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ANNALS OF SBV Volume 1 Issue 2 July - dec 2012

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Patient First: Quality Assurance And Patient Safety In Health Care

A Publication of

SRI BALAJI VIDYAPEETH


Annals of SBV Editor-in-Chief N.Ananthakrishnan

Core Committee T.R. Gopalan K.A. Narayanan Usha Carounanidy S. Kamalam M. Ravishankar

Seetesh Ghose Karthiga Jayakumar R. Pajanivel R. Jagan Mohan

Issue Editor V.N. Mahalakshmi Satistical Consultant G.Ezhumalai Editorial and Production Consultant A.N. Uma Editorial Assistance M. Shivasakthy A. Kripa Angeline Technical Assistance George Fernandez Published, Produced and Distributed by

Sri Balaji Vidyapeeth Editorial correspondence to Editorial and Production Consultant

Annals of SBV Sri Balaji Vidyapeeth

(Deemed to be University, Declared Under Section 3 of the UGC Act, 1956) Mahatma Gandhi Medical College & Research Institute Campus Pillaiyarkupam, Puduchery - 607 402 INDIA E.mail:annals@sbvu.ac.in | Phone : +91 413 2615449 to 58 | Fax : +91 413 2615457 Visit Annals of SBV Online at http://www.annals.sbvu.ac.in


From The Editor’s Desk

V. N. Mahalakshmi * Hospital and healthcare institutions are some of our country’s and indeed the world’s most dynamic, creative, innovative and service minded enterprises. We are in an era where healthcare is both literally and figuratively being revolutionized around the world. It seems that any discussion about almost any issue in the recent times has the word ‘quality’ peppered liberally in it. This apparent obsession with a concept, which is both nebulous and is difficult to define, especially in the realm of healthcare, has often caused confusion and an inability to truly understand what ‘‘Quality of Care’ represents. For some, it is the survival of the patient; for others, it is the successful completion of the procedure, unmindful of the quality of the patient’s experience during the treatment process. To deliver Quality Care, we need the patients to trust in the safety and effectiveness of our services. The advancement of medical technology has brought newer therapies with greater clinical benefits, but also a greater potential for harm. The data from Harvard Medical Practice Study in the late 1990s, which has been repeated in various studies across the world, suggest that between 3 to 25 percent of patient suffer unintended harm due to medical errors. Quality is the product of two factors, one the science and technology of healthcare and the other, the application of them in actual practice. We need to understand these critical components to deliver quality in healthcare. The approach analysis of the components of patient safety such as incident reporting, database review and clinical incident analysis can be applied to different service areas and specialties. Errors and adverse events are fundamentally organizational in their etiology and an understanding of them, would involve forays into a range of disciplines including psychology, clinical epidemiology, quality management, technology, informatics and law. To bring about improvement, we need to evaluate how we deliver care and what factors in our care would improve outcomes. Patient safety is not the province of any one discipline and a real understanding of it would require a collaborative effort from different perspectives and contributions. ‘Patient first’ concept aims to replace our current ‘Physician centered’ healthcare system with the one that revolves around the patient –‘Patient centered’. We need to move from ‘what’s the matter’ with our patients to ‘what matters’ to our patients, focusing on their concerns while assuring safety and effectiveness. ‘Patient first: International conference on Quality Assurance and Safety in healthcare’ 2012, was a Joint International Conference, organized by Sri Balaji Vidhyapeeth – a deemed University, Pondicherry, India and supported byThe Royal College of Physicians and Surgeons, Glasgow, UK. The event was held at Hotel Ananda Inn, Pondicherry, Pondicherry state, India, from November 28th to 30th, 2012. Our initiated a multi disciplinary dialogue on patient safety practices. We brought together some of the leading experts, researchers, commentators and members of the academia to share and debate their experiences and expertise. The conference program combined plenary sessions and keynote lectures with parallel focus sessions on the key issues of Quality of care and Patient Safety issues, and was trans-disciplinary in nature. The conference was attended by over 450 practicing clinicians, hospital administrators and other interested stake holders . We are happy to bring out


the deliberations and the write ups submitted for the event as a special issue for the ‘Annals of SBVU’ for wider dissemination and readership. As long as science continues to expand boundaries of what we can achieve in the healthcare, the pressure to ensure what we do meets the expectations of patients and other stakeholders will not ease. No level of quality can be totally satisfactory, as the threshold continuously keeps shifting upwards. We need to live up to this challenge by developing procedures, processes and techniques that keep tune with this challenge. We do hope that our efforts would help us all to take a positive step in safer, patient centric care.

* * Dr. V. N. Mahalakshmi M.S, M.Ch., FRCS , Professor of Paediatric Surgery, Organising Secretary, Patient First: International Conference on Quality Assurance and Patient Safety Sri Balaji Vidyapeeth, Pondicherry


Index Incident reporting and its implications for patient safety - Bill Runciman

1

Equity in healthcare - Perspectives and Prospectives - Ian W R Anderson

2

Making Your Hospital a Patient Friendly Hospital - B Krishnamurthy

3

Minimizing health care errors: a problem-based approach - Kathleen A Holloway

5

Healthcare-Patient Interface 6 - Subramoniam Rangaswami Diabetes in adolescents - challenges and rewards - Colin Perry

12

New treatments for Type 1 and Type 2 diabetes - Miles Fisher

13

Brain-body medicine & health outcomes 14 - B.Sivaprakash Yoga in Health Care 15 - Yogacharya Dr.Ananda Balayogi Bhavanani A Critical Appraisal of Current Status of Music in Health care - Thirumalachari Mythily

25

Spirituality and Well being 28 - Achariya Shruthi Chaitanya Efficiency and Effectiveness in Emergency Room Services - Moses Kirubairaj

31

Ethics in Clinical Trials. 32 - Balakrishnan S Ethics in Assisted Reproductive technology 33 - Mirudhubashini Govindarajan Setting Clinical Data Standards and Data Portability - Nrip Nihalani

34

Tracking and Reporting of Adverse Events 35 - Bill Runciman Is Robot Safe and legal? 36 - Narmada P.Gupta


Safe surgery saves lives – An appraisal of the who initiative - N. Ananthakrishnan

38

Central Venous Access and Ultrasound 45 - Abhiram Mallick What do patients expect when things go wrong? - Ramkumar Raghupathy

46

Alternate Dispute Rednessal Mechanisms In Healthcare - S.V. Jogga Rao

49

Patients for patient safety 50 - SeeteshGhose


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Incident Reporting and its Implications for Patient Safety Bill Runciman *

Although awareness of the possibility of healthcare harming those for whom a reduction in illness and suffering is intended goes back to the dawn of civilisation (the Code of Hammurabi and the Hippocratic aphorism “first, do no harm�), the modern patient safety movement started less than 40 years ago, and only gained momentum at the turn of the century. Things that go wrong in healthcare are characterised by being made up of a relatively small number of categories that account for about 20% of the problems, and then a very large number of categories would make up 80%. Each of these are encountered only rarely. This situation means that classical prospective quantitative research methodology cannot be used for the bulk of the things that go wrong. Moreover, clinicians are taught as students not to implicate the system or their colleagues when things go wrong, so little can be leaned about the underlying causes of the problems from medical records. Instead we are left either with real time studies (observation and interviews) which are valuable but expensive, or collecting information about what happened after things have gone wrong. Systems available to do this include incident reporting, complaints, medico legal files, and coronial recommendations. The evolution of the methods available to collect and analyse this information will be traced, and the information that has been learnt will be summarised, and an account of the International Classification for Patient Safety and its development will be given. Some suggestions will be made as to how systems might best be set up and used in the future.

* Prof.Bill Runciman, Professor of Patient Safety, University of South Australia President, Australian Patient Safety Foundation. Annals of SBV

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Equity in Healthcare - Perspectives and Prospectives Ian W R Anderson * Health care is one of the foremost issues affecting all countries in the world and the challenges of how to deliver effective and affordable health care concentrate the minds of politicians, professionals and the public globally. With the recent surge in technological change, modern medicine promises to deliver standards of investigation and treatment which previous generations would have found bewildering, but they threaten to do so at a cost which could cripple even the strongest of economies. Without doubt, the major challenge in the near and medium term will be how to cope with the scourge of noncommunicable disease: in particular, cancer care will prove an increasing problem for developing societies even more so than in the developed world. Metabolic problems and in particular, diabetes, are already a major emerging problem for health care systems and at the same time, an increasingly attractive market for big pharma. These issues will be highlighted and there will be an opportunity to discuss the ways and means to cope with these problems in individual environments.

*Mr. Ian W R Anderson, President, Royal College of Physicians and Surgeons of Glasgow.

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Making our Hospitals Patient Friendly B Krishnamurthy * Some of us may be pre-destined to go through life without disease. But many are likely to fall ill and may find it necessary to go to a hospital either as an outpatient or as an inpatient. Though we are forced to do so, it is not a task that any one of us is fond of. The following words succinctly explain this state: “Hospital patients are people whose lives have been interrupted because of a significant and often frightening medical issue. From the moment they enter that hospital door, their world changes. They are surrounded by strangers who give them instructions and warnings that they may or may not fully understand. They are inundated by noise from machinery, beeps from electronic devices, bright lights, and the bustling voices of hospital staff, while sharing a room with someone they’ve never met before. Even with efforts to mitigate these disruptive factors, a hospital experience is disorienting”. (Excerpts from “Sick, Scared and Separated from loved ones”: A report by Newyorkers for patient & family empowerment: New York public interest research group. August 2012). It is obvious hospitals cannot be done away with. It is also well known that several aspects of the hospital are less satisfactory than they should be. Hence the authorities who manage the hospitals would do well to consider those aspects of the hospital which are abhorred by the patients and take necessary action to rectify these issues. The first duty of a patient friendly hospital is to provide safe, effective, efficient, equitable or affordable, timely, patient oriented quality medical and nursing care. It has to do so while being ethical, legal and transparent. Hospitals are generally either “For profit “or “Not for profit “organizations. Whatever be the motive behind the running of the hospital, there is no doubt that hospitals are ultimately responsible to the community they serve and shall abide by the unwritten but commonly accepted rules of the community. A patient friendly hospital shall never forget the fact that the patient is the most important person in the hospital and is to be treated as such. A patient friendly hospital ensures that all its staff, aided by suitable systems, practices and infrastructure, work towards providing a warm and personal human touch to the care given to patients, their relatives and other visitors to the Hospital. It is the duty of the hospital management to ensure that every one of its employees knows that “A patient is the most important visitor on our hospital. He is not dependent on us; we are dependent on him. He is not an interruption of our work; he is the purpose of it. He is not an outsider to our business; he is a part of it. We are not doing him a favor by serving him; he is doing us a favor by giving us an opportunity to do so.” (Modified quote from Mahatma Gandhiji). A patient friendly hospital makes known its vision, mission, quality and safety policy, its performance results and scope of services. It is necessary for the patients to know the services that are NOT available. Patients have to be informed of their rights and responsibilities and of any complaints and grievance procedure. A patient friendly hospital shall ensure easy access to the hospital through website, telephone and road. Provision of adequate parking, well located front desk for enquiries, with informed and trained staff, well located directional and warning signages, a transparent queue system, a quick and convenient registration process and provision of help to fill up various forms are aspects that need to be considered. Provision of basic amenities like comfortable and adequate seating, drinking water and clean toilets, periodical updates on doctors’ availability and possibility and reasons for any delay go a long way in ensuring patient friendliness.

* Dr B Krishnamurthy, MD DA FRCA ,HOD; QMS Baby Memorial Hospital Kozhikode Annals of SBV

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A patient who comes to a hospital undergoes many processes before and while receiving medical care. Registration, appointment fixation, triaging, initial patient assessment, cross consultations, laboratory and radiology and imaging investigations, nursing, nutritional and physiotherapy assessment, care plan generation, prescription and medication administration are common processes that any patient may undergo in outpatient and emergency departments. Comfortable consultation rooms with adequate privacy, caring and informative doctors, efficient support services like pharmacy, laboratory and other diagnostics, an active patient feedback system and complaint handling system shall be necessary to satisfy out patient service requirements. It would be ideal if the hospital can reduce waiting times for sample collection, imaging and radiology services and report delivery. Single window systems help in this process. An inpatient may undergo additional processes that include admission, invasive and non invasive procedures, intensive care, surgery, anesthesia and moderate sedation, blood and blood product transfusion. Most hopefully become better and get discharged. In others, results may not be this desirable and may need transfer to a long term facility, hospice or worst to the undertakers. Multiple interconnected processes, multiple health care workers and many managerial staff are needed to make these processes happen smoothly. In patients may need additional facilities, the more important being quick and minimal paperwork for both admission and discharge, a precise allotment of the bed and room requested, update on room availability in case of immediate non availability, adjustable visiting hours, display of do and don’ts for visitors and well displayed safety instructions. A general consent incorporating all this shall be obtained during admission. The patients have to be appraised of the reasons for admission, the disease process, the treatment or care plan, the expected results, possible complications and expected duration of stay. The patient friendly hospital has a clearly drafted procedure for obtaining informed consent. In India most patients will have attendants who either stay with them or stay in the hospital premises. An attendant area with clean restrooms, comfortable chairs and couches and a vending area, facilities for washing and drying of clothes, access to a pantry with coffee, instant hot water, small snacks and an assortment of hot drinks and milk, decent cafeteria food are needed for the attendants. A small but quiet garden with shady trees and comfortable chairs and an area where people can pray in silence would also add to the comforts of the attendants and patients. It is necessary to give a written indication of expected cost of treatment. When packages are used for charging a patient, it must be clearly stated what the packages include and do NOT include. The patients who come under insurance schemes should be clearly told of the steps that will be taken by the hospital in ensuring cash less admission or claims reimbursement. The patient must be aware of his/her commitment if the claim is rejected. A patient friendly hospital encourages its staff, patients, visitors and other stake holders to comment on its services and offer suggestions. It treats all complaints as opportunities for improvement and acts upon them. Every complaint is taken to its logical conclusion and the complainant informed of complaint closure. A patient friendly hospital has a “Patient Safety Programme” in place and ensures all steps are taken to identify various risks faced by patients, and ensures all risk reduction activities are in place. The hospital has a mechanism in placing for monitoring of these activities and reporting of incidents. It shall act on each incident and ensure corrective and preventive action. The patient friendly hospital shall also be environment and community friendly. It shall follow all measures to conserve resources like water and electricity and ensure its biomedical waste management conforms to prescribed local and legal standards. It shall identify common internal and external disasters that it may be subjected to and shall ensure all its staff are trained and prepared to deal with the internal or external emergency and continue to function effectively during crisis. In summary, every hospital has to ensure that it looks after the hospital side and hospitality side of patient care. There is no doubt that hospital visits are abhorred by most patients and all efforts should be taken to reduce the discomfort associated with them. This can be done only if the organization understands that the hospital is “for the patients, by the patients and of the patients” and works diligently towards identifying their stated and implied needs. Hospital management should make specific efforts to exceed patients’ expectations, monitor and correct their actions, when found to be deficient. Page 4

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Minimizing Healthcare Errors : A Problem - Based Approach Kathleen A Holloway *

Unfortunately, health care errors are a frequent occurrence in medicine and thus it is important to take action to minimize their occurrence. This paper concentrates on minimizing health care errors due to medicines and provides an overview of the scale of the problems and reviews the causes and solutions. It has been estimated in developed nations that adverse drug events occur often, are a frequent cause of morbidity and death, and cost the health care system millions of dollars per year. There is a paucity of data from developing countries. The main causes of adverse drug events include medication errors, adverse drug reactions, poor drug quality and inappropriate use of medicines. The paper focuses on how to investigate an adverse drug event, identify the exact nature of the problem and its cause and take corrective action, which should include action to prevent such events from recurring. The paper also describes the common types of medication error, adverse drug reactions, drug quality and inappropriate use and how these particular problems may be tackled both at the local and national levels. Finally the role of the Drug and Therapeutic Committee and its importance in implementing quality improvement cycles are discussed in order to minimize health care errors from medicines. It is concluded that active measures are required to encourage staff to report all problems, which should be investigated in a non-confrontational way and followed by action to correct both the immediate problems and to prevent future similar occurrences. In addition regular prescription audit should be done to identify prescribing problems in advance and to take corrective action so as to minimize health care errors due to medicines.

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* Dr Kathleen A Holloway, Regional Advisor Essential Drugs and Other Medicines World Health Organization, Regional Office for South East Asia New Delhi, India. Annals of SBV

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Healthcare - Patient Interface Subramoniam Rangaswami *

“The ignorant sailor and the learned physician will equally long, with the most craving anxiety, for green vegetables and the fresh fruits of the earth.” James Lind (1747) “[This] is endemic to a system in which an expanding medical establishment, faced with a healthier population, is driven to medicalising normal events, converting risks into diseases and treating trivial complaints with fancy procedures . . . The law of diminishing returns necessarily applies.” Roy Porter (1998) The Greatest Benefit to Mankind Abstract Modern medicine has fixed its own birth date around the last years of the 18th century. The healthcare-patient interface must have gone through significant changes as caring for the sick emerged from being a noble mission, evolved into a consulting profession and advanced to its current standing as healthcare system. This commentary examines the reasons for the paradox of the growing discontent with modern medicine against the backdrop of one of the most impressive epochs of medical achievements in the past fifty years. While reliance on a decidedly technological base has been charged with weakening the humane face of today’s biomedical science by some, the tangled interconnectedness that the health delivery system has introduced into its complex organizational structure is pointed out by others. The role and effectiveness of ‘patient-centered care’ as recommended by the Institute of Medicine and implemented by some hospitals and academic medical centers are reviewed. The question of the disturbing incidents of preventable medical errors recurring with alarming frequency and some of their remedial measures are examined with the observation that just as it is crucial to address technical and safety issues in the healthcare environment, it is equally important to pay attention to patient experience issues. Finally, the serious consequences of the ‘healthcare vs medical care’ schism pervading the minds of health policy makers in India are highlighted. The essay concludes with a brief look at the healthcare scenario of the future with specific reference to the interface and the emerging trends in health communication through social networking and transactional models in our rapidly emerging ‘Connected Age.’ Key words: healthcare, medical care, interface, paradox, patient-centered medicine, system failure, communication, health financing, universal healthcare, social networking. It is important to make clear the distinction between healthcare and medical care at the beginning of this commentary. Medical care implies diagnosing and treating illnesses where the beneficiary is the sick person, the patient. A strict definition of healthcare on the other hand should include, in addition to patient care, welfare measures like sanitation, nutrition and other schemes for health maintenance and promotion initiated and implemented by the state; and the beneficiary is the entire community. The two expressions however, have been used interchangeably in reports and articles on the subject. As the theme of the conference and the title of this presentation make pointed reference to the ‘patient,’ the comments in this paper will be centered on medical care. Modern medicine has fixed its own date of birth as being in the last years of the 18th century.1 Caring for the sick, however, had emerged as a righteous and noble mission from the most ancient times and in almost all ancient civilizations. The accounts and aphorisms of the earliest physicians like Hippocrates, Charaka and Susruta bear testimony not only to their skill and analytical logic in understanding and treating diseases but also to their abiding faith and dedication to the moral and ethical dimensions of their calling. Perusing their elaborate descriptions of illnesses and their remedies, one senses the refreshing setting of trust, awe and fortitude that must have pervaded the physician-patient interface of their times.

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* Prof.Subramoniam Rangaswami , Professor of Eminence in Medical Education & Former Vice Chancellor, Sri Ramachandra University, Porur, Chennai.

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The healthcare-patient interface has witnessed enormous changes ever since the care of the sick saw progressive evolution from being a healing art to a committed pursuit, a consulting profession and advanced into what is recognized as healthcare delivery system or healthcare ‘industry’ today. Some of the changes the care environment saw probably never left impressions big enough to be counted as historic and their effects were hardly felt by the public or the profession whereas others were momentous and transformative. The healthcare profession has seen more fluctuations of the latter category compared to other traditional professions like law because ‘medicine alone has developed a systematic connection with science and technology.’2 One is similarly inclined to agree with Michel Foucault’s observation (on ‘clinical gaze’) that ‘What has changed is the silent configuration in which language finds support: the relation of situation and attitude to what is speaking and what is spoken about.’1 The stories and reports that keep coming in the media, consumer forums and professional literature provide examples of the extent to which the ‘relation of situation and attitude’ have not just changed, but changed radically in the past decades. What has brought the growing discontent with modern medicine against the backdrop of one of the most impressive epochs of medical achievements in the past fifty years? In his award-winning book The Rise and Fall of Modern Medicine, physician, journalist and author James Le Fanu comments specifically on this issue. ‘Any account of modern medicine has to come to terms with a most perplexing fourlayered paradox that at first sight seems quite incompatible with its prodigious and indubitable success.’3 In the ‘fourlayered paradox’ that has undermined the healthcare-patient interface, Le Fanu mentions the following: • Disillusioned Doctors - from 14% in 1966 to 58% in 1986 according to the London-based Policy Studies Institute. • The Worried Well - a medically inspired obsession of people with trivial or non-existent threats to health. • The Soaring Popularity of Alternative Medicine • The Spiraling Costs of Health Care Whereas the first three may be recognized as symptoms of the discontent, the fourth paradox is clearly important as its cause. The curious paradox of these paradoxes, Le Fanu feels, ‘is precisely because medicine does work so well.’ To these may be added the overbearing influence of Health Insurance schemes and managed care practices especially prevalent in USA and the widespread impression among patients and their families about the failure of effective communication on the part of the care professionals. Medical Educational Institutions and Academic Medical Centers will be expected to implement practice guidelines to overcome such paradoxes. Although the concepts of patient-centered care and communication skills have been included as part of the learning requirements in medical curricula, convincing and measurable outcomes of such steps are yet to come from primary and hospital-based patient care scenarios. One of the reasons for the anomaly could be the transition of the clinician-patient interface from a warm and informal affair with its basis on empathy and understanding to a complex and rigidly orchestrated system engaging an assortment of experts, services and personnel. The nebulous interface over time morphed into what could only be described as a mighty fortress wherein physician income, prestige and power in an atmosphere of severe timeconstraint defined the guiding principles of medical practice. It was perhaps not without reason that A. J. Cronin, who studied medicine at the University of Glasgow, chose to title his novel The Citadel seventy five years ago.4 Cronin’s disparagement of the medical practice of his times portrayed in the novel is considered one of the important factors that helped to change the British Government’s attitude towards medical practice, paving the way for the creation of the world’s first National Health Service in 1948. (As a brief aside, it may be pointed out that the Indian connection with the story of The Citadel continued in the 1971 film Tere Mere Sapne – ‘Your Dreams and Mine’) It would be instructive here to consider the distressing experience of a clinician on the treatment his wife received in a modern academic medical center (where he also worked as a clinical faculty) for a series of medical complications burgeoning off an allergic vasculitic neuropathy – thrombophlebitis, pulmonary embolism, myocardial infarction, ARDS and cardiac arrest.5 Dr. Southwick’s report was published in the Annals of Internal Medicine almost twenty years ago. The story understandably remains an emotional one but could be justified, because, as the author says, ‘Sometimes a

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profound personal experience speaks louder than averages, standard deviation, or statistical significance.’ The list of disappointing experiences reported by the doctor includes: • Seeming disregard by the Consultant Neurologist. • The sense of being abandoned by his colleague clinician. • Delegation of care by attending physician to senior resident and in some instances even to rotating interns / house staff. • Preoccupation of senior clinicians with research work, professional conferences etc at the expense of time spent on patient care. • The fragmented and at times impersonal care. • Ambiguous assignments of responsibility for care. • Inadequate transfer of information and authority. • How academic physicians sometimes forget the sacred trust patients and families put on them. • How the care remains fragmented among many specialists with little communication between them and little effort to integrate it. In the midst of the mounting inventory of complaints, the author does not forget to mention and appreciate the astounding skill and ability of the acute-care, full-time academic physicians in reversing what could otherwise have ended as a fatal complication in his wife’s case. Equally important, if not more, is the report of the revisit by the same doctor and his reanalysis of his wife’s case after a gap of 15 years.6 Unlike in the earlier report, the most important insight from reanalysis through the ‘lens of complex systems design’ stresses on the effects of the flawed and dysfunctional system in which the healthcare team operates rather than on fault-finding on any individual member of the team. ‘In a dysfunctional system, even the most conscientious physician may be viewed as uncaring’ feels the author. Findings from systems analysis of his wife’s case under six algorithmic stages convinced Southwick that consistent and acceptable delivery of healthcare can be guaranteed only by focusing on the systems of care delivery and working on quality improvement. After all, ‘patients and their families see the system and the physician as one.’ A dysfunctional and recalcitrant system brings to mind Cronin’s Citadel again. The concept of ‘patient-centered’ medicine was introduced more than forty years ago by Enid Balint.7 In her reckoning, a ‘patient-centered’ as opposed to ‘illness-centered’ approach, should include, in addition to trying to discover a localizable illness or illnesses, everything the doctor knows or understands about his patient. In a 5-day retreat in 1998 at Salzburg, Austria, the 64 participants from 29 countries created a mythical republic which they christened PeoplePower. For PeoplePower the participants developed a consciously utopian vision reflecting the hopes and aspirations of both providers and beneficiaries of a modern healthcare delivery system.8 An important feature of the system was the liberal use of computer-based guidance and communication systems to enhance the physician-patient relationship. The goal of the system, the authors say, “is a level of service that delights and surprises both the “caregiver” and the “caregetter” with unanticipated levels of excellence.” The operational dictum of PeoplePower was: nothing about me without me. The ‘Patient-centered Medical Home’ proposed by the American Academy of Family Physicians may be a step in this direction.9 Another proposal, close to being ‘mythical’ again, is the scheme put forward by Dimitrios Sotiriou of Athens University for ‘Modern Asclepieions’ modeled after the famed healing centers of ancient Greece.10 A major goal of Modern Asclepieions is to make the concepts of inclusion, equity of access and citizen empowerment a reality by exploiting the potential of modern Telecommunications Technology. The World Summit on Information Society (WSIS) recently included the project ‘The Modern Asclepieion for Citizen Empowerment’ (MACE) as part of its stocktaking activity.11 The theme was also presented at Med-e-tel 2005 Conference in Luxembourg. The Institute of Medicine in the United States recognizes quality as a ‘system property’ and has included patientcentered care as one of its six quality aims based on its observation that a discrepancy exists between the kind of care that patients receive and the kind of care they should have.12 The IOM defines patient-centered care as: Healthcare that establishes a partnership among practitioners, patients, and their families (when appropriate) to ensure that decisions respect patients’ wants, needs, and preferences and that patients have the education and support they need to make Page 8

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decisions and participate in their own care. The IOM’s six specific aims for improvement were built around the need for healthcare to be: • • • • • •

Safe Effective Patient-centered Timely Efficient Equitable

Has proclaiming the ideal of patient-centered care and its induction into clinical practice and physician-training brought about measureable, or, more importantly, palpable outcomes? Or, as a recent commentary suggests, is it only a recent salvo, a rhetorical slogan? ‘Patient-centered medicine,’ the author of the NEJM article says, ‘is above all, a metaphor. “Patient-centered” contrasts with “doctor-centered” and replaces a Ptolemaic universe revolving around the physician with a Copernican galaxy revolving around the patient.’13 Metaphor or not, it is agreed that the patient and physician today must coexist in a therapeutic, social, and economic relation in a complex system of shared and vastly interconnected prerogatives. This is the message one gets from Sanjaya Kumar’s recent analysis of the gravity and overwhelming impact of preventable medical errors in the present “fractured” health system in USA.14 In a highly disquieting narrative, the author takes us through a step-by-step account of eleven instances of preventable adverse effects, six of which ended in death of the patient. Although the quality of in-hospital care and safety issues remain the predominant concerns in his book Fatal Care, one finds pointed recommendations for system correction at the end of each case. Proposals to ‘Protect yourself in today’s healthcare system’ for example, appear consistently after the description of each story. ‘Regardless of where the blame is placed,’ Kumar tells us, ‘the bottom line is that people and systems failed.’ Reminding the readers that ‘excellence does not mean infallibility,’ he recommends that healthcare consumers must be the ones to drive future changes that will improve healthcare safety for all. One of the important features in this will be measures to foster effective communication among stakeholders. ‘Why do these stories of bad patient experiences continue to appear from every health care system?’ was the question raised more recently by the Toronto-based healthcare researchers Levinson and Shojania.15 Recounting two examples of bad patient experiences in hospitals - one in France and the other in the UK - Levinson and Shojania conclude that care often falls short of what patients want and expect. They feel that ‘the overworked and stressed staff members are also unhappy with their inability to provide the kind of care they know is best for patients.’ Frontline staff are often frustrated with infrastructure issues and problems with routine equipment such as beds, storage space, inpatient care areas, and procedures for repairing or replacing defective equipment. They feel these undermine their work and affect their morale. Just as technical and safety issues are addressed, it is equally important to pay attention to patient experience issues. Executive walk rounds in hospitals for example, can help to uncover frustrating infrastructure problems.

Healthcare Vs medical care schism in India

The semantic distinction between healthcare and medical care mentioned at the beginning of this essay assumes greater relevance in the Indian context. Provision of acceptable standards of healthcare is the exclusive prerogative and responsibility of the nation state whereas establishing and running medical care and educational facilities can be shared with private parties and non-governmental organizations supported by a responsive civil society. A look at the scenario in post-independence India will show how the state has fallen severely short of achieving the former objective whereas the private enterprise in the country supported by a rapidly expanding middle class and an articulate civil society has been able to fulfill the requirements of the latter. Several recent reports confirm India’s appalling performance in many areas where the state’s role is desperately needed – health, education, provision of safe drinking water, child immunization, clean environment and so on. In spite of its commendable record of economic growth, India has one of the worst records in human development – with rates of infant mortality, child malnutrition and figures for child immunization worse than those of countries like Bangladesh, Cambodia and Pakistan. The reason for the anomaly becomes apparent when one realizes that healthcare expenditure in India has remained pathetically low and continues to stay at or below 1.2% of the GDP which is less than that in many neighboring countries, not to mention industrialized nations. Annals of SBV

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The recommendations by the Public Health Foundation of India and the Lancet India Group towards achieving the ambitious goal of universal healthcare by 2020 are noteworthy.16 The proportion of out of pocket spending for health at around 75% in India remains the highest in the world. ‘To sustain the positive economic trajectory that India has had during the past decade, and to honour the fundamental right of all citizens to adequate health care, the health of all Indian people has to be given the highest priority in public policy’ says the report and adds that without mechanisms for health financing and universal health insurance schemes that would make health care universally accessible, even improvements in the quality of health services will not be provided to many people in the population. Many families are driven ‘below the poverty line’ after succumbing to unexpected healthcare expenses. On the other hand, the significant achievements in medical care facilities the country has made - mostly under the private sector - in the last 25 or 30 years can be quoted as admirable examples of vision, dedicated pursuit of excellence and willingness to learn from and implement best practices followed in the finest centers in the world. It is not just that they have been able to bring the best that medical technology can offer - many privately run hospitals and academic medical centers have done precisely that - they have been able to establish high levels of patient care and safety standards and implement contemporary management practices in governing and running their institutions. Many examples of such institutions that have been recognized by national and global accrediting agencies like NABH, NABL, ISO, Joint Commission, American Association of Blood Banks etc., can be sited. They are able to attract patients from several countries for diagnosis and management of complex medical and surgical problems. The startling discrepancy in the performance of healthcare as against medical care in India qualifies for the evocative phrase ‘private success amid public failure’ that Gurcharan Das employs in his penetrating study of the prevailing socialpolitical-economic landscape in India.17 As in the case of its economy that has managed to flourish under a ‘flailing state’ or in spite of it, medical care too, in India, has been ‘growing at night’ – while the government sleeps! What we need to remind ourselves is that the expression - its seemingly veiled note of humor notwithstanding - needs to be taken seriously; especially when we consider the health of our nation, because, while lethargy is damaging, somnolence is deadly. Coming back to the question of ‘patient-centered’ medicine as a fitting metaphor to initiate system-correction in the healthcare-patient interface, it would be prudent to remind ourselves that healthcare outcomes rely on an effective teamwork and communication between the patient and the doctor assisted by other professionals, all working in a collaborating system. As Charles Bardes (who was quoted earlier) says, ‘A better metaphor might be a pair of binary stars orbiting a common center of gravity, or perhaps the double helix, whose two strands encircle each other, or - to return to medicine’s roots - the caduceus, whose two serpents intertwine forever.”13 Or, will it be wiser to turn our gaze further back, and, as the tenacious Wagner in Goethe’s Faust proffers, ‘cast the mind into the spirit of the past and scan the former notions of the wise,’18 and consider establishing modern equivalents of Asclepieions, the venerable healing sanctuaries of the pre-Hippocratic era?

The future

From the discussions so far, it is not certain if one is justified in entertaining guarded optimism on the healthcare profession’s ability to learn from its perception of the human dimension in health and disease as much as it has learned from its experience in the practice of the science of medicine and shape a fitting social and economic organization for health delivery for the future. The striking paradox of public discontent against the background of the spectacular achievements of biomedical science mentioned earlier cannot be discounted; neither can the formidable complexities that the health system has introduced into its organizational settings be ignored. An inventory of likely stakeholders who will decide and guide the health system’s objectives, policies and practices in future years will look even more challenging. The growing list of players and stakeholders will include: • The patient, his/her family • Doctors (Family Physician, Specialist, Consultant) • Supporting healthcare workers (Nurse, Technician etc) • Hospital administrators • Government departments (Health, Finance, Social Welfare, Human Resources etc) • Licensing & Accrediting authorities • Pharmaceuticals/Medical equipment manufacturers

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• • • •

Health insurance firms Information Technology/Robotics experts Other professional organizations (Architects, Education, Consumer Forum, Law) Social networking and transactional models in the rapidly emerging ‘Connected Age.’19

Mutual consultations and consensus building across the divergent groups of stakeholders will assume greater importance in guiding healthcare planning and policies in future than the weight of authority of the medical profession with its jealously guarded autonomy as the sole and expert agent for such decisions. By the same token, in an era fogged up with such diverse factors as Acquired Immune Deficiency, antibiotic resistance, transplant surgery, joint replacement, assisted reproductive technology, regenerative medicine and robot-assisted procedures, the healthcare-patient interface is bound to experience novel tensions and turbulences hitherto unencountered. To this must be added the growing population of the ‘worried sick,’ who, burdened by medicalisation of normal events and fanned by lay publications and the media, demand redressal of non-existent or dubious pathologies in a setting of overstretched resources. Particularly nightmarish will be a scenario (though imaginary) where, as in Bertrand Russell’s satirical story of robots that are ‘indifferent to the joys of sense’,20 our health and well-being are overwhelmed and expropriated by an escalating population of androids – or worse still, by a band of robot-like professionals practicing the ‘uncertain art’ of medicine!

References:

1. Foucault M (1963) The Birth of the Clinic: An Archeology of Medical Perception. 2. Freidson E (1970) Profession of Medicine: A study of the Sociology of Applied Knowledge. 3. Le Fanu J (1999) The Rise and Fall of Modern Medicine: Little, Brown and Company. 4. Cronin A. J (1937) The Citadel: Penguin Books (1999) 5. Southwick F (1993) Who Was Caring for Mary? Ann Int Med; 15 January, 1993, Vol. 118: No. 2 6. Southwick F (2009) “Who was Caring for Mary?” Revisited: A Call for All Academic Physicians Caring for Patients to Focus on Systems and Quality Improvement: Academic Medicine Vol. 84, No. 12/ December 2009 7. Balint E (1969) The possibilities of patient-centered medicine J. Roy. Coll. Gen Pract. 1969, 17, 26 8. Delbanco TL, Berwick DM, Boufford JL, et al. (2001) Healthcare in a land called peoplepower: nothing about me without me. Health Expect. 2001;4:144–50. 9. American Academy of Family Physicians (2012) Patient-Centered Medical Home. www.aafp.org/online/en/online/home/membership/initiatives/pcmh.html 10. Sotiriou D (2004) Modern Asclepieions: A World-wide Movement to Provide Modern ‘Health and Culture Parks’ for the New Millennium. www.itu.int/.../Modern-Asclepieions-paper-for-publicationMarch-14-2... 11. The World Summit on Information Society (2012) The Modern Asclepieion for Citizen Empowerment (MACE) – ITU www.itu.int/wsis/stocktaking/scripts/documents.asp?project... 12. Institute of Medicine (2001) Crossing the Quality Chasm: A New Health System for the 21st Century, Vol. 6. Washington, DC: National Academy Press; 2001. 13. Bardes C. L (2012) Defining “Patient-Centered” Medicine : N Eng J Med; 366: 782-783 March 1, 2012 14. Kumar S (2008) Fatal Care: Survive in the US health system: Pub. IGI Press. 15. Levinson W & Shojania K. G (2011) Bad experiences in the hospital: the stories keep Coming: BMJ Qual Saf: November 2011, Vol. 20 No. 11 pp 911-913 16. Reddy K. S et al (2011) Towards achievement of universal health care in India by 2020 : a call to action : Lancet 2 011; 377: 760–68 17. Das G (2012) India grows at night: A liberal case for a strong state: Penguin Books India. 18. Goethe J. W: Faust - Translation Philip Wayne: Penguin Books (1949) 19. Shirky C (2010) Cognitive Surplus: Creativity and Generosity in a Connected Age - Allen Lane (Penguin Group) 20. Russell B: Dr. Southport Vulpes’s nightmare: in The Collected Stories of Bertrand Russell Simon and Schuster 1972.

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Diabetes in Adolescents - Challenges and Rewards Colin Perry *

The management of diabetes during adolescence presents a unique set of challenges. Physiological as well as behavioural changes pose particular problems. Compliance with insulin therapy may deteriorate as parental supervision is withdrawn, while clinic attendance may fall as patients transfer from paediatric to adult services.There is no single formula to address all of these issues, however establishing a relationship between the diabetes team and the patient is key. Many of the challenges relate more to adolescence than diabetes; patients need support that is accessible and responsive to their needs. The transition of patients from paediatric to adult services also requires careful co-ordination. Once transferred to adult services, young people should be seen in age-banded clinics that focus on the needs of young people. Other strategies such as group meetings, mentor programmes and activity holidays may also be helpful. While some individuals will inevitably prove especially challenging, providing non-judgemental support and establishing trust is crucial; often the most rewarding outcomes result from not losing faith in a troubled young person, and seeing them later move into adulthood where they are better equipped to manage the challenges of diabetes and adult life.

Diabetes in hospital - emergencies, surgery and management of inpatient diabetes 20% of inpatients in UK acute hospitals have diabetes. A recent audit demonstrated unacceptably high levels of hypoglycaemia and insulin errors in these patients, as well as there being an increase in length of stay associated with having diabetes. Novel approaches to managing this problem are required; in England, many hospitals have implemented the Think Glucose programme with varying success. Scotland has piloted this approach, and involved Healthcare Improvement and patient safety agencies in an effort to achieve real and sustainable improvements. Interim results suggest improvements in insulin prescribing, hypoglycaemia management, early assessment of patients and a reduction in the frequency of hypoglycaemia. In conjunction with this initiative, several Joint British Diabetes Societies protocol documents have been published recently with particular relevance to inpatient diabetes, such as surgical management and management of hypoglycaemia, while Scotland has produced a national protocol for the management of diabetic ketoacidosis. Widespread implementation of these remains a challenge, however raising the national profile of inpatient diabetes and attracting interest and support from Government has led to progress that may well see long term benefits in terms of improved patient experience, reduced costs and a fall in morbidity and possibly mortality. The healthcare-patient interface has witnessed enormous changes ever since the care of the sick saw progressive evolution from being a healing art to a committed pursuit, a consulting profession and advanced into what is recognized as

* Dr. Colin Perry , Honorary Senior Clinical Lecturer University of Glasgow.

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“New Treatments for Type 1 and Type 2 Diabetes” Miles Fisher *

It is now 90 years since the discovery of insulin. There have been many improvements in insulin therapy over the years, with purer insulins, insulin analogues, and insulin pumps. Further improvements continue to be made. Insulin degludec is an ultra-long acting insulin with a flat insulin profile, and early clinical use has shown less hypoglycaemia in patients with type 1 diabetes. Metformin is established as the drug of first choice for the treatment of type 2 diabetes. Sulfonylureas can cause weight gain and hypoglycaemia, and several second-line alternatives are now available. Aleglitazar is being studied in diabetic patients following acute coronary syndromes, and seems to have many of the benefits of pioglitazone. Like pioglitazone is can cause weight gain and fluid retention. DPP-4 inhibitors do not cause hypoglycaemia and are weight neutral, several daily drugs are now available, and once-weekly DPP-4 inhibitors are in phase 3 development. SGL2 inhibitors decrease the urinary reabsorption of glucose, promoting weight loss and reductions in blood pressure. Finally, several newer GLP-1 receptor agonists are being developed, including once weekly preparations, and preparations that are injected every three months.

“Reducing CV risk in diabetes”

Recent studies have challenged the notion that for CV risk reduction in people with diabetes lower is better. Attempts to normalise glycaemia have been associated with increased mortality in people with type 2 diabetes, and an HbA1c target of 7.0% is safer, especially for patients with longstanding disease or established cardiovascular disease. Similarly, attempts to normalise blood pressure have not shown any major reduction in cardiovascular endpoints beyond conventional blood pressure targets, but have been associated with more side effects. For cholesterol however, the use of higher doses of statins does seem to improve outcomes in people with diabetes. The place of fibrates and of newer lipidlowering treatments is at present uncertain. Ezetimibe has been shown to reduce outcomes in patients with renal disease when added to low dose simvastatin, and the results of further outcome studies are awaitied with interest.

“Interactive case discussions”

We will present a series of diabetes case histories and will ask the audience to vote on possible treatment options to control glycaemia and / or to reduce cardiovascular risk.

* Prof. Miles Fisher, Honorary Senior Clinical Lecturer University of Glasgow.

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Brain-Body Medicine & Health Outcomes B Sivaprakash *

ABSTRACT

Mental functioning is fundamentally interconnected with physical and social functioning and health outcomes. For example, depression is a risk factor for cancer and heart diseases. There is also evidence that depression predicts the incidence of heart disease. People suffering from chronic physical conditions have a greater probability of developing mental disorders such as depression. Research has confirmed that mental & physical comorbidity results in poorer health outcome. Psychosomatic medicine seeks to promote and advance the scientific understanding and integration of biological, psychological, behavioral and social factors in human health and disease, and to foster the application of this understanding in health care. Related fields include mind-body medicine, behavioral medicine, integrative medicine, and health psychology. It is well-established that the mind is an expression of neural activity within the brain.Thus, the influence of the mind on physical health can only be mediated through physiological pathways connecting the brain with other organ systems. The new field of brain-body medicine focuses on interactions between the brain, peripheral pathways and bodily end-organs.Bi-directional brain-body pathways can be thought of as the mechanistic substrate that mediates the relationship between emotions, stress and physical health.The brain interacts with the other organ systems through three physiological systems: the autonomic nervous system, the neuroendocrine pathway, and the neuro-immune pathway. Recent research in the field of brain-body medicine shows that pathways connecting the prefrontal cortex, limbic system, hypothalamus & brainstem centers have a profound impact on the autonomic nervous system, the endocrine system, and the immune system, resulting in diverse effects on systemic health. Such research has been facilitated by tremendous advances in neuroimaging techniques such as functional magnetic resonance imaging & positron emission tomography, along with the ability to simultaneously measureperipheral physiological processes. In addition, mental health influences overall health through the health behaviour / lifestyle pathway. The term health behaviour covers a range of activities, such as eating sensibly, getting regular exercise and adequate sleep, avoiding smoking, and adhering to medical therapies. The practical implications of research findings from psychosomatic medicine & brain-body medicine can be conceptualized under three categories: knowledge, attitude & practices.Acquisition of new scientific knowledge pertaining to brain-body pathways& the health behaviour pathways lays the foundation for positive changes in attitude & health care practice.Many physicians & other health care professionals have traditionally viewed the psychosomatic concept with skepticism. Modern research in brain-body medicine has an immense potential to change this unfavorable attitude. Demonstration of an unequivocal biological basis for the impact of the mind on overall health will strengthen the biopsychosocial model of disease & radically change the way in which health care is provided.Research findings from psychosomatic medicine & brain-body medicine may serve to improve health care practices. Addressing mental health issues while caring for patients with physical disease can improve quality of patient care &overall health outcomes. Therefore mental health care needs to be integrated with physical health care to achieve holistic care. Mental health screening of patients with long-term medical conditions such as diabetes & heart disease is a practical measure that can serve to detect stress & psychiatric comorbidity. Research indicates that screening for and managing stress & mental health problems in medical patients is likely to improve health outcomes.

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* Dr. Sivaprakash B, MD , Professor, Department of Psychiatry Mahatma Gandhi Medical College & Research Institute, Pondicherry, India Email: drprakashb@hotmail.com Page 14

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Yoga in Health Care

Ananda Balayogi Bhavanani * ABSTRACT: We are today faced with numerous debilitating chronic illnesses related to aging, environment, and hedonistic lifestyle, such as cancer, diabetes, osteoporosis, and cardiovascular diseases as well as many incurable diseases such as AIDS. Modern medical advancements provide the rationale for the integration of various traditional healing techniques including Yoga to promote healing, health, and longevity. It is imperative that advances in medicine include the wholistic approach of Yoga to face the current challenges in health care. The antiquity of Yoga must be united with the innovations of modern medicine to improve quality of life throughout the world. While modern medicine has a lot to offer humankind in its treatment and management of acute illness, accidents and communicable diseases, Yoga has a lot to offer in terms of preventive, promotive and rehabilitative methods in addition to many management methods to tackle modern illnesses. While modern science looks outward for the cause of all ills, the Yogi searches the depth of his own self. This two way search can lead us to many answers for the troubles that plague modern man. It is suggested that a two way integration of the experimentally tempered modern science with the experientially modelled science of Yoga can lead us to many answers for challenges plaguing modern humankind such as debilitating chronic illnesses related to aging, environment, and hedonistic lifestyle. Modern medical advancements provide the rationale for the integration of various traditional healing techniques including Yoga to promote healing, health, and longevity. It is imperative that advances in medicine include the wholistic approach of Yoga to face the current challenges in health care. The antiquity of Yoga must be united with the innovations of modern medicine to improve quality of life throughout the world. INTRODUCTION:

Yoga is the original mind-body medicine that has enabled individuals to attain and maintain sukha sthanam, a dynamic sense of physical, mental and spiritual well being. Bhagavad-Gita defines Yoga as samatvam meaning thereby that Yoga is equanimity at all levels, a state wherein physical homeostasis and mental equanimity occur in a balanced and healthy harmony. Yogamaharishi Dr Swami Gitananda Giri Guru Maharaj, the visionary founder of Ananda Ashram at the International Centre for Yoga Education and Research (ICYER) in Pondicherry and one of the foremost authorities on Yoga in the past century, has explained the concept of Yoga Chikitsa (Yoga as a therapy) in the following lucid manner. “Yoga Chikitsa is virtually as old as Yoga itself, indeed, the ‘return of mind that feels separated from the Universe in which it exists’ represents the first Yoga therapy. Yoga Chikitsa could be termed as “man’s first attempt at unitive understanding of mind-emotions-physical distress and is the oldest wholistic concept and therapy in the world.” To achieve this Yogic integration at all levels of our being, it is essential that we take into consideration the all encompassing multi dimensional aspects of Yoga that include the following: a healthy life nourishing diet, a healthy and natural environment, a wholistic lifestyle, adequate bodywork through Asanas, Mudras and Kriyas, invigorating breath work through the use of Pranayama and the production of a healthy thought process through the higher practices of Jnana Yoga and Raja Yoga.

PSYCHOSOMATIC DISORDERS:

From the Yogic viewpoint of disease it can be seen that psychosomatic, stress related disorders appear to progress through four distinct phases. These can be understood as follows: 1. Psychic Phase: This phase is marked by mild but persistent psychological and behavioural symptoms of stress like irritability, disturbed sleep and other minor symptoms. This phase can be correlated with vijnanamaya and manomaya koshas. Yoga as a mind body therapy is very effective in this phase. 2. Psychosomatic Phase: If the stress continues there is an increase in symptoms, along with the appearance of generalized physiological symptoms such as occasional hypertension and tremors. This phase can be correlated with manomaya and pranamaya koshas. Yoga as a mind body therapy is very effective in this phase. 3. Somatic Phase: This phase is marked by disturbed function of organs, particularly the target, or involved organ. * Yogacharya Dr.Ananda Balayogi Bhavanani , Hon Advisor CYTER, MGMCRI

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At this stage one begins to identify the diseased state. This phase can be correlated with pranamaya and annamaya koshas. Yoga as a therapy is less effective in this phase and may need to be used in conjunction with other methods of treatment. 4. Organic Phase: This phase is marked by full manifestation of the diseased state, with pathological changes such as an ulcerated stomach or chronic hypertension, becoming manifest in their totality with their resultant complications. This phase can be correlated with the annamaya kosha as the disease has become fixed in the physical body. Yoga as a therapy has a palliative and quality of life improving effect in this phase. It also has positive emotional and psychological effects even in terminal and end of life situations.

POTENTIALITIES OF YOGA:

Extensive research on Yoga being done all over the world has shown promise with regard to various disorders and diseases that seem to be amiable to Yoga therapy (www.iayt.org, www.icyer.com, www.svyasa.org ). These include psychosomatic, stress disorders such as bronchial asthma, diabetes mellitus, hypertension, irritable bowel syndrome, gastro intestinal ulcer diseases, atherosclerosis, seizure disorder and headache. It also includes physical disorders such as heart disease, lung disease, and mental retardation. Psychiatric disorders such as anxiety disorders, obsessive-compulsive disorder, depression and substance abuse can also be managed along with other therapies. Musculoskeletal disorders such as lumbago, spondylosis, sciatica and carpel tunnel syndrome can be tackled effectively with Yoga practices that offer a lot of hope in metabolic disorders such as thyroid and other endocrine disorders, immune disorders, obesity and the modern metabolic syndrome. According to Dr B Ramamurthy, eminent neurosurgeon, Yoga practice re-orients the functional hierarchy of the entire nervous system. He has noted that Yoga not only benefits the nervous system but also the cardiovascular, respiratory, digestive, endocrine systems in addition to bringing about general biochemistry changes in the yoga practitioners. Dr. Dean Ornish, the eminent American doctor who has shown that Yogic lifestyle can reverse heart isease says, “Yoga is a system of perfect tools for achieving union as well as healing”. Dr Swami Gitananda Giri says, “Yoga is scientific and many of it practices can be measured by existing scientific methods. As a science of mind it offers a safe method of concentration and meditation educing a practical application of the power of the human mind. Its entire process is centered in awareness that is why I call it the science of awareness.” It is well established that stress weakens our immune system. Scientific research in recent times has showed that the physiological, psychological and biochemical effects of Yoga are of an anti-stress nature. Mechanisms postulated included the restoration of autonomic balance as well as an improvement in restorative, regenerative and rehabilitative capacities of the individual. A healthy inner sense of wellbeing produced by a life of Yoga percolates down through the different levels of our existence from the higher to the lower producing health and wellbeing of a holistic nature. Streeter

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et al (Med Hypotheses 2012;78: 571-9) recently proposed a theory to explain the benefits of Yoga practices in diverse, frequently comorbid medical conditions based on the concept that Yoga practices reduce allostatic load in stress response systems such that optimal homeostasis is restored. According to the theory proposed by Streeter and colleagues, the decreased parasympathetic nervous system and GABAergic activity that underlies stress-related disorders can be corrected by Yoga practices resulting in amelioration of disease symptoms. HRV testing has a great role to play in our understanding intrinsic mechanisms behind such potential effects of Yoga. Innes et al had earlier (J Am Board Fam Pract 2005; 18: 491-519) also postulated two interconnected pathways (given below) by which Yoga reduces the risk of cardiovascular diseases through parasympathetic (vagal) activation coupled with reductions in per4ceived stress and decreased reactivity of sympathoadrenal system and HPA axis. Innes and Vincent (eCAM 2007; 4: 469-86) also postulated similar mechanisms to be operating in reducing risk for Type 2 Diabetes mellitus (DM 2) and for complications related to DM 2.

PSYCHOSOMATIC MECHANISMS OF YOGA:

Yoga understands the influence of the mind on the body as well as that of the body on the mind. This is the principle of adhi-vyadhi elucidated in the Yoga Vasishta more than 5000 years ago! It is interesting that modern medicine has only realised this connection in the last hundred years whereas Yogic of India were teaching and practising it for thousands of years. No wonder Yoga may be considered as the original mind-body medicine. We are what we think, yet we also start to think that which we do. Yogic concepts and techniques enable the development of right attitudes towards life and enable us to correct the numerous internal and external imbalances we suffer due to our wrong lifestyle/ genetic potential. Yoga enables us to take responsibility for our own health and happiness and as Swami Gitananda Giri would say, “If you want to be healthy do healthy things, if you want to be happy do happy things�.

The following are just a few of the mechanisms through which Yoga can be said to work as an integrated mind-body medicine: 1. Cleanses the accumulated toxins through various shuddi kriyas and generates a sense of relaxed lightness through jathis and vyayama type activities. Free flow in all bodily passages prevents the many infections that may occur when pathogens stagnate therein. 2. Adoption of a Yogic lifestyle with proper nourishing diet, creates positive antioxidant enhancement thus neutralizing free radicals while enabling a rejuvenative storehouse of nutrients packed with life energy to work on anabolic, reparative and healing processes . 3. Steadies the entire body through different physical postures held in a steady and comfortable manner without strain. Physical balance and a sense of ease with oneself enhance mental / emotional balance and enable all physiological processes to occur in a healthy manner. 4. Improves control over autonomic respiratory mechanisms though breathing patterns that generate energy and enhance emotional stability. The mind and emotions are related to our breathing pattern and rate and hence the slowing down of the breathing process influences autonomic functioning, metabolic processes as well as emotional responses. 5. Integrates body movements with the breath thus creating psychosomatic harmony. In Yoga the physical body is related to annamaya kosha (our anatomical existence) and the mind to manomaya kosha (our psychological existence). As the pranayama kosha (our physiological existence sustained by the energy of the breath) lies in between them, the breath is the key to psychosomatic harmony. 6. Focuses the mind positively on activities being done, thus enhancing energy flow and resultant healthy circulation to the different body parts and internal organs. Where the mind goes, there the prana flows! 7. Creates a calm internal environment through contemplative practices that in turn enable normalization of homeostatic mechanisms. Yoga is all about balance or samatvam at all levels of being. Mental balance produces physical balance and vice versa too. 8. Relaxes the body-emotion-mind complex through physical and mental techniques that enhance our pain threshold and coping ability in responding to external and internal stressors. This enhances the quality of life as seen in so many terminal cases where other therapies are not able to offer any solace. 9. Enhances self confidence and internal healing capacities through the cultivation of right attitudes towards life and moral-ethical living through yama-niyama and various Yogic psychological principles. Faith, self confidence and

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inner strength are most essential if at all we wish for healing, repair, rejuvenation and re-invigoration. 10. Yoga works towards restoration of normalcy in all systems of the human body with special emphasis on the psycho-neuro-immuno-endocrine axis. In addition to its preventive and restorative capabilities, Yoga also aims at promoting positive health that will help us to tide over health challenges that occur during our lifetime. This concept of positive health is one of Yoga’s unique contributions to modern healthcare as Yoga has both a preventive as well as promotive role in the healthcare of our masses. It is also inexpensive and can be used in tandem with other systems of medicine in an integrated manner to benefit patients.

INTEGRATING YOGA AND MODERN MEDICINE:

At first glance, allopathic medicine and Yoga may seem to be totally incompatible and in some ways even antagonistic to each other. Practitioners of either system are often found at loggerheads with one another in typical modern oneupmanship. However it is my humble endeavor as a student of both these life giving, life changing and life saving sciences, to find the similarities that exist between them and build a bridge between these two great sciences of today’s world. It would of course be much easier to build a bridge between Yoga and Ayurveda as both share many similarities of concepts such as the Trigunas, Tridoshas, Chakras and Nadis. They also understand that a healthy balance between body, mind and soul leads to total health. Diet and behavior are given importance in both systems and the ultimate goal of both is the attainment of Moksha. Though modern medicine may not share all of these concepts with Yoga, it is to be seen that there are a great many ‘meeting points’ for the construction of a healthy bridge between them. Both modern medicine and Yoga understand the need for total health and even the Word Health Organization has recently added a new dimension to the modern understanding of health by including spiritual health in its definition of the “state of health’. Spiritual health is an important element of Yoga and now that even the WHO has come around to understanding this point of view, there is hope for a true unification of these two systems. Modern medicine has the ultimate aim and goal of producing a state of optimum physical and mental health thus ultimately leadings to the optimum well being of the individual. Yoga also aims at the attainment of mental and physical well being though the methodology does differ. While modern medicine has a lot to offer humankind in its treatment and management of acute illness, accidents and communicable diseases, Yoga has a lot to offer in terms of preventive, promotive and rehabilitative methods in addition to many management methods to tackle modern illnesses. While modern science looks outward for the cause of all ills, the Yogi searches the depth of his own self. This two way search can lead us to many answers for the troubles that plague modern man. The potential and manifest integration of Yoga and modern medical science can be discussed under different sub headings as follows:

PROMOTION OF POSITIVE HEALTH:

Yoga is an excellent tool of promotive health that can enrich modern medicine. The practice of Yoga leads to the efficient functioning of the body with homeostasis through improved functioning of the psycho-immuno-neuro-endocrine system. A balanced equilibrium between the sympathetic and parasympathetic wings of the autonomic nervous system leads to a dynamic state of health. Yogi Swatmarama in the Hathayoga Pradipika, one of the classical Yoga texts gives us the assurance, “One who tirelessly practises Yoga attains success irrespective of whether they are young, old decrepit, diseased or weak”. He gives us the guarantee that Yoga improves health of all alike and wards off disease, provided we properly abide by the proper rules and regulations (yuvaa vrddho ativriddho vaa vyaadhito durbalo pi vaa abhyaasaat siddhimaapnoti sarvayogeshvatandritah-Hathayoga Pradipika I:64). The World Health Organization (WHO) defines health as a state of complete physical, mental, and social well being and not merely absence of disease or infirmity. WHO has also in recent times suggested a fourth dimension of spiritual health but has fallen short of defining it without confusing it with religion. From a Yogic perspective it is heartening that the WHO definition gives importance to ‘well being’ that is a vital aspect of ‘being’ healthy as well as ‘feeling’ healthy. There is no use in a doctor telling patients that all their investigations are ‘normal’ when the patients themselves are not feeling ‘well’. This qualitative aspect of health is something that Yoga and Indian systems of medicine have considered important for thousands of years. The definition of asana given in the Yoga Sutra as sthira sukham implies this state of steady well being at all levels of existence (sthira sukham asanam- Yoga Darshan II:46). Patanjali also tells us that through the practice of asana we can attain a state that is beyond dualities leading to a calm and serene state of well being (tato dvandva anabhighata- Yoga Darshan II: 48). Yoga aims at enabling the individual to attain and maintain a dynamic sukha sthanam that may be defined as a dynamic sense of physical, mental and spiritual well being. The Bhagavad Gita defines Yoga as samatvam meaning thereby that Yoga is equanimity at all levels. (yogasthah kurukarmani sangam tyaktva dhananjaya siddiyasidhyoh samobutva samatvam yoga uchyate – Bhagavad Gita II: 48) This may be also understood as a perfect state of health wherein physical Page 18

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homeostasis and mental equanimity occur in a balanced and healthy harmony. One of the main lacunae of the WHO definition lies in the use of the term ‘state’ that implies health is something to be achieved ‘once and for all’ with no need for care about it thereafter! It is definitely not so. We need to keep working on our health with great vigour and dynamic enthusiasm for the entire span of our life. If health is to be understood as a ‘state’, then it must be understood as a dynamic state that varies from day-to-day and often from minute-to-minute! It is often actually more challenging to maintain this dynamic state of health than to even attain it in the first place. Ask any World No.1 sports champion and they will testify to this inherent truth that applies to sports as well as to life itself.

MANAGEMENT OF DISEASES AND DISORDERS:

Yoga doesn’t negate the use of drugs and other methods of modern medicine. Maharishi Patanjali in his Avatar as Charaka didn’t shy away from the need to use medicinal herbs as well as surgical methods when necessary for the benefit of the patient. The system of Ayurveda is more in tune with the Yogic views of healing in this regard but definitely the modern antibiotic treatment of infectious diseases as well as the emergency medical and trauma management techniques of modern medicine must be understood to be life-savers in times of need. No Yoga therapist in his or her right mind should try to treat an acute myocardial infarction or an unconscious accident victim by Yoga alone. A symbiotic relationship between the techniques of modern medicine and Yoga can help the patient more than a dogmatic refusal to see the ‘other side’. Yoga has a lot to offer in terms of psychosomatic disorders and in stress related disorders such as diabetes, asthma, irritable bowel syndrome, epilepsy, hypertension, back pain and other functional disorders. Yoga can help reduce and in some cases eliminate drug dosage and dependence in patients suffering from diabetes mellitus, hypertension, epilepsy, anxiety, bronchial asthma, constipation, dyspepsia, insomnia, arthritis, sinusitis and dermatological disorders. To quote Dr Steven F Brena, “Yoga is probably the most effective way to deal with various psychosomatic disabilities along the same, time-honored, lines of treatment that contemporary medicine has just rediscovered and tested. Asanas are probably the best tool to disrupt any learned patterns of wrong muscular efforts. Pranayama and Pratyahara are extremely efficient techniques to divert the individual’s attention from the objects of the outer environment, to increase every person’s energy potentials and ‘interiorize’ them, to achieve control of one’s inner functioning. Moreover, in restoring human unity, the Yoga discipline is always increasing awareness and understanding of ourselves, adjusting our emotions, expanding our intellect, and enabling us not only to function better in any given situation, but to perform as spiritual beings with universal values.” Yoga therapists must work in tandem with medical doctors when they are treating patients who have been on allopathic treatment. There are many instances where the patient stops medical treatment thinking that it no more necessary as they have started Yoga. This leads to many catastrophes that could be easily avoided by tandem consultations with a medical specialist. Similarly many modern doctors tend to tell the patient to take up Yoga or relaxation and forget to mention to the therapist what they actually want the patients to do. Most allopathic medications need to be tapered off in a progressive manner rather than being stopped suddenly. We often find this mistake in regard to corticosteroids as well as cardiac medications where sudden stoppage can be harmful. We must remember Plato’s words when he said, “The treatment of the part shouldn’t be attempted without a treatment of the entirety,” meaning that the treatment of the body without treating the mind and soul would be a useless waste of time.

REHABILITATION:

Yoga as a physical therapy has a lot to offer patients of physical and mental handicaps. Many of the practices of physiotherapy and other physical therapies have a lot in common with Yoga practices. Mentally challenged individuals can benefit by an improvement in their IQ as well as in learning to relate to themselves and others better. As their physiological functions improve with Yoga, the combination of Yoga and physical therapies can benefit such patients as well as those with learning disabilities. Musculoskeletal problems can be treated by the combination to improve function as well as range of movement, strength and endurance abilities. Balance and dexterity can also be improved by the combination therapy. The use of Yoga can help those recovering from accidents and physical traumas to get back on their feet faster and with better functional ability. An example of this was Dr Swami Gitananda Giri who managed to get back on his feet and function normally after a debilitating stay in a full body cast for more than six months. Swamiji used to say, “Modern medicine kept me alive, but Yoga gave me back my life as otherwise I may have been a cripple for life”. Yoga also has a lot to offer those suffering from drug and substance abuse in assisting them to get back to a normal life. Yoga helps develop their self-control and will power and also gives them a new philosophy of living. This is vital as otherwise they will lapse into their old negative habits.

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HEALTHY DIET:

This is a place that modern medicine and Yoga can help give a patient as well as normal person the proper wholistic values of a proper diet. Modern research shows us the benefits of the ‘break-down’ study of foods on the basis of their physical and chemical properties. This is important for the person to know how much of each constituent of food is to be taken in the proper quantity. Yoga can help a person to learn the right attitude towards food as well as understand concepts based on the Trigunas and Tridoshas for better health. Yoga teaches us that the cause of most disease is through under (Ajjeranatvam), over (Atijeeranatvam) or wrong (Kujeeranatvam) digestion. Yoga also teaches us about the approach to food, the types of food as well as the importance of timings and moderation in diet. A combination of the modern aspects of diet with a dose of Yogic thought can help us eat not only the right things but also in the right way and at the right time thus ensuing our good health and longevity. Yoga emphasizes the importance of not only eating the right type of food but also the right amount and with the right attitude. Importance of not eating alone, as well as preparation and serving of food with love are brought out in the Yogic scheme of right living. Guna (inherent nature) of food is taken into consideration to attain and maintain good health. Modern dietary science of diet can learn a lot from this ancient concept of classification of food according to inherent nature as it is a totally neglected aspect of modern diet. We are what we eat! The great Tamil poet-saint Tiruvalluvar offers sane advice on right eating when he says, “He who eats after the previous meal has been digested, needs not any medicine.” (marunthuena vaendaavaam yaakkaikku arundiyathu atrathu poatri unnin-Tirukkural 942). He also says that life in the body becomes a pleasure if we eat food to digestive measure (attraal alavuarinthu unga aghduudambu pettraan nedithu uikkum aaruTirukkural 943). He also invokes the Yogic concept of Mitahara by advising that “eating medium quantity of agreeable foods produces health and wellbeing” (maarupaaduillaatha undi marutthuunnin oorupaadu illai uyirkku -Tirukkural 943).

PSYCHOSOMATIC RELAXATION:

Most medical doctors understand that it is important to relax in order to get better. The problem is that, though the doctor tells the patient to relax, they don’t tell them how to do so and maybe in fact they don’t know the answer themselves in the first place. Hatha Yoga and Jnana Yoga Relaxation practices help relax the body, emotions and mind. Relaxation is a key element of any Yoga therapy regimen and must not be forgotten at any cost. Shavasana has been reported to help a lot in hypertensive patients and practices such as Savitri Pranayama, Chandra Pranayama, Kaya Kriya, Yoga Nidra, Anuloma Viloma Prakriyas and Marmanasthanam Kriya are also available to the person requiring this state of complete relaxation. It is important to remember that relaxation on its own is less effective than relaxation that follows active physical exertion.

COPING SKILLS:

Yoga has a lot to offer those who unable to cope with death and dying as well as those suffering from incurable diseases. The Yoga philosophy of living sees death as an inevitable aspect of life that cannot be wished away. Swami Gitananda Giri used to tell us that the whole of life is, but a preparation for the moment of death, so that we can leave the body in the right way. Those who are taking care of the dying as well as those taking care of patients of incurable diseases and major disabilities are under an extreme amount of stress and Yoga practice as well as its philosophy helps them gain the inner strength necessary to do their duty. Yoga can help break the vicious spiral of pain-drug dosage-pain and by doing so help reduce the drug dosage in patients suffering chronic pain. It has been reported that Yoga helps improve the quality of life in patients suffering from cancer and also helps them cope better with the effects of treatment. It relaxes them and helps them sleep better. As someone rightly said, “Yoga may not be able to always cure but it can surely help us to endure”.

REDUCING EXPENDITURE:

Modern medicine is often criticized for the cost involved in its methods of treatment. Yoga offers an inexpensive method of health that can be added to the medical armory when required. Yoga only requires the patient’s own effort and really doesn’t need any paraphernalia. Of course the modern Yoga industry would rather have us believe that we need tons of Yoga equipment to start Yoga, but they are awfully of the mark in this case. Reduction in drug dosage and avoidance of unnecessary surgeries in many cases can also help reduce the spiraling cost of Medicare.

HEALTHY AGING:

Aging is inevitable and Yoga can help us to age gracefully. Modern medicine tries to help retard aging and help

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people look better by costly surgical methods that are only an external covering over the underlying aging process. Healthy diet, regular exercise, avoidance of negative habits and cultivation of the positive habits and a healthy lifestyle can help us to age with dignity. Yoga can also help our ‘silver citizens’ retain their mental ability and prevent degenerative disorders such as Parkinson’s disease, Alzheimer’s and various other dementias. Physical accidents such as falls can be minimized and many an artificial hip, knee or shoulder replacement surgery can be avoided. My own revered fatherGuru Swami Gitananda Giri, Yogashri T Krishnamacharya, Sri Kannaiah Yogi, Swami Suddananda Bharathi, Sri Yogeshwarji, Sri Yogendraji, Sri pattabi Jois and Padma Bhushan BKS Iyengarji are but a few of the Yogis who have shown us that its is possible to grow old without losing any of the physical or mental faculties of youth.

PSYCHOTHERAPY:

In the field of psychotherapy and psychoanalysis we can find a lot of ancient Yogic concepts being reiterated time and again. Many modern psychotherapeutic concepts such as identification, projection, and transference are similar to concepts in Yoga psychology. Yoga psychology integrates diverse principles within a single body. CG Jung had a great interest in Yoga and the eastern thought and said, “Chakras represent a real effort to give a symbolic theory of the psyche”. His ‘Centre of Personality’ concept based on dream analysis is very similar to the Yogic concept of a central psychic or spiritual personality. He also correlated Chakras to the archetypes that abound in the collective unconscious. Yoga helps the psychotherapist in training self awareness, and in the self regulation of body, diet, breath, emotions, habit patterns, values, will unconscious pressures and drives. It also helps in relating to the archetypal processes and to a transient being. It offers an integrated method rather than one that is found in isolation in many different therapies. The theory of Kleshas is an excellent model for psychotherapy while emotional therapies of Yoga include Swadhyaya, Pranayama, Pratyahara, Dharana, Dhyana and Bhajans. Development of proper psychological attitudes is inculcated via the concepts of Vairagya, Chitta Prasadanam as well as Patanjali’s advise on adopting the attitudes of Maitri, Karuna, Mudita and Upekshanam towards the happy, the suffering, the good and the evil minded persons. Yoga also has a lot to offer in terms of spiritual therapies such as Swadhyaya, Satsangha, Bhajans and Yogic counseling. It is also interesting to note that both Yoga and psychoanalysis share common ground in understanding that symptoms of the disease are often willed by the patients. While all psycho analysists must undergo psychoanalysis themselves, it is taught in Yoga that one must first undergo a deep Sadhana, before attempting to guide others on the path. However while psychoanalysis searches the unconscious, Yoga attempts to understand and explore the super conscious.

LIFESTYLE CHANGES:

Yoga helps patients take their health in their own hands. They learn to make an effort and change their life style for the better so that their health can improve. Life style modification is the buzzword in modern medical circles and Yoga can play a vital role in this regard. Yogic diet, Asanas, Pranayamas, Mudras, Kriyas and relaxation are an important aspect of lifestyle modification. To live a healthy life it is important to do healthy things and follow a healthy lifestyle. The modern world is facing a pandemic of lifestyle disorders that require changes to be made consciously by individuals themselves. Yoga places great importance on a proper and healthy lifestyle whose main components are Achar (healthy activities on a regular basis), Vichar (right thoughts and attitude towards life), Ahar (healthy, nourishing diet) and Vihar (proper recreational activities to relax body and mind)

WOMEN’S HEALTH:

Women are the chosen ones blessed with the responsibility of the future of our human race. Healthy mothers give birth to healthy babies and a healthy start has a great future ahead. Yoga has a lot to contribute in combination with modern medicine to the health status of womankind. Puberty and menopause become easier transitions with the help of Yoga and many eminent Yoginis have said that they were not even aware of a single menopausal symptom as they went through this difficult period in a woman’s life. Similarly our young girls can vouch for the fact that their pubertal changes and menarche has been relatively smoother than their counterparts who don’t practice Yoga. The benefits of Yoga in terms of family planning are also an important aspect that needs further study, as they can be an effective part of the contraceptive armory. The risk of side effects is negated and the entire control restored to the individuals themselves. The Oli Mudras as practiced in the Gitananda Yoga tradition have great potential in this regard and also the Swara Yoga theories of conception have a lot of exciting possibilities. Once conception occurs, Yoga helps the young mother to be, to prepare herself physically and mentally for the upcoming childbirth. Yoga helps open the joints of the pelvis and hip as well as strengthen the abdominal muscles for childbirth. Later, simple Pranayamas and relaxation techniques help the new mother relax and enjoy the new experience of her life. Post partum introduction of simple practices along with

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breathing, relaxation and a lot of crawling helps her come back to normal earlier and this can be used in all maternity hospitals along with allopathic management. Yoga practices can also help reduce the drug dosage in medical problems that often complicate a normal pregnancy such as diabetes, asthma and hypertension.

RESEARCH:

The positive benefits of Yoga research are of vital significance and an understanding of how the various practices work in different conditions and in normal situations are of great value for both the science of Yoga as well as for the world of medicine. Yoga therapists can benefit a lot by a scientific understanding of Yoga postures and other techniques. This will bring about a rational approach to Yoga therapy rather than a haphazard application of individualistic knowledge. Under the department of AYUSH, Morarji Desai National Institute of Yoga has created advanced centers for Yoga in JIPMER, NIMHANS, AIIMS and DIPAS to promote all aspects of Yoga in these premier medical institutions of India. Various private institutions are running in our country and doing their best to propagate Yoga-Vidya. Yoga therapy is being used both in conjunction with modern medicine or alternative systems of medicine as well as on its own in various centers. Various conditions such as diabetes, hypertension, arthritis, mental depression, bronchial asthma etc have been found to be relieved by Yoga Therapy and centers such as ICYER at Ananda Ashram, sVYASA, Kaivalyadhama, The Yoga Institute and Krishnamacharya Yoga Mandiram are doing a great deal of work in this field. Though there is a lot of research on Yoga being done by medical doctors these days but it is important to remember Swami Gitananda Giri’s words when he said, “We must research Yoga and not the lack of Yoga”. Many studies are badly constructed and manya-time we find that the Yoga practices performed by the patients have no real relation to Yoga at all. The higher aspects of Yoga are still not in the ‘researchable’ realm of modern science.

NEED FOR COORDINATION:

The need of the modern age is to have an integrated approach towards therapy and to utilize Yoga therapy in coordination and collaboration with other systems of medicine such as Allopathy, Ayurveda, Siddha and Naturopathy. Physiotherapy and Chiropractic practices may be used with the Yoga if needed. Advice on diet and lifestyle is very important irrespective of the mode of therapy that is employed for a particular patient.

PRESENT SCENARIO:

The therapeutic potential of yoga has been recognized world over and studies have shown its beneficial effects in numerous psychosomatic disorders like diabetes, hypertension, asthma, arthritis and other chronic diseases that are a great burden on our health care delivery system. The International Association of Yoga Therapists in the USA (www. iayt.org) is doing a lot of work to make Yoga Therapy acceptable to the medical community worldwide. They have given details of hundreds of research studies done all of over the world with regard to yoga as a novel and adjunct therapy to be used along with modern medicine. In India Yoga Therapy is under Dept of AYUSH in Ministry of Health and Family Welfare and through its Morarji Desai National Institute of Yoga (www.yogamdniy.nic.in) five Advanced Centers for Yoga have been set up in our country. The Advanced Centre for Yoga Therapy, Education and Research (ACYTER), a collaborative venture between JIPMER and MDNIY is functioning since June 2008 and focusing primarily on the role of Yoga in the prevention and management of cardiovascular disorders and diabetes mellitus. More than 30,000 patients have benefited from the Yoga therapy consultations and practical sessions till date. The centre also aims to popularize the science of yoga among medical professionals (Yoga Vijnana 2008; 2: 71-78) and general public and has conducted workshops and awareness programmes to this effect. Central Council for Research in Yoga and Naturopathy in the Ministry of Health and Family Welfare (www. ccryn.org) funds research studies in Yoga and ran a National Programme on Yoga and Naturopathy in 2010-2011. Yoga therapists have been appointed under the NRHM programmes in government hospitals all over the country and most major private medical hospitals have established Yoga and Healthy Living Centers. Though there are many private hospitals hosting Healthy Lifestyle Centers for their patients, it is only in recent times that the Public Sector Hospitals have started such centers. AIIMS was one of the first centers to have such a unit (Indian J Physiol Pharmacol 2008; 52: 123-31) but today numerous units are functioning all over the country under the

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patronage of the Ministry of Health and Family Welfare, Government of India. The Centre for Yoga Therapy, Education and Research (CYTER) is running at MGMC&RI under the patronage of Sri Balaji Vidyapeeth and a scientifically sound Yoga therapy programme is running since 2010. Awareness programmes have been conducted for medical and paramedical personnel and more than 5000 patients have benefited till date and many studies under publication.

A WORD OF CAUTION:

A word of caution is also required. Though Yoga and Yoga therapy are very useful in bringing about a state of total health it is not a miracle cure for all problems. It needs a lot of discrimination on the part of both the therapist as well as the patient. It may not be useful in emergency conditions and there is a strong need to consult a qualified medical doctor where in doubt. Each patient is different and so the therapy has to be molded to suit the individual needs rather than relying on a specific therapy plan for patients suffering the same medical condition. A very true problem is that there is a different approach of the different schools of Yoga to the same condition. It is better to follow any one system that one is conversant with, rather than trying to mix systems in a “Yogic Cocktail’. One must also be vigilant as there is a strong presence of numerous quacks pretending to be Yoga therapists and this leads to a bad name for Yoga therapy as well as Yoga in general.

CONCLUSION:

The art and science of Yoga has infinite possibilities for providing answers to most health problems troubling modern humankind. However we often misunderstand this science and want it to be a miracle pill. A pill that we take only once, and want all the problems to vanish into thin air! Yoga is a wholistic science and must be learnt and practiced with a holistic view. The dedicated practice of Yoga as a way of life is no doubt a panacea for problems related to psychosomatic, stress related physical, emotional and mental disorders and helps us regain our birthright of health and happiness. It is only when we are healthy and happy that we can fulfill our destiny. With the adoption of a proper attitude and lifestyle through the Yogic way of life, we can rise above our own circumstances and our life can blossom as a time of variety, creativity, and fulfillment. Yoga helps us regain the ease we had lost through dis-ease (as implied by sthira sukham asanam-PYS). It also produces mental equanimity (samatvam yoga uchyate-BG) where the opposites cease to affect (tato dwandwa anabhigatha-PYS). This enables us to move from a state of illness and disease to one of health and wellbeing that ultimate allows us to move from the lower animal nature to the higher human nature and finally the highest Divine Nature that is our birthright.

REFERENCES AND RECOMMENDED READING:

1.Ajaya Swami. Psychotherapy East and West. Himalayan institute, Pennsylvania, USA 1983. 2.Anand BK. Yoga and Medical Sciences. Souvenir: Seminar on Yoga, science and man. Central council for re search in Indian Medicine and Homeopathy. New Delhi. 1976. 3.Anantharaman TR. Ancient Yoga and Modern Science. Mushiram Manoharlal Publishers Pvt Ltd, New Delhi. 1996 4.Anantharaman TR. Yoga as Science. Souvenir: Seminar on Yoga, science and man. Central council for research in Indian Medicine and Homeopathy. New Delhi. 1976. 5.Back issues of International Journal of Yoga Therapy. Journal of the International Association of Yoga Therapists, USA. www.iayt.org 6.Back issues of Yoga Life, Monthly Journal of ICYER at Ananda Ashram, Pondicherry. www.icyer.com 7.Back issues of Yoga Mimamsa. Journal of Kaivalyadhama, Lonavla, Maharashtra. 8.Bhatt GP. The Forceful Yoga (being the translation of the Hathayoga Pradipika, Gheranda Samhita and Siva Samhita). Translated into English by Pancham Sinh, Rai Bahadur Srisa Chandra Vasu. Mothilal Banarsidas Publishers Pvt Ltd, Delhi. 2004. 9.Bhavanani AB, Ramanathan M, Harichandrakumar K T. Immediate effect of mukha bhastrika (a bellows type pranayama) on reaction time in mentally challenged adolescents. Indian J Physiol Pharmacol 2012; 56 : 174–180 10.Bhavanani AB. Concepts of Health in Dravidian Yogic Treatises. Open Access Scientific Reports 2012; 1: 123. doi:10.4172/scientificreports.123 11.Bhavanani AB. Don’t Put Yoga in a Small Box: The Challenges of Scientifically Studying Yoga. International Journal Of Yoga Therapy 2011; 21 ; 21. 12.Bhavanani AB. Understanding the Science of Yoga. SENSE, 2011, Vol. 1 (1), 334-344 13.Bhavanani AB. Yoga as a therapy: A perspective. Yoga Mimamsa Vol. XLII (January 2011) No. 4 pp 235-241. 14.Bhavanani AB. A primer of Yoga theory. Dhivyananda Creations. Puducherry-13. (2008) 15.Bhavanani AB. A Yogic Approach to Stress. Dhivyananda Creations, Iyyanar Nagar, Pondicherry. (2ndedition) 2008.

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Ann. SBV, July - Dec, 2012 1(2) 16.Bhavanani AB. Yoga for health and healing. Dhivyananda Creations. Puducherry-13. (2008) 17.Bhavanani AB. Yoga Therapy Notes. Dhivyananda Creations, Iyyanar Nagar, Pondicherry. 2007 18.Brena Steven F. Yoga and medicine. Penguin Books Inc. USA. 1972. 19.Carlson LE et al. Mindfulness-based stress reduction in relation to quality of life, mood, symptoms of stress, and immune parameters in breast and prostate cancer outpatients. Psychosom Med. 2003 Jul-Aug; 65(4): 571-81. 20.Chidbhavananda Swami. The Bhagavad Gita. Ramakrishna Tapovanam, Trichy, 1984 21.Datey KK, Deshmukh SN, Dalvi CP, Vinekar SL. “Shavasana”: A yogic exercise in the management of hypertension’. Angiology 1969 ; 20: 325-333. 22.Feuerstein Georg. The Shambala Guide to Yoga. Shambala Publications Inc, Boston, Massachusetts, and USA.1996. 23.Gitananda Giri Swami and Meenakshi Devi Bhavanani (Ed). Bridging the gap between Yoga and science. Souvenir of the international conference on biomedical, literary and practical research in Yoga. ICYER, Pondicherry, India. July 25-28, 1991. 24.Gitananda Giri Swami. Yoga the art and science of awareness. Souvenir 1996; 4thInternational Yoga Festival, Govt of Pondicherry. 25.Gitananda Giri Swami. Yoga: Step-by-Step, Satya Press, Pondicherry, 1976. 26.Go VL and Champaneria MC. The new world of medicine: prospecting for health. Nippon Naika Gakkai Zasshi. 2002 Sep 20; 91 Suppl: 159-63. 27.Innes KE, Vincent HK. The Influence of Yoga-based programs on risk profiles in adults with type 2 diabetes mellitus: A systematic review. eCAM 2007; 4: 469-86. 28.Innes KE, Bourguignon C, Taylor AG. Risk indices associated with the insulin resistance syndrome, cardiovascular disease, and possible protection with Yoga: a systematic review. J Am Board Fam Pract 2005; 18: 491-519 29.Khalsa SBS. Yoga as a therapeutic intervention: a bibliometric analysis of published research studies. Indian J Physiol Pharmacol 2004; 48: 269-85. 30.Madanmohan, Rai UC, Balavittal V, Thombre DP, Swami Gitananda. Cardiorespiratory changes during savitri pranayama and shavasan. The Yoga Review 1983; 3: 25-34. 31.Madanmohan. Introducing Yoga to medical students: the JIPMER experience. Yoga Vijnana 2008; 2: 71-78. 32.Nagarathna R and Nagendra HR. Integrated approach of Yoga therapy for positive health. Swami Vivekananda Yoga Prakashana, Bangalore, India. 2001. 33.Ramamurthi B. Uphill all the way. Guardian press, Chennai. 2000. 34.Ramanathan Meena. Thiruvalluvar on Yogic Concepts. Aarogya Yogalayam, Venkateswara Nagar, Saram, Pondicherry-13.2007 35.Selvamurthy W, Sridharan K, Ray US, Tiwary RS, Hegde KS, Radhakrishan U et al. A new physical approach to control essential hypertension. Indian J Physiol Pharmacol 1998; 42: 205-13. 36.Sharma R, Gupta N, Bijlani RL. Effect of Yoga based lifestyle intervention on subjective well-being. Indian J Physiol Pharmacol 2008; 52: 123-31. 37.Streeter CC, Jensen JE, Perlmutter RM, Cabral HJ, Tian H, Terhune DB et al. Yoga asana sessions increase brain GABA levels: a pilot study. J Altern Complement Med 2007; 13: 419-26. 38.Swami Satyananda Saraswathi. Four Chapters on Freedom. Bihar School of Yoga, Munger, India. 1999 39.Vijayalakshmi P, danmohan, Bhavanani AB, Patil A, Kumar Babu P. Modulation of stress induced by iso metric handgrip test in hypertensive patients following yogic relaxation training. Indian J Physiol Pharmacol 2004; 48: 59-64 40.Yoga the Science of Holistic Living. Vivekananda Kendra Patrika. Vol. 17- 2. 1988.

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A Critical Appraisal of Current Status of Music in Health Care Thirumalachari Mythily *

Introduction

Music Medicine has developed into an active and comprehensive discipline. The international society for Music in Medicine, supports research and inquiry, bringing together researchers from around the world in major conferences. An increasing number of physicians have joined with research scientists and therapists to provide for a synthesis of thought and technique. The development of sensitive techniques to obtain information from functioning human brains noninvasively by brain scans also has been a factor. In short, Music Medicine has arrived even as it continues to expand.

Music as therapy belongs to INDIA

Our sacred motherland Bharata Varsha, India, possesses in abundance a rich heritage of Sanskrit Literature. It is the greatest treasure and the finest gift of our country. The Vedas constitute the earliest sacred literature (orally passed through generations). When I speak about the Vedas, my mind goes back to those periods in which history has no record, and listens from then on. Music when sung properly infatuates the universe in no time. Pleasant tone transferred good vibrations and good feelings, likewise good and correct music transfers pleasant mood and enhances the same. The subtle vibrations keeps the participants mesmerized for hours. The individual who underwent the therapeutic sessions experiences the unique feeling of trance; to this there is no difference in status, rich or poor male or female al are one. Basically, Indian Music is a combination of series of sounds some repetitive and conforming to a set pattern in a given scale, bound vertically by an octave and laterally by laya or rhythm. Analytically the notations of the system and the presence or absence `of the seven notes with some differential nuances of pitch and consequent creation of ragas or tunes make for uniqueness. The approach is most effective in familiarization of other music system. As for sound, it is scientifically proven that all things, animate and inanimate have a resonance. Sound is one of the dimensions of life and existence. It manifests through waves and vibrations and has positive and negative effects, when tolerable and intolerable respectively. Similarly musical sounds influence the lower and higher cerebral centers which comprise the seat of the all sensations, emotions and aesthetic feelings. Hence the emotional quality of music and its importance as a therapeutic aid has been explored. Music has the power to bring hope and comfort to people in challenging circumstances. All people / every one deserve to have great music in their lives. I feel the responsibility to provide & develop programs that respond to community need based on the organization’s mission and civic position.

Impact of music

Music has a transforming impact on people’s lives. Music is a primary force in the lives of individuals and their social environment. The recorded history of 1000 years reveal that across the cultures humans are interested in music, they make music, improvise music. Rhythm as a concept does a lot in the collective experience of individuals. The cognitive neuro science of music studies the mechanisms involved in the basic understanding of music. Music is having several components- like rhythm, melody, pitch, timber, tone and singing, improvising, listening, playing the instruments, comprehending the music’s microtones and differences in pitch, variations in timber and many aspects of

*

* Dr. Thirumalachari Mythily PhD, DSc., Cognitive Neuro Psychologist, HOD Music Therapy. Apollo Hospitals, Chennai. Annals of SBV

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music making. Musical aesthetics, musical emotion are part of the individual involvement and experiences in the areas of music. When listening the mellifluous music ( selected for therapeutic purposes) for more than 22 minutes the brain produces a level of Gamma waves those linked to consciousness, attention, learning and memory. The neuro science literature registers this information as unique in this field of research. Music activates and shapes the human brain. It is sharpening the mind’s ability to hear/ listen and interpret speech and music. It encodes the memory and polishes the emotion and refines the behavior. Music has biological base in human life/ brain.

Music & the Brain

Resonant frequencies, Plannum Temporale which in the left side of the brain within the Wernicke’s area Music in Health care, in making music as a health care requirement of human power. Research specific areas and special conditions 1. Pain, stress, anxiety, 2. Gerontology,- cognitive aspects of all learnt materials/ motorlearning, 3. Parkinson’s - Music with exercises and physical movement 4. Alzheimer’s- dementia- music with regular mental rehearsals in the new route of the previous learning, recitations of numbers and its related activities in the musical background, music aided memory rehearsals, previously learnt materials rehearsed with the support of music/instrumental 5.Oncology 6. Mental Health, 7.Rehabilitation—substance abuse, 8.Veterans 9. End of life

In the Pediatric Care Pregnancy—During pregnancy every action of the mother observed by the fetus.…! From the first trimester onwards mother to be , listens the specified therapeutic music given to them in a prescribed pattern everyday at a given time regularly. Benefits- fetus sticks to the timings, gives extra kicks to the mother if music has not been presented on time, if the mother does not able to listen the music at an appointed time every day. This gives the concept that fetus develops a sense of discipline even in womb. On account of this regular exposure to therapeutic music the pre frontal lobe functions of the child gets enhanced. The ability to be with the music persists with the baby for 84 months after the delivery. During this period if you initiate the baby in any one of the aesthetic activities pertaining to right hemisphere, the child learns ahead of the schedule by four weeks. Number works planning cognition, depth perception, craft, music, dance computer software programming like actions are comes to child easily when compared to other children who does not have the exposure to therapeutic music in the womb. Labor – on account of exposure to music during pregnancy, it ensures smooth and easy delivery, further it shortens the labor time provided other conditions and parameters for normal delivery are in line. On account of this it shortened the hospital stay. It helped to create optimal conditions for the course of pregnancy and heightened pain sensitivity threshold by means of improving the functional, hormonal and psycho emotional conditions of pregnant and lying- in women. Thus the labor process became more natural, the delivery non traumatic and motherhood more happy and safe too. Neonatal intensive care, premature infants, music therapy helps to gain the required weight to get discharged with adequate weight. Learning & developments- in the education side of the progress, helps to learn clearly on account of the training in music . Autism, Music as a therapeutic medium helps to modify the behavior and learn appropriate behavior needed for the everyday activities. Adolescent problems,- the period of storm and stress can be tackled effectively with music as a therapeutic aid and help to modify the behavior. It works as a morale booster in their quest for identification problems.

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Many of the Pediatric illnesses along with music as a therapeutic medium helps the parents as well the children to get in line with the treatment. Music Therapy Types of music therapy, implementation, utilization‌ Opportunities in music & health care 1 Nature of interaction, 2 Access, 3.Dose and duration, 4. Type of music/ type of people 5 Research – source of knowledge, reliability, limitations 6. New technologies/ depending on machines/ software and possibilities. The therapeutic Music in its classical format, in both the segment of the medical field , along with medication does enormous good and yeomen service to medical fraternity. The healthcare-patient interface has witnessed enormous changes ever since the care of the sick saw progressive evolution from being a healing art to a committed pursuit, a consulting profession and advanced into what is recognized as

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Spirituality and well being Achariya Shruthi Chaitanya * Blend of science and art

How do I a seeker in spirituality and you all medical people meet. Both our professions share a peculiarity that sets us apart from all others. All other activities in the world are either a science or an art – either something to be studied intellectually and retained in memory or a skill to be practiced with subtle inherent talents. In medicine and spirituality, knowledge is essential, no doubt, but it also has to be practiced according to the demands of the situation. In medicine as well as spirituality there is a blend of art and science. As medical people you are scientists, but as individuals you help to remove the pains and sorrows of others. You need to make contact with the suffering, which is an art. Also in such a way that in the midst of the sorrowful or suffering around me, I don’t loose my joy or balance. In spirituality as a seeker, I need to study the science of religion for years. This study is to be strengthened by the art of practice. I need to move in society serving all, and derive joy through my contact with people and beings around. If this art is not there, I would move in the world an erudite scholar, a great person of words, but may actually live a life of sensuality and passion without any joy within nor spreading peace around me.

Spirituality as a way of life

Spirituality is not portraying something as a god, residing beyond the clouds, or an experience after death, but a way of life here and now, in the present moment. When spirituality is adopted as a way of life, it brings about certain adjustments in our intellectual attitudes, emotional equilibrium and physical relationships with the world outside that is concomitant with healthy living. How should I as a doctor do my work? Guruji, present head of Chinmaya mission worldwide has said ‘Our place of practice (Hospital or clinic) is our temple. Patients are God. Treating them is our worship. Self Actualisation is our reward.’ If an individual’s only goal is to get the maximum money with minimum effort, then his mind will also think along crooked lines – printing counterfeit money, corruption, pick pocketing. But, one who has a noble idea – ‘I must do something great for my country,’ or before I die I must give more to the world than the world has given to me – will have more creative thoughts and his actions will also reflect it. His endeavours will naturally be geared towards a more noble way of living. Whatever profession I may belong to, the beauty of one’s activities will depend upon the quality of thoughts entertained which in turn are determined by the nature of the ideal in the mind. If my goal is merely to satisfy my biological urges, then in what way am I different from the four-legged ones? Its head, heart, belly and all the rest are in one line. But as man head is on top, then the heart, then the belly, followed by the rest. Clearly mans glory is to live up to his intellectual convictions. Emotional and intellectual satisfaction takes precedence over the demands of the belly. To live thus is being spiritual. Today everyone wants minimum work and maximum profit! Consider a family’s condition if all its members want to do the minimum, but take the maximum! Spirituality pushes man to imitate nature. In nature emphasis is on giving than taking. Sun pours out energy. Never has it asked for dividend or share in our profits. The rivers, ocean, wind, air, sky, the trees, plants, animals everyone of them unintelligent though they may be, give in abundance. Nature’s law seems to be: Give, Give, give. It is only the intelligent man who wants everybody else to give, except himself. Only a person who produces more and gives back to the world more than he takes wins our respect.

*

* Achariya Shruthi Chaitanya, Chinmaya Mission, Puducherry

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See all your patients as God. We only treat. Nature or God cures. Dr. Lakshmi from Hyderabad approached Pujya Gurudev and said ‘ Swamiji how can I practice spirituality amidst my busy schedule. She was a Government Doctor having a private practice too and also a family to take care with siblings. Gurudev said When a patient enters, say narayana. After you listen and you are to write the prescription say narayana. Give it to him saying narayana. What You as doctors and me as seeker of God have in common is our dedication. If you want to have the privilege and joy of serving the world outside, you will have to sacrifice your own personal comforts and dedicate our efforts for the well being of others. Now medicine has become a profession and a lucrative one! Unfortunately, the main consideration now is how much money can be made out of it. The first few stanzas of the Ayurvedic Sastras instruct the physician to accept whatever is given by the patient out of gratitude as prasada from the lord. He is advised to live with the bare minimum and experience the joy of serving others and reducing their sorrows. There is no place here for the joy of hoarding wealth! For that, one can go and conduct business in big city, which is the place to make money. The purpose of this sacred profession is to relieve the pain of others and gather the wealth of the inner joy of fulfillment. Attitude towards illness at empirical level: All diseases inflict pain, and therefore they are disliked by everybody. But they do come at any age and at any time. The body is called the hutment of diseases. How should they be regarded? Though they are painful, one must understand that they are not enemies. In fact, they are our well-wishers. This is difficult to accept. Any disease does not come suddenly. Generally there are some symptoms prior to its manifestation. When there is some kind of impurity in the body, it always throws up some symptoms. But we get agitated by these. It is said that symptoms warn us that something serious is coming up. Human beings are peculiar. We set up an alarm but when it rings, we get irritated and shut it off. The body too, rings an alarm but we do not pay attention to it. Instead we get angry or worried. What should we do when symptoms are detected? From the worldly standpoint discarding any kind of worry, fear or dislike, we should become alert and go to a doctor and ask about the problem and its remedy. And after knowing the remedy, we must follow the prescription with extreme patience. A patient must have great patience. In Mahabharata yaksha asks yudhisthira what is the greatest gain? Yudhishtra answers enjoying good health is the greatest gain. In English also there is a saying, ‘health is wealth’. To gain wealth people lose their health and then to regain health lose a lot of wealth! So good health is important. If you are not well you will not enjoy even a comedy show. Attitude towards medicine People love to eat good food and indulgence in eating causes diseases. What is there to be surprised then, when they hate the medicine which is beneficial to them and cures them. In ayurveda, it is said that patients should look upon medicine as the mother. Just as the mother is a well wisher, so is the medicine. It will cure you. From Dharmic view point: Dharma sastra gives another viewpoint. It says, the sins committed in earlier lives manifest in the form of diseases. As I go through the disease my sins are being washed off. I should be happy that they are gone. This is a positive approach with regard to disease. Follow the prescription faithfully and do not complain. Go through it. The disease is a very auspicious thing. It is releasing me from my sins. It is not a cause of sorrow. This entire vision should be from our own standpoint – how to look at our own disease, without worries and anxieties. As far as others are concerned, we must make all efforts to relieve their pain. from the spiritual standpoint: Surrender to Lord: When you are in the hospital, you must surrender to the doctor who knows best what is needed for your treatment. The all benevolent Lord has placed us here, in this world for curing us. Whatever we may get in our small intelligence we may not know the reason for the pain or tear or joy that we experience. He knows the reason. The manufacturer of Ford cars will know how to get the car out of its problems when it coughs and stops. Lord knows the Annals of SBV

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reason for our existence and the purpose behind our coughs and he knows how to get us out too. ‘I leave all care with Him above whose love for me is endless and true’ Attitude of acceptance: Quote “ What I get is His gift to Me. What I do with what I get is my gift to Him.“ Lets do our best with whatever equipments we have however they may be. The great Lord is our creator, a master artist. Do the colour or brush or the paintings ever quarrel with the painter? An attitude of acceptance saying – “Whatever you do, O Lord, who am I to quarrel with Thee? Does a picture ever quarrel with the painter?” goes a long way in bringing well being within. Ask how and not Why? Arthur Ashe, the legendary Wimbledon player was dying of Cancer. From world over, he received letters from his fans, one of which conveyed : “Why does GOD have to select you for such a bad disease”? To this Arthur Ashe replied: “The world over -- 5 crore children start playing tennis, 50 lakh learn to play tennis, 5 lakh learn professional tennis, 50,000 come to the circuit, 5000 reach the grand slam, 50 reach Wimbledon, 4 to semi final, 2 to the finals, When I was holding a cup I never asked GOD “Why me?”. And today in pain I should not be asking GOD “Why me?”. Instead of asking why me? Lets ask how me and act towards recovery. Let us fill our hearts with gratitude for the gifts we have received from the Lord. See what we have, instead of seeing what we don’t have. For a person who gifts me a wrist watch, I offer so many thanks. Lets take time to tell our gratitude to the one who gave us the wrist to wear the watch. give up identification and attachment to the body, rise above the worries and abosorb the mind in the Lord who is one’s own Self, because the ultimate physician is Lord. Someone asked a mahatma who was suffering from a painful disease, ‘what did you do when the pain was unbearable?’ The mahatma replied that at such times he went into Samadhi. He meditated. Ramakrishna paramahamsa had throat cancer. He could barely talk to the visitors. Swami Vivekananda persuaded him to pray to mother to give him some relief so that he could eat and drink something. On his insistence Ramakrishna prayed once. And mother’s reply was, ‘are you not eating through other peoples’s mouths?’ this is rising above the affliction. Diseases are the best way for practice of spirituality - to check how much attachment they have for the body. Even spiritual people come to doctors to solve their problems. Such is the noble work of doctors.

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Efficiency and Effectiveness in Emergency Room Services Moses Kirubairaj * An efficient emergency department is a well planned and structured organization that provides seamless round the clock service to people at their most desperate situations. An effective emergency department is where this efficiency is made productive without the quality being compromised and patient safety being ensured. It is my pleasure to represent the Emergency Department of Christian Medical College, Vellore and to share our department’s journey over last 20 years to make it effective and efficient. The metamorphism of a chaotic casualty into a academic, largest private sector emergency department has happen because of visionary planning, syncronised team work and an edge for details. The academic training, clinical research, public awareness programs, periodically revised SOP’s and quality improvement initiatives are some of the initiatives which have led to to the progressive improvement of our department. Innovation of user friendly cost effective equipments, development of locally relevant guidelines, and pioneering in indigenous diseases treatment have helped us in continuing to be effective over the years. The need to provide seamless emergency care across boundaries like poverty, poor infrastructure, poor pre-hospital care, lack of awareness and poor political will is enormous, but there is hope improvement with commitment, attention to details and innovation.

* * Dr. Moses Kirubairaj , Emergeny Physician CMC, Vellore Annals of SBV

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Ethics in clinical trials. S Balakrishnan * India has a well written ethical guidelines for clinical trials in human beings drafted by the Indian Council of Medical Research’s (ICMR). Still, many trials violate the ICMR ethical guidelines for biomedical research and the World Medical Association (WMA) Declaration of Helsinki: Ethical principles for medical research involving human subjects. The Drugs Controller General of India (DCGI) does not require placebo-controlled trials before granting a drug marketing approval. However, the DCGI does not ban the use of placebo-controlled trials. The ruling on whether a trial design violates ethical principles is left to individual local ethics committees. A trial refused permission by an ethics committee at one trial site may be submitted to another and approved. According to the journal articles reporting these trials, they were conducted after receiving clearance from the local ethics committees. The existing regulatory apparatus therefore permits unethical trials of no benefit to Indians. There is no evidence that government policy permitting such unethical trials will change in the future; on the contrary, the government priority is, apparently, to ensure that clinical research in India produces good quality data according to Good Clinical Practice standards. Ethical guidelines – including its own ethical guidelines – seem to be of secondary importance.

* * Dr. Balakrishnan S, Pondicherry Institute of Medical Sciences, Pondicherry Page 32

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Assisted Reproductive technology - Adverse outcomes associated with multipleconceptions and multiple births Assisted Reproductive technology - Adverse outcomes associated with multipleconceptions and multiple births

Mirudhubashini Govindarajan *

Assisted reproductive technology is associated with a 10-30 fold increase in multiple pregnancy rates as compared to the rate of multiple pregnancies in spontaneously conceived pregnancies (>30% vs 1-3% in general population). It is the single most common adverse outcome of assisted reproductive technologies. Dizygosity (or higher zygosity) results from multiple embryo transfer. However, monozygotic twinning can also occur. Studies have documented monozygotic twinning with in vitro fertilization and embryo manipulation. Assisted hatching and extended culture to blastocyst stage are contributory factors. The increased risk for multiple pregnancies is higher for all stages of pregnancy and neonatal period. These include miscarriage, gestational diabetes, pre eclampsia, impaired fetal growth, stillbirth problems during labor including intrapartum hypoxia and increased need for elective and emergency caesarian sections. Most significantly twin pregnancy carried a 5-6 fold increase in preterm birth. These in turn leads to a prolonged NICU care, mental and physical handicap including cerebral palsy, mental disability, learning difficulties and chronic lung disease. Multifetal birth accounts for 17% of all preterm births (>37 weeks), 23% of early preterm births (>32 weeks), 24% of all low birth weight infants (<2500 gms) and 26% of very low birth weight infants (<1500 gms) Transferring two embryos can limit the occurrence of triplets in younger women who have good prognosis without significantly decreasing the overall pregnancy rate. The American Society for Reproductive Medicine and Society for Reproductive Technology have developed updated recommendations on number of embryos per transfer to reduce the risk of multiple gestations. The multiple gestation risk of ART unlike superovulation can be effectively managed by by limiting the number of embryos transferred. When considering how to minimize multiple gestations, ART can be viewed as safer and more favorable approach compared to superovulation. At present the vast majority of multiple pregnancies secondary to ART are the result of replacing multiple embryos. Multiple pregnancies are indeed perceived as an ideal outcome by many parents. Adequate counseling regarding the risks may go far towards changing this scenario.

* * Prof. Mirudhubashini Govindarajan FRCS (Canada) , Director, Womens Center, Coimbatore Annals of SBV

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Setting Clinical Data Standards and Data Portability Nrip Nihalani *

As consumerism catches up with healthcare the demand for best processes which are technology enabled becomes apparent. Within the last 50 yearsthe biomedical industry has advanced far enough to improve the reliability of healthcare provision. Information systems are making important contributions towards the creation of a safer industry through improving access to information, reducing reliance on memory, increasing vigilance, and contributing to standardization of processes The need for information sharing between different healthcare entities is now critical. Data sharing can be a bottleneck, starting fromissues with incompatible systems when getting the data from an external institution to unstructured data not being meaningfully used for population studies. The need for interoperable systems is evident in every part of the healthcare ecosystem. A patientâ&#x20AC;&#x2122;s data,structured as well as residual, at different times is used and modified by physicians, hospitals,laboratories, insurers and researchers. Interoperability requires the creation, acceptance, and implementation of clinical data standards to ensure that data in one part of the system is available and usable across a variety of clinical settings. A data standard depicts the required content and format in which particular types of data are to be presented and exchanged. These standards are merely rules which govern how patient information is sourced, electronically stored, mathematically processed and exchanged.

* * Mr.Nrip Nihalani, Director Product Management Plus 91 Technologiesnpvt.Ltd Page 34

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Tracking and Reporting of Adverse Events Bill Runciman *

Research by the RAND Organisation in the US has shown that American adults received “recommended care” for thirty common conditions, only 56% of the time in the years 1999 and 2000. We undertook a similar study within Australia, broadly based on the RAND study and showed that Australian adults received “appropriate” healthcare (“care based on evidence- or consensus-based guidelines”)at 57% of eligible healthcare encounters. While some healthcare providers achieved over 80% compliance with indicators, others achieved less than 25%. Also, although there was high compliance for some conditions, it was unacceptably low for many important indicators (for example, an average of 1% for risk management tools associated withdiabetes, community acquired pneumonia, stroke) and 5% for appropriate handling of hypertension with blood pressure ≥ 180/110. This is despite considerable efforts in safety and quality, and the dissemination of well documented national guidelines. The Cochrane collaboration showed that the use of structured care plans and feedback were both associated with improvements. However, reduction in variance by the use of structured plans is less likely without agreement on clinical standards. First we are embarking on a series of meetings to obtain national agreement on clinical standards for common conditions; less common conditions can be dealt with over time. Standards must be limited to conditions about which there is widespread agreement. (See box for our definition of “standards”). Second, we are developing “tools” (see box for definition of “tool”) with the appropriate attributes to facilitate audit and feedback to allow their use for the credentialing of individual practitioners and the accreditation of services. Placing these tools in the hands of both healthcare providers and patients, by so structuring the provider- and patient-held electronic records so that they are easily accessed and used, will provide a common knowledge base and focus attention on the areas that require attention. Box Definitions for “clinical standard” and “clinical tool” • A clinical standard is an agreed healthcare process or outcome that should occur for a particular circumstance, symptom, sign or diagnosis (or a defined combination of these). • It should be evidence-based*, feasible to apply, easy to measure and produce a benefit or efficiency, at least at the population level. • If a standard can or should not be complied with, the reason/s should be briefly stated A clinical tool should: • Implicitly or explicitly incorporated in the standard • Provide a guide to facilitate compliance • Be easy to audit, preferably electronically *this includes Level 4 evidence (consensus)

* Prof. Bill Runciman, Professor of Patient Safety, University of South Australia President, Australian Patient Safety Foundation. Annals of SBV

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Is Robot Safe and legal? Narmada P.Gupta * Computer is entered in every walk of life and it looks impossible to wokk without computers, Similarly computeres has entered in the operation theatre. Computer transmits the surgeons hand movements in to patient through robotic arms in key hole surgery. The term robot was first coined by Karel capek in 1921 in his play Rossums Universal Robots. The robot word was derived from the Czech word “Robota” meaning “Industrial worker”. It has gained popularity through science fiction such as Blade Runner & Star Wars. A robot can be defined broadly as a mechanical device that is controlled using a computer system. The first medical specialities to use robots were neurosurgery and orthopaedics. Robotic systems were developed for neuronavigation, stereotactic localization, and robotic assistance. Neuro Mate is commercially available FDA approved device. In Orthopaedics, the Robodoc was developed for placement of prosthetic joints. Robots became popular in cardiac surgery for coronary bypass surgery. In general surgery, it is used in Bariatic surgery, in gynaecology, for reversal of tubal ligation, vault prolapsed, hysterectomy etc. The Food and Drug Administration (FDA) cleared the da Vinci Surgical System in 2000 for adult and pediatric use in urologic, general surgical, gyneacologic procedures, general non-cardiovascular thoracoscopic surgical procedures and thoracoscopically assisted cardiotomy procedures

The da Vinci surgical system

The da Vinci surgical system consists of a surgeon’s computer console for surgeon interaction, a surgical cart that houses the video and lighting equipment, and a robotic tower that supports three or four arms. The surgeon’s console provides the user a three-dimensional view through a binocular viewport. Interaction is through “masters” in to which surgeon inserts his or her hands. The masters allow free movement that is translated intuitively in to seven degrees of freedom at the robotic instruments tips. A double lens laparoscopic system is combined in to a single three dimensional binocular view. The robotic tower supports three or four robotic with one arm controlling the camera. Endowrist instruments come in a wide range including graspers, scissors, hook, knives, hot scissors and surgical energy devices. The master slave system has advantages of an ergonomic environment for performing surgery for the surgeon. Surgeon can make natural hand movements rather than counter intuitive movements. It filters hand tremors and scale movements, by digitizing surgeon’s hand movements. The robotic arms provide additional degree of freedom inside the patient’s body. It provides 3-D view of the surgical field & improves depth perception. With the seven degree of freedom at the instrument tips and 3-D view, suturing becomes much simpler in comparison to laparoscopic surgery. The port placement is important in robotic surgery to avoid robotic arm collisions. The robotic arms are heavy and there should be a minimum gap of 8 cms between the ports. The camera port and other robotic ports should be in triangulation for easy suturing. There is lack of tactile sensation in robotic surgery which is compensated by magnification and visuals. The Patient’s advantage of robotic surgery is that it is a minimally invasive procedure with less morbidity, shorter hospital stay and early return to work. The disadvantage of robotic surgery is the initial cost of equipment and cost of reusable robotic instruments. At present, the usage is limited to only 10 per instrument. As a result, cost of the surgery is more compared to open and conventional laparoscopy. As any new procedure, there is a learning curve in the robotic surgery also, however in comparison to laparoscopic surgery; there is a shorter learning curve for the complex urological procedures. The duration of surgery is same as for open surgery and initially may longer during the learning period. The comparative trials are going on to find out the efficacy and effectiveness of robotic surgery in comparison to open and laparoscopic surgery. At present, there are no training facilities in India where as dry and wet animal lab facilities for training in robotic surgery are desirable.

*

* Dr. Narmada P.Gupta, Chairman, Academic and Research, Urology Medanta- The Medicity Gurgaon, Delhi NCR Email:narmadagupta@gmail.com Page 36

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There are 2,341 da Vinci速 System are installed as of 6/30/12. There are 1,707 in United States, 389 Europe, 245 Rest of World. Approximately 360,000 da Vinci速 procedures were performed in 2011, up 29% from 2010. About 150 system are installed in Asia and 21 systems in India. The 1st system in India in 2002 in a cardiac set up and in urology at AIIMS in 2006. After that , there was slow progress and during last year, most of the systems were installed. In Urology at AIIMS, 487 procedures were done till March 2010 and in Medanta medicity hospital, 412 procedures done in urology during the last 2 years. During all these procedures, we have seen minor errors of the robotic system which were correctable during the procedure. We have to convert to open/laparoscopic surgery in 2 cases only. For all the advanced features the da Vinci system offers, it is surprisingly reliable. In various studies, device failure resulted in case conversion, procedure abortion, and surgeon handicap in 0, 0.5%, and 0.4% of procedures, respectively. As such, a lowered device FR of 0.5% should be used when counseling patients undergoing robotic surgery. To avoid futile general anesthesia, a policy should be enforced to ensure that the da Vinci system is completely set up before the patient enters the operating room. No major complications are reported in the literature due to robotic system. The over all complication rate of a procedure are less in robotic surgery in comparison to open surgery.

Conclusion

Robotic surgery is a significant advance in the realm of urologic surgery esp. for urogenital cancers and for reconstructive procedures. It is associated with ease in dissection, incision and suturing with less steep learning curve in comparison to laparoscopy. It provides all benefits of minimally invasive surgery. The development of Robotic surgery is slower in Asian countries due to high cost of the robotic system and instruments. Robotic surgery is practiced in few hospitals in Asia. After initial learning curve, outcome is equal. In comparison to open surgery, it has less complications. Robot surgery is safe and legal and is going to stay

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Safe Surgery Saves Lives – An Appraisal Of The Who Initiative N. Ananthakrishnan * Surgical procedures have the inherent capacity to cause unintended harm to the patient if performed without due care. It is the very nature of the specialty which by its invasiveness carries the risk of causing major or minor morbidity and sometimes even mortality. The factors which may contribute towards adverse effects during surgical procedures are: • Involvement of multiple personnel – Residents in wards ( who do the workup and pre-op orders) – Nurses in the wards( who are responsible for carrying out the pre-op orders) – Attenders (transport to and from the operating rooms) – OR – nurses, technicians, surgeons , anesthesiologists – Ancillary departments– Pathology and other laboratories which contribute to patient management • Frequent change of personnel contributes to the possibility of errors since everyone assumes that someone has carried out the required instructions and occasionally no one really has.

Magnitude of the problem:

It has been estimated that the global volume of surgery amounts to 187-281 million procedures annually or approximately 1 per 25 human beings (1). The rate of complications varies from 3-22% in different countries. Half of these contributions are considered to be preventable (2). Taking an average death rate of 0.5% due to these complications (although the death rate varies from 0.4-0.8% in developed countries and 5-10% in developing countries), over one million patients die annually directly due to the consequences of surgery (2).

It has been estimated that this represents 164 million DALY (Disability adjusted life years) or about 11% of the entire disease burden due to surgical causes (3). Gawande mentions that in USA alone, each American has approximately 7 operations in his life time. This amounts to 50 million operations per year and accounts for 150,000 deaths annually (2). There is, therefore, a crying need for attention to this matter and for steps which can reduce the potential harmful effects of surgery. Previous work: The major reason why errors occur in the process of surgical management is due primarily to two reasons, viz. the complexity of the task and the difficulty of remembering to carry out all necessary activities relying on memory alone. It has been mentioned that the levels of cognitive function are often compromised with increasing levels of stress and fatigue(4).It is a logical corollary of this realisation that having a checklist of things to do would contribute to avoiding errors. Several attempts have been made successfully in the past which have demonstrated that institution of checklists has improved the functioning of health care providers. Pronovost in Johns Hopkins in 2001 instituted a five item checklist to reduce the morbidity of placement of central lines. The items were i. Washing hands before the procedure

*

* Prof. N. Ananthakrishnan, Professor of Surgery MGMCRI, Pondicherry Page 38

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ii. Cleaning skin with an antiseptic iii. Using sterile drapes iv. Wearing masks / sterile gowns / gloves v. Placing sterile dressing on the wound after the procedure. These measures reduced the ten day infection rate from 11 to 0%. It was estimated that 43 infections and 8 deaths were prevented by this measure in just one hospital (5). Even for the lay public, simple measures to jog the memory have contributed significantly in reducing health care morbidity. Luby et al in an experiment in Karachi, Pakistan, insisted on washing hands with soap prior to i. Washing themselves ii. After defecation iii. Before handling an infant iv. Before eating v. Before serving others This simple measure reduced the incidence of diarrhea in children by 52%, pneumonia by 48% and impetigo by 35% (6). Offering incentives for improving care has been tried without much success. Lindenauer et al published the results of their study on the pay for performance scheme in the USA. Using changes in adherence to 10 individual and 4 composite measures of quality, they compared public reporting data of 207 pay for performance hospitals with 406 others who indulged only in public reporting of data. It was found that pay for performance resulted in improvement in only 2.6-4.1% over two years (7).

Risks in Surgery: There are four major risks in surgical procedures. These are: i. Infection ii. Bleeding iii. Anesthetic problems iv. Unexpected complications such as a. excess bleeding, b. un-expected pathology c. Retained surgical instruments, sponges etc. Any measure which seeks to reduce the complications of surgery must address these issues. In addition there are two very important aspects which are exceedingly significant. These are communication and team work.

Importance of communication and Team work:

Research reveals a pressing need to develop a better understanding of those social behaviors and cognitive skills that are needed by individual members of an operating tem to ensure safe and efficient surgical performance (8). Communication is acknowledged as a key component of team performance but in surgery, it is often assumed to be a desirable and inherent attribute rather than being regarded as an important and acquired clinical skill which may need to be applied with care (9). Lack of continuous communication between various healthcare personnel can result in actions which can have adversarial consequences as demonstrated by a study by Burda et al (2005). Review of case records in 79 patients showed discrepancies between surgery and anesthesiology preoperative medication histories in 73% of patients; a. 23% had different allergy information b. 56% had different preoperative medication and c. 43% had different doses of drugs In other studies it was shown at Johns Hopkins, that improved OR briefing resulted in decrease in wrong site Annals of SBV

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operations (11). At Toronto General Hospital, it was shown that getting teams to talk by use of a 21 item check list improves communication in the operating room. (12).The group had earlier shown that communication breaks occurs in approximately 30% of cases in the OR of which one third jeopardize patient safety (13). Mazocco et al the Sharp Health Center in California conducted a study using a standardized instrument to assess team behavior(14). They did a retrospective chart review to measure 30 day outcomes after adjusting for ASA scores. It was found that the odds of complications or death in operated patients increased if the following behaviors were exhibited less frequently • Information sharing during intra-op. phase • Briefing during handoff phase • Information sharing during handoff

The WHO Initiative:

It is in this background that the WHO initiated a move to make surgery safer. The following material is drawn from the WHO publication – “WHO Guidelines for Safe Surgery, 2009, Safe Surgery Saves Life” and is largely a summary of the same. The team was led by Atul Gawande of Harvard, University, USA. The findings of the team were published subsequently in the New England Journal of Medicine (15). The problems visualized by the team included the fact that surgical safety was a complex issue. Surgical safety was yet to be recognized as a significant public health problem, data was sparse, even existing safety practices were not uniformly applied and there was lack of resources. They felt that essentially there were three areas which required to be addressed. These were: – Prevention of SSI by • Hand washing • Appropriate use of antibiotics • Antiseptic skin preparation • Atraumatic wound care • Instrument decontamination and sterility – Establishing safety of Anesthesia by ensuring • Presence of a trained anesthetist • Anesthesia machine and medication safety checks • Pulse oximetry, heart rate monitoring • Blood Pressure monitoring • Temperature monitoring – Establishing safe surgical teams by • Improved communication • Ensuring correct patient site and procedure • Informed consent • Availability of all team members • Adequate team preparation and planning for the procedure • Confirmation of patient allergies The approach of the WHO team was to disseminate information on role and pattern of surgical morbidity and safety measures, define minimum set of uniform measures for surveillance, identify simple set of surgical safety standards by employing checklists and Testing / improving checklists by pilot study. Besides it was felt that the recommendations to ensure the above should be simple, widely applicable and measurable. The WHO team considered the following as their principal objectives: A. Objective I – operate on correct patient, correct site by a. Verification b. Marking c. Checking before surgery Page 40

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B. Objective II -Measures to reduce harm from anesthesia and protect from pain by attention to a. Equipments b. Gas supplies c. Monitoring d. Ancillary equipment and medication e. Instruments (supplies and standards C. Objective III – Recognize and effectively prepare for life threatening loss of airway or respiratory function by a. Airways assessment b. Airways management c. Aspiration of gastric contents D. Objective IV- Recognize and effectively prepare for risk of high blood loss by a. Considering probability of blood loss b. Preparing adequately c. Managing optimally E. Objective V – avoid inducing allergic / adverse drug reaction for which patient is known to be at significant risk F. Objective VI – consistently use methods known to reduce risk of Surgical site infection G. Objective VII – Prevent inadvertent retention of instruments and sponges in the surgical wound H. Objective VIII – Secure and accurately identify all surgical specimens I. Objective IX – Effectively communicate and exchange critical infection for the safe conduct of the operation using checklists to improve communication J. Objective X – Hospital and public health systems will establish routine surveillance of surgical capacity / volume / results. These should include considerations of a. No. of surgeons, anesthetists, nurses, para-medicals b. Infrastructure c. Economic considerations d. Positive incentives e. Negative incentives f. Case mix and risk adjustment Based on the success of checklists in earlier efforts in improving patient care, the team decided to adopt the checklist approach. A nineteen item checklist was finalized. It was so designed that it was “Do confirm type rather than a read do type”. It was in three parts to be completed in three steps, first before induction of anesthesia, second before the incision and the third before the patient leaves the OR on completion of the procedure. All the issues of concern mentioned earlier which contributed to lack of safety in the OR were addressed. The checklist is reproduced below: A. Before Induction of Anesthesia 1. Has the patient confirmed his / her identity, site, procedure an d consent? 2. Is the site marked? 3. Is the anesthesia machine and medication check complete? 4. Is the pulse oximeter on the patient and functioning? 5. Does the patient have a known allergy? 6. Difficult airway or aspiration risk? If yes, is equipment and assistance available? 7. Risk of blood loss - if >500ml or 7ml/kg in children, have two IV lines and central access and fluids been planned? Annals of SBV

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B. Before skin incision 8. Confirm team members have introduced themselves by name and role 9. Confirm the patients name, procedure and where the incision will be made 10. Has antibiotic prophylaxis been given within last 60 minutes? Anticipated critical events 11. To Surgeon a. What are the critical and non-routine steps b. How long will the case take c. What is the anticipated blood loss 12. To Anesthetist • Are there any patient specific concerns 13. To Nursing tem • Has sterility (including indicator results ) been confirmed • Are there equipment issues or any concerns 14. Is essential imaging displayed C. Before patient leaves the operating room Nurse verbally confirms 15. Name of the procedure 16. Completion of instrument, sponge and needle counts 17. Specimen labeling (read specimen labels aloud including patient’s name) 18. Were there are any equipment problems to be addressed? 19. To Surgeon, Anesthetist and Nurse: – What are the key concerns for recovery and management of this patient? Having finalized the checklist, the WHO team did a pilot study in eight hospitals which were geographically and economically disparate, so that they form a representative sample. Four of these hospitals were from high income countries and four from mid and low income countries. The hospitals chosen are shown below: Four High Income countries • UWMC (USA) • Toronto GH (Canada) • St Mary’s Hospital (London) • Auckland City Hospital (New Zealand) – Four Low / middle income countries • Philippines GH (Manila, Philippines) • Prince Hamza Hospital (Jordan) • St Stephen’s Hospital (Delhi, India) • St Francis Hospital (Tanzania) Basal statistics were collected from these hospitals over a three month period in spring, 2008. Following education and counseling of all involved health care personnel on the checklist, the checklist was implemented. The study extended over a six month period. There were a total of 3733 patients in the pre checklist period and 3955 patients after the checklist. Six outcome measures were used by direct observation to ensure that the checklists were being consistently applied. These outcome measures were • Objective evaluation and documentation of airway before anesthesia • Use of pulse oximetry at anesthesia • Presence of two IV catheters or a central line before incision when estimated blood loss> 500 ml. • Prophylactic antibiotics within one hour of surgery • Oral confirmation before incision of • Identity of patients • Operation site Page 42

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• Procedure to be performed • Sponge count at end • The mean values of improvement in these test measures is shown in following table which is a condensation of the original published by Haynes et al (15). Process measure

Before

After

p

Airway evaluation

64.0

77.2

<0.001

Pulse oximeter

93.6

96.8

<0.001

Venous access

58.1

63.2

0.32

Prophylactic Antibiotic

56.1

82.6

<0.001

Patient ID and site

54.4

92.3

<0.001

Sponge count

84.6

94.6

<0.001

All

34.2

56.7

<0.001

There had been significant improvement in all measures except for obtaining venous access in patients with estimated large volume blood loss. The parameters selected for assessment of improvement by institution of the checklist were a. Rate of surgical site infection b. Rate of unplanned return to the OR for complications c. Incidence of pneumonia d. Mortality rate and e. Complication rate. Significant improvement was seen at most of the sites regarding most of the parameters although the extent of improvement was different in different hospitals. The mean results are shown in the following table which is a condensation from the original as reproduced by Haynes et al (15). Parameter

Before (%)

After (%)

p

Surgical site infection

6.2

3.4

<0.001

Unplanned return to OR

2.4

1.8

=0.47

Pneumonia

1.1

1.3

=0.46

Death

1.5

0.8

=0.03

Any complications

11.0

7.0

<0.001

Although significant only for two parameters overall, a trend towards improvement in all parameters is evident. The only uncertainty of this study was whether the improvement was a true event or a Hawthorne effect due to observation. Annals of SBV

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It was also not a randomized control study. However, the feasibility of implementation of the checklist across hospitals in all countries was proved. Subsequently by 2009, more than 12 countries had enrolled in the program including 10% of all American Hospitals.

References 1. Weiser TG, Regenbogen SE, Thompson KD et al.An estimation of the global volume of surgery: a modeling strategy based on available data.Lancet 2008;372:139-44. 2. Gawande A. The checklist manifesto â&#x20AC;&#x201C; how to get things right.New Delhi,Penguin Books, 2009. 3. Debas HT, Gosselin R, McCord C et al.Surgery.In: Jamison DT, Breman JG, Measham AR, Alleyne G, Claeson M, Evans DB, Jha P, Mills A, Musgrove P, editors. Disease Control Priorities in Developing Countries. 2nd edition. Washington (DC): World Bank; 2006. Chapter 69. 4. Hales BM, Pronovost PJ.The checklist--a tool for error management and performance improvement.J Crit Care 2006;21:231-5. 5. PJ Pronovost. Needham D, Berenholtz S et al. An intervention to reduce catheter related blood stream infection in the ICU.New Eng j med 2006;355:2725-32 6. Luby SP, Agboatwalla M, Feikin DR et al. Effect of handwashingon child health: a randomized control trial.Lancet 2005;366:225-33. 7. Lindenauer PK, Remus D, Roman S et al. Public reporting and pay for performance in hospital quality improvement. N Engl J Med 2007;356:486-96 8. Youngson GW, Flin R. Patient safety in Surgery: non-technical aspects of safe surgical performance. 2010,4:4, http://www.pssjopunal. com/content/4/1/4 9. ElBardissi AW, Regenbogen SE, Greenberg CCet al Communicationpractices in four Harvard Surgical services: a surgical safety collaborative. Ann Surg 2009;250:861-5 10.Burda SA, Hobson D, Pronovost PJ. What is the patient really taking? Discrepancies between surgery and anesthesiology preoperative medication histories. QualSaf Health Care 2005;14:414-6. 11.Makary MA, Mukherjee A, Sexton JB et al Operating room briefings and wrong site surgery. J Am Coll Surg. 2007;204:236-43. 12.Lingard L, Espin S, Rubin B et al. Getting teams to talk: development and pilot implementation of a checklist topromote interprofessional communication in the OR. 13.QualSaf Health Care 2005; 14:340-6.Lingard L, Garwood S, Poenaru D. Tensions influencing operating room team function: does institutional context make a difference? Med Educ 2004; 38:691-9. 14.Mazzocco K, Petitti DB, Fong KTet al Surgical team behaviors and patient outcomes. Am J Surg 2009;197:678-85 15.Haynes AB, Weiser TG, Berry WR et al. A surgical safety checklist to reduce morbidity and mortality in a Global population. 16.N Engl J Med 2009;360:491-9.

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Central Venous Access and Ultrasound Abhiram Mallick *

Central venous access (CVA) is required for a number of indications including haemodynamic monitoring, intravenous drug delivery, renal replacement therapy, parenteral nutrition, cardiac pacemaker placement and fluid therapy. This has traditionally been done by puncturing a central vein using surface anatomical landmarks or passing a long catheter from a peripheral vein. An experienced operator can achieve a high success rate using the landmarks but failure rate has been reported to be as high as 35%. The CVA is associated with complications including arterial puncture, pneumothorax, nerve injury, and multiple unsuccessful attempts. The risks and consequences of these complications vary between different patient groups depending on patientâ&#x20AC;&#x2122;s anatomy (obesity, short neck and local scarring), the circumstances in which CVA is carried out (patient receiving mechanical ventilation or during emergencies such as cardiac arrest, and other co-morbidities (emphysema or coagulopathy). Ultrasound provides the operator with visualisation of the desired vein and surrounding anatomical structures before and during insertion. It also helps identifying the precise position of the vein, its anatomical variants and avoiding inadvertent arterial puncture. There are a number of RCT comparing the complications of CVA using ultrasound versus landmark technique. All meta-analyses suggested that ultrasound guidance was significantly better than the landmark method. The key benefits from the use of ultrasound included reduction in needle puncture time, increased overall success rate, reduction in carotid puncture, reduction in carotid haematoma, reduction in haemothorax, decreased pneumothorax and reduction in catheter-related infection. These findings suggested a compelling case for routine use of ultrasound to guide central venous access and it does lead to improved patient safety. The UK National Institute of Clinical Excellence in 2002 provided a technology appraisal recommending ultrasound for IJV cannulations. This appraisal was based on expert opinion. Now in 2012 ultrasound guidance has become standard of care for central venous access in the UK. Successful use of ultrasound requires adequately trained operators who are skilled in its use. Departments must invest money to purchase appropriate devices and training time for their staff. Ultrasound machine should be available in the operating theatre or in the ICU where most of central venous access is performed.

*

* Dr. Abhiram Mallick , Clinical Director for Critical care medicine. Leeds University Hospital, UK.

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What do patients expect when things go wrong? Ramkumar Raghupathy *

The Joint Commission on Accreditation of Healthcare Organization (JCAHO) requires that patients be informed about adverse events. “It is the right of patient to receive information about clinically relevant medical errors.” “Disclose information regarding the errors to the patient on a prompt, clear and honest manner”. How to do this tricky issue, the four step approach :Step 1 – Tell patient the truth – what happened in a plain language. Step 2 – Accept responsibility on your own and on behalf of the institution. Step 3 – Apologize Step 4 – Describe the next steps – (i) for the patient what to do and (ii) prevent these in future List of serious reportable events

1.SURGICAL EVENTS :-

A. Surgery performed on the wrong body part B. Surgery performed on the wrong patient C. Wrong surgical procedure performed on a patient D. Retention of a foreign object on a patient after surgery or other procedure E. Intra-operative or immediately post – operative death in a ASA Class 1 patient.

2.PRODUCT OR DEVICE EVENTS

A. Patient death or serious disability associated with the use of contaminated drugs, devices or biologics provided by the health care facility. B. Patient death or serious disability associated with the use or function of a device in a patient care, in which the device is used for functions other than as intended C. Patient death or serious disability associated with intravascular air embolism that occurs while being cared for in a health care facility.

3.PATIENT PROTECTION EVENTS

A. Infant discharged to the wrong person B. Patient death or serious disability associated with patient elopement (disappearance) for more than four hours. C. Patient suicide, or attempted suicide resulting in serious disability, while being cared for in a health care facility

4.CARE MANAGEMENT EVENTS

A. Patient death or serious disability associated with a medication error (e.g. errors involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation, or wrong route of administration. B. Patient death or serious disability associated with a hemolytic reaction due to the administration of ABOincompatible blood or blood products. C. Maternal death or serious disability associated with labour or delivery in a low-risk pregnancy while being cared for in a health care facility. D. Patient death or serious disability associated with hypoglycemia, the onset of which occurs while the patient is being cared for in a health care facility. E. Death or serious disability associated with failure to identify and treat hyperbilirubinimia in neonates.

*

* Dr. Ramkumar Raghupathy , Dean of G. Kuppuswamy Naidu Memorial Hospital , Coimbatore. Page 46

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F. Stage 3 or 4 pressure ulcers acquired after admission to a healthcare facility. G. Patient death or serious disability due to spinal manipulative therapy

5.ENVIRONMENTAL EVENTS

A. Patient death or serious disability associated with an electric shock while being cared for in a health care facility. B. Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains the wrong gas or is contaminated by toxic substances. C. Patient death or serious disability associated with a burn incurred from any source while being cared for in a health care facility. D. Patient death associated with a fall while being cared for in a health care facility. E. Patient death or serious disability associated with the use of restraints or bedrails while being cared for in a health care facility.

6.CRIMINAL EVENTS

A. Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed health care provider. B. Abduction of a patient of any age. C. Sexual assault on a patient within or on the grounds of the health care facility. D. Death or significant injury of a patient or staff member resulting from a physical assault (i.e. battery) that occurs within or on the grounds of the healthcare facility. Event means a discrete, auditable and clearly defined occurrence. Adverse describes a negative consequence of care that results in unintended injury or illness, which may or may not have been preventable. Adverse event range is -> extra day stay -> Missing a dose of medicine Unintended medical errors are a big threat to patient safety. Health Care errors resulting in patient harm are a leading cause of morbidity and mortality although there is no national reporting of such occurrences. WHO says – 1 in 10 hospitals has adverse event - 1 in 300 admissions has death In 1999, in USA,  44,000 to 98,000 per year die of medical errors. Indian statistics shows only a few in – AIIMS, New Delhi Rajiv Gandhi Institute of Med. Sciences, Karnataka CMC, Vellore  The Institute of Medicine (IOM) recommended that healthcare errors and adverse events be reported in a systematic manner. This systematic reporting to be shared with the other states and will be beneficial for the patient safety. These reports are generated electronically and issued quarterly and annually. Also, • Newsletters • Video and Teleconferencing • Regional and local conferences • Individual exchange • Patient Safety Net (PSN) • Online system for analysis  Automation  Intimation to concerned person  Root cause analysis  Lessons learned  Lessons applied On a similar basis, national institute of patient safety – by AIIMS was found a year ago. • HOW Annals of SBV

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• • • •

WHEN WHERE WHY WHAT

Negligence happened

• Mistake Call it what you want • Mishap The sacred relationship • Mischief Patient and Doctor crumbles In GKNM Hospital, we have Sentinel Events 23 and Near Miss Events – 40. These methodologies put in safety rounds in the hospital. Administrative Rounds for patient safety and quality. Finally, • Patient Compensatory System • Hallmark • Prompt recognition of medical injury and payment opportunity to recognize and learn from mistakes It is free from, • Blame game • Less defensive medicine • Cost effective • False security protection ‘Poka-Yoka’ is the Japanese term for mistake proofing to ensure mistake never happens again. “Human errors in healthcare is defined as Medical errors”. A medical error is a preventable adverse effect of care, whether or not it is evident or harmful to the patient. How to improve the patient safety? A new healthcare discipline emphasis the reporting, analysis and prevention of medical error leading to adverse healthcare events. There is a critical need for Healthcare Organisations to be now accountable for the safety and well being of the patients. Medical Error Reporting System [M E R S ] Changes in organizational culture, the involvement of key leaders, the education of providers, the establishment of Patient Safety Committees, the development and adoption of safe protocols and procedures, and the use of technology are all essential elements in hospital and healthcare facilities’ efforts to reduce medical errors and improve patient safety. A broad range of approaches follows, with special focus on strategies selected by AHRQ grantees as having special promise for efficacy and ease of implementation. These are called MERS Information First, Quality of care in hospitals is a legitimate concern for those inheritances in improving patient safety. Secondly, goals and aims of incident tracking and reporting is to provide a vehicle for hospitals to improve patient safety. I would like to conclude that all Doctors take Hippocrates Oath that we shall do only good for the patients. Never do harm to anyone. Hippocrates quoted [460 B.C.] “Primum non nocere” “First do no harm”

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Alternate Dispute Rednessal Mechanisons S.V. Jogga Rao *

in

Healthcare

Honest and transparent communication between Doctor and Patient in a given situation, many a time prevents onslaught of potential and impending litigation. Needless to add, a Doctor-Patient relationship premised on trust-deficit and lack of faith, in the event of any kind of adverse consequence, inevitably leads to Court litigation i.e., aggrieved patient dragging either Doctor or Hospital or both to the Court. Paradoxically, in our context, we experience both, with only one striking difference, namely, dwindling culture of the former and entrenching influence of the later. Consequently, Professional Indemnity Insurance has become the order of the day for almost all the Medical Practitioners, who construe it as a perfect safeguard. As a result, the unwritten norm acquires crucial significance, namely, stance of self-protection and corollary to non-disclosure. Meaning thereby, the communication between Doctor and Patient becomes almost extinct. * Advocate & Healthcare Consultant, Legalexcel. Formerly, Professor of Law, NLSIU, Bangalore and Dean and Professor of Law, RGSOIPL, IIT Kharagpur. More than two decades of experience in this regard, has only revealed that more or less 10-12% of cases resulted in Court/Forum’s awards against Doctors and Hospitals. This success in a way further strengthened the resolve that stance of self-protection indeed protecting the interests of Doctors and Hospitals. So is non-disclosure. This naturally led to further erosion of trust and faith in a Doctor-Patient relationship and cemented popular perception against medical practitioner and corporate healthcare or establishments. Hence, for an aggrieved Patient, Court litigation (Civil, Criminal or Consumer or Statutory Authority) is the only option. One may or may not succeed in getting redressed but surely will harass, shame and shun Medical Practitioners and Hospitals before media and public at large. In the process, the popular public mood has become insensitive to the fundamental nuances and underlying complexities of medical practice in general and health care delivery in particular. Similarly, Hospitals and Doctors caught in the web of revenue maximization which drives the spate of illegal and unethical elements in professional conduct which is responsible for health care delivery. It has become such a vicious whirlpool, everyone gets sucked into the same. Adverse consequence per se is construed on par with negligence and claim as to grievance redressal ensues. Likewise, Patient provides an opportunity for the establishment and the Doctor in a highly competitive environment. In the backdrop of this kind of matrix, thinking about ADR is not only challenging but also quite perplexing in nature. Considering our own context and more particularly etiological factors of unabated systemic failures, Justice delivery has received a severe blow and resultant erosion of public faith. Undoubtedly, ADR is no longer a matter of choice but a matter of inevitable necessity. In the broader contours of conflict resolution, ADR has much to offer and respond. However, the obtaining reality is not very encouraging. Much water needs to be flown. That doesn’t mean that effective initiative in this regard can’t be introduced in the realm of healthcare. Be that as it may, much deeper concern in this regard is, whether ADR can be invoked in cases of medical errors or medical negligence or professional misconduct or unethical conduct or culpable criminality? The ultimate challenge is whether ADR can serve as a positive and influencing force to improve medical care or not? Undeniably, ADR in healthcare deserves a meaningful attempt and purposeful push primarily, so as to revive honest and transparent disclosure and communication in a Doctor-Patient relationship. Similarly, genuine patient grievance redressal must be addressed outside the domain of Court rooms and in the presence of neutral mediators. By attempting to do so, apart from many other tangible benefits for everyone, ADR protects and promotes interests and relationships, which is the essence of our lives which we * lead and cherish! * Dr. S.V. Jogga Rao , Dean of G. Kuppuswamy Naidu Memorial Hospital , Coimbatore. Annals of SBV

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Patients for patient safety SeeteshGhose *

Background

Patient safety is the absence of preventable harm to a patient during the process of health care. The discipline of patient safety is the coordinated efforts to prevent harm, caused by the process of health care itself, from occurring to patients. The frequency and magnitude of avoidable adverse patient events was not well known until the 1990s, when multiple countries reported staggering numbers of patients harmed and killed by medical errors. Some of the most common and worrisome patient issues are wrong site surgery, medication errors, healthcare acquired infection, falls , readmissions and diagnostic error.Recognizing that healthcare errors impact 1 in every 10 patients around the world, the World Health Organization calls patient safety an endemic concern. Although human factors,system factors and equipment/infrastructure factors were considered issues in patient safety, patient as a stakeholder for his own safety was realized as late as1999. In October 2004 WHO launched World Alliance for Patient Safety in response to a World Health Assembly Resolution (2002) urging WHO and Member States to pay the closest possible attention to the problem of patient safety. Its establishment underlined the importance of patient safety as a global health-care issue. The goal was to develop standards for patient safety and assist UN member states to improve the safety of health care. The Alliance raises awareness and political commitment to improve the safety of care and facilitates the development of patient safety policy and practice in all WHO Member States.

Why “Patients for Patient Safety”

• Patientsandtheirattendantsseethingsthatbusyhealth-careprovidersoftendonot. • Offertherichestresourceofinformationrelatedtomedicalerrorsasmanyofthemhavewitnessedeverydetailofsystemsf ailuresfromthebeginningtilltheend. • Patientshavemuchmoretoofferthanmerereminderstohealth-careproviders,administratorsandpolicymakersthatw earevictimsoftragicmedicalerrors. • Thevoiceofpatientsandfamilieswhohavesufferedpreventablemedicalinjuryisapowerfulmotivationalforcefor health careproviderswhowish,first,todonoharm • Whenpatientsregisterconcerns,theyareoften perceivedasadversarialthreatsthatlackevidence,ratherthan potential knowledgecontributions. • Patientsandtheirfamilieshavegenuineadditionalneedsandwantswhenthingsactuallygowrong. • “PatientsforPatientSafety”emphasizesthecentralrolepatientsandconsumerscanplayineffortstoimprovethequalitya ndsafetyofhealthcare.

How to achieve“Patients for Patient Safety”

I. Education and Awareness Actions that need to be taken in individual hospitals and health systems include: • Establishing interactive, interdisciplinary education programs that bringtogether patients and professionals by targeting: a. The general public, including patients, families, media Explaining about • Definition and principles of patient safety • Frequency of medical error • How to safeguard your own care and partner with your providers • What to do if you experience a mistake or error b. Healthcare organizations and professionals Explaining about • Patient/family perspective is important and should be activelyintegrated into culture of institution. c. The behavioural health community, including counsellors andsocial workers

*

* Dr.SeeteshGhose,MD, Professor& Head, Department of Obstetrics and Gynaecology, MGMCRI,Pondicherry, Page 50

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Explaining about • Experience of medical error differs from other types of trauma —patients and families who experience harm due to a medical errormay need specific types of support and advocacy. II. Building A Culture of Patient and Family-Centered Patient Safety Meaningful change cannot take place without a fundamental change inthe culture of patient safety. The following actions are aimed at buildingpartnerships with patients and families. Actions that need to be taken by individual hospitals and organizations: • Teach and encourage effective communication skills for patients, theirfamilies and healthcare professionals • Train and utilize patient representatives for patient safety advocacy inhospitals and health systems • Implement Patient and Family Advisory Councils in each hospital andhealthcare organization • Incorporate patient and family representation on Boards of Trustees • Develop patient safety task forces and/or coalitions in each state III. Research Suggested areas of internal and external research: • “Bridging the Gap”: Effective methods for building relationships andcommunication between patients, caregivers, and providers. • Disclosure — Methods and their effects on patients and families. • Short- and long-term effects of integrating patients and families into thehealthcare system. • Review of current patient safety information and resources available forpatients and families, and their effectiveness. • Post-traumatic stress specific to medical error. • Team relationships (including patients and families) IV. Support Services There are three phases of medical error: preventing the error, preventingharm caused by the error, and mitigating the effects of a harmful error. Support services are needed to address this last category.  A national resource center and information line  A peer resource counselling program to connect patients who haveexperienced a medical error with trained individuals who have alreadybeen through the experience  National training programs  Individual organizations and local coalitions should provide:  Support groups  Disclosure and communications programs  A long-term goal in this area is:Emergency line

Organizations associated with “Patients for Patient Safety”

 Governmental organizations: - WHO [World Alliance for Patient Safety, Patients for Patient Safety (PfPS)], Aus and NZ [Therapeutic Goods Administration and Adverse Drug Reactions Advisory Committee, Australian Commission on Safety and Quality in Health Care, New Zealand Health Quality & Safety Commission],UK[National Patient Safety Agency, National Institute for Health and Clinical Excellence],USA[ Composition, Agency for Healthcare Research and Quality, Food and DrugAdministration].  Independent organizations:-Aus (Australian Patient Safety Foundation), Canada (Canadian Patient Safety Institute, Institute for Safe Medication Practices Canada) Germany(German Agency for Quality in Medicine, German Coalition for Patient Safety),UK (The Health Foundation),USA (American Society of Medication Safety Officers, National Quality ForumLeapfrog, Joint Commission on Accreditation of Healthcare Organizations , Pittsburgh Regional Health Initiative, National Patient Safety Foundation, United States Pharmacopeia, Institute for Safe Medication Practices ,Safe Care Campaign, TMIT, ECRI Institute, Institute for Safety in Office-Based Surgery,Clarity Group, Inc.)

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Functions ¾¾  ¾¾  ¾¾  ¾¾  ¾¾  ¾¾  ¾¾ 

Patient safety organizations may use several approaches to reduce adverse events Collect data on the prevalence and individual details of errors. Analyze sources of error by root cause analysis. Propose and disseminate methods for error prevention. Design and conduct pilot projects to study safety initiatives, including monitoring of results. Raise awareness and inform the public, health professionals, providers, purchasers and employers. Conduct fundraising and provide funding for research and safety projects Advocate for regulatory and legislative changes

Conclusion

Over the past ten years, patient safety has been increasingly recognized as an issue of global importance, but much work remains to be done. Patients’ perceptions with regard to Patient Safety have to be addressed.T he patients should be involved in making the hospitals safer places for them. There should be more opportunitiesofinteractionbetweenservic eproviders,patients,families,administratorsand policymakers. Systemshouldbedesignedwhichaddressgrievances/doubts/ suggestions.Awarenesslevelsaboutpatientsafetytobeenhancedbyprovidinginformationaboutpatientsafetyinthehealthorg anizationssuchthatitreachesthecommonman.

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Annals of SBV Sri Balaji Vidyapeeth

(D eemed

to be

U niversity , u / s 3, UGC A ct , 1956)


Annals 2012 (2)