Monday, January 23, 2012


This for us medical men and women means meeting periodically to learn, update and exchange ideas. In short, it means learning so as to ultimately benefit our patients.

To conduct a conference we need several requirements. These are: a suitable place, an organization to oversee the conduct, participants, delegates and speakers. One needs money to take care of the hunger and thirst of the speakers and delegates for the period of time these worthies hang around in the memorable cause of learning.
Over the years it has become a custom to hold these conferences in hotels. Depending on the reputation of the organizers the hotels are selected. If it is lowly paced general physicians it may be in three star hotels and if it is a super specialty conference it may be in a seven star location.

The concerned body of doctors will start working months in advance advertising in the specialist media as to this meeting and we begin getting mails giving the details of the topic and the registration charges. The higher the hierarchy the higher is the registration fee.

Now it will be interesting to know who will be the delegates [listeners] and who the speakers? Delegates are supposed to pay the entry fee which will cover their lunches and dinners and other expenditures incurred by the organizers in hosting this conference. The speakers are specialists in their fields who will have either paid for their coming or they will have been sponsored by the research grants to present their views. In reality none of this is true. The delegates are there because someone would have picked their bill of travel and stay. And speakers would have been taken care of by the companies or firms interested in high lighting their research to boost their sales of a particular product or devise.

In a major conference which drew 1500 delegates on the subject of advances in diabetes there was no registration counter! This means there were none who paid and came as delegates! Diseases like diabetes, hypertension, and heart disease afflict the rich more than the poor. Drug companies are interested in selling their products related to treatment of these diseases. They know that here is a huge market for drugs used in the treatment of diabetes and India is emerging as the diabetic capital of the world and here lies the truth of this mega conference where in an estimated 2 crores of rupees were spent. How appropriate it would have been had this money been spent on funding research on a vaccine to cure malaria [essentially a poor man’s illness]

Let us assume there are still doctors who don’t want to be sponsored and would like to pay and attend and learn. This foolish class is rapidly dwindling and if things are going as they are they may soon disappear! These doctors are generally honest professionals and therefore unlikely to be rich and cannot afford the travel and stay expenses of going to another city or country and therefore are forced to stay back. What about their learning? I asked a friend of mine who attended this hyped up sponsored conference on diabetes as to what he learnt new? He said,’ very little of practical importance.’

There is still hope for this class of doctors. Internet has come to their rescue. Most advanced research of practical importance gets published in journals and subscription costs of one or two standard journals is sufficient to keep one updated. These journals have very interesting and novel teaching methods which I find far superior to the didactic delegate’ speaker method of learning/unlearning.

What is the future of these conferences? As I see they continue to thrive but the quality is likely to come down. There is going to be major changes in learning methods and these will be more and more web based and my worry is that here too drug companies will play a role [as they will have to spend less!] and this will leave a set of unhappy doctors who are denied of their free travel , food and drink!

Wednesday, January 18, 2012

Communal feasting

My balcony overlooks the backyard of another home. Here grows a Sapota tree. Sapota or Chikoo [Manikara Sapota] is a fruit bearing tree which originated from Brazil and has spread all over the tropics and in India Chikoo is a major horticultural produce. The tree fruits twice a year and a well looked after tree bears fruit in thousands.

The owners of this tree are old and cannot reach the upper levels of the tree with ease and thus lots of fruits remain unplucked and I am ever grateful to them for their unintended generosity. Twice a year the tree fruits and it becomes veritable bird watcher’s paradise. I have on a previous occasion written about a family of squirrels who has laid claims to the fruits and how jealously they guard against predators, mainly the birds. It was a pleasure to watch the mostly futile attempts of these small animals trying to chase the birds away.

This year they seem to have found that it is waste of time to chase the birds away especially when there is plenty of food for all! Another new feature I noticed this year is that all the birds have begun feeding at the same time unlike previous years when they took turns. The green barbets came first and the others followed. This year I am able to watch all of them feeding at the same time. I had not noticed Mynas in the earlier years. This year there are at least ten of them. Most fastidious and elegant of all the feeders [according to me that is] is the Koel. This big bird perches next to the fruit and elegantly pecks without disturbing the fruit or letting it fall. The worst of the lot is the Parakeet. Not only is he very noisy [I tolerate his screech only because he is a bird, good looking one at that!] but also he is very wasteful. Parakeet’s beak is curved and designed to open pods and eat the seeds and not really to eat ripe fruits .In attempting eat, he ends up in dislodging the fruit which falls to the ground only to be eaten by the crow. More I see the crows, more I am impressed with their intelligence. Earlier I used to see them eating the fruit still attached to the branch. Now they wait below for the half eaten fruit to fall to the ground. They unlike the other birds are unafraid of us humans and can risk doing this, their easy way to get at the fruit.

Parakeet [Rose ringed] till recently was a visitor. Now he has become a resident. I was wondering at the unusually prolonged presence of this bird around my home when I discovered his nest! The preferred nesting site is a tree with a dead branch or one with some holes in the trunk. There is a dead coconut tree some 100 yards away and this dead tree stands some fifty feet tall. This is an ideal location for the parakeet’s nest. I have begun watching these birds sallying to and fro and by the way they are behaving there sure to be hungry chicks in there.

Chikoo is a not a fruit where one sings paeans of praise unlike Mango where people go crazy in their praise. But it is a great fruit not only in the abundance of yield but in taste and structure. There is very little wastage in this fruit. The skin is thin and the seeds are few and the rest is delicious flesh. No wonder I and my avian friends like it so much.

Sunday, January 8, 2012

Going back to dark ages?

It was in the twenties of last century that antibiotics were discovered. First came the sulfa compounds and then came that remarkable antibiotic penicillin and then many more. In less than 90 years the microbes have learnt to live and occasionally thrive in the presence of these antibiotics. The last shock of the discovery of ESBL [Extended spectrum betalactamase resistant] was some years ago and now comes the report not of multi drug resistant but all drug resistant Tubercle Bacillus which causes tuberculosis. This is like icing on the cake or to be more precise adding insult to injury.

This means that in the near future if you get tuberculosis there may be no drug to cure you and in likelihood you will die. How you will die depends on the organ that is infected. TB germ can infect all organs from head to foot.

Human arrogance that he is the sole lord and master of this earth is responsible for this state of affairs. Microorganisms have been in existence for many millions of years before multicellular organisms AND other forms of life including humans evolved. They are self contained remarkably efficient life units who have learnt to survive in extreme adversity. We, primarily doctors believed that we can win the battle of infection by using these antibiotics. We used these liberally and indiscriminately and are still using them. Most infections are self limiting and antibiotics are redundant. But it has been common practice to use these in all infections trivial or otherwise. To give two examples. One is Staphylococcus. This is the germ which causes the common furuncles and abscesses. These, left alone will burst and heal or can be drained by a simple cut. But we routinely use antibiotics and now this organism has developed multidrug resistance. Another one is a germ called E-Coli. This one has a special liking for our urinary tract [especially women’s].This one too has become multidrug resistant. These two have become major headaches for us doctors and now are no longer simple germs that got killed by one or two doses of antibiotics. They have become killers.

If one considers one out of one hundred Indians have TB, then imagine the havoc this all drug resistant TB germ is likely to cause?

We are heading towards the dark ages of pre antibiotic days and we may have to look up and see how the physicians of those days managed their patients!

Friday, January 6, 2012

Awareness of self

When I wrote the story of Mrs A, I said I would write about two of them. This one is the other which I meant to.

She has been my patient for many years and must be in her mid sixties now. With a strong family history of cancer and heart disease she is extra careful with her health and gets her tests done on a regular basis and keeps her twice a year visits to me without fail. Living with another sister who keeps indifferent health adds to her worries. Let me call her Ms M.

When Ms N came to see me when she was not due to see me, some three months ago, it was for another reason. She had severe back and hip pains of few weeks duration. Ms N is a frail vegetarian and when I found that her back and hips were generally tender with no specific localizing signs, I thought she has osteoporosis with add on Vit D deficiency, this despite her taking calcium tablets and a drug named alondrenate which is given for osteoporosis.

Vit D is manufactured by our skin only when there is sunlight exposure. Modern living and fear of sunburn makes people become Vit D deficient which can give rise to many signs and symptoms and aches and pains are some of these. Vit D deficiency was virtually unknown in the earlier years of my practice. Now I see this quite frequently for reasons mentioned above and also easy availability of tests to detect deficiency.

Mrs N was asked to do these tests and come back. The bone calcium density was not bad but her vitamin levels were low. I thought there you are! You have the diagnosis and the treatment is easy. Just give her Vit D supplements and get her to sit in the sun and her pains will disappear in a month or two. Thus reassured, Mrs N went her way.

She came back six weeks later, in acute distress. She was in such severe pain that she had to be assisted into my clinic by her brother. Instead of getting better she had gotten worse. I really cannot blame her for having gone to a specialist doctor in rheumatology [illnesses related to what is loosely called connective tissue]. This doctor had done a large number of tests to detect antibodies against her own cells. These were negative.

Here I must explain the basics of this fascinating aspect of life. We are each of us, unique, in the sense our cells [the ultimate functioning units of our body] are our own and there is an elaborate mechanism which allows our cells to recognize each other as belonging to one person and this mechanism has the ability to recognize something which enters our body as foreign. After this recognition there is an elaborate system of defense [major research area] to counter these invaders. This recognition of self from non self is fundamental to life. Occasionally, for various reasons, some understood and some still to be understood, this intricate system of recognition fails and the resulting clutch of disorders, go by the name of auto immune diseases.

Like we all have a life span [bible limits it to three score and ten, meaning seventy. I should be dead by this time going by this!]. Our body consists of various organs which perform various functions. Each of these organs is made up of millions of specialist cells. And all these cells too have their own life span and it is not threescore ten. Cells lining our mouth have a shorten life span than that of cells of our brain. When a cell dies the innards are released and these find their way into our lymph and blood stream. This dead material when once it comes out of the cell should be quickly disposed off. Or else these become potent antigens [foreign] and the our immune system begins to fight these by forming antibodies and the resulting fight takes place all over but when it occurs in our connective tissue it becomes painful and the illness too is widespread. Connective tissue is the one which binds the various structures and gives shape and structure to us. The resulting plethora of illnesses is called auto immune disease. I have given a rather simple explanation and I may be pardoned by my specialist friends for any error.

Ms N had one of these illnesses. Which one was the issue? The rheumatologist too must have been in this quandary and therefore had given her a non specific drug and wanted to review her after she tries it for few weeks. Why then she got back to me when my earlier treatment gave her no relief?

Sometimes we doctors stick our necks out and sometimes it is to benefit our patients and occasionally we get hung by! This is what I did. While reading about another problem I chanced upon this condition called Polymyalgia Rheumatica and the symptoms and signs fitted to what Ms N had like a glove. It occurs rather suddenly to only those above sixty, three times more common in women, large muscles of the spine hip and shoulders are preferentially involved, and markers of inflammation CRP and ESR will be very high. All of these were true in Ms N’S case.

I made bold to call her. I knew her name and the locality she lives and finding her number in the phone book was not tough. She must have been taken by surprise at my request to see her as soon as possible and she agreed and thus the present consult.

I explained to her the possible diagnosis and treatment. It took some convincing for her to agree to the treatment as it meant taking small dose of steroid [compared to what is given for other allied conditions]. Another motive was the dramatic freedom from pain she is likely to get if the diagnosis is right [sticking my neck out]
She agreed and three weeks ago took the initial shot of long acting steroid followed by oral tablets. Even I was surprised by the result.

When she came ten days ago, she came on her own could move all parts of her body, could bend, sit up, walk all without pain. Both her CRP and ESR which were sky high had returned to normal!

Practice of medicine is indeed rewarding. Don’t you agree?

Sunday, January 1, 2012

Cure or Kill?

My fading years of practice still provides me with patients whose problems test my skills, patience and occasionally my knowledge. Experience gained over 40 years of practice and occasionally sheer serendipity comes to my rescue. The month of December saw me solving two such problems with the help of a combination of the factors told above and I consider them as the best New Year gifts received even before the old year ended.

It is required that I take permission to tell their stories, especially when they are alive and kicking as in these two instances and I have done so and I must thank them for permitting to do so. Let me begin with the first one, Mrs A.
Mrs A is mother in law of a close friend of mine. She is a well built lady in her mid eighties and spends time living for some months with each of her children and for a long time she was my patient until her elder son retired from the army and came to live in this city 5 years ago. Since then she is being cared for in the army hospital and in a private hospital whenever an emergency arose. With another son living abroad money is not an issue that came into the picture as far as care is concerned.

As it often happens with us GPs, patients leave us to what they think or what their children think, for better pastures, which often is true but not in this case as later events proved. Fifteen or so years ago, when she came under my care, she was an obese, hypertensive, seasonal asthmatic and had fairly well compensated heart failure due to leaking heart valves. She was also severely arthritic with painful hips. Averse to any form of regular exercise and fond of food it was no surprise she kept gaining weight and her hip pains only became worse. We took a risk and got one of her hips replaced and the cardiology opinion was that she was a high risk patient and ideally have her heart valves replaced and the surgeon felt it was not worth doing it considering she is being fairly well managed medically as far as her heart failure was concerned.

Four years ago, when she was not under my care she got her other hip replacement done! She had a stormy post operative period but made good recovery and now she has both hips replaced and was pain free. One would have thought she would exercise and get her weight down but as I said earlier she did not and her weight remained as before and when I occasionally saw her socially [as she is my friend’s mother in law] I felt her weight had only increased. Since last one year her health seemed to worsen and she has been in and out of hospitals for one reason or the other.

Six weeks ago, she was taken to a nearby hospital [with corporate ethos] and was admitted as she was complaining of weakness and was short of breath. Given her heart condition the diagnosis was obvious. She was in heart failure due to leaking valves. The cardiology team of that hospital is good and most of them are known to me but as I was not involved in her care I did not personally check with them as to the details of the treatment. What her son in law and my friend told me was that the cardiologist felt her heart failure was under good control and he advised her increased activity and she was discharged home.

This time the home she came to was the daughters. She continued to be unwell and kept telling her relatives that her end is near, so bad was her feeling! One evening, the son in law [my friend] came to my home and asked me to come and have a look at her before they took her back to the hospital.

I went with him to see her. She was lying flat on bed, a slab of pale flesh with deathly pallor. She looked very ill. She had constant feeling of nausea and was off food for the last week and was barely able to keep fluids. She also felt it impossible to even to get up and sit and the daughter was having a hard time nursing her. Quick examination showed her blood pressure under control, but her heart’s beating was irregular. Her feet were swollen and her lungs showed few abnormal sounds suggesting beginnings of fluid accumulation. She complained of discomfort in the pit of her stomach.

I wanted to see her records. The record keeping had stopped in the year 2006 when she was under my care. Rest were all hospital discharge summaries and prescriptions. I saw the latest prescription. This had 9 drugs. One to stabilize the heart, another to remove the fluid from her lungs, yet another to keep her blood pressure under control, a different one to prevent clotting, another to prevent the possible side effects on the stomach because of all these drugs and the usual masala of vitamins.

Digitalis is a time honored drug and has a fascinating history. The plant Foxglove from the leaves of which the steroid glycoside Digoxin was extracted, belongs to the family Sacrophulariaceae, was time honored native medicine in Europe for many centuries. It came to widespread use due to an accidental discovery by the 18th century English physician William Withering. A patient of his was very unwell with Dropsy [old name for fluid accumulation all over the body]. After visiting her, Wuthering came back home leaving her to die, so hopeless was her state. Few days later the patient, now recovered, visited him. The surprised Withering found out that she had consumed a concoction made out of the common garden plant, Foxglove! It to his credit that he published his meticulous observations and extract of foxglove, digitalis, came to be used universally in heart failure patients and has with stood the test of time and is in use even to this day.

This wonder drug however, has one major problem. The margin of safety between the therapeutic dose and the toxic one is thin and if one is not careful the drug can become from a life saver to a life taker!. This is especially true when used in the very young and the very old. The toxicity is on the stomach and worse, on the heart. In the stomach it causes severe gastritis manifested as loss of appetite and severe nausea and on the heart with irregular to very fast beating leading to failure, the very illness for which it is given!

Madam A had classical Digoxin toxicity! The drug was stopped and it took 48 hours for her to eat her first solid meal in three weeks. Her heart’s beating returned to normal and the deathly pallor was replaced by a cheerful expression. She began moving around the third day and was able to walk up and down the stairs of her home. Yesterday she made a long car journey to her other son’s place to a town some 6 hours away!

Mrs A escaped from certain death [if she had continued with digoxin].

This story has taken too much of time. Will do the other one sometime next week.