Wednesday, November 30, 2011

Fire test

Our revered epic Ramayana has an episode where in Lord Rama tests his wife's chastitiy by making her walk through fire [even in those days there was no need to test the male's chastity]

So this was considered to be the best way to separate the noncorrupt from the corrupt. The first ones to be tested were the ruling party memebers. One by one they were made to walk through the fire pit.

The first to emerge unscathed by fire was Antony. Next to emerge was Manmohan singh holding his backside which was singed but not burnt.After anxiously waiting for a while Antony tells Manmohan,'I donot think we should wait any more, there is a lot of work that we both have to handle' Manmohan says, ' You go, I will wait, I am sure next one to emerge will be madam!

At the time of writing he is still waiting!

Saturday, November 26, 2011

Hazare and the whip

I imagined the scene where Gandhian Anna Hazare is going around the country with a whip in his hand looking for persons who like their drink. What would I do if faced with this spectre? I would humbly request him to taste thimble full of wine before he takes up his whip. I am quite confident of winning him over.

Why is he so anti wine? Easy to understand. He has seen addiction to drink ruining families and thinks flogging is the answer. While not advocating that one should take to drinking, I am totally against this kind of thinking. This kind of puritanical attitude is going to draw people away from his movement to eradicate corruption. Instead he should advocate moderation and educate people not to become alcoholics. There is overwhelming medical evidence that small doses of alcohol is good for health!

The question is how small is small?

Thursday, November 24, 2011

Nature’s culling

Authorities in national parks allow hunting of wild life if they find one form of life exceeding the limits. This is called culling. This however doesn’t apply to us humans. We are at liberty to breed and multiply and test the resources of mother earth. This over populating the earth is in a way insulting nature. If you go by this yardstick human life is the most dangerous form of life ever evolved. Is there a scheme of things behind this profligacy? I wonder. There are different theories for the disappearance of earlier life forms. For example the Dinosaurs and the Woolly Mammoth. The dinosaurs became extinct after major upheaval die to meteor hit and the woolly mammoth because of rapid advance of ice age. If we are to believe there is an in built wisdom in nature which is not conditioned to safe guard human life, then I am afraid we are in for some form of correction which may well mean disappearance of humans. From the point of view of mother earth nothing much will be missed by the disappearance of this none too attractive a species. How will this be brought about?

Many centuries ago Rev Malthus propagated a theory that natural calamities like famine, fire or floods will correct the balance and the population gets naturally culled. This may still happen if you go by what is happening in Ethiopia where millions are dying or going to die if the rest of the world sits back and watches. A more likely event will be mutation of a run of the mill virus into a killer with widespread deaths uniformly spread throughout across all nations. Next possibility is nuclear explosion which will kill selectively and therefore unjust!

Going by the life span of stars and planets, earth has few more million years left before it gets blasted to smithereens. Therefore when doom is inevitable why worry? Get on with our wasteful ways and hell with coming generations of life forms.

Monday, November 21, 2011

Corporatization of health

Indian government seems to have washed its hands off of providing health care to its citizens. Going by the evidence of measly allocation of funds in the budget for health and its acceptance of corporate hospitals to provide health care to its employees, the trend is firmly set that we are going the American way. What then is going to happen to the existing health infrastructure, the vast network of primary health care centers and secondary and tertiary care hospitals? If the present trend of encouraging corporatization of medicine continues it is inevitable that these institutions will gradually go to seed and one day will altogether disappear. Imagine the situation where in excellent institutions like AIMS [Delhi] PGI [Chandigarh] NIMHANS and Jayadeva at Bangalore deteriorating and becoming places where only destitute go!

Nations are spending a considerable percentage of their GDP on providing health care. As the population ages health care costs are going to go up and India is no exception. But neglecting government run institutions and encouraging private clinics and hospitals run by corporate and health management funds is the right way of providing health care?

Far from it, it is the worst way, especially for a poor country like India. Some you who are not Indians may wonder when I use the word poor to describe India. What you read or hear about India in the news and electronic media is all about the doings of the 5% of Indians who have done well for themselves.

This 5% is what the corporates are interested in. This 5% consist of the upper middle and the rich. Our politicians [even the grass root ones], beurocrats belong to this class. These are supposed to use the health facilities of the government. Hardly anyone does this and all of them with rare exceptions make a beeline to corporate hospitals when they fall sick or even for their routine health checks. If the top echelons of the government have no confidence in their own institutions how can one expect the ordinary citizens to have any confidence? They too will and have to go to these privately run institutions.

With increasing play by the private sector, falling ill has become a risky proposition. Let me explain. As the private players are mostly businessmen/venture capitalists/health management funds, the end point of their venture is to make money. They are not doctors who are supposed to think of patients welfare first and money next [many doctors too are becoming money first and health next thinkers]. They think of maximum and quickest return on their investment. If the investment is on building they will look at how much a square foot of the building will earn, if it is bed how much a bed will earn, or if it is human in the form of a doctor how much this doctor will earn for them. That is how they look at each item as money earners. Let us say the expected return on a bed is x amount in a year and the year end sees that bed earning is less, then the hospital administrator is pulled up and he in turn will pull up the doctor. The doctor who is so pulled up for not providing the hospital with enough business will either has to quit or adopt methods which his famous Hippocratic oath forbids him to. Most doctors are not in the real sense businessmen to begin with but they become one due to this kind of pressure. So what happens is this. When a patient goes to a corporate hospital and sees the doctor the first likely thought that comes to the doctor is how much I can get out of this patient and not what might be wrong with the patient. This attitude I am sorry to say is widespread and leads to lots of unnecessary investigations and procedures and needless hospitalization.

The sucker is the hapless patient. If he belongs to middle or lower income group, these institutions will make them feel that death would be preferable than the torment of raising sufficient resources to meet the expenditure that a hospital stay brings on.

This fear has led to the mushrooming of health insurance industry. This is another sordid story. Between corporate hospitals and insurance companies there appears to be a cozy relationship. It is not uncommon to hear the hospital reception asking the victim whether he is insured or not. If he is uninsured the smile of the receptionist is likely to be replaced with a frown. This is because you are likely to opt for less paying bed and at the time of discharge haggle, ask for concession, create a scene or as it happens occasionally, simply abscond!

So what is the solution? May be in the next write up.

Wednesday, November 9, 2011

Ganpathi Bhat Hasanagi

There are some who strike you as brilliant at first meet. Most don’t. Meet could be personal or distant. In music, art, sport, it could be distant. I have written about personalities whom I have met personally and those whom I have not but have close relation through their work and performance. One such field where though I lack personal knowledge I have gotten close is in the field of classical music. I have had occasion to write about Bhimsen Joshi and Gangubai Hangal [both of them no more]

Another such who is still relatively not so well known is Ganpathi Bhat. I am no exponent of Classical music. My knowledge is primitive but what I know is heartfelt. Many brush Gangubai off as singer with shrill voice. But to me she was manifestation of great talent and her voice played a minor role when I listened to her. When I first heard Ganpathi Bhat some ten years ago it was like a shock wave of pleasure hitting me. He has a rich voice, brilliant control and the variety he brings in without much ado is breath taking.

Those of you who love Hindustani classical music must listen to his music. It will be a divine experience.

Wednesday, November 2, 2011


I got trained in the old school of thought as far as patient care is considered. There were several dos and don’ts that were dinned into our heads. Some of these were, don’t prescribe an expensive drug when an alternative cheaper one is available. The other is don’t investigate unless absolutely necessary. Always listen to the patient then proceed to examine and always try and come to a clinical conclusion. If you have to confirm do the minimum lab and other tests. When you are in doubt get another opinion.

These principles have stood me and my patients in good stead over the years and saved us lots of head ache and money. But occasionally it has backfired, to give an example or two.

I am against routine annual medical examinations and investigations to all and sundry and with valid reasons. I consider these a waste of money. But when there is a definite indication to screen a high risk patient I do order the required tests. In this case the Youngman’s company does many tests as a part of the employee benefit and an electrocardiogram is one of them. He knows that I am against routine screening for heart disease in low risk groups and the youngster was one such. He reluctantly came and apologetically asked me to have a look at the reports. The company and done many tests which included an ECG.

The ECG was abnormal. Though the rhythm was alight the rate was very high. Even if one gives margin to the fear of doctors and machines many have with the resulting increase in the heart rate, this kind of increase was a cause for concern. The report just said sinus tachycardia and the physician who signed it had not bothered to see the patient. There was also a marginal increase in the levels of thyroid hormone.On talking to him I realized he had lost weight, had been having some diarrhea and when I examined him he had a heart rate of 130 beats per minute. A repeat test for thyroid function revealed he had increased activity of thyroid gland and this was duly treated. Had he not done the annual tests would he have come to see me? Probably not immediately but would have because he was concerned with his loss of weight. He would have come much later when treating him may have become tougher than it did.

Another patient this time a friend of mine, who by nature a thrifty sort of a fellow [there is a very thin line between thrifty and miser].He tries his best avoid consulting me [read paying me]. He also treats himself with some success. He had symptoms of hyperacidity a year ago and as his usual antacid failed to help he sought my attention and I advised him to take a course of different class of anti acid drugs and get back after six weeks. He got better and did not get back to see me. When I met with him on the golf course he said he was well but once in a way he has to take the medicine. This worried me as at his age one should not have recurring symptoms like this. As the golf course is not the ideal place for a professional consultation, I asked him to see me in my chambers. This he did when his wife came to see me, he sort of hitched a ride.

I found he has been taking the medication prescribed and managing. Though there was nothing much detected on physical examination I told him to get an endoscopy done to have look at what his stomach looks like [this meant going to the hospital and getting a flexible tube thrust down the throat right up to the stomach, a not very pleasant procedure but was needed]. He said alright and went away. He did not go to the hospital. He came three months later with worsening of symptoms. I had no doubt about the diagnosis. He had cancer of the stomach and further tests including the endoscopy showed the cancer had spread all over. He does soon after.

Looking back I feel guilty for not having insisted that he get the tests done. I could have told his wife and she would certainly have succeeded in getting the tests done. Would he have survived had the tests been done six months earlier? Yes he would have.

There is a saying that you can take the horse to the water but you cannot make it drink it. Sometimes it is difficult to force the issue. But difficult or not I should have done it and he would have probably few more years of life. Now I am carrying this burden and it will be with me and his face will keep coming to haunt me, may be, till I die.

Another patient and another time. This person was a medical shopper. He saw many doctors and I was one of them. He had painful sensations on the skin of his thighs extending down to the calves. Only sensory involvement of pain sensation carrying nerve fibers may be due to many causes and cancer is one of them. He was a smoker and on testing he was found to be a diabetic. I was happy because diabetic neuropathy is very common and good control of diabetes will help. He was told the diagnosis. He appeared happy that a cause was found and went with the diet sheet and prescription. For three months I did not see him. When he did come he had with him records of three other doctors, one of them a homeopath. His diabetes was under control but his neuropathy [pain] had worsened. A neurologist who had seen him had done a scan of his spine and brain with no abnormality. Now he also had weakness and loss of weight which was attributed to diabetes. What is this patient’s illness?
I expressed my worry about cancer to the patient and told him to get a PET scan [an expensive test but will reveal cancer activity] of his whole body. After much deliberation and visit to another doctor [fortunately he too advised the same] this test was done. A tumor was found in the patient’s intestine [ceacum]!
Though nearly six months had elapsed from the onset of pain in region far removed from the place where the cancer was, it was found to be operable. The patient lived few more years but died due to recurrence. Here again if we had forced him to do this test and the diagnosis had been done early, may be, he would have lived his normal span of life. All of us [many doctors whom he went to] thought that diabetes is the cause when all the time it was cancer. This episode too has remained in my memory but does not haunt me as the other one does.

Despite this experience I stick to the principle of investigating only when necessary. But as you can guess, I have started forcing and even threatening them with dire consequences if they don’t follow my advice. Once bitten twice shy, that is what I have become.

Medicine is, in many ways, a cruel profession. You may be right 99 times out of 100 but you remember the 100th because willy nilly, you were responsible. And to the patient who suffered it is 100 percent.