Monday, December 31, 2007

Ushering in the new year

When you know that to morrow is going to be like any other day, why celebrate and wish?. Then, there are lots of things that are special. We would have aged by one year and may be a bit wiser, you remember your friends and relations at least this one day and vice versa. What do we wish each other? Usually peace, prosperity and happiness. Experience tells me that peace is unrelated to prosperity and so is happpiness. Peace and happiness can be related and coexist.In addition, I feel one should wish the other good health both mental and physical.Goodhealth is a prerequisite for peace and happiness.Physical health needs regulated eating and daily physical excercise and mental health needs detachment, a giving attitude and freedom from greed, jealousy and anger.

I wish all of you this in the coming year.

They say beauty is in the eyes of the beholder. I see it when the morning sun penetrates through the branches of trees laden with green leaves and the mist melts, in the round pearls of water on the leaves of the water lilly, in a child playing unobserved, a starlit cloudless sky in the still of the midnight and in the guileless smiles on the faces of Dalai Lama and swami Nithyananda

Thursday, December 27, 2007

Doctor's dilemma

A large percentage of our population depend on private medical practitioners for their primary care needs. This is despite the fact of there being in place a well structured and widely spread network of PHCs [primary health centres] and sub health centres [SHCs]. It is beyond the scope of this article to describe the ills besetting this network of health centres and why people don’t chose to seek help in these centres.

GPs come in different hues and colours. They include practioners of different systems like Ayurveda, Siddha, Unani, Homeopathy, Naturopathy, Electrotherapy, Hydrotherapy, Reiky, several kinds of Yoga and the like. Some of these combine their craft with dispensation of allopathic drugs. If you include chemists who also dispense advice and medicines you would not be very wrong. All these provide some sort of primary care. My paper is confined to the working methods of doctors who practice allopathic system and who have a basic MBBS degree.

In this write up I have tried to analyse why this section of qualified allopathic doctors have failed to deliver comprehensive, affordable quality medical care. As this is linked to unethical practices, it has some relevance to what is being discussed in this conference

It is a basic principle that when a cheaper and effective drug is available, that should be used preferably by the oral route unless there are specific reasons for not doing so. This rule is generally not followed. The reasons are: patient’s belief that injected drug is more powerful than the oral one and also their willingness to pay more. Doctors put in no effort to dispel this belief and in fact exploit this by obliging the patient. Costs of injectables are much higher than oral drugs and the cost of care thus goes up. Many doctors run unnecessary IV drips and the reason is the same. Demand for X-rays, Ultrasounds, CT and MRI studies and many lab tests is far in excess of actual need and again is driven by commercial rather than clinical considerations.

With the advent of private players into the health care scene urban India is witnessing a bloom in institutions providing health care. These laboratories and hospitals are competing for custom of the paying Indian. Doctors are enticed with monetary and other inducements to refer patients. It is common knowledge that this cut practice is wide spread and it adds to the cost of health care. It is also a medically known fact yearly medical examinations [package deals] as screening methods, when indiscriminately applied to all and sundry, are a huge waste of money and another reason for pushing up the cost of care.

Pharma companies and medical men have always been cosy bedfellows. One encourages the other to the detriment of the patient. When one can carry out a decent family practice with about 200 drugs where is the need for 10,000 odd combinations and brands of drugs which are available in the market? Pharma companies and equipment manufacturers sponsor doctors CME [continued medical education]. These meetings can be local, in another town or even abroad. Depending on his use to the company, the doctor’s travel, stay and even entertainment is taken care off. The sponsor naturally expects and in fact gets the returns by the way prescriptions and use of the branded equipment. Those who don’t want to enter into such a relationship often find it hard to organise professional meets or participate in one. That there are still few doctors left who have survived is fact that surprises me.

Are these facts not known to the consumers? Of course they know or are coming to know. This one of the reasons why they no longer hold us with the same degree of respect that they did 30 years ago. Physical assaults and increasing litigation are the direct outcome of this perception that we are exploiters.

Why are we unethical? The answers are many. A combination of prevailing socio economic scenario and the compulsion to keep up with the Joneses at any cost is one reason. Add to this the basic human quality of greed and inability to accept a low profile life in a society which seems to respect only the wealthy is another. Add family and peer pressure, we have a tailor made situation for practicing unethical medicine.

The only silver lining is that society is becoming more informed. Hopefully, the informed citizen of the future will seek out honest doctors if they exist, and will be able to get the profession to mend its ways.

This write up is based on a presentation made at the recently concluded bio ethics conference.

Sunday, December 16, 2007

Dhruva's test

Dhruva is a six years old youngster and much more knowledgeable than I when it comes to the electronic gadgetry he plays with. This provides him with great deal of fun and merriment when ever he comes to see me. The latter part takes more time than the actual consult. On one occasion he may bring his battery operated car with a hidden starter button and will demonstrate a trial run on the floor and challenge me to do the same. I cannot to this simple act to his great delight. Like this, each time he comes he has new gadget or a toy and usually I end up getting defeated. He also asks me simple riddles and most often I answer wrong. Dhruva has come to the inevitable and fair conclusion that I am a rather stupid and backward person.

Recently he was unwell with fever and he was brought to see me. I wanted to take his temperature and requested him to keep the thermometer tip under the tongue. He reluctantly agreed and after I finished, he asked me why don’t I take it from the ear which is very fast as his mother does? This was news to the backward doctor. Seeing the disbelief on my face, he explained patiently how it is done and promised to get me one when he comes over next time.

His father came after a few days with some problem and gifted me with a new digital thermometer with an ear piece. You have to just place it like you do with an otoscope and press a button and you get the reading. Dhruva however was very specific in his instructions to his father. ‘That doctor, he doesn’t know, you just don’t give it to him and come away, you show him how to use it by putting it in his [mine] ear’ The father told me this, but had the grace not to actually do it.

I am pretty sure Dhruva, when he comes next will test me. I am a bit nervous that I may fail!

Thursday, December 13, 2007

Practice experience

Old age has its advantages it is often said. The disadvantages however overweigh the advantages. Of the many, is the inability to cope with adversity. There was a time when I was able to handle several serious patient related issues simultaneously with out getting unduly affected. This is not so now. Patients who have been with me and have grown old alongside are getting into serious personal, family, financial and health related problems. Often they have no one near enough but not involved, to go to for advise except I. Earlier on when they brought their problems to me I could evaluate them dispassionately and then forget about them soon after. This is no longer possible. The feeling of immense sorrow long after the party has left my premises lasts often days and weeks after the event. My thoughts go back to the days when I was witness to the joys of the newly married couple 25 years ago, now occupied with an intense and hateful war with each other. I find it hard to accept or understand this hatred and not able to sort out any of their problems adds to my owes. This kind of happening is deeply disturbing and leaves me with profound disquiet which does seem to go away as it did in my younger days.
My patients seem to die more frequently now. Don’t be under the impression it is because of my doing, it is because of old age and related issues. Unlike younger doctors older doctors like me have more number of geriatrics. These have been my patients since their younger days and I have been a party who has watched their life’s drama [melodrama] unfold over the years, like they have watched mine. Yesterday I saw a deeply jaundiced patient of mine of 70 years who underwent rescective surgery for carcinoma gall bladder. We including the dynamic young surgeon thought we had achieved a cure as the problem was detected very early. Not more than five months have passed and she is back and almost certainly with liver mets. I have been her friend in the days she suffered looking after her husband who died after a prolonged struggle against restrictive lung disease and IHD. No sooner he went she developed this problem and now she is on her way out. Both have been my patients of over twenty years.
These episodes are becoming common and as I said earlier leaves me emotionally drained. They say in youth the emotions are brittle, but I feel it is so when one grows old. What made me write these few lines and share these feelings is the hope that by doing so I may lighten this burden.

Any naturalist who is lucky enough to travel, at certain moments has experienced a feeling of overwhelming exultation at the beauty and complexity of life, and a feeling of depression that there is so much to see, to observe, to learn, that one life time is too short a time to be allotted for such a paradise of enigmas as the world is. You get it when, for the first time you see the beauty, variety and exuberance of the tropical rain forest, with its cathedral maze of thousand different trees, each bedecked with gardens of orchids, epiphytes, enmeshed in a web of creepers: an interlocking of so many species that you can not believe that the number of different forms have evolved. You get it when you see a vast concourse of mammals living together, or a vast, restless conglomeration of birds. You get it when you see a butterfly emerge from a chrysalis; a dragon fly from its pupa; when you observe the delicate and multifarious courtship displays, the rituals and taboos that go into making of the continuation of species. You get it when you see a stick of leaf turn into an insect, or a piece of dappled shade into a herd of zebras. You get it when you see a gigantic school of dolphins stretching as far as the eye can see, rocking and leaping exuberantly through their blue world; or a microscopic spider manufacturing from its frail body a transparent, apparently never ending line that will act as a transport as it sets on its aerial exploration of the vast world that surrounds it.

Gerald Durrel. Naturalist, zoo keeper and writer.
From his book, ‘golden bats and pink pigeons.’

Truth and Beauty
The light alone, like the mist over the mountain driven,
Or music by the night wind sent,
Through strings of a still instrument,
Or moonlight on a midnight stream
Gives grace and truth to life’s unquiet dream.


Thursday, December 6, 2007

Vanity and Ego

Many years have gone by since the incidence narrated here occurred but it is still fresh in my memory not because of the nature or rarity of presentation of the illness but the aftermath of it.

The middle aged well groomed lady was brought by her son and daughter in law because she had been having chest pains for the past couple of months. They had brought with them a sheaf of papers which had investigation reports and prescriptions from doctors whom she had already consulted.

I wanted to examine her. At the best of times examination of an Indian woman properly for a male doctor is difficult and it is more so with women belonging to some orthodox communities and this was one of them. With extreme reluctance she removed the outer black covering of her body. There were three more to go. It took another five minutes to convince her to remove at least one ore of them. She wanted her own son to go out before she divested herself of this second garment. She would not go any further and I had to make do with this. So I proceeded to examine her. On her left chest where I normally place the head of my stethoscope, beneath her blouse, I could not hear her heart sounds because of a hard object.

Our women have this habit of carrying a small mini purse inside their left bra. This is for right handed women and for lefties it is the other side. They consider this a safe and easily accessible place to keep their money I told the lady to please take this purse out so that I can proceed with my examination. She said she carried no purse!

What she had was cancer of the left breast which had already fairly advanced. Sadly her right breast too showed a less advanced tumor. I called the son inside, and to the three of them I explained the problem and convinced them to see my oncology team. That they disregarded my advice and went elsewhere is another matter.

You are wondering how we allowed this lady to go undiagnosed for so long. Often they don’t allow proper examination and this is the main cause and we doctors too don’t insist for the fear of offending them. I could detect it because it was already pretty big and difficult to miss. I too would have missed it had she come when it was small and refused a proper examination as she must have with other doctors.

I heard later that she passed away in a few months time.

Some years later an elderly gentleman came to consult with me. I don’t remember what his problem was. After the consultation was over, before he took leave he told me that he was the husband of the lady who had cancer of the breast and I was the one who spotted it first. I thought he was going to thank me. Instead he said, doctor, ‘my wife is no more, but when you told the bad news to my children and not tome who is her husband it hurt me very much, this I want you to know’.
This left me stunned, taking my silence for apology the old man left.

I did not even know he was outside waiting when the lady was being examined. The children had taken over and who should I tell? Had I known he was outside would I have called him in and told him? I don’t know. It is always easy to break the bad news to the young relations than the old ones. But he was right. He was her husband he should have been the first person to know. But why rake the issue after so many years?

Human ego and vanity presents in many ways and this is one such example. I only hoped that the resentment he had carried for so long went after he made his point. A sort of catharsis would you say?

Sunday, December 2, 2007

Advice unsolicited

I used to know an elderly lady as a patient. She suffered multiple chronic illnesses like severe diabetes, heart disease, skin eczema and she managed her life with these disabilities fairly well. She was a good patient in that she kept her appointments, followed my instructions and paid me well.

She lived alone with a helper but had a large number of relations living in the city, country and abroad and she was popular with all of them and they frequently visited her.

Recently she came to see me and I could see that she was very anxious and agitated. I asked her what the matter was. She said, ‘Doctor my nephew told me that I have Parkinson’s disease. I went to the Internet soon after he left and got very scared, how can I manage with this new disease now?

I could sympathize with her as Parkinson’s disease is an illness which can be very disabling. The sufferer gradually loses control over muscle coordination and becomes stiff and rigid. Worse there is no proper treatment or cure in sight. But she did not have Parkinson’s disease and how could she believe her nephew? I asked her. She said, ‘no doctor, he is a neurosurgeon living in the US and when he saw me shuffling he told me that I have this disease and I should take treatment’

It took me more than half an hour to convince her that merely a shuffling gait is no evidence of this disease and lot of elderly men and women take small steps but have no other signs and she has excellent gait and movement. She went convinced.

This is a problem that I have frequently faced in my practice. Unsolicited advice given on the spur of the moment like this neurosurgeon did. One look at his aunt’s shuffle and he diagnoses Parkinson’s disease. If he had that much concern he could have called me and expressed his concern instead of needlessly frightening his aunt out of her wits. I would have tried convincing him. Weather I would have succeeded or not is a different matter.

My patients receive this kind of unsolicited advice from other doctors at casual social meetings and cause me no end of problem afterwards. I also get asked questions and opinions like this from persons who are not my patients. I have a stock answer. I tell them to see me in my clinic if they are unhappy with their own physician. This usually shuts them up and some times ends the conversation which is to my advantage! because I like to be left alone most of the times!