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Don’t be in a hurry to treat a patient

Dr A K Dewan is a graduate from Maulana Azad Medical College, New Delhi with MCh (surgical oncology) from Cancer Institute, Adyar, Chennai. Dr Dewan gained his experience at Tata Memorial Hospital, Mumbai, then served at Safdarjung Hospital, New Delhi and currently he is with Rajiv Gandhi Cancer Institute and Research Centre (RGCIRC) since the day of its inception.

Dr A K Dewan

Dr Dewan has keen interest in head and neck surgical oncology and is presently the chief of head and neck services at RGCIRC, performing composite resection (commando operation) for oral cancer, conservative laryngeal surgery and laryngectomy for laryngeal cancer, maxillectomy, skull base surgery, parotidectomy, thyroidectomy, various neck dissections etc. He practices evidence-based medicine with emphasis on multimodal approach.

According to Dr Dewan, it is the multidisciplinary team-effort that gives desirable end result. His motto is “Cure & Care with Passion”. He is technology savvy with an endeavour to provide highest standard of quality care.

In an exclusive interview with AalaTimes, Dr Dewan talks about the scope and opportunities available for research in oncology.

What made you specialize in surgical oncology? Who inspired you?

My success story of surgical oncologist started with failures. After my post graduation in MS (general surgery), I could not get a job for three months. I got my first break in 1984 at Safdarjung Hospital as Medical Officer. There I got posted in Neurosurgery, CTVS (cardiothoracic and vascular surgery) and General Surgery but none of these fascinated me. Ultimately, I got into the Cancer Surgery department where Dr K K Pandey was heading the department at that time. He had been my teacher in Maulana Azad Medical College. He is a great academician and an intuitive surgeon.

Today wherever I stand it’s because of Dr K K Pandey and my wife, Dr Rupali. Both of them motivated me to go further and here I am – ‘From a Medical Officer of Safdarjung Hospital to Medical Director of RGCIRC’.

What’s been the most important change since you joined the medical profession?

There has been a sea of changes in diagnostics and treatment of cancer. Today we have various blood tests, imaging tools, new drugs and new technologies to deal with cancer. Still we are very far from victory on cancer as we did in the case of polio.

The understanding of cancer biology is still incomplete. When I joined medical profession we had conventional X-rays and Ultrasound had just come. There was no CT scans or MRIs.

The concept of screening, early detection was not there. Every solid tumour was treated with surgery or radiotherapy but now it is combined modality treatment (1+1 makes 11). I remember we used to treat all breast cancer cases with surgery, which looks foolish in today’s context. I am sure the next generation will say the same thing for me “how foolish we are in 2012 that we are treating cancer with surgery, radiotherapy and chemotherapy”. May be in coming years we will have some targeted therapies or magic bullet or may be some vaccines for different cancers!

More importantly, the outcome of many cancers has improved. Few cancers are highly curable like ALL (acute lymphoblastic leukaemia), CML (Chronic myeloid leukaemia) and germ cell tumours.

What sort of challenges have you faced so far in your career? How did you tackle them?

There are many dreams in healthcare profession but only few are achieved. Medical career is the most challenging job. It requires full dedication, attention to detail, precision and intuition. Mistakes in judgment can lead the other person to graveyard. Few points that make a doctor’s life more challengeable:

a)     The most important question in surgery is — how to do, when to do and when not to do. With experience a prudent onco-surgeon develops a knack of when not to do. Every young doctor wants to do something new, learn new technology. It is challenging to practice new technology in this competitive world.

b)     You may put a happy face – empathy to patient but you might hide the pain inside you.

c)     No time for family.

A healthcare professional should:

a)     Have the right type of attitude — either we make ourselves happy or miserable; the amount of work will remain the same. So, why not work with a positive and happy attitude.

b)     Set his priorities in life. Focus on job is most important.

c)     Remember that technical skill is as important as soft skill.

d)     Have a purpose in life — give care and comfort to patients.

e)     Be self-motivated, enjoy interaction with people.

‘There is no elevator to success; you have to take the stairs!”

What sets RGCIRC apart?

Human touch given by the staff, dedicated professionals, advanced technology, exceptional people, rewarding place for people to work (motivated work force), ethical practices are few factors which make RGCIRC an ideal place for healthcare professionals and patients.

How RGCIRC has been deploying and using technology as quality control measures and providing better care to its patients?

RGCI strives to use latest technology to provide quality treatment. Very good examples are:

a)     Latest RT (radiation therapy) machines – IGRT (image guided radiation therapy), IMRT (intensity modulated radiation therapy). The aim is precision, providing focused radiotherapy safeguarding normal structures. The use of high technology “Treatment Planning Systems” in radiotherapy is another good example.

b)     The use of robotic surgery in Uro-Gynae oncology. The aim is better precision, less blood loss, decreased hospital stay and decreased discomfort to patients.

c)     The infection control team monitors infection control practices. Whatever safety measures are recommended by the team are adopted or propagated by the management.

d)     Technology needs not to be costly but it could be simple measure for patient safety.

How has the field of oncology as a career developed over the years?

Oncology has started developing in the last three decades only.

Radiotherapy post graduation courses existed even earlier but radiology and radiotherapy was considered as one specialty. Then they were separated in 70’s.

Surgical and Medical Oncology was started in 1985 in Adyar, Chennai. Before that physicians, paediatricians and general surgeons treated cancer patients.

Now you have cancer surgeons, medical oncologists, paediatric haemato oncologists. Some institutes have gone further, at RGCIRC, we have head and neck cancer surgeons, gynae-uro oncology surgeons, breast cancer surgeons, GI (gastrointestinal) onco-surgeons, onco-pathologists, onco-radiologists and so on and so forth.

The quality of patient care has improved dramatically with super specialty developments. Future will see organ or site wise specialization in oncology.

What are the opportunities available in the area of research in this field?

Cancer research is a basic research into cancer in order to identify causes and develop strategies for prevention, diagnosis, treatments and cure. Cancer research ranges from epidemiology, molecular bioscience to the performance of clinical trials to evaluate and compare applications of the various cancer treatments.

Opportunities available for research in this field are:

a)     Jobs in pharmaceutical companies / health industries / research institutions

b)     Fellowships in research institutions

This type of research involves many different disciplines including genetics, diet, and environmental factors (i.e. chemical carcinogens). Research is an important focus at RGCIRC. The institute is committed to the advancement of cancer research and works diligently to discover promising new diagnostic and treatment methods every day.

How do you compare medical research in India with that in developed countries?

India lacks the infrastructure and facilities especially with reference to the basic science research. Funding is poor. Even the funding agencies weigh everything in terms of commercial outcome. More important than resources is the research mindset of doctors. Majority of the doctors are involved in their clinical work and have no time for basic research. Moreover, clinicians do not work in tandem with the researchers in basic science.

Career opportunities in basic science are limited in India.

We only ‘Re-Search’ what has been researched.

What should be done to attract young doctors towards medical research in India?

Research fellowships or incentives should be made available to young doctors to attract them into the field of research. Research should be made a compulsory part for career development. We need to focus more on basic science without expecting immediate commercial gains.

How do you think the country can bridge the huge gap between demand and supply of qualified medical practitioners?

The answer lies in overall development of peripheral centres and rural India. We must provide infrastructure at the periphery, at primary health centres and secondary health centres level. Make the job so lucrative that young doctors are attracted towards Primary Health Centres (PHC). Preference in post graduate courses should be given to those who have served in the periphery for at least two years.

I feel the answer lies in retaining our manpower and re-distributing them judiciously within the country rather than producing more doctors.

How can healthcare be made more affordable?

A few suggestions, which I think can make healthcare more affordable in our country, are:

a)     Hospitals should focus on designing cost effective treatment for patients.

b)     Major cost is taken up by medicines. Everyone should contribute in lowering the cost, for e.g., the government should reduce taxes; pharma industries can lower the prices and doctors may use the generics rather than branded drugs.

c)     Social insurance schemes.

d)     Judicious use of investigations and technology by doctors.

e)     Patient education on disease prevention is far more important and cost effective than cure.

How telemedicine can help in better healthcare management?

Telemedicine is the use of communication to provide information and services. It mainly facilitates delivery of healthcare in areas where distance is a critical factor. It is also a useful tool between a general practitioner and a specialist available at remote locations, for instance GPs in Nepal consult with us (Oncologists at RGCIRC) for cancer diagnosis and treatment.

a)     Telemedicine can make specialty care more accessible to underserved rural and urban populations.

b)     It can alleviate prohibitive travel and associated costs for patients.

c)     It offers new possibilities of continuing medical education (CME) and training of medical practitioners in rural areas, who may not be able to leave rural practice and attend educational meetings and CMEs.

d)     It can help in cutting costs of medical care in rural areas.

e)     It can make possible to telementor and teleproctor various surgical procedures at remote places.

Why do you think telemedicine has not really taken off in India?

Patients’ fear, unfamiliarity, financial unavailability, lack of appropriate tele communications technology, illiteracy, diversity in languages are some of the reasons why telemedicine has not taken off in India. But I strongly feel it is the man behind the machine, which is not available. We do not have qualified medical manpower in terms of experts who can spend their valuable time on tele consultation. Nowadays tele technology is inexpensive. What we need is mindset of experts who can devote some time to telemedicine (tele consultation, tele diagnosis).

What are the major issues facing the medical fraternity?

 

Some of the major issues are:

a)     Loss of credibility and erosion of faith.

b)     Over use of and over dependence on technology. We should be high tech but high touch rather than high tech and low touch.

c)     Industry driven practices.

d)     Disconnect between expectations and reality.

How India can increase its share of the global medical tourism market?

More and more Indian hospitals should go for national and international accreditation and certifications like NABH (National Accreditation Board for Hospitals and Healthcare Providers) and JCI (Joint Commission International). This will instil confidence in foreign patients that Indian hospitals can provide world-class treatment and quality care.

The hospitals should also try to improve marketing strategies, make treatment affordable and create awareness about their facilities.

If you were not a doctor what would you have been?

At the far end of my career you are asking me if I were not a doctor what I would have been! If I were not a surgical oncologist I would have been a cardiothoracic surgeon.

If not in medical profession, I would have been a teacher; I belong to a family of teachers, my parents and uncles were teachers.

What’s your message to the budding oncologists?

a)     Do not be afraid to learn. Knowledge is weightless. A treasure you can carry easily, keep reading in life.

b)     Attitude determines altitude in life. Put yourself in your patient’s shoes and then speak to and treat the patient.

c)     Don’t be afraid to admit that you are less than perfect. May be someone else can do a better job in patient’s interest. Practice ethically.

d)     In oncology, young oncologists learn how to treat; experienced oncologists know when to treat; and mature oncologists know when not to treat. It is well said: “Young docs kill their patients, old docs watch them die”. It is extremely important to set it right first time. Don’t be in a hurry to treat a patient.

e)     Technical skill is as important as soft skill in practice.

by Rajni Pandey

One Comment

  1. Prof. Param Bhuja Prof. Param Bhuja Thursday, April 5, 2012

    It is amazing Dr. Diwan has not talked a line about the real reason why he is to day to know so many things about the comprehensive oncological management .The Post Doctoral Degree that he got and the knowledge that has empowered him to become an oncologist from a butchering surgeon who are more often than not responsible for non curability of cancer.( now reports of this facts are available in peer reviewed journals.
    He has also forgotten to mention the exposure of a sophisticated clinical research set up and its excellent working that is not seen anywhere in South Asia. But for this rigorous training that he underwent he would have been just another self proclaimed Onco Surgeon, many of them minting money by doing what they should not do….operating those cases, just for money where surgery may lead to disastrous consequences . and some of the names mentioned are notorious for such activities.
    Which is why when one of his night duties as M.Ch. Surgical Oncology student when he gave what he thought was a lucid report about a post a operative case , his mentor and maker asked him a simple question for which he had no answer!! The question asked by Prof. S. Krishnamurthy, the Father of Oncological Sciences , was Dr. Dewan, What is patients temperature and pulse?. Patient was running high temperature and Dr. Dewan did not know despite his experience at TMH and SJH.
    We forget about the steps we climb that take us to such heights!!!

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