This is a complete, edited transcript of Episode#1 of the You+AI podcast.
Podcast and Host intro
Ranga 0:01
Hello and welcome. Youplusai is pleased to present a podcast series on healthcare and artificial intelligence. In this season, we are focused on doctors to get their perspectives of healthcare practice, largely in Indian context, understand the challenges, and then brainstorm together where artificial intelligence could play a role that could result in better outcomes for all.
I am Ranga, the host of the youplusai podcast and the human face of youplusai in Twitter, SoundCloud, Medium, and YouTube. After getting my Master’s in Electrical Engineering from Stanford University, I have been a technologist all my life in the networking domain, working for Hewlett Packard Enterprise and then for Aruba networks. I am passionate about artificial intelligence and this is my effort to bring awareness on both sides, that is for medical practitioners to know what kind of solutions artificial intelligence can bring forth and for technologists to understand the challenges and problems that face healthcare practice in the Indian context.
Guest intro
Today, our guest in the youplusai podcast is Dr. T. R. Gopalan.
Dr. T. R. Gopalan got his MBBS and MS From the prestigious Maulana Azad Medical College in New Delhi. He was conferred the fellowship of the Royal College of Surgeons and physicians from Glasgow, United Kingdom. He was attached to Sri Ramachandra Medical College and Research Institute, Chennai as a professor of general surgery. Thereafter, he worked as the Dean of the Sathya Sai Medical College near Chennai. He has more than 4 decades of experience in the various aspects connected to general surgery, education, healthcare, and research. So, let’s welcome Dr. T. R. Gopalan and get to it.
Dr. TRG 2:35
Hi, thanks, Ranga. That’s nice to be with you on the show.
What are the key challenges in Doctor-Patient interaction?
Ranga 2:38
Great doctor. So let’s, let me ask you, first of all, I mean, you have had a wealth of experience of being a practitioner, clinical practitioner in India and also in UAE. I would just want to know from your perspective, what do you see the main challenges in Doctor-Patient interaction in a developing country like India?
Dr. TRG 3:05
Well, that’s a very interesting question Ranga. The most important aspect of the doctor patient relationship is basically to develop a good sense of trust between the doctor and the patient, and obviously, the patient has to trust the doctor. At the same time, the doctor has to get the right type of information from the patient. So this sort of trust is built over a period of years of time. And that’s based basically on good communication skills between the patient and the doctor.
So you got to be listening to the patient so that you will be able to communicate better with the patient. So that eventually gives you a long lasting doctor patient relationship.
Ranga 3:57
So you’re saying that when the patient comes and meets you, you’re saying that the doctors, in meeting with the patient should have a patient ear for listening to the patient’s problems and the concerns, and that is sort of foundational to the trust that will get built over time.
Dr. TRG 4:15
Yeah, sadly, the point what’s happening in most countries, including India is that as soon as the patient starts telling his symptoms or his problems, as early as even 10 to 15 seconds, the patient is interrupted by the clinician.
Ranga
Wow.
Dr. TRG
..and 10 to 15 seconds the interruption starts. That is he is not given a chance to complete exactly what he’s supposed to be telling you. And that’s the challenge which as a clinician we are able to face because the reason for that is that the clinician is probably over pressed with the fact that he has got too many patients to see in too little time and therefore, he tries to rush of things.
Ranga 5:04
So, is this true of when you talk about too many patients in a short span of time, is this true of only developing countries like India where typically I think, I don’t know the exact doctor to people ratio in India, but I believe that the World Health Organization publishes statistics. So, is it because, a developing country like India has a huge population and the number of doctors are lesser, that’s why doctors see many more patients and therefore this kind of an issue happens?
Dr. TRG 5:38
See, traditionally, what the WHO recommends is a 1 in 1000, the doctor patient ratio. There are countries like USA, Canada, Australia, UK, they’re all well over 3 to 4 per 1000. India is still less than 1 per 1000, alongside Afghanistan, Bangladesh, Pakistan, etc. So there is definitely a paucity of the doctor patient ratio. And needless to say, the nurses to patient ratio is still worse. So the population is one issue, but we are never able to catch up with the doctor patient ratio in spite of the overwhelming growth of private and other institutions coming up in the country. So one of the causes of the overload on patients and especially in hospitals can be the amount of cases and the paucity of doctors.
Ranga 6:40
Right and then,
so you talked about sort of patients getting interrupted in 10 to 15 seconds when they come in and they try and explain their case or their problems. Obviously, because like you said, that doctors are hard pressed and probably they want to come to a diagnosis very quickly. What could be the downside of this, like, for example, let’s say, maybe the patient has something to say that doesn’t come out in the communication? What could be the downsides of sort of this kind of an interrupted interaction that you have?
Dr. TRG 7:13
See the the real downside is that the patient wants to tell a host of information to the doctor, for him to be enabling him to make a diagnosis. So probably if he has more time and gives a better hearing to the patient, he will be able to get at the finer points. I’ll just give you a simple example. Sometimes I have seen the doctor telling the patient, why did you tell me you’re a diabetic? And the patient tells me sir, but you never asked me.
Ranga 7:45
Okay.
Dr. TRG 7:46
So that’s the issue. So basically, it is the doctor patient relationship. Basically, I’m saying the foundation lies on a good communication between the patient and the doctor and that communication seems to definitely improve I mean, it means a lot depends on the listening capacity of the doctor, to the patient. And when the doctor gives the diagnosis and he gives the instructions, it’s for the patient’s time to listen to the doctor and follow the instructions as what the doctor says.
Ranga 8:16
So would you say that by some means, if we are able to give more time, let’s take an example. Let’s say that typical doctor patient meeting last a few minutes today. And now let’s say you were able to improve it by 20% or 30%. Right? Would you think that this would lead to better outcomes of understanding and building sort of the trust because now we have more time to sort of exchange information and sort of get to the right root cause of things?
Dr. TRG 8:56
Absolutely. You see, there are a number of specialties in the clinical side where the patient doctor communication is very vital. And that gives a strength of the foundation of the trust. There are certain specialties like radiology and pathology, where the doctor may not be required to be in a direct relationship with the patient. So it may not matter so much. But in a scenario like this, it will be excellent if all what the patient wants to say, is already gotten to the doctor beforehand, so that he gets the complete history. And so you can start from that foundation. The whole point is that patient feels that he is not heard well, so if the doctor is able to somehow pass on the message that yes, I have gone through your data, I got everything what I wanted to know, I read through it, but I need to have a certain clarifications on these things, then I think the trust will definitely grow beyond that level.
Ranga 9:52
Wow. So doctor, I want to ask you, in India especially, maybe I’m more familiar with India than other places. I’m sure you must have seen different kinds of patients. See some patients who come in, to the aspect of data that you were speaking to – some patients may have a lot of reports, they might have been tested at multiple labs, maybe they know their medical history, they can give you an idea of what medicines they’re taking and all that upfront, or at least if they are asked the right questions, they can tell you that. But then there must also be patients who are very low on this data, like probably they haven’t gotten the right reports, or maybe the earlier guidance was not so correct, and they have come here. So how would you look at these different classes of patients and come to some sort of a sort of a working plan of how to move forward? How would you categorize them first of all, and how would you address each of these cases?
Dr. TRG 11:02
See, when it comes to categorization, I don’t think there is a standard guideline which is available off the record. But I can tell you one thing for sure that in India, only less than 10% of the patients of all formats would be having data in a in a in a classified manner to be handed over to the doctor. All other cases, including the educated persons, the influential people, or the so called business people, or whatever it is, somehow the investigations, the reports are all haywire and when a doctor asks any particular report, he seems to be saying – yeah, sometime back, we got the surgery done but the pathology report is missing. They told me it was not a tumor, and things like that, so it’s always ifs and buts and it’s very, very difficult. I would say just less than 10% of them really having the data in a very organized fashion, and that is a very great challenge among Indian patients. That also would be one of the factors in the outpatient department which is very busy. The patient comes in shoves about 60 reports of reports starting from 1967 onwards, it will be very difficult for the doctor to sit and see those reports at that point of time. So, that said, if things can be classified, and given in a nice format, I’m sure it will help the clinician to a large extent. Then they concentrate more on the diagnosis and treatment rather than spending time looking at these papers.
Ranga 12:38
So from what you said, Doctor, it seems like both are a problem – one the person who has excessive amount of data like you said, I present you data from the last 10-15 years, starting from all the ailments I had – that also is a problem because it probably introduces more that is not needed at the relevant time. of the incident. And on the other hand, people hardly have anything – they have missed reports, they have missed diagnosis, or as you said in the right example, somebody forgot to tell you that he has diabetes but had a full conversation. So I guess both ends of the spectrum are problematic, if I were to understand.
Dr. TRG 13:21
Absolutely. I think most of us would agree that that’s the issue basically.
Ranga 13:29
As we talked about, there are all these different dimensions of data like lab reports and what the person tells you and perhaps the physical examination that you will do. So what is the most basic set of patient data that is required by you to make the next right step as far as diagnosis goes? What is sort of the minimal data that you are looking at, which gives you the right information?
Dr. TRG 13:57
Again, I’ll tell you and quote you what exactly has been told in years and years of proper medical education. That almost 85% of the clinical diagnosis is made on a good history and a physical exam. Another 10% of the diagnosis can be made by laboratory investigations, etc. There may be about 5% of the cases who may not be able to come to a diagnosis even after several investigations. So what I’m trying to say is let’s concentrate on the 85% of the patients – where everybody says, here’s a patient, willing to give you the diagnosis by giving you a good history. And therefore we tell right from our medical school, that’s about the as soon as the graduated enters into medical school, when he passes out through one and a half years of his anatomy, physiology and biochemistry and comes into the clinical classes. We tell them to go through a regular history taking and physical examination of the patient. And there is a particular pattern of history taking, it says history of present illness, history of past history, personal history, socio economic history, dietary history, allergic history, history of immunizations, history of any insurance, if you have any allergies, so, all these things have to be documented in a particularly regular fashion, history of any previous surgeries and things like that. So, this is what is called as a good clinical history. And people say that when a clinical history is taken well, you will be able to come to a fairly reasonable clinical diagnosis based on which you can conduct a certain set of physical examination of the patient.
And that physical examination will be divided into two groups. We call it as a general physical examination where we do a general examination of the patient – how his eyes are, ears, vision, tongue color, pallor, anaemia, pulse, blood pressure, respiration etc. And then we come to a local systematic examination of which particular system is involved. Suppose it’s a digestive system, we examine the abdomen, suppose it’s a respiratory, we examine the lungs, suppose it’s cardiovascular, we examine the cardiovascular system, and so on and so forth. And then neurological examination. So with all these things, we do a history and the general physical examination and local systematic examination, we will say that we will come to a fairly important clinical diagnosis in almost 80% of the cases for sure.
How would you interpret the socio-economic history of the patient?
Ranga 16:36
Doctor, the dimensions of history you mentioned, some of them I probably never heard of, at least in the context of a doctor patient interaction. For example, could you tell us more about the term socio economic history – what is that? How would you interpret that?
Dr. TRG 16:55
Excellent. That’s a very, that’s a very valid point. See, because I tell you, it’s very important to know about the socio economic history, because there are people in India and of the Third World who all come from a very low socio economic strata. So, it’s very important to tailor and what is expected, they may not be able to express everything to you. So, you may need to spend a little more time to get the good and the rightful history from those patients. They are not very well educated, they cannot tell you in that much quick fashion exactly what they need to know – as far as that is concerned. There are a set of patterns of diseases, for example, diarrheal diseases, infectious diseases, which happen in the lower socio economic group. In fact, in India, especially another thing poverty, hunger, malnutrition is one of the very common thing which happens still in the lower socio economic strata. So, the diagnosis is based on also the taking the socio economic history into consideration.
Coming back to the importance of socioeconomic history again – when the doctor finishes the diagnosis and comes to a diagnosis, treatment and wants to explain the treatment modality, he must tailor his talking to the patient based on the socio economic status of the patient. For example, if he is wanting to talk about a cancer and he wants to talk about surgery, he must tell in such a fashion to this patient, who is let us say a plumber or a carpenter or a farmer – in such a term that will be acceptable to him and he will be able to understand what we are talking. There’s no point suddenly talking about tumor markers and suddenly talking about immunohistochemistry to those people. It’s not for the doctor to tell or vomit out whatever he has in his head to the patient – he must tailor his statement to what the patient would understand.
To get an idea of the socio economic history, you will know for example, you see a lot of diseases are caused by Beedi smoking. Beedi is a particularly common thing of the low social socio economic strata, so is betel-nut or paan chewing. There are certain particular diseases which come to that particular group of people. I think socioeconomic status indirectly next links to the dietary history. I’m sure I’ve seen some doctors telling to a patient suddenly, okay, you’ll have to take two eggs, you like to take two glasses of milk, etc, you’re going to talk to this to a very low socio economic status patient. They are the ones who don’t even have one glass of milk for themselves. So I think we have to be more realistic and practical. And I think socio economic history is very, very important. We must take it in such a fashion which does not hurt the patient. When you ask him, how many people are working in your house, roughly how much money you make. So what is the thing, so I think it’s all important to suggest those things to make a reasonable diagnosis and tell it to the patient in the fashion which he can digest.
Ranga 19:55
Very valid points doctor. I certainly wouldn’t have thought that – in fact this is almost like you’re a professor talking to your student because the professor may know so many things, but if he tells in that language, no student is going to understand it. So somewhere, you have to get to the level of the student and make it easy for them to kind of understand what you’re saying.
Dr. TRG 20:17
Absolutely correct. I think your comparison is quite good.
Ranga 20:21
And you also mentioned about insurance history. So is this is to find out whether they have insurance or not and sort of tailor the treatment modality based on that?
Dr. TRG 20:35
See now the one is the fact that there are a number of schemes which are available for even for the common person about insurance. We’ve got the Prime Minister’s health insurance schemes. we have the Chief Minister’s health insurance schemes, which are now actually percolated into almost all district hospitals. So once you know that the patient has got some element of cover, we can offer the sort of the treatment of choice, what is ideal for the patient, because it is all covered up. For example, I’m just trying to tell you that if you’re going to talk about a coronary artery block, who will require a stent. And if it’s going to be covered partially even by the scheme of insurance scheme, what I’m talking about, I mean, the patient would be extremely happy and relieved to hear about it. So the insurance history is very important. And wherever the insurance is not there, we’ll have to talk about other modalities of treatment, what is tailored to that particular group of people? I think insurance plays a very vital role nowadays.
How could data relevant to the patient be put together?
Ranga 21:36
Interesting. So doctor, on that track, right, so you talked about different kinds of history. And essentially, what all of this history is, is data about the patient, so that you get a very comprehensive view about the patient in different dimensions, like you said in socio economic dimensions, insurance dimension, dietary dimension, family history, hereditary, drug medical history, then history of the present illness that you talked about. And then you sort of combine it with the physical exam, because physical exam is at the point that the patient contacts you. Now, again, sticking on the data part of it, right – how do you think this data could be sort of put together? For example, I’m just thinking whether patients these days with the penetration of mobile phones in India – I was wondering whether people using their mobile phones could record simple symptoms that they have.
Sometime back when I had a fever and a sore throat, and in fact, I was asking my doctor to recommend whether I should have antibiotics. And he said that – well, we’ll get to that later. But make sure you monitor your fever every four hours. And then you have the fever medicine, one in the morning and one in the evening, you monitor for fever every four hours and note down. And then you also look out for other conditions, like whether you’re having a vomiting or whether you’re having appetite, and note all of these down. Then come back to me after two to three days. And then we’ll take a call on whether you really need to be going on antibiotics or not. So I was religiously doing that. So based on that, and based on what you said about history, I was wondering if there is a role that the patients could play in recording such things such that it gives a better view to the doctor, maybe not in all dimensions, but at least in some dimensions?
Dr. TRG 23:37
Now, certainly, I think today, as you said, in view of the mobile technology, and now obviously everybody has a mobile phone in India, almost. So I think if suppose I’ll just give certain examples. One of the example what you quoted was very correct about fever. See, when we want to know about fever, we talk generally about the three types of fever a continuous fever, intermittent fever or a remittent fever. The doctor wants to know, has the fever ever touched normal?
Dr. TRG 24:07
That question is asked, the patient invariably says that I’m not sure. But I think it may be normal. So if there was a system, definitely on the mobile phone, simple technology, which can just record this temperature, and he said, this was the temperature morning, six o’clock, this was at 10 o’clock, this was at 2 o’clock and this was at evening six o’clock, he will be able to tell the doctor exactly the pattern whether the fever has ever come down, has it touched normal, or it has always been about normal.
Dr. TRG 24:35
And similarly, I like to quote here in another example, about cough. Suppose you’re having a particular type of cough and the doctor wants to know, is it a productive cough or non productive cough? Is it a cough producing sputum or not producing sputum? What is it? What is the color of the sputum? Is it yellowish color or mucus tinged? So all these things and what is the nature of cough? Is it a dry cough? Is it a wet cough? Is it a continuous type of cough? Or is it one big cough? So this can exactly tell you whether the cough is arising from the upper airway, or middle airway, or even the lowermost airway, which comes from the lungs. So all that the patient needs to do is to record his cough and say, Doctor, this is the type of cough I’ve been having for the last 10 days or five days. And that can give an exact clue. The doctor may suggest that your cough looks like actually it’s coming from the lower respiratory airway.
Similarly, the pulse rate as you said, the other way today, which we can use it is when people most did a lot of diabetics, India as a diabetic capital. So we are asking people to record the blood sugars, we know he does a blood sugar he records it on his mobile phone, keeps a track of it and just tells these are the blood sugars over the last one week doctor – fasting you wanted. So then I, I think the technology of mobile technology can be used so well, all that they need a little bit of patient education. And I think it can be a fine medium of patient storage of the various data which the patient can give to the doctor.
Ranga 26:16
Yeah, like I said, see even the questions that you asked about cough, even if I were to go to my doctor, and if he asked me, I can for sure tell you I would be puzzled. I don’t think I’m able to remember all that and give you proper answers short of coughing right in front of you. So I probably couldn’t do that. So I think maybe that’s a good example if we could take a video or, or even an audio of somebody coughing, who has had a persistent coughing, and maybe that itself would be a good proof point to the doctor. That would help the doctor further diagnose where the problem is.
Dr. TRG 27:01
Ranga, in the same tone, if the cough is actually coming from the upper airway, there’s no point wasting an X ray chest for the patient.
Ranga 27:07
Ah, okay.
Dr. TRG 27:09
You know it’s coming from the larynx and above – so you know, it’s something to the pharyngitis or laryngitis or trachiatis.
So why unnecessarily expose the patient to an X ray? So I think a lot of things have got to do about all these things, making a good clinical history and diagnosis will help you also coming to the correct type of investigations which are required, also for the patient and patients not ending up overspending also, and unnecessarily exposing to radiation which is not necessary.
Ranga 27:34
Yeah, I think that that’s a very important point, if we can reduce the cost as well as unnecessary exposure like this, like the example – that is very valuable for the patient.
Dr. TRG 27:43
Exactly.
Ranga 27:44
So doctor, you also mentioned about allergies, right? Sometimes I get skin rashes and some skin lesions or whatever. If the patients were able to send picture to you, would you be able to tell what kind of what kind of a problem this is? Is that also something that you could probably do using a mobile phone?
Dr. TRG 28:12
See the one of the best places where we can use this sort of mobile technology of pictures is in Dermatology. I can even quote straight away a recent example, when one of the caretakers of my father said that he developed a particular type of rash.I asked him to send a picture.
He sent me the picture in the morning, and I found there were small blisters on his face. And immediately I told him, it looks like chickenpox. Please don’t come to work from today. Take care. Take this following medicines. Take it for two weeks. So that’s one place.
The second place in skin I tell you is – people try to tell you that there is a lesion which is black, which is a mole, which I’m a little scared, it’s growing, it’s itchy. So we can easily say see this is a mole. You need to worry about it or you don’t need to worry about it by looking at it. So I think most of the skin lesion because it’s always said skin is the mirror of the body. People can look at the skin and even make a host of diagnosis. So if you notice his skin well which can be pictured and sent to the doctor, many many diagnosis can be easily made by those pictures. There are also if you can extend it to a little more of a video conferencing call like any other place, if somebody as I recollect another case of my own grandson. My daughter called up and said he had fallen down while playing and she was a little concerned as there was a little bit of swelling. So I just had to ask her to come on a video call. I asked him to just show me his leg. There was a swelling around the ankle. I asked him to move his toes. I asked him to move his ankle a little bit. I asked him to stand on both legs. I asked him to stand on one leg. Then when he was able to do everything I just told her just use some ice compress and put a crape bandage. Do not rush tonight for an X ray. I hope the swelling will settle by tomorrow, keep his leg over a pillow, looks like a ligament sprain only, he should be alright. All I’m saying is that was done on a video call. There are many issues like this, which where I think the technology can definitely help. And the patients are just trained a little bit to do about it. I think it can work wonders.
Ranga 30:31
Yeah, I think I think your case points to telemedicine, right. I mean, telemedicine is definitely something maybe where we can do this and especially during these times. By these times, I mean the pandemic times where we are having the Covid19 infection. Telemedicine can help a lot because you don’t have to interact with the patient directly and be at risk to exposing yourself from the patient side as well as the doctor’s side.
Once when we were there in the initial days, telemedicine used to be a costly affair. Now with almost the 4G technology and mobile phones available with almost everybody the telemedicine has become a very economically viable affair.
Sure, yeah. And anybody pretty much having a mobile phone has an option right. So doctor, you mentioned all these examples. So, definitely patients can do their bit in sort of recording this data, they have the technology with them. Now, the point is that, once this data is available, recorded data, whether a fever, cough, or skin lesions, or even their their family history, if all of this is available, then the next question becomes, how to extract all this data? Extract all the data and give it in a meaningful form at the time of the doctor patient interaction, when the patient visits the doctor. Somewhere, we talked about what is the importance of historical data and the historical data is in so many dimensions. And then what we need now is with patient participation, whatever data is collected, combined with other lab data or other medical history data needs to be presented in a meaningful form. So that I think would make, as you said in our discussion, the interaction much more valuable.
How could the digital footprint of the patient be presented in a platter?
Dr. TRG 32:26
Absolutely, I think the amount of information with which the patient comes, even nowadays, when patients come, I’ve seen patients come in with a diary. Patients coming with a notebook and trying to tell whatever they wanted – they’ll say, oh, I forgot to tell you all these things, I may forget, so I’m writing everything and bringing. So I totally agree with you. If that the time of appointment of the patient, the doctor has entire data served to him on a platter, as they would say, it will be excellent because he just goes through the checklist. He goes through the entire points. And then he spends time looking into the exact areas which he needs to examine, and spends more time communicating and telling him about the disease process. And the same is true even for investigations, everything should be classified. This was in 87. This was in 92. This was in 96. If he brings such a data, everybody will be able to know – for example, we want to know whether a person has had that colonoscopy every year. So I just want to know what happened in a colonoscopy in 2005? What happened in 2006? The he says I did in 2005, I lost the report of 2007 but I have of 2009. I don’t have it here but it is there with my son in law in UK, like that it goes.
So if everything was available in one single point, I would say both investigations and diagnosis and the various history on a platter – I think that’s going to be the key. And that’s exactly the area where we are looking for some form of supportive machine help to know to give us on a platter. If only that could be done, it could save a lot of time for the doctor and have a more meaningful doctor patient relationship, thereby enable to build a trust to develop more.
Ranga 34:12
Definitely thanks for laying that out. So clearly, that is certainly something that the technologists would love to hear. And technologists would love to help sort of build that connection. In fact, that technologist in me woke up when you talked about timeline, when you talked about things, it’s almost like the way we all use Facebook today. And Facebook has this neat timeline, where it kind of tells you which are the events that happened, of course, it tells events like, I have travelled to this place, this is this person’s birthday. Imagine each of those events were really like a medical event like you said e.g. I had a colonoscopy on that date. Then, I started having this kind of medicines at this time. It’s almost like a timeline. And in the timeline, you get these various events which mark various important medical events in your in your timeline. Different doctor visits and what kind of drugs you were taking during the separate periods, if something like that could be there, that would be a very nice picture. And further on, I’m thinking that once the patient meets the doctor, imagine that the doctor has a dashboard, which is sort of the digital footprint of the of the data from the patient, right – all the medical data, all the relevant data and all the different historical data – this dashboard pops up the most important things right in front of the doctor. And maybe the doctor can quickly go through that, very comprehensive picture and then dive into those parts that he thinks are more relevant, and which match what the patient is currently telling him.
Dr. TRG 35:47
Exactly we need, we need something like a dashboard. A dashboard is the right word I think you’ve chosen. It has to give us the correct information and everything should be there highlighted. It flags you that here’s a diabetic patient. Here’s a patient who has undergone a gallbladder surgery. Here’s a patient who’s diabetic. Here’s a patient who has had a complicated last time in anesthesia – he was in ICU for 10 days. If everything is written there, the doctor is able to plan his surgery, plan his treatment, plan everything properly for the patient, because everything is already there for him, nothing goes missed. So, the gist of information is already there, the only problem I sometimes find is probably there will be over information in these particular cases. So it is to get us neither under information not over information, we should get appropriate information and that’s I think, where we should develop such dashboards which are so relevant. So I think everything will be based on the history again, if the history is taken perfectly and the examination is taken perfectly, you know you’re going to do the proper investigations, then you will be able to get that everything in an order. So I think everything goes back to the basics, and therefore if the history of physical exam is nicely documented and given to the doctor,it is going to be of a great value.
Ranga 37:05
Yeah. And I think your point about the under information versus over information – I think that’s where medical professionals like you, and technologists, like me and my technology communities should sort of come together. Because if we sit to define what’s the most meaningful thing, then there is value in that innovation, or value in that product that finally comes up. So I think this conversation is probably towards that, is probably to make sure that the technologists understand what doctors like you want, when you’re actually meeting patients and prescribing treatments for them.
Dr. TRG 37:43
Oh, that would be great. That is great. That is great.
Ranga 37:46
So doctor, maybe now I’ll have to ask you a slightly difficult question. I’ve seen some articles and maybe talked to some people and there’s some opinions about why it’s always difficult to sort of get some of these technological innovations in the healthcare space. There may be many reasons for that – historical regulations and so many other things. But one of the reasons that’s quoted, is that this question that comes up, that why should the doctor adopt such technological innovations? And the point here is, why should the doctor do it? What is in it for the doctor himself or herself to kind of go along with this kind of an approach that is assisted by technology?
Dr. TRG 38:46
See, I think you’re just coming to the most important aspect of our discussion. See this, this is going to be the real point – the patient is coming and telling you a few facts about some real problems. Everything is available on a dashboard. He’s trying to give you a diagnosis – it is for you as the doctor to pick up the diagnosis, get into the treatment, and promptly treat him and make him happy and improve the doctor patient relationship. Because I keep telling people and my students over and over and over again, it’s this patient who’s going to get you the next patient.
Ranga 39:19
So therefore, one patient gets another patient is the key point.
Dr. TRG 39:23
Precisely and this is happening everywhere. If I go to a restaurant and I like it, I’m going to tell you please go to the restaurant, it’s good. If I go to the restaurant and I my experience was not good, I will tell you straight away, don’t go there. So I think, in medicine this is very, very applicable – one patient will bring to us another patient. And if you ask what is in it, the whole practice of medicine is getting more and more patients and to develop your own practice. So if I’m going to follow a systematic system in which all the things are given in a particular order, I must follow it. I must take it to our benefit, and I must treat the patient and if I treat a patient and that patient is going to be happy, that is going to get me more patients. The moment he is not going to be happy, he’s going to walk down the roads and take the next doctor who is going to have the similar data. Yeah, and he’s going to treat him better.
And as simple as this, Ranga, why would you choose Zomato or why would you choose Swiggy? Why would you choose Uber? Why not Ola? You just call Ola one day – he just canceled your Ola and took 50 rupees extra from you. He never bothered to repay it. Imagine the other guy did it for you. I think it’s as important as that, to give a thorough professionalism. I think it’s very, very important to take this data in a very right manner. And so what is it in for us? It will make you a better professional. And if you make a better professional will get you more patients and more patients means you become more experienced. I think that’s the way it goes.
If every doctor has the same patient data made available in a platter, then what differentiates one doctor from another?
Ranga 40:50
Well, great to hear that from you. I think it’s important that doctors like you take that message across rather than technologists like me, batting for technological inroads into medicine. So, on that point, you made a good example – you said that, okay, if this doctor doesn’t use this technology on his dashboard, he’s gonna walk across the road and go to the doctor, the next doctor who is going to use it. Now we say that technology is a great leveler, right. So if multiple doctors or pretty much all doctors let’s say are going to get access to this comprehensive patient data and they’re going to have the same or similar tools to visualize that data. So they have all the diagnostic assists, so to say, they have everything on par. Then the question comes, what differentiates one doctor from another? How would you look at this?
Dr. TRG 41:58
See, ultimately a patient wants the doctor to be a human being. He does not want the doctor to be a machine. He wants the doctor to use the machines.
Please listen to this carefully – if the doctor does not use a thermometer or blood pressure apparatus or does not touch him to check his reflexes etc., he feels that the doctor has not even touched him. But after touching him, if he doesn’t talk to him, and doesn’t explain to him and say everything is written on the paper, you can go home and read, he’s not going to be happy. At the end of the day, the patient expects a doctor to put his hands over his shoulder, have an eye to eye contact, make him calm, make him cool and tell him his problems clearly, give him the options of treatment well, and if he is able to do all those things, and you know not only treat the patient but treat the family as well. You know, sometimes it’s not possible, treating the patient alone does not solve the problem. I’ve seen many of our Indian patients tell me after talking to them for half an hour, they say my husband is waiting outside, please tell him also. Then when the husband has come, then she says please tell my in laws also, they are also waiting outside. Sometimes we used to finally say please call all of them and we will have a complete meeting and please explain to them. What I’m trying to say is, when we treat patients, sometimes we need to tell the family itself exactly. So how humane are you, how you’re able to touch them, and how you’re able to convince them – this is where I told you the socio economic history in the initial part was very important – because we must tell it in such a language that the family and the members can understand you well, and, you know, so that they can digest the whole fact. You know, breaking bad news, telling it’s cancer, you’ll have to be compassionate. You’ll have to show it with a certain amount of emotion, some empathy has to be shown. I think if you show these things only, you’re considered a doctor. I’m sure, I doubt whether any machines can show empathy and sympathy and all. But definitely the doctor has to, you know, beat those machines using those machines, using the technology of the machines. But finally, giving the report, the report will say stage four cancer, that’s what the machine will say. But the stage four cancer when the doctor breaks the news to the patient must be told in such a way that it is stage four, but still, everything can be taken care of. That’s the way he should be able to put to the patient. I think that’s the difference between one doctor to the other doctor – the successful one to the less successful one.
Ranga 44:36
Lovely to hear that doctor. So I think your point is, the more humane you are, that’s what patients will expect doctors to be. And for sure, I don’t think we have artificial intelligence yet that has figured out how to be empathetic. So I think that’s a far cry from where we are. And I think to your point I really liked the way you put it because yes, we may talk so much about artificial intelligence and certainly give you the tools to do your job well, but certainly it’s not going to replace, like you said, putting the arm on the patient and explaining what it says, or talking to their family, or putting a reassuring hand, having a reassuring, soothing voice to the patient, to convey news, even if the news is as bad as a cancer diagnosis. I think those things certainly, I don’t think we have machines today that can do that. They cannot. I think we certainly need humans to do it. I think you as physicians and clinicians are at the forefront of it.
Dr. TRG 45:42
And the same way I would say – you see the machines, I would call them as unsung heroes. Because tthey are very, very important, very vital. Let me make it very clear that artificial intelligence is useful – because this is what is going to help the doctor to save time, get the information on a platter, do everything in an organized fashion, everything is fine – the doctor uses all the information. They are unsung heroes. But once the information is got from the artificial intelligence or from the machines, etc. finally the word of how the disease is going to progress, what is it going to happen, how it’s going to go on from here, how often they should come, what should be the reaction on the drugs, everything they like to hear from the doctor. And that’s where I think, the edge of human is, after having completely taken entire data from the machine. The doctor has to convert that into a concoction of humanity and humaneness and put it to the patient to make it as a successful combo.
Ranga 46:39
Sure, I think that’s very well put Dr. Gopalan. Thank you. I think that’s a great message for us, as technologists and for fellow physicians in your community to take back. It’s been an absolute pleasure. talking to you about the doctor patient interaction – how it is today and how with the intervention of technology, artificial intelligence, how this will be in the future. And at the same time how important very human emotions are, and how important empathy is. Perhaps that is what makes us human after all. Thank you so much.
Dr. TRG 47:25
Thank you, Ranga for inviting me and asking me to share my views on such a very important topic of the doctor patient relationship. This has been close to my heart for over a long, long time. I’m glad you brought it out. And I’m very keen to work with you as to how we are going to take this forward to a very, very meaningful conclusion. Thank you very much Ranga.
End credits
Ranga 47:48
Thank you folks for listening in. Do give this podcast a five star rating in your favorite podcast app. Do connect with me Rangaprasad Sampath on LinkedIn and follow my online handle @youplusai on Twitter, SoundCloud, Medium and YouTube. I’ll see you soon with another episode. Enjoy!