The document discusses the concept of medical professionalism and the importance of the doctor-patient relationship, highlighting the ethical standards and skills expected from medical professionals. It addresses the challenges faced by doctors today, such as increasing patient dissatisfaction, violence against healthcare workers, and the need for better communication and empathy. The document emphasizes the necessity for government and institutional policies to improve healthcare environments and reduce violence, while also advocating for a focus on soft skills in medical training.

1. MEDICAL PROFESSIONALISM
&
DOCTOR PATIENT RELATIONSHIP
MODERATOR
DR SHAMRENDRA NARAYAN
PRESENTER
DR NAVNEET RANJAN LAL

2. The Noble Profession Of Medicine
There is no career nobler than that of the physician.
The progress and welfare of society is more
intimately bound up with the prevailing tone and
influence of the medical profession that with the
status of any other class…”
Elizabeth Blackwell, MD 1889

3. What is Professionalism
• Medical Professionalism
• A self disciplined group of individuals
• Possess a special skill derived from training or
education
• Who are prepared to exercise that skill primarily
in the interest of others
• Has special relationship with those whom it
serves. Ex: Patients, students…
• It has distinctive knowledge base which is kept
up to date.

4. Definition of Professionalism
• Medical professionalism is a belief system in which
group members (professionals) declare (profess) to
each other and the public:
The shared competency standards and ethical values they
promise to uphold in their work and
What the public and individual patients can and should expect
from medical professionals.
• It describes the skills, attitudes, values and
behaviors common to those undertaking the
practice of medicine.

5. Stages of Career
• Entry
• Establishment
• Exploration
• Specialization
• Mastery

6. Stages Of Professional Life
• No work, No money, lots of time
• Some work, some money, some time
• Plenty of work, plenty of money, no time

7. Today’s Successful Doctor
• Clinician
• Academician
• Manager
• Financial Expert
• CEO
• Family care Provider
• Self care taker

8. Doctors: common indicators
• Having lots of patients
• New car / plot every year / lots of money
• Publishing papers in journals
• Teaching students

9. Doctor : Facts
• All are dissatisfied due to lack of time for
themselves or their families, inability to meet all
the expectation as described in previous slide
• Average life 10 years less
• Depression 4 times higher than general
population

10. Signs Of Lack Of Professionalism
• Abuse of power
• Arrogance
• Greed
• Misrepresentation
o Lying
o Fraud
• Impairment
• Lack of conscientiousness – failure to fulfill
responsibilities
• Conflict of interest – self promotion, advertising
etc.

11. Doctor Patient Relationship
Do’s and Don'ts

12. Doctor Patient Relationship
• The practice of medicine is an art, not a trade; a
calling, not a business; a calling in which your
heart will be exercised equally with your head.
Often the best part of your work will have
nothing to do with potions and powders.
William Osler, MD, 1925

13. Legal aspect of DPR
• A relationship between a doctor & patient is
established when a doctor accept a patients call
for consultation & treatment.

14. Legal aspect of DPR
• The relationship from
the time of seeking
advice and diagnosis to
the final eradication of
the disease or infirmity.
• Till the doctor-patient
relationship exists; the
doctor has to abide by
many regulations.

15. Present Scenario
Has the Doctor changed ?
Or
Doctor is facing the changed society ?

16. Causes of sourness in Doctor patient
relationship
• Patient Dissatisfaction
• Mistrust
• Medical litigation
• Professional Negligence

17. Trust Equation by David Maister
T = C + R + I + S, where
T - Trustworthiness
C - Credibility
R - Reliability
I - Intimacy
S - Self orientation

18. T = C + R + I + S (Cont…)
Credibility - Can your patient trust what you
say ?
Reliability - Can he trust your actions,
confidently that you will act
honorably?
Intimacy - Is he comfortable discussing his
feeling and emotions with you?
Self orientation - Can he trust your motives,
knowing that you care about him, and will
act in his best interests?

19. Rationale for customer service in
radiology
• Service providers and consumers may evaluate
the quality of customer service very differently.

20. Let’s understand this by an
example

21. Service Providers - Pilot (Airlines service)
• Traveler arrives at the airport
• Boards an airplane for an on-time departure
• Pilot routes the plane safely to the expected
destination ahead of schedule
• From the pilot’s point of view, this experience
represents good customer service.

22. Same Scenario From The Passenger’s Point
Of View:
• List of confusing fares during Booking
• Arrives at the airport 2–3 hours before the departure
• Fees to stow his baggage.
• Wait in line and partially undress to pass security
check up
• Wait until his boarding section is called.
• Cramped Seats
• Costly and limited food service.
• At baggage claim find that his luggage is lost.
• So, From the passenger’s point of view, this same
travel experience represents poor customer service.

23. A similar vignette can be created in the
Radiology / Hospital setting.

24. In Hospital (From Doctor's perspective)
• Patient arrives for MRI/… appointment.
• Imaging examination is performed on time
• Radiologist expertly creates a high-quality report
• The report is finalized and sent to the referring
provider
• From the radiologist’s point of view, she/he has
provided excellent customer service.

25. • However, once again, this impression might
change when the same vignette is considered
from the patient’s point of view.

26. • The patient is concerned about a new symptom
• Thinks that she might have cancer.
• MRI / USG / CT advised.
• The next available appointment for MRI is in 3
weeks.
• Patient receives a packet of information
regarding the upcoming examination. The
information is inconsistent and includes
confusing instructions,
• Not to eat or drink the night before the MRI
examination.
Cont…..

27. On the day of the appointment
• Patient is hungry and unsure whether she should take her regular
medication.
• She arrives for the appointment 2 hours early but spends 30
minutes looking for a place to park her car.
• Once she finds a parking space, she must navigate through a
series of confusing hallways With inadequate signage to find the
radiology department.
• The technologist is impersonal and makes comments that are
relayed in medical jargon such as, “Oh, you didn’t need to be NPO
for this study” and
• “Do you have any ferromagnetic items on or in you?”

28. • MRI report contains more medical jargon, including
impression points such as “cystic renal lesion, Bosniak
2” and “small hyper enhancing lesion in hepatic segment
VI without washout, LI-RADS 2.”
• The patient must wait for her next appointment while
convinced that she has cancer.
• She receives several bills, all for the same MRI
procedure
• So from Patient points of view it’s a poor service by
doctor in hospital

29. Factors stressing Indian doctors

30. Medical Litigation
• Professional failure in diagnosis or treatment
• Lack of communication
• Some form of insensitivity by the doctor to upset
them emotionally – insult adding to injury.

31. Professional Negligence
• = Malpractice
• Breach of a duty caused by the omission to do
something which a reasonable man would do or
doing something which a prudent and
reasonable man would not do.

32. Professional Negligence Includes
• Errors in interpretation
• Errors in communication
• Errors in reporting
• Interventional procedure errors

36. Causes Of Violence
• In India, more than 80% of doctors are stressed
out due to various reasons like
– violence against them
– harassment by police as well as politicians,
– long duration of the study,
– lack of personal or social life,
• Poor quality healthcare in the majority of govt
sector
• Negative image of doctors and the role played
by media
Cont…

37. Causes of violence ……
• Poor socioeconomic status of the patient and the
ever-rising cost of the treatment
• Poor communication
• Vulnerability and susceptibility of hospitals
• Low awareness and knowledge about health-
related issues
• Lax security or Inadequate security
arrangement,
• Mob mentality, and
• Instant justice.

38. Setting of violence against health care
workers in India is different from that in west
In India
• Violence perpetrators are mainly patient relatives
• Unknown sympathizers
• Criminal offenders
• Even politicians
• Hardly 33% of the healthcare expenditure is
borne by the government, the rest by the patients
themselves

39. India….
• Low insurance penetration
• Unexpected healthcare expenses often push
families into a trap of debt and financial
instability.
• Here, within the background of smoldering
anxiety of financial implications, verbal abuses
easily escalate to violence

40. Causes of violence in Western world
• Majority of the incidents occur during
– The night,
– In intensive care units
– In Psychiatric and Pediatric wards
• Financial anxiety is not a causal factor as the
healthcare expenditure is borne by the
government
• The main offenders are the
– patients under the influence of drugs, alcohol,
– Psychiatric patients or their close relatives
– Criminal mindset

41. MC types of violence against Indian DR

42. Violence against doctors leading to the number
of strikes in hospitals reported in India from
January 2007 to November 2019

43. Warning signs of violence
S - Staring
T - Tone
A - Anxiety
M - Mumbling
P - Pacing
• Stamp approach alerts the physician by looking
for early warning signs of violence.

44. The STAMP approach consists of the following
 Staring is a prospective sign of violence. Staring was to threaten
them into a quicker response.
 The tone and volume of voice are connected with violent
episodes. Most cases involve not only raised voices and yelling
but also sarcasm and caustic replies.
 Anxiety in coming to the emergency department makes patients
stressed out. Before it reaches dangerous levels, ideally the
doctor intervenes, but sometimes, it escalates to violence due to
patient anxiety.
 Mumbling is an indication of violence as it reflects
frustration. Pacing by relatives is seen as a symbol of agitation.

45. Prevention of violence against
doctors

46. Several steps can be taken in this
direction
1. Government Policies and Responsibilities
2. Steps Institution/Doctor Should Take
3. Steps to be Taken by The Patient
4. Steps to be Taken by Media
5. Role of Medical Schools

47. 1.Government Policies and Responsibilities
• Increased government spending on healthcare to
improve the infrastructure of the hospitals
• Stricter implementation of rules, laws, and punishment
for violence under Indian IPC.
• Non-bailable offense
• Damages should be recovered from the persons
responsible for the violence.
• Government should take responsibility for the safety of
healthcare workers.

48. 2. Steps Doctor Should Take
• Taking valid and informed consent : Audio-visual
consent preferred
• Proper documentation
• Communication should be done preferably in the
patient’s native language
• Improving communication skills
• Shouldn't try to overdo or overreact and remain calm
and composed.

49. DO’s for Doctors
• If too many anxious attendants, send them one or another
job. Eg – Bringing medicines, arranging blood – energy
utilization
• Only one attendant should be allowed to enter examination
room
• Never argue with attendants
• Argument will trigger them, at the same time your calmness
and promptness will even calm down a triggered person.
• Try to solve/resolve crisis immediately.

50. Continue…
• Identify a prominent person:
– Important person/relative – explain him initial
assessment immediately
– Explain them investigation has started
• Ask if they have any questions
• Call senior consultant as per requirement, talk to
them telephonically if there is possible delay in
arrival.

51. Do’s
• If there is gang war – call police

52. Don’ts
• Never argue with attendants. This situation
teaches you how to remain calm in provocative
circumstances.
(No book in the world can teach this)

53. Communication
• Communication, communication, communication
about costs of investigation and challenges.
• Doctors must make efforts to educate and inform
the public at late about diseases and medical
problems.

54. Communication
• 7% - Spoken words
• 38% - Voice quality like Tone, Tempo, Intonation
• 55% - Body Language

55. Communication skills
• Patients don’t care how much you know them.
They know how much you care.

56. How to perfect non verbal signal
• Smile
• Open Posture
• Forward Lean
• Touch
• Eye contact
• Nod

57. Components of clinical communication
skills
A. Rapport Building (starts with history taking)
• Giving adequate time in taking history
• Do not criticize previous doctor prescription
• Use patient name whenever possible – makes
rapport building easier.
• Do not make false promises regarding
prognosis

58. B. Empathic listening
• Show empathy & respect
• Putting yourself in patient situation
• Developing listening skills
• Maintain eye to eye contact
• Avoid changing the topic mid way by
interrupting
• Empathic listening is most useful in dealing
emergency cases

59. C. Effective Questioning skills
• Elicit maximum information in shortest
possible time using purposeful & inoffensive
questions
• Ask one Question at a time
• Wait until the previous question is fully
answered

60. D. Answering skills
• Weakest communication skills among Indian
medical Professionals
• In Indian context patient satisfaction is largely
decided by the quality of answers &
explanation given by doctors
• Understand the question clearly, answer fully
& clearly but briefly
• Avoid major technical terms

61. Barriers to communication
• Work overload on doctors
• Shortage of man power – less time for individual
patient
• Lack of training in communication skills during
medical education
• Individual attitude & personality traits

62. Improving Relationship
• Teaching of ethics & communication skills in UG
curriculum
• Teaching of sociology aimed at creating cultural
sensitivity, empathy & respect for patients dignity
• Teaching legal aspect of practice
• Physician has to enter patients world to see
illness through patients eye.

63. 3.Steps Institution Should Take
• SOP should be made and followed strictly
• Code Purple should be declared and all measures
should be taken in case of violence
• Security staff to respond and assist immediately.
• All staff (except Operation Theatre & ICU) should form a
human chain.
• All staff should remain calm & practice restraint.
• CCTV monitoring in sensitive areas is a must and
should report to the Police immediately

64. Display of warnings & other
information
• Display warning in hospital premises mentioning
the consequences of violence against doctors in
hospital
• Display flow chart / plan in emergency room

65. 4.Steps to be Taken by The Patient
• Be aware of the health situation. Doctors practice
medicine they can’t do magic and certainly, not
everyone can be revived.
• Doctors cannot be held responsible for every death
occurring in the hospital on the ground of negligence.
• Cost increases with the type of treatment & its
advancement.
• If not satisfied with a doctor can speak to the
concerned authority and take an appropriate decision
to continue treatment or not.

66. 5.Steps to be Taken by Media
• Must put forward the unbiased news.
• It shouldn’t sensitize the news.
• It should highlight the doctor's predicament
• The causes for the rise in violence against them.

67. 6.Role of Medical Schools
• Should teach about patient-doctor relations, Communication
with the patient in an effective way.
• Empathy towards the patients and their relatives.
• Teach how to handle tactfully when the patients or their
relatives behave aggressively and the situation turns chaotic
and violent.
• Teach them how to remain calm and responsible during
those times without compromising the quality of patient care
as well as safety.

68. The above steps can prevent workplace
violence against doctors but the most
important thing among them is
• Communication by the doctor and the hospital.
• Proper communication can allay the situation or
defuse the crisis.
• A senior doctor or someone from the management
(preferably a senior one) should be able to
communicate the condition and seriousness of the
injury/disease of the patient to the relatives or
attenders.

69. Conclusions
• Unless there is an entire overhaul of the prevailing
healthcare system, it is a herculean task to curb violence
against doctors.
• The medical curriculum should include soft skills and
communication skills required to empathize, remain calm,
and twiddling my thumbs regardless of repeated prodding
by the anxious patients.
•
• Along with this increased communication between the
doctors and patients, filling crucial gaps in communication
between doctors, patients, and relatives will help in
mitigating the violence in a long way.

70. Take Home
 Fall in love of being a Doctor
Derive pleasure in work wherever & in whatever
capacity you are working. You always have the
potential to contribute to patients & society
 Work & practice with medical professionalism
 Use common sense. Identify local socio-cultural
practices & integrate in your working style.

71.  Do unto other as you would have them to unto you
 Don’t end at result of single prescription /
consultation. Target long lasting patient doctor
relationship
 People prefer those Doctors with average clinical
skills but good communication skills rather those
with excellent clinical but poor communication skills
 Most of the complaints are made against doctors
who do not communicate

72. “ Successful Medical Practice is like
successfully driving a car where you
not only take care of your own mistakes
but others mistake also”

73. THANK YOU

74. References
• 1. Framework guidelines for addressing workplace violence in the healthcare sector. [Jun;2020
];https://apps.who.int/iris/bitstream/handle/10665/42617/9221134466.pdf Geneva. 2002 3:1. [Google Scholar]
• 2. Bureau of Labor Statistics (BLS). Non-fatal occupational injuries and illnesses requiring days away from work. [Jun;2020
];https://www.bls.gov/news.release/archives/osh2_11082012.pdf 2012
• 3. BMA survey finds one-third of doctors attacked physically or verbally in 2007. [Jun;2020 ];Pitcher
G. https://www.personneltoday.com/hr/bma-survey-finds-one-third-of-doctors-attacked-physically-or-verbally-in-2007/ 2008
• 4. Over 75% of doctors have faced violence at work, study finds India News - Times of India. [Jun;2020
];https://timesofindia.indiatimes.com/india/Over-75-of-doctors-have-faced-violence-at-work-study-finds/articleshow/47143806.cms 2015
• 5. [Violence in the emergency department] Derazon H, Nissimian S, Yosefy C, Peled R, Hay
E. https://pubmed.ncbi.nlm.nih.gov/10959292/ Harefuah. 1999;137:95–101. [PubMed] [Google Scholar]
• 6. Assault and kidnap of a specialist doctor. Bengali: The Daily Kaler Kantho; 10 May. (2010 [Google Scholar).
https://www.researchgate.net/publication/213527222_Violence_Against_Doctors. DOI [Google Scholar]
• 7. Violence and abuse faced by junior physicians in the emergency department from patients and their caretakers: a nationwide study
from Pakistan. Mirza NM, Amjad AI, Bhatti AB, et al. https://doi.org/10.1016/j.jemermed.2011.01.029. J Emerg Med. 2012;42:727–
733. [PubMed] [Google Scholar]
• 8. Aggression and violence towards medical doctors and nurses in a public health care facility in Lahore, Pakistan: A preliminary
investigation. Imran N, Pervez MH, Farooq R, Asghar AR. https://www.kmuj.kmu.edu.pk/article/view/11811 Khyber Med Univ
J. 2013;5:179–184. [Google Scholar]
• 9. The Lancet violence against doctors: Why China? Why now? What next? Lancet. 2014;383:1013. [PubMed] [Google Scholar]
• 10. Microblogging violent attacks on medical staff in China: a case study of the Longmen County People’s Hospital incident. Jia Tian and
Li Du. BMC Health Services Research. 2017;17:363. [PMC free article] [PubMed] [Google Scholar]
• 11. Workplace-related homicide among health care workers in the United States, 1980 through 1990. Goodman RA, Jenkins EL, Mercy
JA. JAMA. 1994;272:1686–1688. [PubMed] [Google Scholar]
• 12. Five people beat resident in BHU Hospital Varanasi. Jagran. [Nov;2020 ];https://m.jagran.com/lite/uttar-pradesh/varanasi-city-five-
people-beaten-resident-in-bhu-hospital-varanasi-19724111.html 2019
• 13. "Bihar goons tie doctor to a tree, gangrape his wife, teenage daughter; 20 suspects detained". The New Indian Express. [Jun;2020
];https://www.newindianexpress.com/nation/2018/jun/14/bihar-goons-tie-doctor-to-a-tree-gangrape-his-wife-teenage-daughter-20-
suspects-detained-1828218.html 2018
• 14. How an intern doctor's fractured skull has Kolkata up in arms as BJP blames Trinamool. [Jun;2020 ];Delhi June 12, India Today Web
Desk New. https://www.indiatoday.in/india/story/kolkata-doctors-protest-nrs-medical-college-1547175-2019-06-12 2019 2019:24. [Google
Scholar]
• 15. Kolkata doctor was beaten up after Garden Reach child's death | Kolkata News - Times of India. [Jun;2020 ];Jun
5. https://timesofindia.indiatimes.com/city/kolkata/doctor-beaten-up-after-garden-reach-childs-death/articleshow/69656632.cms 2019
• 16. Drunk' attendants assault NIMS doctor. The Hindu. [Jun;2020 ];Reporter Reporter, Staff (21 May
2019. https://www.thehindu.com/news/national/telangana/drunk-attendants-assault-nims-doctor/article27190528.ece 2019

75. • 17. Assam: Doctors protest over assault on Dikom tea garden physician. Northeast Now. [Jun;2020 ];http://2019 NORTHEAST NOW. 11
May. 2019
• 18. Doctors at Gandhi Hospital go on strike after assault | Hyderabad News - Times of India. [Jun;2020 ];Feb 27, TNN | Updated; 2019;
IST, 7: 33. https://timesofindia.indiatimes.com/city/hyderabad/doctors-at-gandhi-hospital-go-on-strike-after-
assault/articleshow/68177325.cms 2019
• 19. Doctor suffers damage to rib and lung in the attack by patient's kin | Hyderabad News - Times of India. [Jun;2020 ];Jan
1. https://timesofindia.indiatimes.com/city/hyderabad/doctor-suffers-damage-to-rib-and-lung-in-attack-by-patients-
kin/articleshow/67332572.cms 2019
• 20. 12 hr Assam Bandh: Central Hospital NEC Doctor assaulted in Digboi. The Sentinel. [Jun;2020
];http://www.sentinelassam.com/news/12-hr-assam-bandh-central-hospital-nec-cil-doctor-assaulted-in-digboi/ 2019
• 21. Doctor ‘assaulted’ at nursing home. [Jun;2020 ];https://timesofindia.indiatimes.com/city/kolkata/doctor-assaulted-at-nursing-
home/articleshow/67212107.cms 2018
• 22. Doctor assaulted at Bhadrak District Hospital. The New Indian Express. [Jun;2020
];https://www.newindianexpress.com/states/odisha/2018/dec/02/doctor-assaulted-at-dhh-1906165.html 2018
• 23. PMCH nurses seek security after the assault. [Jun;2020 ];https://www.telegraphindia.com/states/bihar/patna-medical-college-nurses-
seek-security-after-some-of-them-were-assaulted-by-patients-attendants/cid/1676410 2018
• 24. Protest against the assault on the doctor at Chengalpattu GH. [Jun;2020 ];10 November
2018. https://www.dtnext.in/News/City/2018/11/10031300/1095052/Protest-against-assault-on-doctor-at-Chengalpattu-.vpf 2018
• 25. Madhya Pradesh: Relatives of patients assault Scheduled Tribe doctor, demand an upper caste one. [Jun;2020
];https://scroll.in/latest/898304/madhya-pradesh-doctor-assaulted-after-patients-relatives-demand-someone-from-an-upper-caste 2019
• 26. Police officer 'slaps'. [Jun;2020 ];https://www.telegraphindia.com/states/west-bengal/police-officer-slaps-cmri-doctor/cid/1655093 2019
• 27. Resident doctors at Mumbai's JJ Hospital call off their strike. The Quint. [Jun;2020 ];Resident Doctors at Mumbai's JJ Hospital Call Off
Their Strike". The Quint. https://indianexpress.com/article/cities/pune/orthopaedic-doctor-of-dhule-hospital-thrashed-by-patients-kin-brutal-
attack-on-doctor-sparks-anger-among-medical-fraternity-4569235/ 2017
• 28. Orthopaedic doctor of Dhule hospital 'thrashed' by patient's kin: Brutal attack on doctor sparks anger among medical fraternity. The
Indian Express. [Jun;2020 ];https://indianexpress.com/article/cities/pune/orthopaedic-doctor-of-dhule-hospital-thrashed-by-patients-kin-
brutal-attack-on-doctor-sparks-anger-among-medical-fraternity-4569235/ 2017 2017:14. [Google Scholar]
• 29. Pune: Resident Doctors brutally thrashed post patient's death". [Jun;2020 ];https://medicaldialogues.in/pune-resident-doctors-brutally-
thrashed-post-patients-death Medical Dialogues. 1 August. 2016
• 30. Violence against doctors: a wake-up call. Ghosh K. Indian J Med Sci. 2018;148:130. [PMC free article] [PubMed] [Google Scholar]
• 31. Fixing India's healthcare system: Strong political commitment is needed to build a system of universal health coverage and better
regulations. [Jun;2020 ];Shiva Kumar AK. https://www.businesstoday.in/current/policy/govt-cuts-health-budget-spending-near-20-percent-
for-fy15/story/213819.html 2014
• 32. Govt to cut the health budget by nearly 20 percent for 2014-15. [Jun;2020 ];Kalra A. https://www.businesstoday.in/current/policy/govt-
cuts-health-budget-spending-near-20-percent-for-fy15/story/213819.html for 2014-15. Business Today 23 December. 2014
• 33. Aggression against doctors: a review. Hobbs FD, Keane UM. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1295659/ J R Soc
Med. 1996;89:69–72. [PMC free article] [PubMed] [Google Scholar]
• 34. Workplace violence in different settings and among various health professionals in an Italian general hospital: a cross-sectional study.
Ferri P, Silvestri M, Artoni C, Di Lorenzo R. Psychol Res Behav Manag. 2016;23:263–275. [PMC free article] [PubMed] [Google Scholar]
• 35. Violence in general practice: a survey of general practitioners' views. F D Richard Hobbs. BMJ. 1991;302:329–332. [PMC free
article] [PubMed] [Google Scholar]
• 36. A study of workplace violence experienced by doctors and associated risk factors in a Tertiary care hospital of South Delhi, India.
Kumar M, Verma M, Das T, Pardeshi G, Kishore J. J Clin Diagn. 2016;10:0. [PMC free article] [PubMed] [Google Scholar]
• 37. STAMP system can help professionals to identify potentially violent individuals. [Jun;2020
];https://www.eurekalert.org/pub_releases/2007-06/bpl-ssc062007.php BLACKWELL PUBLISHING LTD. 2007