Thursday, November 27, 2008


The city of Bombay[Mumbai] is under attack by a group of well armed organised terrorists. Why would a country like India, where people belonging to different religeons live peacefully together and has done no harm to others, be the subject of this kind of mindless violence? What this world is coming to? I feel sorry for the young who have long lives ahead of them and wish want them to echew hatred which breeds this kind of mindless violence.

Such a waste.

Mistaken Identity

I have always kept records of my patients. The records are with the patients unlike other doctors who keep records with them. I make the patients keep their records for two reasons. One it helps me to conserve space in my little clinic and spares me the bother of searching for the file when the patient visits me. Those of you who have no knowledge of the working conditions here need to be enlightened. Unlike other countries most of us have no receptionist/secretary/recordkeepr/assistant that takes care of these matters. Here, in most solo practices the doctor is all in one. He is the baby sitter, bottle washer and cook cum housekeeper. At best he may have an assistant to help keeping the patients to order in the waiting area and protect the doctor from unforeseen problems. Not unlike a bouncer in a bar [I am exaggerating this a bit]. Records with the patient also helps the other doctors because our patients go shopping form one doctor to the other and the records help the other doctor in not committing the same mistake that I probably did and other details of past illnesses and medications that he has had.

This also has several disadvantages. One major one is that patients need training to bring their records with them each time they come. In a generally indescilplined population such as ours it is tough to get them to do it. In some cases they are just incorrigible and it is impossible to get these to maintain records. But it is to my credit that most of my regulars do maintain records and it is a pleasure for me to see case records dating back to mid seventies! Some do bring their records but not always. There are reasons. Misplacement and no time to search or they would have come from office and have not gone home to get the records are common explanations for not bringing records. But one who did exasperate me by not only in not bringing records but also by the regular irregularity of follow up is Mr. Jayaram.

Jayaram is a chronic asthmatic and those days, asthma was one illness which kept us literally on our toes. The maximum number of house calls and night visits were made to see patients with acute asthma. If I remember right the only inhaled drug available then with some effect was Cromolyn. Inhaled steroids which have virtually eliminated acute asthma in my practice now were yet to make their advent thirty years ago. Mr. Jayaram who is now sixty five is so well controlled that he rarely visits me. Those days he had to see me regularly and I had to meticulously titrate the drugs to keep him free from distress. But regularity was not a word in Jayaram’s dictionary. He chose his day and time which was when his wheeze became worse. When he came with breathing difficulty I used to get wild with him. The reason why I wanted him to come regularly was precisely to avoid this distress. I used to administer injection of adrenaline under the skin ever so slowly and the results would be dramatic. The patient got immediate relief but also would have severe head ache, his heart would race and often he would vomit some times on the nearest person which was I. Though I hated using this drug I used it often enough and my friend Jayaram was one of these recipients. Despite my telling him that he can avoid these if he came in for regular follow ups, he persisted in being errant. Worse, he always had a valid excuse. I held my abuse at bay till the distress was relieved and then would let him have it. Those days I was called with some justification, ‘a good doctor with a short fuse’. With age and experience and mainly due to my forgiving patients, I have now become a doctor with longer fuse but I am aware that the fuse still remains.

Jayaram has other interesting characters. He was always smiling. Even when he came in distress he had that smile. This smile occasionally got on my nerves. When I am discussing some important issue I don’t want my patient to be smiling vacantly at me. He was always well dressed in contrast to my wayward dressing methods. He sported a goatee and a moustache which were confluent and in addition had bushy eye brows. All this combined gave this small time contractor, the looks of a distinguished college professor.

So, when he came again with one of his acute attacks and after the tiresome administration of adrenaline and relieving of his attack I asked him for my file. His face was blank. He said,’ what file? ‘The file with your records which you are supposed to bring with you’ I said. ‘You gave me no file’ he said. This irritated me no end. I wondered whether his asthma attack has made his memory lapse or is he feigning? I, after numerous encounters with him could not put this beyond his capabilities. I insisted he does have the record file and has forgotten to get it with him and is now pulling a fast one on me. He said,’ really doctor, you have not given me any file, last time I came you gave me this paper’. He showed me a note which had a prescription and his name. The way he said this made me take a closer look at him. This was not my old friend and tormentor Jayaram but his look alike! Except for a few additional greys in the goatee everything else was the same, even the voice. I looked at the prescription, the name read Charan Shukla. This north Indian gentleman bore an uncanny resemblance to my errant friend Jayaram and has suffered from the same illness. The reason why he did not have a file is that I had not started one as yet in his case. How is it that I missed the resemblance last time he came over? I apologized and told him of the resemblance and wondered how I could have missed it last time he had come. He said, ‘Doctor I have grown this beard since the time I met with you last!
So a clean shaven Shukla looked different from the bearded Jayaram and with the beard they were virtually same. My apologies were well accepted and a grateful and relieved Shuklaji took my leave.

Few days later Jayaram arrived once again in an acute attack of asthma. Before administering any drug I asked to make sure that he is not Shukla, even in his distress he gave me a worried look and said, ‘ sir don’t you know me? I am your old patient Jayaram and not Shukla; I have come here so often’. Thus confirmed that there is no mistaken identity, I asked him to show me his file [after giving him the dreadful adrenaline]. As usual he had mislaid the file and did not know the dosage details of the medications he was currently on. His bashful grin raised my heckles. I gave it to him and told him to find another doctor and stop bothering me hence forth. He stood there for some time looking at me. For a change his grin had gone. I would not talk. He waited for a while and went out. I thought to myself good riddance, I don’t have to deal with this fellow any more.

I got busy with the waiting patients and an hour or so later, finished the morning surgery.
‘Sir, may I come in’ my friend and tormenter Jayaram was at the entrance. He asked me,’ sir are you still angry?’

Looking at the grinning face, I could not help but laugh. He promised to come on time next time and surely would bring his records without fail.

I don’t have to add that he remained as errant as ever. Now he rarely gets severe attacks and takes the inhalers regularly and at 65 his health is better than when he was 30, thanks to the advent of inhaled corticosteroids.

Sunday, November 23, 2008

Dress code

Why do we dress as we do? Is it just to attract attention or there is something more to it than that meets the eye? Is attracting the opposite sex the sole motive? If that is so nature would not have made men and women different. So dress must have a meaning other than mere sexual attraction. My own theory is it has to do with hierarchy and expression of power. Well dressed person [well dressed has different connotation in different societies] attracts attention. One can go to any extent to get attention. One can deck himself with brightly colored clothing however ill fitting it may be; deck himself or herself with heavy jewelry. May even have attachments like bright feathers, caps, hats toupees and the like. Medieval rajas had a decorated umbrella over their heads and sat on ornate thrones. The desire to dress elaborately and thus be identified as different and important is not confined to the rich and the powerful. It applies even to the clergy. One has only to look at the way the clergy of different communities dress to see my point.

Are they comfortable in their preferred dresses? Surprisingly comfort is something that is often practiced. I asked a consultant friend of mine who was in a full suit on summer morning, the rationale behind his attire. His reply was that without his suit he feels naked! I would, given a choice, rather be naked than wear a suit on a hot Sunday morning. Our beurocrats too like to be suited; that they stick out like sore thumbs in most of the gatherings is another matter which does not seem to bother them.

Doctors and white coats are synonymous. Add a stethoscope strung around the neck you have the complete uniform. This is ostensibly to ward off dirt and germs? Or is it for the patients to identify the class? For many the white coated figure of the approaching doctor causes extreme anxiety bordering on fear.

Now those of you who are my patients know why don’t wear a white coat.

Wednesday, November 19, 2008

Great leader

Today’s newspaper carried two news items of significance.
One was the chaos, a political party’s election jamboree which attracted over 200,000 sons of the soil from different parts of the state, caused. These sons of the soil were ferried to the venue located in central Bangalore in every available forms of transport, mostly hired busses and trucks. A small percentage came on their own out of love for their political leaders. For most it was a sort of all found holiday of sorts. The vehicles they came in were parked anyhow and everywhere. There was absolute anarchy on the roads of Bangalore and for many it was a nightmarish experience. School children were stuck on the roads without food, water, toilet facilities for over 8 hours and many had to walk back home. Naturally many complained. The leader of these sons of the soil party has this to say by the way of response. ‘Those who complain for this one day’s inconvenience are those who don’t go and vote and the children of these non voters suffered for one day, whereas the sons of the soil who came are the ones who vote and their children have to walk many kilometers daily to the school!’ You can surmise what is in store when the leaders of these sons of the soil come to power. They will make all the children of these non voters walk to the school, several kilometers every day!

The second was a huge half page advertisement with a huge photograph to remind us of another great leader who is no more. It is her birthday to day. I remember this great leader very well. Most of my active life was spent when this great leader was in power. During this period of her rule I saw the worst kind of poverty, indiscipline and corruption in my country. We are still one of the most corrupt countries in the world thanks partly to this great leader. Yesterday’s rally reminded me of the great leader’s days when New Delhi used to witness such rallies almost daily. I dread to think of the return of such leadership which appears very possible.

Thursday, November 13, 2008

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 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 had 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 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.

Thursday, November 6, 2008

Count Narayan Rao

Both Narayan Rao and his wife are no more. Count died many years ago and madam Rao a few years ago. They had lived not far from my clinic and as Count had many health problems, I was a frequent visitor to their home. He very rarely visited my clinic and would joke with me,’ If I came there, I would get some more illnesses with all those patients there coughing and sneezing.’ This opinion I shared with him and have often marveled at the very few times I have fallen ill considering the number of times and patients with infections that I am exposed to over the years.

Narayan Rao, when he passed away was in his early seventies. He was related to a classmate of mine and that was their reference to see me. He had retired from a corporate executives’ job, but the habits of corporate life remained with him. To look at, he was a tall fair and handsome man, with a red, florid face. He spoke with naturally accented good English. He reminded me of characters I had seen in the movies and read in Wodehouse novels and that is the reason why I came to call him Count Narayan rao. In the course of our brief association I came to call him simply as count.

I looked forward to the visits I made to his home, because I never returned without feeling good and happy after the visit. The reason was not money. As a matter of fact because of the close relationship I did not take any fees from him. The feel good factor was the man himself. He enjoyed life and wanted to share his enjoyment with others which happily included me. He suffered from diabetes, has had several heart attacks and was in early chronic heart failure. But the disease that bugged him most was Gout. I used to make fun of him that he had a rich man’s disease [Gout affects royalty more than others is the popular notion]. Narayan rao was not rich but he led a rich life. Both of them were socialites of the then Bangalore and often they would be out of home attending this party or the other, despite his sickness.

Out of necessity he had to take multiple drugs and that included anti gout drugs. Like it is now then too, the treatment of acute gout was with either colchicine or Indomethacin.Count did not tolerate colchicine so I had no option but to give him Indomethacin, a toxic drug, especially given his other problems. Naturally my prescriptions were niggardly and never more than ten tablets at a time.

Once Count became breathless and I had to rush and see him. His wife was not at home and count was alone and with great difficulty he came and opened the door for me. Then he went back and lay down on his bed. After examining him I found his lungs filling up and wanted to know how much of the prescribed diuretic he was taking. He said he did not know but directed me to the cupboard where his records were kept. I opened cupboard and found a mini pharmacy there along with my notes in one of the drawers.

After giving him an injection of a diuretic, I returned to the pharmacy. I found lots of drugs which he was taking but not prescribed by me, and also several strips of Indomethacin. How did he get hold of this many tablets and has been using them without my knowledge?

I was very worried not only with the toxic Indomethacin but also the variety of unnamed pills and tonics many of them belonging to the class called herbal medicines. The injection had the desired effect and in a short while his breathing eased off. I asked him, He not only agreed that he took the tablets liberally and stocked them as they gave him very good relief. Sometimes he took three to four of them in a day. Horror! This despite my very clear instructions to the contrary. I was so upset that I had to admonish him, out of respect for age rather gently. He said,’ it is I who gets the pain, not you’. For this, I had no adequate repartee, so I kept quiet. After a while I asked him, how he managed to get the tablets without a prescription? He said it was very easy. He tore a white paper out of his letter pad, cut out the portion that had his printed name, wrote out Narayan rao and age and below which wrote the trade name of the drug and the required quantity. Signed my name underneath! He said no druggist has ever refused him so far! He felt no guilt what so ever! This reminded of my old pharmacology professor who used to say, ‘in this country committing suicide is very easy, you just have to go to the nearest chemist’

I stopped all the herbal medicines and told him how this over dosage of Indomethacin was having an adverse effect on his heart’s condition and his diabetes. He became less liberal in the use of that drug. Whatever may be the reason, his condition improved and he lived a few more years and died ultimately at home with chronic heart failure, in my presence.

Few days before his death when I was there with him, a party of his socialite friends had come to see him. By then the news of his seriousness had spread. When they were leaving, count called me aside and pointing to one of the women, whispered,’ that fellow with her is her third husband; I hope she will not have a fourth one’. His wit never left him, so was his jest for life.

Wednesday, November 5, 2008

Congratulations Obama

The skinny kid with a funny name has done it! Barak Hussein Obama has become the president of the Unite States of America.

The last time I remember being this happy and excited was when the low profile, utterly honest, sincere, able and who went unsung, our own Lal Bahadur Shastri , was elected prime minster of India some 45 years ago. He was probably the ablest prime minister we have had. That Lal Bahadur lived only for two years as prime minister was a major tragedy for our country.

I wish President elect Barak Obama a long and fruitful life in the service of not only Americans but all of us in this troubled world.

Lastly, to those of you, Americans, who read my appeal in my blog and voted for Barak Obama, my special thanks.

Sunday, November 2, 2008

Watch Dog

My friend has a Doberman pet dog. He is peculiar in his behaviour. Unlike the other dogs of his breed he welcomes guests with a whine and a vigorous shake of his head and tail. When he sees any one from the house hold leaving the house he gets upset and starts barking. If you consider my practice as home and my patients as family members and I as Doberman pincer you will be able to follow what follows. Like my friend’s Doberman I too fail more often than not and the reason you will know why if you read the next few lines.

Most of you watch television and newspapers and you meet friends and relatives. Subject of health, doctors and hospitals is a favorite topic of conversation. Morbid details of someone’s illness and death make very interesting topic of conversation as the conversants are not involved. But there is a lurking fear that they would be the subjects of such conversation at a later date. Then how to avoid this fate? Many believe that periodic testing [called whole body testing in their language] will tell them if they are fit or not. Little do they realize that these tests will only reveal that the tests are normal but will not tell them if they are normal or not. Thus this rush to get annual or bi annual tests done is thoroughly uncalled for and it has become one of my primary duties to prevent my patients from indulging in this foolhardy and expensive venture. Am I successful? Sadly, no. The media pressure and the false propaganda by the interested parties are so strong that I am like a Poodle facing of a pack of Pit bulls.

The other fad is running to consult specialists. This is another foolish and unhealthy activity. We call this compartmentalized medicine. The body is divided into several compartments and each compartment has a specialist. Heart has one, brain has one, nose has one, stomach has another and the list is growing every day. As the joke goes, a patient went with a stuck cotton bud in his left ear to an ENT [ear nose throat] specialist. That specialist refused to see him because his specialty was right ear and not left. It is my lot to see these unfortunates after they do the rounds. A person with chest pain would have gone to a cardiologist and finding nothing wrong would then have gone to lung man and then to a stomach doctor [some times stomach illness can cause chest pain] and then to a psychiatrist [if there is no cause that the other specialists can find, then, there must be something mentally wrong with the patient] and then he deems fit to see if he is lucky, a family physician. He may find the cause to be an injury to the chest wall. Supposing he had gone to the family doctor in the first place, if he [family doctor/General practitioner] had not found the cause, he would at least know where to send him. He would have saved the patient lots of money and head ache.

Another is the health insurance racket. A person who has healthy habits, who takes regular exercise and eats moderately, remains healthy well into his seventies. So why does he have to take insurance? The same premium money he can save up and invest or keep it by instead of loosing it every year to keep the insurance company happy. If you are unhealthy you will not get insurance or there will be an exclusion clause any way. Older people who really need insurance do not get it as they run a high risk of illness and therefore are not profitable for the insurance companies. The whole gamut of insurance business runs on one factor. That is fear.

Recently I have had an occasion to visit a hospital and spent some time at the reception where the patients are initially confronted. One of the first questions asked is whether you have health insurance or not? Why is this question? Will this mean that you get better attention? Certainly not. It will mean you go to a separate bracket where in your charges will certainly be higher. This is my hunch. So I advise my patients to put by some money each month and invest it. When the time comes when you are ill needing hospitalization [which never comes to most as death comes unannounced for many of us who are blessed] mostly in your old age, you have enough to take care of your expenses. Most insurance companies also have a ceiling beyond which they will not pay. In this game the insurer is not the winner; the winner is the insurance company. Do I succeed? You guessed it right? I do not.

I find a large number of my patients swallowing daily, potions of vitamins, tonics, A to Z [there is actually a name like that] minerals, health restorative oils, health foods. Again all of this is utterly useless stuff. But do they listen to me? Yes, they listen but don’t follow.

What is the solution to these problems in the community? Find a good watch dog and look after him and listen to his well intentioned barking.