Medicine, no longer a career choice?

I have known Dr S since her school days. She passed her MBBS and internship four years back. I remember the time when she came to see me with her intention to become a doctor,having secured good marks in her PUC. I had tried then to counsel her against her choice by giving the true picture of what awaits a young doctor in this country, especially a woman doctor. She was adamant and duly proceeded to get a seat in the government quota in one of the medical colleges that have mushroomed in and around Bangalore. She proudly said after she got a seat that it was in government quota and not in management quota which meant bought seats and generally of inferior quality. I knew of this college's unsavoury reputation, but prudently kept quiet.

Now she has come to see me, nearly seven years later. Instead of a sprightly and healthy 18 year old young woman, I was seeing an obese woman with features of hypothyroidism. I asked her where is she working and what has brought her to me.

She said.' uncle, I am not working full time, I am preparing for yet another NEET! This will be my last attempt. If I don't make it, then that will be the end for me' She was on the verge of breaking down. Long experience has taught me, that in such situations, the best way to show empathy is to remain silent. After a while, she continued, 'I should have followed your advice, this profession is not for me. I am earning 20,000 Rs  working night shift and my sister who is younger to me is earning 1,50,000 working as a software engineer. She is also getting married in six months.' another pause and she continued, 'as you can see, I am also unwell, I went to Dr.... and she has put me on hormone pills and it has made me put on more weight' her torrent of misery stopped at last.

Here, with this young woman I was facing two problems. One is physical and the other is emotional.

Handling the physical part was lesser of the two problems,Though both were likely to be interlinked.
It took me more than an hour to counsel her that passing NEET is not the end all of one's life and the importance of regular exercise and managing her diet and taking care of her body and also her mind. And how earning money and comparing her with her younger sister will lead to mental illness and how improper such comparisons are.

She went with advice to get her thyroid profile, blood sugar and an ultrasound scan to exclude PCOS [Polycystic ovarian syndrome]

When she went she appeared to be in a better frame of mind than when she came in to see me.

She is an example of the fate and uncertain future many young doctors in our country are facing now.

Alcohol habit and

Helping the cheat

I am not sure if I have written this before, if so, my apologies for repetition. As a story told at different times, takes different colors, it may be still worth reading!

This incident occurred some twenty years back. Recollection came about because of a recent finding of clandestine drinking by a habitué.

The old Brigadier must have been in his 70s when this episode occurred. The main players Brig and his wife are no more. Brig Menon enjoyed his two large whiskies every evening and has been doing so for many years and was none the worse for this. His wife was not a party to this habit and was very critical of this and was trying her best to get him off. She was not very pleased when after seeing his lab reports and finding his liver function tests normal, when I told the Brig that he can have his two large pegs without worrying about liver damage. She admonished me for being frivolous for giving such advice!

They would visit me once or twice a year and during their next visit,’ I asked the Brig, ‘How are you doing’ Before he could answer, ‘the major general [wife ] took over,’ she said, ‘ doctor, he is very much better, that he is not drinking now’. I was a bit surprised at this and asked him how come he managed to get rid of the habit’ Again Major General replied,’ he was forced to stop as his cardiologist advised him that too much drinking is bad for his heart and liver. This threat of twin danger obviously has had the effect and the old Brig had stopped drinking. I did not like the advice given by the cardiologist, if true that is, that has deprived the old man of the one simple pleasure in his in his old age. Brigadier was sitting silently and I felt he did not like his wife that much at that moment.

Few months later, they met up with me again. This time it is because of Brigadier’s frequent urination at night. Doctor, ‘he goes too often, sometimes every fifteen minutes and it is worse in the night time’ said his wife. Brigadier as usual was quiet. I asked him and blood test done to exclude diabetes? The answer was yes done recently and there is no diabetes. Now I was fairly sure, Brig was having trouble with his prostate gland. After some discussion, it was agreed that he gets the tests done and then see me.

Next day Brigadier managed to come alone to see me.

‘Doc, I need to tell you something in confidence, he began, I still have my two drinks in the evening. I keep the whisky in an empty dettol bottle at the top shelf in the bathroom where my wife cannot see it and even if she sees it she will think its dettol and at that height she cannot reach it’ My frequent visits to the cloak room has made her bring me to you and you thought it is due to my prostate enlargement’ Now you have advised her to get me the test done, I have no option but to do so''.

I thought for a moment and sat thinking for a while, then I said, ''Sir, you get the tests done, at your age the report most likely will say there is enlarged prostate, you bring the report and I will tell your wife that such frequent urination only at some hours in the night does not need treatment and if it becomes worse, then we can give medication and no surgery is needed’’

Major general, when she visited me next, complimented me for diagnosing he husband’s condition and giving correct advice!

That is what happened and all of us, brigadier, major general and I remained happy ever after, till their demise that is!

Happiness and other such matters of mind

This morning the button which that anchored my pants up snapped. Fortunately it happened at home and no embarrassment ensued. I needed to sew the button back on the appropriate slot.Though this was no emergency, I felt I should try my hand at it.

My wife keeps a kit with sewing thread rolls and assorted needles. It's some years since I have done this and wasn't sure if my 75 plus years old eyes are up to this job. It was with some tremulous hands I took hold of the needle and thread and it took me just three attempts and I succeeded in threading the needle. Sewing the button on was pretty easy That I was able to thread the needle made me very happy at that moment.

 Happiness is difficult to describe. In a way we can say it's the opposite of sorrow. Sadness is easy to define but happiness is not that easy. One can say that It's a state of mind where at that moment there's a sense of euphoric contentment. I have experienced this often. There is a pair of bulbuls who are resident around my home and they regularly patrol and part of it is the shrubs that line my driveway. Bulbuls have a very fruity call and when I hear the call I go out and watch them.For almost a week I didn't hear or see them and I was becoming a bit anxious about their safety and two days back I heard their call. This was happiness. The other morning while playing golf I witnessed a glorious sunrise and that was happiness.

 But all these sensations/feelings are ephemeral. Can we make this feeling permanent even when we are faced with problems, pain and suffering? I heard a Buddhist Monk speak on this subject. According to him it's possible by meditation which will rid the mind of negativity and will elevate and educate the mind to experience happiness all the time. Such a mind will be rid of desire,jealousy, anger,anxiety,which are the basic causes of most suffering. I honestly don't know if meditation helps or not but I know this much. Material possessions don't bring happiness. On the contrary they can be the cause of unhappiness

 What about pain? Does meditation help to overcome or lessen the pain sensation? Sage Ramana Maharshi was seriously ill with disseminated cancer and he was in severe pain during his last days. When asked, he told his disciple, yes body is suffering and the mind is not or some such.Those who are interested can get more details on his last days by googling. I have written in the past about Robert Trent Jones,the all time great golfer and the stoic way he suffered the disability caused by Syringomyelia. There appears to be a lot more to learn about how mind controls matter. It may make good reading to access Norman Cousins’s books, Anatomy of an illness and the healing heart.

Research
What is research? The literal meaning is that one searches for something that is already been searched by some one else. But the real meaning is that you do something which is original or contributes to or enhances the existing knowledge. There is continuing effort in this direction allover the world in all fields of human activity and there is thus an explosion of knowledge happening almost daily.
Most of this kind of work is from western world predominantly from europe and USA and lately from China.
Despite having a surfeit of technically qualified men and women in our country our research output is abysmally low in comparison. Often we blame the inadequacy of resources,equipment, money and discordance between industry,universities and the government. While all this being true to some extent, there are some, more valid causes for the lack of research. The most significant one is I feel is the hierarchical structure of our institutions. Let us take for example a university professor who has 50 undergrads and ten post grads under him and five other teachers working with him.From where the research ideas arise? From the 60 students or from the 6 faculty?Ideally the ideas should be from the students and may be some extent from the faculty. The role of the faculty should be to to guide the student in the research methodology and to take the idea forward to wards the logical end. That is publication.
For any idea to come up one must have an inquisitive mind. This is natural when one is young and education is to encourage the growth of this. Unfortunately in our institutions lot of importance is given to accumulation of already known facts which is tested at the end of the year by an examination. As the numbers are large the interaction between the teacher and the taught is also not intense. This is the main reason why indian students do so well when they go to USA or Europe where the student teacher interaction is better and the student becomes a quality researcher as he is encouraged to develop an inquisitive mind which has laid dormant when he was here in India.
As we have seen, what ever quality research papers that have an Indian origin have come from few institutions who do not have this hierarchical structure and where there is more student guide interaction.
When a young man/woman is given the freedom to think and allowed to freely interact with others, be it faculty or seniors in an informal group many ideas will emerge. So there should be an inquisitive mind, an atmosphere and suitable environment for any research ideas to emerge/sprout.

Let me illustrate with a real life example.

There are a group of young doctors headed by another not so young doctor. I closely interact with them on a day to day and on need based occasions. No harm in naming them, The young ones are Dr Swathy and Dr Akshay, the not so young is Dr Ramakrishna Prasad and the oldie in the group is yours truly.

Couple of days ago four of us met. We were discussing B12 deficiency in diabetics who are on Metformin. The question that the inquisitive minds wanted an answer was whether it is due to combination of diabetes and metformin or only metformin? Do those diabetics who are not on metformin also prone to B12 deficiency? If so when combined with metformin the deficiency becomes worse? All these were research questions which needed to be found out and we are at it.
Another question that was posed was why so many people develop B12 deficiency? Even amongst non vegetarians. The only answer I could give is that these are people who eat meat occasionally and are there fore de facto vegetarians. Is there any other reason? Are they absorbing the vitamin poorly?
Then came the best route of administration. Oral or in the injection form. I said the injection form. She asked why? I said in my experience there is quicker absorption and better results. Is there a proof that B12 given orally is less effective? I didn't have a proven answer. Another research idea

By the above example one can realise how effective this method of interaction between interested groups that will result in emergence of research ideas.

Following is the comment from Akshay

Akshay S Dinesh	10:58 AM (8 hours ago)

The hierarchical nature of research in institutes has a lot to do with the hierarchical nature of funding and more importantly passion. If we want to increase India's research throughput it is not just guidance on research that we'll have to give students, but also guidance on life in general. Our education systems may truly have to fulfill Vivekananda's words:

Education is not the amount of information that we put into your brain and runs riot there, undigested, all your life. We must have life building, man making, character making assimilation of ideas. If you have assimilated five ideas and made them your life and character, you have more education than any man who has got by heart a whole library...

I suppose when people think about "purpose" of life and "meaning" of life, that is when they will have enough passion to do the hard work that research takes. When people are worried about "settling" in life, that's when the problems start creeping in.

Akshay

Craze for changing names

The British, when they were masters of this nation, gave names as their fancy took, to our towns, cities, streets, homes, flora ans fauna. In this process the english tongue often mutilated the existing name! thus the name Mulagathanni became Mulligatawny, Udhagamandalam became Ootacamund,Veerarajapet became Virajpet, Madikeri became Mercara,Thiruvananthapuram became Trivandrum, Thiruchinapally was nicely shortened to Trichy. They some how did not fully damage Srirangapattna which became Seringapatam. Thankfully the latter name didn't stick and the old name is in common use now. Incidentally Srirangapatnam was once a very famous city being the capital of the Mysore empire under Hyder Ali and his son Tipu Sultan.

Bangalore, sorry Bengaluru was a sleepy village before the British established their cantonment there and the present day Coxtown and Fraser town are older than the extensions of Basavangudi and Malleswaram. The old town was just about a kilometre area confined to couple of narrow streets, bearing the names such as Balepet, Chickpet. There is a also street called Thigalarpet. Named after the community of Thigalas who emigrated from Tamilnadu in waves in the 15 and 16 centuries.In the famous yearly Karaga festival  the idol bearer is a Thigala youngster.

If one digs facts from history, one will find these men like Frasor, Cook, Richards, Bowring did a lot to improve the conditions of living in the erstwhile Bangalore and the names need to be retained and not changed. What is done is done, We cannot go back to Fraser town which has now become Pulikeshi nagar and Cox town has become Sarvajna nagar. Fortunately some names have remained like Assaye [in memory of a battle] Road, Osbourne road, Richards town, Bowring Hospital. St Marks road. Hopefully will remain so.

The naming or altering the names did not confine to towns and cities only. It extended to plant and bird life too. Peepal tree[Ficus Religiosa] is well known and worshipped by the devout Hindu.There is another tree, the leaves of which resemble that of Peepal and the Britisher who observed this called it bastard Peepal!. Similarly he called another tree as bastard Mahogany. The sturdy darkish grey kite became Pariah Kite and the elegant russet and brown coloured one, Brahminy kite. I some times wonder if the british planter who sat on the porch of his estate home sipping his tonic water and observing the trees and birds around him must have thought of these names in a partially inebriated state!.

There is an interesting  background to tonic water which is now a popular commonplace add to Gin or Vodka, has its origin to those days of British Raj. Tonic water contains Quinine which gives it that slightly bitter taste. Tonic water came to be used as a preventive to control of Malaria which most of them must have suffered and some have succumbed.

The other day I was taking a walk and saw sign board on one of the side streets of Domlur. It bore the name of Erapalli Prasanna. The legendary off spinner of the sixties who lives nearby. This I thought was apt.

A friend and his illness
It was on 28th of august 2014 this incident took place. My close friend who lives nearby, Mr N dropped in to show his blood reports and the chest X Ray. As it was in the afternoon, he came to the main door of the house. There were two friends of mine sitting in the drawing room. Mr N also knew these two persons. On seeing them, instead of recognising and wishing, ' he gave them a vacant stupid looking smile' One of the friends asked him,' how are you? He replied,looking at me instead of that friend,'doctor'

I knew then something was amiss, that this is not normal behaviour. Took him to my examination room and asked him.'you know who those two are? He again gave me a vacant smile and obviously was at a loss.

He suffers from periodic mild episodes of bronchospasm and responds well to inhaled combination of bronchodilators and steroids. He had come two days before and as there was slight fever in addition to the wheeze, I was thinking of stating an antibiotic, but before that to make sure it was  not bacterial infection, I had asked for the tests which he had now come to show. He looked unwell and a quick check of his lungs showed wide spread sounds and he continues to have fever. This plus his odd behaviour led me to diagnose delirium due to lung infection despite fairly normal Xray and blood picture.

This was indeed an emergency and I rushed him to the hospital after getting in touch with Dr R who was the head of one of the medical units. He assured me that the resident at the emergency will take care of the patient. In the emergency  the work was fast and furious. The bedside PO2 showed level of 56 and the ECG was bizarre. This with the rattling chest in a 70 plus year old, the first thought was that he is in acute heart failure and my telling the young resident that he has this LBBB ECG pattern for many years did not convince him [I don't blame him one bit]. He went ahead and ordered the necessary tests, the results of which showed sodium levels of 120 and normal cardiac enzymes.
Now the doctors were convinced that this is no heart attack but an acute lung infection with spasm and electrolyte disturbance. Appropriate measures were instituted and naturally he was admitted in the ICU.

Now another drama began. I got a call from my friend at 10 pm that night. He said.'doc, am i going to die?'
I asked him why does he think so?
He said, ''they have put me in the ICU and the patient in the next bed has died just now''
''Didn't the doctor tell you what your problem is?''
He said, ''one young doctor told me that I have lung infection and electrolysis''
He meant electrolyte abnormality.
It took me fifteen minutes to explain what the problem is and why he is not going to die'

His last request was for me to use my influence and get him out of the deathly ICU.
After taking this promise from me thankfully he hung up.

Next day, my friend Dr R could only talk to me late afternoon when he could find some time. I told him my friend's request. He said, ''your friend though beter is not responding to inhaled steroids given through nebuliser also. I have started him on IV antibiotics and he needs to be in the intensive care for a few more days. I will shift him to the semi ICU as soon as possible where he will be more comfortable.

I thought I saw the end of my friend's problem. But I was mistaken. A call from him two days later. One problem with cell phone is that it's easy accessibility. He said, ''doc they are still keeping me here in this different ICU, and have not shifted me to the ward. Here too there are very sick patients. Next to me is one of them, he coughs non stop.I am afraid I will end up getting another and more serious disease if I continue to be here. '

His concerns were genuine and I told him I will look into this.

The problem we GPs face when a patient of ours get admitted to the hospital, is communicating and following up with the consultant concerned. Many hospital have this ladder of hierarchy and the junior doctors bear the brunt of routine work and they generally cannot give accurate information and even if they do, they cannot often take decisions like this one shifting from semi ICU to the ward. Again I waited for my friend Dr R to return my call..

I had to wait till late evening to get his call. I told him the problem. He up dated me like this,''I had to begin oral steroids and Mr N's diabetes has gotten out of control and now I am struggling with his infection, asthma and diabetes. You please advice him to put up with the discomfort for two more days and I will shift him to a room''.

I called my friend next morning and asked him, How are you? He said,'' they want me to be in this place for two more days, they have put a mobile screen around my bed now'' Hope this will protect me from getting infected'' I couldn't help but laugh, usually such screens are put around the bed of a very seriously sick patients so that the other occupants need not witness the gory scenes that some times occur in these ICU wards. In my friend's case it is the reverse so that he need not see the others's serious condition. That much credit for my influence.

He duly recovered and came home.

He has had three similar episodes and the last one was three weeks back. But fortunately not that serious as the first one, all the same needing oral steroids,antibiotics,worsening of diabetes and use of insulin. At the time of writing I have taken him off insulin and have tapered his prednisolone to 5 mgs a day and put him back on old dose of metformin.

A pulmonology consult last year was of no help. Looking for any pre existing cause also showed no results. His IgE levels are normal and his lung function is near normal

why does he gets these in this characteristic pattern, remains an enigma.

And when he falls ill, I feel it would have been better that I fell ill instead! because of the tension I go through.

Taking unbiased care of close friends and relatives is always  difficult. The worse thing is that, they don't know this and will not allow us to get some one else to take care of them.

Return of the native


I am pretty sure many of you must be wondering what ever has happened to me?
By the very fact I am back to blogging shows that I am not dead. I am also not seriously ill. Then why I didn't keep my blog going. Too many other activities, laziness, disinterest, poor reader response? all of these?
No valid explanation for the absence. But then why have I come back to blogging? You will find the reasons in the following real life story of the last four years

AFPI and other such

some  four years back, I was invited to speak on the importance of family medicine at a seminar organised by an organisation. In the audience sat Drs Col Mohan Kubendra, Jaya Bajaj and Bhaskar Puttarajanna. Col Kubendra had retired from the army a year or so back and was the president of AFPI[academy of family physicians of India], Bhaskara was the secretary and Jaya was the scientific head. After the talk they met with me and requested me to be the chief guest at their first state level conference

Thus began my fruitful association with this vibrant group of young family physicians and these four years have been very rewarding in that I became their mentor [ so named by them!] and continue to be so with the new team which is going to to take office next month. A telegram based group was formed and another inner group [what's app based] for day to day discussion also took shape. I felt the need for a newsletter and journal for the organisation and I became the head of the editorial team. This electronic journal was brought out once in three months and has found wide acceptance. Once in three months meetings were held and here too I was involved.

Then came another group again an offshoot of AFPI called Restore health. Though it has an independent structure, the motivator and the head of this start up is Dr Ramakrishna Prasad was and is the vice president of AFPI. This family medicine based set up not only does see patients in the clinic, but also has an arm which manages patients at home. They also have the capacity to look after the special needs of the marginalised communities like the sex workers, transgenders, gay community and the like. They also have a counselling and psychology help. Associating with this group of young doctors has kept me busy and productive in more ways than one

In addition to bringing out this newsletter cum journal I also authored singly or jointly some fifteen articles/papers and got them published.

Now you know that I haven't wasted my time in the last four years. Yes I know, I still have not answered your question of my return [ return of the native is the title of a book by Thomas Hardy,if my memory serves me right!]

Dr Akshay Dinesh who is one of the Restore health group, has just taken over the responsibility of editorship from me. Akshay in addition to his many endearing qualities has a very enquiring mind, is a self taught computer programmer. He also writes and speaks well. Add a self effacing nature, he makes an ideal leader and I am fortunate to have come into contact and become friends with him.

Few days back, he told me,'Rao sir, I want you to restart blogging'
I asked him why?
he said, 'so that I can get ideas to write'

This is the reason why I have once again started and hopefully will continue