Wednesday, March 30, 2022

 

 

Mr. S S Acharya [Shagri Srinivas Acharya]

It was in the year 1970 that I first met with Mr. Acharya. I was scouting around to find a suitable place to begin my practice. This area was just beginning to develop but was mostly rural and Mr. Acharya was one of the very first to settle here after his retirement. Most of his service was in Calcutta and his  family spoke more Bengali than their native tongue Tulu. My uncle had asked me to meet up with him to get the hang of the area as a potential possibility for  my starting practice

Thus, one fine afternoon I landed at his place and rang the doorbell. It took a while for the front door to open to reveal a dour elderly gentleman dressed in Khaki shorts and a white banyan. Later, I realized that it was his standard mode of dress at all seasons. He was obviously unhappy as it was probably his siesta time and  to have abruptly woken up.

I made a quick intro and dropped my uncle’s name. At this his demaneer changed and a smile appeared on his face, and he welcomed me into the house. He made me sit on a hard chair and made himself comfortable on an easy chair. Many years later he told me that it was his ploy to make unwanted visitors uncomfortable so that they would leave early. But then he  also told me some visitors have no shame but sit on for hours despite the discomfort.

Mr. SS after having seated me on that uncomfortable metal chair and coming to know the reason for my visit, proceeded to grill me as to my origin and antecedents. Normally this sort of queries related to my personal matters end up annoying me, but then, here I am a visitor, welcome or not and had to respond to his questions. At last, after this test, he seemed to be satisfied with my pedigree, he proceeded to give me a talk on what he expects from a doctor, frequently quoting the example of his own family doctor at Calcutta and telling me that I too should be like him, available at all hours, never loosing ones cool and at all times keeping service as the primary objective in one’s life etc.

The interview lasted more that an hour and after satisfying that I am a good listener, he gave me a cup of tea and wished me good luck

Thus began our fifteen years of relationship which lasted till his death

Mr. S.S was a diabetic and was insulin dependent and the tragedy was he was also very fond of food. Though I became his trusted doctor, I don’t think I really succeeded in adequately controlling his diabetes. Being from the same area and belonging to the same clan, we would often be invited to same social function or the other and Mr. SS would wait and watch where I would be before he took a seat as far away from me as possible, so that he could eat his meal in peace  away from my watchful eyes. He took one extra dose of insulin before committing this crime!

Mr. SS owned a nondescript car which he  was very fond off and maintained it himself. Often, I would find him with greasy hands tinkering the innards of that car, Once even found him spreadeagled under the car with his scrawny legs sticking out! He would make trips to Shivajinagar raddi shops in search of spare parts for his car. Though this car was a liability [my opinion] Mr. SS did not think so, and turned a deaf ear to his wife’s entreaties to buy a new car!

He was also fond of gardening and had flower bushes and fruit trees in his back yard and on many occasions, he would bring  a fruit or two or some flowers and present these to me with pride and pleasure. As my consulting place was close to his house, it was easy for him to take a walk and see me

He had a trying time during his last couple of years. He developed complete heart block and suffered a stroke. Those days this city did not have any cardiac intervention worth the name. As he suffered frequent episodes of syncope, he needed a pacemaker. This was available in Mangalore [or is it Manipal]. Mr SS  went and got this done and though his syncopal attacks ended, and his quality of life was better in a way, his hemiplegia troubled him and put an end his many interests and for me it was painful to see him going around with a stick and the lopsided hemiplegic gait.

He suffered another CVA and lapsed into coma. I withdrew all the medications and he passed away a week later at home.

Even now, when I pass by the road where his house once stood, these memories come flooding back

Some of you might wonder at my phenomenal memory which has enabled me to recall these details of his life. This is partly due to the diary I have kept which has these record of patient stories, some of these you will find in this blog and not due to any super memory!

 

Dr [Capt.] Thimmappaiah

It was some time during 1972/73 that I came across Dr Capt. T and remained his friend till he died some years ago at the ripe old age of 92.

Those were the days, when compared to now, communication  was primitive and only way was to either personally meet or use the telephone which only few lucky ones possessed. There was three years wait list for processing this valued instrument, though on paper, doctors were supposed to get it out of turn! Having found myself out of date as for as medical knowledge goes, I was looking for avenues to update and the only active body was the local IMA branch, located in the heart of the city. I tried calling to find out if there are any ongoing programs only to find staccato noise at the other end! I decided to pay a visit to the IMA house.

IMA house then and even now houses the state and the local city branch under the same roof and one afternoon, I paid a visit. Considering the time, the building was impressive, and the city office was located on the ground floor. Few tables and couple of chairs with filing cabinets made the office. Most were empty except one which was occupied by and elderly gentleman who later I came to know was the manager and ran the office and the office bearers. I made my enquiries as to the CME programs. While I was talking with him DrT made his entry.

Dr T was always impeccably dressed in a dark-colored suit and with his tall and slim frame, he made an impressive personality. Add to this, his fame as a cricketer, athlete, social worker helped to increase this aura. At that time, I did not know all these additional attainments of his but by his demaneer could gather that he is a doctor. I introduced my self and after he came to know my army background, he became very friendly and next half an hour was spent in telling me his own army experience in the world war on the Burma front. There was not a hint of bragging in his narrating his exploits. I think he must have decided that I am worthy of being in his inner circle at that first meeting itself. He then proceeded to tell me about the various activities of the IMA and how it needed to improve its academic activities and invited me to be part of the activity.

During next couple of years, I became the secretary of the IMA college of general practitioners of the state and my friend Dr S.K Srinivasan, the state secretary. We began running a series of education programmes which sadly ended coupe of years later as the state and the local units were taken over by doctors who had little interest in academic activities, and we were forced to start our own association which came o be known as Family physicians’ association [FPA] that has grown to be a 1000-member body at the time of writing.

Let me get back to Dr T. During his school and college days T was an athlete and a stage artist. Being good looking, he was given female roles. This necessitated shaving of arms and forearms as you cannot have a hirsute playing the female role. On one occasion, after the performance the previous evening, there was an athletic meet next morning where he was taking part in the 200 meters  run. The athletes duly took their stance and next to T was Abdul Khaliq, a classmate and competitor, Khaliq tells him,’ Thimmu, what is this? all hair on your arms gone? I thought u only shave the beard area, u have now begun this new fashion of shaving arms also?’ This was to distract T. Irritated, T replies, E thuruka, u concentrate on running and not on my shaven arms!

Dr T was  more than average cricketer and played for Karnataka in the Ranji trophy matches and has the distinction of being the first one to score a century for Karnataka in a Ranji match. He was also a medium pace bowler and when he was in his mid-fifties was seen bowling to Dilip Veng Sarkar, some 30 years his junior. More than a player Dr T was known as an administrator. He along with Mr Chinn swamy, was instrumental in building the present stadium which goes by the latter’s name. After the demise of Chinna swamy, Dr T became the president and remained at the helm for several years

He was active in the affairs of the IMA, and I remember on one occasion going with him to attend a national conference at Lucknow. We were 5 of us and I have vivid memories of that trip. One of them was in chronic cardiac failure and had poor effort tolerance but who insisted on doing what others did and being the youngest, I was put in charge of this doctor. As he was on diuretic tablets, he needed to urinate often and finding a loo/convenient spot was a major problem. He would often [jokingly] threaten me with this imminency. Throughout the 3-day trip to and 3-day trip back I remember playing poker with no loss of money. Another vivid memory of Dr T on that trip was his stopping play when we approached Whitefield station on the journey back and going to the lavatory. When the train was approaching East station he emerges, clean shaven with his trademark suit on. The West Indies and India test teams were being hosted by him as president of KSCA and he was getting down at cantonment station and had asked his nephew to come to the station to ferry him to west end hotel which was close by. Ten minutes later he bid goodbye to all of us and made his regal departure.

The present IMA building came up because of Dr T and his friends. To name a few Dr Subramanyam, Dr Nagaraj, Dr Ashwathnarayan, Dr Shivram  and Dr Ramaswamy. I may have missed some names. All these stalwarts are no longer with us

He was also interested in classical music and started his lessons when he was in his mid-thirties.  A lady teacher would come home to teach. Dr Subramanyam would often pull Dr T’s legs saying, ‘our Timmu’s wife also began learning not because of any interest in music but to keep a watchful eye on the music teacher’ may not be with out substance given Dr T being so handsome

As I know he was president of a cooperative society, a bank, a music association, and the Indian red cross.

One is justified in wondering how he managed his clinic located in the  city center on Kilary road. I once asked him. He said,’ when I get time, I go there and open the doors. Patients come to know I have come and they arrive, when they are finished and go I too close the doors and go, I earn enough to keep the body and soul together’

This was Dr T

Though very fit, his last years were plagued by back ache and sciatica which he bore with lot of grace.

 

 

Friday, March 18, 2022

 

I am tired

 Mr R is a 70-year-old retired engineer. Mild diabetic and hypertensive on medication. He underwent a successful coronary artery bypass surgery eight years back and since then he has been seeing me twice a year with out fail. Lately however, he has not been able to keep up this schedule for many reasons. One of them being the strong rumor that I have given up practice and have gone away to the US to be with my daughter. Substantiating to this, Mr. R on several occasions had found my consulting chambers locked and my neighbors informing him that doctor has stopped practice. While the first one has no basis the second one has some. Two years ago, I took a deliberate decision to be available to only those who book prior appointment and to keep the doors open only at that time and keep them closed rest of the time. This information given to my well-meaning neighbors resulted in their informing those who came with out appointment and finding the doors shut to  believe that I have shut practice!

Be that as it may, let me get  to  back to Mr. R. He joyfully,[according to him] found out that I am alive and kicking and have not stopped seeing patients. And thus, here he is now, in front of me.

After the usual pleasantries, I  asked him,’ what is the problem’

I am extremely tired, can’t walk even half a km’ he said

Since when, I asked. In the past two weeks he replied.

What have been doing in the last two weeks, I asked

‘ Fearing worst, I went to see my cardiologist and got tests done, he showed me the cardiology test reports and the prescription. All the reports were normal, and he was told not to worry and take the vitamin pills  and get back when due.

I proceeded to examine him. Like his cardiologist ,I too found him with normal pulse, BP with no evidence of failing heart.

Now I am faced with the problem of why is Mr. R is having this recent onset tiredness?

A thought occurred, could he be having low sodium levels? He gave no history of vomiting, diarrhea, recent infection which could have caused his  low sodium and weakness.

How  much water, are you drinking? I asked. ‘ At least two liters in the morning and may be another two during the day, he replied. No doctor, more than that, it is now summer, he is always drinking, his wife chimed in her input.

Is he on low salt diet, ? was my next question

Yes doctor, since my surgery, I am on low salt diet, he replied

Here is a possible explanation for Mr. R’s tiredness. Onset of summer, high fluid intake, low salt intake resultant hyponatremia [low sodium] causing tiredness.

I asked the patient to get his blood electrolytes checked urgently and drink a glass of lime juice, with half spoonful of salt  three times a day and restrict his water intake awaiting the results

But then doctor, his BP will go up if he takes so much of salt, this was the wife’s worry

‘Unlikely in the short run’, I reassured her

With that, they took my leave.

That was three days ago, and there was no news from Mr R or his wife. Now I was worried. Did I miss any, is the patient alright or in serious trouble? Is he in the hospital?

I called him, His wife took the call, I asked her ,’how is your husband doing?

‘Daaktre,[doctor in kannada]’ He is perfectly normal and has now gone for his walk, I wanted to ask u, How long does he need to take this extra salt? She replied

What about the test results? I asked

We did not go, as he was feeling normal, she said and wanted to know if he still needs to do the test?

Two weeks of illness, got cured by two spoonful of salt!

Friday, June 18, 2021

 The second wave

Last July, when the first wave of the Corvid pandemic was in full flow, I posted a personal experience of handling a major family crisis and the effect that it had on me. This year with the second wave much worse that that of last year, I again went through anxious times, this time related to my patients and friends and lost two, who were very close to me.

We still don't know every aspect of this illness. What appears as a trivial illness, suddenly takes a severe turn, occasionally ending in deaths. Though the percentage of severe morbidity and mortality is still low, given the huge numbers infected, even this small percentage when added has had devastating effect on our health care facilities. It had a major disrupting influence on our economy and the ones who have suffered most are the socioeconomically backward, who form the majority in our country. The ripple effect is felt by all of us which ever strata of society we belong to.

Socializing is very important of our mental well being. This pandemic and the subsequent lockdowns in most part of the country has had a major impact on people, especially the young, more so in school going children. Schools and colleges are not just places of learning, they are places where one meets and interacts with others and indulge in various forms of physical activity. This leads to friendships and empathy towards each other. This is also so in offices and work places. Working from home is not a great alternative to going to school or college or office or factory. I am witness to increasing incidences of this already. Anxieties, phobias, depression are on the increase.

Physical inactivity, which is forced due to this pandemic and subsequent lockdowns have had their own adverse consequences. Many have gained weight, developed diabetes and high blood pressure. Home bound elderly have had more number of falls and fractures and many have found it difficult to get urgent help. Due to poor agronomics professionals working from home have developed many stress related physical injuries, chief among these being back ache.

What about us doctors? last three months have taken a heavy toll, both mental and physical.Worse sufferers were/are Family physicians and Primary care doctors working in the clinics and primary health centers. Next are the doctors working in corvid care centers and corvid wards of hospitals. The mental stress these doctors underwent and still going is difficult to imagine. I know of GPs who have handled more than 800 cases both in person and on tele consults during these past months. But for this unheralded front line doctors our hospitals would have been much worse off that they did.

At the time of writing this post, there appears to be a countrywide ebb, more so in the city of Bangalore. The lock down is being lifted from day after. What is in store in the coming months? Will our people heed the advice on Corvid compliant behavior or they would again take a care a damn attitude and invite a third wave?

I anxiously wait

 Webinars and I

The noxious advent of COVID-19 virus put an end to physical meetings exactly a year back. Be it weddings, religious gatherings, visit to temples, churches, mosques, friendly week end meets, professional meetings, seminars, CMEs, all came to a full stop, thanks to this tiny life form of life with some 38 genes.

Most of you may nor know that I am part of a club of 15 doctors which meets once a month and we have been meeting for the past 35 odd years and naturally have become close friends. We tried holding virtual meet on Zoom platform which sort of ended in disaster. It was much like a marriage where in the bride and the groom marry and carry on in a virtual platform. This may be tolerable for most of you, who are computer savvy, but to us oldies, it was a real pain in the neck experience. I divide our group into two. One old and the other older. Don’t be curious, I won’t reveal the ages of these two groups. Those of you who know my age can make a reasonable guess as to the age group of the rest of the members.

In the first attempt, I was happy that all were on time. Some faces were visible and some voices were heard. Often the voice belonged to the children or grandchildren who were trying to coach the older and also some old. The cacophony of noise and the blurred images did not contribute to any learning. Adding insult to injury most did not know how to unmute and this ended up many voices at the same time. Amidst the confusion I could make out most of them were trying to share their experience in handling the COVID-19 situation.

The second meeting a month later was not much of an improvement and we agreed to give this up and continued our interaction in our What’s app group.

I get called to participate occasionally as a speaker and often as an audience in the various webinars who seem to have mushroomed since the COVID-19 19 hitting us. I have just enough knowledge in managing these and I am thankful to my young doctor friends who have taught me this know how. Do I enjoy these webinars? The answer is no, I don’t both as a speaker and as a listener. The reasons are many. The most important one is that I miss the physical interaction. When we attend a professional physical meeting, it is not just the topic that we discuss, it is much more, I probably will ask my friend’s health or how his daughter doing or discuss a problem unrelated to the topic, on the sidelines of the meeting. This I cannot do in webinars. The aura of personal interaction whether in a webinar or for that matter in the now necessarily popular tele consults has gone missing and this takes away the very essence of learning and even patient management. Recently I posted a Ted talk given by Dr Abraham Varghese as to why history taking and doing a physical is so important and the damage it does to the patient if this is missing as it is happening in the United States. I feel the same with these webinars and tele consults.

One thing I must accept which is good in these webinars, I am at liberty to snooze unobserved which is tough in physical meets.

One last word of praise, though not as good as a physically held conference, the virtual conference organized by the Kerala chapter of the AFPI was the next best. In these future virtual conferences, I suggest, have a separate place for meeting friends and do the much needed, ‘idle talk [gossip]!

B.C.Rao

 

A glass of water.

 

 Cancer management is developing at a rapid pace. Since it requires a multidisciplinary approach, in most large cities dedicated cancer care institutes have come up that provide holistic care to cancer patients. Most cancer patients directly approach these centres for specialized care. Plastic surgeons play an important role in reconstruction following excision of malignancies but owing to the reason stated above, it is rare for a freelance plastic surgeon not working at a cancer institute to encounter such patients. And rarer so to get something to write about such an encounter!

 

This is a (real) story of my rendezvous with Mr. SN.

 

My first meeting with Mr. SN can’t be described as a pleasant one, not even in the wildest of imaginations!

 

Before I begin my narrative, I wish to briefly outline the facility that lead to my brush with Mr. SN. The general surgeons at our hospital have an attached dressing room while all the surgical super-specialities share a common dressing room. I being a plastic surgeon, dealing with trauma, burns and reconstructions, occupy this other dressing room (henceforth called as dressing room no 2 or DR2) for maximum duration of time on any given day. Almost all my patients need dressings and going by the teachings of my MCh professors, I never (I repeat never ever!!) hand them over to anyone else. I have hence, been declared the uncrowned queen of this DR2 by the staff who time and again joke that the DR2 should be officially declared as the Plastic Surgery headquarters for all practical purposes.  Being the one who has kind of usurped the DR2 ever since I joined there, I have always enjoyed the privilege to finish my dressings first.

 

All was going as per the routine, until one fine day when my queendom stood challenged! And the one who challenged was none other than Mr. SN! He had been shifted into the dressing room by the staff on instructions of the spine surgeon and for one whole hour he occupied the DR2 as the surgeon hadn’t yet finished his OPD consultations and wasn’t able to come to the room to dress him. The patient could not be moved in and out of the room again and again as he was paraplegic and recently operated. Hence, the staff gave me a sorry look and asked me to wait until the spine surgeon came and finished the dressing. Left with no option, I returned back to my OPD room and finished evaluating my remaining patients. By the time I came back to the dressing room, another hour had passed by. However, to my dismay the spine surgeon hadn’t yet arrived and my patients had started breathing down my neck complaining that they had been waiting for nearly two hours for dressing. Although I could empathize with SN’s condition, somewhere inside I was fuming (in all probability due to the challenge posed to my territory). Added to this, nagging by my patients and their attendants raised my temper further. With great difficulty I swallowed my anger and decided to wait, until a call from the OT sister broke the last straw of my patience. I had posted a case at 2pm but some emergency case had come which they wanted to post at 2pm and since the OT was free before that they wanted me to start my case at 1pm and finish it before 2pm or else to operate only after 7pm. A quick glance at my watch and I realized that it was already 12:30pm and all my patients requiring dressings were still waiting for DR2 to be vacated. With all my patience tested, I marched towards the staff nurse seething with anger and expressed great displeasure at their lack of co-ordination with the doctor. I suggested that next time they should take any patient inside only when the concerned doctor had come to DR2 and not in advance and block the room causing inconvenience to other patients for hours at stretch. She responded saying that she was just a staff nurse and couldn’t say no to orders from any doctors. Mr. SN and his attendants were all ears to this conversation and by the look on their face they weren’t exactly pleased by my suggestions to the staff nurse. To my relief as soon as my conversation with her ended, the spine surgeon had arrived. He finished dressing, SN was shifted out, I hurriedly finished my dressings and headed to the OT. This was my first meeting with SN!

 

I had learnt from the staff nurse that SN would come for dressings on alternate days and I made it a point to finish my dressings before he came so that I never encounter him but little did I know that fate had different plans! I kept bumping into him or his attendants almost every other day for next couple of weeks, somewhere in the waiting area or near the dressing room. Needless to say, the look on their faces suggested that there was a kind of cold war going on at my supposedly unconcerned and unkind suggestions to sister at SN’s first visit. Over a couple of weeks after my first brush with him, I learnt that SN had been operated for some spinal tumor. A month into my first encounter with Mr. SN, I had almost forgotten the incident when the spine surgeon called me one evening asking me if I could see one of his patients who had developed wound dehiscence following a surgery. I asked him to send the patient the next day to my consultation room. To my surprise the patient was none other than SN! He and his attendants were aghast to see me. With great reluctance they let me see Mr. SN’s wound. He was having marginal necrosis with total dehiscence of surgical site and frank CSF leak. He looked much weaker and exhausted than when I had seen him for the first time. He coughed badly and was diagnosed as having severe bronchopneumonia and uncontrolled diabetes besides the wound problems. On going through his medical history, I came to know that he was 83 years old diabetic, operated for a spinal tumor at the level of 9th thoracic spine a month ago. He and his family at the time of diagnosis itself had made the decision that they would let the spine surgeon remove the tumor in the hope that patient’s paraplegia improved but in case it turned out to be a malignant tumor they would not want any adjuvant therapy. Histopathology and immunohistochemistry had revealed it to be a low grade B cell lymphoma but the patient only wanted palliative treatment. It was decided that the patient would be admitted under the spine surgeon for observation of CSF leak besides being treated for bronchopneumonia and I would look after his wound and daily dressings. After discussion with the patient it was planned that once Mr. SN’s pneumonia improved, the CSF leak would be repaired and flap cover would be done for his exposed spine so that the quality of his remaining life would not be compromised.

 

Nervousness was palpable on both sides! From their looks and attitude, it appeared that the patient party wasn’t very comfortable with me managing their patient. On the other hand, even I wasn’t exactly keen to manage a patient whose family did not trust me or my intentions. After a long deliberation and convincing by the spine surgeon, the patient agreed to be treated by me. For the first 2 days, I would visit the patient daily, do his dressing, write my notes and come back. I wanted to talk to the patient but he was too breathless to talk. Attempts to talk to the attendants were also not paying off as they were reticent for initial 2 days.

 

On my third visit, the patient’s general condition had improved a bit. As soon as I wished him good afternoon and he opened his mouth to respond, I noted his dry tongue. A quick glance at his urobag showed dark coloured urine. The next question was a spontaneous, “Are you thirsty? Would you like to have some water?” Back came the response in affirmation by nod of his head. The attendants had been asked to wait outside till I finished my dressing and the sister had gone to arrange for dressing trolley. So I spontaneously picked up the glass kept on the table besides his bed and poured water from a bottle kept there. SN eagerly snatched the glass from me like a child and in a matter of seconds drank the entire glass and asked for one more. I happily obliged. I was all smiles inside somewhere patting myself, at having diagnosed his dehydration when he broke the silence and said that “How did you know that I wanted water? You will become a very good doctor one day. You can read through a patient’s mind. I was thirsty for quite sometime now and wanted to drink water but doctors and sisters have been coming for rounds back to back and then they had started me on nebulization so I couldn’t drink water.” I finished my dressing and went to write my notes, after which I left the hospital. This was my first conversation with SN! And it left me happier as that awkward silence was broken.

 

On my fourth visit, he had improved a bit further clinically and to my surprise opened up to me about his family, life and profession. His family also shared with me the challenges they had been facing since he was diagnosed with tumor. They told me how his life came crashing one fine day when he suddenly developed paraplegia. According to his family, he was an extremely self-reliant person whole life and the news of tumor had broken him completely inside. On my next visit, he had a childlike excitement in his eyes and told me that his childhood friend along with his wife were coming to see him from Chennai. He excitedly shared what all he had asked his wife to cook for his childhood friend and how he had been asking his son to call her every now and then to know if everything that his friend liked was on the menu. Over next four days, I had gained the trust of the patient and his family and they would share important events of the previous day with me. They had become comfortable with me and I had renewed enthusiasm to treat the patient who showed trust in me. After all, finally they and I were on the same page that they would let me try my best to heal his wound. Rest they wanted to leave to God.

 

Suddenly, SN became critical the next day and needed ventilatory support but he and his family had decided against the same when he was fully oriented and had signed a note in advance at the time of his admission. To my disappointment, by the time I reached the ward they had already left with him against the advice of his primary doctor and I couldn’t meet SN that day. As I was leaving, the staff nurse handed me a note they had left for me. I opened it with trembling hands. It said, “Thank you doctor for all your efforts but he wants to spend his last days at home. Hence we are taking him.”

 

I do not know how long he would survive but "the glass of water” that broke the ice between him and me is going to stay in my memory for quite some time. On reflection, I realize how a small spontaneous act as small as offering a glass of water changed my equation with the patient. A patient party that had been almost been at war with me (sans the visible weapons of destruction!) had suddenly started respecting and trusting me and my treatment. I realized that there may be times when we may not have exact solution that can cure patients but small acts of kindness that show that we care for them can ease their pain a bit and help them spend their last days well. This is especially true in patients with cancers. Even with all advancements and pathbreaking researches we will many a times encounter situations where we cannot scientifically help such patients much. As I walked to the DR2 with a heavy heart, Leo Buscaglia’s quote echoed in my mind ,”Too often we underestimate the power of a touch, a smile, a kind word, a listening ear, an honest compliment, or the smallest act of caring, all of which have the potential to turn a life around.” This incident brought to my mind the famous quote by William Osler that I couldn’t comprehend when I read it for the first time as a MBBS second year student,

 

As I reflect, I also wonder at what would have been my response had I drank a “glass of water”  my own self when I was fuming on the very first day of my encounter with SN. Could it have extinguished my anger resulting in a calmer approach to the staff, no cold war from patient party and lesser stress to myself? Well… that only a “glass of water” would be able to answer, when I drink it next time I’m displeased with a situation beyond my control!

 

Till that happens, I leave all the readers to reflect on the Hippocratic advice of, This quote perfectly sums up what we as crusaders of cancer need to remind ourselves at all times.

 

From here on it is my editorial comment as requested by the editor

 

“You will become a good doctor someday”

“Cure sometimes, treat often and comfort always!”

“A good physician treats the disease; a great physician treats the patient who has disease”

 

These are three quotes I have taken from the real-life experience narrated by Dr….

 

Most of us become good doctors as we progress in our profession if we have the right attitude. The very sick Mr. SN realized that Dr…is after all not such a bad doctor when he was given that much needed glass of water. He did not say, you are a great doctor but said, “you will become one someday”.

 

Many of us when we enter medical school harbor high ideals of service, compassion, helping the sick and needy and other similar ideals. During the many years of grueling training, these take a back seat and are replaced by the ambition to become some body, earn reputation and money, and climb the social and professional ladder. Patients and their ailments become steps in this direction. In the bargain, many of us ignore health, sleep, exercise, family, friends and other interests. Real happiness becomes a casualty and quality of life suffers in this pursuit.

 

Focusing on the management of disease becomes more important than handling the human being with the illness. This is particularly so when one climbs the ladder of specialization. When one is stressed with work, especially the work as described by the doctor who is a plastic surgeon working in a cancer hospital, where he or she must be seeing very many seriously ill patients, one is in danger of becoming inured to suffering.

 

One major complaint, many patients have is that we are not concerned about them. One hears patients stating, “he did not even place the stethoscope on my chest” or “he did not even ask me why I am there” or “he just looked at my reports and wrote out a prescription”. Often, we take our patients for granted and do not think that their concerns are of great importance, as we already know what is wrong and what to do. But patients have many worries and concerns and want to share these with us. It is our duty to listen to them even if these don’t always make sense to us.

 

We sometimes forget that in their own field of endeavour, they are more accomplished and they are here at the receiving end, not out of choice but because there is no other go. When we seek help from other professionals, say an engineer or an accountant, don’t we expect courteous interaction? We, more than in any other profession, need to be better at human relationships, because we are dealing with the suffering.

 

If one removes the relationship between us and our patients, we become mechanical robots - often very efficient ones - as many of us must have become... This is the death knell of our profession.  Relationship, whether transient or prolonged, is the foundation of satisfaction for both doctors and patients. As aptly described by the author, the act of giving a glass of water triggered the development of this relationship and made the author progress towards becoming a “good” doctor.

 

This relationship is not just with the patient but also with his/her family, relatives, and other well-wishers. It is not merely medical, it is also social and psychological. Can one have a relationship with out getting affected? The answer is no. Involving oneself with the social and psychological aspects of a patient’s illness can be distressing. However, one needs to participate and be a part of patients’ worries, concerns, and not infrequently, their joys.

 

We, more than in any other profession, have this unique opportunity to become better human beings if we learn to treat patients as persons and not a collection of organs. There is also a possibility of being healed ourselves.

 Note

This appeared in the Indian Journal of Cancer and it's editor, Dr Sanjay Pai has permitted it's posting here

 

 

 

Friday, September 18, 2020

Eclipse of clinical medicine?

 

Some sixty summers back we medical students learnt the nuances of clinical medicine mostly on the bedside of the patient. That the patient generally was from a poor socioeconomic background, and who did not mind a group of enthusiastic students poking his abdomen to feel the hernial orifice or repeatedly placing the stethoscope on the chest to hear a heart murmur. These ward rounds were held in all clinical disciplines. Ward rounds resulted in a particular student or students being assigned to get the required tests done and do the follow up. This meant collecting stool and urine samples, drawing blood and if you are a senior student doing pleural, peritoneal tap and other such minor procedures.

 It also fell on us to take these samples to the lab attached to the wards or all the way to the pathology department and to collect the results when due. Often it meant to ferry not only the samples but also the patient. This kind of activity resulted in gaining knowledge not only about the disease but also on the other aspects of the patient, such as his socio-economic status and the why and what of his illness progression.

Thus, by the end of the final year most of us would have imbibed just not about the illness but some of the practical skills described above. During the houseman year these skills were augmented and it was not uncommon for a house surgeon to independently do surgeries such as hernia repair, circumcision, vasectomies, hydroceles and even appendectomy. If I remember right, we were to conduct 25 normal deliveries and assist/observe 5 abnormal ones.These were necessarily done as those days there were no PG students to compete with and the hands of the unit senior houseman and the assistant surgeon were always full!

Over these six decades, there have been far reaching changes in the learning process. First the number of medical colleges have increase exponentially and so is the number of medical students. Post-graduation appears to be the norm for most graduates. What was being done by the medical student of my days is being done by the post grad student/or superseniority aspirant of today. With so many medical colleges, many of them privately managed, there is also paucity of clinical material. Naturally a patient who has paid money to get admitted to a private ward would not like his private parts to be exhibited to a crowd of medical students. In addition, there is a great dilution of standards. I learnt that the present-day medical student is not allowed to conduct deliveries. Imagine an MBBS graduate who has not conducted a normal delivery being posted to a PHC faced with an imminent delivery. I was told it is the job of the nurse!

So, there is major lack of practical training and acquiring skills and the present-day medical student is a mere observer of the patient and the disease process with no direct involvement. Adding insult to injury, after the final year and during houseman ship year, most students waste their time preparing for the PG entrance test, when they should have been spending time acquiring the much-needed skills. There are some 20,000 odd PG seats available for nearly 60,000 aspirants. The remaining are left high and dry. Even those who manage to be one of the 20,000, may not get the specialty of their choice and thus many will end up as square pegs in round holes.

One of the remedies to this dismal situation is to strengthen primary care and see that the basic MBBS doctor acquires basic skills as described above. This will result in a more confident young doctor who when he enters practice will not refer the patient for the procedures which he himself can perform. If Primary care and family medicine is given status and importance, this mad rush for specialization of any sort will come down and there will be all-round improvement in the delivery of health care in this country