Contents

Forewords by Dr H Vinod Bhat, Prof M Vijayakumar and Dr Niranjan Kumar viiPreface to the Fifth Edition ixPreface to the First Edition xiCommunication and Counselling xxiiiDoctor–Patient Relationship xxvii

SECTION I: GENERAL SURGERY

1. Wound, Keloid, Hypertrophic Scar and 3Metabolic Response to Injury� Types of wounds: Classification� General principles of management of open wounds� Components of wound healing� Factors affecting wound healing� Compartment syndromes� Hyperbaric Oxygen� Hypertrophic scar and keloid� Classification of surgical wounds� Healing of specialised tissues� Metabolic response to injury� Recent advances� Negative pressure assisted wound closure� Tissue engineering and regeneration

2. Acute Infections, Sinus, Fistula and 17Surgical Site Infections� Cellulitis� Ludwig’s angina� Lymphangitis� Abscess� Cervical tuberculous lymphadenitis� Boil, carbuncle� Erysipelas� Chronic abscess� Necrotising fasciitis� Acute pyomyositis� Surgical site infections, PIRO classification� Asepsis and antisepsis� Sinus and fistula

3. Tetanus and Gas Gangrene 38� Tetanus� Gas gangrene� A case report of neck rigidity

4. Hand and Foot Infections 47� Paronychia� Subcutaneous infections� Acute lymphangitis of hand� Terminal pulp space infections

� Apical subungual infection� Web space infections� Deep palmar abscess� Acute suppurative tenosynovitis� Mycetoma pedis� Ingrowing toenail

5. Chronic Infectious Disease 58� Actinomycosis� Leprosy� Deformities in leprosy� Syphilis� AIDS

6. Differential Diagnosis of Leg Ulcer and 67Pressure Sore� Clinical examination of an ulcer� Management� Wound dressings� Traumatic ulcer� Venous ulcer� Trophic ulcer� Tropical ulcer� Post-thrombotic ulcer� Rare ulcers� Diabetic ulcer foot� Amit Jain’s classification for diabetic foot� VAC� Maggot therapy, Pressure sore

7. Lower Limb Ischaemia and Popliteal 86Aneurysm� Causes of lower limb ischaemia� Collateral circulation� Clinical features—symptoms� Clinical examination� Fontaine classification� Management� Differential diagnosis� Acute arterial occlusion� Critical limb ischaemia� Peripheral aneurysm

Manipal Manual of Surgeryxvi

� Ainhum� Frostbite� Reperfusion injuries� Fat embolism, air embolism� ICU gangrene

8. Upper Limb Ischaemia and Gangrene 110� Raynaud’s disease� Thoracic outlet syndrome� Axillary vein thrombosis� Vasculitis syndromes� Gangrene, cancrum oris� Acrocyanosis� Drug abuse and gangrene� Intra-arterial drug and gangrene� Subclavian steal syndrome

9. Lymphatics, Lymph Vessels and 124Lymphoma� Lymphoedema—anatomy and physiologyq Lymphatic circulation� Primary lymphoedema� Secondary lymphoedema� Lymphangiography� Hodgkin’s lymphoma� Non-Hodgkin’s lymphoma� Burkitt’s lymphoma� Sezary’s syndrome� Chyluria� Immunohistochemistry� Bone marrow and peripheral blood stem

cell transplants

10. Varicose Veins and Deep Vein Thrombosis 141� Primary varicose veins� Secondary varicose veins� Surgical anatomy of venous system of legs� Anatomy of the long saphenous vein� Clinical examination� Treatment� Complications� Short saphenous varicosity� Deep vein thrombosis� Recurrent varicose veins� Pelvic congestion syndrome� Pulmonary thromboembolism

11. Skin Tumours 161� Classification of skin tumours� Premalignant lesions� Basal cell carcinoma� Squamous cell carcinoma� Melanocytic tumours� Malignant melanoma� Other malignant skin tumours� Other skin lesions

12. Haemorrhage, Shock and Blood 194Transfusion� Haemorrhage

– Classification– Pathophysiology– Management

� Shock– Hypovolaemic– Cardiogenic– Distributive– Obstructive

� Hyperbaric oxygen� Central venous pressure� Pulmonary capillary wedge pressure� Blood transfusion� Blood products� Bleeding disorders

13. Burns 210� Epidemiology� Classification� Clinical evaluation� Burn wound infection� Inhalation injury� Contractures� Electrical burns� Chemical burns� Friction burn� Skin bank

14. Acid–Base Balance, Fluid and Electrolytes 218� Basic definitions� Henderson-Hasselbalch equations� Regulation of acid–base balance� Acid–base disorders� Rapid interpretation of an ABG report� Physiology of fluids� Water regulation� Disturbances of volume� Regulation of sodium concentration� Disturbances in concentration� Disturbances in composition of body fluids� Perioperative fluid therapy� Types of intravenous fluids� Nutrition

15. Tumours and Soft Tissue Sarcoma 240� Benign tumours� Papilloma� Fibroma� Lipoma� Neural tumours� Neuroma� Neurofibroma� Neurilemmoma� Chordoma� Malignant tumours� Paraneoplastic syndromes� Soft tissue sarcomas� Aetiology/Epidemiology of STS� Role of chemotherapy� Differential diagnosis of soft tissue sarcoma� Liposarcoma� Malignant fibrous histiocytoma

� Synovial sarcoma� Angiosarcoma� Rhabdomyosarcoma� Kaposi’s sarcoma� Dermatofibrosarcoma protuberans

16. Cystic Swellings, Neck Swellings and 262Metastasis Lymph Node Neck� Cystic swellings� Transilluminant swellings� Differential diagnosis of midline swellings� Swellings in the submandibular triangle� Swellings in the carotid triangle� Swellings in the posterior triangle� AV fistula� Lymph node secondaries in the neck� Different types of neck dissections� Secondaries in the neck—occult primary� Pancoast’s tumour

17. Oral Cavity, Odontomes, Lip and Palate 306� Oral cancer� Premalignant conditions for oral cancer� General principles in the treatment� Carcinoma of buccal mucosa� Carcinoma of tongue� Ulcers of tongue� Carcinoma of lip� Carcinoma maxillary antrum� Nasopharynx—cancer� Benign lesions in the oral cavity� Odontomes� Epulis� Median mental sinus� Vincent’s angina� Cleft lip and cleft palate� Ectopic salivary gland tumour� Mucous cysts

18. Salivary Glands 336� Surgical anatomy of the parotid gland� Acute parotitis� Chronic submandibular sialoadenitis� Salivary gland tumours� Summary of malignant salivary gland tumours� Frey’s syndrome—Gustatory sweating� Sjögren’s syndrome� Mikulicz disease� Parotid fistula� Surgery for facial nerve palsy� Peripheral nerve repair and transfers

19. Thyroid Gland 355� Surgical anatomy� Physiology� Thyroid function tests� Clinical examination

� Goitre� Multinodular goitre� Retrosternal goitre� Toxic goitre� Graves’ disease� Malignant tumours� Papillary carcinoma� Follicular carcinoma� Anaplastic carcinoma� Medullary carcinoma� Solitary nodule� Thyroiditis� Lingual thyroid� Ectopic thyroid

20. Parathyroid and Adrenals 403� Surgical anatomy� Congenital anomaly� Physiology—calcium and action of PTH and calcitonin� Tetany� Hyperparathyroidism� Cryopreservation� Acute hypercalcaemic crisis� Adrenal glands—anatomy, physiology� Disorders of adrenal cortex� Neuroblastoma� Phaeochromocytoma� Incidentalomas

21. Breast 423� Congenital anomalies� Surgical anatomy� Cystic swellings of breast—classification� Acute bacterial mastitis� Antibioma� Retromammary abscess� Phyllodes tumours� Intracystic carcinoma of breast� Aberrations of normal development and involution� Fibroadenoma� Duct ectasia—plasma cell mastitis� Idiopathic granulomatous mastitis� Macrocysts� Galactocele� Galactorrhoea� Duct papilloma� Carcinoma breast� Effects of lymphatic obstruction from carcinoma of

breast� Breast reconstruction� Male breast carcinoma� Mondor’s disease� Angiosarcoma of the breast� Disorders of augmented breast� Rare breast cancers� A case of carcinoma breast� Oncoplastic breast conservation surgery

Contents xvii

Manipal Manual of Surgeryxviii

SECTION II: GASTROINTESTINAL SURGERY

22. Oesophagus and Diaphragm 483� Surgical anatomy� Physiology� Gastro-oesophageal reflux disease (GORD)� Motility disorders of the pharynx and oesophagus� Achalasia cardia� Nutcracker oesophagus� Carcinoma of the oesophagus� Oesophageal stricture� Oesophageal perforations� Diverticulum of oesophagus� Differential diagnosis dysphagia� Surgical anatomy of the diaphragm� Diaphragmatic hernia� Tracheo-oesophageal fistula

23. Stomach and Duodenum 518� Surgical anatomy� Gastric physiology� H. pylori infection� Gastritis� Peptic ulcer disease� Acute complications of peptic ulcer� Chronic complications of peptic ulcer� Carcinoma stomach� Gastrointestinal stromal tumours (GISTs)� Gastric lymphoma� Complications of gastrectomy� Acid function tests� Acute dilatation of stomach� Volvulus of the stomach� Bezoars� Idiopathic hypertrophic pyloric stenosis� Chronic duodenal ileus� Duodenal anatomy and obstruction� Gastric surgery for morbid obesity

24. Liver 579� Surgical anatomy� Physiology� Pyogenic abscess� Amoebic abscess� Hydatid cyst� Other cystic diseases� Benign tumours� Hepatoma� Secondaries in the liver� Portal hypertension� Ascites in portal hypertension� Portal gastropathy� Portal biliopathy� Budd-Chiari syndrome� Role of octreotide in surgery� Liver transplantation� Haemobilia

25. Gall Bladder and Pancreas 616� Surgical anatomy� Physiology

� Congenital anomalies� Gall stones disease� Acute cholecystitis� Chronic cholecystitis� Obstructive jaundice� Stricture of CBD� Sclerosing cholangitis� Choledochal cyst� Caroli's disease� Chronic pancreatitis� Cholangiocarcinoma� Congenital biliary atresia� Carcinoma of the gall bladder� Carcinoma of pancreas� Endocrine tumours� Acute pancreatitis� Pseudocyst� Annular pancreas� Ectopic pancreas� Cystic fibrosis� Pancreatic divisum� Pancreatic fistula� White bile� Pancreatic ascites

26. Spleen 688� Introduction� Surgical anatomy� Functions of the spleen� Congenital abnormalities� Rupture of the spleen� Complications of splenectomy� Idiopathic thrombocytopaenic purpura� Hereditary spherocytosis� Acquired autoimmune haemolytic anaemia� Thalassaemia� Sickle cell anaemia� Splenectomy for other conditions� Splenic artery aneurysm� Hairy cell leukaemia� Overwhelming postsplenectomy infection� Interesting 'most common' for spleen

27. Peritoneum, Peritoneal Cavity, Mesentery 707and Retroperitoneum� Peritoneum� Intra-abdominal sepsis� Acute peritonitis–Scoring system� Abdominal compartment syndrome� Complications of peritonitis

– Pelvic abscess– Subphrenic abscess

� Special types of peritonitis� Tumours of the peritoneum

– Pseudomyxoma peritonei– Carcinoma peritonei

� HIPEC

� Mesentery– Misty mesentery– Mesenteric cyst

� Retroperitoneum� Retroperitoneal cyst, abscess, tumour

28. Small Intestine 743� Embryology and development� Anatomy� Physiological functions� Abdominal tuberculosis� Tuberculous peritonitis� Tuberculous mesenteric lymphadenitis� Glandular tuberculosis� Intestinal tuberculosis� Inflammatory bowel diseases� Ileostomy� Crohn's disease� Surgical complications of enteric fever� Intestinal amoebiasis� Radiation enteropathy� Peutz-Jeghers syndrome� Adenocarcinoma� GIST� Neuroendocrine tumours� Short gut syndrome� Intestinal fistulae� Small intestinal diverticula

29. Large Intestine 782� Surgical anatomy� Colonic function� Tumours of the large intestine

– Polyps– Familial polyposis coli– Hereditary nonpolyposis colorectal cancer

� Carcinoma colon– ERAS

� Colon screening� Diverticular disease of colon� Faecal fistula� Colonic stricture

30. Intestinal Obstruction 813� Pathophysiology, basic principles in management� Sigmoid volvulus� Meckel’s diverticulum� Adhesions and bands� Gall stone ileus� Intussusception� Mesenteric vascular occlusion� Hirschsprung’s disease� Atresia and stenosis� Arrested rotation with bands� Volvulus neonatorum� Meconium ileus� Imperforate anus� Food bolus obstruction� Paralytic ileus� Malrotation and midgut volvulus� Abdominal coccoon

31. Rectum and Anal Canal 857� Surgical anatomy� Carcinoma rectum� Prolapse rectum� Surgical anatomy of anal canal� Anorectal physiology� Haemorrhoids� Anorectal abscess� Fistula in ano� Fissure in ano� VAAFT� Pilonidal sinus� Sacrococcygeal teratoma� Malignant tumours of anal canal� Stricture of anal canal and rectum� Anal incontinence

32. Lower Gastrointestinal Bleeding 899� Causes� Clinical examination� Investigations� Exploratory laparotomy� Haemobilia� Angiodysplasia

33. Appendix 911� Development and anomalies� Surgical anatomy� Acute appendicitis� Differential diagnosis� Complications� Appendicular mass� Faecal fistula� Neoplasm� Mucocoele� Valentino appendix� Post-appendicectomy sepsis—a case report

34. Hernia 931� Anatomy of the inguinal region� Inguinal defence mechanism� Classification of hernia� Aetiology of hernia� Indirect hernia, direct hernia� Clinical examination of a case of hernia� Complications of hernia� Recurrent hernia� Special hernias

– Giant hernia– Sliding hernia– Sportsman hernia

� Femoral hernia� Umbilical hernia� Incisional hernia� Management of massive abdominal wall hernia� Epigastric hernia� Interparietal hernia� Spigelian hernia� Lumbar hernia� Obturator hernia� Perineal hernia� Parastomal hernia

Contents xix

Manipal Manual of Surgeryxx

35. Umbilicus and Abdominal Wall 967� Classification of umbilical diseases� Umbilical inflammation� Umbilical fistulae� Umbilical neoplasms� Umbilical hernia� Umbolith� Abdominal dehiscence� Divarication of recti� Rectus sheath haematoma� Meleney's gangrene� Desmoid tumour� Endometriosis

36. Trauma—Initial Management, Blunt 978Abdominal Trauma, War andBlast Injuries and Triage� Initial management of trauma victims� Blunt abdominal trauma� Liver injuries

� Small bowel injuries

� Colonic injuries

� Duodenal injuries

� Pancreatic injuries

� Renal injuries

� Retroperitoneal haematoma

� Blast injuries

� Warfare injuries

� Missile wounds of abdomen

� Triage

37. Abdominal Mass 1003� Clinical examination of abdominal mass

� Mass in the right iliac fossa

� Firm to hard nodular mass in the umbilical region

� The cystic mass in the abdomen

� Mass in the epigastrium

� Mass in the right hypochondrium

� Mass in the right lumbar region

SECTION III: UROLOGY

38. Investigations of the Urinary Tract 1029� Urine examination� Blood tests� Intravenous urogram� Retrograde pyelography� Renal arteriography� Cystourethrography� Urethrography� Ultrasonography� Computerised tomography� Radioisotope scanning� Endoscopy� Urethroscopy� MR urography

39. Kidney and Ureter 1038� Surgical anatomy of kidney� Polycystic kidneys� Horseshoe kidney� Renal stones� Ureteric stone� Hydronephrosis� Renal tuberculosis� Renal neoplasm� Wilms’ tumour� Renal cell carcinoma� Pyonephrosis� Perinephric abscess� Dialysis� Renal transplantation

40. Urinary Bladder and Urethra 1063� Surgical anatomy� Vesical calculus� Carcinoma of bladder

� Ectopia vesicae� Acute cystitis� Diverticula� Urinary fistulae� Interstitial cystitis� Schistosoma haematobium� Urinary diversion� Rupture bladder� Surgical anatomy of the urethra� Rupture urethra� Stricture urethra� Hypospadias� Retention of urine� Posterior urethral valve

41. Prostate and Seminal Vesicles 1081� Surgical anatomy� Structural anatomy� Benign prostatic hyperplasia (BPH)� Carcinoma of the prostate� Gleason score� Prostatitis

42. Penis, Testis and Scrotum 1091� Surgical anatomy of penis� Phimosis� Paraphimosis� Carcinoma penis� Peyronie's disease� Anatomy of the testis� Hydrocoele� Undescended testis� Ectopic testis� Varicocoele� Spermatocoele

� Epididymal cyst� Torsion testis� Testicular tumours� Fournier's gangrene� Fracture of penis� Male infertility

43. Differential Diagnosis of Haematuria 1115� Causes� History and examination� Investigations� Haematuria� History

Contents xxi

SECTION IV: SPECIALITIES

44. Chest Trauma, Cardiothoracic Surgery 1123� Chest trauma� Blunt trauma� Pulmonary injuries� Tracheobronchial injuries� Myocardial contusion� Surgical emphysema� Mediastinal emphysema� Mediastinal masses� Pulmonary aspergilloma� Congenital heart diseases� Patent ductus arteriosus� Coarctation of aorta� Coronary artery bypass graft� Off pump coronary artery bypass surgery� Abdominal aortic aneurysms (AAA)

45. Neurosurgery 1150� Head injuries

– Classification– Primary lesions– Secondary lesions

� Extradural/epidural haematoma� Chronic subdural haematoma� Raised intracranial pressure� Fracture skull� CSF rhinorrhoea� Pott's puffy tumour� Hydrocephalus� Brain tumours� Trigeminal neuralgia� Brainstem death

46. Principles of Radiology and Imaging 1163� Barium swallow� Barium meal� Barium meal follow-through� Barium enema� Enteroclysis� Angiography� Computed tomography� Ultrasonography� Magnetic resonance imaging� Interventional radiology� PET scan� Virtual colonoscopy

47. Principles of Clinical Radiation Oncology 1175and Chemotherapy� Radiation� Dose fractionation

� Sources and methods� Measurement� Clinical uses� Curative treatment� Palliative treatment� Radiotherapy reactions� Advances in radiation therapy� Oncology: Concise concepts of chemotherapy

48. Principles of Anaesthesiology 1189� Preoperative assessment and premedication� Regional anaesthesia� General anaesthetic agents� Muscle relaxants� Endotracheal intubation� Monitoring in anaesthesia� Local anaesthetics� Pain and its relief� Complications of anaesthesia� Cardiopulmonary resuscitation

49. Organ Transplantation 1228

� Principles of Transplantation– Pathophysiology– Major histocompatibility complex– Graft rejection

� Liver Transplantation– Indications– Contraindications– Donor criteria– MELD score– Types– Procedures

� Renal Transplantation– Donor– Procedures– Postoperative management– Complications

� Small Bowel Transplant– Indications– Contraindications– Recipient evaluation– Procedures– Complications

� Islet Cell Transplantation– Indications– Contraindications– Islet cell preparation– Technique– Complications

� Drugs used for Immunosuppression

Manipal Manual of Surgeryxxii

SECTION V: VIVA VOCE EXAMINATION

50. X-rays and Images 1241� Plain X-rays� Barium swallow� Barium meal� Barium enema� ERCP� T-tube cholangiography� Splenoportovenography (SPV)� CT scan� PET scan

51. Instruments 1250� Forceps� Retractors� Occlusion clamps� Dilators� Tracheostomy tube� Rubber tubes� Catheters� Sengstaken tube

52. Specimens 1264� TB lymphadenitis� Hodgkin’s lymphoma� Carcinoma tongue� Chronic gastric ulcer� Linitis plastica� Intussusception� Carcinoma rectum� Gangrenous appendicitis� Carcinoma colon� Meckel’s diverticulum� Polycystic kidney� Renal cell carcinoma� Hydronephrosis

� Carcinoma penis� Seminoma testis� Cholecystectomy� Hydatid cyst� Carcinoma stomach� Lipoma� Malignant melanoma� Thyroidectomy� Wide excision of skin� Whipple’s pancreaticoduodenectomy� Splenectomy

53. Operative Surgery, Laparoscopic Surgery 1273and Accessories� Appendicectomy� Herniorrhaphy: Bassini� Surgery for hydrocoele� Incision and drainage (I & D)� Incision of drainage of breast abscess� Circumcision� Venesection or cut down� Vasectomy� Tracheostomy� Suprapubic cystostomy (SPC)� Thyroidectomy� Amputations� Amputations in leg� Upper limb amputations� Open cholecystectomy� Vagotomy gastrojejunostomy (GJ)� Excision of swellings� Colonic surgery� Laparoscopic surgery� High frequency (HF) electrosurgery� Cryosurgery� Lasers in surgery� Staplers in surgery

Index 1309

Communication and CounsellingProf Ashok Godhi

Changing Scenario and the Need for Counselling

Health care has been witnessing phenomenal changesin the recent years. In the past, the doctors planned andadministered the treatment, the outcome of which waswillingly accepted by the patients; the paternalisticattitude was prevalent among the doctors. In choosingthe doctors and the hospitals, the patients had very littleoptions. Illiteracy was rampant and patients weregenerally ignorant about the diseases.

This scenario has been progressively changing in thelast few decades. The people have become moreeducated; the media has played its role in mass healtheducation; common man has some general knowledgeabout the common diseases. Doctors, corporate hospitalsand the nursing homes have proliferated and thepatients have the option of selecting the doctors andhospitals of their choice. Doctors have retracted fromthe paternalistic roles; patients have to participate in thedecision-making process. The phenomenal growth ofmedical science, astounding technological advances,increasing health care costs, improving awareness, risingexpectations of the patients, and most importantly theConsumer Protection Act have brought into sharp focusthe importance of communication and counselling inthe medical practice.

Counselling means exchange of ideas to reach aconclusion (Webster). There is hardly any place forcounselling while eliciting patients’ history; a formalconsent is required for physical examination, especiallythe internal examination, viz. DRE and PV. It is at theend of physical examination that the counselling skillsbecome increasingly important in explaining thediagnostic dilemma, accuracy of lab reports, treatmentoptions, outcome, complications and costs.

Aims of counselling:

• Explain medical details of the disease

Diagnostic dilemma

Lab reports and their accuracy

Treatment options and

Complications

Outcome

Cost

• Address psychosocial, emotional and spiritual issues

• Obtain consent

Explain Medical Details of the Disease

Diagnostic dilemma: The patients often expect thatevery disease should be accurately diagnosed in the firstvisit; in simple disease it is possible, but not incomplicated ones and if this is made known to them,their mind is prepared to accept subsequent changes inthe diagnosis. When the final diagnosis is less seriousthan the first, the patients are happy to accept it; but ifit is more serious, the patients are unhappy and tend tolose faith in the doctor. The intensity of these undesirableeffects of change in the diagnosis can be minimized byproper counselling, e.g. benign looking breast lumpturning out to be malignant in the HPR.

Accuracy of investigation and their complications:Many patients believe that it is possible to prove thediagnosis by lab tests and that more expensive tests aremore accurate; counselling should remove thismisconception; lab tests are not 100% sensitive andspecific. Patients with simple curable diseases do notpose much problem, but those with serious and life-threatening or incurable diseases often demand fool-proof lab diagnosis and such a proof is not alwayspossible to secure. In the absence of such a proof andwhen the lab test reports are conflicting, counsellingbecomes increasingly difficult, e.g. disagreementbetween the pathologists about the presence or absenceof cancer in the specimen. Counselling should alsoinclude a brief mention about the anticipated comp-lications of investigations, e.g. allergic reaction to IVcontrast.

Treatment options and their complications: That thepatient has to participate in the planning and executionof the treatment has become an accepted norm. Thedoctor has to offer treatment options, discuss the meritsand demerits of each of them and then decide toadminister it. Possible complications and their approxi-mate incidence should be discussed, e.g. recurrent nervepalsy in thyroid surgery.

Outcome: It is a fond desire of many patients that everydisease is completely curable. Many diseases, disabilitiesand deaths are not totally preventable by the mostmodern medicine. Discussion about the outcome oftreatment is especially important in surgical patientsbecause operation is an event which has no parallel in

Manipal Manual of Surgeryxxiv

non-surgical branches of medicine; and any adverse post-operative outcome is almost always attributed to surgery.In search of cure for incurable diseases, the patients keepchanging doctors and hospitals spending their resourcesuntil they are told and convinced that the cure isunachievable. Patients’ ability to cope with the diseaseand accept the outcome of treatment improves if it is toldto them before executing the treatment what is theanticipated outcome—palliation or cure.

Cost: It is better to overestimate the cost than tounderestimate it and to express it as a range than as afinite figure, unless it is a package.

Psycho-social, emotional and spiritual issues: Anxiety, illness,ability to function /earn, life span, social status

Fear: Pain, disability, deformity, disfigurement, death

Worry: Cost, family

Shy: Genital/sexual problem

Embarrassment: Previous treatment by some other doctor, askfor second opinion

Patients’ preferences, e.g. CPR in a dying patient

Address psychosocial, emotional and spiritual issues:Anxiety, fear, worry, shy, embarrassment, religious,cultural issues, and patients’ preferences are addressedon individual basis. Patients’ mental make-up and willpower have significant bearing on the management ofthe patients.

Methods of counselling: There is no single best methodsuitable for all patients on all occasions. Counselling isindividualized and personalized. Verbal counselling isthe most common method. Showing charts anddiagrams is an easy and effective way of convincing.Giving patient education material for reading orshowing videos are other methods. Showing otherpatients being treated for similar disease is quite helpful.The patients’ family physician can be used forcounselling because he has a better rapport with thepatient than the specialist. If there are a number ofpatients with the same/similar condition/disease (e.g.

maternity hospitals or cancer hospitals) groupcounselling is useful. Complex situations (e.g. livingdonor liver transplantations) need the services ofcounselling experts. Speaking the patients’ language andhaving good vocabulary and communication skillsmakes the job easier.

Factors influencing counselling: There are many factorsinfluencing the counselling. Patients’ background,literacy, level of understanding and trust in the doctorare the most important factors. Suspicious andindecisive mind of the patient is an obstacle. Patients’perceptions of doctor’s honesty, trustworthiness,dependability and intentions have their own measureof impact on counselling. Nature of illness, whethersimple to diagnose and treat with assured successfuloutcome, or a complex disease, difficult to diagnose andtreat with a guarded prognosis, or a fatal, incurabledisease have an important bearing on counselling.

Factors influencing counselling

Diseases

Curable, incurable, fatal

Patients’ perception about the doctors

Knowledge, competence and attitudes

Ethical, honest, trustworthy.

Compassionate, empathetic

Cheating, exploiting, indifferent

Patients and relatives

Trusting and faithful

Illiterate, ignorant

Educated, knowledgeable

Suspicious and doubting

Indecisive and procrastinating

Patients’ rights: Patients’ rights are supreme and shouldbe respected; right to refuse the plan of treatment, rightto information, to have second opinion, to change thedoctor and the hospital in the middle of treatment. Thedoctor need not feel embarrassed. The ConsumerProtection Act has given another right—right to file a

Methods of Counselling

• Verbal counselling

• Diagrams, charts, illustrations

• Printed literature for patient education

• Patient education video

• Show similar patients treated/being treated

• Using the patient’s family doctor for counselling

• Group counselling

• Counselling experts

Patients’ rights and counselling

Right to

• Refuse treatment

• Have second opinion

• Change the doctor/hospital in the middle of the treatment

Respect their rights

• Do not feel embarrassed/insulted

• Document

suit in the consumer forum. Many consumer casesagainst doctors are avoidable if every patient iscounselled properly and more importantly the coun-selling notes are documented and authenticated by thedoctor, patient’s relative and a witness. Some hospitalshave adopted video recording of the counselling as afoolproof method of documenting.

Counselling and the percentage: In medicine nothingis 100%. This should be used liberally while counselling,e.g. 10% conversion rate in lap chole; 50–60% 5 yearsurvival in cancer patient; 90–95% cure rate in herniarepair; 5–10% recurrence rate after fistulectomy; 50–60%chance of saving a diabetic foot.

Truth and Counselling:

• Tell the truth, the whole truth, nothing but the truth

• Truth is constant, consistent and durable

• Truth need not be remembered

• Bitter truth can be made more palatable

• When the whole truth is not known, tell what is known forsure

Truth and counselling: In a hurry/enthusiasm toconvince the patient, one is often tempted to overstepand overstate the positives and understate the negatives.It is always better to tell the truth, because truth isconstant, consistent and durable, and hence truth neednot be remembered.

Dos and don’ts: Do repeat, reinforce counselling at theappropriate time.

Don’t argue, confront, quarrel, give false assurances,guarantee 100% results, make adverse remarks aboutthe other doctors, give opinions or sensitive informationon phone.

Quality of counselling and its effects: Patients are in astate of physical, psychological, financial and emotionaldistress. Counselling should more or less address allthese issues; it should be cautious, careful, convincing,

re-assuring and consoling. It strengthens the faith andimproves reputation of the doctors and hospitals;establishes rapport, builds relationship, reducescomplaints, consumer cases, assaults and vandalism.

Substandard counselling is done carelessly, isindifferent, confusing and intimidating; it results in lossof faith and reputation of the doctors and hospitals,suspicion in doctor’s intentions, arguments andquarrels, assaults, ransacking, complaints and consumercases.

Counselling triangle: While counselling the doctorshould be acutely aware of the presence of others andplace himself in three different places—his own place,in the patient’s place and the place of the relatives andlook and listen to himself.

Consent: Consent form is an important documentaryevidence in the consumer forum. Printed consent formwhich is usually signed by the patient/relative at thetime of admission, giving blanket consent for all testsand treatment is a weak evidence. Consent taken aftercounselling notes are documented is strong evidenceand can save the doctors from many consumer cases.

Communication and counselling skills are put to acidtest by worst situation such as when the treatmentresults in a severe adverse outcome due to mostunanticipated rare complication, e.g. death due to drugreaction. A successful counselling will convince, consoleand calm the agitated and aggrieved relatives whounderstand the human limitations of the doctors andthe uncertainties of the medical science. Conversely,unsuccessful counselling can result in an extremelyunhappy patient even if the treatment of a complicateddisease was successful and the team of doctors wereextremely happy about the outcome.

Counselling is an art more than science. As much ashare of success of a doctor in the practice of medicinegoes to communication and counselling skills as hismedical knowledge and technical skills.

Communication and Counselling xxv

Doctor–Patient Relationship

Referring to the work of physicians, Dr. Elmer Hess, aformer President of the American Medical Association,once wrote: “There is no greater reward in ourprofession than the knowledge that God has entrustedus with the physical care of His people. The Almightyhas reserved for Himself the power to create life, butHe has assigned to a few of us the responsibility ofkeeping in good repair the bodies in which this life issustained.” Accordingly, reverence for human life andindividual dignity is both the hallmark of a goodphysician and the key to truly beneficial advances inmedicine.

Introduction: What prompted me to select this topic tobe written and published? The answer lies in theobservation that litigations against doctors are becomingcommon. Doctors are being targeted often not onlybecause of complications that happened during theirtreatment of patients but also because they do not haveunity. Expectations from the patients are high and thereasons for litigations are many. Patients expect thatdoctors provide a complete and even miraculous cure.Patients and their relatives feel that the hospital anddoctors have charged exorbitant fees but they did notget cured or developed complications or the patient hasdied. Patients are aware of consumer courts. Manylawyers are ready to support their clients and get themcompensation. All these are facts. Complications areknown to occur in spite of the best treatment. The mainfactor often missing in this entire scenario is the vitaldoctor–patient relationship. This article highlights theimportance of a good rapport between the doctor andthe patient. The following points are important not onlyto maintain doctor–patient relationship but also todecrease friction between the patient and the doctor.

Attitude: Attitude of a doctor towards the patient is thefirst step which builds a rapport between the two. Whenthe patient is in pain and is suffering, identify thecondition properly, treat it and console them. Ratherthan treat them like customers at a hotel or a shop, ahumanitarian approach to make them comfortablewould be much more appropriate and help build a goodrelationship.

Benevolent: A doctor should be gentle while receivingthe patient and then examining the patient. He should

have sympathy and understanding towards the patient.That does not mean that he should shed tears. The doctorshould be kindhearted, gracious, considerate andcompassionate.

Communication, Competency and Continued Learning:The doctor–patient relationship starts from the first visitof the patient to the doctor. The first impression is thebest impression. Good communication skills impress.If we look back to 20–30 years ago, our family physiciansdid not even have MBBS degree, leave alone speciali-sation and superspecialisation. They were ready to listento the patient, do home visits, attend midnight calls andaccept whatever money that was given to them. Doctorswere looked upon as Gods and patients accepted bothsuccess and failure. Their success was largely becauseof good communication skills. The world is changingat a great speed and moving ahead. Communicationalone does not heal and good medical care is needed.Medicine is changing. We cannot sit idle withoutupdating our knowledge. With continuous medicaleducation, theoretical knowledge can be updated. Onecan improve skills by attending conferences, watchingsurgeries in workshops and thus attain competency.Patients also feel happy that the doctor has attendedmany conferences all over the world and has improvedhis knowledge.

Dignity and diversity: India is a country of multiplelanguages and many cultures. Diversity is our strength.The doctor should be sensitive to these culturaldifferences while treating the patients. Give respect totheir culture and appreciate rather than discourage orargue. Our deeds should not have any deleterious effecton the body or mind.

Evidence-based practice and ethics: Every doctorshould appreciate the need for update and be familiarwith different therapeutic modalities, administration of“essential drugs” and their common side effects. Thelatest available after information should be passed onto the patient with scientific data so that he is aware ofwhat best solution for the present problem. Knowledgeis strength and that gives us confidence while talkingto the patient or while attending the courts. Whilemaking the patient comfortable, it is not just enough totell him what disease he has and what can be done.

Manipal Manual of Surgeryxxviii

Convey the various options available and the cost ofthe treatment. Most often, problem arises because ofinadequate information and options. Often the patientsays, ‘Doctor, you do it’. I still do open hernia repairbut I tell my patients about laparoscopic hernia repair.Vast majority of patients agree to what you say. Whenyou cannot do it or do not have facilities, it is better torefer to higher centres rather than provide substandardinitial treatment.

Family physician: In the present times, a surgeon or aphysician cannot truly become a family physicianbecause of specialization. However, we can have all thecharacteristics of a family physician. To name a few:Patient listening, maintaining a smile even at the latenight clinic, enquiring about the patient's professionallife, family life add a personal touch to the practice ofmedicine. They really used to satisfy an importantmission of doing MBBS, i.e. being competent to practicepreventive, promotive, curative and rehabilitativemedicine with respect to the commonly encounteredhealth problems in a patient and in community.

Get Help: Call for help is the most important step intoday’s practice, especially when a complicate surgicalprocedure is planned. It is better to inform the patientthat I have taken/am taking my colleague’s help. It isvital to obtain a proper informed consent afterexplaining all possible complications to the patient.

These are ABCDEFG of doctor–patient relationship.

Conclusion

Just look back at the Hippocratic oath we took whenwe joined medical school (for me, 1977). How many ofus remember the oath? We have worked hard to get thebasic MBBS degree and then postgraduation. Weacquired the basic knowledge to diagnose and managecommon health problems of the individual and thecommunity appropriate to our position as a member ofthe health team at primary, secondary and tertiary levels.We need to introspect about keeping our house neat.These are my final thoughts which are simple andcommon:

1. We must know and accept our limitations.2. Refer patients on time, not late.3. Communicate with patients and their families

effectively.4. Do what is required for the patient at the moment

without commenting on the past or commenting onothers’ treatment.

5. Do not negate patient’s views even after youconvince effectively.

6. Do not react impulsively and adversely.7. Be patient with your patients8. Do your job to satisfy your conscience.9. Be united in critical times.

10. Keep yourself updated about your subject.Wish you all the best, my dear students! I wish you a

bright future.

K Rajgopal Shenoy

Anitha Shenoy (Nileshwar)