Sunday, October 26, 2008

Sahib's constipation

Before we became independent, the British ruled us. There are many opinions as to the way they managed the affairs of the nation. But it is generally agreed that they did a fairly good job of administering this large country. This is especially true of the young officers who managed the districts and talukas. These men were fresh out of their home country, after the initial training, were posted to isolated places, thrown into a culture and people far removed from their own and yet they managed to serve the population as best as they could. They also wielded enormous powers over the subject population under their care. The following story is that of one such young officer.

He liked the country and the people and enjoyed the reputation for being fair and honest. He had to work hard to know his people and to do this he had to tour extensively. Some towns he could visit in his car but often he had to go on horseback. He would start early in the morning after his breakfast and return in the evening. Often he stayed on the outskirts of a big village in a specially designed tent.

There was one blemish which often ruined his otherwise healthy, fun and adventure filled life. He suffered from constipation. Often, days together his bowels bottled up. Help from the civil surgeon who was a fellow white made matters worse. Consultation with local varieties of doctors of different disciplines too did not help. Each morning the young sahib would wake up and wonder what is in store for him that day? If he had a bowel movement, his day was made, if not he would remain grumpy till the next day and wait.

One such morning after having failed to get his bowels move, he gave up the attempt as it was getting late for his rounds, had a hurried breakfast, and left with his driver, attendant and the office clerk who carried the relevant records pertaining to the villages the sahib would visit. The attendant carried Sahib’s Lunch and other requirements. The journey began. They must have gone a few miles when the Sahib started getting strong bowel contractions. This made him feel good. He asked his driver to stop the car at the nearest water body and urged him to hurry.
Soon they reached a bridge with a stream flowing underneath. Sahib got down and having collected his all purpose mug, hurried down to the bank of the stream. He undid his trousers and sat down for the much awaited evacuation. Alas! The strong and urgent contractions disappeared as suddenly as they had appeared. This was no uncommon experience for the Sahib. He knew that if he waited long enough he would get the contractions again and his bowels would move. So he sat patiently with his trousers down. But he kept his solar toupee on to guard against the sun.

He must have waited for ten minutes when he felt a soft thud on the toupee and a splash of gluey muck which splattered down. He looked up in time to see a native hurriedly scampering down from his perch on the side wall of the bridge. Unmindful of the state he was in, the Sahib shouted,’ catch the bugger, don’t let him go, I come up and take care of him’

The witnesses to this awful spectacle, the attendant and the clerk who were sitting by the side of the car ran and were able to stop the shivering native who by now had become aware of the enormity of his offence. He begged for mercy from the Sahib’s assistants who by virtue of their proximity to the Sahib were in themselves were frightful figures.

By now, the Sahib, came panting up the slope without his toupee and shirt which he had thrown into the stream and washed off the gluey muck off as best as he could. He saw the poor villager being beaten by his attendants. He asked them to stop and went to the shaking and shivering and thoroughly frightened villager who stood with folded hands, fear and despair writ large on his face. No sooner the sahib came near him, looking at the half naked white apparition the villager was overcome with intense fear making him fall on the ground begging forgiveness. Sahib asked him to get up and said, ‘hell with your apology, just tell me how you managed to do the job so quickly’.

Rest of the story is irrelevant.

Sunday, October 19, 2008

Sarosh Patel

Some weeks ago, I wrote about my primary school teacher who was responsible for some of the interests I developed later on in my life. Sadly the next fifteen years including the five years I spent in medical school, none of my peers, teachers and professors included, made much of a positive impression on me. Many of them were good teachers but none really enjoyed teaching or helping us out to understand the relationship between illness and patient. May be I am biased, but it was truly a disillusionary period, those five years were, in my life. All my ideas of nobility and sacredness attached to this profession disappeared when I saw firsthand what was happening in the hospital and college. Add personal, emotional and financial difficulties to this and you realize the dismal life I led.

I only realized what a fascinating profession medicine is, when I got out of medical school and began working in the wards as a houseman, directly involved in patient care. I was extremely fortunate in having a rare human being as my mentor. He was late Dr Sarosh Patel. Sarosh was only a few years older to me and worked as a junior doctor preparing for his post graduation in medicine. He was a hugely built man, fair as Parsees go, already balding and had a regal air around him. I was reedy, pale, and ill dressed, always ill at ease and thus we made a contrasting pair. I was fortunate that Sarosh took me under his wing and taught me the basics of patient care. He was a contrast to the boring teachers who made teaching disease centric where as Sarosh’s methods were patient centric. It is from him, for the first time I learnt that the patient was not a collection of organs, that he is ill not for our benefit and that every illness had a socio psychological background to it. Punctual, hard working, he still found time to teach me, sometimes late into the night when both of us were on duty.

He had a very bright future ahead of him. But he did not live long. Within a year of my coming to know him, he died of a brain tumour. I was told even when he was a patient at the Tata memorial at Bombay he would help in the treatment of other patients. Such an extraordinary man was Dr Sarosh Patel. My contact with him was a brief one year but I rate him as one of the finest doctors and human beings I have come across, and now after a lapse of forty-five years, I still grieve at the untimely loss.

Thursday, October 16, 2008

Injection mania

Over the past 35 years the attitude of patients to illness has changed. Much of this is towards the better. They now realize the importance of diagnosis and don’t insist on immediate relief. They also have realized the importance of investigations in the management of illnesses. Many have taken to exercise and prevention of disease has its due place in patient care. Despite all this, one obsession remains strong. This is the love for getting injected. The belief that medication given in the injection form is better than oral form still remains strong. This is more so with the lower socio economic sections of the population though an occasional educated upper class patient surprises me by requesting an injection.

This reminds me of an episode which occurred more than 30 years ago. The middle aged man came in supported by his son. The complaint was pain in the low back radiating down the leg. Diagnosis of disc prolapse was fairly easy. Those days we made the patient’s life miserable by confining him to bed for three weeks with the additional insult of taping the leg and attaching a weight which dangled from the edge of the bed. This we thought provided the required traction and imagined the disc would slip back into place.

We also gave liberal doses of pain killers and the prince amongst these was a drug called ergapyrin [butazolidine], a highly toxic drug but quite an effective pain killer. Adding insult injury we gave this drug in the injection form which meant a house call every day. This kind of activity took most of our time. I tried to be an exception and told this patient the illness takes three weeks and he can be managed with oral medication. He would have none of this and insisted that I give him an injection to relieve his pain for the moment and later he will try my oral medication. Very reluctantly, I prepared an injection of butazolidine and proceeded to inject this into his hip. The patient stopped me and asked what was I doing? I explained. He said that is not the place to give the injection but to his leg [he showed me the calf muscle] where there is maximum pain. My reasoning that the best place is the buttock muscle fell on deaf ears. He said his own doctor always gave the injection to the part where it hurt most and it had produced the best results.

My refusals made him tell his son, ‘let us go back home and wait for Dr----- to come back’. I lost another patient. Those days I lost two patients to every patient gained because of my methods were contrary to prevailing practices. Situation since then is better but the love for injections still remains.

Taking people for a ride

I have on occasions written about the futility of yearly screening for healthy persons. But the practice is becoming more rampant as the years go by, screening must be selective and the physician should decide who should be screened and who should not be. Young fit men who have no history of heart disease are subjected to a variety of tests which includes a hemogram, urine test, Liver and kidney function tests, blood test for lipids and sugar, Lung function test, a treadmill ECG and a resting ECG, Echocardiogram and chest X-ray. Package deals are touted in the lay media and even on television. The latest gimmickry is the laboratory/ Hospital going to the person’s residence/ office to do these mostly useless tests. If you don’t come to me I will come to you seem to be the approach? In any case they will not let you go without these tests! Needless to say that there is active connivance of the medical profession and the HR departments of companies in this money wasting [making] exercise.

Screening for disease is important for some and this should be left to the physician to decide.
Going once a year to ones doctor and taking his advice is far better and cheaper way to health than getting inveigled into these unnecessary tests done by the unscrupulous investigative agencies.

Tuesday, October 14, 2008

Barak Obama

After Jimmy Carter, America did not have a president who had a vision that Americans are part of this world and world’s peace is their peace. I read Senator Obama’s views on health care delivery [NEMJ] and what he would do if elected. I am most impressed. I hope the Middle America realizes what an opportunity it has second time over [first was Al Gore] and votes for him.

Health care delivery and the costs are a major problem all over the world. Only few countries like the UK, Scandinavian countries have a fairly effective health care system. Though not foolproof at least in these countries one has access in the nationalized system. In the US you have to have expensive insurance and access to such insurance is impossible for many. Unnecessary investigations and procedures, lack of organized primary care are other serious problems. No one wants to become a general practitioner! The money he makes is not even a quarter of that of a organ specific doctor[specialist] More incentives to doctors opting for primary care[Obama’s promise] will go some way in solving the problem of providing universal health care.

Reforms come at a prize. One may have to pay more taxes and doctors [super specialists] may have to accept lesser incomes. But the working atmosphere and the beurocratic control will be less and not more if Obama’s plans succeed.

You cannot live peacefully in a world where there is so much of inequality in all aspects of life. If America elects senator Obama, there is some hope for peace not only for America but also for the whole world.

Those of you Americans, who read my blog, please don’t miss this opportunity.

Sunday, October 12, 2008

Ananth Rao

Our lives are shaped by our environment. Our environment consists of both animate and inanimate. Animate environment has people, animals and plants. All these have had their influence on us and among the many people who did have a positive influence on me, the earliest one was Mr Ananth Rao.

Ananth Rao was my Primary/middle school teacher. It was a school located in a semi urban cum rural area. He taught Mathematics and English to a class of forty children of varying background, mostly poor and middle class with a few rich. Those days there were no private schools and everyone went to these state run schools. The teachers did not bother us much and occasionally when things went out of control, however, they made liberal use of the cane.
Ananth rao rarely used the cane. His teaching methods were revolutionary [I realize it now]. His teaching of arithmetic was by using examples. He would not put 8-4= 4 on the black board. He would make eight of us stand and make the rest of us count loudly the number. Then he would ask four of us to come and sit down. Then he would ask the class to count the remaining. That would be a lesson in subtraction.

Though the spoken language in that area was Kannada, Ananth rao spoke only English when he took English language class. He made all of us do the same. He would sit and correct each of us. Sometimes it would take the whole hour to correct a simple sentence but it would stay put in our minds. That was my first lesson in spoken English. It was also then I realized that speaking good English had nothing to do with writing good English.

He had another endearing habit. He would invite a few of us to his home few kms away from school. Some of us would go there after the evening game [unorganized in open fields] more to eat the goodies his wife made rather to learn. That was in the beginning. Later we got hooked to Ananth Rao’s other activities. He would keep us spell bound with stories .I had my introduction to Dickens, Hardy, Shelly, Keats, Wodehouse and Shakespeare there at his home. My interest in Hindustani classical music too had its origins there. Mr Rao had the sense to appreciate the beauty of nature and he would take us out to witness a rainbow or to see a flowering creeper next to his wall. Thus he sowed the seeds of interest in natural history, music and appreciation of colors [became an interest in painting later]

How did a primary school teacher acquire so much knowledge and interest in various fields? It is because he wasted no time and took pleasure in perusing his hobbies and more than anything else, took pleasure in introducing these to us children. He did this for the sake of satisfaction and joy and not for fame or popularity.

Sadly, despite his best efforts, he could not get me to take interest in mathematics and many times he called me muttala because of my inability to come up to his expectations of mathematical expertise. muttala is kannada version of mutt!.

But his efforts did not entirely go waste. My daughter excelled in maths and had Mr. Rao been alive he would certainly been happy.

Thursday, October 9, 2008

Quack adversary

The first few patients who come to any doctor are not the best ones. These are the ones who come either because their own doctor is unavailable, or they owe him [their own doctor] money and cannot pay and sometimes for another opinion. It is only later on that they come to you out of choice. It is thus a hard grind to build a good practice and it takes years, as any GP will tell you. When I began practice the competition was not only from qualified ones but also from the innumerable quacks around. One of these had a formidable reputation for curing all the ailments by just feeling the pulse and went by the name of pulse doctor

One of this pulse doctor’s patients was brought to me by his mother. The boy had evidence of early malnutrition with the typical protuberant belly, discolored hair, pallor etc. I spent a patient half an hour trying to make her understand the importance of proper nutrition and how to make a nutritious meal with in her means. I gave her a prescription for a cheap hematinic and a wormicide and instructed her as to how this should be administered. She listened to me with a bored expression and took the prescription and went away. At that time I did not know what a formidable fellow the pulse doctor was! This was made clear to me within the next three days.

The lady came back and began her angry salvo, ‘What kind of a doctor are you? With your medicine my son nearly died. The pulse doctor saved him in time. You are still young and may not know the powerful effects of these drugs. Here after you be careful’ she ended, panting for breath. I couldn’t make head or tale of what she was speaking. I asked her what had happened to her son? ‘What happened you ask? I gave the medicine you gave and the boy passed hundreds of worms and many were sticking out of his bottom, and I ran to the pulse doctor and he pulled them out, he told me that you are young and inexperienced [true] and without knowing gave too strong medicine and so many worms came out, he said they should be removed few at a time like his medicines do. ‘You better be careful next time around, the next one may not be as considerate as I am to you.’ With this parting threat and without waiting for my explanation she went away.

10 years later.

That was a nasty day. I had returned after making my fifth house call and dog-tired I was but yet to start my evening surgery. There were some patients but they made way for an obviously sick person who was brought in by his attendants. I had not seen him before. History and clinical examination revealed possible pulmonary tuberculosis with cavitation, which proved to be so later on with a sputum examination and X-ray.
I told the patient the diagnosis and the treatment options. I also told him how with the prescribed treatment he should get better in a year [those days we were giving one year’s treatment]. I also told him to come daily for streptomycin injections.

I wanted to enter his name in my records and asked him. He said he is Dr------, my friend and foe the pulse doctor! Later when I came to know him better, I learnt that he was a qualified doctor! After this episode he sent me a number of patients whom he couldn’t handle and remained my friend till he passed away some years ago.

Wednesday, October 8, 2008

Sprucing up

Recently I was away on a two weeks holiday. Made use of the opportunity to get my clinic premises done up. I gave a bare outline as to my ideas of what needs to be done to my architect and friend of many years and went my way. My friends and patients know me better than I myself do and the result of the facelift was much better than it would have been had I supervised the proceedings.

You might wonder why I did spend a packet of money to do up a place which was in no real need of sprucing up. The answer is simple. I was bored looking at the same walls, colors, pictures and wanted something different to look at which would make me happy. I had bought a metal multicolored fresco to adorn the wall facing me and had got the widow glass painted with flowers and falling leaves by a professional artist. The drab off white colours of the walls were replaced with bright yellow green and orange with partial wooden paneling.

Gifted away my old unwieldy desk and big and high examination table and replaced them with small wooden desk and a low couch. My geriatric patients often found it difficult o climb on to the old table and now I am sure they will like the new set up. The floor was re-laid with dull brown sand stone.

When I came back I was faced with this brilliant transformation. A kind of mini miracle in a matter of 15 days. A dull clinic with drab interiors was transformed into something beautiful to look at and work with in. When I told my friend how happy I am, he said, ‘most of the workers know you and wanted to please you and the result is this. There is work done for money and work done for love and what you see is work done for love’

You see my friends, the advantages of being a doctor!

I am happy to be working from the new premises, but what about my patients? Majority of them noticed the change and were happy. There were quite a few who were so immersed in their problem that the change went unnoticed and there were a few who noticed the change but were a bit apprehensive and one or two of them were bold enough to ask me, ‘ doc, I hope you are not going to hike your fee’!

But let me tell you, it does make a lot of difference, if you brighten up the place, to your well being.