Dr. Lalit K Sharma has been practising Radiology specializing in Fetal Radiology in a rural area of Madhya Pradesh for the past 35 to 40 years. Dr. Lalit has been providing dedicated service to the poor people of the area including giving free medicines and free ultrasound exams to the below poverty line population. Dr. Lalit aligns his work with societal needs including trying to reduce avoidable child deaths.
Vampa Ankrur, a freelance writer, is writing a series on talks with radiologists in India especially those associated with the Samrakshan program of IRIA, which aims to reduce deaths among babies during pregnancy. We are happy to share parts of the conversation Mr. Ankrur had with Dr Lalit K Sharma focusing on his Journey as a Radiologist in Rural India.
VA: When did you complete your PG in Radiology?
LKS: I completed my PG in Radiology in 1981 from Gajara Raja Medical College, Gwalior.
VA: How long have you been working in Guna?
LKS: I have been working at Guna since 1982 except for brief period of two years when I went abroad. Approximately 35 to 40 years now.
VA: Why did you choose Guna? Why not a metro or an urban setup?
LKS: Things were different back then. We did not have the variety of choices, in work or in terms of cities to live in, like we have today. There weren’t many opportunities even in the big cities of Madhya Pradesh back then. I joined the Government Service of MP, then joined the public sector NFL Vijaypur at Guna in 1986. It was here that I got opportunity to start ultrasonography in 1987 with training in USG, CT, MRI from AIIMS New Delhi. This was the first ever such set up in any Government or Semi Government organization in Gwalior division.
But the most important consideration was that I was born in a rural background, in the Dacoit filled Chambal region, I belong to a rural background and wanted to serve the rural areas where about 70% Indian population lives. I can understand the struggles they face on a daily basis. I had to give back.
VA: Let us explore more about fetal radiology in a rural area. How important do you think fetal radiology is for a rural area. Why is it important?
LKS: It’s very important. Qualified Specialist must be available to rural population where health services are not up-to standard particularly in specialized fields like Radiology. Rural populations have a lot of struggle, to survive, get married, to have the hope of a home and children. A child may bring some happiness to an otherwise tough life, something to make life bearable. I always felt, the baby has so much struggle to face in life, can I at least give it the best while it is in its mother’s womb? Fetal Radiology is important. A sick child may not receive good care for many reasons like access to care, affordability of care and availability of care. Even if the family wants to give the sick child good care, it may not be possible. Fetal Radiology is important to promote good health of the baby. This is important for all babies but especially true for rural areas.
VA: You can diagnose an abnormality. But what after that? Delays are one of the most important challenges in rural health care. What sort of delays do you face? How do you deal with that?
LKS: This is a reality that most of us who practice in rural areas have to face, on a regular basis. We face various delays and hurdles, after diagnosing an abnormality, in getting appropriate treatment. First of all, I have to explain in detail to the woman including her family members about the abnormality that was found. Sometimes, this may have to be done many times and then the family members will bring other members to be explained again. Most often, this is not because they disbelieve or cannot understand, it is often that they are unable to come to terms with what has happened and want more reassurance. We have to be patient and give them time. Sometimes, I have had to explain to the entire village, well almost the entire village, regarding abnormality, prognosis and appropriate management.
The second delay is reluctance to accept the reality. Every moment we spend discussing over and over again is precious time that is lost in the management of the woman. Once acceptance sets in, the discussion on where to treat comes in. Which hospital can I take her to, can I afford it, Is the Government hospital reliable, willingness to treat in a government hospital (there is also the social aspect that I will be seen as poor if I seek treatment in a government hospital), all these discussions happen. These are not easily resolved and sometimes even takes days for some decision to be made. By this time, management is delayed, and now, due to a lack of facility and worsening condition, the referral is made to a medical college. The nearest medical colleges with good facilities are at least 225 kilometres away from our place. This gets us to the next delay, safe transportation of the pregnant woman. Who goes with her, how many family members, what happens to their work, food and stay for the attendants, all of these questions have to be resolved.
Many babies die in this transit period or soon after reaching the higher care center.
Good healthcare is a balance between the doctor, their skill, resources, communication, willingness of the family to seek care, availability of appropriate care, providing appropriate care at the right time, and the facilities and resources to reach appropriate care centers, trust of the community. When any one of these links are weak, the whole structure breaks. Poor healthcare in rural areas is a result of all of these.
VA: In a rural setting, one automatically presumes that the doctor is engaged or involved with the community. How does a fetal radiologist engage with the community? How do you, specifically, engage with the community?
LKS: Like all professions, some people do get involved with the community, some do not. How do we define what is meant by community involvement? Every person gives what they think they can to the community, in dome way or the other. Some may feel it is more than expected, some may feel it is inadequate.
I think a fetal radiologist should engage with the community. Understanding the community or society from which the pregnant women comes is important. This is important as it helps guide your clinical decisions based on possible risks. It is also important as it gives you an idea of potential delays. You have to know the woman, her immediate family and sometimes the in laws as well as they may influence decisions on treatment. Often, you have women willing to make small changes necessary for their health but who can’t because their parents or in laws do not agree. I hear pregnant women come and tell me “ My mother or mother in law says we never had so many check ups or tests. We also have birth. This is not needed”.
I do not think we should blame the woman in such situations. The woman is a part of a unit, often a vulnerable part, and if we want to help her, we have to engage with the family. Since the family is part of a society, we have to engage with society as well. We have to build trust that we care about them.
I talk to the woman, her family, in laws if necessary and as many times as necessary. I do awareness sessions in different community settings, listening, discussing and sharing my experience and knowledge. Sometimes, it is an old patient, or a neighbour or another villager who is able to convince the woman and her family to seek appropriate care.
VA: Communication with the patient and their family is important in medicine. We usually think of radiology as generating reports given to other physicians to manage. As a fetal radiologist in a rural setting, do you communicate with the family or only with the obstetrician? How important is it to talk with the family?
LKS: In my view communicating with patient and family is first priority. We, Radiologist, Obstetrician or Paediatrician are all working to safeguard mother and child. I have observed sometimes clinician is unable to give much time to our patients due to lot of workload, the next patient is already trying to push through the door. We are not able to discuss all or most possibilities with the woman and end up telling only the worst outcomes. We end up scaring the woman. In my practice, I make it a point to tell everything in detail starting about what examination I am doing for her, why am I doing it, what are we looking for, what do the results mean for her, and in the short-term and long term. I have to reassure them, make them feel comfortable in such a way that they develop faith in me to the extent that I am their guardian. In simple words, they should believe I will always think for their betterment. I put everything in my reports as per recent academic guidelines so that it becomes a legal standard document and generates confidence in mind of patient as well as treating clinician. If any urgent communication is needed, I communicate with clinician on phone too, and follow up with the clinician as needed.
VA: Is fetal radiology a clinical subject alone or can it be a social or community linked subject?
LKS: Absolutely not. Foetal Radiology is not just a clinical subject, where one sits behind or uses a machine and gives a report. In my view, it is a multi-dimensional subject that has to consider and integrate many stake holders.
There are many stake holders around mother and child like, Parents, their close relatives like in-laws, society with its culture, beliefs and practices, and doctors like Gynaecologists, Foetal Radiologist, and Paediatricians.
After delivery, grass root health personnel like Anganwadi worker, ANM and different hospital personnel. Being a Social Radiologist, I make them aware about their role and responsibilities in the care of the pregnant woman and the baby. I use all possible opportunities to sensitize the Society, may it be a social gathering, official club functions, or when I go anywhere as chief or special guest. All foetus being future citizen of India are my first priority.
This was the method I adopted since 2012 April and I have been able to reduce Infant mortality from 75 when I started to around 25 to 35 in my area, but have not been able to reduce deaths around child births including Still births. I attend meetings and conferences, as much as possible, to learn ways to reduce avoidable deaths of babies during pregnancy. The recent meeting on Samrakshan, the program by Indian Radiological and Imaging Association, at Indore was very helpful. It has helped me to understand a better way to reduce avoidable deaths. I discussed my way of practice with Dr. Rijo Mathew, the National Coordinator of Samrakshan. I started completing their documentation forms, following their protocols, which has helped me to make more accurate assessments by connecting the various aspects involved. Dr. Rijo is always available over phone and I take technical guidance from him whenever I get difficulty. The Samrakshan team is proactive and lets us know if they find anything that can be improved on.
Samrakshan has changed me from a general Foetal Radiologist to a more competent, efficient, and focused Foetal Radiologist without the need for expensive courses, or investment in additional infrastructure. I have improved by just working with them to utilize my skill, resources and existing infrastructure more efficiently. During these 6 months after the Samrakshan learning program at Indore, I have examined about 480 pregnant women and can say truthfully that I have been able to prevent almost 30 certain deaths around child birth just by early identification and appropriate follow up and management. Earlier, I would have lost these babies but the Samrakshan protocol has helped me identify and save them.
I give each of my patients a unique identification number so that I can track their medical records whenever they come to me or consult another doctor, and keep in regular touch with all high-risk patients through mobile phones. Patients can give my mobile number to their treating doctors and I speak to them.
VA: Dr. Rijo said you have been practising components of Samrakshan for decades. When Samrakshan came along, how did you feel, and why. What, if anything, excites you about Samrakshan?
LKS: Yes, Dr Rijo rightly said so. As I told to you earlier, I am practicing Social Radiology since long. On 14 Nov, 2011, the then DM of Guna Mr Sandeep Yadav, gave Rotary Club Guna the responsibility of an Anganwadi centre, to help them with the elimination of Malnutrition. Being a Doctor and President elect of the Rotary Club, I was one of signatories between district administration/ Woman and Child Development department and Rotary Club Guna. On 4 April 2012, I started doing ultrasound exams of pregnant mothers who were residents of villages covered by 5 Anganwadi centers and started guiding them accordingly. Now a days, I am doing free services to villages covered by 38 Anganwadi centers, approximately 60,000 population below poverty line, including Urban slums in Guna. My method was based on ensuring an accurate estimation of the weeks of pregnancy at the first visit, which is of utmost importance in taking appropriate management decisions. I give a unique ID number to each and every patient I examine, at the first visit, and follow them accordingly throughout their pregnancy. I document outcomes including results like normal birth or any congenital abnormality, loss of pregnancy, growth problems of baby, and after birth find and document the weight of the baby at birth, Sex of baby and its general health. I provide them free medicines and supplements like Micronutrients, Iron-folic acid and Calcium along with proper guidance regarding nutrition, cleanliness, environmental hygiene and sanitation. I follow each child till 5 years of age to monitor health, vaccination, Infant or perinatal mortality. If There is any congenital heart defect, I arrange to send them for free treatment through RBSK to different tertiary care institutions.
Till now, about 3300 mothers have been examined and about 15,000 sonographies done free including anomaly scans and Foetal Doppler studies. Unique ID system helped to properly follow and document the result of individual patients without any flaw. Best part is, It helped me in completely eliminating female feticide, providing real sex ratio at birth and documentation of congenital anomalies, and low birth weight. Sex Ratio in Guna District is about 912 while in our area it is around the 970 to just above 1000. In 2019, it was 1070 and only 9.6% babies had low birth weight.
So, I am happy I chose maternal and child health services as primary area of focus in my presidential tenure 2012-13 as Rotary Club Guna president. The Rotary principal ” Use your own profession as another way to serve the humanity” helped me in adopting more extensively my Foetal Radiology education and capabilities. In India, practicing foetal Radiology has got legal limitations and is a relatively costly affair for most of rural community. Providing free services to poor and needy people has helped me to fulfil my dream of helping my society, reduce female foeticide and generate faith in a Fetal Social Radiologist in eye of public, political, various government administration departments and health personnel.
VA: Dr Rijo says you have been a big help to the Samrakshan Team. Has Samrakshan helped you ? How?
LKS: So nice of Dr Rijo, if he feels so, it is a great compliment for a grass root radiologist working in rural area. In fact, Dr Rijo and Samrakshan gave me a more systematic structure for my work, suggesting improvements, seeking feedback on the Samrakshan program showing how the Samrakshan Team itself constantly looks critically at its work, trying to improve. My heart felt gratitude to Samrakshan. You don’t feel like you finished a course or training, you feel part of a family that only wants to continuously improve, and for Society. As I am a Social Radiologist, working for my community is my priority and rather only aim of my life. Samrakshan protocol will definitely help me to reduce perinatal Status of my region.
VA: You did your PG quite some time and have a lot of experience. What has changed for good, in your practical use of radiology, and what has changed for the worse, or not changed, during this period?
LKS: Yes, I am practicing Radiology since 1978 when was doing post graduation and Fetal Radiology since 1987. Practice has changed a lot, environments, expectations have changed. Let me focus on the now and good. Many good things have happened after Samrakshan started. I am more academically correct. Samrakshan encourages every radiologist that they can be clinicians working based on sound academics-they don’t say you work in a rural area so don’t need to be very academically focused. On the other hand, they encourage us to look at what we do, document it and use it to learn more. I am able to prevent perinatal deaths and able to generate faith in a Fetal Radiologist among patients’ families and Society at large.
Many times, I wish Samrakshan started earlier. I could have saved many more lives. But everything has its time and place, and I am happy I am a part of the journey now. What I really like is the continuous support and encouragement the team offers fully understanding the difficulties faced in rural areas and single doctor practices. They have ignited the academic fire again by constantly showing us how to use that knowledge for the good of the woman and her baby. We learn to use everything that is shared and to learn from every act we do. We get monthly reports on what we do. They do not set any artificial target, instead, they say simply, if you are improving continuously because you want to, you will find your patients happier, and their health improving. In simple terms, we are encouraged to connect with the pregnant woman and her baby and we feel more connected to the babies we examine. Our patients and babies are not numbers, they are humans.
I have started talking about Samrakshan protocol to all people in society so that they themselves will take responsibility for their health and health of babies. Change may be slow, but I am positive, this change will happen.