MCI has recommended an increase in the number of seats in the medical colleges and this will help to meet the need for doctors in the country. The human resources ministry also seems to think that by allowing or forcing the IITs to double their intake they will meet the demands of the industry and also will help the socially and economically weaker sections to get access to these premier institutions.
Is increasing the numbers without caring to increase the infrastructure [buildings, equipment, and personnel] bring about the desired result? Answer is no and one can see this happening in post independent India. There is definitely an increase in the number of professionals of all types but their quality has suffered over the years as evidenced by the calamities we hear every day in the media [collapsed bridges, train accidents, fires, buildings giving way, patients dying because of wrong treatment]
Some twenty five odd years ago Late lamented Prof B.G.L.Swamy wrote more out of sorrow than anger, ‘I was forced to take double the number of students for the course, this and the number of repeaters made the work of conducting examinations in a decent manner nearly impossible. When I brought this to the notice of the principal of the college and the director of education, the common answer was ‘Swamy, you have to manage somehow’ this somehow resulted in students taking examination, spilling over to the pavement. The principal who came to inspect, seeing students sitting on the pavement, tried taking his ire on me. I said,’ sir, what you see inside the room is any and the one you see on the pavement is how’
This over flowing ill trained students become tomorrow’s professionals and what we are seeing all around is the handiwork of these. A flock of sheep incapable of original thought and deed, capable only of incompetent repetition and blunder.
Who can save this country full to the brim with incompetence?
Thursday, February 23, 2012
Monday, February 13, 2012
Cult of violence
The incident of a 15 year old student stabbing his school teacher to death should come as an eye opener to most of us. While not condoning the student who was driven to this, one should consider why he did this. The teacher who was concerned with the poor performance of the boy reported it to his parents who in turn took the boy to task and the enraged boy took out his frustration on his teacher. For many students, the present day schooling and the methods of learning are worse than spending time in jail. A society which puts scholastic performance as the acme of achievement places enormous pressure on parents and indirectly on school teachers who in turn pass on this burden of performance on school going children.
In post independence India there have been two primary casualties. One is health and the other is education. The government has gradually withdrawn its responsibility of providing these two to its citizens and has allowed the private players to enter the field. I wrote some time back on corporatization of health and the aftermath. The same is happening in the field of education. All sorts of player whose motive is to make money are entering this arena across the board from primary education up to post graduate level. This has not come cheap. These institutions are prohibitively expensive education shops. A situation has arisen in this country where in an average parent is finding it difficult to foot the education bill of his or her children. I know of many who are either stopping at one child or not having children at all for this reason!
Those who do send their children to these privately run schools are under considerable financial strain and to get a report that their ward is poorly performing and thus a poor return on investment must be indeed galling. They will vent their anger on the child and he in turn will resort to violence either on himself or on others, in this instance on the hapless teacher. Suicides are not uncommon during exam time and at the time the results are made known.
To add fuel to fire is the general atmosphere of violence in which we are living. Our media, TV serials and movies, Computer games that children play, glorify violence. A child who grows in this kind of atmosphere can easily justify violence [a la Taliban].
In this land M.K. Gandhi. We are slowly and inexorably slipping into a land of himsa [violence].
In post independence India there have been two primary casualties. One is health and the other is education. The government has gradually withdrawn its responsibility of providing these two to its citizens and has allowed the private players to enter the field. I wrote some time back on corporatization of health and the aftermath. The same is happening in the field of education. All sorts of player whose motive is to make money are entering this arena across the board from primary education up to post graduate level. This has not come cheap. These institutions are prohibitively expensive education shops. A situation has arisen in this country where in an average parent is finding it difficult to foot the education bill of his or her children. I know of many who are either stopping at one child or not having children at all for this reason!
Those who do send their children to these privately run schools are under considerable financial strain and to get a report that their ward is poorly performing and thus a poor return on investment must be indeed galling. They will vent their anger on the child and he in turn will resort to violence either on himself or on others, in this instance on the hapless teacher. Suicides are not uncommon during exam time and at the time the results are made known.
To add fuel to fire is the general atmosphere of violence in which we are living. Our media, TV serials and movies, Computer games that children play, glorify violence. A child who grows in this kind of atmosphere can easily justify violence [a la Taliban].
In this land M.K. Gandhi. We are slowly and inexorably slipping into a land of himsa [violence].
Thursday, February 2, 2012
Wodehouseana
I first read P.G. Wodehouse when I was in school. Both my knowledge of the language and the society in which the characters created by Wodehouse lived were rudimentary. I only read them to please my English teacher and never understood a word of what he wrote. I read him again when I was in college and the results were a bit better. I must have read and re read them many times since then and now his books are my refuge. Whenever my moods turn sour which is often, I take recourse to his books and return refreshed.
Many have told me he is a farce. Of course he is. But he makes me happy. He created a new world of farce based on characters drawn from pre Second World War British society and the characters have stood the test of time and have never become stale. The stories written 75 years ago can still make you laugh. One doesn’t have to necessarily go back to that era to enjoy his works. There is no need to imagine the scenario as it is vividly described when the characterization is done.
Wodehouse was an avid golfer. Another reason for my liking him. He once famously said,’ I wasted the first fifty years of my life because I began playing golf only after’. All golfers will whole heartedly agree with this sentiment. Our lives will be barren and purposeless [exaggeration?] if this game is taken away from our lives. He created a character, an elderly retired gentleman who no longer could play golf but who nevertheless waylaid the unwary in the clubhouse and told them stories recalled from his memory. The stories told by this oldest member [Sage] is available as golf omnibus and these too can be repeatedly read without loss of flavor.
The outstanding characters are of course that of Bertie Wooster and his valet Jeeves. The related uncles and aunts, friends and acquaintances, churches and clergymen, country houses and city clubs fill his books. Some characters are outstanding such as the pig lover Lord Elmsworth and the genteel poor PSmith.
At present I am reading another of Wooster stories and how he is being helped to get out of or prevented from entering holy matrimony yet again. It is fun reading.
Those of you, I am sure, who get occasionally depressed, given the dismal environment [at least true in India] will surely benefit if you take up reading him.
Happy reading
Many have told me he is a farce. Of course he is. But he makes me happy. He created a new world of farce based on characters drawn from pre Second World War British society and the characters have stood the test of time and have never become stale. The stories written 75 years ago can still make you laugh. One doesn’t have to necessarily go back to that era to enjoy his works. There is no need to imagine the scenario as it is vividly described when the characterization is done.
Wodehouse was an avid golfer. Another reason for my liking him. He once famously said,’ I wasted the first fifty years of my life because I began playing golf only after’. All golfers will whole heartedly agree with this sentiment. Our lives will be barren and purposeless [exaggeration?] if this game is taken away from our lives. He created a character, an elderly retired gentleman who no longer could play golf but who nevertheless waylaid the unwary in the clubhouse and told them stories recalled from his memory. The stories told by this oldest member [Sage] is available as golf omnibus and these too can be repeatedly read without loss of flavor.
The outstanding characters are of course that of Bertie Wooster and his valet Jeeves. The related uncles and aunts, friends and acquaintances, churches and clergymen, country houses and city clubs fill his books. Some characters are outstanding such as the pig lover Lord Elmsworth and the genteel poor PSmith.
At present I am reading another of Wooster stories and how he is being helped to get out of or prevented from entering holy matrimony yet again. It is fun reading.
Those of you, I am sure, who get occasionally depressed, given the dismal environment [at least true in India] will surely benefit if you take up reading him.
Happy reading
Monday, January 23, 2012
Conference
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!
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.
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!
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?
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?
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