Thursday, November 29, 2007

Not medicine

35 years ago when I began my practice I used to have plenty of time at my disposal and some of this time I spent with a senior practitioner friend of mine. On one such occasion I went with him on his morning round of house calls.

The call was to see a boy who was having high fever and the mother wanted the doctor to see him at home. When we went we found the mother anxiously waiting for us. The boy did not look very ill but I could see that the mother was very worried and kept plying the doctor will lot of questions which then appeared pretty silly to me. My senior friend went through the rigmarole of an elaborate examination and with a serious expression advised the lady how to look after the boy which included a two hourly temperature record keeping and hourly changing of the wet cloth on the boy’s fore head!

When we were driving back, I could not help asking him the rationality of this advice.
He said, ‘you saw how anxious she was, this will keep her occupied for the next two days and she will not bother us and hopefully the boy will be OK by then.’

Anther time a lady came from a far off place and requested the doctor to give her a bottle of yellow medicine [peela davayi in Urdu]. This yellow medicine was the famous alkaline mixture given for several complaints and illnesses which if I were to list, the modern day doctors will have a hearty laugh. Her complaints were pains in her back, legs head and general weakness. Obviously there was no major disease and she came and took this peela davayi every month. I asked the doctor what good it does to her. He said, ‘I too don’t know, but I know this much, she will manage for the next one month and will not come before that’

I may not have learnt much of medicine from this doctor but I learnt a lot about patient management and that there is more to medicine than just treating an illness.

Sunday, November 25, 2007

Birds and others

For a number of years I hardly took any notice of them, till one day a remarkably beautiful gray and chestnut red bird flew in and sat on a branch of a tree close to the tee box [square piece of levelled turf]. I asked one of my regular foursome who has had some rural upbringing and knows a thing or two about birds, as to what sort of a bird this is? He said it was a crow pheasant and commonly found in all rural areas. That was the beginning. Interest in crow pheasant led to other birds mostly heard and rarely seen. My friend would, whenever asked would give a name to the bird we saw in the course of our play. This I suspected more to shut me up rather than to improve my knowledge of ornithology. I soon realised that there is a great verity of them out there that I did not know and what I did know was far from satisfactory [even now, after nearly ten years of bird watching].

Thus began my quest for knowledge about avian life around me. My partners attributed my enthusiasm to the onset of senility. Having lost interest in one form of birdlife due to aging, you have taken to this form of bird watching, they said. My attempts at informing these ignorants that this is far more satisfying and rewarding, brought forth great guffaws of laughter. One of them began asking me, every time a woman dressed in bright coloured clothes passes by, to name and identify the species!

Armed with a pair of binoculars and that bible of bird watchers, Dr Salim Ali's book on Indian birds, I became an odd fixture on the golf course in the mornings. It provided amusement to my fellow golfers to see me on the course in a pursuit different from that of golf. Recently one of them in trying to draw my attention away from the bird I was watching missed his step and fell into a trench. This obviously succeeded in distracting me and seeing him prone on the ground I rushed only to see him not only unharmed but also full of, according to him, well meant abuses at me for being responsible for his fall.

On another occasion two golfers approached me to find out what I am up to. Finding that I am not there to steal their golf balls [easy to mistake in my shorts and nondescript shirt] they became less hostile and warned me of dire consequences if I trespassed onto the course once again as it is private territory. Needless to say they were beginners and therefore did not know that I was also one of them and pretty senior! But I liked their attitude of saving the course from itinerant birdwatchers and other such unwanted elements. Instead of getting into needless argument, I agreed to abide by their instructions. Few days later when I wished good morning while playing golf to the pair, there was an embarrassed silence and one of them rather sheepishly managed to return my greeting.

It did not take long for me to realise that book and binoculars are not sufficient help when it came to the minutiae of bird watching, especially identifying small pale coloured birds. These were also friskier and it was difficult to hold them in view for more than a few seconds at a time. I needed an expert bird watcher to assist me in the details. Through a mutual friend of mine I got in touch with Mr. T.N.A.Perumal.

Mr. Perumal is a gentleman of indeterminate age. He could be 60 or 70 or more. Because of watching and listening to birds he has developed a keen sense of sight and hearing. However this is restricted to only birdsong and sight was made clear to me on my very first outing with him on the course. He was overwhelmed at the abundance of bird life; [sadly the number and variety has greatly diminished now] he profusely complimented me and the club for planting so many trees and also thoughtfully providing the many waterbodies, an ideal habitat for birdlife. I prudently kept quiet [the water bodies are intentionally created hazards to make the game challenging]. Next to the first green there is an area of scrub jungle [no more] with many tall trees and I have found this a favorite of many birds and I proceeded to take him there.

While we were approaching the green he heard some bird calling and he stood still and to have a better look and inadvertently went on to the middle of the fair way [danger zone]. Sure enough and soon enough there were loud shouts of 'Fore' from the foursome which was teeing off. I had to physically drag him aside away from danger. He was naturally upset at my indiscretion because the bird had stopped calling and he could not properly spot it and wanted to know why I had to drag him away just because few people [bird brains?] shouted. I told him it was the golfer’s call of warning. He gave a grunt and said, ‘such loud shouts will disturb the birds!' We went to the edge of the out of the bound fence and spent the next hour or so watching and identifying. All the time, while we were talking I had to keep telling him to keep the tone of his voice down so as not to disturb the players on the green. This seemed to surprise him. Clearly he thought that birds are more important than golfers and if the game of golf had to be played then it should be done with out disturbing the birdlife!' Successive four balls followed one after the other and as many of them knew me they came up to us and wished me and wanted to know what mischief I am up to. Mr. Perumal did not take kindly to this kind of camaraderie between me and these people who have no respect for birds. He did not say so in as many words but the frown on his face said that.

Later in the clubhouse I told him but for these golfers the golfcourse wouldn't be here and there would be also no birds. Instead there would be another concrete jungle. [All around it has indeed become one now] 'Yes, yes, but they should play their game quietly with out all that shouting' he said somewhat mollified.

In the 12 hours or so I spent with him, over a two months period, we identified and documented more than 50 verities of birds in our course and at the time of writing [that is, when this article was written ten years ago.], I am still at it. In Mr Perumal I have met another of those unsung individuals who persue an interest for the pure joy of it and take pleasure in educating impatient and rather below average students like me.

My near and dear have begun telling me that I am afflicted with one more wasteful habit, this time that of bird watching.

This article was published in a golf magazine some ten years ago.

Thursday, November 22, 2007

Viagra's Advent

The following story was written 9 years ago when I was visiting US and stayed with my Urologist relative near the Canadian border. It was hot news then. I let my imagination go a bit wild and wrote this story which got published. Both the desi version and the imported version are available for several years now and as far as I know the expected calamities described below have not happened!

The imminent prospect of viagra’s advent into the Indian drug scene fills me with trepidation. Why am I anxious instead of being happy with the prospect of many of my elderly patients rediscovering their lost fountain of youth? It appears to work in 60% of men who have organic [something wrong between legs] or psychological [something wrong between the ears] or who have a combination of both. Fortunately it will not enhance sexual performance of normal men. So what is going to happen when sizeable numbers of men start taking this drug? Mind you, one should take the drug an hour before the scheduled performance and some men wrongly believe that once taken it will have the desired effect forever! Most of the wives of these men will be either menopausal or postmenopausal age and many will have lost interest in active sex or reconciled or even enjoying life with out the pester of a demanding husband. Viagra might change this truce and peace and the women may once again have to yield to the sexual demands of their husbands. Number of them will be unwilling and or incapable of enjoying sex. This may lead to problems of aging men chasing wives of other men, younger women and even trying sex workers with all the antecedent social turmoil.

The scene may not be far of when we start seeing respectable elderly men seeking help to get treatment for venereal disease and even worse, for AIDS! Will the warning that those who are on medication for high blood pressure and or heart disease may suffer serious side effects which include death, prevent such men from indulging in this drug? I donot think so. For the pleasure of sex there are many men out there who will not mind having blood pressure or even heart disease! Their commonsense argument may make them think, ‘ok, today or night I will take Viagra and omit the BP pill, any way I have often forgotten to take it and nothing has happened when I have missed! And have a go and hell with the warning.

This drug will sooner or later will hit the Indian drug market. Incidentally the real name of this drug is not Viagra but Sildenafil citrate. Like film actresses changing their names the drug company which makes the drug has given Sildenafil this glamour name and this seem to have really hit among other areas of the body, men’s imagination, as no drug has ever done before. What is going to happen when it hits the market? In the US it is now priced at 10 dollars a pill and is considered expensive even by American standards and that has not prevented Americans who are in real or imaginary need for buying it are lobbying for this drug to be made available against their insurance.

There were reports of Canadians for whom it wasn't available; making a bee line across the border to the US in search of the drug, reminiscent of the liquor starved Andhras crossing over to Karnataka for their FMILS [foreign made Indian liquor]. Going by these indications this Indian made or imported Sildenafil is not going to come cheap. My guess is that it is going to cost anywhere between 100 to 200 Rs a pill and it will be made available only against a prescription. It will be, thus, priced out of the reach of large a majority of us who are poor. These people might have to agitate to get this drug available in our government hospitals and use our voting clout to impress our MLAs and MPs to take up this issue and make it freely available. I am imagining the scene in the parliament where our aging MPs who have had the benefit of free use, strongly advocating the free availability of this drug in their constituencies for the needy or even demand a quota to be allotted to each of them to distribute to those whom they consider in need. Appears far-fetched you think, wait and see.

The remaining, the so-called middle class who always has to pay for their pleasures or their miseries will have a problem. How to get it even if it means only for an occasional indulgence like his half a glass of weekend beer? He will have to go to his own doctor and explain his need to get a prescription. The family doctor being the familiar fool he is, may not take kindly to this request, and may even start talking about the need or no need for sex at his [patient’s] age and what would his [the pill seeker’s] wife think of this sudden urge? And start a sermon on the side effects on his heart BP etc. Having got over this and at the cost of climbing down a notch or two in the doctor’s estimation, and getting the prescription he goes to the chemist. It is quite likely he will get an interested look from the chemist and the precious potion is at last made available. The next step is taking the pill and hope that the wife will appreciate the long forgotten advances and suitably responds. Consider even this hurdle overcome, then the million-dollar question is whether he belongs to the 60% in whom it works or the 40% in whom it will not. Let us say he is the lucky one and belongs to the successful 60%. He may, still have to face the distinct and extremely unpleasant possibility of not only not getting his much needed morning coffee but a stern warning from his beloved wife never to put her through the experience once again.

He will, then have no option but to wait till another potency pill, this time only for women is made available, and fondly hope when that happens, that he may not have to tell his wife what she told him.

Sunday, November 18, 2007

Notes from the past

Relatives of a deseased patient of mine took exception when I said 'good for him' when I learnt of his death. What I meant was that it was good for an 80-year-old to go painlessly and quickly as he did. But to express grief even though you don’t genuinely feel it, is what the social custom demands and readers are forewarned not commit the same mistake as I did when they are faced with similar situation.

Recently I found in my case notes I had written Crazy Mama instead of the patient's name. What had happened was that when she had come on earlier occasion when I had made those notes, she had come with her two kids and she had created such a racket in trying to control her children, simultaneously trying to tell me her complaints, subconsciously I must have written her name as Crazy Mama. Obviously she had not noticed it and even if she had, I don’t think she would have minded it! Needless to say I quietly changed it to her real name.
The foot less prompt to meet the morning dew,
The heart less bounding at emotion new,
And hope, once crushed, less quick to spring again.
Mathew Arnold, on aging.

Thursday, November 15, 2007

Past and present

As I age and spend the last years in my general practice, my worries about the future of new entrants to this branch of medicine and the quality of their practice seem to increase. One such worry is the loss of pediatric group of patients [children] to pediatricians. While I have nothing against pediatrics as a specialty, I am against paedricians seeing routine problems of children, especially their taking over the doing of basic immunization. This must be the preserve of GPs and pediatricians should see patients only when GPs refer. Lot of quality time of pediatricians is now wasted in managing routine problems in children when that should have been spent in handling difficult problems which can not be handled by GPs and which may need hospitalization. Of course one could justifiably argue the same with all specialties but I am particularly vexed with pediatricians because it is such a pleasure looking after children and we are being deprived of what is rightfully our domain.

Most of you must be reading and hearing about practice of evidence based medicine. This simply means doing something when you know that it is going to do good to the patient based on evidence. If one were to strictly follow this then often there would be conflicts with ones experience. Experience is individuals and evidence is collective. Let me give an example. It is well known that most of upper respiratory infections in child hood are viral in nature and don’t need antibiotics. That is evidence but the doctor’s experience over the years is that he gets results by giving all these children antibiotics. What must he do? Old habits die-hard and bad habits however old they are must be allowed to die so that our patients are spared from our unnecessary ministrations. More than any other branch of medicine family medical practice needs evidence based medicine to be practiced. There is a small aside to this. Today’s evidence may be to morrow’s blasphemy, remember the choice but mutilating treatment of gastrojejunostomy with gastrectomy [a major surgical procedure] for ulcer disease not so long ago, before the medical treatment for the germ Helicobacter came in and this common surgical procedure almost vanished?

I don’t exactly remember what was it that made them stop using my services, but I know it was something not very pleasant. Therefore to see her after 25 years, back again in my consulting room was a bit of surprise. 25 years ago she was a good-looking young woman and now she was one of those run of the mill middle aged. She was having episodes of breathlessness, attacks of syncope with spontaneous resolution and had come to me to find out what was wrong. She had already made the usual hospital and specialist rounds and had a file full of records with her. After listening to her and examining I could make a diagnosis of supraventricular tachycardia because she was having one at the time I was examining her and I could record it with an ECG. We discussed the various modalities of treatment including that of electrical ablation of the offending pathway. She went satisfied that at last a proper diagnosis was made and hopes of a permanent cure. Both of us had the prudence [age related wisdom?] not to dig up the past.

Sunday, November 11, 2007

Three festivals

The festivals of Ganesh, Dussera and Deepavali arrive one after another in the months of Sept, Oct and November.

Thousands of idols of Lord Ganesh made out of clay and painted with bright colours are displayed in homes; make shift street corner associations, educational institutions and even in some government departments. Money is collected from the citizens [often coerced] for the performance of the functions.These functions involves braying loud music often into late hours. The idols are kept from two days to weeks and then taken in mini and major processions to be immersed in the nearest water body. These precessions are accompanied by music [noise] makers all the way. Our water bodies are already polluted. These idols and the decorations add to the insult. We spent a lot of money in cleaning up the Ulsoor lake and after this festival it was a pain to see the lake littered with refuse of every kind. Traffic which is already on the verge of collapse did collapse on several days and came to a stand still in many parts of the city when these processions were on the streets.

Next came Dussera. Similar to the above in a different way. Same noise, street side pendals and litter for days on end.

Next was Deepavali. At the time of writing it is just about ending. In causing damage to the environment and disturbance to the peace and quiet of the city celebration of this festival takes the cake. It is supposed to be a beautiful festival of lights. It is no longer so. It has become a festival of noise and smoke. Fire crackers went non stop from dusk to near dawn for the last there days and a blue haze covered the none too clean skies of this city. Noise haters like me have had a hard time. Here I am joined by countless petrified animals [pet dogs in particular].

Don’t we have a better and more cultured way of celebrating these festivals? Should the revelers have no consideration what so ever for others?
When will we become better citizens?

They sit in front of me day in and day out with faces that tell their own story. Some are blank, some sad, some vacant, some stare, and some are worried but very rarely happy and contented. They listen to what I say rarely with attention that I feel I deserve. I can make this out by the expression. The wandering mind has a face on which inattention is writ large. There are some who keep saying 'hu hu or achha achha when I am talking as though to encourage me to continue. Though these expressions of encouragement often irritate me I try not to get distracted but when they are made to hide indifference and inability to follow I tend to get upset and try and bring them back to the subject of the consultation. When a patient is paying me for my time it is his business to try and not waste it by not listening and it is my business to try and make him understand. Both of which frequently doesn't happen even after so many years of practice, is a bit worrying. It is extremely difficult to make an uneducated lay person understand the intricacies of why his or her thyroid is not producing thyroid hormone [when you yourself is not sure why] and why she should be taking the tablet daily, when you are being stared at by an obviously uncomprehending face. But what took the cake was a recent incident when a patient who was patiently explaining his problems suddenly stopped midway and asked me,' Doc are you with me so far?' That stopped me dead in my tracks. Are the roles being reversed? Are my patients too feel the same way looking at my face? These are very disturbing thoughts.

Thursday, November 8, 2007

Two experiences

Years ago I used to see some Russians resident in Bangalore. They usually came accompanied by an interpreter and the consultation was a laborious three-way affair at the end of which in addition to a mild headache, I felt not sure whether I got the problem well understood by both parties. On one occasion one of them was sick and could not make it to my chambers and I was called to do a house call. On reaching his home I was surprised to find the interpreter absent. I was now faced with the problem of communicating with this huge obviously sick and groaning Russian. Looking at my face he must have guessed my predicament and he said in perfect Queen’s English, ‘ Doc don’t worry, I can speak good English’ and proceeded to give an excellent description of his complaints. Taken pleasantly aback I asked him why on pervious occasions he put me to so much difficulty with the unsatisfactory three-way conversation. The reply was that he had to follow the prescribed protocol. Obviously the tartan interpreter was some kind of watchdog keeping an eye over these countrymen of hers!

A snippet I read some time ago in the BMJ prompted me to write this somewhat similar experience that I underwent some time ago in my practice. The couple came in one after the other, first the man and then the woman. The man told his story with no assistance from the woman except she was giving him unsympathetic stony looks. After finishing with him I wrote out a prescription and told him to avoid spicy food for a few days and asked his wife to put less spice in the food. She looked very offended and told me that she is no wife of this unmannered man who barged in to the room out of turn disregarding her and went on to add that I have to put the unmannered upstart in his place and see that he does not do so again. I sat back blinking at both of them. The man took a sheepish leave all the time getting a blistering stare from her.
Those of you who have no receptionist to control entry of patients beware of such situations; all women who accompany men need not be wives!

Sunday, November 4, 2007

Constipation cure

Whenever an elderly gentleman comes with constipation I get worried about cancer colon being the cause. This man was no exception. He is past seventy and I have known him for some years now, I knew his fetish about daily bowel movement and I suspect that he abused laxatives to achieve this objective. Therefore when he came with complaining of constipation of two days, I got a bit worried and told him to try some isobgul powder [which bulks and softens the stool] that night. He gave me a sheepish look and told.’ But doc, I have already taken tablet of dulcolax and it has not helped’. It was with difficulty that I could control my irritation. This is because I do not like any one taking an irritant purgative like dulcolax as it can cause problems when used routinely, and when the habit gets a patient it is difficult to get him off. But I held myself back as I felt it was more important to know why of his constipation than worry about his misuse of dulcolax at that moment.
I told him to get an enema done and gave a note for getting this done at a nearby polyclinic and asked him to come for a proctoscopy [an examination of the lower end of the colon by a small metal tube] later. I also told him to be prepared for a possible colonoscopy [longer version of the proctoscope] and sent him with a worried frown [revealed on his face and not mine].
He did not come back for over a month and when he did come it was for an entirely different reason. Curious to know, I asked him about his constipation. He laughed and said it was due to the news paperboy not delivering the daily newspaper to him on three successive mornings. You are justified in wondering what newspaper has to do with constipation. Let me tell you. Our friend has read his morning newspaper sitting on the commode for the past 40 years and would not move the bowels unless this ritual is followed! Arrived the newspaper and went the constipation!

Thursday, November 1, 2007

Professional pride and being in heaven

Professional pride is important to lead a satisfactory life. Pride should not be mistaken for arrogance that often our profession is accused off, with some justification. Arrogance is unconcerned disregard and I know it all attitude towards fellow men in general and patients in particular. This is the worst quality in medical men and even some of the most technically qualified suffer from this. To some extent the disrepute that the profession has come to, is because of this arrogance.
Pride is an entirely different quality. It is the pleasure and satisfaction one derives for being a competent professional and the feeling one gets when one does a job well. In general medical practice there are lots of opportunities for this. But I have often found this pride lacking in my colleagues. Is it because they feel an inferior status being general practitioners or is it because they are not doing the job as it should be done or is it because their quality of work is not what it should be? It could be a combination of several of these factors. For example let us say you made a brilliant diagnosis of an illness in one of your patients and you should be feeling good about it and justifiably proud. But you are not feeling good though the patient comes and profusely thanks you. Why? Is it because you have accepted a cut from the lab? Or is it because you sent him for some tests that were not required or is it because you kept treating him long after the illness has healed?
A doctor who is unethical will not have that pride and the feeling of being in the wrong will eat into his vitals and this feeling will lead to emotional unhappiness and the quality of life deteriorates. You can always set a price on your service, but don’t compare the performance which can be great with its compensation, be it money, power or fame, which can be often trivial.
Pride in being a true professional is like a halo around one's head. Try and develop that in the course of your professional life. Not only your colleagues but also your patients and friends recognize it and when you finally bid good bye to this world, at least there will be some memory of you left behind in the hearts and minds of your fellow men who survive you.
[This is part of an editorial I wrote some years ago in a professional journal]

I have not been to heaven and unlikely to go if there is one, but I have experienced what it means to be in heaven. That is when a seriously ill person returns back to normal health due to my efforts.

On a day with dimpled light,
In a world of greed and strife,
With a message clear and bright,
God’s angels come to life.
Geetha Srinivasan