Great Equalization: Is MBBS From India Equal To M.D. In U.S.A?

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AAPI Journal • March 2009 SPECIAL ARTICLE Probiotic Theraphy Continued from page 27 disaccharide lactose into the simple sugars glucose and galactose in the Ileum, and thus reduce the discomfort of lactose intolerance. 2. Reduction of intestinal infections: Antibiotic-induced diarrhea has been successfully controlled by Probiotics. Lactobacillus and Bifidobacterium have been used in children and adults for therapy of intestinal infections. 3. Reduction of coronary heart disease: The fact that Probiotic supplementation inhibits cholesterol concentrations in the blood and increases the excretion of cholesterol in the feces has been well documented. Cholesterol absorption is interfered within the gut partly due to assimilation of cholesterol by Probiotic organisms. In addition, Probiotics (Bifidobacterium longum) deconjugate bile salts with the aid of bile salt hydrolase, and thus increase the excretion of free bile salts in the feces. This has the potential to reduce serum cholesterol because the replacement of bile salts would require the utilization of some cholesterol in the body. Thus, the resultant hypocholesterolemia may reduce the incidence of coronary heart disease. 4. Immunomodulation: This is a very important activity induced by Probiotics. Immunestimulating activity is attributed to their bacterial cell envelope constituents such as peptidoglycan. Results of various investigators indicate that Probiotics stimulate the 28 www.aapiusa.org production of antibodies, enhance the systemic activity of macrophages, and increase interferon levels and the number of killer cells. 5. Suppression of cancer: Dietary intake of lyophilized cultures of Bifidobacterium longum has significantly suppressed the development of azoxymethaneinduced aberrant crypt foci (ACF) formation in the colon. The same group of scientists elucidated the ability of the Probiotic strain to inhibit the incidence of colon tumors. 6. Suppression of Helicobacter pylori: Helicobacter pylori is a gram-negative spiral-shaped bacterial pathogen that colonizes in the area between the mucous layers of the stomach and gastric epithelium. The International Agency for Research on Cancer has classified H. pylori as a Group I carcinogen. This is the first pathogenic bacterium to be classified as such. Limited research data indicate that even H. pylori can be inactivated or suppressed with the use of proper Probiotics. Prophylactic Probiotic Therapy for Cancer Suppression: Some of the non-Probiotic type of gastrointestinal flora will convert procarcinogens to carcinogens. Some of the end products of digestion are procarcinogenic. For example, end products of the digestion of beef may be more procarcinogenic than those of vegetables. Procarcinogenic materials may not cause cancer; however, if they are acted upon by certain microbial enzymes (betaglycosidase; beta-glucuronidase; steroid 7 alpha-dehydroxylase; nitroreductase and nitrate reductase; azoreductase; and tryptophanase) in the G.I. tract, it will be converted to a carcinogen. Probiotics, by their innate nature, suppress the growth of these undesirable enzyme-producing non-Probiotic bacteria, and thus reduce the chance of converting procarcinogens to carcinogens. If you analyze the entire mechanism, cancer starts with one cell through mutation. If mutagens are reduced or eliminated in the body, cancer can be controlled. Mutagens can be reduced if proper Probiotics are administered and made to colonize in the gastrointestinal tract. In our opinion, a proper diet and Probiotic therapy is the wave of the future to eliminate mutagenesis, which is the starting point of cancer. In conclusion: Since the efficacy of Probiotic therapy is linked to the proper Probiotic organisms and also their physiological condition at the time of oral administration, the following selection criteria should be followed by the physician: 1. They must be of human origin. 2. They must have high acid and bile stability. 3. They must have adhesion properties to stick and colonize on the intestinal mucosa. 4. They must be safe and clinically proven. 5. They must be clinically validated. 6. They must be produced or manufactured by taking into account the strain stability (plasmid retention), phage resistance and freeze drying survival.
SPECIAL ARTICLE AAPI Journal • March 2009 The Behaviorally Disruptive Physician by Gopal Lalmalani, M.D. Gopal Lalmalani, M.D. Denver, Colorado Some health care professionals may consciously or subconsciously be perpetrators of disruptive behavior in our workplace. New JCAHO standards require that hospital and medical staff leaders recognize such pattern of disruptive behavior and confront these professionals. The Joint Commission states that “safety and quality thrive in an environment that supports working in teams and respecting other people, regardless of their position in the organization. Undesirable behaviors that intimidate staff, decrease morale, and increase staff turnover can threaten the safety and quality of care” This new standard will be applicable to physicians as well as all other health care professionals (including nurses, pharmacists and management). Who is a disruptive physician and what is disruptive behavior? Although there is no clear definition, the term “disruptive” is sometimes used interchangeably with the term “abusive” and the AMA describes this type of behavior as “a style of interaction with physicians, hospital personnel, patients, family members or others that interferes with patient care”. Disruptive behavior encompasses a spectrum of conduct that includes verbal abuse, emotional outbursts, yelling and screaming, use of sarcasm or belittling remarks, and threats of violence. It may also include incidents of inappropriate physical contact, throwing tantrums, and tossing objects. Other health team members are likely to try and avoid contact with the disruptive physician which may then affect the communication needed to provide high quality patient care. Disruptive physician policies are often written vaguely and broadly, and are subjective. As an organization, we need to ensure that these policies are not used to target outspoken medical staff members or physicians who are not “team players”. We need to protect competent and compassionate physicians who truly care for the patient’s welfare, and who provide good-faith and constructive criticisms in order to improve the quality of care in the hospital. The AMA code states that, “criticism that is offered in good faith with the aim of improving patient care should not be construed as disruptive behavior”. We need to also ensure that these disruptive physician policies are not targeted to get a physician off the medical staff by an economic competitor who for some reason or the other may be more “influential” within the hospital. There have been instances where the hospital nursing staff has been instructed to “write up” every action of a “targeted” physician as “inappropriate”. Such false labeling of a targeted but innocent physician could be a blow to his or her practice resulting in loss of reputation in the community and loss of income. Any correspondence from the hospital or medical staff leadership that insinuates that a particular physician may be “disruptive” should be taken seriously and responded to immediately with objectivity and facts. If necessary, legal counsel from a health law attorney should be obtained. Otherwise, the potential for loss of privileges, loss of liability insurance, and termination of hospital contract could be a real one. Furthermore, reports to the state professional health program, the state licensure board, or the National Practitioner Data Bank may further jeopardize the physician’s career. Medical staff leaders need to carefully craft by-law provisions that contain procedural safeguards that protect due process, and offers fair hearing. Physicians who truly exhibit disruptive behavior should initially be referred to a medical staff wellness committee. The key is to get the physician involved as soon as possible. At times, requesting another respected physician colleague to be a liaison or a mentor could be useful in calming a disruptive physician. If disruptive acts recur, more formal action is warranted. If the physician behavior poses a significant risk to patient safety, immediate suspension of privileges may be necessary. If the physician’s behavior does not pose an imminent risk to patient safety, then a meeting should be held by the Medical Executive Committee, and a formal peer review be initiated. Peer review needs to be legitimate, with the sole purpose of protecting patients in furtherance of their quality of care and promoting safety. As physician leaders, and strong advocates for our patient’s care and safety, we should champion the policy on professionalism, define unacceptable behavior, and agree on ways and means of rectifying disruptive physician behavior. Thanks to the national impetus and the headlines recently made on this issue, it is time that we address this matter urgently. www.aapiusa.org 29
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