The Saga of Ancient Indian Medicine - Its Wisdom & Brilliance

It might come as news to the thousands of health industry employees in India that the first ever surgeries were being performed in India around the time Gautama Buddha was taking his first steps towards enlightenment.  And yes, we are talking of a time predating Hippocrates, the Father of Western Medicine, by hundreds of years.  

The Atharva Veda is the earliest document in India that contains allusions to medical subjects, although they are of a somewhat primitive nature, and largely permeated by magic and sorcery.

Archaeological digs, however, confirm that the most comprehensive technical and medical knowledge existed and was applied successfully in the old Indian empires dating back to 4,000 B.C.  By the medieval period, the Indian subcontinent had developed a number of medicinal preparations and surgical procedures for the treatment of various ailments.

Ayurveda, the traditional Hindu system of medicine, was divided into eight volumes:

1. Kaya Chikitsa (Internal Medicine)

2. Kaumarabhrtya (Pediatrics)

3. Rasayanatantra (Geriatrics)

4. Shalya Chikitsa (Surgery)

5. Shalakyatantra (ENT, Dentistry, Ophthalmology)

6. Agadatantra (Toxicology)

7. Bhutavidya (Psychiatry/exorcism)

8. Vajikaranatantra (Sexual problems)

Surgical science was called shalya-tantra (shalya referring to the broken parts of an arrow and other sharp weapons and tantra referring to the application of cosmic sciences in performing ritual acts of body, speech or mind).  The commonest and most dangerous of foreign objects causing wounds and requiring surgical treatment were quite obviously the instruments of war, and experienced surgeons were in great demand. Among the many distinguished names in ancient Hindu medicine, those of Susruta, Charaka, Atreya and Yajnavalkya stand out.  Both Susruta and Charaka are authors of compendiums on medicine and surgery and their combined works are considered the most authoritative on the subject.

Susruta was generally believed to have resided at the court of the Gupta kings at Pataliputra during the ‘Golden Age’ of Hindu culture.  Some accounts depict him as living as far back as 400 BC, although there is no consensus among historians on this point.  The ancient Indian medical practitioners were divided into two classes: the Salya-Chikitsakas (surgeons) and the Kaya-Chikitsakas (physicians), but it was only through the efforts of Susruta that surgery achieved a leading position in general medical training.

Susruta attempted to arrange systematically the experiences of older surgeons and to collect scattered facts about medicine into a workable series of lectures or manuscripts. The result was the Susruta samhita

comprising several hundred texts on medicine, written more in poetry than prose form.  Though this work is mainly devoted to surgery, it also includes chapters on medicine, pathology, anatomy, midwifery, biology, ophthalmology, hygiene, and a little psychology and understanding of what would today be called the “bedside manner.”

Susruta begins his samhita with an allegorical description of the beginning of medical teaching, but he quickly gets into some very practical suggestions about how a medical student should be selected, how he should be initiated, and the oath he should take (quite similar to the Hippocratic Oath).  

He also sets forth quite plainly the qualifications of a physician about to enter practice and rules of personal and professional conduct that are singularly parallel to those of today.

Contained in the text are surgical techniques of making incisions, probing, extraction of foreign bodies, tooth extraction, cauterization, excisions, and trocars for draining abscess, hydrocele and ascitic fluid; the removal of urinary stones and the prostate gland, urethral stricture dilatation, hernia surgery, caesarian section; management of haemorrhoids and fistulae, laparotomy and management of intestinal obstruction; perforated intestines, and accidental perforation of the abdomen with protrusion of omentum; plastic surgery; the principles of fracture management, including traction, manipulation and stabilization; and even measures of rehabilitation and prosthetics.

In the above illustration, surgical training is being provided to pupils by having them operate on fruits, gourds, watermelons, cucumbers, etc.

Susruta has also included a list of blunt and sharp instruments and added that a surgeon, by his own experience and intelligence, may invent and add new instruments to facilitate the surgical procedures. 

He apparently used the heads of giant ants to effectively staple a wound over intestine while performing surgery for perforations.

The live creatures were affixed to the edges of the wound, which they clamped shut with their pincers. The physician then cut the insects' bodies off, leaving the jaws in place.

The samhitas of Charaka and Susruta were translated into Persian and Arabic around about 800 AD, and since Arabic medicine became the chief authority for European medicine down to the 17th century, Indian ideas undoubtedly have indirectly entered modern Western medicine. It is also a less known but interesting fact that British physicians learned the art of rhinoplasty from Indian surgeons in the days of the East India Company. 

So the next time someone talks to you  about the ‘backwardness’ of medicine, science or technology in India, just remind them about  Susruta, and about all other ancient Indian doctors, their wisdom & brilliance in treating their patients using vastly advanced medical technology that was  unheard of in other parts of the ancient world.

And yes, it is also up to us to take India back to its heydays in Science & Technology

Happy Independence Day!

Secrets of Handling ‘The Great Dictators’ in MT

“When people talk, listen completely. Most people never listen.” – Ernest Hemingway

“Most people do not listen with the intent to understand; they listen with the intent to reply.” – Stephen R. Covey

“We have two ears and one mouth, so we should listen more than we say.” – Zeno of Citium (Greek philosopher)

All right, that’s enough. I think you know where I’m going with this. Everyone knows that medical transcription is all about listening. But no one tells you that the hard part is learning to listen. Every time an MT gets a new doctor, he/she has to learn the dictator’s style, accent, and preferences.

Clinics and hospitals cannot do without MTSOs (medical transcription service organisations). It is their transcripts that help dictators in malpractice cases, their connection if they forget to dictate a letter needed for pre-authorisation, and their go-to person who puts their words to print. At one time or the other in their career, most MTSO employees have felt that what they do does not matter to anyone but themselves, but the truth is that it matters to the doctors, nurses, insurance companies, malpractice attorneys, and last, but certainly not least, the patients themselves (even if they don’t know it).

In spite of this, not all dictators take care while dictating. MTs do not expect dictators to speak in slow motion, spell out every word, or exaggerate enunciations. But sometimes it becomes very difficult to make out what a dictator is saying. They may eat while they’re talking and they mumble or stutter, or they’re tired and they yawn while dictating. Occasionally, they forget there is a human at the other end of the process who has to figure out exactly what is being said.

A bad dictator can spoil the whole day for an MTSO employee, since not only is the transcribing MT forced to reduce speed in order to concentrate on accuracy, but the QA who proofreads the file also has his/her other files held up due to that one poor dictator. Also affected are other MTs and/or QAs whose assistance is sought with the dictator.

Given below are some of most common problems faced by MTSOs.

• Dictating punctuations

Most dictators assume that the MT will insert the correct punctuation where required, but some dictators tend to specific them by saying “comma”, “hyphen” and “period” or “full stop.” If the MT doesn’t realise what that word is, he/she may struggle to figure it out, and thus lose precious time and effort. Solution: Practice. 

• Word endings

Sometimes, the dictator may not pronounce the final letter or syllable in a word or may add one instead. For example, fine instead of find, ih-stop instead of stop, or fever-ah instead of fever. Solution: Practice. 

• Sound substitutions

Letters and sounds that are present in one language may not be present in another. So, since not all dictators are native speakers of English, they might exchange the sound or letter with the closest one they know. The exact substitutions vary by culture, but some are listed below:

COMMON SOUND SUBSTITUTIONS

Actual Sound	Dictated Sound
sh (she, sheet)	ch (chee, cheet)
th (this, these, catheter)	D, T, or Z (dis/tis, dees/zees, cadeter)
G or J (gentleman, just)	Y (yentleman, yust)
W (wound, white)	V (vound, vite)
V (virus, Vicryl)	B or W (birus/wirus, Bicryl)
L (collect)	R (correct)

Solution: Practice. 

• Changing genders and tenses

If a dictator starts out by clearly stating that the patient is male or female and then halfway through the dictator randomly shifts between the opposite pronouns (she/her or he/his), it is okay to change it back to the correct one. The same rule applies for random change of tense – past, present, and future – in the course of the dictation. Solution: 1. Alertness. 2. Use Ctrl + F after completing transcription to search for gender or tense changes through the dictation. This is actually advisable for all dictators over all files. 

• Hesitation sounds and pauses

Some dictators tend to say hmm, ah, eh, er, etc. when thinking about what to say next. If a word is unclear try to figure out if it might be one of these words. Solution: Alertness and practice. 

• Incorrect dosages

Some dictators might dictate incorrect dosages, which could be catastrophic. Because treatment decisions are based on information in the chart, accuracy is crucial. A good transcriptionist must therefore cross-check all dosage information dictated, by either using software such as the QuickLook drug index or by looking it up on the Internet. If a doubt still exists in the MT’s mind, he/she must time-stamp or highlight the dosage so that it may be verified by the dictator or the concerned healthcare worker.

As you can see from the above, the solution to most problems with poor or difficult dictators is practice since, as they say, practice makes perfect, and doing something over and over is the best way to learn it well. Though practice takes both time and effort, it is ultimately of tremendous benefit to those wishing to pursue a career in MT.

Given below are some other suggestions to handle such dictators.

1. Reducing the bass or speed: Many physicians are so bad at dictating that you need some special techniques to understand exactly what they are saying. If you find it very difficult to understand a particular dictator, try these approaches: Try to reduce or remove the “bass” to hear the words more clearly. You can also try adjusting the audio file playback speed from very slow to fast. Sometimes varying the speed can allow one to pick up on what is being said.

2. Telling it like it is: One of the best cures for a chronically bad dictator is to return transcription with every questionable word or passage left blank. By doing this regularly, you are indicating that the dictation is constantly poor. If someone, including the bad dictator, tries to imply you just don’t have the skill to perform their work, show them successful transcriptions you have done from other physicians who know how to dictate properly. When all else fails, simply refuse to do their work, if you are in a position to do so.

3. Quiet work environment: Seasoned medical transcriptionists know how important it is to have their surroundings as quiet as possible. If you work from home, you may find that working in the evening or through the night becomes the most productive time for you, if you can fit that kind of shift into your life. If working in a pool of MTs and QAs, ensure that your work environment is peaceful as it can possibly get.

4. Taking a break: Things always seem better when the mind is not fretting or worrying about anything. So try taking a break – eat a snack, drink some fluids, talk to a relative or friend, listen to some music or just take a walk – and then come back to the dictation with a fresh mind.

5.  Asking a colleague: Medical transcription is one of those fields where egos should be left at the door along with the lunchboxes. Nobody, and I mean nobody, can give 100% accurate files at all times. Every MT and QA requires help at one point or another. So do what most MTSOs implore, request and advise their employees to do: never hesitate to ask a co-worker or a superior for help when it comes to difficult or hard to decipher words or phrases. This becomes even more important when processing files of difficult dictators.

6. No guessing: The first and foremost quality of a good transcriptionist is that he/she should avoid guessing what is unclearly dictated or heard. If the problem dictation involves drug names, drug dosages, patient-described symptoms, etc., guessing incorrectly could have dangerous, even life-threatening implications if the error goes unnoticed through the health system. The safest, most professional and ethical approach is to leave a blank in the transcription, preferably with a time-stamp.

The above suggestions are based on years of experience and research into the field. However, each MT needs to develop a system that works for them with the difficult dictators. Maybe you go through the entire report and leave blanks where you are stuck, coming back to listen at the end. Maybe you have a rule about how long you will try to get something before you send it to QA for help. There is no right or wrong answer here; everyone has their own system. What is important is finding a system that works for you and using it to make things easier.