Patient Centred Medical Home- Lessons learnt in becoming someone's primary doctor

I am planning to make this a series of posts. Posts documenting my journey in building practice, in becoming the primary doctor for a set of people. All the discussions, experiences, and skills learnt will be put in a useful manner as far as possible.

Recently,  I saw a patient ABC who was diagnosed with HIV few months ago elsewhere and was started on treatment. But had come for a second opinion about his illness. I could see that he felt lost and had many doubts. He was sitting quite far from me, across the table with his relative being closer than him. I was finding it hard to ask him questions and I could see that the same feelings were reciprocated in him as I got very superficial answers. In order to gain trust of the two, I continued to have a detailed conversation and history taking, did examination in front of the relative, smartly made him sit in a chair closer to me and then requested the relative to give me some time to talk to the patient alone. The relative agreed and sat out. That's when I could ask him about his real concerns. That's when I felt real connection. And I think the same was reciprocated by him as he then mentioned that he still couldn't accept the diagnosis, had doubts about it. No doctor had actually talked to him about it after diagnosis, life had changed. RK, my mentor had introduced himself and left, giving me time to come till this point, when he pitched in. When I stated the patient's concerns to the patient and then was trying to figure out how to address those, I was a bit confused. That's when RK suggested to the patient that we'd set an agenda for the visit and told him genuinely that we will walk through this step by step and that we'd be there with him etc which reassured him. I told him that I'd want him to be okay with the diagnosis and that he'd be healthy. He looked better. Then we did some tests etc..etc.

After he left, RK suggested an exercise where he'd written down some important etiquette that would help in building rapport, that makes a patient comfortable, respected and the whole process of consultation more efficient. I had to rate myself 1-10 on those points, he rated me too and Praneeth and our psychologist Aji nicely discussed what techniques they use out of their experience for each of these points.

As an intern in a government hospital, I had learnt to help the patients get through the system. To fill in the gaps. Like, teaching them how to take their prescribed medicines, how and where to get the investigations done. Talking to them about what their diagnosis was and what was being done for it and what they had to ensure. 

As a fellow in HIV at SVYM, I learnt that care can be 100 X better with the right attitude people around. How to give holistic care. Since I was seeing OPD patients on not a regular schedule, it was only rare to see the same patients in the opd in a planned manner. So every patient I saw, I'd make sure I gave them all the information, and advice they need. I never was a primary doctor to anyone except a few of them who valued my care and stuck to me over the phone. But it was never a plan. I never asked anyone to come back and see me next Monday or so. (Not that this experience was bad, but not enough for learning how to be someone's doctor)

But now, I have the time and space to build relationship with my patients. To ask them to follow up. To go slow and not bombard them with information.

This is the first and major behaviour I've to embrace. Starting to think of every patient as my own and plan accordingly.

Praneeth, my colleague has built his practice beautifully. He was telling for each of the above points on paper how he manages to do it. 

He told us how he remembers some important details about the life of his patients. Not just their symptoms, but who they are, what they like, what they're going through etc etc. He used to make notes before. Now its natural to him. It made me remember a poem I wrote once.

So out of all the discussions, I've mentioned a few here-
1. In order to build rapport, we often call the patient by their name. What happens if their name is difficult? Ask - "What shall I call you as?" or be honest and say, "I'm having difficulty in pronouncing your name, what do you prefer? Help me with it" etc. It shows respect.

2. Keep a sheet to scribble important things you want to remember.

3. After sending out the relative, I had to explain to the patient why I did so. Something like "sometimes for some reasons, we can't be completely comfortable with mentioning everything to our relatives. So I sent him out. What you share now, will remain within this room."

4. Asking the patient "how much time do you have". This will not only give them a sense that we value their time but also help us plan our agenda.

5. "What is your main concern?" always works.  

6. I have this problem of documenting simultaneously while talking. But a smart way would be after the intense sharing that the patient does, we can write with involvement of the patient. Something like "Ah, so these are your main concerns...blah blah..(writing and showing the patient), am I right?" or
"So this is our plan..blah blah..(writing and showing), is that okay?"

7. Always ask them to follow up!

Evidence Based Practice

Yesterday, I was told to savour each day's learning rather than just eating a lot. I liked that idea. Because learning takes a different shape when given enough time to reflect on, and form consolidated applicable information. 

I applied the 3 pillars of evidence based practice to the couple who had been referred for adult vaccination by Dr Rao. Not that I had never applied, but I never had the time to actually reflect on what were the arguments in each pillar I was applying. The pillars being-












The wife was 62 yrs and husband 69 yrs. They had their wonderful family physician Dr Rao who had referred for vaccination to us. They actually expressed while taking history how they approached him for every health issue and felt safe. That reminded me of my grandfather who also was practicing family medicine doing home visits with his suit case. Those days I thought he was old fashioned but now when I don't have a family physician myself, I'm starting to requestion myself.

Since they were elderly, and the husband had chronic lung condition, I wanted to offer them pneumococcal and Influenza vaccine. As I knew they were coming, I got some time to look up on the guidelines and literature. So my dilemma was-

After 65 yrs, one is given PCV13 followed by PPSV 23 after a year to enhance the seroconversion and protection levels for the common strains. But for those adults less than 65 yrs just one shot of PPSV23 is recommended. Eventually when they turned 65 and beyond, they have to be given PCV13 as well. And a few studies showed that giving PCV 13 followed by PPSV23 was better rather than the other way round. So I was confused whether to give the wife just PPSV23 or start with PCV13.

That's when RK asked me to apply the 3 pillars. According to my clinical judgement, it made sense to start with PCV13 as she was close to age 65. I explained the same to her and she was happy to go with that logic. Thus the completion of the 3 pillars.
I'm yet to read up on the efficacy and other aspects of the adult vaccines and the same will follow in my next post.

An Honest Reflection

All my life I've been in the path of Conventional Education System. I excel in that, undoubtedly. Was given the title "Best in class" in primary school classes (due to marks, not exactly best otherwise. Because I can recall a lot of smart friends from school) Best is always relative to what we're referring to.
Then I switched to CBSE syllabus for high school which I was given freedom to choose. So that's the first effort I remember being put where I learnt by myself before the classes of high school started just to be at par with the students who were in CBSE in their primary school too (because state syllabus hadn't actually taught me to think critically). Anyway, high school passed and PU went studying as well as dreaming about what I wanted to be. The desire to be an excellent Math Teacher changed into being a doctor as differentiation and integration started making less and less sense to me in real life (but I understand the potential of these topics now). Also those were the times I started being sensitive towards the issues in the society, inequality, the times I was scientifically curious.

In my second year of MBBS when the clinical postings started, I was posted to surgery department first and I remember the day I was posted to the dressing room discretely. We saw so many feet that were gangrenous, some with a few toes missing, making their lives miserable. And the indirect cause being uncontrolled blood sugar levels. It was unsettling. On further probing, I learnt that most of them became aware that they were having diabetes only after a wound in their foot refused to heel. That's when I respected the value of preventive Medicine. I wanted to screen all elderly for Diabetes and keep their sugars under control, educate them and prevent amputations. That was a dream. Was the screening idea feasible? Cost effective? Well, I didn't and still don't know. But that's when I started loving community medicine and public health. I really wanted to do make a difference to the community. I believe health care to be a basic modality of life and that being said, it not being available to all is unacceptable.


Those days, I used to take walks with my father, and I asked him a lot of questions. One such morning, I asked him who makes changes in the system? He said Government, but IAS officers are the ones who are brainy and who are change makers, who execute necessary actions. That's when I thought I should become an IAS officer. (Later some other day, the family had a chat, which made me realise that's not the only way to make a difference.)


I worked clinically well during my internship and tried to keep my options open just to see if I fell in love with any particular department or specialty. Although I loved treating and taking care of patients I couldn't imagine myself just doing that in future. So by the end of internship, when friends had a good plan of preparing for the entrance exams to become clinical specialists, I was searching for an organisation to work and learn more about public health. That's when I joined SVYM and HIV fellowship as mentioned in my previous post.

But what has all this got to do with what I'm currently doing? Now, I've come out of the conventional path. And it's not easy in multiple ways. Leaving all the new city part aside, I'm working with really smart people around. The work culture is so rich that I'm both excited and scared at the same time. It's very different from the kind of work or learning I'm used to. People are collaborating, doing great things at a great speed. They have such multiple sets of skills in the places I'm working both at NCBS and at PCMH. So I've to speed up and learn a lot of things.

Under this Indo-African Initiative, I can actually learn by doing a lot of things with these people. Expectations from me are as stated here  .
But to sum it up, I've to take a lead in collecting, analysing data, (epidemiological), learn up sequencing and other molecular biology techniques required for independently running tests at the field level. In the process I'll be meeting and learning from some amazing people from the fields of Fundamental Science, Molecular Biologists, Clinicians, Epidemiologist in India and Africa. I'd learn epidemiology in it's practical sense both in the field and in the lab!

For this, I should be ready to start learning all the skills that I always wanted to learn. Because if I want to make any kind of difference in health care like I've been wanting to since years, I need a bundle of skills. Now that I have the right mentors and people around me, I should fear less and get to it!

Who cares if I fall in the bus or break my laptop? Or get nervous looking at a bunch of smart people around a conference hall during presentation? It doesn't matter if one's not perfect to start with but one must not lose the ability to learn. Because, "if it doesn't challenge you, it doesn't change you."
So, I've signed up to a few online courses on coursera like - Epidemiology, Maps and geospacial revolution, R programming, Metagenomics etc. And will be immersing myself in growing. 

The Beginnings

So, it's been a week since I started work and life in Bangalore.
I just finished my exams of fellowship in HIV medicine and people ask me, what next? It's everyone's favourite question, including myself.
The very reason I joined that fellowship was because it was offered at a great organisation, "Swami Vivekananda Youth Movement" which mainly works for the tribal health, education and socio-economic empowerment. I chose to work at Vivekananda Memorial Hospital because I could learn both clinical medicine and community health as the hospital integrates community health, preventive medicine in day to day patient care. Also as a step towards a career in public health I felt and was told by one of my mentors Dr Sumanth MM, it would be a good place to learn from, to build better attitude and contacts of course.
I'm proud of making the decision as it gave me a different perspective of public health. It taught me that public health is not a different domain in health but is an integral part of praticing medicine even if it's done at a clinic. It gave me an opportunity to learn the social, cultural aspects of illness, and how to spontaineously think about them while caring for your patient even during a busy OPD like Dr Seetharam, the orthopedician and President of SVYM does.

During the fellowship, we had many case presentations and a few journal presentations. On one such days we were introduced to Dr Ramakrishna Prasad and his team about which my friend Dr Akshay has written with much clarity here. I should again be grateful to SVYM because it attracts such wonderful people to the organisation. He has now become my mentor.

So with his mentorship, I've joined as a Clinical Research Fellow at NCBS, Bangalore under an Indo-African Initiative. So RK thought I would be a right choice for this work as I had showed up to a "Health Researchers' meet" at NCBS which was conducted as a step towards working in collaboration and not silos in research field. Like they say "80% of success comes by just showing up". I could learn about this meet only because of another mentor who I value Dr Ananth Kumar who was attending this as well.

I've also joined his team - PCMH-Restore Health as a clinician/HIV consultant where I'll be able to care for patients too.

So what's the kind of work I do everyday? Why did I choose it?