[Gansan]

Originally Posted by bblost

This is such an awesome thing to do.

Thank you. Nothing much and nothing financial. Their sons and daughters take care of that end. I just check on them (nowadays over phone only or from outside their door) and facilitate any special needs. Such as ordering groceries and medicines online, cash withdrawals etc.

[RSR]

A question to all the learned doctors on this forum.

Has anyone of you or any friend/colleague of yours moved to, or even tried an online/tele/virtual/e-consultation scenario during these pandemic times?

I mean, not the casual video call with a relative/friend to prescribe medicines, but an actual professional set-up for patients including consultation fee collection?

This mass-murdering coronavirus unleashed upon the entire world either deliberately or inadvertently or accidentally or as the result of an unfortunate natural occurrence from the People's Republic of China has changed our whole world and the way we interact with others completely. People are working from home (wherever they can), classes & lectures are moving online, sports are being played only in empty stadiums, product launches, meetings & conferences are taking place virtually and the popularity of things like online shopping has shot up tremendously.

I'm sure e-consultation has also become more popular now, as it's a safer option for both, doctors and their patients. Of course, not every doctor visit can be done virtually and not every specialist can move his/her consultation online, but I'm sure it can be done for at least half the consultant doctors out there.

Learned docs, if you have any experience with this, please share it here. Thanks!

[Zen2001]

Originally Posted by RSR

A question to all the learned doctors on this forum.

Has anyone of you or any friend/colleague of yours moved to, or even tried an online/tele/virtual/e-consultation scenario during these pandemic times?

I mean, not the casual video call with a relative/friend to prescribe medicines, but an actual professional set-up for patients including consultation fee collection?

This mass-murdering coronavirus unleashed upon the entire world either deliberately or inadvertently or accidentally or as the result of an unfortunate natural occurrence from the People's Republic of China has changed our whole world and the way we interact with others completely. People are working from home (wherever they can), classes & lectures are moving online, sports are being played only in empty stadiums, product launches, meetings & conferences are taking place virtually and the popularity of things like online shopping has shot up tremendously.

I'm sure e-consultation has also become more popular now, as it's a safer option for both, doctors and their patients. Of course, not every doctor visit can be done virtually and not every specialist can move his/her consultation online, but I'm sure it can be done for at least half the consultant doctors out there.

Learned docs, if you have any experience with this, please share it here. Thanks!

It's a big compromise. Medicine is not a complete science even in the hands of the best expert. Not being able to see the patient and examining him/her with their own eyes and hands is like trying to diagnose an engine problem looking at a video. Of course, doctors will be indemnified in case of anything going wrong purely based on the grounds of not being able to personally examine the patient, but is that what the patient wants it of all this?
Can the different types of breath sounds and soft heart murmurs be detected on a video call? Can I feel the extent of a cancer unless I touch the area in question? Can the patient tell me if something is fluctuant or transilluminant? Can a surgeon elicit rebound tenderness or percuss for ascites online? Can this get more ridiculous than it already is?
If only last year this very same govt passed a law barring doctors to prescribe medicines, even to their known patients regularly under their treatment over phone/whatsapp, (after having confirmed their diagnosis on clinical examination) how can it justify diagnosing and treating an unknown patient in the same way? Is this not hypocrisy?
I have been personally examining each of my patients (in the same way I usually would have, except for the added mask on my face) since March, and I can confidently say that no amount of photos, videos, reports can substitute a simple (in person) clinical examination. People who don't subscribe to this may be playing with their health in the bargain.

[RSR]

True! It's just impossible for certain kinds of doctors to do effective online consultation. Even with a medically aware and very co-operative patient, it may not work out well.

Times change, however, and technology rapidly improves with time. Imagine, just a decade-and-a-half ago, tele(phone)-consultation meant the patient and doctor could not even see each other! Going forward, I expect a lot of improvement in the field of tele-medicine, and the pandemic may have kind of accelerated that advancement.

Originally Posted by Zen2001

If only last year this very same govt passed a law barring doctors to prescribe medicines, even to their known patients regularly under their treatment over phone/whatsapp, (after having confirmed their diagnosis on clinical examination) how can it justify diagnosing and treating an unknown patient in the same way? Is this not hypocrisy?

Did they actually do that?

Then, its quite a U-turn by them after the Chinese coronavirus pandemic struck, for they were the ones who launched this National TeleConsultation Service:

https://esanjeevaniopd.in/

It looks simple enough, is completely free, has enough doctors on roll and by the looks of it, has become decently popular.

[DCEite]

Originally Posted by Zen2001

It's a big compromise. Medicine is not a complete science even in the hands of the best expert. Not being able to see the patient and examining him/her with their own eyes and hands is like trying to diagnose an engine problem looking at a video. Of course, doctors will be indemnified in case of anything going wrong purely based on the grounds of not being able to personally examine the patient, but is that what the patient wants it of all this?
Can the different types of breath sounds and soft heart murmurs be detected on a video call? Can I feel the extent of a cancer unless I touch the area in question? Can the patient tell me if something is fluctuant or transilluminant? Can a surgeon elicit rebound tenderness or percuss for ascites online? Can this get more ridiculous than it already is?
If only last year this very same govt passed a law barring doctors to prescribe medicines, even to their known patients regularly under their treatment over phone/whatsapp, (after having confirmed their diagnosis on clinical examination) how can it justify diagnosing and treating an unknown patient in the same way? Is this not hypocrisy?
I have been personally examining each of my patients (in the same way I usually would have, except for the added mask on my face) since March, and I can confidently say that no amount of photos, videos, reports can substitute a simple (in person) clinical examination. People who don't subscribe to this may be playing with their health in the bargain.

Agreed, but having said that, there are some fields of medicine that can do with online consultation very well. Examples include Psychiatry, Psychology and to some limited extent gastroenterology, dermatology, endocrinology.

If someone is already undergoing treatment and wants to show blood reports to the doctor for any change in medicine dosage, online consultation can work very well too.

[diyguy]

Is Metropolis a good lab to do the antibody test? Can someone suggest which is better to do
Anti-SARS-COV 2_reflex IgG or
Anti SARS-CoV 2 IgG
Any other alternate labs that I can get this done?

[sachinayak]

Originally Posted by Gansan

How to secure a death certificate under such conditions?

This is a very tricky question - something that I had faced a couple of years back. My mother was terminally ill (with cancer) and we got her to Bangalore as per her wishes. All her medical treatment / our family doctor was in Bombay, but she wished to get to Bangalore, which we complied with. However, she was now at home, and not at a hospital, as she was completely against hospitalization (and we did not want to extend her suffering).

Knowing the inevitable, I visited a few hospitals around and no doctor was willing to give a death certificate. All hospitals insisted on getting her admitted if we wanted them to issue a DC. One hospital in fact said, upon death, contact St. Johns Hospital, who will come and take the body for post mortem and then give a DC, which just wouldn't work. The situation was extremely gut wrenching for all of us. A couple of my cousins (doctors in Bombay) too had warned me of this situation, but we had no choice.

Thankfully, when my mom passed away, a doctor relative of mine who was completely aware of the case and consulting us remotely all through out, issued us a DC. I still shudder at the thought of what if he did not step in at the right time. Not sure if I could have done anything different, but it is tricky. I would hope some of the doctors on the forum could provide guidance on the right way forward without causing additional trauma to already grieving family members.

As far as I know, if anyone has a family doctor, they would typically help, but now a days we just go to various clinics with no individual rapport or connection with any specific doctor.

[Gansan]

Originally Posted by sachinayak

Thankfully, when my mom passed away, a doctor relative of mine who was completely aware of the case and consulting us remotely all through out, issued us a DC. I still shudder at the thought of what if he did not step in at the right time.

I am sorry to learn that. My brother's MIL passed away in his home during last July. She had a tumour in the lung, was living in another part of the city and was being treated by a doctor from another hospital. But she visited her daughter to spend a few months with her and passed away one night. No hospital was ready to send anyone, or allow them to to bring the body for a death certificate, especially without a Covid certificate. Fortunately her doctor had a friend who was chief doctor in a government hospital near our area, to whom he spoke and vouched for the patient. The GH doctor sent an ambulance for them to take the body there, and told them to bring all medical records. After seeing the patient and perusal of medical records he issued a death certificate.

At least in such cases one is mentally prepared and can plan about possibilities in advance. What happens when an otherwise perfectly normal octogenarian doesn't wake up in the morning? It is a real and scary possibility now.

[Zen2001]

Originally Posted by DCEite

Agreed, but having said that, there are some fields of medicine that can do with online consultation very well. Examples include Psychiatry, Psychology and to some limited extent gastroenterology, dermatology, endocrinology.

If someone is already undergoing treatment and wants to show blood reports to the doctor for any change in medicine dosage, online consultation can work very well too.

Works only for non interventional branches like medicine. I am already seeing the ill effects of teleradiology which has established itself a decade ago - the reporting radiologist would be sitting in another city, even country with no clinical correlation of the patient and reports from such sources do not add any substance in decision making for a treating doctor.
Even in most non surgical branches mentioned above (even in psychiatry), it is important to physically assess rather than just rely on the history, because further interventions would hinge on the completeness of the examination. Even in cases on "regular follow up" you never know what might change and when - which might necessitate a change in treatment. Interpretation of any results of investigations should always be done in the light of findings of a good patient history and detailed clinical examination - this is the golden rule of medicine and no amount of technology can bypass that. A good doctor treats the patient, not the reports.

[Zen2001]

Originally Posted by RSR

True! It's just impossible for certain kinds of doctors to do effective online consultation. Even with a medically aware and very co-operative patient, it may not work out well.

By and large, it works for trivial and routine cases, and everything looks fine till there's a mistake, either due to a gap in communication or interpretation. What happens next is anyone's guess.

Originally Posted by RSR

Times change, however, and technology rapidly improves with time. Imagine, just a decade-and-a-half ago, tele(phone)-consultation meant the patient and doctor could not even see each other! Going forward, I expect a lot of improvement in the field of tele-medicine, and the pandemic may have kind of accelerated that advancement.

There is a lot of technological improvement no doubt, but it works best only when carefully planned - and that requires thorough evaluation to have a plan A and if necessary, a plan B. Even a robotic surgery is actually "performed" by a human! Even with AI, it will only do what it is programmed to do - imagine a program which diagnoses everyone who has fever, bodyache, cough, breathlessness today as Covid19 - what would happen?

Originally Posted by RSR

Did they actually do that? .
Then, its quite a U-turn by them >>>

https://esanjeevaniopd.in/

It looks simple enough, is completely free, has enough doctors on roll and by the looks of it, has become decently popular.

You'd be surprised to know what all the government ACTUALLY has been doing in the MOHFW.
Shortening the basic medical training in the name of "fast-tracking", "bridge courses" to legalize allopathic practice by homeopaths/ayurveds (have you ever heard the opposite?), bogus polio vaccination records, fabricated blood samples for malaria and sputum for TB - all needed to keep the funds coming from respective national "heath" programmes.

[proton]

Originally Posted by DCEite

Agreed, but having said that, there are some fields of medicine that can do with online consultation very well. Examples include Psychiatry, Psychology and to some limited extent gastroenterology, dermatology, endocrinology.

If someone is already undergoing treatment and wants to show blood reports to the doctor for any change in medicine dosage, online consultation can work very well too.

My niece mentioned on a visit from Australia that she was interested in contributing to reformation of the medical educational system in her alma mater. Apparently, her exposure to the systems in Oz and the UK impressed her with a simple difference: the number of diseases taught that could be possibly linked with a symptom was huge, compared to the way it was taught to her, with just the main one.

It never affected me in any way, until I watched the TV series, House, MD. I was shocked at how misdiagnosis is so easily possible, requiring genius ability to isolate the real cause of the disease among the numerous possible, requiring a team of specialists in different disciplines to offer possible causes, and the genius to choose the correct one. Of course, even though the show is based on the real life experiences of Doctor Lisa Sanders, chronicled regularly in the New York Times Magazine, and the episodes on real life cases, most of us know that the medicine described isn't very accurate ( the best is still Scrubs ). However, misdiagnoses is still a very real possibility, especially if the cause is not a common one.

I was chatting with my friend, who has closed his clinic, because he is 80, and his patients are mostly from the slums. He gives free consultations now, over the phone, to patients with medical histories filed with him. Apparently, according to his patients, even paid consultation is hard to come by, nowadays. A well known nursing home requires an upfront payment of INR750/- after which the patient can pick up a phone and talk to the doctor! I asked him how it could work, and he replied it was just scamming.

Teleconsulting and remote care requires a highly developed infrastructure and can actually cost more than hands on treatment. In Germany an operation performed by robotics costs more than that by a human doctor, because the robot is more accurate and steady than it's human equivalent! A very fictionalised demonstration of remote testing, diagnosis, and intervention and monitoring using AI can be seen in Ep 5 of the 5th Season of Doctor X on Netflix, but you can already read up about real life cases on Google and Youtube.

[Zen2001]

Originally Posted by proton

until I watched the TV series, House, MD. I was shocked at how misdiagnosis is so easily possible, ......... most of us know that the medicine described isn't very accurate ( the best is still Scrubs).

I, as a doctor take any televised, dramatised depiction of "real life patients" with a handful of salt. More than half of those verbal exchanges and see saw of decisions never take place in real life. I have worked in government hospitals in India, in the NHS, UK and have many colleagues currently working in hospitals in the US. The drama is always exaggerated in serials, although the politics and other economic/insurance/legal issues are for real.

Originally Posted by proton

A well known nursing home requires an upfront payment of INR750/- after which the patient can pick up a phone and talk to the doctor! I asked him how it could work, and he replied it was just scamming.

Although, I wouldn't subscribe blindly to teleconsults, the subject of "customer satisfaction" is subjective. So, as long as it's feasible (& people scared) some hospitals/clinics have no other option other than losing their patients.

Originally Posted by proton

Teleconsulting and remote care requires a highly developed infrastructure and can actually cost more than hands on treatment. In Germany an operation performed by robotics costs more than that by a human doctor, because the robot is more accurate and steady than it's human equivalent! A very fictionalised demonstration of remote testing, diagnosis, and intervention and monitoring using AI can be seen in Ep 5 of the 5th Season of Doctor X on Netflix, but you can already read up about real life cases on Google and Youtube.

Infrastructure apart, can it ensure no additional "mistakes" (in judgement, conclusion, decision making and treatment execution) than in a human-human interaction? It can supplement, not REPLACE that. Even robotic surgeries have gone wrong (intraoperative) , notwithstanding all the advantages of 3D binocular vision, motion scaling, tremor elimination - owing to the fact that there is no haptic feedback! What's important is that doctors don't let go of their natural intelligence, instinct & common sense (gained over years of training and human interaction) in the pursuit of artificial intelligence.

[proton]

Originally Posted by Zen2001

I, as a doctor take any televised, dramatised depiction of "real life patients" with a handful of salt.

Here's a doctor's review about a Quarantine based House episode.

https://youtu.be/q6vBWzCeprA

It follows the tone of recaps made by web articles posted by doctors of TV medicine, my favourite being Polite Dissent, which became even more famous than House. Sure, the things that are dramatised on TV are rare, sensationalised occurrences. Most cases, treated daily, appear in waves, and diagnoses and treatments are really just standardised protocol. Like my friend's Polo car, which had a DSG gearbox failure last week. It's just an occurrence of a known problem, and he paid over a lakh to get it fixed out of warranty, SOP for India!

Rarely do doctors get new problems to deal with. So, of course, we know that most of the incidents portrayed on TV are not everyday events, that would be so boring! But do the misdiagnoses occur? Again, sure they do.

My relative was diagnosed with Parkinson's, and when he went to Singapore to visit his son, he was re-diagnosed as suffering from Progressive supranuclear palsy. One of the important corrections to his treatment was that the doctor who treated him for PD in India couldn't solve his problem of choking on food. The Singapore doctor advised feeding him only with liquids and semi solids. I still have three cartons of Ensure in my guest room! He survived for three more years, and I have his bills for hiring of hospital bed, oxygen cylinders, canulas for tracheostomy, with me. I got his death certificate last week, while crammed into a room with 12 other people in front of a doctor with no face mask, at a government hospital (naturally, no other body gives DCs)!

This is not criticism of the Indian medical system, because my expat friend was impressed by how quickly he was diagnosed for a cancer that the NHS missed, but just a general observation of how much more complex the human body is, than say, a car. The problem is that the more experienced doctors have a larger pool of personal knowledge to draw from, which is why I prefer old doctors over the young geniuses(!).

This is where AI comes in. The going wisdom is that Computerisation can replace anything that is repetitive. That's why ATMs are taking over from bank tellers.

Pool together the distilled knowledge of any job description, and AI can take over. Since the pool is huge for the medical discipline, AI is very attractive, because no doctor can accumulate the experience of all the experts in any speciality. And we are only talking about peer reviewed opinion here.

The doctor whose Blog I follow asked for more technology to be involved in medicine, because of the subjective nature of most of the work still being done, especially in the treatment of Covud-19, his field as an epidemiologist! We engineers, even though we apply the same science as doctors, have a more objective approach. In medicine, most of the opinions are subjective, even in AI, but they offer the numbers, the percentage risks involved, in the case of AI.

Also, as you mentioned, AI is used as supplementing, rather replacing human input. The robot operates, but the theatre team monitors the progress of the operation, as well as the vitals of the patient.

Where AI is making innovative, and maybe disruptive changes, is as a resource multiplier. A highly specialised practioner can treat global cases from a fixed location, and robotics means that that treatment is not just internal medicine, but also surgery! His expertise is available to more people over his productive life.

Another detail I noticed about doctors, which the blog also remarked on, is that western doctors don't yak about other fields. They get flak if they do.

It seems that being on the ball, and striving to be up to date about their own field, needs so much effort that they don't dare to poke into other people's specialities, because of the legal issues involved. I was chatting with my niece about a friend who specialises in a related field, in-utero-pediatrics, she just wouldn't engage, wasn't even interested in being introduced, even though he also lives in Oz. She told me it was cutting edge. Tell me about it. He was offered a blank cheque to join a well known hospital chain. Don't ask why he refused. He wanted to serve the poor, but the offer was conditional. You can guess the condition!

[am1m]

https://www.theatlantic.com/health/a...campaign=share

"This Overlooked Variable Is the Key to the Pandemic (It’s not R.)"

"In study after study, we see that super-spreading clusters of COVID-19 almost overwhelmingly occur in poorly ventilated, indoor environments where many people congregate over time—weddings, churches, choirs, gyms, funerals, restaurants, and such—especially when there is loud talking or singing without masks. For super-spreading events to occur, multiple things have to be happening at the same time, and the risk is not equal in every setting and activity,"

"Take the case in Springfield, Missouri, in which two infected hairstylists, both of whom wore masks, continued to work with clients while symptomatic. It turns out that no apparent infections were found among the 139 exposed clients (67 were directly tested; the rest did not report getting sick)."

"Oshitani contrasts the Japanese strategy, nailing almost every important feature of the pandemic early on, with the Western response, trying to eliminate the disease “one by one” when that’s not necessarily the main way it spreads."

"It’s not always the restrictiveness of the rules, but whether they target the right dangers"

"Countries that have ignored super-spreading have risked getting the worst of both worlds: burdensome restrictions that fail to achieve substantial mitigation. The U.K.’s recent decision to limit outdoor gatherings to six people while allowing pubs and bars to remain open is just one of many such examples."

[Thad E Ginathom]

I just can't take any more numbers and make sense of them. Never was very good at it in the first place.

For those that can, there seems to be some interesting stuff here and some interesting findings...

Covid-19 spread in some unique ways in India, new contact tracing data shows (mint)

Here's the intro...

Over 70% of those who contract covid-19 do not pass it any further, while a minority act as superspreaders, the first detailed study of SARS-CoV2 transmission patterns in India has shown. The study, which used the largest dataset of contacts of any global study, also shows that children play a bigger role in spreading the virus than earlier believed ... sustained shared travel is the most high-risk behaviour one could indulge in.