Eclipse of clinical medicine?

 

Some sixty summers back we medical students learnt the nuances of clinical medicine mostly on the bedside of the patient. That the patient generally was from a poor socioeconomic background, and who did not mind a group of enthusiastic students poking his abdomen to feel the hernial orifice or repeatedly placing the stethoscope on the chest to hear a heart murmur. These ward rounds were held in all clinical disciplines. Ward rounds resulted in a particular student or students being assigned to get the required tests done and do the follow up. This meant collecting stool and urine samples, drawing blood and if you are a senior student doing pleural, peritoneal tap and other such minor procedures.

 It also fell on us to take these samples to the lab attached to the wards or all the way to the pathology department and to collect the results when due. Often it meant to ferry not only the samples but also the patient. This kind of activity resulted in gaining knowledge not only about the disease but also on the other aspects of the patient, such as his socio-economic status and the why and what of his illness progression.

Thus, by the end of the final year most of us would have imbibed just not about the illness but some of the practical skills described above. During the houseman year these skills were augmented and it was not uncommon for a house surgeon to independently do surgeries such as hernia repair, circumcision, vasectomies, hydroceles and even appendectomy. If I remember right, we were to conduct 25 normal deliveries and assist/observe 5 abnormal ones.These were necessarily done as those days there were no PG students to compete with and the hands of the unit senior houseman and the assistant surgeon were always full!

Over these six decades, there have been far reaching changes in the learning process. First the number of medical colleges have increase exponentially and so is the number of medical students. Post-graduation appears to be the norm for most graduates. What was being done by the medical student of my days is being done by the post grad student/or superseniority aspirant of today. With so many medical colleges, many of them privately managed, there is also paucity of clinical material. Naturally a patient who has paid money to get admitted to a private ward would not like his private parts to be exhibited to a crowd of medical students. In addition, there is a great dilution of standards. I learnt that the present-day medical student is not allowed to conduct deliveries. Imagine an MBBS graduate who has not conducted a normal delivery being posted to a PHC faced with an imminent delivery. I was told it is the job of the nurse!

So, there is major lack of practical training and acquiring skills and the present-day medical student is a mere observer of the patient and the disease process with no direct involvement. Adding insult to injury, after the final year and during houseman ship year, most students waste their time preparing for the PG entrance test, when they should have been spending time acquiring the much-needed skills. There are some 20,000 odd PG seats available for nearly 60,000 aspirants. The remaining are left high and dry. Even those who manage to be one of the 20,000, may not get the specialty of their choice and thus many will end up as square pegs in round holes.

One of the remedies to this dismal situation is to strengthen primary care and see that the basic MBBS doctor acquires basic skills as described above. This will result in a more confident young doctor who when he enters practice will not refer the patient for the procedures which he himself can perform. If Primary care and family medicine is given status and importance, this mad rush for specialization of any sort will come down and there will be all-round improvement in the delivery of health care in this country

Dr Subashchandra

  

Subash, as I knew him

It was some 35 odd years back that I went to Chennai [then called Madras] to visit a patient of mine who had undergone coronary artery bypass graft at the Madras mission hospital. It was there that I first met Subash who had just then returned from the US and who was looking after my patient post op. Incidentally this patient is still alive and healthy. What began as a casual acquaintance then, grew into friendship which became closer and closer as the years went by and remained till his untimely demise.

There were many reasons for this strong bonding. We shared many interests other than medicine. Bird watching, Literature, old books, music to name a few. We also came to know as individuals with shared values. Subash being a person of impeccable integrity was often at logger heads with the corporate hierarchy and on occasions, this was the topic of our discussion and how to manage some of these tricky situations which he would often get into. His dedication to work and the kind of cardiology practice he had built up and his ability to get along with people would help him to overcome the many problems he faced in his illustrious career as a great interventional cardiologist and a team leader.  

Being older [not necessarily wiser] I was privileged to be privy of his confidences on more than one occasion and I fondly recall the time we spent discussing issues related and often unrelated to medicine and the ethical dilemmas that we often faced.

Over these three and a half decades I have referred patients with cardiac problems ranging from acute MI to sick sinus, various types of heart block, tricky septal defects, discordant ventricles and the like. On many an occasion he has managed my patients who would be certainly dead otherwise.

He is also responsible in helping me to interpret TMT tracings when I was not sure of the advice given to patients that it is positive and further investigations like angiography and stenting may be required. Quite often, his advice that the test results are normal has saved my patients lots of trouble and needless to say unnecessary hospitalization and money. There were several  other occasions when his advice has greatly benefitted my patients.

I cannot count the number of occasions when I have disturbed him in emergency situations, often at night, and the response was always the same, quick and to the point. There are many beneficiaries of his professional expertise and experience who are today alive to tell the tale of their recovery, thanks to him.

Some years back, while culling old books in my club’s library I came across a 1904 edition of Sir William Osler’s book Equanimata. Knowing that he collected old books, I presented it to him and I am sure it occupies a prime place in his library

For, nearly thirty years I ran an organization called Family Physicians Association, primarily to educate and update doctors and Subash was a regular teacher whenever a cardiology topic was being discussed.

I also run a small group of 15 doctors for the past 30 years which is called doctors club. This meets once a month mainly to update and discuss difficult problems that we have faced/facing and here too Subash was a valued invitee.

Let me conclude, all lives are precious, but some more than others, and my friend Subash’s is one such.

I miss him.

Dr B C Rao

Medical profession at cross roads?

 For some years now, the medical profession's esteem has taken a nose dive in the eyes of the general public. There have been many instances of abuse both verbal and physical against doctors. There is a perception with some justification that the profession is not living up to the expected ethical standards. Once much loved profession has now become a service which the public perceives as one which exploits the sick. Perception and truth are two different entities. As one doctor involved working in a corporate hospital told me some time back, that only 10% of the total bill amount actually goes to the treating doctors, but as they are the visible arm of the institution, the patients ire, if there is real or perceived mishap, falls on the hapless doctors. Adding insult to injury the craze for specialisation and super specialisation has resulted in a surfeit of these and they are concentrated mostly in urban areas where most of the tertiary care institutions are located. Now, if you consider that only 2 to 5% of the ill need their attention and that these doctors in the corporate health care vie for the upper middle class and the wealthy sick, it comes to even smaller numbers. The corporate honchos are in a position to dictate terms as there are too many of these super specialists vying for the few available posts. Naturally ethical medicine takes a back seat and revenue generation takes the front.Thus most doctors really work under duress and often forced to compromise ethics and there fore many are an unhappy lot.

The same is true in the public sector. Here too the doctors are unhappy as they are under the thumb of beurocracy that is often very ignorant of matters related to health. Working under often appalling conditions, with no hope of improvement in the working and living conditions, these doctors too are an unhappy lot.

Now arrives the Covid virus pandemic and the societal response to wards doctors and other front line workers is far from encouraging. Instead of whole hearted moral and material support, the citizenry seem to consider them as carriers and spreaders of the illness. Except a few among the politicians and beurocrats, most others think that doctors are like dogs who can be whipped to perform. Given the magnitude of the problem and the many decades of neglect of public health and primary care, the battle against the virus is fought by primary care and public health doctors who are not adequate in numbers and receive little support unlike the situation in the hospitals where the conditions are somewhat better.

Given this generally prevailing melancholy, will medicine attract youngsters as a career choice in future? Earlier days there were two classes of young who wanted to become doctors. One is the motivated who would want to become doctors with the aim of service and money was secondary [not always true], the other was the young progeny of the wealthy or who are going to inherit established medical institutions after their graduation [also not always true]. The latter gravitated mostly towards fee and donation run private medical colleges. what will happen now? With no social support and respect, stigmatised, under intense pressure from all quarters, will not an youngster and his family think twice before venturing to take medicine as a career choice?

My impression is that the clamour for medicine will drastically come down in both public and private medical colleges and am afraid quite a few will be forced to close down, more in private and less in public. In a way it may be good as only motivated young will take up medicine as a career and hopefully service in our government run primary health and speciality health care will improve.

 Interesting times ahead.

Education. Future as I see it.

 At present education is mostly is in the form of webinars and virtual class rooms. This is mainly due to the fear of spread of covid virus. This situation is likely to prevail for some time to come, likely to be for the next one year.

When things return to normal, will the education pattern return to pre covid times and is it necessary that the type of class room of pre covid days for imparting education? The answer is yes. But this getting back to conventional schooling does not mean that teaching should be confined to learning accepted material.If one accepts the fact that information in all topics is available at the press of a button why one would focus on providing information in our schools and colleges and presently a lot of time is wasted on this. If information is fed to a machine and that is programmed to perform a given job that it does it better and more accurately than an informed human, why one should waste time in learning the intricacies involved in engineering or commerce or for that matter medicine? It is quite possible in the foreseeable future AI will take over programming a task and the machine will do the task.

How and what then our children and young persons do in the schools of future? if learning and processing and ultimate use of information is done by AI and machines?

It is now realised that socialising and happiness are fundamental to health and longevity. Schools should concentrate on teaching these and basic living skills. How to communicate, how to use our hands and body to do manual work, to fix things around the house and majorly teach how to regreen the environment, If our young are taught the success is not acquiring power, wealth or attaining high positions, but in learning how to be contented and be happy and make others happy, I feel the purpose of education is served.

In medicine, commerce, industry and engineering too the same principles must apply. These will make the consumptive and acquiring one to move towards one which consumes less and prioritises relationship with nature and happiness as more important.

More and more humans will then engage in conservation and improving our fragile environment. They will change their living and eating habits and make this mother earth once more fertile.If this doesn't happen,as I wrote earlier, we will nose dive into Anthropocene phase and commit mass suicide as the Dinosaurs did in another era in the past.

Disruption

Many events have occured in the past that have had major impact on human life and have brought about cataclysmic changes in the way we have lived. To site a few in the living memory, the invention of automobile and air travel in the beginning of the last century. This put paid to the horse dependent transport and revolutionised travel.What was considered as distant became closer, intra continental and inter continental travel, which took days and months became days and hours. The laid back life in small communities gave way to big towns and cities and industrialisation galloped. This period also saw the beginning of increasing consumption of natural resources which only accelerated and we now have entered the dangerous anthropocene era which may be signalling the end of humans.

Next arrived the spanish flu of 1911-12. With no native immunity and in the absence of vaccine technology this virus killed millions and made human race realise the importance and the power of micro organisms. This also led the way to major changes in the life style and personal hygiene and public health assumed major roles in matters of health. A whole sea of change occurred and led to major advances in the fields of vaccine technology and discovery of antibiotics

World wars 1 and 2 again were major disruptive influences. Rabid nationalism and racial discrimination led human race to the brink of disaster. These aslo revolutionalised human thought and brought in women into the mainstream of life. Needless to say these wars also saw increased consumption and destruction of nature.

Next to arrive is the era of Computers. These have greatly eased the way businesses are done and the way we live. Precise and fast calculations, storage of massive data became possible. In the bargain every aspect of our lives has been touched by these machines and the so called privacy appears gone for ever. These machines have led to artificial intelligence which is threatening human brain. There is justifiable fear that a day may come when this AI will subjugate humans.

Now we are in the midst of another crisis. The emergence of a novel virus which is making disruptive rounds around the world. This virus known as Covid though not as lethal as the Spanish flu virus has caused enough turmoil partly due to its rapid spread and the fear of death and disability. Though the death rate is 3% in the young and 6% in the elderly with impaired immunity, nonetheless, for a population which has believed for every illness there is a cure, this illness for which there is no known cure as yet has come as a virtual death sentence. The embargo on social interaction,advice on facial mask and hand washing has made hitherto taken for granted life, that much difficult. The universal exposure of the populence to the electronic and print media which have a tendency to give importance to gory news have only added to the fear. What will happen to me if I get infected seems to be on the mind of most persons

In addition, this disease has caused major disruption in the economic and social activities and we appear to have entered into an era of severe economic, socio psychological depression.The frenetic efforts at the making of vaccine, which may take another year appears to be the only answer in the long run. In the mean time human kind needs to change its behaviour [social distancing, mask wearing and hand washing] to keep the virus at bay and the constant need for the comforting thought that even if get infected, I am likely to belong to the 96% who recover from the illness.

Anything good that one sees in this pandemic? Yes, the realisation that one needs to live a symbiotic life with nature seems to have been realised. The relative stop to consumption may have slowed the process of racing into the Anthropocene era.

Anxiety

anxiety is a state of mind where in there is a constant run of negative thoughts that does not allow the person to perform and live his routine life. I experienced this in the past few months. Several events contributed to this. One is the announcement of lockdown. This prevented the normal social interaction at all levels. For a person, who lived outdoor life 4 to 5 half days a week and enjoyed playing and being with friends, this was like a jail sentence. Worse, the benumbed mind did not allow me to do any constructive thinking and do any writing. There was a constant feeling of restlessness and mild tension.Though the medical practice was only part time and numerically small, the enjoyment of interacting with patients,many of them, my friends, left me quite frustrated. Tele,video consults are no replacement for face to face interviews.

Then occurred another event 4 weeks ago which compounded the ongoing simmering anxiety. My 86 yea old sister in law who has progressive dementia, living alone with a helper,worsened and became unmanageable. We had to wind up her apartment in a hurry and shift her to our home. Then we had to do some frantic search and luckily were able to admit her to a dedicated home.All this took three weeks of intense tension for both of us.Since the past one week I [we] are able to unwind a bit. though the ongoing anxiety,though much less, remains.

What were the signs and symptoms that I experienced during this hard time? The one constant was the feeling of mild sinking in the pit of stomach.This would occasionally become worse, some times associated with nausea but no vomiting. Next was episodes of sweating which worsened when ever there was a phone call or when thoughts of what is going to happen next came up. Third was a mild head ache located at the temples. Sleep was hard to come by and when it did it was disturbed and that too only in the wee hours of morning.All these were classical signs and symptoms of anxiety state but not the dry coughing bouts. On some days when action was involved like shifting her to that home or bringing her to our home, it would be there all the time. On other days it was only for some time in the mornings. In fact if some one heard me coughing like i did they would presume that I had covid infection! Surprisingly,my pulse rate remained normal.

when once she got admitted the first symptom to to go was the sinking feeling, followed by attacks of sweating and the coughing bouts though the early morning ones remained. Sleep too improved. Since the last ten days my tele consults and seeing an occasional patient and friends in person has helped to calm me down and the prospect of restarting my out door activity too has helped to ease up

One can imagine the logistics night mare that we had to go through with restriction on vehicle movement, with the dementia patient living 20 kms away and the dementia home 30 kms away. This was the kind of situation when one realises how important to have close friends. Many helped us to see us through these tough months.

You might wonder, why then the anxiety still on.

Very, mild bearable, mostly due to worry regarding the relative settling in that home and to some extent, thinking about the plight of millions of the socioeconomically disadvantaged country men and women

We are a resilient people and hopefully,in the coming months we will be able to successfully weather this storm.

Information Deluge

Since the advent of Covid19 into our country there has been a flood of information. What started as a trickle has now become a flood. Electronic and paper media are full of the news related to this virus. As I sit and analyse the various reports, I get this impression. Bad news gets more publicity that good news. More gory the details more newsworthy is the story and there is and will be many such stories in future.
Let us look at some facts.

At the time of my writing this piece, there were 75000 positive cases with 1600 deaths. Which means less than 1.5% of the infected cases, which is better than what is seen in most countries.  Even if one considers the possibility of inadequate data collection, the figures are still low. Is this encouraging figure because of the success of social distancing and mask wearing? To some extent it may be, especially because of imposition of travel restrictions. But social isolation of keeping 6 ft away from one another,is an impossibility given the socioeconomic conditions prevailing in our country. So one can take it that it has not been implemented except may be in the 10% upper economic strata. So is mask wearing, though I see many wearing masks, most may not know how long the mask lasts. Cloth masks need to be washed in detergent solution daily. Surgical masks last for 4 to 6 hours and needs to be discarded. N95 masks can also be reused, but again needs to be sanitised before use. I asked a few persons and most of them didn't know these facts. So I presume, this mask wearing too is more or less been not very effective.

Then why is the mortality, is so low? I see the following reasons

1 Travel restrictions
2 Demography. Only 15% of the population are elderly who are more susceptible. As these do not normally socially interact and their numbers are small this could be one major factor.
3 Efficient public health and primary care. In states like Kerala where these are strong the spread is also very slow. In some states who have the machinery in place for disaster management like in Orissa too this is true. States like Karnataka too have shown good results
4 Virus mutation and environment. It is possible that hot weather and a less virulent strain mabe other factors.

What is the likely scenario when the lockdown is lifted

There will be a spike in positive cases and the mortality figures may show a slight increase, when once the travel restrictions are lifted and economic activity restarts. But the doomsday predictions of people dying on our streets etc etc is most unlikely to happen.

Some advice from an old person

We humans are social animals. Social isolation is detrimental to mental and physical health. We should meet and interact. Of course, we need to sanitise our hands, wear proper effective masks and if possible keep a safe distance. In case of flu like symptoms not going in a couple of days get tested with out panic. Remember, it you are young you belong to 93% who will recover and if you are old there is 85% chance of full recovery

And for the next three moths watch less of news TV, read less of newspapers and don't read and what's app forwards!