Saturday, February 29, 2020

Much ado 
Diabetes is one of the eminently preventable disorders. This disorder has now become a money spinner for pharma companies, diet counsellors, endocrinologists and a special breed of doctors who call themselves as diabetologists. There’s so much hype built up, that this is considered as a deadly disease and news, social and electronic media are replete with reports, one way or the other related to this illness to the extent that India now has the dubious distinction of being known as the diabetic capital of the world. And our super doctor endocrinologists taking the cue, repeat this sentence ad nauseam in every CME that is held on this subject.

One of my patients, let me give him a name Banwari Lal.
Banwari came to see me some time back.
I could see him very anxious and tense.
He said,' doctor Saab, I am going to die' 

Banwari is a second-generation patient of mine and I have known him almost since he was born. Now this strapping 40 plus man who has been pretty healthy so far is now here announcing his imminent death.

I asked him,' how are you going to die?'
He said with all seriousness, ' Sugar disease'
How do you know you have one? I asked

Another story emerged. Banwari got a phone call couple of weeks back, the caller identified himself as an executive from Estocare, a nationally known diagnostic company and they have a great offer especially suited for successful business leaders'
Our Banwari was suitably impressed with him being amongst this chosen elite, asked what these tests and the cost.
The executive proceeded to explain that the offer was for 40 tests and cost was only Rs 2000  which normally would cost Rs 3500 and what is more, their technician will come to Banwari's residence to take the blood sample.

Greatly impressed, Banwari placed the order and next day a sample of blood was taken. 
The results came by mail and amongst the mostly unnecessary tests there were some marked in bold font suggesting abnormality. Going by his knowledge of sugar disease (his father too has it) Banwari knew that sugar levels were high and he like his father has this dreaded disorder 

Things would have been different had he come to me in the first place soon after he got the report.

An avid TV watcher, he had heard a discussion on diabetes by a panel of doctors and he thought it best to consult a clinic solely devoted to this disease.
He fixed a date with this super specialty diabetes clinic and went there as suggested in an empty stomach.

There his blood was drawn once again and he was given a breakfast of the clinic's choice.
This done he was asked to get an ECG and ultrasound of the abdomen done. When asked why these additional tests, he was told by the nurse who had a permanently fixed smile that it is to find out if has any additional disease. Thus, held captive in that clinic, he was kept busy till noon when his turn came to see the diabetes specialist doctor.

The conversation went along the following lines.
Doctor gravely looking at the opened file in front of him asked, ' You are Banwari Lal'
Banwari confirmed indeed he is.
You have a problem, said the specialist. 
As he already knew this because of the bold fonted figures, Banwari chose to be quiet.
‘You heard what I said'
This time Banwari was forced to say yes.
Your blood sugar and lipids are high and unless these are brought to normal you run the risk of complications involving your heart, brain and kidneys which may result in serious complications including death.
Banwari did know about diabetes but this disconcerting information about causing death was new to him as his father who is 75 years old, a diabetic and still alive
You need to change your life style, exercise regularly and take medication which I will prescribe now said the specialist. 
He proceeded to give a prescription for three types of medications.

Banwari was now asked to go to another room where sat a lady who specializes in giving advice on diet to diabetics.
The lady took his weight and found him overweight by 5 Kgs.
Banwari is a Guajarati and a devout Jain.The dietary discussion with this lady from Banwari's point of view was very painful. 

When she learnt that being a Jain his last meal was before sunset, she told him in no uncertain terms that he will have to eat according to her chart and not starve. Banwari telling her that he is not starving fell on deaf ears.
Banwari's wife too had gone with him and both were given an hours talk on what each ingredient of the food that they eat [ displayed on a large tray] and the calorie value of each of these.
By then it was nearing 2 pm and past their lunch time and in addition to hunger Banwari also had a headache with all this detailed information stuffed into his head. Except information needed for his business, Banwari’s brain finds it difficult to understand others and this calorie gilorie stuff that the diet expert was telling him was beyond his comprehension and therefore the head ache.

His wife Sunitha too is my patient and it was she who advised him to see me before he does anything like staring the medication and try the diet.

Before I saw his reports, I checked his BP and heart. Both were normal and he had good circulation in the limbs. There was no evidence of any skin fungus. Weight was borderline high. I felt he was in good health.

Now I opened his now fairly bulky file.

His fasting sugar was 140 and after food it was 210 and his LDL was 140 and Triglyceride was 240.
I felt like laughing  
He must have seen the expression 
He asked, ‘doctor Saab, why are you laughing’ in Hindi
I said, it's a smile of pleasure to see these reports, you can get back to normal within next two months if you follow my advice
Then what about heart attack kidney attack? he asked
‘Nothing will happen and you are not going to die and may even outlive your father’ I said half in jest

But what about my evening meal? He asked with some anxiety 
You can have your night meal before sunset’ I said.
I gave him a diet and exercise schedule which would not greatly disturb his life style.

He came back the other day.
His fasting sugar was 130 and after food it was 160 and both the LDL and triglyceride levels had dropped and he was on no drugs.
I told him to continue the slightly altered lifestyle [ bit more of exercise and controlled eating] and assured him at the next visit, in 3 months’ time, all the values will be normal

A very happy and relieved Banwari took a grateful leave, leaving behind a box of sweets

Hopefully his gift will not make me a diabetic.

Saturday, February 1, 2020

Back bencher

I am comfortable sitting at the back in any function, be it a continuing education meeting, a wedding reception or a civic get together. This habit I acquired some 50 years back in medical school. Then it gave me an opportunity to unobtrusively leave the hall through the large french windows placed strategically on the sides of the lecture hall. Those days the lecturers if they noticed one’s absence, took no offence.

This habit has stood me in good stead and gives me ample opportunity to leave midway without offending the speaker or the organizers. On rare occasions, when I had to don the mantle of a speaker I keep a subtle watch on the back rows to see if any one leaving midway, a sure sign of boredom/ inattention. I am rather fortunate that it has not happened often.

In those bygone days, the continuing education programs were simple affairs with a lunch or high tea thrown in at the beginning or at the end. The speakers mostly depended on memory and experience and spoke extempore. Naturally some of them bored us to death. Then too being a back-chair occupier came in handy to take unobtrusive leave.

Has the advent of advanced audiovisual aids motivated me to occupy front seats? Sadly no. I find it has made matters worse. The modern-day speakers, with rare exceptions, have taken to reading these projected slides and not really addressing the audience. Droning voice combined with dimmed lighting is conducive to sleep and it's with difficulty that I keep my head up and eyes open. This goes unnoticed if you are a back seater. When I compare the speakers of yesteryears to the present ones the ones of the past get a higher score. May be, being old myself, I may be biased. I remember vividly my Neurology teacher professor late M.K Mani miming grand mal and petite mal (now the modern neurologists have named these differently) while speaking on epilepsy. Similarly, I remember another M.K Mani ( great teacher, alive and kicking) speaking on hypertension, though with the help of slides but hardly  looking at them.

Lately I am facing a piquant situation. Thanks to my seniority and mop of grey hair, I am easily spotted and given our penchant for recognizing (respecting?) old age, I am forcefully escorted to the front row of chairs to my discomfort. Here again there's is some hierarchical distinction. The front most row is generally is a row of cushioned sofas or well-padded chairs meant for VIPs and thankfully the organizers have not recognized me as one and they usually make me sit behind these.

The front row occupants generally come late and the importance is based on the position they hold rather than to any achievement academic or otherwise. Needless to say, by arriving late, they also hold up the proceedings. In one such meeting a serving police official of ill repute was the chief guest in a professional function. I felt happy that I was not in that front row sitting with this worthy.

It's a different matter in social functions like weddings and receptions. Being the family doctor for generations of families, I often get invited to many of these which even includes ceremonies associated with death. Often, I have the dubious distinction of having presided over these deaths. Readers should not get the impression that I am another Dr Harold Shipman [who killed many an elderly]. In my case these patients who died under my care at home were terminally ill and I saw to it that unnecessary hospitalization and the resulting expense were avoided. Weddings however are joyous occasions. Normally I try and avoid these ostentatious and wasteful ceremonies. But sometimes I have to attend as the families concerned are too close for me to not to.

Recently I went to a wedding. The girl, a third-generation patient, I have known since her birth. She is now placed in the US and the young man; her groom is a German. The girl’s father and mother and the grandparents from both sides also are/ were my patients. Both the grandfathers are dead (under my care at home), but the ailing grandmothers pushing 80 are very much alive. So this intimate relationship made it impossible to avoid this wedding.

The simple wedding ceremony was over and the time arrived to bless the couple. Normally the elders of both sides take the first honor followed by other relatives and friends. In this wedding, this tradition was broken and I was ceremoniously escorted to the platform where the bride and groom sat and was requested to initiate the process. It must be a spectacle to the well-dressed gathering to see this chappal clad, shirt and trouser wearing, nondescript old person belonging to another caste and community, being escorted to initiate the holy process.

This kind of affection, respect and love makes us family physicians feel that we made the right choice in choosing this branch of medicine