Little is known about rheumatology to the vast majority of Indians. Many patients suffer due to lack of knowledge and the resultant inability to make informed decisions. Most often, patients themselves learn about this disease only when it is in its advanced stages.
India has very few rheumatologists compared to western countries and these doctors are hard pressed for time. In such a scenario, we introduce Dr. Nilesh Nolkha, a doctor who is involved in educating and healing patients suffering from rheumatism; rheumatoid arthritis (RA) is one form of rheumatism.
A brief introduction about Dr. Nilesh Nolkha
He has had extensive training in the diagnosis and management of various rheumatological ailments including pediatric cases, use of biologics, intra articular injections and musculoskeletal ultrasound. He is experienced in treating rheumatological ailments in pregnancy.
His aim is to develop an integrated rheumatology unit which can deliver care for all possible rheumatological ailments and train future rheumatologists.
He is currently a consultant in Rheumatology at the Wockhardt hospitals, Mira road.
Good evening, doc! Many thanks for taking the time off from your practice to speak to us.
Well, since patient education is not particularly emphasized in medical colleges, is there something that triggered this thinking when you started to meet patients?
I have always been a believer of patient education. Even doing my training days, I used to make a conscious effort to teach patients about their condition, in their language.
Consider this situation. If I were a patient and if I am going to a doctor myself for some medical consultation, I would expect that the doctor should provide me with enough information so that I am empowered about my disease and I can make my treatment decisions wisely. So would be the case with the patients who come to me. Hence, I have always been a believer in patient education and have been practicing it in my consultations.
What is your assessment of patient education in India with respect to RA and how does educating patients fit into your consultation?
If you look around, you would notice that that there is really a big shortage of India-specific patient education content. There are very good websites relevant to the US and Europe population. They are quite advanced in the way they educate patients providing appropriate information.
However, in India, there is a dearth of good reliable information for patients.
I believe most of the times the patient looks for the right information that can make them take better treatment decisions. Often times, doctors assume that patients don’t require information. But I have noticed that patients prefer to have more information and that too from their doctor. And that’s why the moment I started practicing, I made an effort to educate the patient in whatever way I can.
Invariably, my first consultation with the patient takes a lot of time when I speak a lot about their condition. I also started writing my blog around three years back and I regularly use these blogs to teach my patients.
Doc, but, doesn’t spending such long time with patients cut down the number of patients you are able to meet?
It definitely does. It does cut down the time as I have only 24 hours in a day. But I believe that a very educated patient as also a patient who is provided good treatment can go a long way in building your practice.
It’s very easy to bring down the quality of a consultation by increasing the number of patient load. But as long as my patients are happy with the amount of information I provide them, even if it impacts the number of patients I see in a day, the practice only increases in the long run. We have to decide between quality and quantity and I have been always a believer of quality over quantity. I believe that if you are passionate about that, it really doesn’t matter, from a financial point of view, if you end up seeing fewer patients in a day.
Thanks, doc. It is good to hear. How does spending time and effort in educating patients help in providing better patient care?
I think it helps a lot. There are 4 big benefits.
- When I share information with my patients and later when they see some article elsewhere that is saying the same, it reinforces their understanding and their trust in me.
- The knowledge about their disease helps them in managing their life.
- It helps my patients understand what I’m trying to do.
- It also helps them in taking treatment decisions that is right for them.
Further, it tries to dissolve many myths. So, there are a lot of benefits of educating patients.
Can you amplify these points, please?
See, when patients get educated, they are more in tune with the doctor’s thought process. They understand why we are making certain treatment decisions. They also know what to expect in the future. And when they are well read, they don’t question the credibility of the doctor’s decisions. They’re also well aware of things, for example side effects of certain medications and if they have any issues they can always ping me saying, “Doctor, the leaflet mentioned so-and-so. So probably we have some side effects. Can we come and see you?”
Patients become well aware of their situation. As I said, it empowers them to know so many things regarding the disease and the treatment.
Thanks for elaborating , doc. Can you share more specific insights of what you have been able to provide to patients through your education?
I regularly share with all my patients an article about rheumatoid arthritis. It is a very comprehensive article. It tells rheumatoid arthritis patients of the dos and don’ts of their diseases.
The biggest myth I am able to expel among my patients is that eating proteinaceous food is not bad for arthritis or eating sour food is not bad for arthritis.
It is a very common myth in the Indian context that if you eat anything sour or ‘khatta’, it will lead to arthritis. This leads to a lot of issues. Actually, sour food contains vitamin C which can be very healthy for patients. So, when they avoid sour food, they are avoiding a good source of vitamin C that they need!
Also, patients get misled by claims of alternative medical practitioners who suggest that you shall not have this and that. Many people stop eating pulses and proteinaceous food which leads to a lot of detrimental effect to their health. So I think the biggest effect of education is actually dispelling the myths of diet in patients. I have had two or three articles on the same which patients are very happy to read.
That’s great from a patient’s point of view. While you did mention earlier that patient education helps your practice in the long run, how does it aid you in the short or medium term?
There are a lot of benefits whichever way you look at. The biggest benefit is that the patient’s confidence is available to me. They start believing my actions.
Even if they don’t believe me more, at least then they will choose a different rheumatologist rather than choosing some alternative branch of medicine which might do more harm. And, even if they do go to a practitioner of an alternative branch of medicine and it fails, they have the confidence that what the doctor told previously or educated us previously was the right thing to do.
So, there are a huge number of benefits and I can go on and on.
Doc, do you have a defined structure for educating patients?
As of now, yes. So what so I do?
I have a running blog. I have many articles and I also pick up articles from certain websites. I have created a WhatsApp group. I send regular updates to the group, at least the basic things.
If a patient of rheumatoid arthritis comes in, I send them some basic articles on rheumatoid arthritis and so forth. I also tell my patients to leave me a message whenever they have a need for information.
What is the typical patient journey and what are the challenges you face in educating patients, doc?
By and large, patients come to me referred by another doctor. I usually advise them some tests for confirmatory diagnosis. Once the diagnosis is confirmed, I send them blog articles regarding their disease journey.
The trouble I face is that patients are usually receptive to reading basic articles but not beyond them. I’m still not sure if the Indian population is ready to read very advanced articles regarding their disease and I see most of the times that if I give patients more details, most patients don’t read them!
We are still trying to get out India-specific or population-specific articles regarding various rheumatological diseases and the treatments related to them.
Meanwhile, even if 5-10 percent of my patients read it, I am happy. My exercise is helpful to a small set.
So the whole plan that at this moment is to give patients the articles relevant to the disease; try to source them from other places if I do not have my own, and slowly and slowly build a portfolio of articles which are specific to our population and disseminate them on a regular basis.
Do you any specific tools and assets to educate patients?
As I said, at this moment, the sending of web based articles and links over WhatsApp is what I can fathom. The simple reason being that many people I consult don’t have e-mail IDs and it’s much easier to directly send them the articles to their mobile.
I have noticed that it starts getting very cumbersome after a certain time and that’s where, probably, a platform like HealthyJio can pitch in.
Despite all your efforts, how do you ensure that your patients rightly understand your messages, doc?
You nailed it! This is a very difficult thing. I do understand that many a time, I send patient the articles and they don’t actually read it or even worse, they misinterpret it. And, to add to it, they actually don’t try to correct their doubts.
What I do is that I always ask them, “Have you read the articles. Have you understood everything?” But it does become very difficult and many times I do notice that patients have misunderstood despite using very simple language in the articles. So we are trying to see how patients respond and possibly create articles like that.
Honestly, I’m currently facing a lot of issues because I tend to see a lot of middle class and lower middle class patients where the level of literacy is just adequate. And this set of people do have a problem in comprehending the amount of medical information we give them. But, I guess we have to keep on trying and see where things are going. Do we have an option? Yes, we can choose not to educate but that is even bad and I do not subscribe to that view.
Do you see any opportunities for improvement in the education process?
Definitely a big Yes. I believe that more than 50 percent of my patients do not read the stuff I send them. Very few people take the effort to leave a message for me asking for articles. Most patients are not very keen on learning about their diseases.
I think we have to try to make the whole process of accessing medical information more easy, more palatable. Possibly use more of regional languages. Only then can we possibly reach the standards of Western countries where patients are more educated and well-read to make decisions and can possibly pitch in more to make better treatment decisions. We have to go a long way on that front.
I believe getting out regional content is the crux of many things. And until we do that, just using English as a language to educate patients can be quite restrictive. Though generating India-specific English content can also go a long way in reaching quite a big chunk of population but if we have to reach the masses, we possibly have to bring our content in regional languages.
Thanks for your time, Doc. Also, on behalf of the patient community, thanks for your efforts.