The need for Inpatient Department (IPD) Training for a Homoeopath
If we reflect back on the journey we travelled as homoeopathic students who wanted to learn to be an IPD based physician, a lot of issues come up. As a student there is generally a fascination with some subject and consultant. Perhaps a practitioner of Internal Medicine, a Neurologist, an ICU interventionist would be the role models. Some of us are fortunate to find encouraging teachers who keep the desire alive and set a high standard for practicing Medicine. The like minded senior colleagues gave the right direction to acquire the various skills.
Being a homoeopath there are lingering doubts as to how one could ever legally treat emergency care patients, as the allopathic consultant does. Can a homoeopathic physician admit and treat patients under his care in the IPD? What actually is an IPD, and what is the IPD patient like?
Simply put, the IPD patient is a patient who cannot be managed at home. Our common experience is that of the OPD patient. This patient comes to us with a certain complaint and we prescribe after the necessary examination and assessment. Generally, once we prescribe we see the patient after a week, or may be after 2-3 days in acute cases. We may even see them daily if the condition demands attention. All we do after such an evaluation is ‘prescribe’. We may advise dietary changes, rest, etc. but not really do much apart from that. Maybe the patient does not require anything more than this. In common experience when the demands / requirements of the patient go beyond this, he goes to a hospital and is most of the time admitted.
Such a patient needs rest, special care in understanding the diagnosis, lab investigations, maintenance of nutrition and fluid-electrolyte balance, other nursing care and medicines for treating the underlying illness and its cause. As homoeopathic physicians we are acquainted with only the last part of the management, i.e. ‘prescribing’. Management of the patient in the IPD, as we have seen, is more than just prescribing medicine. We need to institute the ancillary measures as well. The medicines may be homoeopathic, but they cannot replace the needed ancillary measures. Medicines will not generate fluid in the severely dehydrated, nor will they drain the GI secretions in the patient with pancreatitis and IV fluids and Ryle’s tube aspiration respectively, are necessary. One cannot live in a dream world that one can manage such cases by only prescribing homoeopathic medicines, while another doctor looks into the ancillary management. In contemporary medical practice, this shortcoming of the homoeopathic physician has brought on ridicule as a system only for chronic illnesses and having no role in acute distressing illnesses.
We know that this supposed limitation of homoeopathy is not the truth and most of us must have had some exceptional experience of the wonder of the science in the IPD at some point of time. But the experiences are an exception and not the rule. We need to understand the reason behind this shortcoming. The simplest reason is the lack of training in the area and the amount of clinical exposure that homoeopathic students have. We know only when we see, we learn only when we do. Unfortunately we do not have homoeopathic setups to impart the training that is needed for this specialized job. Hence we need to look to the allopathic hospitals for the necessary training. This need not trouble our self respect as the training only moves us closer to achieve the Mission that the Master has set.
The constituents of IPD training module
Looking at the training required for the homoeopathic physician to enable him to manage an IPD set up, we would be able to highlight the following:
What is to be taught? How is it to be taught?
Patient care: Yes, this needs to be taught! A suffering person is not always the best sight to the tender eyes of a budding young physician. The house post provides an opportunity to be in close contact with the patient and gather experience to enable him to become tougher-emotionally. Caring for the patient is not just feeling sympathy, but making sure that the patient receives the appropriate treatment. Care of the person along with the disease is most important. Maintaining this goes a long way in the management of the patient.
Clinical care: This is the main reason for the admission of the patient. Quickness in action is the key. The plan of diagnostic evaluation and treatment is drawn up at the time of the admission and needs to be followed accurately and promptly in order to identify the disease and arrest its progress. Relieving the most distressing symptom, mostly pain, should be on the priority list after the initial diagnostic evaluation. A close follow up of the progress of the illness or recovery makes sure that nothing is left unattended and nothing is hidden from the physician’s eye. Here the resident plays the role of the consultant’s eyes and hands at the bed-side to assess and deliver patient care.
The bedrock of IPD training
The most essential aspect of working in the Homoeopathic IPD is the attitude that one works with. The resident needs to evolve the attitude of an IPD based homoeopathic physician. This means being ready to face the adversities generally encountered in homoeopathic management of a case which are more severe than in the OPD set up. It means being ready for the responsibility of managing the patient which is much more than just prescribing a remedy. Only the evolution of this attitude will allow the student to fully integrate and apply his training. Teaching him to develop a positive attitude in this direction is the foundation for IPD training.
Ingredients of IPD Training
Going in to the specifics, the resident needs to be thorough in the following skills:
1. History taking: This basic part of the medical evaluation becomes very significant, simply due to the variable times at which it is done. Sometimes a patient might need case-definition late at night. The resident has to be trained to do this specialized job at such odd hours.
2. Examination skills: A sound grasp of the general and systemic examination methods is needed to make a rational assessment of the clinical state.
3. Need of Investigation and interpretation: Knowledge about the need for appropriate investigations (tests) in a particular case is of immense importance in the management. Preparation to be made before a particular investigation needs to be known in order to get the correct and valid results. One needs to be careful about over or under investigating the patient for financial reasons.
4. Bed-side procedural skills: Securing an intra-venous line, Ryle’s tube insertion, starting nasal oxygen, bladder catheterization, etc. should be known, as they could help relieve distress immediately. Knowing minor surgical procedures helps in the management of the patient on homoeopathic treatment and expands the scope for homoeopathic management of cases otherwise treated by the surgeon. Knowing Life saving procedures proves to be a boon when the resident faces a near-death patient. For the dying patient, it really does not matter whether the attending doctor was a homoeopath or an allopath.
5. The discharge: This could be for the patient who gets well or one who doesn’t. The patient who gets well sets a positive feeling state in the treating team. This patient should receive appropriate advice for the medication, diet and further follow ups. The difficulty occurs when the patient leaves either against medical advice or is transferred to a higher institute. Though this patient may create a negative feeling in the treating team as a failure of management, the patient needs to be transferred with adequate respect and concern.
6. Documentation: The importance of scrupulous documentation of the clinical data, the investigations, the treatment and the plan of action makes the team function without confusion. The patient’s progress over time can be easily assessed, based on the follow up criteria mentioned in the record. The nursing chart ensures that the orders are followed well. This becomes important from the medico-legal point as the growing consumerism in the health care field makes the physician accountable for the actions taken or not taken. The actions taken on the basis of evidence need to be clearly documented for easy reference when required. The complete document serves a number of purposes – medico-legal, educational, research purposes. The resident has to be taught to keep such meticulous records.
7. Team work: A single person can never manage all the things that we have discussed. A team is needed. The team consists of the houseman, senior resident, the registrar, the medical officer, the chief medical officer and the consultant. The nursing staff gives a helping hand in effectively delivering care to the patient. Thus a multi-layered system makes sure that the team consists of at least one person who has all the required skills in delivering quality patient care. A smooth coordination and communication between these is of utmost importance in managing the IPD patient. Each one has a specific role and that has to be played in the hierarchy stated above. The core objective of the team is patient care, and this should not be compromised at any cost. Individual objectives and ideas that do not come in synchrony with the common goal are in fact detrimental to the patient and should not be entertained. One needs to rise above one’s own ideas and follow the rational plan based on scientific logic and knowledge. This provides the houseman with an opportunity to be a part of the management and at the same time learn without taking up sole responsibility of the patient’s treatment. He is responsible for his own learning and following the orders.
8. The learning: The homoeopathic physician is used to seeing a particular type of patient that comes to him in the OPD. There is a limited number of clinical conditions that he is called on to treat. The IPD set up opens up a vast untapped and hitherto unknown area that the homoeopathic physician can venture into. The IPD provides an opportunity for application of homoeopathy in these cases, and thus gives an opportunity to judge the scope and limitation of homoeopathy. The resident needs to experience this in order to become competent in handling more complicated cases than he is normally called on to treat.
Ancillary skills in IPD Care
Care of Relatives : Any patient is accompanied by a group of relatives who are themselves in distress because of the ailing patient. They have a number of questions and difficulties of their own. A dozen relatives with a young child with an acute asthmatic episode is not an easy situation to deal with. There could be different levels of tolerance and anxiety on their part and the resident has to face and handle the situation with confidence and tact. This can be learned only by observing an expert handle the situation under different circumstances. Clear communication with the relatives avoids a lot of confusion between the doctor and the relatives. This forms an important part of the human care too.
Administrative care: The resident not only has to manage the patient clinically, he also needs to attend to administrative services that allow the clinical management to run smoothly. Looking after the nursing personnel, the accounts, the floor management, maintaining hygiene in the hospital, etc. helps him to provide services to the patient in the proper time. Who else would know the needs of the patient better than the physician himself? He need not become the administrator, but he can keep a watch over the administrator.
With an idea about what is to be learned / taught in the IPD we can focus on how such training can be provided. The following points demonstrate the essential aspects of the training in the IPD.
The nitty-gritty of IPD Training
The location: The obvious place for conducting such training is the hospital ward itself. One cannot make commandos in the class room. The aspirant needs to be put through the adversities to learn adaptation and develop the ability to fight in the worst of circumstances. Similarly, the homoeopathic IPD physician has to be trained in the IPD. Either it needs to be created or the existing allopathic set up should be made use of.
The stay: The trainee student is required to stay on campus 24 hrs in order to attend to the patient who may come for help at any time, or the patient in the ward who may require attention in the middle of the night. The time is unpredictable and hence the presence of the student is required at all the times. He should be given at least three days of a 24 hour on-call duty and the rest of the three days of a half (8-10 hours) duty. The free time is required for personal work as well as academic assignments.
The stamina: We have listed a number of duties to be performed by the resident and those too at odd hours. This calls being physically present at the site. Hence physical stamina is the first thing the resident has to develop. Developing physical stamina without any mental capacity to sustain interest and attention is futile. One needs to be trained to put his mind to work at any time of the day. Along with this one also needs to have adequate emotional strength to stabilize oneself to deal with the suffering and pain that one sees so often.
The rounds: The first thing that the resident does in the morning is taking rounds in the ward. This consists of taking a follow up of the patient, checking his vital parameters, giving fresh orders for the treatment during the day (after informing the consultant). The junior resident has to learn the communication pattern from the senior. The second round with the senior consists of case presentation and discussion on clinical decision making. This is the site for maximum learning, as theoretical knowledge and practical experiences get consolidated in the form of action learning. The consultant’s rounds add icing on the cake for the learner where he can clarify his queries and doubts about the patient, diagnosis and treatment. The vast experience of the consultant has its own importance vis-Ã -vis the theoretical knowledge. This helps in integrating the theoretical knowledge with the practical.
The library: The library has to be utilised to its maximum in order to consolidate the clinical experience. The undergraduate theoretical study has to get converted into a clinically oriented study while enhancing practical knowledge. Latest updates in medicine have to be incorporated in the diagnostic as well as therapeutic decision making in patient care.
Rejuvenation: Every rigorous effort results in wear and tear of the body, which needs some time to recuperate. Recreational activities at periodic intervals go a long way in maintaining the efficiency, enthusiasm and mental state of the resident.
Thus the IPD training of the student of homoeopathy essentially revolves around the attitude, knowledge and skills that a homoeopathic student is expected to manifest. The faculty bears equal responsibility for providing the environment required for the adequate development of the fresh graduate into an IPD based homoeopathic consultant. The field also opens up a vast area for evidence-based clinical research in homoeopathy, which is not so easy at the OPD level. The resident can also take part in the research, and may develop into a researcher eventually making significant contribution to the science.
Dr. Aditya N. Tiwari M.D. (Hom.)
Formerly Medical Officer, Department of Psychiatry,
Rural Homoeopathic Hospital, Palghar
Dr Navin Pawaskar M.D (Hom)
Director, Hospital Services
Dr. M. L. Dhawale Memorial Group of Organizations
Dr. K. M. Dhawale M.D. D.P.M. M. F. Hom. (Lond.)
Dr. M. L. Dhawale Memorial Group of Organizations