Monday, December 31, 2007

Ushering in the new year

When you know that to morrow is going to be like any other day, why celebrate and wish?. Then, there are lots of things that are special. We would have aged by one year and may be a bit wiser, you remember your friends and relations at least this one day and vice versa. What do we wish each other? Usually peace, prosperity and happiness. Experience tells me that peace is unrelated to prosperity and so is happpiness. Peace and happiness can be related and coexist.In addition, I feel one should wish the other good health both mental and physical.Goodhealth is a prerequisite for peace and happiness.Physical health needs regulated eating and daily physical excercise and mental health needs detachment, a giving attitude and freedom from greed, jealousy and anger.

I wish all of you this in the coming year.

They say beauty is in the eyes of the beholder. I see it when the morning sun penetrates through the branches of trees laden with green leaves and the mist melts, in the round pearls of water on the leaves of the water lilly, in a child playing unobserved, a starlit cloudless sky in the still of the midnight and in the guileless smiles on the faces of Dalai Lama and swami Nithyananda

Thursday, December 27, 2007

Doctor's dilemma

A large percentage of our population depend on private medical practitioners for their primary care needs. This is despite the fact of there being in place a well structured and widely spread network of PHCs [primary health centres] and sub health centres [SHCs]. It is beyond the scope of this article to describe the ills besetting this network of health centres and why people don’t chose to seek help in these centres.

GPs come in different hues and colours. They include practioners of different systems like Ayurveda, Siddha, Unani, Homeopathy, Naturopathy, Electrotherapy, Hydrotherapy, Reiky, several kinds of Yoga and the like. Some of these combine their craft with dispensation of allopathic drugs. If you include chemists who also dispense advice and medicines you would not be very wrong. All these provide some sort of primary care. My paper is confined to the working methods of doctors who practice allopathic system and who have a basic MBBS degree.

In this write up I have tried to analyse why this section of qualified allopathic doctors have failed to deliver comprehensive, affordable quality medical care. As this is linked to unethical practices, it has some relevance to what is being discussed in this conference

It is a basic principle that when a cheaper and effective drug is available, that should be used preferably by the oral route unless there are specific reasons for not doing so. This rule is generally not followed. The reasons are: patient’s belief that injected drug is more powerful than the oral one and also their willingness to pay more. Doctors put in no effort to dispel this belief and in fact exploit this by obliging the patient. Costs of injectables are much higher than oral drugs and the cost of care thus goes up. Many doctors run unnecessary IV drips and the reason is the same. Demand for X-rays, Ultrasounds, CT and MRI studies and many lab tests is far in excess of actual need and again is driven by commercial rather than clinical considerations.

With the advent of private players into the health care scene urban India is witnessing a bloom in institutions providing health care. These laboratories and hospitals are competing for custom of the paying Indian. Doctors are enticed with monetary and other inducements to refer patients. It is common knowledge that this cut practice is wide spread and it adds to the cost of health care. It is also a medically known fact yearly medical examinations [package deals] as screening methods, when indiscriminately applied to all and sundry, are a huge waste of money and another reason for pushing up the cost of care.

Pharma companies and medical men have always been cosy bedfellows. One encourages the other to the detriment of the patient. When one can carry out a decent family practice with about 200 drugs where is the need for 10,000 odd combinations and brands of drugs which are available in the market? Pharma companies and equipment manufacturers sponsor doctors CME [continued medical education]. These meetings can be local, in another town or even abroad. Depending on his use to the company, the doctor’s travel, stay and even entertainment is taken care off. The sponsor naturally expects and in fact gets the returns by the way prescriptions and use of the branded equipment. Those who don’t want to enter into such a relationship often find it hard to organise professional meets or participate in one. That there are still few doctors left who have survived is fact that surprises me.

Are these facts not known to the consumers? Of course they know or are coming to know. This one of the reasons why they no longer hold us with the same degree of respect that they did 30 years ago. Physical assaults and increasing litigation are the direct outcome of this perception that we are exploiters.

Why are we unethical? The answers are many. A combination of prevailing socio economic scenario and the compulsion to keep up with the Joneses at any cost is one reason. Add to this the basic human quality of greed and inability to accept a low profile life in a society which seems to respect only the wealthy is another. Add family and peer pressure, we have a tailor made situation for practicing unethical medicine.

The only silver lining is that society is becoming more informed. Hopefully, the informed citizen of the future will seek out honest doctors if they exist, and will be able to get the profession to mend its ways.

This write up is based on a presentation made at the recently concluded bio ethics conference.

Sunday, December 16, 2007

Dhruva's test

Dhruva is a six years old youngster and much more knowledgeable than I when it comes to the electronic gadgetry he plays with. This provides him with great deal of fun and merriment when ever he comes to see me. The latter part takes more time than the actual consult. On one occasion he may bring his battery operated car with a hidden starter button and will demonstrate a trial run on the floor and challenge me to do the same. I cannot to this simple act to his great delight. Like this, each time he comes he has new gadget or a toy and usually I end up getting defeated. He also asks me simple riddles and most often I answer wrong. Dhruva has come to the inevitable and fair conclusion that I am a rather stupid and backward person.

Recently he was unwell with fever and he was brought to see me. I wanted to take his temperature and requested him to keep the thermometer tip under the tongue. He reluctantly agreed and after I finished, he asked me why don’t I take it from the ear which is very fast as his mother does? This was news to the backward doctor. Seeing the disbelief on my face, he explained patiently how it is done and promised to get me one when he comes over next time.

His father came after a few days with some problem and gifted me with a new digital thermometer with an ear piece. You have to just place it like you do with an otoscope and press a button and you get the reading. Dhruva however was very specific in his instructions to his father. ‘That doctor, he doesn’t know, you just don’t give it to him and come away, you show him how to use it by putting it in his [mine] ear’ The father told me this, but had the grace not to actually do it.

I am pretty sure Dhruva, when he comes next will test me. I am a bit nervous that I may fail!

Thursday, December 13, 2007

Practice experience

Old age has its advantages it is often said. The disadvantages however overweigh the advantages. Of the many, is the inability to cope with adversity. There was a time when I was able to handle several serious patient related issues simultaneously with out getting unduly affected. This is not so now. Patients who have been with me and have grown old alongside are getting into serious personal, family, financial and health related problems. Often they have no one near enough but not involved, to go to for advise except I. Earlier on when they brought their problems to me I could evaluate them dispassionately and then forget about them soon after. This is no longer possible. The feeling of immense sorrow long after the party has left my premises lasts often days and weeks after the event. My thoughts go back to the days when I was witness to the joys of the newly married couple 25 years ago, now occupied with an intense and hateful war with each other. I find it hard to accept or understand this hatred and not able to sort out any of their problems adds to my owes. This kind of happening is deeply disturbing and leaves me with profound disquiet which does seem to go away as it did in my younger days.
My patients seem to die more frequently now. Don’t be under the impression it is because of my doing, it is because of old age and related issues. Unlike younger doctors older doctors like me have more number of geriatrics. These have been my patients since their younger days and I have been a party who has watched their life’s drama [melodrama] unfold over the years, like they have watched mine. Yesterday I saw a deeply jaundiced patient of mine of 70 years who underwent rescective surgery for carcinoma gall bladder. We including the dynamic young surgeon thought we had achieved a cure as the problem was detected very early. Not more than five months have passed and she is back and almost certainly with liver mets. I have been her friend in the days she suffered looking after her husband who died after a prolonged struggle against restrictive lung disease and IHD. No sooner he went she developed this problem and now she is on her way out. Both have been my patients of over twenty years.
These episodes are becoming common and as I said earlier leaves me emotionally drained. They say in youth the emotions are brittle, but I feel it is so when one grows old. What made me write these few lines and share these feelings is the hope that by doing so I may lighten this burden.

Any naturalist who is lucky enough to travel, at certain moments has experienced a feeling of overwhelming exultation at the beauty and complexity of life, and a feeling of depression that there is so much to see, to observe, to learn, that one life time is too short a time to be allotted for such a paradise of enigmas as the world is. You get it when, for the first time you see the beauty, variety and exuberance of the tropical rain forest, with its cathedral maze of thousand different trees, each bedecked with gardens of orchids, epiphytes, enmeshed in a web of creepers: an interlocking of so many species that you can not believe that the number of different forms have evolved. You get it when you see a vast concourse of mammals living together, or a vast, restless conglomeration of birds. You get it when you see a butterfly emerge from a chrysalis; a dragon fly from its pupa; when you observe the delicate and multifarious courtship displays, the rituals and taboos that go into making of the continuation of species. You get it when you see a stick of leaf turn into an insect, or a piece of dappled shade into a herd of zebras. You get it when you see a gigantic school of dolphins stretching as far as the eye can see, rocking and leaping exuberantly through their blue world; or a microscopic spider manufacturing from its frail body a transparent, apparently never ending line that will act as a transport as it sets on its aerial exploration of the vast world that surrounds it.

Gerald Durrel. Naturalist, zoo keeper and writer.
From his book, ‘golden bats and pink pigeons.’

Truth and Beauty
The light alone, like the mist over the mountain driven,
Or music by the night wind sent,
Through strings of a still instrument,
Or moonlight on a midnight stream
Gives grace and truth to life’s unquiet dream.


Thursday, December 6, 2007

Vanity and Ego

Many years have gone by since the incidence narrated here occurred but it is still fresh in my memory not because of the nature or rarity of presentation of the illness but the aftermath of it.

The middle aged well groomed lady was brought by her son and daughter in law because she had been having chest pains for the past couple of months. They had brought with them a sheaf of papers which had investigation reports and prescriptions from doctors whom she had already consulted.

I wanted to examine her. At the best of times examination of an Indian woman properly for a male doctor is difficult and it is more so with women belonging to some orthodox communities and this was one of them. With extreme reluctance she removed the outer black covering of her body. There were three more to go. It took another five minutes to convince her to remove at least one ore of them. She wanted her own son to go out before she divested herself of this second garment. She would not go any further and I had to make do with this. So I proceeded to examine her. On her left chest where I normally place the head of my stethoscope, beneath her blouse, I could not hear her heart sounds because of a hard object.

Our women have this habit of carrying a small mini purse inside their left bra. This is for right handed women and for lefties it is the other side. They consider this a safe and easily accessible place to keep their money I told the lady to please take this purse out so that I can proceed with my examination. She said she carried no purse!

What she had was cancer of the left breast which had already fairly advanced. Sadly her right breast too showed a less advanced tumor. I called the son inside, and to the three of them I explained the problem and convinced them to see my oncology team. That they disregarded my advice and went elsewhere is another matter.

You are wondering how we allowed this lady to go undiagnosed for so long. Often they don’t allow proper examination and this is the main cause and we doctors too don’t insist for the fear of offending them. I could detect it because it was already pretty big and difficult to miss. I too would have missed it had she come when it was small and refused a proper examination as she must have with other doctors.

I heard later that she passed away in a few months time.

Some years later an elderly gentleman came to consult with me. I don’t remember what his problem was. After the consultation was over, before he took leave he told me that he was the husband of the lady who had cancer of the breast and I was the one who spotted it first. I thought he was going to thank me. Instead he said, doctor, ‘my wife is no more, but when you told the bad news to my children and not tome who is her husband it hurt me very much, this I want you to know’.
This left me stunned, taking my silence for apology the old man left.

I did not even know he was outside waiting when the lady was being examined. The children had taken over and who should I tell? Had I known he was outside would I have called him in and told him? I don’t know. It is always easy to break the bad news to the young relations than the old ones. But he was right. He was her husband he should have been the first person to know. But why rake the issue after so many years?

Human ego and vanity presents in many ways and this is one such example. I only hoped that the resentment he had carried for so long went after he made his point. A sort of catharsis would you say?

Sunday, December 2, 2007

Advice unsolicited

I used to know an elderly lady as a patient. She suffered multiple chronic illnesses like severe diabetes, heart disease, skin eczema and she managed her life with these disabilities fairly well. She was a good patient in that she kept her appointments, followed my instructions and paid me well.

She lived alone with a helper but had a large number of relations living in the city, country and abroad and she was popular with all of them and they frequently visited her.

Recently she came to see me and I could see that she was very anxious and agitated. I asked her what the matter was. She said, ‘Doctor my nephew told me that I have Parkinson’s disease. I went to the Internet soon after he left and got very scared, how can I manage with this new disease now?

I could sympathize with her as Parkinson’s disease is an illness which can be very disabling. The sufferer gradually loses control over muscle coordination and becomes stiff and rigid. Worse there is no proper treatment or cure in sight. But she did not have Parkinson’s disease and how could she believe her nephew? I asked her. She said, ‘no doctor, he is a neurosurgeon living in the US and when he saw me shuffling he told me that I have this disease and I should take treatment’

It took me more than half an hour to convince her that merely a shuffling gait is no evidence of this disease and lot of elderly men and women take small steps but have no other signs and she has excellent gait and movement. She went convinced.

This is a problem that I have frequently faced in my practice. Unsolicited advice given on the spur of the moment like this neurosurgeon did. One look at his aunt’s shuffle and he diagnoses Parkinson’s disease. If he had that much concern he could have called me and expressed his concern instead of needlessly frightening his aunt out of her wits. I would have tried convincing him. Weather I would have succeeded or not is a different matter.

My patients receive this kind of unsolicited advice from other doctors at casual social meetings and cause me no end of problem afterwards. I also get asked questions and opinions like this from persons who are not my patients. I have a stock answer. I tell them to see me in my clinic if they are unhappy with their own physician. This usually shuts them up and some times ends the conversation which is to my advantage! because I like to be left alone most of the times!

Thursday, November 29, 2007

Not medicine

35 years ago when I began my practice I used to have plenty of time at my disposal and some of this time I spent with a senior practitioner friend of mine. On one such occasion I went with him on his morning round of house calls.

The call was to see a boy who was having high fever and the mother wanted the doctor to see him at home. When we went we found the mother anxiously waiting for us. The boy did not look very ill but I could see that the mother was very worried and kept plying the doctor will lot of questions which then appeared pretty silly to me. My senior friend went through the rigmarole of an elaborate examination and with a serious expression advised the lady how to look after the boy which included a two hourly temperature record keeping and hourly changing of the wet cloth on the boy’s fore head!

When we were driving back, I could not help asking him the rationality of this advice.
He said, ‘you saw how anxious she was, this will keep her occupied for the next two days and she will not bother us and hopefully the boy will be OK by then.’

Anther time a lady came from a far off place and requested the doctor to give her a bottle of yellow medicine [peela davayi in Urdu]. This yellow medicine was the famous alkaline mixture given for several complaints and illnesses which if I were to list, the modern day doctors will have a hearty laugh. Her complaints were pains in her back, legs head and general weakness. Obviously there was no major disease and she came and took this peela davayi every month. I asked the doctor what good it does to her. He said, ‘I too don’t know, but I know this much, she will manage for the next one month and will not come before that’

I may not have learnt much of medicine from this doctor but I learnt a lot about patient management and that there is more to medicine than just treating an illness.

Sunday, November 25, 2007

Birds and others

For a number of years I hardly took any notice of them, till one day a remarkably beautiful gray and chestnut red bird flew in and sat on a branch of a tree close to the tee box [square piece of levelled turf]. I asked one of my regular foursome who has had some rural upbringing and knows a thing or two about birds, as to what sort of a bird this is? He said it was a crow pheasant and commonly found in all rural areas. That was the beginning. Interest in crow pheasant led to other birds mostly heard and rarely seen. My friend would, whenever asked would give a name to the bird we saw in the course of our play. This I suspected more to shut me up rather than to improve my knowledge of ornithology. I soon realised that there is a great verity of them out there that I did not know and what I did know was far from satisfactory [even now, after nearly ten years of bird watching].

Thus began my quest for knowledge about avian life around me. My partners attributed my enthusiasm to the onset of senility. Having lost interest in one form of birdlife due to aging, you have taken to this form of bird watching, they said. My attempts at informing these ignorants that this is far more satisfying and rewarding, brought forth great guffaws of laughter. One of them began asking me, every time a woman dressed in bright coloured clothes passes by, to name and identify the species!

Armed with a pair of binoculars and that bible of bird watchers, Dr Salim Ali's book on Indian birds, I became an odd fixture on the golf course in the mornings. It provided amusement to my fellow golfers to see me on the course in a pursuit different from that of golf. Recently one of them in trying to draw my attention away from the bird I was watching missed his step and fell into a trench. This obviously succeeded in distracting me and seeing him prone on the ground I rushed only to see him not only unharmed but also full of, according to him, well meant abuses at me for being responsible for his fall.

On another occasion two golfers approached me to find out what I am up to. Finding that I am not there to steal their golf balls [easy to mistake in my shorts and nondescript shirt] they became less hostile and warned me of dire consequences if I trespassed onto the course once again as it is private territory. Needless to say they were beginners and therefore did not know that I was also one of them and pretty senior! But I liked their attitude of saving the course from itinerant birdwatchers and other such unwanted elements. Instead of getting into needless argument, I agreed to abide by their instructions. Few days later when I wished good morning while playing golf to the pair, there was an embarrassed silence and one of them rather sheepishly managed to return my greeting.

It did not take long for me to realise that book and binoculars are not sufficient help when it came to the minutiae of bird watching, especially identifying small pale coloured birds. These were also friskier and it was difficult to hold them in view for more than a few seconds at a time. I needed an expert bird watcher to assist me in the details. Through a mutual friend of mine I got in touch with Mr. T.N.A.Perumal.

Mr. Perumal is a gentleman of indeterminate age. He could be 60 or 70 or more. Because of watching and listening to birds he has developed a keen sense of sight and hearing. However this is restricted to only birdsong and sight was made clear to me on my very first outing with him on the course. He was overwhelmed at the abundance of bird life; [sadly the number and variety has greatly diminished now] he profusely complimented me and the club for planting so many trees and also thoughtfully providing the many waterbodies, an ideal habitat for birdlife. I prudently kept quiet [the water bodies are intentionally created hazards to make the game challenging]. Next to the first green there is an area of scrub jungle [no more] with many tall trees and I have found this a favorite of many birds and I proceeded to take him there.

While we were approaching the green he heard some bird calling and he stood still and to have a better look and inadvertently went on to the middle of the fair way [danger zone]. Sure enough and soon enough there were loud shouts of 'Fore' from the foursome which was teeing off. I had to physically drag him aside away from danger. He was naturally upset at my indiscretion because the bird had stopped calling and he could not properly spot it and wanted to know why I had to drag him away just because few people [bird brains?] shouted. I told him it was the golfer’s call of warning. He gave a grunt and said, ‘such loud shouts will disturb the birds!' We went to the edge of the out of the bound fence and spent the next hour or so watching and identifying. All the time, while we were talking I had to keep telling him to keep the tone of his voice down so as not to disturb the players on the green. This seemed to surprise him. Clearly he thought that birds are more important than golfers and if the game of golf had to be played then it should be done with out disturbing the birdlife!' Successive four balls followed one after the other and as many of them knew me they came up to us and wished me and wanted to know what mischief I am up to. Mr. Perumal did not take kindly to this kind of camaraderie between me and these people who have no respect for birds. He did not say so in as many words but the frown on his face said that.

Later in the clubhouse I told him but for these golfers the golfcourse wouldn't be here and there would be also no birds. Instead there would be another concrete jungle. [All around it has indeed become one now] 'Yes, yes, but they should play their game quietly with out all that shouting' he said somewhat mollified.

In the 12 hours or so I spent with him, over a two months period, we identified and documented more than 50 verities of birds in our course and at the time of writing [that is, when this article was written ten years ago.], I am still at it. In Mr Perumal I have met another of those unsung individuals who persue an interest for the pure joy of it and take pleasure in educating impatient and rather below average students like me.

My near and dear have begun telling me that I am afflicted with one more wasteful habit, this time that of bird watching.

This article was published in a golf magazine some ten years ago.

Thursday, November 22, 2007

Viagra's Advent

The following story was written 9 years ago when I was visiting US and stayed with my Urologist relative near the Canadian border. It was hot news then. I let my imagination go a bit wild and wrote this story which got published. Both the desi version and the imported version are available for several years now and as far as I know the expected calamities described below have not happened!

The imminent prospect of viagra’s advent into the Indian drug scene fills me with trepidation. Why am I anxious instead of being happy with the prospect of many of my elderly patients rediscovering their lost fountain of youth? It appears to work in 60% of men who have organic [something wrong between legs] or psychological [something wrong between the ears] or who have a combination of both. Fortunately it will not enhance sexual performance of normal men. So what is going to happen when sizeable numbers of men start taking this drug? Mind you, one should take the drug an hour before the scheduled performance and some men wrongly believe that once taken it will have the desired effect forever! Most of the wives of these men will be either menopausal or postmenopausal age and many will have lost interest in active sex or reconciled or even enjoying life with out the pester of a demanding husband. Viagra might change this truce and peace and the women may once again have to yield to the sexual demands of their husbands. Number of them will be unwilling and or incapable of enjoying sex. This may lead to problems of aging men chasing wives of other men, younger women and even trying sex workers with all the antecedent social turmoil.

The scene may not be far of when we start seeing respectable elderly men seeking help to get treatment for venereal disease and even worse, for AIDS! Will the warning that those who are on medication for high blood pressure and or heart disease may suffer serious side effects which include death, prevent such men from indulging in this drug? I donot think so. For the pleasure of sex there are many men out there who will not mind having blood pressure or even heart disease! Their commonsense argument may make them think, ‘ok, today or night I will take Viagra and omit the BP pill, any way I have often forgotten to take it and nothing has happened when I have missed! And have a go and hell with the warning.

This drug will sooner or later will hit the Indian drug market. Incidentally the real name of this drug is not Viagra but Sildenafil citrate. Like film actresses changing their names the drug company which makes the drug has given Sildenafil this glamour name and this seem to have really hit among other areas of the body, men’s imagination, as no drug has ever done before. What is going to happen when it hits the market? In the US it is now priced at 10 dollars a pill and is considered expensive even by American standards and that has not prevented Americans who are in real or imaginary need for buying it are lobbying for this drug to be made available against their insurance.

There were reports of Canadians for whom it wasn't available; making a bee line across the border to the US in search of the drug, reminiscent of the liquor starved Andhras crossing over to Karnataka for their FMILS [foreign made Indian liquor]. Going by these indications this Indian made or imported Sildenafil is not going to come cheap. My guess is that it is going to cost anywhere between 100 to 200 Rs a pill and it will be made available only against a prescription. It will be, thus, priced out of the reach of large a majority of us who are poor. These people might have to agitate to get this drug available in our government hospitals and use our voting clout to impress our MLAs and MPs to take up this issue and make it freely available. I am imagining the scene in the parliament where our aging MPs who have had the benefit of free use, strongly advocating the free availability of this drug in their constituencies for the needy or even demand a quota to be allotted to each of them to distribute to those whom they consider in need. Appears far-fetched you think, wait and see.

The remaining, the so-called middle class who always has to pay for their pleasures or their miseries will have a problem. How to get it even if it means only for an occasional indulgence like his half a glass of weekend beer? He will have to go to his own doctor and explain his need to get a prescription. The family doctor being the familiar fool he is, may not take kindly to this request, and may even start talking about the need or no need for sex at his [patient’s] age and what would his [the pill seeker’s] wife think of this sudden urge? And start a sermon on the side effects on his heart BP etc. Having got over this and at the cost of climbing down a notch or two in the doctor’s estimation, and getting the prescription he goes to the chemist. It is quite likely he will get an interested look from the chemist and the precious potion is at last made available. The next step is taking the pill and hope that the wife will appreciate the long forgotten advances and suitably responds. Consider even this hurdle overcome, then the million-dollar question is whether he belongs to the 60% in whom it works or the 40% in whom it will not. Let us say he is the lucky one and belongs to the successful 60%. He may, still have to face the distinct and extremely unpleasant possibility of not only not getting his much needed morning coffee but a stern warning from his beloved wife never to put her through the experience once again.

He will, then have no option but to wait till another potency pill, this time only for women is made available, and fondly hope when that happens, that he may not have to tell his wife what she told him.

Sunday, November 18, 2007

Notes from the past

Relatives of a deseased patient of mine took exception when I said 'good for him' when I learnt of his death. What I meant was that it was good for an 80-year-old to go painlessly and quickly as he did. But to express grief even though you don’t genuinely feel it, is what the social custom demands and readers are forewarned not commit the same mistake as I did when they are faced with similar situation.

Recently I found in my case notes I had written Crazy Mama instead of the patient's name. What had happened was that when she had come on earlier occasion when I had made those notes, she had come with her two kids and she had created such a racket in trying to control her children, simultaneously trying to tell me her complaints, subconsciously I must have written her name as Crazy Mama. Obviously she had not noticed it and even if she had, I don’t think she would have minded it! Needless to say I quietly changed it to her real name.
The foot less prompt to meet the morning dew,
The heart less bounding at emotion new,
And hope, once crushed, less quick to spring again.
Mathew Arnold, on aging.

Thursday, November 15, 2007

Past and present

As I age and spend the last years in my general practice, my worries about the future of new entrants to this branch of medicine and the quality of their practice seem to increase. One such worry is the loss of pediatric group of patients [children] to pediatricians. While I have nothing against pediatrics as a specialty, I am against paedricians seeing routine problems of children, especially their taking over the doing of basic immunization. This must be the preserve of GPs and pediatricians should see patients only when GPs refer. Lot of quality time of pediatricians is now wasted in managing routine problems in children when that should have been spent in handling difficult problems which can not be handled by GPs and which may need hospitalization. Of course one could justifiably argue the same with all specialties but I am particularly vexed with pediatricians because it is such a pleasure looking after children and we are being deprived of what is rightfully our domain.

Most of you must be reading and hearing about practice of evidence based medicine. This simply means doing something when you know that it is going to do good to the patient based on evidence. If one were to strictly follow this then often there would be conflicts with ones experience. Experience is individuals and evidence is collective. Let me give an example. It is well known that most of upper respiratory infections in child hood are viral in nature and don’t need antibiotics. That is evidence but the doctor’s experience over the years is that he gets results by giving all these children antibiotics. What must he do? Old habits die-hard and bad habits however old they are must be allowed to die so that our patients are spared from our unnecessary ministrations. More than any other branch of medicine family medical practice needs evidence based medicine to be practiced. There is a small aside to this. Today’s evidence may be to morrow’s blasphemy, remember the choice but mutilating treatment of gastrojejunostomy with gastrectomy [a major surgical procedure] for ulcer disease not so long ago, before the medical treatment for the germ Helicobacter came in and this common surgical procedure almost vanished?

I don’t exactly remember what was it that made them stop using my services, but I know it was something not very pleasant. Therefore to see her after 25 years, back again in my consulting room was a bit of surprise. 25 years ago she was a good-looking young woman and now she was one of those run of the mill middle aged. She was having episodes of breathlessness, attacks of syncope with spontaneous resolution and had come to me to find out what was wrong. She had already made the usual hospital and specialist rounds and had a file full of records with her. After listening to her and examining I could make a diagnosis of supraventricular tachycardia because she was having one at the time I was examining her and I could record it with an ECG. We discussed the various modalities of treatment including that of electrical ablation of the offending pathway. She went satisfied that at last a proper diagnosis was made and hopes of a permanent cure. Both of us had the prudence [age related wisdom?] not to dig up the past.

Sunday, November 11, 2007

Three festivals

The festivals of Ganesh, Dussera and Deepavali arrive one after another in the months of Sept, Oct and November.

Thousands of idols of Lord Ganesh made out of clay and painted with bright colours are displayed in homes; make shift street corner associations, educational institutions and even in some government departments. Money is collected from the citizens [often coerced] for the performance of the functions.These functions involves braying loud music often into late hours. The idols are kept from two days to weeks and then taken in mini and major processions to be immersed in the nearest water body. These precessions are accompanied by music [noise] makers all the way. Our water bodies are already polluted. These idols and the decorations add to the insult. We spent a lot of money in cleaning up the Ulsoor lake and after this festival it was a pain to see the lake littered with refuse of every kind. Traffic which is already on the verge of collapse did collapse on several days and came to a stand still in many parts of the city when these processions were on the streets.

Next came Dussera. Similar to the above in a different way. Same noise, street side pendals and litter for days on end.

Next was Deepavali. At the time of writing it is just about ending. In causing damage to the environment and disturbance to the peace and quiet of the city celebration of this festival takes the cake. It is supposed to be a beautiful festival of lights. It is no longer so. It has become a festival of noise and smoke. Fire crackers went non stop from dusk to near dawn for the last there days and a blue haze covered the none too clean skies of this city. Noise haters like me have had a hard time. Here I am joined by countless petrified animals [pet dogs in particular].

Don’t we have a better and more cultured way of celebrating these festivals? Should the revelers have no consideration what so ever for others?
When will we become better citizens?

They sit in front of me day in and day out with faces that tell their own story. Some are blank, some sad, some vacant, some stare, and some are worried but very rarely happy and contented. They listen to what I say rarely with attention that I feel I deserve. I can make this out by the expression. The wandering mind has a face on which inattention is writ large. There are some who keep saying 'hu hu or achha achha when I am talking as though to encourage me to continue. Though these expressions of encouragement often irritate me I try not to get distracted but when they are made to hide indifference and inability to follow I tend to get upset and try and bring them back to the subject of the consultation. When a patient is paying me for my time it is his business to try and not waste it by not listening and it is my business to try and make him understand. Both of which frequently doesn't happen even after so many years of practice, is a bit worrying. It is extremely difficult to make an uneducated lay person understand the intricacies of why his or her thyroid is not producing thyroid hormone [when you yourself is not sure why] and why she should be taking the tablet daily, when you are being stared at by an obviously uncomprehending face. But what took the cake was a recent incident when a patient who was patiently explaining his problems suddenly stopped midway and asked me,' Doc are you with me so far?' That stopped me dead in my tracks. Are the roles being reversed? Are my patients too feel the same way looking at my face? These are very disturbing thoughts.

Thursday, November 8, 2007

Two experiences

Years ago I used to see some Russians resident in Bangalore. They usually came accompanied by an interpreter and the consultation was a laborious three-way affair at the end of which in addition to a mild headache, I felt not sure whether I got the problem well understood by both parties. On one occasion one of them was sick and could not make it to my chambers and I was called to do a house call. On reaching his home I was surprised to find the interpreter absent. I was now faced with the problem of communicating with this huge obviously sick and groaning Russian. Looking at my face he must have guessed my predicament and he said in perfect Queen’s English, ‘ Doc don’t worry, I can speak good English’ and proceeded to give an excellent description of his complaints. Taken pleasantly aback I asked him why on pervious occasions he put me to so much difficulty with the unsatisfactory three-way conversation. The reply was that he had to follow the prescribed protocol. Obviously the tartan interpreter was some kind of watchdog keeping an eye over these countrymen of hers!

A snippet I read some time ago in the BMJ prompted me to write this somewhat similar experience that I underwent some time ago in my practice. The couple came in one after the other, first the man and then the woman. The man told his story with no assistance from the woman except she was giving him unsympathetic stony looks. After finishing with him I wrote out a prescription and told him to avoid spicy food for a few days and asked his wife to put less spice in the food. She looked very offended and told me that she is no wife of this unmannered man who barged in to the room out of turn disregarding her and went on to add that I have to put the unmannered upstart in his place and see that he does not do so again. I sat back blinking at both of them. The man took a sheepish leave all the time getting a blistering stare from her.
Those of you who have no receptionist to control entry of patients beware of such situations; all women who accompany men need not be wives!

Sunday, November 4, 2007

Constipation cure

Whenever an elderly gentleman comes with constipation I get worried about cancer colon being the cause. This man was no exception. He is past seventy and I have known him for some years now, I knew his fetish about daily bowel movement and I suspect that he abused laxatives to achieve this objective. Therefore when he came with complaining of constipation of two days, I got a bit worried and told him to try some isobgul powder [which bulks and softens the stool] that night. He gave me a sheepish look and told.’ But doc, I have already taken tablet of dulcolax and it has not helped’. It was with difficulty that I could control my irritation. This is because I do not like any one taking an irritant purgative like dulcolax as it can cause problems when used routinely, and when the habit gets a patient it is difficult to get him off. But I held myself back as I felt it was more important to know why of his constipation than worry about his misuse of dulcolax at that moment.
I told him to get an enema done and gave a note for getting this done at a nearby polyclinic and asked him to come for a proctoscopy [an examination of the lower end of the colon by a small metal tube] later. I also told him to be prepared for a possible colonoscopy [longer version of the proctoscope] and sent him with a worried frown [revealed on his face and not mine].
He did not come back for over a month and when he did come it was for an entirely different reason. Curious to know, I asked him about his constipation. He laughed and said it was due to the news paperboy not delivering the daily newspaper to him on three successive mornings. You are justified in wondering what newspaper has to do with constipation. Let me tell you. Our friend has read his morning newspaper sitting on the commode for the past 40 years and would not move the bowels unless this ritual is followed! Arrived the newspaper and went the constipation!

Thursday, November 1, 2007

Professional pride and being in heaven

Professional pride is important to lead a satisfactory life. Pride should not be mistaken for arrogance that often our profession is accused off, with some justification. Arrogance is unconcerned disregard and I know it all attitude towards fellow men in general and patients in particular. This is the worst quality in medical men and even some of the most technically qualified suffer from this. To some extent the disrepute that the profession has come to, is because of this arrogance.
Pride is an entirely different quality. It is the pleasure and satisfaction one derives for being a competent professional and the feeling one gets when one does a job well. In general medical practice there are lots of opportunities for this. But I have often found this pride lacking in my colleagues. Is it because they feel an inferior status being general practitioners or is it because they are not doing the job as it should be done or is it because their quality of work is not what it should be? It could be a combination of several of these factors. For example let us say you made a brilliant diagnosis of an illness in one of your patients and you should be feeling good about it and justifiably proud. But you are not feeling good though the patient comes and profusely thanks you. Why? Is it because you have accepted a cut from the lab? Or is it because you sent him for some tests that were not required or is it because you kept treating him long after the illness has healed?
A doctor who is unethical will not have that pride and the feeling of being in the wrong will eat into his vitals and this feeling will lead to emotional unhappiness and the quality of life deteriorates. You can always set a price on your service, but don’t compare the performance which can be great with its compensation, be it money, power or fame, which can be often trivial.
Pride in being a true professional is like a halo around one's head. Try and develop that in the course of your professional life. Not only your colleagues but also your patients and friends recognize it and when you finally bid good bye to this world, at least there will be some memory of you left behind in the hearts and minds of your fellow men who survive you.
[This is part of an editorial I wrote some years ago in a professional journal]

I have not been to heaven and unlikely to go if there is one, but I have experienced what it means to be in heaven. That is when a seriously ill person returns back to normal health due to my efforts.

On a day with dimpled light,
In a world of greed and strife,
With a message clear and bright,
God’s angels come to life.
Geetha Srinivasan

Sunday, October 28, 2007

First patient

At the start of any venture it is difficult. Medical profession is no different. Especially true when there are so many of us competing for the same custom. The memory of my first patient is still vivid though it occurred some 35 odd years ago.
She came in wiping perspiration off her forehead. Her opening remark was that I should fix an awning in front to prevent the sun shining in. I had not even thought of that as a necessity. After this opening gambit she settled down to the business of finding out my antecedents. After confirming that I am a qualified physician who uses allopathic medications she took out a bundle and small note. Inside the bundle there were foils and small bottles of leftover medications. She said, referring to the note she had in her hand, ‘doctor these are all medicines I bought but have not used and the market value is Rs----- [this she had calculated after consulting with her chemist]. I am willing to give them for Rs--------- which you can see, is less than 50% of the value’. She sat waiting for my answer. Taken aback, I told her that I am not a dispenser of medicines and therefore these were of no use to me. She must have read the disappointed look on my face [as I realized that she was not a patient] as I too did on her face [because I would not buy her medicines].
She grabbed her bundle and giving me a rather pitying look went her way.
I sat wondering if this was what general medical practice was all about?

Thursday, October 25, 2007

Lost weight

Our paths often crossed which was unavoidable. We lived in the same locality and belonged to the same club and she was a fixture in most of the club parties, receptions and get togethers of common friends. She was a woman of uncertain age, weighed 80 kilos which was heavy even for a big built woman like her. Whenever she came to see me it was for obesity related problems and my standard treatment was to hand out a diet chart, which she cheerfully ignored, but kept complaining that despite her dieting her weight remained constant.
Normally when I go out for an evening party which is rare, I try and get back early and when this lady is present it was even earlier. Let me explain why. No sooner the food was laid she would slide up to me and tell me loudly ‘doc, you are a busy man and must be waiting to get back come, you have your meal’ and would virtually drag me to the table, sometimes even handing me the plate. This worked fine with me as I was usually happy to get away from these parties, but once in a way I found it annoying when the host or the hostess is a close friend and I wanted to spend some time there.
On one such evening we were forced in her usual manner to eat an early dinner and depart. We had gone home and my wife remembered her handbag which she had left behind and wanted me to go back and retrieve it. Rather reluctantly I went back to the venue and went straight to where my wife was sitting and to my relief found the bag. I also found sitting there my patient with all her flesh and fat, with her plate heaped full of richest of foods! At my rather cruel and unexpected return her reaction initially was one of surprise and then a mixture of guilt and consternation. I should have wished her goodnight and gracefully got back, but couldn’t help telling her to come next day to my clinic and check her weight!

Sunday, October 21, 2007

Doctors' handwriting

He came in supported on the one side by the son and the other side by the daughter in law. With some difficulty we succeeded in getting him to lie down on the examination table. The history that I could get was that this gentleman was feeling sleepy and tired and not his usual self for the past two weeks. He had seen several doctors and he was in a hospital for a few days. They had a sheaf of papers which included lab reports and X-rays. Those days there was no CT/MRI and I am sure had these modalities been available they too would have been used. All the reports were normal

I proceeded to examine him. He answered my questions fairly correctly but in a slow slurring manner. He was more interested in sleeping than getting examined but was quite docile and cooperative. I did not find anything wrong with him. I found he was on medication for high blood pressure with a combination of beta-blocker [ a popular drug even in those days] and a diuretic. I knew this combination can very rarely produce some weakness and electrolyte imbalance. As I had nothing else to cling on to, I changed his blood pressure medication and asked the relatives to bring him after a few days.

A week later the gentleman came, this time unescorted. Looked and behaved perfectly normal. I too found him normal on examination and told him that it is possible that his blood pressure medication was the cause. He seemed to agree but on parting told me that there have been periods when he felt perfectly normal even when he was on the old medication. This dampened my spirits a wee bit. Nevertheless, seeing him normal was a relief and I hoped that he would continue to be normal hence forth.

He came back two weeks later. Status quo ante. Same story, nothing abnormal on examination but patient distinctly abnormal. When I was literally scratching my head the daughter in law said, ‘doctor he suffers from acidity and takes daonil tablet once in away and when ever he has acidity he has this problem’. Now I had the answer to the problem my friend was having. Daonil is the trade name for an anti diabetic drug called Gliblencamide and he naturally was going in for hypoglycemia [low blood sugar] when ever he took it. But why was he taking this drug for acidity? I asked her. Doctor prescribed it she said. I know there are lots of fools among us doctors but none as foolish as this. I asked her to get the old prescriptions and sent the patient for an urgent blood sugar test and gave him some sugar water to drink after the blood draw. With in the next 15 minutes the patient became near normal.

The blood sugar came as 40 mgs %, low enough to cause problems. The lady came with the old prescription of his previous doctor. The writing was not very legible but I could surmise that the name meant was Diovol [an anti acid drug] and not Daonil and the chemist was happily dispensing daonil when ever our friend developed hyperacidity and that explained why he got the hypoglycemia and also the prolonged periods when he was normal.

It was a relief to all concerned. The patient was put back on his old medication for blood pressure which had controlled the blood pressure better than the one I had prescribed. It was thus a happy ending.

Doctors are known for bad handwriting. But this was my first experience of it causing a near disaster.

Purpose of life.'To laugh often and much; to win respect of intelligent people and the affection of children; to earn the appreciation of honest critics and endure the betrayal of false friends; to appreciate beauty; to find the best in others; to leave the world a bit better, whether by a healthy child, a garden path, or a redeemed social condition; to know even one life has breathed easier because you lived. This is to have succeeded'. [Adopted from Emerson]

Friday, October 19, 2007

Please make me sick

In the beginning years of my practice I have had a lot of trouble with certificate seekers. It is one thing to give a sickness or fitness certificate if the seeker has been my patient but it is altogether a different matter if one seeks such a certificate with out ever being my patient. Most of the certificate seekers who bugged me to no end in those days belonged to this class who wanted these certificates with out having suffered any illness.

Those of you who are not well informed as to how our people live and work the caption I have chosen for this piece may appear strange. But to those of you who are either government servants or working for public sector units or one of those who at one time or other tried to dodge an appearance before an income tax officer or a magistrate or any other such law enforcement agency will readily understand.

Why this class of people? In my country the state runs the show and there fore interferes with all aspects of our living. Except the air we breathe everything else is controlled to a more or less extent by the state. To man these various arms of the myriad departments the government has appointed a large number of people who go by the eponym ‘government servant.’ In today’s India if there is one group of people most disliked, it is this group. This is because the philosophy of governance in this country and the rules of selection are such that the best quality of human resources that is available isn’t used in administering the services. Persons who are thus employed are the ones who make the rules and regulations that govern their service and over years they have seen to it that they have the best of every thing with accountability spread so thin and wide that it is impossible to hold any particular individual accountable for any lapse.

Therefore it should not come as a surprise that they enjoy plenty of leave. If one adds up the various leaves and the government declared holidays it will come to nearly six months! This means 50% of the time they are not working! One would imagine this would be the most satisfied group. Far from it. They are in constant need of more leave. The only option left after they finish the allowed leave is to avail of medical leave. Going by the available records it appears that employees of socialist governments have a higher incidence of sickness. And these governments provide their employees additional leave to take care of when they fall ill. But there is one hitch. The employee who falls sick has to produce a medical certificate from the attending doctor. So the employee in need of additional leave will go to a doctor and entice him to give a medical certificate. It is generally fairly easy to get such certificates. Occasionally however they go to doctors who are unwilling to issue such certificates.

I am one of these and let us see what happens when such a certificate seeker comes to me. He is usually a stranger because my regular patients know they will not get these false certificates and therefore they don’t bug me.

Here comes the certificate seeker. It is 3 P.M. in the afternoon and I am pottering around in the garden at least that is what I call the small patch of land in front of the house. To catch my attention he knocks violently on the gates and forces me to turn around and look at him, ‘Is the doctor home'? he asks, obviously he takes me to be an inefficient gardener. I don’t blame him for this. In my half pants and the faded T-shirt I must have looked anyone but a doctor. Seeing in front of me a fairly fit looking man who obviously is not in need of any urgent medical attention, I tell him.’ Doctor will start working from 5 p.m. and will not see any patients till then.’ He gives me a dirty look and says, ` go and tell him that I want a certificate and it is urgent’. ‘He will not give sickness certificates to fit persons’ I reply. `How do you know with out asking him’? He persists. Now I am forced reveal my identity. I tell him, ` I know because I am the doctor’. He stands there for a while staring at me obviously not believing what he is seeing, then he goes. He must have thought it better any way not to take a certificate from this kind of doctor who does not look and sound sane!

Another man enters my consulting room and sits. I ask him what the problem is. ‘No problem’ he says and is again quiet. Then why have you come? I ask. He gives me a conspirational grin and says, ‘I want a medical certificate’ and specifies 15 days as the time I must make him sick. I am now curious to know why he has come to me, does not he know that I don’t give these certificates? I ask him. Yes sir, I know but I come because factory personnel officer told me to get one from you, then he [the personnel officer] says the management will sanction leave, I refuse to oblige. He goes out in a huff.

Another example. This man enters with a swagger, chest out, top button of the shirt undone with a scarf around the neck in true filmy villain style and demands. ‘Give certificate for one month’. I ask him why? ‘Why, I asked you that is why’ he replies and I refuse, but to make matters clear to this man I take the trouble to explain, ‘ I give sickness or fitness certificates to those who have taken treatment from me but not to others’. His look now became menacing and he shouts at me, ` what do you mean? Are you not a doctor? Do you know who I am; I am the secretary of workers union ’. This was clearly a threat to coerce me to give him a certificate. I pick up the phone and dial the police. He doesn’t expect this. He says` why call the police, what can they do? You think you are the only doctor around? There are any number who will give me what ever certificate I want, you stuff your certificate up your --, he says with a loud shout and goes.

Another certificate seeker enters and requests timidly for a sickness certificate. He appears really in need of this. I told him why I couldn't oblige him. He politely listens and asks,' are not you qualified?' I saw the board in front that says you have MBBS and other degrees in front of your name? Now this man is clearly under the impression that any man who has medical degree must give a certificate false or otherwise and a degree is a passport to commit this offence which he doesn't even know is an offence. I tried to explain my point of view and that doesn't impress him, he had come with fond hopes of easy success. He asks me who else does this, I give several names. He appears happy and gives me a parting shot, 'don’t worry doctor I will not tell the police about your degrees! He obviously is under the impression that as I am reluctant to give this certificate which is the right of a qualified graduate, my refusal means only one thing, my degrees are false and police can take action if he lodges a complaint! And by the magnanimity of his heart he is not doing it and is allowing me to carry on my nefarious unlawful activities!

Another guy comes and puts his demand. I tell him the same story of my not giving false certificates. 'That I know saaar, but my company's personnel officer has asked me to bring it only from you', he said. This was interesting. Why would the company's personnel chief would ask a certificate to be brought specifically from me? Curious I called the guy in question and asked him the reason. Doc, he said,' our managing director knows you don’t give false certificates and one from you will make him believe and I am interested in getting this employee this leave which he deserves though he has used the leave for some other purpose'. This left me speech less and it took me some persuasion to convince him to send the unfortunate leave seeker to another doctor!

In a scenario where doctors keep printed forms where in they only will have to fill the name, illness and the duration of leave required and liberally give these to all and the sundry, if one considers me crazy in the head and not qualified will you really blame him?

This was written before the days of economic liberalization when the hold of government on our lives was worse that it is now

Sunday, October 14, 2007

Health. An ecological perspective.

Two isolated yet related events made me write this article. The first was a tucked away news item in a newspaper which said that the central government has issued instructions that hence forth bamboo is to be preferred to wood in making furniture required for use in government offices. The other was my reading the proceedings of a symposium held during Dec 98 at Rishy valley on environmental problems.

The government order on the use of bamboo was with the intention of saving wood and there by trees which are felled legally or illegally all over the country, to make furniture and fittings, news print and for use as fuel. Vast areas of forest have disappeared to meet this demand. The universal use of tables and chairs and wooden cots in middle class Indian homes is comparatively a recent phenomenon. About 75 to 100 years ago we managed with cotton durries and cushions and used reed mattresses for sitting and sleeping. Use of chairs for sitting has brought in its wake some problems such as stiff back and hips. A sample survey of 50 men and women of middle-class were asked to squat from a standing position and the get up with out support. Most of them failed this test did not come as a surprise. This is one minor example of use of furniture on health. The larger issue of cutting trees on a large scale is much more dangerous. Cutting trees results in washing away of the top soil and silting of our rivers which overflow the banks and inundate vast areas of land with loss of cultivable land and creates swamps that breed mosquitoes and you know what happens when the population of mosquito increases. There is a resurgence of malaria, filaria, encephalitis and dengue fever. There is also increase in the incidence of cholera, typhoid fever and gastroenteritis which is due to contamination of drinking water with sewage which is common during floods.

You hear of inadvertent trespassing of whatever little wild life there is on to human habitat. This is because of destruction of their habitat partly due to encroachment and partly due to destruction of forest cover and disappearance of feeder species of plant and animal life. Bamboo furniture is not going to solve the problem. Large-scale cutting and use to make furniture out of bamboo is also not the answer, as bamboo groves naturally growing, is a link in the ecological web of the forest. The ultimate solution lies in changing our life style and going back to way of our forefathers. Our homes then will not have to have wood based products. Metal can be a better substitute to wood and may be, less ecologically damaging. Destruction of plant cover that includes forests has serious long term economic and health consequences.

Rendering the land fallow will mean desertification with no economically feasible agricultural activity with the resulting less grain production and starvation. Malnutrition related illnesses are very common in our country. Malnutrition invites all kinds of illnesses including that major scrounge, tuberculosis. To sustain minimum nutrition standards we need to increase the grain production. We have so far done this by taking recourse to introducing hybrid high yielding crops with ample supplementation of the soil by chemical fertilizers and keeping the pests at bay by using liberal doses of pesticides. This has proved a very shortsighted success and has had disastrous long-term consequences. These pesticides and chemicals have already got into our systems and the result is that we are seeing an increase in the incidence of hitherto unknown illnesses and an increase in the incidence of cancer. The land enriched with chemical will not sustain plants for long and we will be in for a major disaster if these practices are continued.

The only viable solution is to use organic natural manure for which we need animal and plants and above all abundant supply of water. Many parts of our country that once sustained verdant plant and animal life is now fallow. Large areas of such land can be reclaimed not with western technology but by following methods indigenously developed by pioneers. Efforts of a single man, Rajinder Singh has brought about an agri revolution to 650 villages in Rajasthan. What he did, million others can repeat. He simply observed the natural flow of rainwater and built check bunds to slow the rate of flow and made this water collect in small and large percolation tanks. This made the water table go up and charged the wells which were hither to dry. This primary phenomenon of availability of life sustaining water makes all the difference to the lives of our people from one of poverty and misery to one of at least minimum sustenance. This will also arrest the flow people to town and cities in search of livelihood. Rishy valley is another such example. What was once barren land of dust and rocks has been successfully greened with immense economic benefits to the villages around. The same result can be seen by the work of Anna Hazare at Raalgoan Sidddi in rural Maharashtra. When once a villager becomes self sufficient in food, his and his family's health improves and he will listen to what we talk about family planning, sanitation, nutrition etc. An empty stomach resists all attempts at progress. Thus health is linked to nutrition which is linked to crops which are linked to the availability of water which is linked to plant cover which is linked soil retention which is linked to us not cutting trees.
All of us will be forced to realize that natural resources does not exist for man alone and this manipulation of nature that is going on world over to serve the interests of humankind will only invite disaster. When once this simple truth is understood by us and our governments, then humans will start repairing the damage to the environment, reduce their consumption and nature may forgive the injuries that she has so far suffered. If this does not happen, the humans are on their way to sure self-destruct.

This article was written ten years ago and is still relevant.

Sunday, October 7, 2007

The fever that never was

Those were difficult days. Difficult in more than one sense. Professionally, there was a trickle of indifferent patients with an occasional house call thrown in. For most of these, I was either the second or third choice physician. Who would come to a young man just out of medical school, working out of an unimpressive single room and who for most of the time was found either sitting idle or reading the day’s newspapers? Most of them were also drifters whose usual mode of payment was a promise to pay tomorrow. Neither that tomorrow nor the patient would ever come.

Such was my state when I was called to see an eight-year-old boy at home. House calls those days were welcome as they brought in much-needed additional income. I went with the mother to see the boy. I found him in bed, looking fairly OK except for a fever of 103 degrees. After the usual examination and assurance that all would be well in a couple of days, I was about to leave when a young voice behind me asked if I would like to wash my hands. A bright and pretty 12-year-old stood with a soap tray and a towel near the wash basin. More to accede to her request than for any real need to wash, I washed my hands and returned home. After two days, the call came again. The boy continues to have fever and would I mind coming again to see him? Racking my brain as to what could be the cause I rushed to his home. Those inexperienced days only the worst and the rarest illnesses would come to my mind and by the time I reached his home, I was prepared for the worst scenario. I found him sitting in bed reading a comic. I examined him, found everything normal except for the temperature which was now 102 degrees, and lower than last time but high enough to cause worry. I thought it was time to get a few basic tests done to find out the cause. I asked the mother to get these done and after the ritual hand-washing, ably assisted by that charming sister of the patient, returned home.

The next two days were agony. It is every doctor’s hope when treating these cases that the fever would go away and peace would prevail. This is what I was expecting when the mother came to see me in my clinic. I went through the sheaf of lab reports she had brought. They were all normal, and she said, ‘Doctor, my boy still has fever of 102 degrees and would you mind seeing him?’ With growing desperation, I reached his home. The patient was nowhere to be found. A frantic search in the house did not produce the errant patient. Enquiries revealed that the boy was playing cricket in the next street. A sick boy with a 102-degree fever of unknown cause playing cricket! That too in the hot afternoon sun! Blasphemy. My heart sank and I sat rather heavily on a nearby chair. The ever-present assistant brought me a cup of merciful water to drink.

The mother and daughter combination succeeded in bringing the wretched boy home and forced him to lie down on the bed. I examined him. He appeared to be in fine fettle except that he resented this unwarranted interference with his cricket. I took his temperature. It showed 102 degrees! I stood there looking at the thermometer and wondering what to do next. I heard the voice of the sister asking me, ‘How do you know that the thermometer shows the correct reading?’

Yes how? I quickly washed the instrument and thrust it under the tongue of the young girl. After a minute’s anxious wait, it read 102 degrees!

It took a 12-year-old girl with an enquiring mind to spot the problem. It was such a relief to know that the boy had no fever that I almost forgot to thank his sister and congratulate her. I asked them to buy a new thermometer, discharged the patient to resume his cricket and with a dancing heart, returned home. Since that episode the young lady and I have both aged. She went on to do her graduation, post-graduation and has settled abroad. We have kept in touch; when she visits me, I see in front of my eyes a chirpy 12-year-old who taught me the home truth that common sense and an enquiring mind is often more important than knowledge in one’s professional life.

Thursday, October 4, 2007

How to choose your doctor

I am sure most of you have faced this problem at one time or the other. For many of you who have the benefit or otherwise of a regulated health service where the decision is made for you and you really have no choice but to go to particular doctor. There are others who are living in a free market economy with the government run health services being what they are [like in India] have no choice but to select a personal physician in the immediate neighborhood. How does one go about doing it? I asked several persons some time ago and also some of my new patients why they chose me. The replies narrated here, I hope will make interesting reading.

Many said they asked their friends for a referral. The friend who recommended, if knowledgeable as to the doctor’s ability would have done you a service. God forbid, if he is one of those who believed in the dictum that there is a treatment for every itch and stitch in your body, then you would get referral to a doctor who is fond of medication and you will end of getting treatment for any and every complaint of yours and may be get investigated from head to foot.

The other common source of recommendation is the neighborhood chemist, the mister know all of medicine. This man can make or break you with his advice. If he likes a doctor because he gets a lot of prescriptions from him, it is likely that you are dealing with the type of doctor mentioned above. Sometimes he can be quite perceptive and may recommend the right type. But most businessmen chemists have no idea as to judge the merits of a doctor.

Another source is your previous doctor. This occasionally works. But here too, the recommendation is based on personal friendship rather than the knowledge of one’s professional efficiency. I know of a well known orthopedic surgeon of the city who recommended a very mediocre physician to his own cousin!

The other rare method is when you are going for a walk, you see the doctor’s board and you decide to pay him a visit. This may or may not work.

Thus as you can see, none of these are foolproof. Most patients, however after a period of trial and error, get the type of physician of their liking sooner or later, but the example of how two of my patients chose me is interesting.

She was a middle aged woman who dropped in with complaints of aches and pains and also to get her blood pressure checked. After the examination and consultation, she made a strange request, ‘Doctor, will you please check my pulse.’ I thought she wanted me to count her pulse properly which I had not done because while taking her blood pressure I had an idea of her pulse rate too. But I felt it to be a reasonable request and I had nothing to loose but a few extra minutes. So I proceeded to count her pulse. Normally the radial artery is located on the outer front aspect of the wrist and easily felt. But in this patient I couldn’t get the pulse. I groped around for a few minutes and felt the other wrist with the same result. No pulse! I then went up and felt the brachial artery where the blood pressure is taken. Presto! The bounding pulse was felt! I counted the pulse and made sure that the blood supply to her hands was alright. I told the lady that both her radial arteries are placed under the tendons and could not be felt and warned her to tell her next doctor this fact. She smiled and said, ‘there is going to be no next doctor, you are my doctor’. She had gone to three doctors before she came to me and all the three had failed in this test! She knew of her anomalous arteries and has been using this as a test to test the efficiency or otherwise of the doctor. According to her this is a foolproof test and those who passed this test have turned up to be good doctors! Though a bit put off by this way of choosing I could see some merit in her method.

The other person’s explanation was straight forward. He followed his doctor father’s advice. ‘Go to a doctor whose patients waiting area is never very full or never fully empty. The person whose waiting area is overflowing will not have time to examine you properly and the other fellow who has no patients is obviously no good’. Fortunately he found my clinic fulfilling these two criteria on the day he sought my help!

Some aches are private and silent
Some open and obvious
Some need to be told and shared
But all must be endured

Sunday, September 30, 2007

Take my fever out

When that middle-aged woman brought her teenaged son for treatment, little did I realise that I was in for another lesson that there is more to practice of medicine than mere diagnosis and treatment. The boy had fever for some days and the mother was naturally very anxious. I suspect not just because of her son’s illness but also because I was not her usual doctor. After examining the boy and finding nothing wrong with him, I thought it must be one of those viral infections, tried convincing the mother that all would be well in another two or three days and sent them home.
The lady returned three days later with a very ill-looking son. To prove the point, the boy retched violently and vomited all over. The mother was so anxious and jittery that she would not allow a proper examination with her constant chatter. She kept telling me that I should give him something stronger than the last time, preferably a powerful injection. At this point, I did not want to have anything to do with this duo and thought this combination of a highly-agitated mother and a very sick son the cause of whose sickness I had not a clue, advised that the boy be taken to a hospital. We doctors who run solo practices in the community often resort to this when stumped. Off they went to the hospital.
That is not the end of the story. Three days later, both returned, only now the roles were reversed. This time, the mother was sick and the son was the escort. The symptoms were exactly the same as that of the son’s and my suspicions of a viral infection were thus confirmed. The mother’s attitude in the new role of the patient was worse than when she came as an attendant. Though she was miserable because of her illness, she remained aggressive and I suspect there was also the feeling that I was incompetent.
This was confirmed when she made a strange demand in chaste Tamil, ‘Doctor, you please take some blood out of my body and my fever will soon go, this is what they did to my son at the hospital; the next minute his fever vanished’ This left me speechless. A blood draw for tests coincided with spontaneous remission of her son’s fever and this lady was demanding of me to do the same!
Her experience against my useless knowledge! Needless to say, she stopped coming to me thereafter. Why should she? When according to her I did not know the simplest of procedure to cure a fever? My explanation to the contrary must have fallen on understandably deaf ears.

Little I know why
He is ill and unwell
He thinks I know
The art of medicine
The blissful ignorance

After a particularly difficult day

In the robes of ochre and orange
With a smile spread huge and wide
Exuding sympathy and goodness
Sat the Dalai, saintly and simple

After an encounter with Dalai Lama

Thursday, September 27, 2007

Hot tea and chest pain

Mr Ramesh is a good friend and also a patient, a dreadful combination. He came to me complaining of chest discomfort and insisted that it was due to drinking scalding tea that morning. Ignoring his diagnosis, I started asking him the usual questions we doctors ask to exclude pain due to heart disease. Where was the pain, did it go up to the neck and down the arm, was there any sweating, how long did it last, etc.

When I was asking these questions, he sat there giving me a bored look. I knew what was going on his mind. ‘I came here with some trivial problem and this fool is asking me these stupid questions. He looked at his watch twice in those few minutes I spent trying to get a proper history.

Despite his protests, I did a cardiogram. The tracing showed severely compromised blood supply to a portion of the heart. I explained the gravity of the problem, gave him a note for hospital admission, called the cardiologist friend of mine and sent him on his way.

The same afternoon I went to the hospital to see him. I went directly to the coronary care unit. I did not find him there. Then I went to my cardiologist friend to find out what had happened. Before I could open my mouth, he asked me, ‘where is your friend?’ Having made sure that he was not in the hospital and worried, I called his office only to be told by his well-meaning secretary that he was fine but in a meeting and would I mind calling him after an hour or so? The knowledge that he was alive was reassuring but all the same the worry was no less.

I went to his house to apprise his wife about the serious nature of the problem. I found her having her prized afternoon siesta. After I finished my tale regarding her husband’s erratic behaviour, she gave me a splendid piece of advice. ‘Doc, you always worry too much. He gets these pains after drinking hot tea. You have advised him to stop this bad habit [I did not remember this piece of expert advice having been given] and if he does that, he will be OK, you wait and see!’ I requested her to please send her husband to the hospital with out wasting any more time, drank the cup of tea which she made and returned home thoroughly depressed and worried.

Are you wondering what happened to my friend? He didn’t want to go to the hospital, especially now when all the pain had gone and he felt very good. He made an uneventful recovery. His subsequent ECGs showed a small scar and his treadmill test came back negative. According to his wife, he gets no chest pains now because he has stopped drinking hot tea. No credit whatsoever to the poor me who spent several sleepless nights and anxious days looking after an unwilling and, I suspect not very grateful patient! Even now he says he takes the medicines to keep me in good humour!

This true life story I wrote several years back. This episode illustrates the fact that many patients do well despite us doctors.

Of the many pleasant sounds that go unheard
Of the many magnificent sights that go unseen
Of the many unfelt emotions
That most of our lives are made

Sunday, September 23, 2007

Drugs, doctors and education

The pharmaceutical scenario in our country [India] can be described as an ocean full of fish of which only a few are edible. The medical profession can be compared to a skillful swimmer who knows which of these are edible but will not always make his patient eat these. The patients are those who are ignorant of the ocean and the fish and keep eating inedible or useless fish because they don’t know the difference.

There exist a huge quantity and number of worthless or drugs in the market and most of them sell. The famous or as some wont to say infamous Haathi committee which recommended many years ago, one hundred odd drugs as essential for the practice of modern medicine has been given a descent burial as is the fate of most of such honest reports in our country.

One estimate is that there are more than10, 000 drug formulations in the market and more than 1000 drug companies peddling these! I may not be very accurate in my figures but they will give you a general idea how many players are involved and what a powerful lobby they constitute.

Let us now consider the common problems faced by our people. Anaemias with or with out vitamin deficiencies, infectious diseases of all types, diseases like high blood pressure, diabetes, heart disease, asthma, cancers, various pains and aches form most of these. All these can be adequately managed with drugs mentioned in the recommendations of the expert committee mentioned above. Let us take one example that of tonics. I don’t know how this word came into common usage by the patients, industry and the profession, but on this one word depends a multi billion rupee industry. Tonic is something that is supposed to pep you up or will make you feel stronger and it is a common experience with doctors to be asked by a patient to prescribe a tonic or give one. Will our friend the doctor say that there is no such a thing as a tonic that gives the patient strength and risk losing a patient? No fears, most professionals, with honorable exceptions, oblige the patient with one.

I must recount a personal experience here, years ago on a visit to my grand uncle I found him taking two spoonfuls of a famous brand of one such use less tonic daily. Knowing that he could ill afford such wasteful expenditure I felt compelled to tell him so. He told me off and said in no uncertain terms the efficacy of this tonic and that he owed his longevity to the continuous consumption of this over 40 years. The old man is no more but the brand is still alive and healthy and millions of Indians must be swearing by it!.

If these are medicinally useless then why patients take them? When they say they feel better are they lying? Sadly no. In medical parlance there is a term called placebo. Placebo is something that you give will result in some benefit even though it contains nothing aimed at such a benefit. The profession and the industry are dependent more on this placebo value of most of the formulations than the real drug content.

It is known that, that wonderful organ brain produces substances called endorphins that are literally like morphine in their chemical structure. Morphine is an opioid derived from poppy plant and has pain relieving and pleasure giving properties. Endorphins do the same. If given by doctor to a believing patient with a strong suggestion that he will be OK, the brain will release these endorphins and the patient will feel better. But the same result can be achieved by giving coloured salted or sugared water at a fraction of the cost! Only the patient should not know, and then he may not produce any endorphins!

Treating many of the major health problems of the nation is not difficult. Let me take two examples to illustrate my point. Hook worm infestation and the resulting anemia are responsible for lot of ill health especially in rural India. To eradicate the worms will take single dose of a wormicide and daily tablets of iron for two to three months. The cost of whole treatment for three months will be less than 100 rupees. I regret to say that usually the patient ends up paying much more than this because of his faith in tonics and doctors not educating the patients. Not long ago two drugs were available which were cheap and effective against iron deficiency anemia. One was called ferocelate, which contained enough of iron, and 100 pills would cost less than 5Rs and number of doctors used this with benefit on the poor patients. Today this brand which was selling well was bought over by another company and is being sold 20 times the cost. Another useful formulation was called macrafolin iron B12 this was also available around 10 Rs for 100 tablets. Today it is no longer available in the market. These two examples are sufficient to illustrate the social responsibilities of our leading pharma companies. Where as there are hundreds of compounds attractively packed containing the same iron and vitamin selling at exorbitant rates. Doctors prescribe, pharma companies sell and the poor sucker of a patient is forced to buy.

This brings me to the relationship that exists between pharma companies and the medical profession. With few honorable exceptions this is a perfect example of you scratch my back and I will yours. Doctors who don’t prescribe or dispense don’t impress the patient. The patient is like the devotee who goes to the temple and expects the priest to give him some thing as tokes of god’s good will. It may be some thing to eat or drink or it may be an offering of a flower. So is with the doctor. A patient will not like to return empty handed after consulting the doctor. On this single fact of patient psychology a whole industry of worthless drugs has been built up.

Pharma companies adopt the latest selling gimmickry to entice the doctors to prescribe. They send their representatives to visit, shower the doctor with gifts organize dinner/cocktail events with the ostensible purpose of introducing new products and even paying a leading or important doctors, travel [holiday?] expenses. What about doctors? Do they, who are supposed to belong to an exalted profession, respond to these overtures? I have hardly come across any one who refuses these goodies.

Doctors have to be educated and continually have to update their knowledge and skills. They will have to attend continuing medical education classes every now and then. Who pays to organize these? You think doctors pay for their education? Have no such illusions. It is usually the pharma companies who pick up the tab. occasionally medical organizations do attempt and charge a registration fee but this is enough to cover only part of the expenditure.

At present a sorry state of affairs exists. Even good [ethical] doctors are dependent on sponsorship to get educated! It is a shame that a simple luncheon meeting or a tea meeting attracts a small number where as a cocktails and dinner [education] evening will attract a huge number of hungry and thirsty doctors. You normally don’t bite the hand that feeds you. And the doctors who attend these meetings [eatings as I call them] end up prescribing the product. Here I must hasten to add that not always the promotion is for a worthless product.

Can't then doctors organize programs with out the help of these companies? Of course they can but it will mean spending money and when there is some one else to do this, which fool likes to? They have so gotten used to getting sponsorship it has become difficult to organize any meeting with out the help from one or other of these companies.

There are few doctors who can with stand this pressure. On the one hand from patients who clamour for drugs and on the other this kind of salesmanship by the drug manufacturers. The result is a sea of drugs in which the doctor and the pharma companies enjoy their swim and the poor patient drowns.


Robert Trent Jones, popularly known as Bobby Jones was an all time great golfer. His playing carreer was cut short because of Syringomyelia which left him crippled. At the 1971 Augusta national, an old friend met him and couldnot hold back his tears. Bobby told him,' now, now, we won't have that, we are supposed to play the ball as we find it'
An inherent part of any sport is a set of virtues that mirrors all the qualities desirable in the society. Integrity,honour, respect, rules and discipline, to name a few.

Saturday, September 22, 2007

Two drunks

It was later than my usual closing time that evening. There were no patients waiting and I was thinking of closing up when I heard a commotion and sounds of chairs overturning in the waiting room. I went out to investigate and saw this twosome, one supporting the other, obviously drunk, vainly trying to set the chairs upright. I asked the lesser of the two drunks, ‘What is the matter?’ ‘John Anthony Gonsalves,’ he replied.
I said I wanted to know what the problem was and not his name. He now pointed to his friend and said, ‘this is my friend, he in trouble, he want help.’
I asked him, ‘What kind of help?’ With a drunk you never know. He said, ‘Saar, he drink too much, vomit, vomit, vomit, and I tell him, don’t worry, I know good doctor and I bring him here.’ When dealing with drunks, the best policy is to talk as less as possible. I told him to put his friend on my examination table. With my assistance, he managed to half-lift and half-push him on to the table. No sooner was he on the table; the friend curled up and tried to sleep. I tried shaking him awake and as an opening gambit, asked, ‘What is your name?’ Not getting an answer, I asked Gonsalves, ‘What’s your friend’s name?’ At this, Gonsalves went to his friend, shook him rather rudely and shouted into his ear, ‘tell doctor your name’. There was some mumbled reply. Gonsalves turned to me and said with a grin, ‘saar, he says his name Palaniswamy.’
I wondered what kind of friendship this is when one did not know the other’s name. Or is Gonsalves so drunk that he does not remember? I was now in a hurry to get rid of this drunken duo. I went and asked the sleeping form of Palaniswamy, simultaneously shaking him to get his attention. ‘Where is it hurting?’ At this, Palaniswamy’s left hand slowly moved down and rested on his upper abdomen. I pressed hard several times in that area but got no response from the drunken patient. I surmised that this must be alcohol-induced gastritis, which would settle with a few antacid tablets and a few days of laying off alcohol. I wrote out a prescription, gave it to Gonsalves and told him that his friend must not drink. He said, ‘Yes saar, drinking is bad, he drink too much, he must stop this bad habit.’
‘What about you?’ I could not help asking. ‘I saar, drink full bottle, nothing happen. I no chicken like this man here,’ he said, pointing to the supine and snoring form of Palaniswamy.
I was not interested in Gonsalves’ capacity to imbibe alcohol but only in getting rid of them. I told him to take his friend home. Gonsalves took the prescription, thrust a few notes into my hand and saying, ‘saar, I bring auto’. By now it was past 10 pm and I had this additional worry of keeping guard over this unknown drunk till his friend and transportation arrived.. What if this Gonsalves chap did not turn up? I decided to wait for 15 minutes and then drag the drunk out of my rooms and prop him up against the wall outside. As and when he woke up, he would be able to find his way home. To my relief, I heard an auto rickshaw stop outside and J.A. Gonsalves come tottering in. Both of us carried the inert form of Palaniswamy to the vehicle. I heard Gonsalves saying, ‘thank you saar, you are a good man, Saar’. Gonsalves had paid me three times my normal fee and I thought the hour spent with these two drunks was after all worth it.
I closed up and went home.
Two days later, a new patient came in to consult me. I felt I had seen him before but could not place him. I asked him. He said, ‘saar my name Palaniswamy. Doctor so soon forget. I came other night, doctor give me medicine, I now alright’. My friend was now cold sober but how did find me? I asked him. He said, ‘saar, your address on the medicine chit [prescription].’
I asked him, ‘Why have you come? Are you still unwell?’ ‘No saar, I very well but want to know name, address of man who bring me here that night.’ Surprise again. He does not know his good friend’s name and address. I said so. ‘saar,’ he said, ‘he no friend, he meet me at the arrack shop, we drink too much, I vomit, he helps me yes, but saar, he pay for drink my money, pay you my money, pay auto my money and he go away with all my money.’
Now I knew his purpose of asking me. It was to trace his ‘friend’ through me and if possible recover some of his money. I told him that Gonsalves was a stranger to me too. His face fell. Looking at him, I felt really sorry for him and gave him the excess money his friend had given me. He brightened up a bit, and saying ‘thank you’ over and over again, went on his way.

This incident occurred 30 years ago. Those days I had another office some 6 kms away from my present premises and worked long hours. There I used to see these types.

Thursday, September 20, 2007

Muniappa and Madiah.Modern Ekalavyas

Our government since independence has in place what are called reservations for socioeconomically backward and very backward classes of people. The very backward are given a special name. They are called scheduled classes. Despite the privileges given, most of these remain backward is another story. To corner these privileges of reservation several socially and economically advanced communities are vying to prove that they are indeed backward. I don’t think of any country where in this kind of negative affirmative action is being tried!

15 years ago the golf course I go to play was being built and we had a number of labourers belonging to this scheduled caste. We did not have a practice range then and would use a secluded spot to practice. The children of these labourers would do duty as ball pickers at a time and age when they should have been in school. As they earned some money and were occupied, the parents who worked on the course too were happy. These little boys in the age group of 10 to 12 years were a lively bunch and I was one of those with whom they were friendly with. Soon after my practice session, few of them would hitch a ride in my van till their hutments or some times up to my home which was couple of kms away. When they came home they usually returned after having some snack or the other, courtesy my wife.

Two of this bunch were Madiah and Muniyappa
Living on the golf course and being with golfers, many of these boys took to golf despite lot of difficulties. Madiah and Muniappa also took to golf and by the time they were 20 they started winning tournaments locally. Out station travel was a luxury they couldn’t afford and some of us sponsored them in the first couple of years to the extent we could. They lived frugally and in the next couple of years their performances all over the country made people sit up and take notice. My club started defraying their travel and stay expenditure and now their name is a fixture in the Indian circuit.

Though blood relations [cousins] they were contrasting characters. Madiah was outgoing and had an attitude bordering on being reckless, Muniappa is self-effacing and quiet. On the course while playing both had no fear and had nerves of steel which our gentleman pros lack. I remember when Madiah won a motorcycle for a hole in one in a tournament at Pune, the ecstasy and the sheer pleasure in his voice when he phoned to tell me the good news.

They were going great guns when tragedy struck Madiah. He died 3 months ago in a motorcycle accident off Hosur while on his way to his village. People who saw the mangled remains felt he was reckless when he drove. I felt he used his motorcycle the same way as he used his one wood. Sheer reckless abandon. He died as he lived. He was only 27.

I met Muniappa soon after and he was disconsolate and couldn’t find words to express his grief.
He is doing well and has a standing of 8th rank in the Indian circuit and he told me that he would like to play Asian circuit if he could find a sponsor.

He has no glamour of a Sania Mirza or M.S.Dhoni. But for persons like me, when I see him play and the adverse life conditions he has overcome, he is better than any sports personality I have known.

Now you know about him, and would want to sponsor him or know any one who can afford to do so, please get in touch with me.

From the beginnings humble,
Up they came to shine
Write and read they knew not
But hit the ball they did
High and long
Touch the ball soft and slow
Smile and glow they did
It was all but brief for one of them.