28th May 2000
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Second opinion

Medical Measures

Quacks -Big dangers of little learning

The Government has recently begun a crackdown on "errant" doctors engaging in private practice during working hours. Several incidents in which doctors were nabbed in the act made headlines in newspapers. Disciplinary action was also instituted against these doctors, reports said. 

That should indeed be so. No profession, however noble, is above the law. And for some time now there have been instances where some doctors-not all of them, perhaps only a minority- have been taking the law into their own hands. So, this action against such miscreants is welcome. But this begs another question- are the authorities mistaking a molehill for a mountain? We know that there are probably as many quacks in this country as there are doctors. However, their "clinics" thrive and all those concerned- the Health Ministry, the Medical Council, the Police- seem to be turning a blind eye.

As the law stands now only persons registered as doctors with the Sri Lanka Medical Council can practise western medicine in the country. Ayurvedic physicians have a similar system of registration and are also legally empowered to practise their profession. Moreover, the Sri Lanka Medical Council also registers certain professions allied to medicine: nurses, pharmacists, physiotherapists, radiographers and many other supplementary professions. 

Quacks, of course, come in many kinds. There are the "absolute" quacks who have no learning whatsoever but have acquired some skills that enable them to pass off as medical practitioners. Then there are the more learned quacks who have some training in a discipline related to medicine, but practise posing as fully-fledged doctors. Those in the latter kind are more dangerous in that they do not know that they do not know and as a result they are more liable to cause more damage to patients. Thus, we have dental technicians practising as dental surgeons, optometrists as eye surgeons, pharmacists as physicians and counsellors and hypnotists acting as psychiatrists! And of course, who can forget the many abortionists who act as obstetricians, sometimes blatantly advertising their services in the classified sections of newspapers? 

The Government Medical Officers' Association and other responsible medical bodies have time and again brought this malady to the notice of the authorities. Unfortunately though, these warnings have largely been ignored by those who matter. The Medical Council would arguably be the body to inquire into these matters but it too appears to have dragged its feet on this issue. 

Then again to turn a blind to this veritable industry of quacks is not prudent for a responsible body which claims to maintain the standards of a profession which is empowered to deal with people's lives. 

All concerned seem to adopt the position that 'no complaint has been made' but then, that is hardly a justifiable excuse for what amounts to a criminal offence. The policy-makers, the authorities and even the general public are well aware that this malady exists and they all turn a blind eye! Isn't it time then that the Health Ministry gets its priorities right and focuses its attention on this menace which is definitely more detrimental to the public than a handful of doctors doing private practice during working hours? 

Or, are we all waiting for more patients to be mismanaged and perhaps even killed at the hands of quacks? A little learning, after all, is a dangerous thing. 

Don't squeeze, scratch or poke!

With the onset of adolescence, teenagers often have one good reason to look at themselves for long hours in the mirror: pimples or "acne" as they are medically termed. 

Time is the only real cure for acne, but these tips may help: 

o Keep your skin clean. Wash often with plain soap and water. 

o Use a washcloth. Work the soap into your skin gently for a minute or two. 

o Use a clean washcloth every day. Bacteria, which can give you more pimples, love a wet washcloth. Leave your skin alone! Don't squeeze, scratch or poke at pimples. They can get infected and leave scars. 

o Wash after you exercise or sweat. 

o Wash your hair at least twice a week. Keep your hair off your face. 

o Don't spend too much time in the sun. 

For men: Wrap a warm towel around your face before you shave. This will make your beard softer. Always shave the way the hair grows. 

For women: Use only water-based makeup. Don't use greasy or oily creams, lotions or makeup.

Men, get them checked out!

Nowadays most men are conscious about their health. So, they get themselves 'checked out.' In our country, these tests are seldom carried out under medical advice and mostly consist of tests for cholesterol, diabetes, high blood pressure and perhaps an electrocardiogram (ECG). Many are the men who are reassured simply because this handful of tests is normal. 

But after 50, some other screening measures may be helpful, so here are some suggestions and also some advice about those cholesterol and blood pressure measurements:

Eye examination: 
If your vision doesn't require correction and you are under 50 years, an eye exam every three to five years will suffice. If you wear corrective lenses or are over 50, you should have eye exams every two years or so. Men with diabetes, high blood pressure, or a family history of vision problems should be examined at least once a year. 
Dental examination: 
At least once a year, your dentist should check the health of your teeth, gums, tongue and mouth, and check for oral cancer. Smokers may need more frequent visits. 
Blood pressure:
An inflatable cuff wrapped around your arm can detect high blood pressure, hopefully long before complications, such as heart attacks and strokes, ever occur. If you are below 50, your blood pressure should be taken every two to five years. At 50 and above, it should be tested annually. If you have a family history of high blood pressure, heart or kidney disease, or strokes, or you have diabetes or are overweight, you should be tested annually. 
Cholesterol test: 
A blood test that measures cholesterol, including LDL ("bad" cholesterol) and HDL ("good" cholesterol), can help to evaluate your risk for coronary heart disease. Beginning at the age of 20, you should be tested every five years - assuming that your results are within desirable ranges (readings between 80/50 and 130/85 are considered normal, in general). If your cholesterol level is above these ranges or you have a family history of coronary heart disease, you should consult your physician about testing more frequently. 
Prostate examination: 
The common digital rectal exam (DRE) is a direct examination of your prostate gland to check for unusual growths or tumours. The prostate specific antigen (PSA) test measures the amount of a protein secreted in the blood. Higher-than-normal levels can also indicate cancer. You could begin annual testing at the age of 40. If you have a family history of prostate cancer, it's a good idea to begin screenings earlier. 
Testicular examination:
Doctors suggest monthly self-exams of your testicles for unusual changes or growths. However, these can't substitute for a doctor's examination. Testicular cancer is usually curable, especially when detected early. Men between the ages of 15 and 35 should have a testicular exam at every physical examination, at least every two or three years. Doctors may not automatically perform this test, so you should request this exam or other tests listed here if they are not offered during a physical. 

Mammogram will catch the cancer

By Chris Fernando
Q: I am a 45-year-old, who married at 19 and had my third and last child at 25. I breast-fed all my children and the youngest until she was three-and-a-half-years-old.

At 27, I developed a severe pain in my left breast. My doctor said there was nothing abnormal and gave me painkillers, but I got the pains on and off. This was not just during my period.

About five years ago, my breast started to hurt unbearably. I consulted a senior surgeon in Kandy who dispelled fears of breast cancer, after extensive examinations and tests. He prescribed a dose of strong antibiotics and painkillers for six weeks and the pain abated.

Six months later, I developed pains of the same intensity as before. I consulted another surgeon and he too allayed any fears of cancer and prescribed antibiotics and painkillers. However, the pains still recur. What could be causing them?.

A: Pain in the breast or mastalgia is usually due to fibroadenosis, which is also referred to as mastitis. This aggravates prior to periods and subsides with the ending of periods. This is due to the breast tissue reacting to cyclical hormonal changes in a female.

This condition can produce painfully large cysts and continuous pain with lumpiness in the breast, which I think, is the cause of your discomfort. However, if a surgeon has examined you, I am sure he would not have found any suspicious areas, which need a biopsy. From what you have written, I see that you have not had a mammogram. This is a mandatory procedure, because a malignancy can co-exist with mastitis. A mammogram will show suspicious areas as regions of micro-calcification, which can be selectively taken out and biopsied for further histological examination.

Medication-wise, mastitis is usually treated with mild to moderate analgesics (painkillers). If there is no improvement, despite adequate doses of painkillers, then hormonal therapy is recommended. 

It is obvious that your doctor has made a firm diagnosis of mastitis. However, a mammogram is a must. This would exclude the possibility of a malignancy. So I suggest that you go ahead and do a mammogram.

Lumps can occur in the breast with or without pain. A lump can be a cyst, which is a collection of fluid or it can be a solid lump, which can be a fibroadenoma, the most common non-malignant lump that can occur at any age. On the other hand, it can be a solid lump containing malignant features. The first procedure of course, would be to find out whether it is a cyst or a solid lump.

To do this, the doctor would stick a needle with a syringe into the lump and if there is fluid, he will be able to draw it out. The lump will then disappear. This lump can be classified as a cyst. Of course, if the fluid that is drawn out is bloodstained or if there is a suspicion of malignancy, then the fluid is sent for further examination.

If no fluid comes out, then the lump still remains and this is classified as a solid lump. It is always advisable to have this type of lump removed under local or general anaesthesia. 

Another method of treatment would be to take a sample of this lump out for examination through a procedure called the needle biopsy, where a trucut needle is inserted into the lump to withdraw a small portion for analysis. This process can be performed at the Outpatients' Department itself.

Another common condition is a discharge from the nipple, which can be due to a local infection of the skin of the nipple (eczema) or mastitis, which gives out a greenish discharge. Nipple discharge should be taken seriously since it could also signal the onset of malignancy in the breast or a warty growth inside one of the 14 to 20 ducts that open into the nipple from the breast tissue, especially if the discharge is bloodstained.

In cases of mastitis or fibroadenosis such as your condition, cystic masses can develop and these lumps can also grow in size to become noticeable. They can also produce a greenish nipple discharge.

You may wonder why I say that a mammogram is mandatory. If there is a clear suspicion of a lump, then a doctor can go ahead with the procedures that I have already outlined. 

But a mammogram will detect suspicious areas, which have still not developed into a palpable lump. So by a mammogram, we are able to catch the formation of a cancer at its very early stages, thereby giving a good prognosis for the entire situation. 

I would recommend a yearly check-up for patients with your condition and also for females with a family history of breast cancer.

Your Health

Now it's doctor on the net

By Dr. Sanjiva Wijesinha
"One of the biggest dangers for patients these days," says my friend Dr. Ranjit Rasalam, "is that they can easily bypass their doctors. They can now go bouncing around on the Internet (like children on an electronic trampoline) searching for information on virtually any issue they consider important. 

The problem exists because much of this readily accessible information comes from sources that are entirely unreliable." 

In the old days, the family doctor was a trusted figure - someone to whom one turned to, for information and advice about illness. Today, many people seek help from non-medical sources. Those who have access to that minefield of information called the worldwide web seek information on their computers, while others go to popular magazines and alternative therapists. One's doctor is no longer one's guide and philosopher - and hardly even a friend. 

More often than not when they do ask their doctors for advice, patients will listen nicely and then go out and do precisely what the doctor told them not to do! This is usually because the doctor's advice conflicts with what they discovered on the Internet or from their next door neighbour or the old school friend whom they met last week. 

And just like in days gone by when people used to say with confident authority, "It has to be true - I saw it myself in the papers!", the 21st century claim for authenticity is becoming, "I downloaded this from the Internet - so it has to be accurate!" 

Why this downgrading of the role of the medical profession? Why do patients no longer view doctors as their advisors - or even trust them for advice? 

Australian journalist Philip Adams recently spoke to a couple of hundred people about their experiences with doctors and found, again and again, that it was the lack of a bedside manner that was going against the medical profession. 

While patients missed the old sense of comfort and sympathy they used to get from their doctors, the main thing they claimed to be receiving from their alternative therapists was more time and better empathy. 

The family doctor who provides callous, careless and perhaps even contemptuous treatment to his patients would certainly be a rare being. But far too many doctors these days are seen to be spending too little time with their patients - practising assembly line medicine rather than the care that people expect. 

Sadly, we doctors are seen by the public - the Citizen Pereras of this land - to be poor communicators, spending too much of our energies squabbling over irrelevant issues or matters of money rather than communicating with the public. 

During the 21st century will the local doctor be replaced by computers - where patients can shop around, not just using their keyboard and mouse but with voice activation triggering soothing and gentle voice responses? With a video camera focused onto the rash on their forearms, will patients be able to get an accurate diagnosis from a computer database cunningly disguised as a human being? Will they be able to mooch around in cyberspace, getting second and third opinions from service providers five, ten or fifteen thousand miles away? 

In time to come, people (in some parts of the west no longer called patients but referred to as "clients" or "consumers") will surely be able to order their drugs from the great electronic shopping malls in cyberspace. They will no longer have an overzealous pharmacist warning them that the new wonder-drug they heard about on the Internet has some nasty side-effects and so is not allowed to be sold in this country. 

Will this be how we get health for all by the year 2100? The mind boggles. 

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