How to wean a baby - a guide to complementary feeding for Doctors - Dr Ashwini Bhat at Docplexus

As community physicians, we are hit by malnutrition among under five children so hard on the face that our heart starts aching. Under nutrition is worst in the age group of 6 months to one and half years. This is not just because of a delay in the introduction of weaning foods but also due to the poor quality of foods combined with inappropriate practice of feeding. According to the NFHS 3, only 21% of the children in India were offered any semi-solid food between 6 and 23 months. How tragic! At the time of maximum growth, the child is deprived of essential nutrition. 

Who is at fault? Is it the mothers or the doctors? An intervention in Haiti taught mothers to use inexpensive local foods to prepare nutritious food for their children. This was highly successful in helping mothers rehabilitate their malnourished children: the children of the mothers who received demonstration-education had under-nutrition related mortality rates that were 68% of the same as experienced by children of the mothers who had received growth-monitoring but no demonstration-education. So let’s take the blame on us now. We are no doubt emphasising growth monitoring as a tool to tackle under nutrition but at the same time we are getting so busy that we aren’t counselling the mothers regarding weaning foods and feeding practices. Here is what WHO has told us long ago. 

We should make it a point to spend at least 10 minutes counselling one mother who is about to wean her child irrespective of we sit in our offices or work in the field, irrespective of whether we are the busiest or we have all time on earth. World Health Organisation’s guidelines for appropriate complementary feeding is as follows - Continue frequent, on-demand breastfeeding until 2 years of age or beyond. Breastfeeding should continue besides complementary feeding up to 2 years of age or beyond. It should be on demand, as often as the child wants. Breast milk can provide one half or more of a child’s energy needs between 6 and 12 months of age, and one third of energy needs and other high quality nutrients between 12 and 24 months. Breast milk continues to provide higher quality nutrients than complementary foods, and also protective factors. Breast milk is a critical source of energy and nutrients during illness , and reduces mortality among children who are malnourished. Practise responsive feeding, applying the principles of psychosocial care. Feeding time is the period of learning and love. Mother ought to give her undivided attention to the child while feeding the tiny tots because as important as what is fed is how and where the child is fed. More active style of feeding can improve dietary intake. Mother should find a way of interacting with her child and drawing the tot’s attention towards her like singing or telling a story or showing attractive books or photos and videos etc. 

Patience is of utmost importance. If children refuse many foods, experiment with different food combinations, tastes, textures and methods of encouragement. A mother must always talk to children during feeding, with eye-to-eye contact. Practise good hygiene and proper food handling. Microbial contamination of complementary foods is a major cause of diarrhoeal disease, which is particularly common in children 6 to 12 month’s old. This can be prevented by safe preparation and storage of food. Keep all utensils, such as cups, bowls and spoons used for an infant or young child’s food thoroughly washed. 

Hand washing is of paramount importance, before preparing the food as well as feeding the child. Mother’s hands as well as child’s hands need to be washed thoroughly.  Keep raw and cooked foods separate. Cook thoroughly so that even the centre of the food roll boils. Keep food at safe temperatures. Bacteria multiply rapidly at room temperature. So, the foods need to be refrigerated if they are to be kept for long. If refrigeration is not possible, then it is important to finish the food within 2 hours. Infants should preferably be fed with freshly prepared food. Use safe water and raw materials. Start at 6 months of age with small amounts of food Start with liquid foods like cow’s milk or clear fruit juices or cereal porridges. Initiate with 2–3 tablespoonfuls per feed. Such 2–3 meals per day may be offered. Gradually increase the food consistency, quantity and the number of times that the child is fed complementary foods as the child gets older. Gradually thicken the consistency of the cereal porridge so that it can stay on spoon without dripping off. Also start giving pureed or well mashed foods. 

Foods that are thicker are more energy- and nutrient-dense than the liquid foods. Increase the quantity to half of a 250 ml cup per meal till 8 months and 3/4th of the same cup then on. Depending on the child’s appetite, 1–2 snacks can be added. Bring in more variety in food as the infant grows older, adapting to the infant’s requirements and abilities. Once the child starts to accept cereal based diet, gradually add pulses, vegetables and animal foods one by one. Feed a variety of nutrient-rich foods to ensure that all nutrient needs are met. Cook with less water and make a thicker porridge, replace some (or all) of the water with milk. Add extra energy and nutrients to enrich the thick porridge. 

For example add milk powder and sugar (or margarine or ghee); or add groundnut paste (peanut butter) or sesame seed paste. Adding fatty / oily foods makes thick porridge softer and easier to eat. Toast cereal grains before grinding them into flour. Toasted flour does not thicken much, so less water is needed to make porridge. By 8 months, most infants can also eat finger foods. By 12 months, most children can eat the same types of foods as consumed by the rest of the family. Use fortified complementary foods or vitamin-mineral supplements for the infant, as needed Unfortified complementary foods that are predominantly plant-based generally provide insufficient amounts of certain key nutrients (particularly iron, zinc and vitamin B6). Inclusion of animal-source foods can meet the gap in some cases, but this increases cost and may not be practical for the lowest-income groups. 

Furthermore, the amounts of animal-source foods that can feasibly be consumed by infants are generally insufficient to meet the gap in iron. Hence, foods fortified at the point of consumption with a multi-nutrient powder or lipid-based nutrient supplement may be necessary. Increase fluid intake during illness, including more frequent breastfeeding, and encourage the child to eat soft, favourite foods. After illness, give food more often than usual and encourage the child to eat more. 

During an illness, the need for fluid often increases but the child’s appetite for food often decreases. At that time breast milk may become the main source of both fluid and nutrients. A child should also be encouraged to eat some complementary food to maintain nutrient intake and enhance recovery. Intake is usually better if the child is offered his or her favourite foods, and if the foods are soft and appetizing. Child must be given more frequent, smaller meals. When the infant or young child is recovering, and his or her appetite improves, the mother should offer an extra portion at each meal or add an extra meal or snack each day. Reference: Infant and young child feeding Model Chapter for textbooks for medical students and allied health professionals. Geneva, World Health Organization, 2009. 

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A Simple Way To Increase Your Productivity And Profitability for a Doctor's clinic - by Dr Aniruddha Malpani

While most doctors have great clinical skills, we often don't learn to manage our practice very well . Even though every clinic is a small business, and every doctor is an entrepreneur who needs to earn a profit in order to provide high-quality medical care to his patients,  we are never taught any business skills. 

This is why we often end up trying to do everything ourselves. We want to be in control of everything, and our medical training teaches us to be the captain of the ship, and to take responsibility for everything we do. We become expert micromanagers, and are very uncomfortable delegating duties to a receptionist or assistant. In fact, most doctors don't even have an administrative assistant, because they feel that they are incompetent. This often becomes a self-fulfilling prophecy . Because they are not willing to invest the amount of money needed to get a good secretary or personal assistant , they usually get poorly trained front office staff, who cannot perform the complex tasks needed to run a clinic, which is why the doctor often ends up doing all his administrative duties himself. This is a complete waste of his energy. His precious ( and expensive time) would have been more fruitfully deployed taking care of patients, rather than on doing administrative trivia, such as giving appointments, or collecting his fees - duties which are better assigned to an assistant. 

Because doctors pay peanuts , they get monkeys , and then they feel that an assistant cannot add any value to their life.  Working in a doctor's clinic can be quite a complex job. The hours are long; and there are multiple tasks which need to be accomplished simultaneously , such as answering the phone; assisting the doctor; answering his summons; and trying to pacify patients, who are upset because the doctor is always running late. 

Learning medical jargon is a challenging exercise, especially when  the doctor does not provide any training , and expects the assistant to figure out everything for herself while working on the job. We usually set them up for failure, and when they do fail, we get a chance to complain that the young generation of Indians is lazy and useless, and refuses to work hard. Doctors need to understand that they cannot afford to be penny-pinchers when employing team members for their clinic.

 The only way doctors can improve their profits is by seeing more patients, but they end up being the biggest bottleneck in their own profitability . They hurt themselves by hampering their personal productivity by trying to do everything themselves. They need to increase their efficiency by seeing more patients , and the only way they can do this is by delegating their administrative tasks to an assistant. The rule is that any task which can be done by someone other than the doctor should be done by someone else , because the doctor is the highest paid employee in his clinic. You should concentrate on taking care of your patients , so you don't need to waste your time and energy on doing routine things like giving appointments , or collecting fees. This is something which is far better done by a receptionist , but you need to be willing to pay your receptionist well . 

A good receptionist can add so much value to your life !  Even if you end up seeing just one patient more daily, she will have more than paid for her salary .  Equally importantly, a good receptionist can help to improve the quality of your life as well.  If you do not have to worry about the boring , mundane routine chores of running your clinic , you will have more free  energy and bandwidth , and will be able to devote more time to taking better care of your patients . The person you employ needs to very talented, and you should be willing to pay her what she is worth. Every leading doctor has a great personal assistant, who runs their clinic for them, and they will no tbe able to function without her.

It's not easy being a medical receptionist-cum-personal assistant-cum-secretary-cum telephone operator, and you need to appreciate her efforts. Let's not forget that a major reason patients prefer going to corporate clinics as compared to the traditional family doctor is because they employ better secretarial help. We need to learn from them , and stop treating our staff salaries as an expense - they are really an investment, and often one which is far more cost effective than a new ECG machine! A good secretary can be a huge valuable asset because she is the friendly smiling face of your clinic . Patients are reassured when she picks up the phone and greets them, because she is a familiar figure they can connect with. A good assistant will let you know exactly what's going on in your clinic, and will alert you when a patient is upset or unhappy, so you can take corrective measures. She can pacify patients who are getting restless when you are running late, and can help you to pick up your pace when a patient wants to just sit and chat with you. She can act as a peripheral brain and  alert you to medical problems ( such as an abnormality in a lab report) if you are able to retain her for long enough, because she will learn a lot from you by osmosis. She can help to put you in a good mood by making sure you get your tea on time; and will help to make sure that patients like coming to your clinic , by ensuring that it is kept clean and tidy. A  good secretary is worth her weight in gold, and she can make your life much more fulfilling . She can help you to earn more money by allowing you to reclaim more time for yourself and your patients.

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Money And Doctors, Shame Or Pride - Guest Post by Dr Manoj Manikoth - Docplexus

Born to three generations of government employees, I was so full of ideology when I finished my medical school. I wouldn’t practice, I said. I would only serve the poor, I proclaimed; a good teacher would I become, I yearned. And so was it, over the next few years. I wasn’t unhappy at all. I had very few needs and no serious financial commitments. Life was good, and little things kept me happy. 
But over time, I started feeling uncomfortable. Was I doing enough? I fancied myself a good surgeon-to-be, and as and otolaryngologist, I needed technology to go a step higher. But that needed money. I decided to work for it, but also balefully remembered my classmate in school, a perpetual cynic, who told me once, without mercy- “soon, you will be just the same as everyone else- do things only for money, and rot inside”.  I so badly wanted to prove him wrong. 
Then, as if by sheer chance, I happened to watch a TV interview of the well-known psephologist. He said, and I felt it strike a chord inside me - “the middle class are often bought up thinking that making money is bad- we need to get out of it and understand that to make money well is actually satisfying and benefits a lot of people”. Voila, I thought- I can actually relate to that. 
Lets now fast forward thirty years. I now am a surgeon with considerable repute, have a really good, well equipped hospital, employ over a hundred people. No, I didn’t have any inherited wealth, I didn’t marry for money, neither did I have wealthy friends who would pitch in for me. I also didn’t, much to my childhood friend’s surprise, make money the wrong way. All of us here work to protocol, never prescribe a drug, or order a test unnecessarily, refuse more surgeries than we do and there’s a strict no-no to pharma funding of any kind. How was this possible? There’s no magic here, no providential hand. Just a formula that can just as easily be adapted by anyone else with reasonable skill and a little bit of guts. 
Let me try and enumerate what made me do well. We must remember that for most of us, our only earning comes from the patient. This money is never given thankfully- illness is a burden and the expense related to it’s alleviation is given grudgingly. Understanding this basic equation must make us strive to make each rupee of that money count for the patient. So, the first recommendation from my side to an aspiring entrepreneur is to make sure that you give value. We have long been caught in a vortex of trying to undercut our charges to gain practice. It is a losing game. We have to add value, albeit slowly, for everything we do. A better waiting room, more efficient patient management, transparency and education, everything counts for the patient, and they would actually like paying for it. It is simple economics. If you intend to spend an x amount of money to increase the facility in your clinic/hospital, you need to spread it over the patients that you see now, and look at the increase in patient flow due to the better system to make your profits. You just can’t work the other way, it is foolish to invest heavily and think they would come pouring it just because the waiting room rivals a luxury suite. The increase in your professional worth is what should give you profits. 
Let us take an imaginary scenario. There are often patients who present with a symptom that could be because of two different conditions. Doctor A, is cautious, ill trained and afraid of failure. He would investigate heavily, and when that too doesn’t give him enough clues, gives the patient medications for both conditions. The patient gets better, yes, but the doctor would never know which medicine has made him so. The spiral begins, and patients get investigated more and more, medicated more and more, side effects of treatment spirals and skill acquisition is minimal. Let us look now a doctor B. He is shrewd, well trained and is not afraid to experiment. He starts with the same uncertainty. He, by using an analytical, but yet unskilled brain, thinks in favor of one. He doesn’t investigate much because he trusts his instincts. If the patient gets better, he is elated- he is proven right. If he doesn’t, there’s always option 2. To prevent the discomfiture of an irate patient irked by the delay in treatment, he uses kind words and counseling to reassure the patient that he is only trying to avoid unnecessary medications and investigations. Over time, doctor B gets more and more skilled. He now has acquired that sixth sense which tells him what the patient might be having instead of over investigating. If the doctor B has entrepreneurial skills, he will now increase his charges. What the lab gets and what the pharmacy gets is now his. Money, now flows into the coffers, and a beaming patient praises the doctor. Doctor A is, unfortunately, still despondent.  
 The same goes for investing in surgical equipment. If you think that a particular instrument would greatly add to your results, buy it, but do not look at charging for it every time you use it to repay your loans. It creates stress and stress reduces your results. You would buy a Laser, simply because the salesman would pitch in with a formula “Sir, you might have ten laser cases a month, so x times ten times twelve, your loans are over in so many years” It is a gambit we fall for. I would buy a Laser only if it significantly improves my results. I would never even advertise or boast about it. I would use that in my counseling for a surgery if I think its absolutely necessary. But I would increase charges over my entire operation list for the month to make sure I am not pressurized to use it when I don’t really need it. Thereby I have only marginally increased charges; I have no stress if I don’t have any laser cases for a month, and if I do get one, I do a pretty damn good job. And this creates more patients, while shouting from the rooftop that I have an expensive laser would only have created suspicion, and sometimes, jealousy. We have to prioritize our investments- I would rather buy a good equipment than say, a fancy car or a palatial house that I can very well do without. If my choice of the purchase was founded on good grounds, it is often that the house and the car would follow, even if you can’t really count on it! 
Similarly, we must understand that a well run professional medical establishment offers far greater returns that those fancy stock market juggle. I was once told about this by some one who I consider my mentor and hold that close to my heart. My only real investment is my hospital- and if I retire, that should give me returns in decent terms for as long as I live. Another important lesson I received early on in life is from a senior neurosurgeon colleague. He once told me that it was a dangerous ploy to keep referral patients over 10%. It surprised me then, but the logic was irrefutable. Referrals are fickle. A doctor who refers to you can stop referring to you, even if he is not unhappy with you. But your patients, those who come to you for solace and comfort, are your real saviors. They bring more convinced patients who in turn, become your well wishers again. Many doctors spend a lot of efforts on placating the referees, little knowing that it is really not worth the effort. If you spend a quarter of that time with your own patients, the results are astounding. 
Nearly thirty years in practice, my referrals are still less that that magical figure. And I am in no way unhappy. A very good financial trick is to stick to the things you do best, or add someone to the team who would do something better than you. I have often seen people holding on to patients too long, and not referring out of fear of losing them. Referrals should be made early and to the appropriate person, not someone who calls you home for a weekend treat! Over time, you might lose friends, but keep only the good ones who value your intention. As I have surmised before, earning trust is worth its weight in gold, and nothing improves your stature more than the feeling you create that if you can’t do it, you will send them to someone who can. You also need to plan a retirement. 
For many doctors, this is unthinkable. To prevent burn outs, and to improve your family and social life, this is of paramount importance. A simple formula is to calculate how much you need now, once your loans are paid off and then plan to have that over the next twenty years, giving 10% to inflation. So, after you have reached the fifties and if you’ve been successful, you need to delegate your practice to deserving youngsters who respect your principles of practice and think about a system which gives you a share of the practice you have so painfully built up. You should, at that time, put yourself at a premium. Reducing your consulting hours and increasing your charges will allow you to work less for the same amount of money. And, for your social responsibility to be satisfied, you can also use your free time, involving your family too, to do your mite to the society, what appeals to your heart. 
Finally, you need to invest in your health. Eating properly, exercising regularly and reducing stress will help you to enjoy what you’ve reaped. And for those unfortunate times when ill health can strike without warning, it is important to be properly insured. An ideal health insurance should cover even the costliest procedure done, and should cover your family too. I am currently insured for 95 lakhs, and feel safe under its umbrella, even if I don’t even have a health issue at present. It might look an overkill, but considering the peace of mind it offers- priceless. Even more adequate should be your life insurance. This should give your family the same income even with you not being around. And do junk those policies that offer you a lot of investment benefit. The health and life insurance policies are useless for me if I am in good health and if I am alive- but I would rather be happy that I am healthy and alive! What made me want to pen this all down? Being a person who cannot resist being on social media for doctors, I see a lot of frustration and angst. I see many who feel that they are being hunted, victimized for no fault of theirs. I see people who feel that they do not receive their due. At the other end, I see the public who are critical, and out to malign the medical community for the wrong doing of a few. And there seems to be no way to make these radically different view points meet. It appears that the level of frustration is related to the failure of the medical profession to make it pay, and for the customers to realize what they are paying for. Let us not kid ourselves anymore- medical profession is just another profession, and it is no more noble than that of a lowly servant nor any worthier than that of a soldier. We have only one small difference- we aren’t in control of many things that we deal with. We deal with uncertainties and changing patterns of  ever increasing knowledge that rival most other professions. But we cannot, under the cloak of that nebulousness, neither wallow in self pity, nor puff out in artificial pride. We have to deal with this as a profession, and aim to give our very best, and by making sure we are doing so, to get in return what is due. Once we realize this, most our our helplessness should disappear. I do not consider myself a special person, and I do not ever want to think I am indispensable to many. I am here to do a job as best as I can, and with that, take my due. No one, I think, should ever suspect that I am taking more than I could, or attempting to do more than I should. This is all that I ever need.

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