Those were difficult days. Difficult in more than one sense. Professionally, there was a trickle of indifferent patients with an occasional house call thrown in. For most of these, I was either the second or third choice physician. Who would come to a young man just out of medical school, working out of an unimpressive single room and who for most of the time was found either sitting idle or reading the day’s newspapers? Most of them were also drifters whose usual mode of payment was a promise to pay tomorrow. Neither that tomorrow nor the patient would ever come.
Such was my state when I was called to see an eight-year-old boy at home. House calls those days were welcome as they brought in much-needed additional income. I went with the mother to see the boy. I found him in bed, looking fairly OK except for a fever of 103 degrees. After the usual examination and assurance that all would be well in a couple of days, I was about to leave when a young voice behind me asked if I would like to wash my hands. A bright and pretty 12-year-old stood with a soap tray and a towel near the wash basin. More to accede to her request than for any real need to wash, I washed my hands and returned home. After two days, the call came again. The boy continues to have fever and would I mind coming again to see him? Racking my brain as to what could be the cause I rushed to his home. Those inexperienced days only the worst and the rarest illnesses would come to my mind and by the time I reached his home, I was prepared for the worst scenario. I found him sitting in bed reading a comic. I examined him, found everything normal except for the temperature which was now 102 degrees, and lower than last time but high enough to cause worry. I thought it was time to get a few basic tests done to find out the cause. I asked the mother to get these done and after the ritual hand-washing, ably assisted by that charming sister of the patient, returned home.
The next two days were agony. It is every doctor’s hope when treating these cases that the fever would go away and peace would prevail. This is what I was expecting when the mother came to see me in my clinic. I went through the sheaf of lab reports she had brought. They were all normal, and she said, ‘Doctor, my boy still has fever of 102 degrees and would you mind seeing him?’ With growing desperation, I reached his home. The patient was nowhere to be found. A frantic search in the house did not produce the errant patient. Enquiries revealed that the boy was playing cricket in the next street. A sick boy with a 102-degree fever of unknown cause playing cricket! That too in the hot afternoon sun! Blasphemy. My heart sank and I sat rather heavily on a nearby chair. The ever-present assistant brought me a cup of merciful water to drink.
The mother and daughter combination succeeded in bringing the wretched boy home and forced him to lie down on the bed. I examined him. He appeared to be in fine fettle except that he resented this unwarranted interference with his cricket. I took his temperature. It showed 102 degrees! I stood there looking at the thermometer and wondering what to do next. I heard the voice of the sister asking me, ‘How do you know that the thermometer shows the correct reading?’
Yes how? I quickly washed the instrument and thrust it under the tongue of the young girl. After a minute’s anxious wait, it read 102 degrees!
It took a 12-year-old girl with an enquiring mind to spot the problem. It was such a relief to know that the boy had no fever that I almost forgot to thank his sister and congratulate her. I asked them to buy a new thermometer, discharged the patient to resume his cricket and with a dancing heart, returned home. Since that episode the young lady and I have both aged. She went on to do her graduation, post-graduation and has settled abroad. We have kept in touch; when she visits me, I see in front of my eyes a chirpy 12-year-old who taught me the home truth that common sense and an enquiring mind is often more important than knowledge in one’s professional life.
Sunday, October 7, 2007
Thursday, October 4, 2007
How to choose your doctor
I am sure most of you have faced this problem at one time or the other. For many of you who have the benefit or otherwise of a regulated health service where the decision is made for you and you really have no choice but to go to particular doctor. There are others who are living in a free market economy with the government run health services being what they are [like in India] have no choice but to select a personal physician in the immediate neighborhood. How does one go about doing it? I asked several persons some time ago and also some of my new patients why they chose me. The replies narrated here, I hope will make interesting reading.
Many said they asked their friends for a referral. The friend who recommended, if knowledgeable as to the doctor’s ability would have done you a service. God forbid, if he is one of those who believed in the dictum that there is a treatment for every itch and stitch in your body, then you would get referral to a doctor who is fond of medication and you will end of getting treatment for any and every complaint of yours and may be get investigated from head to foot.
The other common source of recommendation is the neighborhood chemist, the mister know all of medicine. This man can make or break you with his advice. If he likes a doctor because he gets a lot of prescriptions from him, it is likely that you are dealing with the type of doctor mentioned above. Sometimes he can be quite perceptive and may recommend the right type. But most businessmen chemists have no idea as to judge the merits of a doctor.
Another source is your previous doctor. This occasionally works. But here too, the recommendation is based on personal friendship rather than the knowledge of one’s professional efficiency. I know of a well known orthopedic surgeon of the city who recommended a very mediocre physician to his own cousin!
The other rare method is when you are going for a walk, you see the doctor’s board and you decide to pay him a visit. This may or may not work.
Thus as you can see, none of these are foolproof. Most patients, however after a period of trial and error, get the type of physician of their liking sooner or later, but the example of how two of my patients chose me is interesting.
She was a middle aged woman who dropped in with complaints of aches and pains and also to get her blood pressure checked. After the examination and consultation, she made a strange request, ‘Doctor, will you please check my pulse.’ I thought she wanted me to count her pulse properly which I had not done because while taking her blood pressure I had an idea of her pulse rate too. But I felt it to be a reasonable request and I had nothing to loose but a few extra minutes. So I proceeded to count her pulse. Normally the radial artery is located on the outer front aspect of the wrist and easily felt. But in this patient I couldn’t get the pulse. I groped around for a few minutes and felt the other wrist with the same result. No pulse! I then went up and felt the brachial artery where the blood pressure is taken. Presto! The bounding pulse was felt! I counted the pulse and made sure that the blood supply to her hands was alright. I told the lady that both her radial arteries are placed under the tendons and could not be felt and warned her to tell her next doctor this fact. She smiled and said, ‘there is going to be no next doctor, you are my doctor’. She had gone to three doctors before she came to me and all the three had failed in this test! She knew of her anomalous arteries and has been using this as a test to test the efficiency or otherwise of the doctor. According to her this is a foolproof test and those who passed this test have turned up to be good doctors! Though a bit put off by this way of choosing I could see some merit in her method.
The other person’s explanation was straight forward. He followed his doctor father’s advice. ‘Go to a doctor whose patients waiting area is never very full or never fully empty. The person whose waiting area is overflowing will not have time to examine you properly and the other fellow who has no patients is obviously no good’. Fortunately he found my clinic fulfilling these two criteria on the day he sought my help!
Some aches are private and silent
Some open and obvious
Some need to be told and shared
But all must be endured
Many said they asked their friends for a referral. The friend who recommended, if knowledgeable as to the doctor’s ability would have done you a service. God forbid, if he is one of those who believed in the dictum that there is a treatment for every itch and stitch in your body, then you would get referral to a doctor who is fond of medication and you will end of getting treatment for any and every complaint of yours and may be get investigated from head to foot.
The other common source of recommendation is the neighborhood chemist, the mister know all of medicine. This man can make or break you with his advice. If he likes a doctor because he gets a lot of prescriptions from him, it is likely that you are dealing with the type of doctor mentioned above. Sometimes he can be quite perceptive and may recommend the right type. But most businessmen chemists have no idea as to judge the merits of a doctor.
Another source is your previous doctor. This occasionally works. But here too, the recommendation is based on personal friendship rather than the knowledge of one’s professional efficiency. I know of a well known orthopedic surgeon of the city who recommended a very mediocre physician to his own cousin!
The other rare method is when you are going for a walk, you see the doctor’s board and you decide to pay him a visit. This may or may not work.
Thus as you can see, none of these are foolproof. Most patients, however after a period of trial and error, get the type of physician of their liking sooner or later, but the example of how two of my patients chose me is interesting.
She was a middle aged woman who dropped in with complaints of aches and pains and also to get her blood pressure checked. After the examination and consultation, she made a strange request, ‘Doctor, will you please check my pulse.’ I thought she wanted me to count her pulse properly which I had not done because while taking her blood pressure I had an idea of her pulse rate too. But I felt it to be a reasonable request and I had nothing to loose but a few extra minutes. So I proceeded to count her pulse. Normally the radial artery is located on the outer front aspect of the wrist and easily felt. But in this patient I couldn’t get the pulse. I groped around for a few minutes and felt the other wrist with the same result. No pulse! I then went up and felt the brachial artery where the blood pressure is taken. Presto! The bounding pulse was felt! I counted the pulse and made sure that the blood supply to her hands was alright. I told the lady that both her radial arteries are placed under the tendons and could not be felt and warned her to tell her next doctor this fact. She smiled and said, ‘there is going to be no next doctor, you are my doctor’. She had gone to three doctors before she came to me and all the three had failed in this test! She knew of her anomalous arteries and has been using this as a test to test the efficiency or otherwise of the doctor. According to her this is a foolproof test and those who passed this test have turned up to be good doctors! Though a bit put off by this way of choosing I could see some merit in her method.
The other person’s explanation was straight forward. He followed his doctor father’s advice. ‘Go to a doctor whose patients waiting area is never very full or never fully empty. The person whose waiting area is overflowing will not have time to examine you properly and the other fellow who has no patients is obviously no good’. Fortunately he found my clinic fulfilling these two criteria on the day he sought my help!
Some aches are private and silent
Some open and obvious
Some need to be told and shared
But all must be endured
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
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
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.
Miscellany
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.
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.
Miscellany
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.
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.
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.
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