Monthly Archives: September 2017

The Untold Slaughter

The Untold Slaughter
(c) Dr. Rajas Deshpande

In my first year of Residency, I was waiting near the hospital elevator, with a colleague, already late at 8.30 AM. The Dean, who is the highest authority in medical campus, on his morning rounds, came with his routine flock: Medical Directors and Superintendents, Nursing Chief, and Assistant Medical Officers, and waited for the elevator. I wished him a Good Morning, he reciprocated and looked at his wrist watch. I understood. “Sorry Sir, I had an emergency last night, I left wards at 7 AM” I said. He nodded and smiled.

He was a respectable odd man out in the system at Government Hospitals then. He was clean and non-corrupt, extremely punctual and active. This reflected in cleaner wards and better services, availability of staff, medicines and devices, although the patients who benefited rarely knew who was the guardian angel behind the service. He had become Dean by a rare chance: there was no one qualified and willing to take on that responsibility, so he was given the charge. However, now those in the “good books” of power were ready to take over, and awaited the right moment.

Like most straightforward and non-corrupt officers with a spine, he was generally hated by the system. He had stopped the bribery and corruption that started from some ward assistant / ward-boy level to all the purchases, appointing committees of different heads. He had stopped the purchase of medicines and devices / catheters from dubious companies which had flourished for years around the town. “Local Cheap Pharmacies” run by the “Well Connected” or aliases of those in power were affected badly, as their whole set-up was designed to run via such government hospital purchases.

The doctors, clinicians and residents like us were happy that the patients got good quality drugs, it is otherwise horrible to witness treatment failures which can never be proven to substandard drugs or catheters. The only face to blame is that of the doctor for a politician or a patient.

Naturally, he was on the hotlist of many in power. The best weapon in politics: the caste card was being used against him. The labour organisations and staff associations that belonged to a different caste / religion than that of this Dean were continuously active to create nuisance, hoping to spread the fire and bomb the press at the first correct opportunity.

Almost all elevators at government hospitals are the basic old re-repaired ones: slow, jerky, unreliable, like many offices. As we waited, few others joined the elevator queue. Among these was a middle aged sweeper lady, who came limping.

“What happened?” asked the Dean to her.
“I fell at home, it’s just a small sprain, I am taking medicine Sir” she replied politely.
The elevator came. As patients rushed in, the Dean held open the door for her, and asked her to get in first.
“Pehle aap andar aao” he said (“You come in first”).
The lady politely replied “Nahi Sir, aap chaliye pehle” (‘No, Sir, You get in first”).
He went in, some staff went in with him, then he asked the sweeper lady to come in too, by a hand gesture.

That was enough. The next day, there was a huge agitation. The allegation was that the Dean said “Aati Kya” (“Will you come with me”) to a sweeper, and made an obscene hand gesture. There were morchas, road blocks in the campus. The sweeper lady declined to comment, her husband who was among the association leaders gave the press interviews. Some student organisations based upon caste and religion were involved, their gusto fueled by those in power. Two of the doctors who accompanied the Dean that day on the rounds also testified that the allegations were true. One of them was in fact the next in line to become the Dean. Everyone sane in the campus felt ashamed.

I was too insignificant then, just as I am today. But I went to the Dean with my female colleague, and we offered to testify what had actually happened.

He smiled through the hell he was going through.
“It was my mistake, Rajas, that I accepted the post. This is how the system works, this is the power they have. It is never any party or caste or religion, it is merely a human tendency and unfortunately, that is in abundance today. We have no chance against the majority, and if the majority chooses to be a mob, we
are helpless. Because mobs are bought and blinded, they have no logic or reasoning. The wisest thing in certain situations is to continue to survive, do your best, till you can help engineer a change”.
“But Sir, those allegations are so unfair and vulgar” my colleague said.
He looked at her straight in the eye, and said “Do you believe all that the politicians say?”.

The change happened overnight.
Disgraced and sent on leave, our Dean did not resign.
“I am the small good that must remain in the system. Twisting facts, making allegations that need no proof, exposing personal lives and relationships, misusing culture, philosophy and wisdom as per convenience are new-age essentials for most political leaders. Illiteracy is a dangerous force. The only hope is those who do not succumb to pressure, keep their eyes open and think with their own brains” he told his friends.

Two years later, when I met him to give him sweets for my passing, to touch his feet and seek blessings, I found the same sweeper lady and her husband waiting outside his office. I told him so when I went inside.

Calmly, he replied “Yes, their son has passed twelfth standard, they need some financial help for his college fees”.
I did not ask him what he would do. Doing good is an obligation with such human Gods, irrespective of what they get back in return.

That places them above every other form of human being dry-blabbering about humanity. I touched his feet thrice that day.
© Dr. Rajas Deshpande

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PS: Some facts changed to mask identity.

The Babaji Doctors

The Babaji Doctors
© Dr. Rajas Deshpande

“Today’s young doctors of today don’t know anything” the famous Senior Surgeon told her, smiling bitterly, “You have nothing wrong. Go home and take a pain killer, you will be fine tomorrow.”
The next day, at 2 AM in the morning, she was comatose, as my Neurosurgery professor in Mumbai prepared to operate her brain. She was found to have a huge tumor in her middle part of brain, that was about to kill her in few minutes.

This student, a girl aged about 21, came to me with a severe headache and mild imbalance. A senior physician was accompanying her as a local guardian, as her parents were in Mumbai. I had found that she had some warning signs, and told her to go for an urgent MRI. This is a standard protocol for any headache with neurological dysfunction. The accompanying physician told her in front of me “We will go and have a second opinion from the famous senior doctor. He is my friend”. I was not offended at all, this is the right of every patient. A senior doctor would definitely have better experience if not knowledge or specialty training. But I did feel sad about the ease with which this senior physician had underplayed my opinion. That he didn’t understand something did not give him a right to challenge it. © Dr. Rajas Deshpande

Next morning the girl messaged me that the F.S. doctor had told them “Nothing was wrong, that new doctors advised unnecessary tests, told her to take a painkiller and go to college next day.’

She went home and rested that night. The headache was a little less by morning, she texted me so. By afternoon, in the college, she started feeling drowsy and had a vomiting. Her local guardian physician asked her to travel to Mumbai to her parents and take rest. On the way to Mumbai by car she became unconscious. Her friend accompanying her called me (the F.S. did not pick up their call). I advised them to immediately contact my Neurosurgery professor in Mumbai for further help. I called him and informed so too. They reached Mumbai late evening. Her MRI showed a large brain tumor that was blocking the flow of fluids around the brain, and causing compression on the lower part of the brain. She was minutes away from death. My professor decided to operate her immediately.

Starting new practice, in the beginning weeks in India after three years of fellowships in Canada, I had far less patients, and more time to spend with each one. Very proud, I was also somewhere pleased by the brilliant competition I faced, and the fact that malicious bitterness was usually a certificate of good work. According to a saying, critics help one thrive. So long as I set my practice standards high and respected them myself, I wasn’t interested in any competition, nor feared any. Silence was the best weapon and I used it freely in many situations especially when refusing to be dragged in low level gossips and backbiting, not uncommon even in the medical world. © Dr. Rajas Deshpande

“Say what you must. Make your point twice and move on. Don’t argue, because then you presume everyone is equally intellectual. The greatest rule of all is that truth will prevail.” Dr. Sorab Bhabha, my professor had taught me. I follow that to date, but I fail in the test of tolerance sometimes.

Many times, to impress the patient more than one’s competitor, some doctors resort to quite unfair and unethical means. To cunningly use patient’s dissatisfaction, reluctance and doubt about medical expenses and to say ‘immediately pleasing and gratifying’ things to make the patient happy is an art which some (senior and junior) doctors wisely incorporate into their practice.
“Don’t do surgery that the other doctor advised you, Those tests were all unnecessary, We will take a second opinion because I am not sure about this doctor, etc.” are the common tricks used. This gets them the instant faith of the unsuspecting frightened patient. This can then be gradually used to drive home the same advise as of the first doctor, but in different words that please the patient. © Dr. Rajas Deshpande

I am not against unnecessary sweet talking, although I don’t want to ever do that. Most doctors of my generation don’t believe in it. The patient must be told the truth compassionately, in the least hurting, non-frightening way, and any queries / doubts that may arise should be realistically addressed. Patients should be told the good and bad of every treatment option, and they should be encouraged to make informed decisions.

A doctor is a scientific, intellectual and compassionate service provider, and should refrain from being a pleasing-gratifying, patronizing or clownish entertainer at the cost of patient’s health by making compromised healthcare decisions, just to keep his/ her “Famous and beloved” status.

Some doctors also think of patients as their “personal property” and when they refer such patients to the specialist, they send a list of instructions and interfere with the specialist’s planned strategy. Some admit under their care patients who do not belong to their own specialty, then pay a good specialist for the correct diagnosis, and then google-treat the patients from standard treatment protocol sites (harmful, because the same treatment protocols do not apply to each patient). This unhealthy practice, mainly based on referral / cuts, will hopefully reduce with laws against cut practice.

Any intellectual will understand this: that with the vast expanse of medical field and research, no doctor can claim to “know it all”. One can only be proficient in one’s own specialty. Where a specialist is not available, or in emergency (this is the term most misused in such cases) one can use the best of one’s knowledge to treat the patient. Unfortunately, India is full of illiterate and poor (and also educated paranoid) patients who will only believe what is most financially suitable to them, will easily fall prey to the magical sweet talking abilities of a doctor, and blindly follow what is told, without ever knowing right or wrong. That is the reason of a rise in the “Babaji Doctors” in this country with so many Godmen in almost all religions! © Dr. Rajas Deshpande

These medical equivalents of “Baba”s will have a benevolent smile, talk very reassuringly, speak only what the patients like to hear, and wisely try to convey that they know better than any other doctor, even the best specialists who have had excellent training in very specialized areas. Quite fortunately, younger generation patients are far wiser than to be affected by these pseudos: sweet talking without a reason is an immediate turn off for most intellectual young.

The hierarchy of education, qualification and specialised training is always superior to the hierarchy of experience. An MBBS passed out 50 years ago cannot be better than a MD passing out today. The ones with higher qualifications and training, even if far younger / junior, must be treated as above one’s expertise in their respective field. Yes, if the degrees and training are equal, then experience matters. © Dr. Rajas Deshpande

“ I don’t agree with your diagnosis, I don’t think that this patient has Parkinson’s disease” a senior surgeon once told me in front of a patient he had referred.
I know no one can be perfect, and I can be wrong. But I also know who is qualified to say that I am wrong.
“With all due respect, Sir, you are not qualified to comment in this specialty, just as I cannot challenge your diagnosis in yours” I replied. Age that does not match its behavior need not intimidate me, especially where a patient’s diagnosis is concerned. A doctor’s first duty is to tell the truth to his patient, and a part of that truth is what the doctor does not understand.

Pretending expertise in medicine may be fatal for a patient, no true blooded doctor can accept that.

As for the girl who was operated that midnight, she is now married and has two kids. She called a few months later to tell me she was doing well.

I continue to meet patients every other day, who have visited the F.S. doc, and tell me how he told everyone else was wrong.
Unfortunately, the only treatment in such cases is awareness.

© Dr. Rajas Deshpande

PS: Most doctors follow the ethics of not criticizing other doctors, which is required by the Medical Council. However only very few senior doctors have a heart big enough to welcome competition. This causes immense difficulty to the newer generations of specialists. Hence this article.
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Homoglobin

Homoglobin

© Dr. Rajas Deshpande

“How much is your experience, doc? Have you ever seen any cases like this?” she asked. She was accompanying her father who had Parkinson’s Disease, quite common all over the world.

Many hilarious and abrasive retorts came to my mind:

‘Do you ask such questions about the pilot or driver when you board a plane or bus? , Do you ask such questions when someone absolutely inexperienced is made a minister of important portfolios like health, defence, environment etc.?’ If you can have faith in them, why cannot you trust your qualified doctor?© Dr. Rajas Deshpande

However, being on the doctor’s side of the table, I could not allow myself losing patience so easily. I chose the most professional answer, forcing a smile: “I am practicing since 25 years, over 15 as a Neurologist, and I have seen over two lac thirty thousand patients till now. Almost every Neurologist sees an average of 30-40 patients per day”.

When the rural / illiterate populace asks these questions innocently, I am never offended, but if it is the literate suspicious kind who treat manners and etiquette as an ‘optional’ part of communicating with the doctor, I feel just like when someone spills my ice-cream. It is difficult to connect with a paranoid literate, however hard one tries.

Apparently satisfied with my experience, she shot her next google bullet: “Can this happen because of his low Homoglobin? I read it on a blog.”

“The correct term is Hemoglobin”, I told her, “and its low level does not cause Parkinson’s”.

It was over 45 minutes since they entered, I had replied to every point on the question paper that they had prepared from a Googlesearch syllabus. The next patient must be already angry now, I thought.© Dr. Rajas Deshpande

“How can you be so sure that this is Parkinson’s Disease? What’s the proof?” Fired she.

“There are many diseases where there are no proofs of diagnosis, some can be proven, most are based upon the doctor’s clinical judgement. Sometimes quite costly tests are required to prove what is an obvious diagnosis. You are welcome to obtain a second opinion” I replied.

“Can his Parkinson’s be the side effect of the knee surgery done eight years ago?” She.

“No” me.

I now issued a DNR (Do Not Resuscitate) order for my gasping patience.

Most doctors know the simplified versions of how to explain the patient in layman language about the common diseases/ disorders. Every type of case requires a lot of reading and actual handling / treating to gain insights about that condition, something that is impossible to explain exactly to the patient / relative, especially because they do not know the basic concepts, organs, their functions etc. What even the brilliant medical students take repeated readings and many case studies to understand well, cannot be simplified enough to explain to all and sundry.© Dr. Rajas Deshpande

Add to this: every patient even with the same diagnosis is different, needs an individualised approach, and no google guidelines or statistics can replace the doctor’s wisdom in making a treatment decision especially in complicated cases. To make the most accurate decision and to explain it is a doctor’s duty, but the understanding quotient of the patient or relative cannot be the doctor’s responsibility. Medicine is so complicated, that even the most experienced doctor in the world cannot say he knows everything about any single medical condition.

The more you attempt to educate some literates, the deeper in a quicksand you enter. Because they are not satisfied with the fact that the doctor is making the best effort to educate, but look upon this as an opportunity to question the knowledge and wisdom of the very expert whose opinion they are there to seek!

They try and catch words and cross question as if it is a legal argument.

“You said swelling: show me where is the swelling?” most common question.

“Well, it is called Inflammation in medical language, there is no accurate translation for that word even in Hindi, hence we commonly use the word swelling. It may not be a visible swelling”.© Dr. Rajas Deshpande

It is not always the fault of doctor’s ability to communicate, it is often the over-expectation that one can understand everything. It is laughable that even those some whose life is a mess, who are failures in their own chosen paths try and argue about medical diagnosis and decisions with highly qualified doctors.

However profound a doctor I may think I am, there are so many things I do not understand: politics, finances, many people’s behaviour, mathematics, government, etc., and I am ok without ith not understanding most. However I do not have the audacity to ask an expert in these fields / professor / CA whether he / she has enough experience.

But with a doctor, these liberties are becoming rampant now.

“I think he has convulsions because of his spondylosis” one halfpant+crocs combo tried to punch a new hole in my knowledge recently.

“Let me decide that” was all I replied, rather than explaining how he was beyond wrong.

The shorter you keep it, the sweeter it remains. I would rather save and use my time for those worried, panicked patients who have enough faith in my abilities, who understand mutual respect, and who will have at least this insight: that the doctor knows best how to treat patients.© Dr. Rajas Deshpande

Of course I am aware that there are some doctors too, who initiate rude conversations, do not respect simple etiquettes, and are quite difficult to connect to. Most patients even when offended by rude doctors, kindly choose not to react although they carry home a bitter feeling. Every medical student, every doctor must be taught in the earliest parts of internship about the code of etiquette and mutual respect while dealing with any patient, and only then expect the patient to follow it too.

Coming back to this lady, I wrapped up the session by telling them to follow up after a month.

“Can he continue to take his three large pegs of rum every night? He cannot sleep otherwise” she asked.

“In my 25 years of practice, I haven’t met anyone whose health improved with alcohol. Do please google that.” I gave her the dose she had begged for.

© Dr. Rajas Deshpande

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