The Plight of the Professional.

          “Poor doctors,” I said.

          “Oxymoron,” said Shri Husband.

          “Means?” I asked. He uses big-big words when he wants to flummox me.

          “Why are you saying ‘poor doctors’ anyway,” he said. Shri Husband asks back-questions when he doesn’t want to reply to something. It’s more the rule than the exception.

          “The government is making it difficult for them to go abroad,” I said. I’m cautious when I make such statements because he always want to know where I read or heard about it, the facts, the statistics, any reliable source, etc. (Yes, it drives me nuts, but what to do; they say marriages are made in heaven. I’ve nothing to prove it, but when I stated this once, Shri Husband asked: “Who’s ‘they’?” Can’t win with the Great Questioner.)

          So he snatched the news report that I was reading, about doctors being discouraged from leaving India, read it for himself and, in a rare moment of agreement with me, commented: “True, poor doctors. It’s an unfair deal.”

          I was so excited that he’d actually concurred with what I’d said, that I blurted: “Yes, no? Yes, no? Poor doctors, see?” That annoyed him and thus began that day’s cold war. After the mandatory five minutes silence, he started his tirade.

          “I don’t see why only doctors should be targeted to work in rural areas or for lesser salaries or in abominable conditions,” he said.

          “Abominable means?” I asked, getting a horrid look from him.

          Bai Goanna, arbitrator, friend and nose-poker reacted: “Ceilings that leak, toilets with blocked plumbing, rats in cupboards, no drinking water, things like that.”

          Shri Husband, irritation reduced by a degree, snapped: “Also, no basic medicines available for patients, no nurses/technicians or other trained professionals to help out, poor hygiene in examination rooms—if such rooms exist--, rusty trolleys, dim bulbs, ancient wheelchairs, no way to transport ill patients from Primary Health Centres to bigger hospitals…in most parts of India, the scene is grim.”

          Abba, I thought, lecture-baazi shuru. I was correct.

          He pontificated: “…that’s not all, the cost of fees through medical college, the amount of time it takes to gather knowledge, the difficulty of becoming a specialist, the no-reward-for-merit future…”

          “It’s worse than I imagined,” I sighed.

          “And you wonder why they don’t want to be forced to stay in India?”

          “They should stay back and help to improve the situation,” I said energetically, giving another point of view. “They are the upper strata of society, the thinking, elite class, they are the ones who should tackle the evil and let good win. It’s a noble, life-saving profession, no?”

          Shri Husband suddenly went silent. I wondered what I’d said wrong. Bai Goanna broke the silence and said: “It’s the same story with all professions, yaar. Teachers, soldiers, professors, engineers… How can you say which one’s superior to the other? I mean without primary school teachers, we couldn’t have any doctors, right? Without ward-boys and nurses, no hospitals could run, right? Even taxi-drivers are important.”

          “But,” I argued, changing tack again. “The government isn’t saying anything about stopping the others from leaving the country, no? This report says only about making it difficult for doctors to leave the country.”

          Shri Husband added: “That’s true. There’s nothing stopping good plumbers, carpenters, electricians, tailors, physiotherapists, hotel industry professionals, even Information Technologists from leaving the country. It’s unfair to have this pressure only on the medics, just because it’s considered a life-saving, noble profession, especially because quite often the doctors do the jobs of the ward-boys and nurses in many places, in order to treat the patients under their care.”

          What-to-do, we thought, as if the burden of saving the country and its skill bank lay on our three shoulders. Think of an industry and its human ‘products’ wished to leave the shores. Bureaucrats take sabbaticals to do post-graduation in terrorism/culture/liberal arts studies at universities abroad. Agriculturists, nuclear scientists, creative writers, classical singers, Bollywood stars, even priests who conduct Hindu marriage/death ceremonies fly across the oceans when opportunity beckons. Therefore, not fair to the medics. We agreed. Wordlessly, of course; agreements are so rare in my home, we run out of words when we do agree. But when our thoughts match, we sort of know what’s going on in the other’s mind.

          On FB, my second source of information, the first being Google, a very long thread of rants by doctors was interesting. A number of them posted on their own and others’ walls that lay people ‘just (didn’t) understand what doctors went through’ and how the medics worked ’unbelievably long hours with erratic meal timings’. I thought, if one eave’s dropped on the conversations of pizza-deliverers, soldiers, traffic constables and labourers on construction sites, there would be similar opinions. (Come to think of it, would there ever be a ban on migration of pizza-deliverers, etc.?  Which country would want their inexpensive labour? Once upon a time when the UAE was being built, those types exited India in hordes to build roads and skyscrapers, but I can’t think of any country right now that would want persons possessing such ‘skills’. Whereas the medics, they’re always in demand in countries abroad, so it seems.)

          “If,” Shri Husband debated aloud, “Medical professionals including nurses, therapists and technicians are allowed to go abroad permanently, who will look after us, our rural population?” Then countered it himself: “Why single them out? After all, the government spends a lot of money on subsidizing a lot of higher education, in many streams. Poor doctors.”

          Bai Goanna was brave enough to stop Shri Husband’s soliloquy: “You said poor doctors was an oxymoron. Because there are some doctors who become rich unethically. You said something about abominable conditions. You went on and on with this on-the-other-hand talk…”

          And thus began a quarrel afresh on a happening Sunday morning.

Feedback: sheelajaywant@yahoo.co.in

            

Death on the Table.

          I read to Shri Husband a disturbing item from a non-local newspaper. “A three-year-old girl died on a dentist’s chair.”

          Shri Husband wanted to know why/how she died. Inquisitiveness runs in his genes. Always asking why this, why not that.

          “How would I know?” I said. “The paper says she died for whilst undergoing a root-canal treatment. The girl-patient’s parents have filed an FIR and are demanding that the dentist’s licence be taken away.”

          “Children don’t just die for no reason at all. Filing an FIR is fine. Why take the licence away when the reason isn’t known?” (See, another why.) “Doing a post-mortem is the correct thing to do; it will clarify matters, tell us why the girl died. Maybe she was ill with something else, something undiagnosed. Maybe she had a condition no one knew about. The report that you’re reading is incomplete.”

          Shri Husband’s first eight words struck a chord. I remembered the death of a child in one of Goa’s malls about four years ago. The newspapers gave it headlines for a day or two, then the news just vanished. No follow up, no mention at all about the incident. No post-mortem report was brought to light, or whether one was done at all to find out the reason. Did the child have a severe asthmatic attack? Or a sudden unknown allergy? Did she fall and have a fatal head-injury? Did someone kill her by accident or intent? No one will know now. What was written as cause of death on her death certificate? Did the doctor who signed it guess the cause or did he know for sure? An unexpected, unusual death in a public place arouses curiosity. I was curious then as I was this morning, reading the article from the newspaper.

          I read aloud some more: “This was her third root-canal sitting. The first two times nothing happened. She felt a little giddy the paper says.”

          “It’s an incomplete report if they haven’t interviewed other, senior dentists and paediatricians to know what might have happened. Newspapers can’t or shouldn’t give opinions unless specified tests are done on the body and the findings revealed. These days media has become the judge for everything. How can one make an issue of an accidental death? Besides, doctors have a right to know what happened to their patients. A post-mortem is a must. That’s what the media must follow up.”

          How could one have an accidental death on a dentist’s chair, I wondered.

          As if reading my mind, Shri Husband growled: “One can swallow one’s tooth.” Some sense of humour, that. I didn’t laugh. Then he added: “Maybe she had a rare reaction to a pain-killer, who knows? The Press needs to educate itself, stick to reporting not passing judgements. You see what they do when there’s a plane crash… even before the black-box is found and the technical enquiries have started, they guess they know what’s happened and flash it as ‘news’. Or they pluck local ‘experts’ – same ones over and over again—to tell us what they want us to hear…”

          Shri Husband in lecture-baazi mood, I thought. I don’t talk much when that happens. Cancel the ‘much’: I don’t talk when that happens.

          “This wasn’t on television, but in the papers,” I ventured after a few minutes. There was a snort that sounded like ‘same thing’ and in the brief silence that followed, I remembered some instances during my hospital-job tenure.

A doctor in charge of intensive care (ICU) had to treat a patient whose heart had stopped just as the ambulance brought him into Casualty. The patient was put on a trolley. Through the glass pane of the Casualty window, the relatives saw him perform a Cardiac-Pulmonary Resuscitation (CPR) on the patient. What the doctor did: tried to get the heart to restart pumping by physically exerting pressure on the ribs/thorax, using a balloon-pump to force air in and out of his (patient’s, not doctor’s) windpipe. What the relatives thought they saw: doctor and nurses beating the patient hard on his chest, jumping around, choking him by covering his face with a strange black rubber thing, filling injections, making him convulse by giving him shocks. Later, one relative told me: “He was fine when he came. They killed him by all that beating.” If, I had gently asked, he was fine, for what reason was the ambulance summoned? It took a long time for them to accept that the doctor had been trying to save the patient’s life. And that patient had been without a pulse on the trolley even before the doctor had arrived.

Another instance: a child undergoing an MRI in the OPD collapsed and had a ‘heart-attack’. The anaesthetist present revived her (she’s now a grown woman, a mother) but refused to let her get discharged until she (the anaesthetist, not the patient) knew what had happened. Several tests later, it was discovered that she (patient, not anaesthetist) was born with a defective heart that caused her to almost not survive the sedation she was given.

          The bigger mysteries of Aarushi Talwar and Sunanda Pushkar don’t intrigue me. They’re over-discussed and there are several motives/angles involved. In this little girl-patient’s case, trial by media is stupid. But I’m curious. What might have happened? The reason for the curiosity is because 99.99 times things go ok. And that .01th time, it gives the doctor nightmares. No media covers those. My sympathies lie with as much with the doctors as with the bereaved families.

Feedback: sheelajaywant@yahoo.co.in

Doctors’ Instinct

          Our friend fell down some steps, then couldn’t move because the pain in his hip was terrible. His wife took him by public ambulance to the closest, very new hospital, partly owned by a semi-retired orthopaedic surgeon. He gave the friend a pain-killing shot and took an x-ray. Later, the wife found him (doctor, not friend) poring over the film, palm on forehead, mumbling, “… the neck should be broken, must be broken..” She wondered whether the semi-retired doctor was also semi-stupid.

“How was I to know,” she told me later, “that he meant neck of femur (thigh bone)? To me, a neck is something that attached one’s head to one’s shoulders.”

The only way to prove the neck-was-broken was by doing a CT-scan. The closest CT machine, this was in Noida, UP, was some kilometres away, even in an ambulance an agonizing ride. Friend’s wife did some sms homework and was assured that doctor had a good ‘hand’. So without ‘photographic’ evidence, she signed the consent for the surgery. In a couple of days, the friend’s hip was fixed and functioning. Opinion-based diagnosis had saved the day.

During my recent back-pain episode, my Goan doctor DB, sensing agony in my phone-distilled voice, recommended: “Complete bed-rest.” The Mumbai consultant who saw my MRI via Picture Archiving and Communication System on Everest Base Camp, sent realtime instructions via smartphone to his registrar sitting by my bedside: “Complete bed-rest.”

When I mentioned opinion-based versus evidence-based practice to someone, this is what he said: “Without doubt, evidence-based. How can anyone say I think the patient has fever? You check the thermometer, read the value and you have proof of temperature.” (Healthcare professionals reading this, hold your giggles; that’s how lay people perceive it.)

Even the brightest physicians are thankful to ultra-sound inputs to pass judgement on ‘pottanth khubba dukhtaan’. Who might be responsible for the painful crime: gall-bladder stone/ renal colic/ appendix/ secret tumour?

Experience versus modern technology, that’s the debate. Can skills (l)earned over 18 hrs/day x 11 months/year x 25 years of practice be superior to blood tests done in a laboratory? There are times when an opinion-based practitioner won’t wait for a typhoid result, but start treatment pronto, not wanting to waste time/ lose patient.

But… in evidence-based practice there is no guesswork. Therefore less chances of making mistakes when one depends on lab-tests. Think blood-sugar levels, typhoid/ dengue detectors.

There are those who don’t believe in modern technology, who believe that doctors must use their heads and hands alone. But should the doctor made a mistake, they say: aaj-kaal beshta suvidhaa aastana kitya upyog karap na. Would they include stethoscopes and blood-pressure checking gadgets as ‘modern’ things?

(I know people who believe landline phones are acceptable technology, but mobile phones are not. It’s ok to have a fridge, but no micro-wave. No one complains about cars, air-conditioners and electricity. No one even realizes that technology goes into the manufacture of office-chairs, sliding-windows and shaving-gear. Where does one draw a line regarding ‘modern’?) 

When it comes to curing our ailments, we want both, experienced doctors with great instinct plus state-of-art technology.

Experience crawls. Young doctors lack it and benefit with the evidence-based method. What doctors of my age learned through their MBBS and PG years, the youngsters cram into a short period because the amount of knowledge they need to know is more.  Cutting-edge stuff is cold, distant, without the human touch. And expensive. If we were to depend only on it, we’d need diagnostic centres next to every other biscuit stall and even then we’d have long queues, so dense is our population.

Leave aside serious road traffic accident cases or those with bleeding in the brain, where no surgeon would touch a scalpel without following the protocol of checking on blood-clotting time, exact location of ‘trouble’, etc, there are many illnesses that can be prevented by modern methods. Dyes injected through arteries and the presence of higher-than-normal levels of creatinine in the blood can detect heart/kidney troubles. Same with some kinds of cancer.

Evidence-based practice is here to stay. To prevent thoughtless prescriptions, to know how and when to use which tests, how to interpret the results correctly, doctors will have to fall back on Experience. Those who have insights through medical humanities, who recognize the importance of the natural history of a disease, will be more accurate in their dealings with different diseases/ ailments/ injuries/ illnesses. At the end of the day, opinion-based practice will still have higher value. Doctors’ instinct develops over time.

Anywhere At All.

(10 Jul ’11)

            We were in a rattling, overcrowded bus winding our way on some ghats. A couple of villagers were sick, and throwing up out of the windows with abandon. Undigested rotis and daal splattered the walls of the vehicle. The smell choked us. At the next stop, my classmate, Dr Girish, dug some anti-nausea medicines out of his haversack and offered them to all who felt queasy so that we could have some comfort for next couple of hours. When the bus started its journey again, the middle-aged, pock-cheeked man with the city-tailored shirt-pant asked him what he did for a living. “Doctor?” he confirmed. From then on, Girish fielded questions about dyspepsia, drop foot, infertility, wax coming out of the ears, falling hair, backaches… not just of the fellow-passenger himself, but about his brothers, his sister’s children, wife’s family, everyone. When he ran out of relatives, he graciously permitted another passenger to take his seat and place so he could make full use of the dear Daakter whilst the bus continued to snake its way to its destination. Everybody took their turn. By the end of the journey, without examination, without even being present, several ‘patients’, mostly in proxy, had been diagnosed and the prognosis cheerfully given. One or two were declared ‘back from Yama’ and everyone in the bus was happy at the thought. At the end of the ride, a grateful sample of rural India’s population offered the good doctor a hen, some potatoes, a bagful of peanuts, firewood, and a used but warm scarf.

            Where do you practice, I once asked my doctor friend. “Anywhere at all,” had been the prompt reply. The moment someone finds out a person is a doctor, symptoms come tumbling out. Headaches that have not been cured for years, heartaches that have lingered for months, near-death experiences, even boils in unmentionable areas. Add to that opinions on ancient traditional methods of treatment versus these toxic capsules that one consumes these days and you have a veritable university set up in someone’s dining room at a late night party. Or beside a waterfall at an away from the city picnic spot.

            What’s more, a doctor’s a doctor, no matter what his or her specialization. At dinners and parties, pediatricians are asked questions about skin problems, dermatologists are asked for their opinions on heart ailments. I guess gynaecologists are the only ones spared. Nothing like a free consultation in these days of inflation. And ‘friendly’ advice somehow seems more genuine than ‘professional’ stuff (this is a misquote from someone who actually expressed the view).

            There are advantages. In a car-rally where a couple hadn’t qualified, they managed entry because “we’re doctors, you know, might be useful”. Another time, someone wanted her child babysat for an evening. She cooked up the every useful ‘emergency’ to have her neighbour take care of it for a couple of hours. Policemen at signal seldom fine doctor-drivers because of the life-saving rush they’re in.

            If a doctor is young, then much interest is generated wherever s/he goes. Prime catch. “My niece/nephew is of marriageable age” is the thought that crosses every middle-aged mind when a young doctor’s introduction happens. The thought is often translated into direct questions, too, and sometimes carried forth to visits home, exchange of biodata, etc. There have been cases of people who have actually made formal appointments with doctors, paid the fees, presented themselves as patients just so they could check out the bride(groom)-to-be. The latter didn’t have the tiniest clue of what was happening.

            Doctors are also supposed to have cures for all ills, even social and financial ones. “Please tell my son to study.” “Please tell my mother to stay out of our married life.” “Please tell my husband to change his job.” “Please tell me how to handle my quarrelsome neighbour.” Or “Do you think such and such bonds are a good buy?” “Do you think so and so mutual funds are doing well?” As well as “is this car better than that?” Over a period of time, can’t blame the medics for believing that they really are the experts on defence, finance, foreign affairs, education, sports, arts and culture. For the perks of their practice is to get invitations to events, discussions, conferences, plays, dances, forums, inaugurations, all sorts of functions. It is assumed that they attend them and assimilate every nugget of information received. All intelligence and smartness is incorporated in that word ‘doctor’.

            The flip side is that they cannot, dare not, fall ill. “How can YOU get fever/diarrhea/toothache/nausea?” is a common question, followed by the rider: ‘you’re a doctor’. Or ‘X is a doctor’s daughter, and still she got typhoid/jaundice/pimples/whatever .’

            It isn’t easy for any human being to live up to such expectations. No wonder then, they lived in cocooned worlds quite often, not easily mingling with self-confessed lesser mortals. For if they didn’t, they’d be constantly at work, answering questions about others’ health-issues real or imagined, with no boundaries of time or location, anytime, anywhere.

@@@@@