Thursday, March 27, 2008

Every man has a price?

Marketing is the buzzword these days. 30 years back, when I began practice in this city, there were very few private hospitals, nursing homes and laboratories. And those few that existed did not feel the need to market their services in the manner that is being done now. Some of us had a side lab, an X-ray and an ECG machine and these were quite sufficient to handle almost all of our patients. The notion that ‘more labs, more hospitals, more doctors, more specialists will mean more patients’ was unknown to us.

May be we lost some patients for want of sophisticated equipment [CT and MRI] and procedures [endoscopy, angioplasty, thrombolysis], but saved many despite not having these. Now it is tough not to do a TMT [exercise electrocardiogram or stress test or treadmill test] in a young man with indeterminate chest pain or a CT[computerised tomography] in a person with headache. Adding to this there is the menace of high-pressure salesmanship. Let me narrate a recent episode.

That was an unusually busy day and the lady must have waited a while before coming in. Smartly attired in a business suit, she said as an opening gambit, 'you have a lot of nice patients'. She must have meant neatly dressed [wealthy?] patients. My reply was a smile. She said that she represents a diagnostic service provider and went on to explain the various facilities and the services of the many well-known consultants of the city that are available there. So far so good. Now came the acme of her sales pitch, it was direct and to the point. For every patient sent to them I would get 15% commission. My expression was blank. She waited for a minute for a response and seeing that none was forthcoming, she upped it to 20%!.

I felt sorry for myself. Despite my best efforts to keep these executives at bay over so many years, these never take no for answer and I have this unpleasant job of explaining time and again, why they should not see me. It was now my turn to tell her why I don’t take cuts or commissions and thanked her for taking time to come and see me. She looked a bit disappointed but thanked me for my time and went away. I sat back thinking about this widely spreading malady in the profession.

There was a knock on the door and the young woman was back. ‘Sir, she said, I just talked to my chief, he has agreed to give 25%, and we cannot go beyond that!’

She must be a firm believer in the dictum, ‘every man has a price’

My declining even this offer must have made her wonder how and where she went wrong?

Monday, March 24, 2008

Warblers and other birds

Some of us don’t need an alarm clock to wake up. Those who are sensitive and know how to listen to birdsong can wake up to their call [Mr. Seetharam’s observation]. The breeding season for the avian life is about to begin now [march to may] and the first call is often that of the Barbet. The loud kkttroooo----Ktrooooo repeated over and over is enough to wake any one up. But most don’t do so is because they are deaf to bird call. If one sees the size of a barbet [about that of a small Mina] one cannot help but marvel at its ability to produce this high pitched sound. The Small Green Barbet has a white patch on the cheek below the eyes and some brownish freckles on the neck. There are many varieties but the ones you see in and around here is the small green one.

Some years ago I witnessed a spectacle of a crow trying to get at the eggs inside a barbet’s nest. The alarmed parents were making frantic calls perched on a nearby tree. They need not have worried as they did, because try as it did, the crow couldn’t reach inside the hole and the cavity where the eggs lay! The nest was dug out of the wood from the centre of a cut branch of a tree. Next year too they chose the same spot and the depth of the cavity was just enough to defeat the crow’s beak!

After the Barbet’s call comes the Koel’s. A melodious to shrieky kuooo---kuooo, over and over with the female responding with a rather ugly quik quik response. The Koel is easy enough to identify as the male is smaller and sleeker version of the jungle crow. The red eye is a giveaway. The female is shy and not as good looking as the male with the body speckled with brown and white. The Koels are on the increase and this I suspect is because of the increase in the Crow population. If you are wondering why, it is because the lazy Koel drops its eggs in the nest of the unsuspecting Crow.

Next to give a wakeup call are the tailor birds. At my home it is around 6.30 am.
I am not an ornithologist and neither am I an expert bird watcher. The former needs knowledge of taxonomy and the latter hours of patient observation. Both of which I lack. Therefore I often make the mistake of naming them incorrectly. This specially is so with small birds like the warblers [Prinias]. This is because they are so frisky and never stay more than a few seconds at any one place. It took me couple of years to determine the pair of warblers who are resident around my house that they are indeed tailor birds, because as Mr. Seetharam pointed out it, it is by their song, a kind of sweet and loud teewity teewity, that I was able to place them. The other common warbler one sees is the Ashy Wren warbler which makes a noise like that made by garden shears cutting a hedge, a chuck, chuck sound. Another common one is the plain Wren warbler seen amongst scrubs and bushes. But the most remarkable one is the Orphean warbler which migrates to India all the way down up to Tamilnadu during winter months and goes back to Afghanistan and Baluchistan! Again makes a chuk chuk sound and during mating season has a melodious loud calling song! Can be identified by its grayish black top and off white lower portion. How this bird which is about the size of a sparrow flies all the way and survives to breed here is beyond my comprehension.

The other common bird that one occasionally sees is the Robin which is a black beauty with a small white patch on the side. The female is a rather pale brownish coloured and commonly seen with the male. If you are fortunate you can see and hear the Bush chat which closely resembles the Robin. This bird has such a melodious song the like of which I have not heard. Like the other members of the Avian world the male is far more beautiful [to the human eye!] than the female.

Next comes the Sunbird. You can see this one, which is half the size of a sparrow, on almost all the flowering trees because it is a nectar feeder [also berries and small fruits] and usually seen in groups. If you have a Singapore cherry tree around your home be on the lookout for these birds during the fruiting season. One must see the bird with binoculars to appreciate the multiplicity of the colours and the beauty. Common one in our neighborhood is the Purple Rumpled one. This bird has crimson, purple, blue, light yellow and green colours. I consider this as the most beautiful of the birds that I have been fortunate to observe!

After 7 am there is no point in trying to listen to the bird song. The cacophony of us humans would have begun by then.

Tuesday, March 18, 2008

Cassias and Tabubias

In the midst of so much that is ugly in our city, there are these magnificent trees belonging to two families giving us immense visual pleasure. The bloom is around this time and the trees are a pretty common sight in any neighborhood. The cassia family has one set of trees which have red to pale pink and off white flowers and another set which have yellow flowers. They are all smallish trees and when in bloom the whole tree is one big spectacular display of colour with hardly any leaves visible. Amongst the red variety the one which I like most is the called cassia nodosa or pink cassia and I am fortunate that I have many specimens of this tree in the vicinity and they give me lot of joy even when they are not in bloom! Of the trees which have the yellow flowers the best and the most beautiful is cassia fistula. Not as common as the other ones in urban environs, this tree is in full bloom now. Few years ago we had gone trekking in the foot hills of Nilgiris one evening with a vague hope of sighting elephants near a watering point and in the middle of dry brown scrub land I saw this specimen in full bloom. The inflorescence has hundreds of flowers drooping upside down and the placement of each flower is such that it looks like an inverted golden necklace with a broad base and a tapering end. I am at a loss to describe the beauty of the flowers. Imagine the whole tree full of these flowers! I have not seen this tree in Bangalore, but I was told there are some in Lalbagh. May be it is exploited as the fruit and flower pulp is used as a laxative!

Tabubia is another family which has fair representation in Bangalore. The ones which catch every one eye is the common stunted gnarled misshapen smallish tree laden with golden yellow bunches of flowers [tabubia argentea, T.tacoma]. When in bloom there is no leaf and it is all flowers. Tabubia rosea is a big well shaped tree with a huge crown of deciduous leaves which make way for pale rose pink flowers and the whole tree is covered with flowers and it is a traffic stopping sight. The bloom is just ending and some of you may be fortunate as there are some trees which are just beginning to flower. But the one I like most is Tabubia avellanidae. This is another common and favorite avenue tree, smallish with broad leaves and when in bloom the whole tree is magnificently mauve. Those of you who live in and around my area can see these trees in full bloom on either side of Jeevanbimanagar road in the month of December. You can also see a number of them arranged in a circle in front of Public Library in Cubbon park.

Last but not the least there is the all time favorite, Jacaranda, again in full bloom now. This delicate tree showers its blue flowers and the ground underneath looks as though covered with a blue blanket. Don’t miss the sight, they are all over. If you are driving along the airport road, after Manipal hospital, look to your left and you see a blue screen of these flowers.

The pleasure that these trees give uplifts the spirit. To experience it is pure joy.

Friday, March 7, 2008

One more thing

I spend anywhere from 15 minutes to an hour with each patient of mine. When I finish with the process of history taking, examination and treatment advice and feeling relieved that the brain now can get a few minutes rest before the next problem comes in, the patient instead of taking my leave pipes in, ‘doc, one more thing, I forgot to tell you’ and proceeds to tell me the one more thing.
This one more thing often turns out to be the most important issue and it will make me rethink my diagnosis and the treatment I had advised! Also means reexamination and spending more time!
When this one more thing comes up which is not infrequent I have often felt like throwing my stethoscope at the patient. Have not done it though.

Thursday, March 6, 2008


My friend Dr.B.S.Prabhakar is a busy practitioner in the inner city area. Like many other GPs who have busy practices he too finds it difficult to make house calls during his clinic hours which often extends to late nights.

When the call came requesting an urgent visit to see an elderly patient it was 7 pm and the clinic was full of patients and there was no way he could get out leaving them waiting as the caller lived 5 kms away and going by the dense traffic it would be two hours before he would return. He however couldn’t refuse the call either as the patient was an old family friend and suffered from diabetes and heart disease. He told the caller who was the eldest son of the patient that he would try and make the call around 10 pm and if the condition of the patient is very serious, he told him to shift he patient to a nearby hospital and let him know.

At 8 pm the call came informing him that the night visit was no longer required as the patient has breathed his last. This occasionally happens to us GPs because despite advise patients refuse to go and seek help elsewhere and sometimes pay a heavy price. Doc Prabhakar was now a very unhappy man with many troubling thoughts in his head. Had he gone leaving his clinic when the call came would the patient be alive, had he failed to assess the seriousness of the call, should he have insisted that they take the patient to the hospital? He was filled with guilt and remorse. These feelings remain for weeks and months and torment us and form an unpleasant part of a GP’s life.

A shaken Prabhakar did not sleep well that night. Early next morning he went to the house of the diseased with the intention of offering his condolences to the bereaved family and to issue a death certificate. Normally the atmosphere in and around the house where a death has occurred is somber and sad. This is often contrived is a different matter. One would see groups of friends and relations of the diseased huddled and engaged in hushed conversation with grave looks on their faces. Amongst most Hindu families there would also be a small earthen pot filled with burning wood emitting smoke, a sure signal to all and sundry that a death has occurred in that home and you are at liberty to take a breather and gawk.

To Doc’s surprise and some consternation, none of these were visible outside the house. For a moment he thought that the body has already been removed and the mourners had left. Then who could have issued the death certificate without which the body cannot be cremated? Would it be that another doctor was called to attend on the diseased and has he issued the certificate? This thought made him feel a bit better. These were his thoughts when he pressed the call bell.

After a while the door opened and the old man who was supposed to be dead was standing in front with a wide grin on his face. Needless to say it was a shock and made my friend take a step back.
After a few seconds when there was no speech from either party, the old man’s son arrived on the scene and narrated the following story.

‘After I made the call to you I went back to see my father. He was restless and breathing very hard and moving his hands as though to tell me something. After few minutes he stopped breathing and his arms and legs became still and he closed his eyes. I thought he has died and I called you to tell you not to come and informed the relatives and friends of his death. Within the next half an hour people began coming and one by one they started pouring spoonfuls of milk in to the mouth as is our custom. This went on for some time when we noticed it [he pointed towards his father] moving the legs and making noises. This made the relatives scatter in a hurry. I too was frightened. A little later my father got up and looked around and asked what all these people were doing? He also said he feels very hungry. We fed him and told him what all had happened. Father has not stopped abusing me since then’ the son looked appropriately contrite.

The old diabetic had missed his lunch and taken very little food in the evening. He had taken his insulin shot later than usual that day and had gone into a coma induced by low blood sugar and the family thought he was dead and the milk that was poured into his mouth had revived him!

The old man lived for another five years and didn’t do any repeat performance and when he did die it was dead certain.