Apr 14 2014

Should Patients be given access to physician notes

Nurse explaining to patient

Do patients need to have access to the notes made by doctors and nurses?

This promises to be controversial!!

Way back in 2011, a report was published, in The Annals of Internal Medicine.

Now, where we live and work, patient’s are NOT routinely given their investigation reports.

This is in the UAE, and I am a doctor practicing in the private sector. Many patients come to us, having undergone part of their treatment in the public sector hospitals, and they come without any papers – no investigation reports, no clinical notes – sometimes even without prescriptions!


Some of the time, they have lost the prescription paper, and all they have is a polythene bag full of medicines, which they dump unceremoniously – even accusingly on your desk – as if to say, “Your medicines don’t work!” even if I am not the doctor who made those prescriptions!


They have my full sympathy; I believe whatever tests are done in a clinic or hospital, they are the property of the patient and they have a right to have a copy of their own. In the hospitals where I have worked, this principle has always been applied.

Back in our home country, India – quite a few hospitals in the private sector also don’t hand – over these reports to the patients, ostensibly to ‘keep them safe’. But it is quite transparent that they do it so as not to lose a client!


But this article is on a different dimension now; this study is to identify what doctors and laymen (read patients’) feel about getting access to doctors’ and nurses’ notes!

Now this can be very controversial – for doctors, at least. Errors would not be hidden anymore! Lack of proper documentation cannot be kept a secret. The study finds that “..Overall, 69% to 81% of participating PCPs across the 3 sites and 92% to 97% of patients thought open visit notes were a good idea,…” Participating PCPs refers to those Primary Care Physicians who participated in a voluntary program where access to clinical notes was provided on an experimental basis.

The authors further quote: “…participating PCPs and patients generally agreed with statements about potential benefits of open visit notes…”, and that “…74% to 92% anticipated improved communication and patient education,…”


Among these doctors, 50% to 58% expected that open visit notes would result in greater worry among patients; far fewer patients concurred (12% to 16%).

In this study, more than half of the participating doctors anticipated more questioning by patients as a result of this openness, but few expected to be subjected to more lawsuits.


The authors concluded that the doctors varied widely in their opinions on the effect on the patients as a result of this kind of exposure to doctors notes, whereas most of the patients were far more enthusiastic about it – which is quite expected!


Here’s a LinkedIn Discussion on this topic, and there are some strong opinions there!


Some of the commenters are very enthusiastic about this, and have this to say:

John Stafford, Health and Wellness

“There is no question that patients should be able to access their own medical record except that the concept of a medical record is too limiting. It should be at least a health record (i.e. with notes of nurses and allied health professionals regardless of which health agency provided that care, radiological and pathological results and pharmaceuticals) and better still a wellness record where the patient can contribute their own data (e.g. home monitoring for diabetes or blood pressure) and also recording their weight, nutrition, physical activity, sleep and so on….”


Hille Meetsma, Healthy & Active Aging by VitalinQ, Your Personal Health Assistant, a Social Media for Your Health.

“In my opinion the individual person must be granted to have at least a copy of the medical data that is stored about him/her. The medical data also must kept stored to the ‘hospitals’ or what ever place for later use in case of an emergency or for scientific research.
Ownership means more ‘have the right to have a copy’ then ‘i decide what to do with it’.”


Dr Rajinder Kumar Bajoria
Dr Rajinder Kumar Bajoria, Surgeon cum Sonologist at Neera Nursing Home ,Karnal

“In my opinion there is no harm in providing the record to the patients or relatives ,it only improves quality and confidence”


In your opinion, how might access to visit notes improve patient care, or would this be confusing to patients and trying to physicians?


The study can be found here: http://annals.org/article.aspx?articleid=1033220


Mar 29 2014

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Mar 17 2014

Overcoming Negativity


This is a great quote from one of the greatest motivational speakers, Zig Ziglar.


As you can see, it attracted hundreds of comments and thousands of shares on Facebook.


Even a small sampling of the comments will tell you that there are varied responses; a majority, of course, agrees. A few dissenters, however, don’t think it is a good thing to leave ‘Negative People’ alone. In fact, their point of view is that we should involve these people in dialogue, help them overcome their negativity, and so on.

But the common theme is that there are ‘Positive People’ and then there are ‘Negative People’. It is “Us vs Them.”

Very few, in fact, seem to agree with me: people in this world are not divided into Negative and Positive people. We are ALL, without exception, BOTH positive and negative to varying degrees.


At times, we are VERY positive; especially when things are going in our favor or as per plan. Negativity surfaces when things go awry.
Some people lose their composure faster, at minor things; for others, it takes a lot to shake them.
But don’t you think that we are positive or negative depending on our circumstances – for a majority of our lifetime?
When the ups and the downs in our life become too much to bear, then a little wisdom percolates down. We realize that becoming negative in response to external events is taking a toll on our health and happiness.
A majority of old people like to say: “Don’t chase after material wealth so much; be contented with what you have.”
This is not such a bad advice when taken in the right spirit. The statement says ‘Don’t chase’, it doesn’t say ‘Don’t even try’. And being contented with what one has does not mean that one must not try to improve one’s life.
But to get back to the original quote: negativity comes into each of our lives when we are faced with an adverse situation, and here is where the value of contentment should be appreciated.
In fact, the word ‘Gratitude’ comes even closer to the value that I would inculcate. When the chips are down, remembering the things we are grateful for can help us overcome our negativity.
People who always appear negative, the so – called ‘Negative People’, are, in my humble opinion, those who have not learnt the value of gratitude and contentment. They hanker after things, and when they fail to get them, negativity surfaces.
So, to sum it all up:

  1. There are no ‘Negative People’, there is Negativity within people
  2. We all have some amounts of Negativity within ourselves
  3. Negativity within us surfaces when things go adversely
  4. A general habit of being positive and upbeat all the time will help us avoid negativity from surfacing
  5. One must practice GRATITUDE for things we have and the goodness in our life, regularly and diligently to maintain a positive frame of mind.
  6. Those around us who are afflicted by a lot of negativity within their minds – we cannot help them by criticizing them for it; we can only show them our positivity and attract them to it, and they will ultimately give up their bad habit.

Mar 12 2014

The doctor – patient relationship

The doctor - patient relationship should be a friendly one

The doctor – patient relationship should be a friendly one



As a doctor, I face this question on a daily basis:”Doc, we just found out my dad/mum/bro/sis/wife has this —- disease. How do we get cure for this problem?”

Over the years, I have realised that, irrespective of the underlying disease, three conditions have to be met for successful treatment.

Supposing you find out you have cancer; the first thing you must then do is to find out the address of a cancer specialist,  and visit him.

The next,  equally mandatory thing you must do is to listen to him and follow his directions.

But before all this can happen, the MOST crucial thing you MUST do – and here is where the vast majority falter – is to REALISE you have the condition, accept the diagnosis, and be motivated to get the appropriate treatment for the condition.

This is true, in fact, for every situation in our lives.
When we don’t accept that our conditions in life are not the way we want them to be, we are hardly likely to seek advice to improve it, or to listen to someone willing to help us improve it.

In my experience,  I have faced patients even with very serious illness and with very poor quality of life – yet they are not in the proper frame of mind to listen or accept advice.

For such people, I make sincere efforts to help them understand their situation; but this is not met with universal success. In that situation, I accept it as God’s decree and that person’s destiny.
I never give up on anybody; but I do take a step back to let the person evaluate his situation and come to terms with it.
I have found that is the only way you can let the person have his dignity, and preserve your’s, too. You can never convince anybody against his own sense of dignity.

Nov 23 2013

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Nov 22 2013

Cholesterol report – how to interpret it

Nov 20 2013

Cholesterol New Guidelines

Cholesterol has been at the center of much research for a long time – ever since it was identified that stroke and heart attacks result from a process happening in blood vessels called atherosclerosis.

What is Atherosclerosis?

Atherosclerosis simply means hardening of the blood vessel walls; what it entails is a progressive deposition of cholesterol in specific regions of the vessel wall with subsequent changes, all of which lead to formation of ‘plaques’ in the vessels walls. These plaques undergo further changes and can become unstable, rupture, and form clots or thrombus (plural, thrombi) on their surfaces.


Atherosclerotic plaque

Atherosclerotic plaque

What is Embolism?

The clots on the surfaces of these plaques can block the blood vessel or lead to “embolism” in which the clot breaks up into smaller pieces of “emboli”, and these smaller pieces then migrate along the blood stream. A shower of such emboli can lodge in a smaller blood vessel, blocking it, and leading to damage to the underlying tissue ( a kind of damage called ischemic infarct).



Prevention strategy

This whole process of cholesterol deposition to plaque formation to embolism may take many years – so the time course for prevention can also work over many years. Prevention strategies are also aimed at different levels.


People who have diabetes and high blood pressure are more prone to develop the negative consequences of high cholesterol levels in the blood. Uncontrolled diabetes is especially potent in increasing the risk of heart disease and stroke through this mechanism.

One strategy to reduce the risk of stroke or heart disease is to lower the levels of cholesterol in the blood. This is not such a straight – forward goal as it may be thought.


Cholesterol does not enter or leave the body so easily. In fact, Cholesterol is entirely synthesized in the body – inside the liver, in fact. It travels around in the blood stream using different vehicles, called lipoproteins. We know these as ‘good cholesterol’ which is HDL (or High Density Lipoprotein), ‘bad cholesterol’ , which is LDL (or Low Density Lipoprotein), and so on. What we absorb from the diet are in fact the fatty acids which are used to synthesize cholesterol.



LDL = Bad Cholesterol
HDL = Good Cholesterol


Beyond this, things in the Cholesterol World start getting murkier. Why isn’t it such a simple matter to reduce the cholesterol level in the blood? Why did a new Expert Panel have to come and change the guidelines and completely upset the apple cart?


Existing guidelines for lowering cholesterol

In the ATP III report, which published the existing guidelines for cholesterol control, lipid lowering was based on targets such as treat – to cholesterol target, lower cholesterol is better, and risk – based treatment approaches, etc. Over the last few decades, these guidelines spawned the use of many different drugs to lower cholesterol in people who were barely at risk for heart attack or stroke. If somebody had chest pain, bang, he had a Lipid profile done; if his LDL was over a 100 mg/dL, Bang! he was prescribed a statin. Even women in their thirties (pre-menopausal), who were always traditionally considered to be protected from heart disease were evaluated for heart disease.


It became fashionable for men and women in their twenties and thirties to undergo TMTs and Lipid Profile evaluations and for everyone to be on lipid lowering therapies. Based on the previous guidelines, an army of clinicians had broadened the scope of  the guidelines to included more and more patients from diverse ethnic backgrounds and with minimal risk factor profiling to be treated with lipid lowering drugs.

Industry – Driven

A large part of this was industry – driven. The result of this was that a majority of results seen in trials was not replicated in real life. The Expert Panel was therefore constituted to exclude certain levels of evidence not considered robust enough, and to frame new guidelines based on only the best evidence, which basically means Randomized Controlled Trials (RCTs).


RCTs are limited in number at the moment, owing to the fact that they are difficult to design and expensive to conduct. The new set of guidelines are not comprehensive, nor do they entirely replace the older set of guidelines.

So What’s new in the Guideline?

Here is a link to the pdf to the Full Guideline on Circulation

  • The Expert Panel recommended that Statins should be used in 4 identified “Benefit Groups” (see below)
  • They do not support specific LDL – Cholesterol treatment targets
  • They also do not support specific HDL – Cholesterol treatment targets
  • For the “Benefit Groups” Statin therapy should be used in appropriate intensity/dose
  • Non – statin therapy not recommended
  • They recommend a new Pooled Cohort Equation to estimate 10 year risk for heart disease or stroke

The 4 “Benefit Groups” identified by the Expert Panel are:

  1. Those with clinical Atherosclerotic Cardiovascular disease i. e., those who had a heart attack past or present, or unstable/stable angina, those having undergone a coronary revascularization procedure such as stenting or bypass, those who had a stroke or TIA, or those with peripheral vascular disease
  2. Those whose LDL – C levels are >= 190 mg/dL
  3. Diabetes aged 40 – 75 years, with LDL – C between 70 – 189 mg/dL even without clinical evidence of Atherosclerotic Cardiovascular Disease i.e., never had heart attack or stroke
  4. Those with an estimated risk of heart attack/stroke/peripheral vascular disease using the new Pooled Cohort Equation > 7.5% (even if they don’t have Diabetes and elevated LDL – C).

The factors considered in this Risk Estimator are: Gender, Age, Race, Total Cholesterol, HDL – C, Systolic BP, Treatment for BP, Diabetes, and (Whether or not a) Smoker.

Submit your information using the form below, and I will get back to you with your Heart Attack and Stroke Risk Estimation using the Pooled Cohort Equation created by the Expert Panel.


Name: *
E-mail: *
Gender: *
Age: *
Race: *
Total Cholesterol: *
HDL Cholesterol: *
Systolic Blood Pressure: *
Treatment for High Blood Pressure: *
Diabetes: *
Smoker: *
Word Verification:

I am working on getting this latest Pooled Cohort Equation online for my readers to use.

Nov 18 2013

Night Owls and Early Risers Have Different Brain Structures

See on Scoop.itNerve Health

Sleep and wake times are strongly influenced by genetics.

Dr Rajshekher‘s insight:

Are you a morning lark or a night owl? New research is beginning to show that night-owls are more prone to depression and white matter lesions (something euphemistically labelled as ‘decreased white matter integrity’); but they are also identified as people who are more productive, with greater analytical ability, have more stamina throughout the day, have greater reasoning abilities, and so on. I don’t know: with recent demands of business and work in my life, I have changed from a morning lark to a night lark/owl! Do you want to know what role genetics plays in this? Do you want to know how to override the infulence of genetics on our sleep pattern and on our circadian rhythms? Then this article is definitely for you!!

See on www.psychologytoday.com

Nov 18 2013

The Science Behind What Naps Do For Your Brain–And Why You Should Have One Today

See on Scoop.itNerve Health

Studies of napping have shown improvement in cognitive function creative thinking and memory performance. Ready set . . . snooze.

Dr Rajshekher‘s insight:

Do you take cat naps during the day? I do: it helps me improve my thinking, concentration and memory for the rest of the day, not to speak of behaviour, mood, and performance. Here is some scientific information to support your pet activity!

See on m.fastcompany.com

Nov 12 2013

A Story of our Times

Grand parents tell stories

Grand parents tell stories

Grandfather tells a story


During our summer holidays, I loved going to our grand – parents’ home in the hills. I especially enjoyed the evenings when our grand – father would tuck us in and regale us with a story. Some of them would be short, while others would go on for days. Many of them were later on adapted for TV serials – though I suspect it could have been the other way around. But the fun part of it was the way he told them; he would be totally absorbed, he would make animal noises, and change his voice to suit character, the mood and the moment. He had been an actor at one time, but then he got married; and you know what happens after that: somebody else takes over all the talking part.

How the story began

The story I am about to tell is one such, and was especially meaningful, because we had had an argument over arriving late for appointments. Grandpa had had a stint with the Army, which had made him a stickler for time all his life, as old – timers tend to be, and many of his stories centered around the importance of being on time. This one is a lot more than just that, but it started with that.

Getting late for the Doctor’s appointment


At the village fair - buying stuff

At the village fair – buying stuff


Games at the village fair

Games at the village fair

We had planned a visit to the village fair for a couple of hours before the scheduled appointment with the doctor. I learnt that day that village fairs cannot be planned affairs. That is, you can plan when you enter, but you cannot plan your exit time. We ended up spending rather more time and money than we intended, with the result that we were several hours late for the doctor’s appointment. Another thing: in villages, loud protestations will usually get you into the doctor’s room, but grandpa was really peeved by this behavior. This seemed to rankle in his mind even after dinner, because he was talking about it even at bed – time.

More games at the village fair

More games at the village fair

The Troubled King


Barren foothills of himalayas

Barren foothills of Himalayas


Living in hardship in the himalayas

Living in hardship in the Himalayas

It was story – telling time, so he started it in the same mood.”You know,” he began, “this reminds me of the story about this kingdom in the foothills of the Himalayas. The King was very benevolent and just, and most of the kingdom was peaceful and prosperous. But the region right at the foothills was not so very prosperous; the people living there were mostly tribes. The land was not very easy to cultivate, it was barren. The hills did not provide an easy living, and the people lived in hardship. There were many small tribes and they were in constant war and conflict. It was a big headache for the king, and he could do very little for their uplift. He worried about it night and day, and dearly wished some way could be found to improve the situation.

The Monk

“Now, in the foot-hills lived a mendicant, a detached soul. In all such stories, you will always find such characters – they provide you a contrast from the other characters who are either greedy, or jealous, or selfish, or cruel.”

The Raging River

“There, in the foot-hills, also was a river – not a very helpful river, I am afraid! It was in spate most years – during the monsoon, it flooded the region, and people lost their lives trying to swim across it. They could not save their crops due to the flooding. They dearly wanted a dam to be built, and a bridge over it; but the lack of peace in the region meant that such construction was not easily possible. It was at best a treacherous proposition.

Flooding river

Flooding river

To Build a Dam

“The King, hearing about the Monk, and learning he was well – respected, and hoping he would be the right person to find a way for the improvement of this region, summoned this mendicant, and asked him what could be done. The Monk spelled out the needs of the region – the dam and the bridge to be built, the cost and the resources that would be needed. The King instantly sanctioned everything. ‘What else?’ he asked of the Monk. ‘I will,’ said the Monk, ‘ speak to the leaders of that region and make sure they cooperate.’ In this way a plan was hatched for improvement of this region.

Crops damaged by floods

Crops damaged by floods

The Minister Arrives

“One day, a Minister arrived at the Monk’s hermitage. He was the King’s envoy, bringing with him the requisite gold and resources for constructing the dam and the bridge. He was, however, a day late; the Monk’s disciples informed him that after waiting for him till late evening, their Gurudev had left at night for the foothills, to attend another meeting – it was a secret meeting they knew nothing about, the only thing they knew was that he would be back the following day.

The Minister with his entourage

The Minister arrived with his entourage, but was late – Guruji had left

The Construction Begins

“The minister was very angry for not being received and for being made to wait. When the Monk returned, he fussed and fumed. He threatened to return without handing over the things the King had sent. Before the Monk could explain anything, he ordered his soldiers to put him in chains, and thereafter began construction of the bridge.


“Over the next few weeks, work started at a fast pace and the soldiers, who were well – trained, started building the dam. But soon they were faced with resistance. The warring tribes began sabotaging their work. They would find the work done in the morning undone by night. Their best engineers would be found dead with their throats slit. Some of their laborers were ambushed.

“The commander in charge of construction summoned the Minister, who panicked and informed the King. When the King heard the Monk had been put in chains, he rushed to the spot, freed him, begged him for his forgiveness, and asked him to explain everything.

Local Politics


“With folded hands, the Monk explained, ‘O King! On that day, when Mantriji came with his entourage, I was to meet the opposing war – lords of the major tribes in the region. They have been at war for centuries. A glimmer of hope was appearing at that time. The daughter of one is madly in love with the son of another. I was negotiating between them to join this young couple in wedlock. Should these two tribes unite through marriage, peace could reign in the Valley. To me, peace in the Valley through this marriage is far more important than the dam through your money; so which meeting was more important? When Mantriji got delayed, I had no choice but to let him be received by my disciples. But these chains didn’t allow me to complete the negotiations, and lead to the unfortunate events that followed.’

“Off With His Head”

“The King turned to the minister, trembling with rage, and for a few terrifying moments everyone thought that was the end of Mantriji. Gradually, the King controlled his breathing, and then said, ‘Mantriji, if I were to be as impatient and angry as you were, your head would roll on the ground. But as the just ruler of this kingdom, I give you one chance to undo what has happened here.’

All’s Well That Ends Well

“So the humbled Minister then set about to make peace between the warring tribes, and then with their help completed the construction of the dam and bridge over the river, which helped control it, preventing floods, bringing peace, harmony, and prosperity to the region.”

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