the beginning is a sharing of experience between patient and doctor and certainly time consuming. A consultation can allow a patient to pour out his agony. They may be upset about their condition or with the frustrations of many other aspects of life other than the present affliction and it is important to allow patients to give vent to these feelings. Ultimately how it may be transformed from the grumbles of a heartsink patient, to a useful diagnostic and therapeutic tool is what matters.

The traditional method of detailed history taking and physical examination and thinking about what tests to be ordered, (if any) are needed may take somewhat longer time with the patient, but must remain the cornerstone of clinical practice. The content of the history involved in primary care consultations is very variable and will depend on the presenting symptoms, patient concerns and the past medical, psychological and social history.

However the general framework for history taking is as follows:
    First is the presenting complaint.
    History of presenting complaint, including investigations, treatment and referrals already done and provided.
    Significant past diseases/illnesses, surgery, including complications, trauma.
    Medications now and past, prescribed and over-the-counter, allergies.
    Family history must be enquired to especially parents, siblings and children.
    Social history also matters. Here we find many habits and his addictions like  smoking, alcohol, drugs, accommodation and living arrangements, marital status, baseline functioning, occupation, pets and hobbies.
                Finally, the systems review: cardiovascular system, respiratory system, gastrointestinal system, nervous system, musculoskeletal system, genitourinary system.

Let’s go back to the coma patient Prabhakar. Prabhakar, who went and consulted three doctors but never mentioned his fall from the bike, thinking that it is insignificant. He thought the presenting complaint; neck pain is not even remotely connected with the fall, which happened three months back. None of the doctors have any leading questions to this effect like, ‘did you have any fall in the past?’ sometimes you may have to ask some wild questions when you as a doctor have no other suspecting reasons. The doctors set no agenda in this case and they missed the vital clue, which finally ended in a tragedy. 

After taking the history, it's useful to give the patient a run-down of what they've told.  For example: 'So, Prabhakar, from what I understand you've been getting this pain since one month and you are sure no incident worth mentioning like any fall in the recent past. Is that right?'. This summarizing or leading question could have helped Prabhakar mentioning the history fall, which he felt trivial.

It is vital to remember that a good elicitation of the patient’s history, in his own words coupled with few leading questions from the doctor can help the latter to arrive into ‘provisional diagnosis’. This does no suggest the patient doesn’t need any detailed evaluation.   History alone cannot lead into a definitive diagnosis unless until validated by other pertinent tests. Having said that, history taking has an integral and irreplaceable role in the appropriate diagnosis.  'Listen to your patient; they are telling you the diagnosis' is oft quoted aphorism. In olden days, it is widely taught that diagnosis is revealed in the patient's history.  It is true even today, provided the doctor is willing to listen.

Sunday, 8 October 2017

You can get quality elder care but be prepared to pay for it. SOUMYA NAIR


Aged care in a care facility is no more cheap. But when you think about it you are paying for somewhere to live, your meals, laundry, electricity and a number of people to look after you around the clock. The good news is that it is actually a lot of comfort and support in the fag end of life when the aged person needs assistance with daily living. Majority starts cribbing about the cost as if they are caught unawares.

Sharon D’Souza never dreamt that elder care can be such a difficult thing. Past two years with her bed ridden mother’s long term care, she learnt a different lesson. Sharon’s mother is bed ridden and needs round the clock care. But when a care home bill tops 45000/- a month, the best-laid plans get tossed aside unless you anticipate. Like others faced with the stunning cost of elderly care, Sharon did the math and realized that her mother could easily outlive her savings, a nightmare haunting her. Experience taught her She had followed the expert advice, planning ahead in case she wound up unable to care for herself one day.

Even with her mother’s savings, 78 year old Mrs. D’Souza, a rheumatoid arthritis patient who is bed ridden past two years still had to top up with around 15000/- every month to cover her care in a care home in Pune. "An awful financial situation," said her daughter, Sharon. For the two-thirds of middle class Indians over 70, who are expected to need some long-term care, the costs are increasingly exorbitant. The cost of staying in a decent care home has climbed at twice the rate of overall inflation over the last five years, according to our experience. One year in a private room now runs a median Rs. 300000/- a year, while annual cost for home-health aides runs Rs. 250000/-.

"If you have any money, you're going to use all of that money," a frustrated Sharon said. "Just watch how fast it goes." Sharon wonders how people manage the widening gap between their savings and the high cost of caring for the elderly? In India insurance doesn't cover long-term stays, so a large swath of elderly people wind up on the personal savings and ‘beg for charity from children’.

"Within the first year most people are tapped out," said Philip Cherian, a practicing chartered accountant and the director of two retirement homes in Bangalore. "Middle-class families, though cash rich, just aren't prepared for these costs." Cherian sums up.

Everything changes when, for instance, an aging father struggling with dementia requires more help than his wife and children can manage. Remember plans that looked solid on paper are no match for their bills. Cherian says plans for care and finance are equally important to prevent unpleasant happenings and inferior care.

Many of the retirement homes in the country just provide accommodation, housekeeping, food and this will be included as basic cost. Linen, laundry, physiotherapy, medical, consumables, TV, internet, grooming, maintenance, etc., are all charged extra and considered as hidden charges. On average, a shared room in a nursing home costs anything between 20k to 40 K without care. A private room, or a studio apartment can still costs higher. All the facilities collect deposits with various modes of deductions. Deposits range anything between 2 lakhs to 60 lakhs, depending upon the facilities and the size of accommodation.

Now comes the variables of the long term care industry. "The amount of care you need dictates the price," said Swetha Banerjee, a geriatric care manager in a care home in Kolkotta, "and there aren't that many ways around it."

Hiring an aide to spend the day with an elderly parent living at home is often the cheapest option, with aides paid a minimum of 15000/- a month in some parts of the country to 35000/- in few metropolitan cities. But hiring them to work around the clock is often the most expensive, Swetha said. "Needing help to get out of bed to use the bathroom in the middle of the night or patients with peg feeding or sleep disturbances means you need at least two attenders round the clock and in that case better to choose a nursing home," she said. She also points out to other costs like physiotherapy, and consumables like diapers, gloves and masks, catheter management, and other paraphernalia associated with long-term care. Last but not at all the least, now a day, as the medicines in old age are costly. Many elders have multiple conditions necessitating the consumption of many costly drugs.  This adds up to the cost.

Sushma Kavale, another Bangalore expert in long-term care has a different take on this so-called ‘awful financial situation’. According to her, for those solidly in the middle class, however, the answer is actually not very complicated, rather a hype. ‘Anticipate cost, and be prepared to spend and expect rising trend to continue’, she asserts.

After a close look at Sharon’s mother’s financial situation, there is no grim picture as the way it made out to be. Taking Sharon’s case study, Sushma wants to dispel the myth of ‘finance crunch’ for a middle class family. They have too much money for all the luxuries  under the sun but not enough to cover the typical few years of care of their ‘beloved’ mother.

When I told Sushma about me writing an article on the financial distress faced by many families, as a veteran in long term care, Sushma too admit that it is no easy affair, unless the old man/women plans well in advance. ‘You can get quality elder care but be prepared to pay for it’. Financial distress is the result of many factors. It can be the actual crunch. But according to her, majority of middle class and above have sufficient means or income but not willing to pay up.

Older adults those are deprived of the qualitative health care at their fag end of life, citing reasons like "too expensive" "poor affordability" "siblings doesn't go dutch" are unlikely and unconvincing excuses. Most elderly parents are made poor during infirmity by draining them off their resources by the children or immediate families. Many elders have some savings, assets or some little fall back from their life long hard work and earnings. In a household when the elderly parent retire from active life, assets and savings are parted among children either by persuasion or parents willingly share. In few cases parents hold some of their assets and savings. In a phase where they are infirm and bedridden no more able to run their finances on their own children chose how much to spend or what kind of quality care to offer, sadly its Price that's preferred over Quality leaving the older parent to inferior care. Considering a middle class elderly parent in India, majority got some assets or meager savings which actually can take care of their rainy days in a most dignified and graceful manner. Yet, they elders get deprived of it because their old age care is not their choice but their children's or someone else's.     

Having money and not spending it may be a problem lots of caregivers wish their families had, but it’s a problem nonetheless. “Money is a very emotionally charged issue,” Ms. Sushma said. “It’s hard for rationality to rule.” “I can’t afford it” provides a good all-purpose excuse.