Category Archives: Medicolegal

“Is The Diagnosis Wrong, Doctor?”

“Is The Diagnosis Wrong, Doctor?”
© Dr. Rajas Deshpande

“Doctor, there is no improvement at all” said the angry husband, throwing the case-file upon my table.

Well this is not an extraordinary sentence for any doctor, one must be prepared to openly deal with this. I had been quite polite and well mannered with them, there was no reason he had to cross that line. I could understand though. When they pay my fees, they expect some result or satisfaction.

While teaching my students, I have always insisted that if the patient / relative says that there is no improvement or change with the prescribed medicine, one must first consider the possibility of a wrong diagnosis, a missed condition or a misinterpreted finding. Doctors are humans, and do commit mistakes, or misinterpret findings. This is normal, and happens with every doctor. Medicine is far more complicated than most people think they know. A good doctor knows this and learns, while all the time keeping patients safe, but a doctor with ego kills his own practice, and may cause harm to the patient.

I asked them to sit down and reassessed the case in detail. A 28 years old female. Headache, giddiness, imbalance, palpitations, breathlessness. Lack of sleep and bouts of crying. Past and family medical history not contributory. Physical examination completely normal. MRI of brain normal, Vitamin B12 and D levels low. I had started vitamin supplements, anti-anxiety medicines and an SOS for headache.

She told me all her earlier complaints had improved, but now she had a severe backache. I told the patient that I was trying my best to understand her condition, and to resolve her problem, but her findings and complaints didn’t match. She looked at her husband, and asked him “May I speak frankly to the doctor?”.

Openly agitated, the husband sarcastically offered to wait outside if she needed privacy. However he stood glued to the chair as if he knew her answer. © Dr. Rajas Deshpande

The patient thought for a moment, told him it’s ok he can wait inside, then started to talk. She revealed that she was the only child of her affluent parents, had passed engineering, but now had to quit job and stay at home to raise children. They lived in an extended family, with grand in-laws, in laws and an elder brother, his wife and two children. This patient was the ‘last in the line’ to take orders, all others being senior to her. Her husband and in-laws were perfectionists, and she was tired of their continuous expectations. She had dreamed of making a career too, wanted some free time outside home for herself, but year after year, she didn’t get even a minute for herself. She was tired of it all and there seemed no respite. © Dr. Rajas Deshpande

“I am not averse to hard work, but the continuously condescending and fault-finding attitude makes me feel that I am useless”, she said, and added cautiously: “We were in the same institute and my ranks were always better than him. Look at where I am now” she started crying.

I offered them water and coffee, and waited for her to settle down. The husband became restless and defensive, but his tone was far lower. “I understand her problem, doctor, but what can I do? I cannot leave my family. My work pressures are quite high too, the IT industry is going through a bad phase”.

“I can assure you that she has no neurological problem now’ I replied, “she should improve with lifestyle changes, counseling for the family, and adequate free time for herself. I will refer you to a good counselor” I told them.

The husband laughed. “I can understand, but my parents will not. We will see what best we can do for her”. A bitter tone in his voice didn’t escape me.

‘Sir, she told us what bothered her, and must not be held guilty for trying to speak her mind. It will only help identify and treat the problem better. Please see a counselor together and avoid discussing this at home right now” I requested the husband. © Dr. Rajas Deshpande

There are many reasons why a patient does not improve. Untreatable medical conditions, depression, seeing the wrong specialist are the most common reasons, but there also are patients who want medical leave,those who want to avoid work, who want attention, so will keep on complaining of false symptoms. They do not improve with drug treatment.
On the other hand there are many who keep on taking the wrong medicines for years, those who self-medicate, do atrocious / injudicious dieting and exercises, yoga that doesn’t suit them, and do not follow the doctor’s instructions about abstinence, who keep on indulging salt, sweet, oil, alcohol, tobacco and other drugs freely available in India. © Dr. Rajas Deshpande

A doctor remains a lifelong medical student. A doctor who thinks he / she is always correct is most dangerous. It is not uncommon to meet doctors who are angry / upset with the patient / colleagues when their diagnosis, treatment is questioned. The first thought of a doctor when the patient does not respond positively should be to consider a misdiagnosis, reevaluate the case in more detail, reassure the patient, and obtain a second opinion if necessary. All this done, one must look into other possibilities, with an approach to resolve the issue rather than trying to shove down the patient’s throat their own faults.
We all go through bad patches in life, doctors and patients. If the child is wrong, the parents correct them still with love. A doctor’s attitude should be similar, with due care to also protect themselves. If not the doctor, who will understand the patient whose family refuses to understand them? In so many ways, especially in the Indian society, the doctor must don the role of an elder brother/ sister. Although patronising is legally discouraged in medical practice, and should be refrained from in cases where trust is questionable, one can make exceptions for some cases that need reassurance where the family fails to do so.

The nobility of our profession also lies in reassuring the patients that they are well cared for by their doctor, through the thick and thin of their life.
© Dr. Rajas Deshpande

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Beyond Ridiculous!

Beyond Ridiculous!
© Dr. Rajas Deshpande

A 9 year old child with fits / seizures was taken to a renowned Paediatric Neurologist. He started treatment with one of the most commonly recommended (by almost all textbooks) used medicine in the treatment of seizures: carbamazepine. One of the most effective medicine, used since over 50 years in children, that can cause side effects of rashes in less than 1/1000 cases. Still rarely, the side effects can be very severe, causing extensive damage to the skin.
The doctor explained this to the child’s parents, and then started the recommended doses. Pediatric doctors are the best trained doctors in dose calculation, they are more aware than any other specialty about the side effects in general, because children often cannot even speak and parents may not notice some side effects. © Dr. Rajas Deshpande

Every medicine has side effects. Even vitamins do. Any medicine can potentially cause life threatening reaction, and that’s why the common warning with each medicine: do not use if you are sensitive to this medicine. How will one know whether there will be any allergy / reaction to the medicine without having used it?

Most medicines can cause side effects at high doses, but some can cause dangerous reactions even with the tiniest dose, or test dose. Some medicines (even the one mentioned above) can cause side effects after many months / years of safe use. While the dose dependent (high dose= higher side effect) side effects are somewhat predictable, the ‘idiosyncratic’ (meaning occurring in individual, not all cases, because of the natural tendency of that person) and “allergic” side effects are totally unpredictable, and can be caused by even such common medicines as paracetamol, aspirin, antibiotics or vitamins. Even deaths have been reported after the use of some common medicines, but even in the highly legalized western world, no court holds doctors guilty for the side effects of medicines, if these were discussed and informed to the patient / family. This is against common sense. © Dr. Rajas Deshpande

This child unfortunately developed a rare but well known side effect of this drug, called Stevens Johnson Syndrome (severe skin rashes), had to be admitted and treated, it cost them one lac rupees. While we sympathise with the child and the family, and wish them the best recovery and health, this is hardly the mistake of a doctor.
But the forum, in a regressive decision, held the doctor guilty, fined him 90000 rupees. This is beyond ridiculous. The court observed that “ if the doctor knew that this drug can cause side effects, he should not have prescribed it”. Translated intellectually, that means NO DOCTOR CAN PRESCRIBE ANY MEDICINE! © Dr. Rajas Deshpande

Moreover, what will this court advise for the child now? Every seizure medicine has some rare dangerous side effects. There are no medicines free of side effects. Shall the child be left without treatment now? Which doctor will want to treat such a case? Which court will guarantee that the rarest of the rare side effect cannot happen again in this case, and with such ill-informed forums, the next doctor trying to do good to the child will not be held guilty? © Dr. Rajas Deshpande

Technically, if using a drug that can cause side effects is a crime as per this court, it should hold everyone concerned guilty: the textbooks / medical bodies that recommend this drug, the pharma which produced it, and even the government which allowed it to be sold. Applying the same logic, if some child developed peanut allergy in a hotel or side effects of pollution and dust by travelling on Bangalore roads, will this court hold the hotelier or the city administration guilty and punish them too? Has this forum/ court banned tobacco and alcohol yet, or will it punish the government for the side effects and thousands of deaths caused by these? © Dr. Rajas Deshpande

The IMA, other medical bodies, Neurological society, and intellectuals should stand by this doctor who has suffered the mental agony. This decision must be challenged in higher courts.
We regret that some patients suffer side effects, no one should, but at the same time, the “side effects of medicine” is not the doctor’s fault, especially in this case where he had explained the parents about such possibility.
We need medically educated forums and judges who can refrain from populist tendencies.
© Dr. Rajas Deshpande
PS:
I respect courts. I respect higher courts more. But I refuse to believe that every decision made by every judge is correct, that every decision is impartial, that it is not affected by pressures. This article is solely based upon the attached news clip. I must admit that this reporter Ms. Meghna Singhania has done an excellent and impartial reporting. Doctors must please stand united against this decision.

https://medicaldialogues.in/side-effects-of-prescribed-m…/…/

Fate and The Fatal Healthcare Gamble

Fate and The Fatal Healthcare Gamble.
© Dr. Rajas Deshpande
 
In the rush of a local station, a 25 year old man suddenly shouted in a scary way and threw a fit. His eyes rolled up, his body shaked violently, and he fell down. The jerks kept rocking his body and shocked people around him noticed blood stained frothing from his mouth.
 
Some strong person, too eager to be a hero by the demonstration of gym-built strength, kept his foot on the leg of this patient and pulled his tightened hand to straighten it, till one heard the obvious sound of a bone breaking. Another slapped at the face of this convulsing patient, abusing, and telling the bystanders that the ghost holding this patient must be scared off. © Dr. Rajas Deshpande
 
Yet another, with the confidence of experience, thrust a dirty leather footwear under his nose. Someone else shouted for an onion or chilli, guaranteeing that it will immediately stop this voodoo. This too was then applied to the nose of this patient who was still convulsing. The patient had a lock-jaw, his teeth were clenched together. A spoon was then forcibly inserted between the teeth, and so strong was the effort that few teeth broke and blood oozed out.
 
By this time the convulsion had stopped, and everyone who had thus “treated” the patient proudly explained how each of these tricks always worked.
 
None of them knew that an epileptic attack would automatically stop within a minute and a half, that one should not force open the mouth or straighten the hands or legs, because that will only hurt the patient. The excessive electrical discharge in the brain that causes such fits will not stop by doing anything externally. Within a minute, such activity stops automatically as the brain energy and the currents cannot sustain, and the patient recovers consciousness in most cases. Rarely, such fits go on beyond a minute or two, in which case, only the trained medical practitioners must handle the case, preferably physicians or neurologists. © Dr. Rajas Deshpande
 
This patient was still unconscious.
An ambulance which had the “contract” for that station arrived, and the “paramedics” got the patient in. Relieved that all was well, people, as always after whatever happens, carried on.
This ambulance then took the patient to a “contract” hospital far away, even when there were many good hospitals on the way, thus wasting the most precious time. The patient had aspirated: his blood and saliva had now blocked his respiration.
By the time he was taken to this hospital, he was almost gasping.
 
The contract hospital, owned by an organization that had excellent political links, was designed to hide the deficiency of the most important element in good healthcare: well qualified and experienced, genuine specialists. Being the one to provide the lowest cost treatments, it only employed doctors willing to work on the lowest salaries. Poorly qualified, rarely experienced and already fed up with the workload. But in these days of beautiful, colourful signboards and deceptive advertising, declarations of “world class healthcare”, one rarely questions the training, qualification and experience of doctors. © Dr. Rajas Deshpande
 
The patient was taken into ICU, intubated and ventilated. An orthopedic surgeon attended his manmade fractures.
Legally everything was completed and correct. All forms signed. Critical status explained, understood, accepted. Relatives happy about the charges and the behavior, explanations by the doctors and specially appointed PROs. A qualified Neurologist was called in for a visit, who guided the treatment and went away. He was scarcely in a position to advise the relatives that the basic life support systems require great experience in such cases, and this hospital didn’t have that kind of a team. That would be unethical, plus the hospital had enough connections. That’s what got them the contract in the first place. Also, his calls would stop if he spoke beyond what he was called for.
 
The patient had suffered damage to the brain due to the delay in starting the treatment. He remained unconscious. Then in a week he developed septicemia: infection from the lungs that spread via blood to all his body. © Dr. Rajas Deshpande
The relatives were explained everything, except the fact that the team was inexperienced, ill qualified to treat. They were broken when the patient passed away., blaming their ill fate
It was indeed the fate of that patient to have a fit just there, just then. A young man who could have come back to normal health in few minutes was killed.
 
Or was this fate alone?
 
This death was preventable: a fit generally needs no treatment while it is happening. In this case, people had broken his bones and teeth, forced dirt in his nose, and caused bleeding. The ambulance, due to the obvious “loops”, wasted precious time reaching the “contract” hospital rather than the nearest hospital, the contract hospital took the case in spite of not having well qualified expertise and team to handle the situation, and the relatives did not care much beyond the financial implications. All equally guilty. This was a murder with multiple murderers.
The only thing one can do to help a patient having a fit is to make sure their head does not bang upon a hard surface, remove any sharp objects upon or near the patient, and turn the neck gently to one side, so that the food / tobacco/ anything that the patient has in the mouth comes out and does not block their respiratory pipes. Simultaneously, call an ambulance. © Dr. Rajas Deshpande
 
Remember the 6×6 feet supermarket that sells everything, in the corner of your lane? Something similar is happening with healthcare now. One wants every specialist in the nearest location, with cheapest competitive rates, and so long as their advertisement is good, people are happy when quality takes a backseat. A specialist is a specialist, so long as he / she has any degree, so long as the govt. approves, and especially if they offer concession, nobody cares about tomorrow.
 
The extensive training that goes into making of quality doctors is now replaced by many options: some low quality private medical colleges run by those in power, where money buys almost everything and merit/ hard work doesn’t matter, cross pathy and bridge courses, allowing too many unscientific treatments to take center stage in the country’s healthcare, defaming those who try to improve the system , projecting the philosophy that “all healthcare that is cheap is alone good, costly means corruption” etc. © Dr. Rajas Deshpande
Who suffers when inadequately qualified doctors with poor merit, experience and dedication treat the patients? Who suffers when those who have made their career based upon political support or corruption, treat the patients?
The worst gambling in India is in healthcare. People happily stake their lives to save some money.
 
God save my dear India in this healthcare crisis.
Jai Hind
© Dr. Rajas Deshpande

Are You Respectable, Doctor?

Are You Respectable, Doctor?
© Dr. Rajas Deshpande
 
“Send in the next patient” I told the receptionist.
As no one came in for a few moments, I opened the door. A trembling, shuffling old man in his eighties, standing with the support of his son and daughter in law, was fumbling to remove his sandals outside my door.
“Let it be, it’s ok” I told him.
Smiling, embarrassed that he was unable to move fast, he folded his hands and said ”Namaskar Doctor! You are like a God and your room a temple for me. You give life to so many. I don’t wear sandals in a temple. Let me remove. I am sorry, please give me one minute more”.
It was my turn to be embarrassed. Do I deserve this respect from a stranger just because I am a doctor? © Dr. Rajas Deshpande
 
Mr. Wamanrao, who was a teacher before retiring decades ago, walked in. After examining him, I explained to him and his family that he had a degenerative problem of brain that caused imbalance and stiffness. The concerned family asked some questions earnestly.
 
“Tell them I am old and must leave this world now” said a smiling Wamanrao.
 
Pausing to think for the right words, I explained them the condition, and told him “At present I do not see a reason to worry. I don’t find anything life threatening in your examination, we will also do some tests. But there is no need to think about an end at this time. You should improve, let us try. And yes, it is very fortunate and enviable that your family loves you so much”. It was impossible for me not to remember my own father.
 
In tears, he folded his hands, then blessed me by keeping his hand upon my head, and left.
 
Many patients came in that day, and I kept on thinking: that most of them, especially the illiterates, poor and elderly came with a lot of respect, behaved politely, and followed the instructions well. Some came in bitter with their experiences with some other doctors and hospitals and confessed the reason of their angst. The young, rich and highly educated mostly walked in with a paranoia and refusal to trust. But these were very few, mostly because I don’t dance different for the high class patient. The most difficult class to handle were the uneducated rich and the politico poor, who think everything can be bought, threatened or manipulated, including a doctor. © Dr. Rajas Deshpande
 
This last class offends and frustrates most doctors who work with a feeling of dignity for their profession. Not because they ask too many questions, but because they misbehave, are too arrogant to tolerate, and cannot trust anyone. The last thing that a doctor wants is a trustless patient: it means trouble in future even if the best is done for such a patient. Even if saved from a coma, they will belittle the entire profession and file cases for bills. © Dr. Rajas Deshpande
 
We always claim that some doctors are bad and the good ones bear the brunt, then we must also understand that some patients behave bad, but most others suffer the consequences. The “On-Guard” new generation doctors have now started to become too ‘legally correct’, talking in terms that lack feelings. They are not always wrong, because the law of the land, the crass class of media and many administrators openly badmouth this noble profession that carries the entire healthcare of this country upon their shoulders.
 
However, we as doctors must also think if we always behave respectably. There still is an inherent respect for the profession, in the minds of most. But if a doctor thinks that he / she should be treated like God just because they have a degree, there is a grave misunderstanding. One must be proud of one’s merit, but the patient shouldn’t have to pay the fees for that pride. © Dr. Rajas Deshpande
 
Many doctors are usually well behaved, but we also see very rude, “head in the clouds” type of doctors. A little success, a little affluence, and a ballooning ego is a common picture. Such doctors then refuse to acknowledge the patient (or even their own junior) as another human being to be treated as an equal, with dignity and respect. They will crowd their waiting rooms, make patients wait unnecessarily while they chat / entertain “rich and influential clients” etc. They will behave high handed and rude with patients and juniors, pretend to be in a hurry when the patient starts asking questions and even walk out to see another patient in another room. Many quite senior big doctors actually classify the patients financially, so that the assistant filters out and treats a certain class of patients.
 
Some doctors talk “only the legal” language to patients who are emotionally disturbed, in a state of shock or grief. The other end is the “Always smile and keep the patient in a state of false hope till they can pay bills” type of doctor, who disappears once the patient cannot pay or takes a bad turn of health. Some doctors do not even follow the common decencies of respecting elders and women. Manners and etiquette are fast disappearing among doctors, it is time to remind ourselves that a doctor is one of the highest respected intellectual in our society, and just like the heroes upon the big screen, many, especially children emulate the good behaviors of doctors too.© Dr. Rajas Deshpande. It is sad that our media, movies and comedy shows take pride in belittling Indian medical profession, considered one of the best in the world, but it is also true that some doctors indeed provide them with a reason to do so. © Dr. Rajas Deshpande
 
No one will salute a doctor just for his / her degrees, experience, post or affluence. If a doctor wants to be respected, he / she must carefully learn to respect others, use the right language, and follow manners and etiquette at his end. There indeed are a minority who will mistreat a doctor, who will take advantage and misunderstand manners as weakness or an inferiority complex. Give them a sincere chance to change their opinion. If they are still paranoid, arrogant or rude, then a doctor must move on, politely refusing to see them again. © Dr. Rajas Deshpande
 
In absence of any support from the politicians or media, we must learn to cultivate a positive doctor-patient relationship culture rather than ourselves becoming paranoid. We must learn the new language of “legally correct yet compassionate” medical talk. Patients are an inseparable part of our profession, success and daily life, we cannot be at war with them just because of a few imbeciles.
 
I myself am not free of mistakes, and I want to continue to improve, for the day that I think I cannot improve anymore, that I am the best, I can no more be a good doctor.
 
For my birthday tomorrow (07. January), it was necessary that I reminded myself what my parents and the best of my teachers taught me. The best gift life has given me is the ability to be a doctor, and I must take in stride everything that comes with it.
© Dr. Rajas Deshpande
 
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The Unholy Medicine

The Unholy Medicine
© Dr. Rajas Deshpande

“Close your eyes and take it. Absolutely no reason to worry. It is excellent in improving mental and physical health. It improves memory, skin texture, hair thickness and even vitality” said the medical shop salesman, winking one eye, handing over a big plastic bottle to the posh middle aged couple.

“It is all natural. These products have zero side effects” he said.
“But it costs nearly two thousand rupees” said the wife.
“What’s costlier than your health, mam,? This product is selling so fast, you will come back again to ask for it once you realize how good you feel without all the side effects”.

I had stopped on my way back from the hospital to buy some vitamins from a large medical store on the way. The shop, like all other medical shops now, had far lesser allopathic medicine . Most prominently displayed were sex boosters, chocolates and beauty products, from various pathies and with pics of different Babas. The next most prominent were various “organic” products, from juices to tablets in blingy packaging. © Dr. Rajas Deshpande

One common factor was prominently printed matter on most such products: “Guaranteed to cure”, “100% natural, free from side effects” “No adverse effects” “100 % Scientific secret formula” etc. Some packets claimed to even cure incurable diseases. Most of these did not have the content printed. Most of these also had valid licenses.

The shop owner and staff didn’t know that I was a doctor. Out of curiosity, I looked for the same bottle on the shelves, and read what it was that the assistant so confidently vouched for. It was a juice of some routine vegetables, with an additional “unspecified” herbal formula. It was made locally, and wasn’t refrigerated. The cleanest ‘Natural” food we cook at home with love, even “Maa ke haath ka Gajar ka Halwa” rots in three days if kept without refrigeration. I wondered what magic formulas kept these “Natural products” free of the millions of microorganisms. But then, I had no right or authority to question the massacre of scientific medicine. I was merely a doctor, not a highly uneducated politician or a religious preacher. © Dr. Rajas Deshpande

Just last week we had in critical care unit, a lady from an affluent family, who was given some precious powder by a “self-proclaimed” natural products expert, (wife of a politico in a taluka place). The 100 grammes powder had cost 45 thousand rupees, and came with a guarantee of “reducing wrinkles and hairfall”. The patient had consumed it for a week, and came to the casualty with a convulsion on the eighth day, found to have poisonous levels of heavy metals in her blood. Few months ago we had a young man who almost died because of clotting in the brain, after taking some injection of a “secret formula” given by his Gym trainer!

Bacteria, viruses and other microorganisms in some of these “natural” products grow for a few weeks, and cause infections, many a times life-threatening. This usually happens after 2-8 weeks or even later, when the patient has long back finished the doses. Some have heavy metals/ ingredients that may cause kidney / liver problems or other diseases months or years after consumption. © Dr. Rajas Deshpande

Wake Up, India! Long gone is the era of “secret formulas”. It is the right of every consumer to know what is the content of every medicine he / she bought. Unfortunately, the “Planned propaganda against allopathy to sell the products of the influential” blinds even the well educated. © Dr. Rajas Deshpande. There is a huge number of people who ask “some medicine” for all their complaints from a medical shop salesperson to avoid paying the fees of a qualified doctor. This qualified / unqualified pharmacy assistant, without even touching the patient, makes his own diagnosis/ conclusion and decides the treatment, the patient happily pays for it, thinking that he / she has saved a lot by not visiting a doctor!

The very governments which cap the prices of allopathic medicines allow other pathies and “homemade remedies and secret formulas” to be sold for the cost of gold and diamonds. Apparently many people have enough money to buy extremely costly herbals, beauty / personal care products, chocolates and sex boosters, but suddenly become poor when a scientific medical product by a standard international pharma company is to be paid for.

In India, movies make 100-500 crores, cricket matches fetch billions in betting and tickets, most of the lawmakers are crorepatis, but everyone seems concerned only about the fees of doctors and cost of allopathic medicine!

The same people in administration who ask qualified doctors to reappear for tests to reprove their merit frankly allow rampant “cross pathy”, babas and gurus, hakims and other self-proclaimed experts to keep on selling health products at unimaginably high prices. Imagine the bribes and commission is involved at all levels in the sale of such “natural” products. What more can describe the paradox in Indian Healthcare where aloe, karela (bitter gourd)and doodhi / lauki (bottle gourd) juices sell at a price far higher than many essential medicines? © Dr. Rajas Deshpande

No surprise we get many patients now a days, who come with early- age blood clots, digestive problems, severe headaches and vertigo, serious allergic reactions, convulsions, kidney, liver and other metabolic problems, thanks to the “secret and purely natural 100 % scientific formulas absolutely free of side effects” that they had consumed weeks / months / years ago.

Is it impossible for the Courts to act here?
What’s the proof?
There cannot be any proof unless each of these products is scrutinized with the same vehemence that once a famous international noodles brand was scrutinized. There cannot be any proof till the scrutiny and people involved in it are completely corruption and influence free. There cannot be any proof till those in power are involved in the sale of such products. Those who have basic deduction powers intact will know it for themselves. From public transport busses and autorickshaws to malls, there are blatant lies in advertisements selling such health products. The word “Scientific” is now used by almost every such product.

The fact that most of those in power use imported phones and cars, and visit foreign countries for medical treatments is enough clue.

As I paid for my vitamins, I asked the salesman what sold most at his shop.
We all know the answer.
It is not any medicine.And sadly, there appears to be no treatment!

© Dr. Rajas Deshpande

Issued in the interest of everyone who likes to be mentally and physically healthy. Please share unedited for the benefit of your patients.
Jai Hind!

Dictatorial Actions?

Dictatorial Actions?
© Dr. Rajas Deshpande

If one minister commits a mistake, does the entire government go?

Even the wrong ministers rarely go.
If one doctor / department has committed a mistake, how fair is it to cancel the license of an entire super-specialty hospital, where over a hundred specialists work, many hundred patients are already admitted and many thousand patients follow up for their regular treatment? What about those who had planned major surgeries and treatments there?

There indeed was a grave mistake. The relatives have suffered an immeasurable loss, and this must be investigated and the guilty must be brought to justice. Every doctor feels sympathy for every life lost. This is a science and practice of life where human mistakes are not impossible, they should be scrupulously avoided. If however they do occur, one must not overreact, especially for populist advantages. © Dr. Rajas Deshpande

Whether it was one person or an entire team that was wrong, they must be tried. But how fair is the action of closing down the entire hospital? Is this not affecting the basic human rights of the other patients, doctors and staff working there?

Is this a good tradition to follow in a country with an already collapsed government healthcare system? Someone has lapsed. Who made the hospital protocols? Who implemented them? Were they followed? Who issued the hospital license without confirming standards? If license was issued that means some standards were defined. If not, why was the license issued in the first place? If these standards were defined, it is easy to find out who was at fault, and take action accordingly. © Dr. Rajas Deshpande

It is well known that corporate / majorhospitals have to pay hefty bribes almost everywhere to get every permission. They are business houses promoted by an administration that cannot deal with the country’s healthcare overload. That is also a reason why some hospitals / teams may not follow standard protocols, and confidently overbill the patients. Why doesn’t the government define the limits of profits on commodities rather than capping doctor’s fees? The answers are simpler to the wise. © Dr. Rajas Deshpande

What about the many other good doctors who worked at this hospital, who had joined there as a career, who had bought homes nearby to reach the hospital faster? What about the students who had joined there as post graduates in various specialties? What about the staff?

Was it impossible to hand over the charge to some doctor’s body / organisation or under a competent authority for better running rather than closing down the hospital? The correct action then should have been suspension of the involved department / team till the facts were found out, and after medical and legal opinions, trial as per law. This is what every minister, every administrator, every TDH of any significance demands and gets as a basic right even after grave crimes. © Dr. Rajas Deshpande

There was of course a basic investigation. Why not exactly find out and take strict action against the medical / non medical administrators or owners involved? Add to this the apathy shown by medical bodies and other hospitals in this case.

Welcome to this glimpse of future that will be commonplace for all hospitals if no one acts now. Populist headlines will never solve the grave healthcare that deficits India faces.
© Dr. Rajas Deshpande

My sympathies, as those of every good doctor in India, lie with the relatives who have suffered. They must get justice.But that should not be at the cost of destroying the careers of many other medical and non medical people who were not guilty

© Dr. Rajas Deshpande

Respect: The Depreciating Indian Salary

Respect: The Depreciating Indian Salary
© Dr. Rajas Deshpande

“Over 1.5 Crore Every Year! That becomes more than ten lacs per month! Wow!!” my student showed me the news that some brilliant engineering students passing out from India were hired by some software biggies in Campus Interviews, “They will start their careers at that salary. That’s life!”

I felt proud, as always, these news and similar have always made me feel that the Indian academic talent has always been looked up to and rewarded by the developed world. The tiny speck of jealousy that we earlier felt for our classmates who went for engineering and had their own homes and cars while we were still finishing internships has faded away long ago. The only regret that sometimes peeps out from the past is that of never having fully enjoyed our teens and youth. The fact that most doctors from India also earn huge salaries in the west as well as the middle east speaks a lot about the flaws in our “Indian” thinking.

“Doctors get respect and that is the best that you can get in life. People think of doctors as Gods. You should never think about money” told every sore-throated, pot bellied and self proclaimed socialist who did not become a doctor, and mostly had no doctor in family. This ranged from our own classmates to the highest administrators in the country.

Over the years, I now feel that even the engineering or other stream’s graduates are almost in the same boat. I cannot wish upon the newer generations what we went through.
What is really making us proud here? That India cannot afford to use its own best talent in any field? That the best in all fields are taken away, because what the best Indian companies can offer them is nowhere near what the world outside offers them? That the best salaries in all government jobs are reserved for bootlickers above the age of 55? That in no field can the government find the young talents superior to white haired yes men? © Dr. Rajas Deshpande

Or boast with a shameless pride that the most revered Satya Nadellas and Sundar Pichais made in India cannot find career scope in their own country?

Or, while proclaiming “Vasudhaiv Kutumbakam” (The World Is My Family) on one hand, are we going to perpetually cry the same song of socialism and patriotism, expecting all of them to only follow the examples of the rare (and respectable) ones who chose to shed material life for the country? India needs a million good volunteers in every field who will live and die poor while serving the society. But to force this upon all those who graduate from India is to invite them to leave the country. From politics and administration to Judiciary and lawyers, we need people who will work free or low cost, because the main disease: poverty and illiteracy, is a never ending curse in India. These are the people who choose the governments who throw “low cost everything” crumbs at the society, rather than uplifting the society to respectable self sustaining, paying capacity. © Dr. Rajas Deshpande The lifelong perks of representatives elected for even five years, from any political party are regularly updated, but the salaries and pensions of doctors and other employees who work lifelong are never upgraded without agitations and then only with allegations of greed!

No doctor wants to be a bad doctor, but no doctor wants to spend life in poverty and insecurity.

If at all a doctor decides to do charity and see all patients free/ concessional all his / her life, not only will they be lost to poverty and anonymity, but our government or media will never notice them. All they get is more paperwork to comply with every day, fear of suspension humiliation by the administrators and a salary that’s a shame given their talent and hard work.

There is this curious tendency in India: to force or to beg in the name of charity, social service or patriotism rather than rewarding the talent. There are very few examples of honesty, hard work and talent rewarded without political connections. © Dr. Rajas Deshpande

Are the medical students any less talented than their counterparts in engineering or other streams? Don’t they study equally hard and work 24/7 many more years before they qualify? Even after that, the highest salary that the government offers the starting doctor (even engineer) is laughable, and if they wish to work at a private/ corporate hospital, they cannot decide the rules of payment strategies. If they must start their own set up, they need huge investments, over fifty permissions, many recurring, every one requiring bribe in some form or other. And whichever one they choose from the three career options above, from day one the society and media will have already presumed them guilty of extracting money from patients, the government and even some judges urging them to understand the feelings of relatives beating up doctors. I wonder how many ministers , judges or media bosses would like to understand the feelings of those who beat them up for something their client/ petitioner didn’t like. The most pathetic part is that while all of the above officers are inaccessible to common man, they still have armed security, and the junior most doctor who faces armed relatives is denied security even by law! © Dr. Rajas Deshpande

Most top medical graduates and postgraduates, like almost all other streams from India are leaving voluntarily because of this situation. To deal with this, the best options that some governments came up with were long term bonds to force govt. service (without telling anyone where the govt. spends so much on medical education), and canceling permissions to leave India even after the bond is completed. Bravo! © Dr. Rajas Deshpande

The Hon’ble PM has time and again declared many institutes like AIIMS to be opened across India. This is welcome, but we must also look at the state of conditions and staff in the existing health institutes run by the government. That needs billions for repairs, facilities and hiring better staff. Unless the salary structure for young and talented medical specialists increases , there are no chances of any AIIMS-like institutes running efficiently, they will soon become dirty buildings with low budget staff, where desperate patients are chronically dissatisfied and mobs find chances to vent anger.

Earlier I had immense respect and pride for every doctor who decided to return to India with a positive attitude and a wish to serve the society, their only expectation being living a modestly good life. Now I doubt if they are doing justice to themselves or their family, by choosing a life of financial and personal compromises, where they not only sacrifice, but are still looked upon as “looters”, face a violent society and a prejudiced government.

Ten years ago, I would have told this student of mine “let go of a good life, stay in India, we have a lot to do for our country”. Today, I don’t interfere with their decisions to make a career outside India. Because I love my India as much as any soldier would,and I also love the talented people in it.

Jai Hind!
© Dr. Rajas Deshpande

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The Richest Doctors

The Richest Doctors

(c) Dr. Rajas Deshpande

“He needs an urgent bypass surgery. Very risky, high chances of death on table.” the cardiologist told us.

My friend’s father, a businessman, was admitted just after midnight for chest pain and breathlessness. The cardiologist rushed to the hospital within an hour and arranged for an agiography. As my friend’s father did not have any cash upon him, and neither my friend nor myself had sufficient amount in the bank, we requested the cardiologist to please proceed without deposits (most hospitals charge the complete bill to the doctor if the patient does not pay). I told the cardiologist that I was working as a resident doctor. He told me not to worry, signed on the paper that he will be responsible for the bills, and the patient was wheeled into the cathlab. When he came out, the doc told us that patient will need an urgent bypass surgery. (c) Dr. Rajas Deshpande

My friend and his mother were devastated. They were passing throough a bad financial phase, and had no funds ready. The patient himself had taken big loans from few business partners / friends, and started a new venture recently.

“You find out the best heart surgeon, we will try and arrange something” my friend told me while his mother kept on repeating prayers, crying in a corner of the waiting hall.

I spoke to my teachers and found out two names who had excellent results in cardiac surgery. Of course they were fully busy, appointments were difficult to obtain, and the surgical costs were an embarrassing thing to bargain: knowing that the best will come at a cost.

“Don’t bargain, I want my father to be operated by the best, I don’t want the doctor to feel that we will skimp. I will arrange somehow”my friend told me.

The best advantage of becoming a doctor came my way to help me: many medical doors open easily for the co-professionals as with any other profession. The same evening I was sitting in front of one of the best Cardiac surgeons in Mumbai with my friend. The VVIPs in the crowded waiting room angrily looked on at two youngsters allowed in ahead of them. (c) Dr. Rajas Deshpande

“He needs surgery urgently for sure. I will plan it tomorrow, although I will have to readjust my schedule, but you will have to shift him to this hospital where I am operating the other case too. We will arrange for the cardiac ambulance, don’t worry.”said the surgeon. (c) Dr. Rajas Deshpande

“Sir, how much will be the charge?” I asked, hesitant and already scared of the answer.

He replied without a blink. Our hearts skipped a beat together, and my friend looked at the ground with wet eyes.

“Sir”, I said pleadingly “Can we get some discount?”

My friend squeezed my hand, and said firmly, but with tears: “No Sir, please proceed, please do the best for my father. We just want him to recover. We will arrange for whatever charges you say”.

“Don’t worry. Please sign the papers so my juniors will arrange to shift your father here early tomorrow morning. I will do my best”said the heart surgeon.

That night, my friend called up many relatives and his father’s friends to get some help. As expected he got none. But after an hour, he started receiving many calls from those who had lent money to his father. They wanted it back immediately. (c) Dr. Rajas Deshpande

By early morning, most of those ‘friends’ from whom the patient had borrowed money gathered in the hospital. They had a meeting with my friend’s mother, who pleaded them and assured that all the money will be returned once the patient recovers.

“What’s the guarantee? We heard that he may die during the operation. We cannot afford that” said the calm leader of the group.

“Please don’t talk such words, I beg of you” cried the lady, visibly torn by what she was facing, “I will sell our house and return your money, we just need some help till his surgery. Please wait for a week”. (c) Dr. Rajas Deshpande

As my angry friend got up to reply, his mother asked him to just shut up. She pleaded the group with folded hands “I promise you, we will sell our house and return your money”.

The group whispered for some time.

“We will wait only if your husband signs that on a bond paper before going in for the surgery. Otherwise we will block his ambulance”. The leader said.

While shifting the patient, a ‘break’ in the ambulance journey was arranged during which the patient on the stretcher was taken into a ‘friend’s’ home on the way to the hospital, made to sign various papers while still wearing his oxygen mask, and only then did the lenders allow him to be shifted to the next hospital. Business is business, and our society condones everything in the name of money, except when paying for health. Along with my friend, I earned quite a big scar that day.

He was taken in the Operation Theater. Inside, the cardiac surgeon’s junior told the boss about the horrific “break” they had to take. The cardiac surgeon didn’t react.

The surgery was successful, the patient was discharged in seven days. (c) Dr. Rajas Deshpande

The cardiac surgeon didn’t charge the patient. He did not mention it to us too, we came to know during discharge. We went again to thank him. He was smiling now.

“It’s Ok. Carry it forward” he told me, then turned to my friend “You too”.

We touched his feet and left.

As we finished our coffee that night at the famous cafe on Marine Drive, my friend told me “Earlier I thought there is no money in medical profession, you people work too hard for what you get. Doctors are kind of “Use and Throw“ community. Now I feel, you people are still the richest whether you earn or not! That cardiac surgeon, by just not charging my father even after saving his life, owns everything I will ever earn in my life! Thank you!”

(c) Dr. Rajas Deshpande

Based upon a true story.

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A Dangerous Disease Called ‘Relatives’

A Dangerous Disease Called ‘Relatives’
© Dr. Rajas Deshpande

“What all can happen, doctor?” asked the young lady accompanying her father.

He had had a vertigo for two years, now had developed headaches and had seen best of the specialists. Some of them had advised him an MRI scan, but the daughter who was “in-charge” of her father had decided to wait. They had undergone many treatments simultaneously: allopathic, Ayurvedic, Homeopathic, Herbal, Diet, plus various random suggestions by relatives (almost all patient’s relatives are experts on all medical topics except actually paying bills and donating blood).

The father, a victim of experimentation by a health enthusiast daughter whose profession was law, was visibly anxious and almost shaking.

After examining him, I told them that there were some soft signs, but also that a physical examination may often be inconclusive, hence it was wise to investigate. What must be done must be done. A true Saint, scientist, soldier or doctor will always live by those words. I must stress the need for the right investigations. I told the daughter that he must undergo a scan. © Dr. Rajas Deshpande

That’s when she asked “What are the possibilities?”
Imagine an anxious person sitting in front of you, dead scared of death or illness. He / she is praying God or providence that the doctor does not use and scary words like cancer, heart attack, paralysis, dementia, parkinson’s or early death. No one likes these words, the doctor likes them least. Almost every doctor thinks of the patient’s mental status before choosing the words in such cases. Some patients can even commit suicides if they are too stressed with the fear of long / grave disease.

However, the hyper daughter refused to be subtle.
I told her “You can ask me all the questions you want. But please remember that some answers may scare the patient, Also, I may not have all the answers at this point.’

“Can this be something dangerous? Like cancer? Can this be an emergency? Can it cause death? If so we will do the MRI today itself. Otherwise we will wait.” She said.

To protect the patient from death, suffering and disease is a doctor’s duty, but the law does not allow the doctor to protect the patient from such insensitive relatives. © Dr. Rajas Deshpande

“Madam, there are limitations of physical examination,and we cannot see inside his body. Sometimes we find things wrong inside that can be cured with the correct early treatment. That is the reason we have tests and scans”. I told her patiently.

“But what are the chances of this being a cancer or something life threatening? If at all the scan shows something dangerous, can you guarantee it will be cured?” she asked.

I gave another shot of adrenaline to my patience. © Dr. Rajas Deshpande

“How does that help you?” I asked her, “Even if the chance of a dangerous possibility is low, say 5 %, will you take a chance on your father’s life just to avoid investigations? How can I guarantee the treatment or cure of something we both don’t know yet? By the way, what is your objection to get his scans done?”

“We will do the scan if you say this is urgent” she said.

My patience kissed me a goodbye.

“It is indeed necessary, I cannot say it is urgent. Now I must see another patient.” I replied. Then looking at her anxious father, I reassured him “It is a very low chance that there will be anything dangerous. Please relax. And we have cures for many diseases now, I am with you. Don’t worry”.
“Then can we wait for the MRI?” the daughter was incurable.
“No” I replied, calling in another patient.

I received many messages for next few days from her and her invisible brother asking if the scan was really necessary, where was it done cheapest, etc. I didn’t reply.

They returned after a week. The MRI showed a tumor causing pressure effects on the vital areas of lower brain. This indeed was an urgency, if not emergency. I told the daughter so.

“How come he developed a tumor? He never had it earlier. No one in our family had it ever” she asked angrily, “Is it the side effect of all the medicines he has taken in last two years?”.

I had almost forgotten in which society I was practicing. Education does not always convert into common sense. Money, skimpiness and hatred replace logic here. © Dr. Rajas Deshpande

“In most cases, a brain tumor is not the effect of commonly used medicines. I don’t know the contents of all the medicines you tried upon him. But the delay in doing tests is one definite major factor that your father has suffered so long”. I told her. What must be said must be said!

She changed the topic, a knack every doctor must learn from some lawyers!

The patient has now undergone a surgery by one of the best neurosurgeons, and fortunately the tumor has turned out non cancerous. His headaches and vertigo have gone. However his anxiety and fear will take a long time to go, he is on the medication for that.

The daughter has changed a lot too. The last time she visited for her own headaches, I told her to get a check scan done, and she showed me the reports the same evening. They were normal, she is happy now!

Many patients suffer for years, develop disability and some die due to such dangerous relatives who experiment upon them, delaying investigations and treatment. The most common purpose is saving money, but there are also whims and illogical, dangerous treatments without the knowledge of the contents and interactions between medicines of different medical and quackery streams. The doctors who try hard to save the damage in the last moments often become victims of criticism. This dangerous disease called “Relatives” who suggest everything but disappear when the patient truly needs them has become rampant in our society!

As for my patience, I had to take it for a long night drive and feed it a lot of icecream that day to agree to return to stay with me again.
© Dr. Rajas Deshpande

(Yes, some doctors take advantage and earn money through tests. This is definitely wrong, but the price of delayed and denied tests is far more. In fact, many relatives make that an excuse to avoid spending for the tests. It is conveniently forgotten that almost all essential tests are available at govt. / charity hospitals at a negligible cost).

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Death and Disability by Overwork:  An Indian Diagnosis 

Death and Disability by Overwork:
An Indian Diagnosis
© Dr. Rajas Deshpande

“We are helpless, our life has no worth in the eyes of authority “ said the school teacher.

He had recovered from unconsciousness just a few hours ago, his brain had developed huge clots due to thickening of blood, because he was dehydrated overworking. Due to back pressure generated in the blocked veins, there was bleeding in his brain.

“I was out on the election duty, and did not get time to eat or have water. I returned late night and felt nauseated because of the bus travel, so just had a little rice and slept off. The next morning I had terrible headache. Just after the breakfast the headache worsened and I started vomiting. As our leaves were canceled, it was compulsory to go to work. So in spite of the headache I went for a bath, then I don’t remember, till I woke up in the hospital”.

His wife continued: “I heard a big noise in the bathroom and rushed there, found him lying in a pool of blood, convulsing”. She paused to wipe tears, still unable to overcome the horror of that memory, then resumed: “I called our neighbors, one of them took us to the rural hospital in his tractor. They did a CT scan and started treatment “.© Dr. Rajas Deshpande

“But you are a school teacher, why were you doing an election duty?” I asked him.

“It is compulsory for all govt staff. We must comply or we won’t get our salaries or promotions.” He replied.

This wasn’t new. Doctors often attend many a police, labourers, and other “government service“ personnel serving either the state of central government (under different political parties), who drop either sick, unconscious or dead while overworking. The common factor is they are almost all low level desperate employees who cannot say ‘No’ to the forced additional work thrust unto them. I have never seen a senior officer or a politician coming to the hospital due to physical overwork. © Dr. Rajas Deshpande

To add to the inequality, it is the senior officials / politicos, ministers who can avail of deluxe / higher budget private medical facilities including overseas medicare, whereas the actual ones who get sick shedding blood and sweat in the field are left at the mercy of scanty healthcare facility in government hospitals or low budget schemes at private hospitals. Much like the red light cars ferrying ministers getting preferences over even the ambulances for the poor.

Recently a police officer was brought by his colleagues, he had developed high blood pressure due to an extended duty. A blood vessel in his brain had ruptured, causing huge bleeding. With a great effort he recovered from the coma in few days, but his speech is now forever gone, and he is bedridden due to paralysis on one side. © Dr. Rajas Deshpande

Doctors working in different state / central hospitals too are not an exception. Many tasks / schemes / targets are mindlessly shoved into their routine, presuming that if someone is a government servant, he/ she is a slave to the whims of authorities who can order anything. Besides being taken for granted about 24/7 availability, besides completely ignoring the human right recommendations about working hours, the threatening, demeaning and pressurising humiliation continues almost in every field, where the lower you rank, the worst your slavery.

In a country with excess population, why should there arise a need for one person being burdened with the work of two or three? Why should a school teacher perform an election duty, population stats/ census duty, etc? Why should a police employee work beyond his / her physical capacity? Why cannot the governments hire more people in a country teeming with unemployed youths agitating about almost everything everywhere?© Dr. Rajas Deshpande

If someone wants to work extra for patriotic or financial reasons, they should be able to. But when one is forced to work beyond capacity and legitimate duty, we are encouraging not only health risks, but creating chances of nothing being done correctly. Stress is a major killer via diseases like diabetes, high blood pressure, heart attacks, strokes and depression/ suicides, and while we encourage Yoga for stress relief, we must also reduce overloading one with the duties of three.

“I sympathise with your condition, you should recover well, but you must avoid such overworking now. Also never fast. Drink plenty of water. I feel bad about your extra duties.” I told him.

He smiled in embarrassment, and said “I feel ashamed that while I teach my students to stand against injustice and inequality, to courageously fight to set right what is wrong, I am myself a coward who cannot do so, for without this job I will not be able to survive. I want to be a good teacher, I love teaching and my students love me very much, but inside, I feel I am lying to them when I accept this humiliation by those who I work for. Believe me, doctor, that even when I got unconscious, no one among those who ordered me extra work cared whether I woke up or not”.© Dr. Rajas Deshpande

He was telling the desperate story of many, and I found myself unable to answer once more: that if we have so many educated people who have time to quote history and protest against various political parties or events, if we have so many rich leaders who openly award crores for killing someone (hello, Milords of Indian Justice!), why cannot we distribute duties well and let a school teacher happily just teach instead of dying forcibly doing something else?

© Dr. Rajas Deshpande

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Dedicated to all teachers.