Challenges and Opportunities in Family Medicine with Dr. Ashutosh Pandey (Part-1)

Hello, I am Dr. Ashutosh Pandey, a third-year resident of DNB Family Medicine from BPS Government Medical College for Women. During my childhood, I actually wanted to be a cricketer. However, as time passed, I realized that the medical profession has the potential to help people the most. So, I pursued a career in medicine. So, I started preparing for the NEET exam and was selected for MBBS at NEIGRIHMS. I stayed in Delhi for one year as JR at Guru Gobind Singh, a government hospital. After that, I worked as a resident medical officer at the National Brain Research Center in Maneswar, Haryana. Meanwhile, I was also preparing for my postgraduate studies. I opted for family medicine, which is a multi-specialist training program in internal medicine, pediatrics, and other areas. I want to pursue Diabetology, and currently, I am preparing for the MRCP (Membership of the Royal Colleges of Physicians) UK exam. Thats all about my professional life.

Being a Hindi medium student, the biggest challenge I faced in medical life sciences was the language barrier since everything is predominantly in English. I chose a medical college located far away from my hometown Varanasi. In the Northeast, people and culture there were different, but within a few months, I made many friends and adapted to the unique weather. In the medical field, life can be very stressful as we have to work hard to pass exams and endure the long duration of the course. It requires maintaining a high level of patience and willpower. Being away from home, we faced challenges related to food, as the cuisine was different from what we were used to. However, despite these difficulties, I remained focused on my goal and ultimately achieved it. I am happy with the outcome.

I understood my inclination towards Family Medicine during my internship. As an intern, I had to rotate through all the specialties, and I found myself particularly drawn to internal medicine. However, the field of Family Medicine was not widely accepted at that time. In MBBS (Bachelor of Medicine, Bachelor of Surgery), we received training in pediatrics and gynecology, which made Family Medicine a better fit for me. Throughout my MBBS journey, I developed a liking for this field of medicine.

We can generally divide our medical training into two parts: surgical and medical. In the medical field, we have specialties like dermatology, internal medicine, and pediatrics. On the other hand, surgical branches include surgery, ophthalmology, and ENT.

In general medicine, the focus is on studying more, understanding concepts, and developing our own diagnostic approach. One aspect that I didn't particularly enjoy in both fields was the long periods of standing. In surgical cases, a single case can take 3-4 hours, whereas in general medicine or medical branches, you have more time to interact with the patient.

Interacting with patients is easier in medical branches as you can spend more time listening to them and understanding their concerns. The treatment approaches may be similar for both surgeons and physicians, as both have their expertise and experience. However, there tends to be more patient interaction for physicians in medical branches.

Sometimes, it can be incredibly frustrating when patients don't disclose all of their symptoms. As interns, we often felt frustrated in such situations. However, as time went on, we came to realize that the patients seeking our help were not in a good state. They were suffering and unhappy. Understanding this, we learned the importance of maintaining our patience. We remind ourselves that the patient is going through a difficult time and may not be able to fully express their concerns. It is crucial to remain patient and empathetic towards their situation. In government hospitals, it is often that patients have to wait in line for about three hours before they reach you. In such deteriorating situations like, when a sick person has to wait in line for 4-5 hours, we choose to overlook our anger. Yes, sometimes it can be frustrating, but later on, we are able to let go of it.

Yes, we have daily duties in the emergency department, and our shifts typically last for 24 hours. During these shifts, we are responsible for attending to all emergency cases that come in. In the OPD, patients are generally not in critical condition. In the emergency department, however, you primarily deal with the patient's relatives rather than the patient themselves. In cases such as road traffic accidents (RTAs) or strokes, your interaction is focused on diagnosing the patient rather than having extensive conversations with them.

The main challenge in the emergency department arises from the distress and concerns of the patient's relatives. For example, if a patient has had a stroke and you inform them that intubation (ventilator support) is necessary, their relatives might request you to explain the situation to their brother-in-law, father, or mother. This creates tense situations.

If a patient's condition requires care beyond what our setup can provide, we have to refer them to another facility. In such cases, we need to explain the reasons for the referral, where they are being referred to, and the available facilities. Due to these factors, emergency cases are given top priority, followed by the OPD. In the OPD, it is comparatively easier to explain things directly to the patient, whereas in the emergency department, it can be challenging. These are some of the problems that arise in the emergency department.

We daily see around 50 patients. Out of those 50, approximately 30 patients may express various concerns. Some patients may even resort to using abusive language. Despite their outbursts, we still need to address their medical issues. For instance, a patient complaining of a headache might insist on getting an MRI, while as a specialist, you understand that it is likely a case of migraines that doesn't require MRI or CT scans.

Unfortunately, it can be challenging to satisfy such patients who have already made up their minds about getting unnecessary tests done. However, there are other patients who show improvement after taking medication for a week. Chronic pain subsides, diabetes is under control, and their quality of life improves. It is these patients who express gratitude and make our day.

The best moment in college is when we receive our MBBS degree. Throughout the 5.5 years of the MBBS program, there are countless memorable moments that we cherish. However, the greatest moment is when we hold our degree in our hands, as it signifies the completion of MBBS and makes us eligible to pursue a specialization. After obtaining the MBBS degree, we can apply for a doctorate. This moment is truly special because it represents the culmination of years of hard work and dedication. While medical college is filled with numerous memorable experiences, receiving our degree stands out as the best moment of all.

In complicated cases, the process is not straightforward. It involves different stages and experiences. Let's consider my internship. On the first day of my posting, I was assigned to the Community Health Center, which lasted for three months (although it was later reduced to two months during my time). I was stationed in a place called Shillong, where the local language was unfamiliar to me. There was a condition when "dow" or "axe," which posed a life-threatening situation, causing profuse bleeding from the neck. Being new and inexperienced, it was incredibly challenging for me to handle the situation. I reached out to my seniors for assistance, and they guided me through the process. It's not as simple as updating someone in a room about a bleeding case. It requires knowledge, skills, and the ability to remain composed even in intense situations. Even after 4-5 years, the conditions remain the same, and we frequently encounter gunshot wounds. However, it doesn't affect our composure. We treat patients calmly, drawing from our experience. These skills are not explicitly taught in any medical degree but are developed over time. Therefore, it is essential to give oneself time and have patience to learn and master these aspects. You will observe that a new doctor tends to get angrier than a professor who communicates calmly. These skills are honed through experience and time.

We have updated PG books that help us stay updated. We also use various apps to stay updated on common diseases. We dedicate time to read about them. For common diseases, we make sure to dedicate time to stay updated. For instance, if I have a simple typhoid patient, I am aware that typhoid guidelines change frequently. Therefore, I follow the recent data from our updated books.

In case of any confusion or if it has been a while since I last studied a particular topic, I make an effort to update myself. We have various apps that provide updates, and we consult them regularly. We also refer to books, participate in CMEs (Continuing Medical Education), attend conferences, and engage in discussions at our own general club. These multiple avenues help us stay informed about the updates in the field, ensuring that we avoid using outdated information.

Topics like asthma, COPD, etc., are often presented through topic presentations or case presentations, providing us with opportunities to learn about the latest developments. Despite our busy schedules, we set aside an hour or two daily to study. This commitment to continuous learning is our best source for staying updated.

In the case of a cardiac arrest, we ensure that no incorrect treatment is administered. There are several steps involved in this process. Firstly, we obtain the patient's ECG to assess the symptoms such as chest pain, left-sided pain, or radiating pain. By analyzing the ECG and troponin levels, we can determine if the patient is experiencing a posterior myocardial infarction (MI) or ST-segment elevation MI (STEMI).

These medical procedures may become complicated if explained in detail. However, we have various methods to differentiate and rule out possibilities. Once we have made a precise diagnosis, we proceed with the appropriate treatment.

To ensure accuracy in medication administration, we take steps to ensure that the prescribed dosage is correctly written and explain it to the nursing staff. This reduces the likelihood of errors at every step. However, even with these precautions, there is a small chance of error (around 1-2%). In such cases, we have mechanisms in place to address and modify the error promptly.

For example, if a patient exhibits an allergic reaction to a medication, we take immediate action to counteract the allergic response. We are well-equipped to modify the treatment plan and minimize the chance of errors. It is important to note that such incidents are rare in practice.

Suppose you are in a hospital in Haryana, and you encounter a patient with a severe fever of 105 degrees. The patient's condition and symptoms may be perplexing, making it challenging to identify the exact cause. In such situations, we rely on sticking to the basics that we have been taught.

The first step is to ensure the airway is clear and the patient's vision is unaffected. We then assess the pulse, blood pressure, and other vital signs. Next, we focus on managing the symptoms, such as reducing the high temperature, following established protocols for temperature reduction. Simultaneously, we seek guidance from our senior resident doctor. This collaboration allows us to address cases where we lack clarity and work towards providing the patient with appropriate treatment based on basic research.

In emergency situations, we resort to fundamental approaches, such as catheter sponging and administering injections like paracetamol. If needed, we consult with our senior doctors to gain further insights. It is crucial to understand that there is no patient waiting for us to have all the answers immediately. The emergency setting follows a structured pattern based on the basics of medical science. By adhering to the protocols and guidelines we have been given, we can mitigate challenges and alleviate panic.

Experienced professors and senior residents are available to assist us in diagnosing and managing complex cases. Therefore, despite encountering challenging cases, we are not unduly perturbed.