Sunday, October 28, 2007

First patient

At the start of any venture it is difficult. Medical profession is no different. Especially true when there are so many of us competing for the same custom. The memory of my first patient is still vivid though it occurred some 35 odd years ago.
She came in wiping perspiration off her forehead. Her opening remark was that I should fix an awning in front to prevent the sun shining in. I had not even thought of that as a necessity. After this opening gambit she settled down to the business of finding out my antecedents. After confirming that I am a qualified physician who uses allopathic medications she took out a bundle and small note. Inside the bundle there were foils and small bottles of leftover medications. She said, referring to the note she had in her hand, ‘doctor these are all medicines I bought but have not used and the market value is Rs----- [this she had calculated after consulting with her chemist]. I am willing to give them for Rs--------- which you can see, is less than 50% of the value’. She sat waiting for my answer. Taken aback, I told her that I am not a dispenser of medicines and therefore these were of no use to me. She must have read the disappointed look on my face [as I realized that she was not a patient] as I too did on her face [because I would not buy her medicines].
She grabbed her bundle and giving me a rather pitying look went her way.
I sat wondering if this was what general medical practice was all about?

Thursday, October 25, 2007

Lost weight

Our paths often crossed which was unavoidable. We lived in the same locality and belonged to the same club and she was a fixture in most of the club parties, receptions and get togethers of common friends. She was a woman of uncertain age, weighed 80 kilos which was heavy even for a big built woman like her. Whenever she came to see me it was for obesity related problems and my standard treatment was to hand out a diet chart, which she cheerfully ignored, but kept complaining that despite her dieting her weight remained constant.
Normally when I go out for an evening party which is rare, I try and get back early and when this lady is present it was even earlier. Let me explain why. No sooner the food was laid she would slide up to me and tell me loudly ‘doc, you are a busy man and must be waiting to get back come, you have your meal’ and would virtually drag me to the table, sometimes even handing me the plate. This worked fine with me as I was usually happy to get away from these parties, but once in a way I found it annoying when the host or the hostess is a close friend and I wanted to spend some time there.
On one such evening we were forced in her usual manner to eat an early dinner and depart. We had gone home and my wife remembered her handbag which she had left behind and wanted me to go back and retrieve it. Rather reluctantly I went back to the venue and went straight to where my wife was sitting and to my relief found the bag. I also found sitting there my patient with all her flesh and fat, with her plate heaped full of richest of foods! At my rather cruel and unexpected return her reaction initially was one of surprise and then a mixture of guilt and consternation. I should have wished her goodnight and gracefully got back, but couldn’t help telling her to come next day to my clinic and check her weight!

Sunday, October 21, 2007

Doctors' handwriting

He came in supported on the one side by the son and the other side by the daughter in law. With some difficulty we succeeded in getting him to lie down on the examination table. The history that I could get was that this gentleman was feeling sleepy and tired and not his usual self for the past two weeks. He had seen several doctors and he was in a hospital for a few days. They had a sheaf of papers which included lab reports and X-rays. Those days there was no CT/MRI and I am sure had these modalities been available they too would have been used. All the reports were normal

I proceeded to examine him. He answered my questions fairly correctly but in a slow slurring manner. He was more interested in sleeping than getting examined but was quite docile and cooperative. I did not find anything wrong with him. I found he was on medication for high blood pressure with a combination of beta-blocker [ a popular drug even in those days] and a diuretic. I knew this combination can very rarely produce some weakness and electrolyte imbalance. As I had nothing else to cling on to, I changed his blood pressure medication and asked the relatives to bring him after a few days.

A week later the gentleman came, this time unescorted. Looked and behaved perfectly normal. I too found him normal on examination and told him that it is possible that his blood pressure medication was the cause. He seemed to agree but on parting told me that there have been periods when he felt perfectly normal even when he was on the old medication. This dampened my spirits a wee bit. Nevertheless, seeing him normal was a relief and I hoped that he would continue to be normal hence forth.

He came back two weeks later. Status quo ante. Same story, nothing abnormal on examination but patient distinctly abnormal. When I was literally scratching my head the daughter in law said, ‘doctor he suffers from acidity and takes daonil tablet once in away and when ever he has acidity he has this problem’. Now I had the answer to the problem my friend was having. Daonil is the trade name for an anti diabetic drug called Gliblencamide and he naturally was going in for hypoglycemia [low blood sugar] when ever he took it. But why was he taking this drug for acidity? I asked her. Doctor prescribed it she said. I know there are lots of fools among us doctors but none as foolish as this. I asked her to get the old prescriptions and sent the patient for an urgent blood sugar test and gave him some sugar water to drink after the blood draw. With in the next 15 minutes the patient became near normal.

The blood sugar came as 40 mgs %, low enough to cause problems. The lady came with the old prescription of his previous doctor. The writing was not very legible but I could surmise that the name meant was Diovol [an anti acid drug] and not Daonil and the chemist was happily dispensing daonil when ever our friend developed hyperacidity and that explained why he got the hypoglycemia and also the prolonged periods when he was normal.

It was a relief to all concerned. The patient was put back on his old medication for blood pressure which had controlled the blood pressure better than the one I had prescribed. It was thus a happy ending.

Doctors are known for bad handwriting. But this was my first experience of it causing a near disaster.

Purpose of life.'To laugh often and much; to win respect of intelligent people and the affection of children; to earn the appreciation of honest critics and endure the betrayal of false friends; to appreciate beauty; to find the best in others; to leave the world a bit better, whether by a healthy child, a garden path, or a redeemed social condition; to know even one life has breathed easier because you lived. This is to have succeeded'. [Adopted from Emerson]

Friday, October 19, 2007

Please make me sick

In the beginning years of my practice I have had a lot of trouble with certificate seekers. It is one thing to give a sickness or fitness certificate if the seeker has been my patient but it is altogether a different matter if one seeks such a certificate with out ever being my patient. Most of the certificate seekers who bugged me to no end in those days belonged to this class who wanted these certificates with out having suffered any illness.

Those of you who are not well informed as to how our people live and work the caption I have chosen for this piece may appear strange. But to those of you who are either government servants or working for public sector units or one of those who at one time or other tried to dodge an appearance before an income tax officer or a magistrate or any other such law enforcement agency will readily understand.

Why this class of people? In my country the state runs the show and there fore interferes with all aspects of our living. Except the air we breathe everything else is controlled to a more or less extent by the state. To man these various arms of the myriad departments the government has appointed a large number of people who go by the eponym ‘government servant.’ In today’s India if there is one group of people most disliked, it is this group. This is because the philosophy of governance in this country and the rules of selection are such that the best quality of human resources that is available isn’t used in administering the services. Persons who are thus employed are the ones who make the rules and regulations that govern their service and over years they have seen to it that they have the best of every thing with accountability spread so thin and wide that it is impossible to hold any particular individual accountable for any lapse.

Therefore it should not come as a surprise that they enjoy plenty of leave. If one adds up the various leaves and the government declared holidays it will come to nearly six months! This means 50% of the time they are not working! One would imagine this would be the most satisfied group. Far from it. They are in constant need of more leave. The only option left after they finish the allowed leave is to avail of medical leave. Going by the available records it appears that employees of socialist governments have a higher incidence of sickness. And these governments provide their employees additional leave to take care of when they fall ill. But there is one hitch. The employee who falls sick has to produce a medical certificate from the attending doctor. So the employee in need of additional leave will go to a doctor and entice him to give a medical certificate. It is generally fairly easy to get such certificates. Occasionally however they go to doctors who are unwilling to issue such certificates.

I am one of these and let us see what happens when such a certificate seeker comes to me. He is usually a stranger because my regular patients know they will not get these false certificates and therefore they don’t bug me.

Here comes the certificate seeker. It is 3 P.M. in the afternoon and I am pottering around in the garden at least that is what I call the small patch of land in front of the house. To catch my attention he knocks violently on the gates and forces me to turn around and look at him, ‘Is the doctor home'? he asks, obviously he takes me to be an inefficient gardener. I don’t blame him for this. In my half pants and the faded T-shirt I must have looked anyone but a doctor. Seeing in front of me a fairly fit looking man who obviously is not in need of any urgent medical attention, I tell him.’ Doctor will start working from 5 p.m. and will not see any patients till then.’ He gives me a dirty look and says, ` go and tell him that I want a certificate and it is urgent’. ‘He will not give sickness certificates to fit persons’ I reply. `How do you know with out asking him’? He persists. Now I am forced reveal my identity. I tell him, ` I know because I am the doctor’. He stands there for a while staring at me obviously not believing what he is seeing, then he goes. He must have thought it better any way not to take a certificate from this kind of doctor who does not look and sound sane!

Another man enters my consulting room and sits. I ask him what the problem is. ‘No problem’ he says and is again quiet. Then why have you come? I ask. He gives me a conspirational grin and says, ‘I want a medical certificate’ and specifies 15 days as the time I must make him sick. I am now curious to know why he has come to me, does not he know that I don’t give these certificates? I ask him. Yes sir, I know but I come because factory personnel officer told me to get one from you, then he [the personnel officer] says the management will sanction leave, I refuse to oblige. He goes out in a huff.

Another example. This man enters with a swagger, chest out, top button of the shirt undone with a scarf around the neck in true filmy villain style and demands. ‘Give certificate for one month’. I ask him why? ‘Why, I asked you that is why’ he replies and I refuse, but to make matters clear to this man I take the trouble to explain, ‘ I give sickness or fitness certificates to those who have taken treatment from me but not to others’. His look now became menacing and he shouts at me, ` what do you mean? Are you not a doctor? Do you know who I am; I am the secretary of workers union ’. This was clearly a threat to coerce me to give him a certificate. I pick up the phone and dial the police. He doesn’t expect this. He says` why call the police, what can they do? You think you are the only doctor around? There are any number who will give me what ever certificate I want, you stuff your certificate up your --, he says with a loud shout and goes.

Another certificate seeker enters and requests timidly for a sickness certificate. He appears really in need of this. I told him why I couldn't oblige him. He politely listens and asks,' are not you qualified?' I saw the board in front that says you have MBBS and other degrees in front of your name? Now this man is clearly under the impression that any man who has medical degree must give a certificate false or otherwise and a degree is a passport to commit this offence which he doesn't even know is an offence. I tried to explain my point of view and that doesn't impress him, he had come with fond hopes of easy success. He asks me who else does this, I give several names. He appears happy and gives me a parting shot, 'don’t worry doctor I will not tell the police about your degrees! He obviously is under the impression that as I am reluctant to give this certificate which is the right of a qualified graduate, my refusal means only one thing, my degrees are false and police can take action if he lodges a complaint! And by the magnanimity of his heart he is not doing it and is allowing me to carry on my nefarious unlawful activities!

Another guy comes and puts his demand. I tell him the same story of my not giving false certificates. 'That I know saaar, but my company's personnel officer has asked me to bring it only from you', he said. This was interesting. Why would the company's personnel chief would ask a certificate to be brought specifically from me? Curious I called the guy in question and asked him the reason. Doc, he said,' our managing director knows you don’t give false certificates and one from you will make him believe and I am interested in getting this employee this leave which he deserves though he has used the leave for some other purpose'. This left me speech less and it took me some persuasion to convince him to send the unfortunate leave seeker to another doctor!

In a scenario where doctors keep printed forms where in they only will have to fill the name, illness and the duration of leave required and liberally give these to all and the sundry, if one considers me crazy in the head and not qualified will you really blame him?

This was written before the days of economic liberalization when the hold of government on our lives was worse that it is now

Sunday, October 14, 2007

Health. An ecological perspective.

Two isolated yet related events made me write this article. The first was a tucked away news item in a newspaper which said that the central government has issued instructions that hence forth bamboo is to be preferred to wood in making furniture required for use in government offices. The other was my reading the proceedings of a symposium held during Dec 98 at Rishy valley on environmental problems.

The government order on the use of bamboo was with the intention of saving wood and there by trees which are felled legally or illegally all over the country, to make furniture and fittings, news print and for use as fuel. Vast areas of forest have disappeared to meet this demand. The universal use of tables and chairs and wooden cots in middle class Indian homes is comparatively a recent phenomenon. About 75 to 100 years ago we managed with cotton durries and cushions and used reed mattresses for sitting and sleeping. Use of chairs for sitting has brought in its wake some problems such as stiff back and hips. A sample survey of 50 men and women of middle-class were asked to squat from a standing position and the get up with out support. Most of them failed this test did not come as a surprise. This is one minor example of use of furniture on health. The larger issue of cutting trees on a large scale is much more dangerous. Cutting trees results in washing away of the top soil and silting of our rivers which overflow the banks and inundate vast areas of land with loss of cultivable land and creates swamps that breed mosquitoes and you know what happens when the population of mosquito increases. There is a resurgence of malaria, filaria, encephalitis and dengue fever. There is also increase in the incidence of cholera, typhoid fever and gastroenteritis which is due to contamination of drinking water with sewage which is common during floods.

You hear of inadvertent trespassing of whatever little wild life there is on to human habitat. This is because of destruction of their habitat partly due to encroachment and partly due to destruction of forest cover and disappearance of feeder species of plant and animal life. Bamboo furniture is not going to solve the problem. Large-scale cutting and use to make furniture out of bamboo is also not the answer, as bamboo groves naturally growing, is a link in the ecological web of the forest. The ultimate solution lies in changing our life style and going back to way of our forefathers. Our homes then will not have to have wood based products. Metal can be a better substitute to wood and may be, less ecologically damaging. Destruction of plant cover that includes forests has serious long term economic and health consequences.

Rendering the land fallow will mean desertification with no economically feasible agricultural activity with the resulting less grain production and starvation. Malnutrition related illnesses are very common in our country. Malnutrition invites all kinds of illnesses including that major scrounge, tuberculosis. To sustain minimum nutrition standards we need to increase the grain production. We have so far done this by taking recourse to introducing hybrid high yielding crops with ample supplementation of the soil by chemical fertilizers and keeping the pests at bay by using liberal doses of pesticides. This has proved a very shortsighted success and has had disastrous long-term consequences. These pesticides and chemicals have already got into our systems and the result is that we are seeing an increase in the incidence of hitherto unknown illnesses and an increase in the incidence of cancer. The land enriched with chemical will not sustain plants for long and we will be in for a major disaster if these practices are continued.

The only viable solution is to use organic natural manure for which we need animal and plants and above all abundant supply of water. Many parts of our country that once sustained verdant plant and animal life is now fallow. Large areas of such land can be reclaimed not with western technology but by following methods indigenously developed by pioneers. Efforts of a single man, Rajinder Singh has brought about an agri revolution to 650 villages in Rajasthan. What he did, million others can repeat. He simply observed the natural flow of rainwater and built check bunds to slow the rate of flow and made this water collect in small and large percolation tanks. This made the water table go up and charged the wells which were hither to dry. This primary phenomenon of availability of life sustaining water makes all the difference to the lives of our people from one of poverty and misery to one of at least minimum sustenance. This will also arrest the flow people to town and cities in search of livelihood. Rishy valley is another such example. What was once barren land of dust and rocks has been successfully greened with immense economic benefits to the villages around. The same result can be seen by the work of Anna Hazare at Raalgoan Sidddi in rural Maharashtra. When once a villager becomes self sufficient in food, his and his family's health improves and he will listen to what we talk about family planning, sanitation, nutrition etc. An empty stomach resists all attempts at progress. Thus health is linked to nutrition which is linked to crops which are linked to the availability of water which is linked to plant cover which is linked soil retention which is linked to us not cutting trees.
All of us will be forced to realize that natural resources does not exist for man alone and this manipulation of nature that is going on world over to serve the interests of humankind will only invite disaster. When once this simple truth is understood by us and our governments, then humans will start repairing the damage to the environment, reduce their consumption and nature may forgive the injuries that she has so far suffered. If this does not happen, the humans are on their way to sure self-destruct.

This article was written ten years ago and is still relevant.

Sunday, October 7, 2007

The fever that never was

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.

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