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.

Wednesday, September 19, 2007

My thoughts.Screening for disease

Two days ago I dwelt on the matter of doctors/ institutions performing unneccessary tests and the reasons why they do these, at least why they do in this country [India]. I also said that screening for disease is required and it should be selective. Let me elaborate on this a bit. Let us presume that a woman has a history of mother or her [mother's siblings] having had breast cancer.Then it becomes mandatory that this lady needs screening for breast cancer through out her life.This includes 3 monthly self examination of breasts beginning at 20 years and a mammogram from the age 25 owards [follow the laid out protocol as to the periodicity, older the patient more frequent the screening]. Let me give another example. A smoker needs a chest xray done every year even though he remains symptom free.The risk of radiation in him is too small compared with the risk of getting lung cancer. A person who has a strong family history of diabetes, hypertension, heart disease, cancer colon also needs to be screened.
What about this bogey of blood lipids and statin use? Blood lipids when abnormal needs to be monitored and treated with statins. But on routine testing if a person is found to have normal levels of lipids he needs no furthur testing for next 5 to 10 years for lipids. Same is true for blood sugars.
Often patients pressurise doctors to do these tests. Doctors should become educators and should be willing to spend time with patients. But where is the time? This brings me to another topic of waiting time at doctors chambers.

Recently I was asked to comment on an article criticizing the ways doctors work in India. The author was very critical of the way the patients were taken for granted and he had suggested ways to improve the patient management methods. He was all praise for the system that is being followed abroad. Though biased he had made several valid points. I thought it is worth bringing these to the notice of our readers

Patients waiting time. In most busy practices this is common. A full waiting room can be stressful to the patient and the doctor. It may give the doctor confidence and satisfies his ego, but to the patient it will mean stress filled boredom in addition to avoidable waste of time. It is also unhealthy for the patient and attendants as it is ready made for cross infection. Is there some way we can lessen this rush? The author goes to great lengths to describe the advantages of appointment system and tells us that it is a win win situation. Let me share with you my experience. I see patients by appointment for two hours every day. Many don’t keep the appoimtment.The reason given is forgetfulness, being out of station or simply that he got better and therefore didn’t feel the need. The other less told reason I suspect is that he has gone elsewhere to seek attention. Basically our patients are not captive; in the sense they are abroad where they will have to see one particular doctor as the health scheme they are members of dictates it. In such a system it is not difficult to follow the appointment system. Here we also have a large number of acute cases who demand urgent attention, how would one accommodate these which form at least 50% of our practices?
One way out is to see all chronic cases and follow up patients by appointment and others as and when they come at a given time. Feasible you think?

Sits up front at a meeting
Looks keen and interested
Laughs and claps loud
Knows how to suppress a yawn
Asks questions and also answers
Doesn’t know what is right and what is wrong
Is a doctor long past his prime.

Wednesday, September 12, 2007

My thoughts

I am a practicing family doctor of over thirty years of experience.I am fond of writing on matters related to medicine and people. I know, the modern day medicine suffers from lot of deficiencies and often I think about these and want to share my thoughts with u out there.
That is why I have called my blog, 'my thoughts'