Category Archives: Parkinson’s Disease

The Higher Suffering

© Dr. Rajas Deshpande

Stuck in the heavy traffic due to rains, I tried to remain calm. The cellphone kept on ringing, patients who were waiting, those who wanted appointments, those who were to catch their ride out of station anxiously asked when will I reach. Some lost patience and raised voice. In addition, there were calls about the patients admitted in the hospital: critical decisions to be made, idiotic questions by insurance companies to be replied to. There were huge processions, the traffic was diverted, without any arrangements for ambulances. Impatient, aggressive and violent people is a reality on almost all Indian roads now. No one cares for law on the road. You are at the mercy of anyone who chooses to pick up a fight with you.

There were some issues at home too, the cook had called in sick, we had to do some emergency cooking. That had delayed my start.© Dr. Rajas Deshpande

At last, an hour late, I reached the OPD, and entered running. Faces with controlled anger greeted with cultured politeness. Prepared for bitter comments, I called in the first patient.

This was a free patient, she did not need a follow up. But being free, she visits almost religiously every month, whenever she has a fight with her husband. Sometimes, when the only guaranteed compassion is from a doctor, it can be misused. However, as I was late, I decided to respect their patience, and told them to visit a counselor. Nevertheless, my irritation heightened, that this added to the wait of other patients.© Dr. Rajas Deshpande

I certainly am impatient with meaningless waste of time, and sometimes the traffic, the sudden changes in schedules due to someone’s irresponsible behavior, and misuse of compassionate services bring me to the edge of a reaction. This was one such moment. My face must have become grim.

The next patient walked in, an elderly gentleman with Parkinson’s disease. He was accompanied by his wife. They were supposed to come back three months later, but had followed up early. I examined him, found him quite stable neurologically, but the usual twinkle in his eyes was absent. Even his usually smiling wife appeared lost. It must be the traffic, my late arrival or something likewise, I thought, and curbed my curiosity to ask them. Today was heavy and behind schedule, I must wind up fast. Yet, as I explained them that everything was stable and alright, that they need not worry, I noticed the unspoken uneasiness in their body language. A little reluctantly but keeping up with the expectation of my own heart, I asked them: “You look quite disturbed and stressed. Is anything the matter? I am sorry I came late today”.

“No, no doctor, it’s not that. But yes, he is stressed and disturbed said the wife, and looked inquisitively towards her husband. ”Shall I tell him?” she asked.

Looking down, hiding his face, the husband nodded.

“Doctor, we lost our only son ten only days ago. Someone killed him on the road. Some drunk goons dashed his car from behind, and when he got down to check the damage, they attacked him and hit him on the head with some rods. He was lying on the road for a long time, and by the time police took him to the hospital, he was gone. We came to know after a few hours. He was our only child, an engineering scholar who had returned to India with great dreams .”

The lady was silently weeping as she kept her emotions in control. The patient was sobbing, I called the receptionist to get a glass of water.© Dr. Rajas Deshpande

“We have done so much for our town and the society” said the patient, “but now I feel it was all useless. No one is safe even on the roads. We see so many rules and laws broken, so many violent and aggressive people that it has become difficult to question anyone even when they misbehave”.

I had no words to pacify them. What can pacify the parents of a dead child, that too a victim lawlessness?

The receptionist called “Sir, the next patient is shouting” she said.

“Five minutes” I requested her.

“You are busy, doc, we will leave. But I brought him here only because he feels better when he meets you. Once you reassure him, he will feel a little secure. Even I feel better when I see you. Otherwise we sit at home just staring at each other’s sunken souls. We have no relatives”.

That was a bitter eye opener to me. They had chosen me to be their lifeline in the worst times of their life, and here I was, thinking about my worries, my time, and the inevitable small happenings that block the path of every working person every day. I had momentarily ignored the fact that I must still enter the hospital with a smile, push behind myself all the negatives that pull me down. For every patient here to see me comes with a hundred fears and a thousand expectations, the least I can do for them is be compassionate and reassuring, whatever may have happened till that moment.© Dr. Rajas Deshpande

“You may see many patients in a day and listen to their troubles, doc, but you are the only doctor your patient meets in a long time. I don’t know about you, but we always feel good when we see you”. The wife added.

Yes, I had heard that earlier, in my teacher’s cabin. Once a patient develops trust in his / her doctor, they look upon the doctor as one of the most reliable resource for courage, compassion and troubleshooting, even beyond the expertise of that doctor. As doctors, we must never forget this, and stand up tall above all our personal problems to be the supermen and superwomen, the Messiahs, the Saviors that we are expected to be. Law and some idiots do push a stick in our wheels, but then the patient is far above both. A patient’s suffering is always far above that of any doctor.

I stood up, held the patient’s hand, and reassured them: that they do have a relative here in Pune. “According to the Pune tradition”, I said, “one should offer tea only when the guests are half out of the door, but I will make an exception today .”

Having them sit in the next empty room, I proceeded with the OPD. Ordering tea for everyone in the OPD waiting room, I stole a few more minutes to calm the ruffled souls of those two, and asked them to see me again, whenever they wished.

As I returned late after dark, even through the rainy night, a sweet moonlight made the raindrops glow. Just like every doctor brings back the smiles to the burning hearts of their patients!

© Dr. Rajas Deshpande

The Changing Blood Group

The Changing Blood Group

(c) Dr. Rajas Deshpande

“He is sinking” shouted Dr. Siya.

The casualty registrar rushed to the bed, checked the vitals. Pulse very fast. Blood Pressure very low. Lips and nails white, hands and feet cold. The young man, unconscious, was on the verge of death.

“He must be bleeding inside. Get an urgent sonography of his abdomen”said the registrar to Dr. Siya, and call the blood bank. He will need at least two units of blood urgently”.

It was Dr. Siya’s first week into internship, she was thrilled with the idea of actually saving lives. At the young age of 22, she was witnessing death almost every other day. Along with that she was amazed to see the darkest sides of human nature: the potential of humans to hurt each other: via rapes, accidents, murders, fights. She had decided to not let this affect her attitude, and to continue to try and save every life she could.

That late night, this young man of about her own age was brought in unconscious by someone, who had just dropped the patient in the casualty and left without leaving any identity of himself. “I found him lying unconscious on the road. I don’t know anything else about him. I am just doing my duty, I have a train to catch”said the stranger and left. The patient was reeking of alcohol. He had a visible head injury. A quick CT scan had revealed minimal bleeding due to a small skull fracture. He also had had bleeding from wounds from his hands and legs, they were sutured. The patient had no identity marks, wallet or cellphone. The policy of the hospital was to provide basic treatment and shift the patient to the government hospital. The police station was already informed. Treatment was started.

Dr. Siya requested two units of blood. The blood bank called. They had only one unit of the blood for his blood group. The registrar had the same blood group, and like many doctors working in the emergency departments, he went down to donate blood.

It was nearly midnight. The fate of the life of a young man depended upon what the junior doctor did just then. There was no one to sign any consents, the protocol was to inform the hospital’s medical director and obtain consent for emergency transfusion or procedure. Dr. Siya finished the formalities, obtained the permission, and started the transfusion. If the patient had reacted or something went wrong now, they all feared, there will be a havoc in the media: that they had let an unknown patient die because they wanted money!

Dr. Siya kept on managing the show. The angry and disturbed relatives of other critical patients kept on taunting her, speaking rude and reluctant to complete simple formalities and paperwork.

The sonography was thankfully normal.

Just as the first unit of blood was over, the patient became conscious, and revealed his name. He was quite shaken with the surrounding, but told in broken sentences about his friend’s number and address. He revealed that while returning from a party, his bike was interrupted by a bunch of goons, he had fallen down, they hit him upon the head and left with all this belongings.

The friend was called, and came in. He revealed that the patient was used to smoking weed and drinking alcohol in huge quantities. They were staying in the hostel of a famous college.

The second blood unit was started, and in a short while the patient threw a convulsion. He was immediately given injectables for controlling the convulsions, he slept off with the effect.

His parents arrived early next morning.. The shocked mother was consoled and explained about the situation by Dr. Siya. The elderly father, like all fathers, equally shocked but being a father unable to cry, kept mum, just holding hands of the boy.

When the patient woke up again, the father came to Dr. Siya, and touched her feet. Too embarrased, she told him that the registrar had donated blood for the patient. The father went and thanked the registrar, again trying to touch his feet.

As Dr. Siya had finished her night duty, she prepared to leave. “Beta, Will you come soon please?”asked the tearful mother to her. “Yes Auntie, I will be back soon. Don’t worry, he is ok now”she reassured and left.

On her way back her genius young mind tried to look at the situation sitting upon her shoulder, the little third person that resides within each one who has a conscience. That booze and weed was easily available to youngsters in almost all Indian hostels, that even educated people rode bikes without helmet, that crimes were happening almost everywhere that injured and killed people, that law and order was a laughable term in many parts ofthe country, that there was no government mechanism in place to provide emergency medical / paramedic support ambulances to raod / traffic accident victims: which one is the most responsible cause, when patients like these died? Who is responsible?

She reached home, told her proud parents what had happened, that she had helped save a life. Her mother folded her hands towards the sky, said “God, let my daughter save many lives everday”.

While having the breakfast, her father turned on the TV. A famous but ill educated political leader, in his mind-and-other- organs blowing speech in Karnataka, was explaining the illiterate public how all Indian doctors charged in excess, how they were only after money, how everyone except himself was the enemy of the millions of patients surviving from critical heart attacks, accidents, strokes and other diseases. All patients getting better all over te country was only thanks to himself and his government!

Dr. Siya’s father laughed bitterly. “Next time you need blood for any poor or unknown patient, call him” he said.

Dr. Siya replied, laughing “That kind of ëver changing blood group doesn’t match anyone, it is useless for any patient, Papa”.

(c) Dr. Rajas Deshpande

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“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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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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An Ideal Patient

 

An Ideal Patient
© Dr. Rajas Deshpande

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“My health is my domain, you are a member on my health team. You have a part to play, and I have a responsibility to imbibe your advice with complete trust, along with that of the other specialists I see. There are so many things in my life that are beyond your control: what I eat, what I do, how much I work or sleep or exercise, how I react, my mentation, and even my spirituality. All these affect my health, and I must assume the responsibility for that. My illness if not your fault.
Rajas, we meet like the tips of two pyramids, with few specific issues to resolve. We cannot know the entire pyramid, and it is unnecessary too. I have strong faith about why we should have met even as a doctor and a patient, I believe destiny has a purpose. The meeting between a doctor and a patient, not only you and me, can be so much beyond only a professional medical consultation: just so long as we have enough trust and shoulder our respective responsibilities well”.

These are the precious words of Ms. Prema Camp.

Once she came to my OPD, and asked me why I looked stressed. I told her my mom was critically ill, admitted at the same hospital. Mom was conscious then, but was quite shocked due to her recent worsening, As a son, I had limitations in counseling mom. Ms. Camp took my permission, went to the room where mom was admitted, and chatted with her a few hours, relaxing her with gentle anecdotes.

My patient and now a friend from last 5 years, Ms. Prema Camp shuttles between USA and India frequently. She maintains a meticulous record of all her health related documents, follows all advice to the last dot, enquires about every doubt that crops up, reads extensively still only asks relevant questions, and manages her side of the responsibility perfectly: researching and finding out the right type of food for herself, following strict and disciplined schedules of diet and exercise, and avoiding all unnecessary medicines. She has a phenomenal memory, but she has never used it to relate any bad experiences from her past, in spite of having many. If at all there’s something negative about her past, she mentions only the good that invariably came out of it. Age does not affect her at all, and she independently manages everything without any assistance (although she has highly placed daughters in the USA who care for her). Her blogs have an enviable readership too!

Every time she comes over, I learn something precious, especially about the effect of mind upon health and life. She brings me books and films related to health, hoping that it will help other patients too.
I do not know if it is entirely due to her growing up with the freedom of thought in USA, the spiritual pursuits which brought her to India, or both, but I find something quite rare in her: the ability to pursue a thought or an idea fearlessly to its conclusion, and to then honestly accept that conclusion. Irrespective of whether the world has yet grown up to it or not. Irrespective also of personal likes and dislikes.

Although I always stick to the professional etiquettes with a poker face, there are patients who crossover to this side of me and become friends. Then the barter system of payment via goodwill and information exchange works best, money becomes so redundant! Needless to say, she has never once misused the facility to call or message in spite of having my personal cell.

When I apologized for being late today, she smiled and said “Oh I enjoyed every bit of waiting here, I could get some time to read”.
I wish I keep learning these things from her!

© Dr. Rajas Deshpande

The Medical Secret Service: Unknown Angels

The Medical Secret Service: Unknown Angels
© Dr. Rajas Deshpande

“Hullo, Vishwa? Please consider this an emergency. One of my rural patients is here, she is on XXX brand of tablets, she has finished the dose, needs more immediately for another three months. She cannot get them. She has to return by an evening bus. Can you do something?” I was in a hurry, between patients.
“Yes, Sir, I will arrange within a few hours” Vishwa said, and indeed, within two hours, the nearest medical shop called, saying that the medicine was available for the patient at a discount.
That evening I called to thank Vishwa, only to be shocked.
“Sir, you were in a hurry today morning so I didn’t tell, I had a heart attack last night, and an angioplasty was done. I am ok now.” said the 30 year old to me.
Like the thousands of his community, the Medical Representatives, he is immensely contributing to the healthcare industry, unrecognized and unacknowledged. © Dr. Rajas Deshpande

“”What is your job? Just passing on bribes to the doctors? My cousin said to me, Sir, and I did not reply. You should not argue with the one who has poison in his heart. People look down upon us, but they will never understand what we do” said a 60 year old man who had spent life as a medical representative, now a national manager. “We have no choice of judgment, our job is to be the link between the doctor and the company, and to make sure our medicine is available” he said.

Millions of busy doctors, overloaded with their work, have no clue how many pharma companies exist, what medicines they make, what medicines are newly launched, what is the brand name or price etc. It is not practically possible to read the whole new drug launch book every month. This community of medical representatives alone is the link between the pharma companies and the doctors, updating us about various new drug launches in India, their availability etc. They also arrange for academic events so necessary for the doctors and medical students. © Dr. Rajas Deshpande

“Some Doctors are very good and treat us respectfully” said Janvi, who has spent over 20 years in this profession, “but some expect favours from the companies, in the form of tours, dinners and other things. Sometimes, I have had an occasional trespassing of moral lines by some doctor, but that was rare. One needs to be able to take care of one’s dignity and self -respect. Especially Indian women face a lot of difficulty and gender bias when making a career, at all levels.” she said.
“The pressure for women in this industry is immense, and like any careerist woman, I faced a lot of presumptive hate too. If a woman, and especially good looking, is successful, our society already has made its judgment as to the reasons of her success. Most Indian men do not tolerate the idea of a woman succeeding ahead of them. Of course, one must clearly set priorities as to whether one wants to make a career or family, and if both, where the compromises will be, because both are full time jobs at least for any woman. Most doctors have treated me well though, and most doctors also want to do good for their patients”. © Dr. Rajas Deshpande

In my 20 years of career as a doctor, I have never come across a Medical Representative who turned down my request to help a patient: lacs of rupees worth of medicines I have asked them to arrange free for my patients, and they have arranged without a question. Thousands of poor patients receive free / discounted costly medicines, injectables, even stents etc., thanks to the generous efforts of this community and their companies. Thousands of medical camps are arranged all over India, where patients get free check ups from doctors and free medicines by pharmas, arranged by the Medical Representatives, but there is seldom any recognition of this service.

Unlike in most other professions, this community helps out its members without bringing in the competition, and in a recent event, when a regional manager suffered a critical head injury, MRs from different companies collected funds to pay for his bills.

Very few people notice how cruelly difficult the life of a medical representative is. They have to meet a certain number of doctors every day. They often stand for uncertain hours and have days longer than 18 hours, as some doctors finish their OPDs long after midnight. Family life is screwed. They are also responsible for making available the stocks of their brand medicine at different medical shops, and have to bargain with everyone: the stockist, distributor, hospitals, and sometimes the medical shops for making their brand available. The final sale figures are their assessment at every month-end. To achieve targets is essential in pharma industry as in any business, to survive. It is the Medical representatives community that faces the brunt on both sides: company pressure and the medical profession.
Unfortunately, our hate-bespectacled society cannot see anything beyond its suspicions: that all companies offer bribes and all doctors take them, that all doctors deliberately prescribe costlier medicine to earn cuts, and that the whole medical service is driven by money. This is somewhat like a suspicious husband who has a very beautiful and loyal wife, but cannot be happy with her because of his own paranoia. © Dr. Rajas Deshpande

I know many doctors who do not ask for any personal favours from the pharma, do not accept gifts, and pass on all the benefits to their patients. But I do not know any mention of gratefulness for such doctors anywhere. Without the medical representatives playing their part well, the medical profession will be quite helpless.

This article is to salute the thousands of medical representatives who work hard day and night, live an extremely compromised life, and still contribute to the service by medical profession, making life easy for millions of patients.
© Dr. Rajas Deshpande

If a medical representative has helped you / your patient, please share this article.

Allopathy? Oh, No!

Allopathy? Oh, No!
© Dr. Rajas Deshpande

“Doctor, I don’t believe in Allopathy. There are so many traditional remedies that work wonders. We heard of this treatment where you eat certain flowers, and they cure everything, even cancer and AIDS.”
“Doctor, we hear that there are cures to many diseases, but the pharmaceuticals and doctors want people to be ill for longer, so the right treatments are hidden, and only useless costly medicines are prescribed.”
“I don’t want any medicines that cause side effects. I am allergic to almost every allopathic medicine”.

One standard answer:
“Then why are you here today?” © Dr. Rajas Deshpande

We live in a world brimming with superstitions and claims of all kinds. From parents killing a girl child to dowry deaths, from voodoo to sophisticated five-star magic healers, we have it all in our society.

Add education and a degree (not mandatory), add internet, and one becomes the King or Queen of personalized wisdom. Now one can question anything except one’s beliefs and random internet claims. Even years of training and scientifically proven facts, good or bad.

From scorpion bites to poisons of different kinds, from heavy metals in overdose to drinking one’s own pee, there are claims of cure that have been refuted by authentic scientific research, but then the easiest thing to question and suspect today are scientific knowledge and a doctor’s integrity and training, no matter how little one has studied medicine. Just as most hospitals struggle to fight infections, people happily drink urine: mostly studded with some of the deadliest microorganisms known. The fact that many children have died of Urine therapy does not seem to affect the popularity of this myth. By this logic, a person with kidney failure who is not urinating should become immortal! But only the proponents of this therapy will be able to tell why kidney failure patients die within hours of not passing urine. © Dr. Rajas Deshpande

I had a classmate who would blindfold his eyes and cross a live railway track, to prove his courage. Whenever someone questioned his safety, his pet answer was “I have done this many times, nothing has happened”.

It stands to reason (again a doubtful criteria in some communities: why base arguments upon reason when there’s superstition?), that if you believe that all Allopathy is a hoax, you have a complete freedom to stay away from it all your life; that at least will save the Allopaths some burden and free them from the daily sins they are so presumed to commit by treating with a hoax science! May be one can wear brass badges that say “I don’t want Allopathic treatment, don’t take me to an Allopathic hospital even if I am serious”.

While some Allopathic doctors do use medicines injudiciously sometimes, it is seldom with an intention to cause harm, no doctor thrives on a bad reputation. Everyone wants their patient to get better.

Those who do believe that doctors are only after money, that Allopathy is just another deception, that most treatment choices that doctors make are selfish, they are welcome to never enter another hospital again in life. There are umpteen non Allopathic therapies from magic to music that are claimed to cure every ailment that Allopathy cannot.

Is there nothing better to do in your life than to visit places that you don’t believe in? Do you get a high questioning a doctor’s scientific knowledge while being unable to question your own unscientific hearsay myths? © Dr. Rajas Deshpande

God forbid, but next time someone is sick and dehydrated, down with a pneumonia that stops breathing, has a heart attack, or bleeding from a head injury, please call that friend who suggested that scorpion stings heal everything. May be he can help.

What will happen if children are not vaccinated? What will happen if all Allopathic hospitals are shut down?

Stand outside the discharged patient’s section in any Allopathy hospital, you will hear daily stories of returning from death’s clasps. From polytrauma to cured cancers, from patients recovering from a paralysis to stopped hearts beating again, Allopathy brings life to most. Have some respect for what science has achieved!

Allopaths should stop wasting time arguing with those who continuously belittle Allopathy and sing praises for the unscientific. Use that time for saving lives of those who need you better. The easy answer is: “Yes, you may drink your pee or pet a poisonous scorpion if you enjoy its bites for your health”. Reserve the social education for those who understand logic.

We don’t believe that science needs permissions to be accepted. What is proven goes through rigorous scrutiny and is then marketed. But then again, this is expected to be understood by only those with a certain mental education, reasoning ability and logic, those who are not carried away by every myth they hear.

As for the rest, may your faith and belief alone heal you.
© Dr. Rajas Deshpande

PS: There are some traditional remedies that help some medical conditions. That does not refute the benefits that Allopathy has brought to mankind.

Targets and Doctors: A Fatal Flaw

Targets and Doctors: A Fatal Flaw
© Dr. Rajas Deshpande
“What will you become when you grow up?” a common question heard in childhood. Always weary of doing the routine and fond of a little spice in life, I had kept a list of answers to surprise and occasionally shock the questioner uncle / aunt, based upon the spontaneous dislike they generated by other questions and general behaviour and replied something like “It’s a secret” or “It depends upon when in future” etc. There is no better revenge than vagueness for some. In the moment when they paused to react to that vague answer, I would make an innocent face and ask “What was your percentage when you were my age?”. Then the explanations of how things were more difficult and in general marks were lower back then were very entertaining! Curiously, those uncles / aunties did not ask me further questions. Target hit.
© Dr. Rajas Deshpande
For the better and polite class of grown ups, I had the standard answers that my parents would like: Doctor, Scientist etc. The real answers were too “out of the league” for the culture I grew up in then. One thing was sure: the big-eyed respect that the words “I want to be a Doctor” evoked from the listener was sure better than any other response.
Somehow the wish to become a doctor caught hold better, probably because of parental influence. Once I completed MBBS, I loved the actual interaction and started realising the enormous satisfaction potential that the skill generated. The ‘high’ of vast complicated knowledge sharpened daily by experience was superior to the ability of a non-medico to understand or praise it. It was an autonomously growing satisfaction.
Then came the thought that I want to learn more. There are better skilled people, who could treat better than me. Getting admission to MD Medicine was very difficult, there was no question of paying in private colleges as we could barely even afford the govt. medical college fees. A lot of somersaults later, I got admission. There was an explosion of medical knowledge and wisdom suddenly, and there was no choice but to comply. Good and bad patients, good and bad teachers, good and bad friends, good and bad times were all drowned by the prime necessity and survival technique of every genuine doctor: Study!© Dr. Rajas Deshpande
Ego is greedy. Mine too. After MD, there was a desire that I want the highest specialisation: DM. More battles. More scars. All worth the title. With that degree, it felt like I have won the world.
At that time if anyone had said I worked for a financial target, I would have declared a war.
Many more steps in education later, I woke up to the naked reality: however good a specialist you become, you have to either have your own multicrore hospital, or work at someone else’s. Basic medical practice is far different from specialty practice, which requires more time, more investigations, intensive care and complicated treatment strategies / surgical techniques.
When one joins a private hospital, one realises this more intensely: there really are good and bad specialists. Some are very thorough in their academic base but cannot convert that in good patient outcomes or numbers. Some are very sweet and courteous with patients but they lack proper skill, knowledge or experience. The spectrum is wider than one can imagine. Obviously like in every profession, some think of earning more money as their primary aim.
Anyone who owns a hospital must invest many crores of their private money, directly or via bank loans. Sometimes the govt. helps in reducing the cost of land. But in each case, the maintainence cost of any hospital runs usually in lakhs to crores, more with each bed added. Intensive care beds are the costliest investment.© Dr. Rajas Deshpande
When the owners of any hospital invest crores of rupees, they have targets to return their loans., to maintain the expenses that run in crores again: right from 24/7 failproof electricity and water arrangements to the availability of medicines, stents, catheters etc. in the hospital premises. The nursing, reception, helper, technician staff (in most major hospitals, the staff runs in thousands) must be engaged in three shifts, and paid in time commensurate with other establishments/ professions.
The only help that comes from the govt. is initial subsidy in land / water prices. There are no tax relaxations for any hospital/ staff. 20% of all services and beds are reserved for the poor. (If anyone has doubts that the poor-reserved services are not utilised, they can verify with the charity commissioner any day). On top of this all govt. employees must be seen at pathetically low rates, and even that amount is usually pending to be paid for years if not decades.© Dr. Rajas Deshpande
Add to this the profiteering that the medical insurance companies have created: on one hand twisting the arms of private hospitals to provide specialty medicare at bare minimum rates, while on the other hand declining many deserving patients medical coverage due to idiotic reasons.
In this scenario, the last thing that a corporate / private hospital can afford is a non-performing specialist, whose salary runs in lacs of rupees every month (which is what that cadre deserves).
Most corporates / private hospitals are aware of this, and usually support a budding practitioner till his practice picks up. After that, the least he / she is expected to do is to maintain that level of practice or increase it, returning the investment that the hospital has made in his growth. The provision of a furnished room, electricity, washroom, cafeteria, parking, staff and salary to a non-performing or underperforming doctor is not affordable for every hospital.© Dr. Rajas Deshpande
This generated the word “Target”, which was quickly coloured villainous by many. Which financial endeavour can be run without setting financial targets? If anyone is naïve enough to think that all hospital owners will invest their hard earned crores for charity and leave the returns to fate, they must get examined by a qualified practitioner. If the hospital cannot generate enough profit money, there won’t be any growth in medical technology. If they cannot repay loans, the hospital will be confiscated by banks.
Many hospitals of excellent doctors have closed down because they could not sustain the charity they attempted. Indian poverty and healthcare need is beyond the capacity of even the govt. to cope up with, so to expect a private company / doctor / hospital to provide free / concessional high quality continuous medical care to everyone can only be a fool’s dream. This applies to the MRI centers, diagnostic facilities, labs, physiotherapy units etc. where multiple crores are invested.
Some hospitals realised the potential of profit making in this “Target setting” and turned greedy. Mostly good specialists do not stay at such hospitals. Even if most hospitals pinch most doctors to achieve certain numbers, not every specialist works to achieve that target. I know many who would rather keep their ethics and be good clinicians, still staying in the lesser favourite class of management, rather than selling their ethics to shine among the administrators.
The notion that “Every specialist in every big hospital is working to achieve targets by deceiving the patient” is a fatal flaw developing in the mind of our society . Fatal because this also generates fear of going to the right specialist or reaching too late for them to be able to save life.© Dr. Rajas Deshpande
If I cannot afford a Mercedes, I will drive the car I can actually afford, rather than blaming and maligning the entire car industry. Many other cheaper, equally safer options are available for travel.
The problem is, everyone wants the best, highest class of super specialty medical care in luxurious set-ups, at the price list of a sarkari dawakhana. Most doctors who studied in govt. hospitals know that the quality of doctors is very good there too, but if we give that option to the patient, they say “No, not in sarkari” because they want to avoid long lines and “general population treatment”.
As the doctor is the only responsible face that the patient sees in the hospital, many obviously end up thinking that every penny they pay is going to the doctor, at least in percentage. Many will be surprised to know that a doctor usually gets less than 10 % of the total hospital bill as his fees in most cases.
Few will understand that the real “Target” that most doctors work for is to do good to the patient, to save lives. Millions of successful treatment and surgical outcomes from the corporate and other hospitals are a proof of this.
© Dr. Rajas Deshpande
Dedicated to the private hospitals started with the aim of making available specialty medical care for the society and caught up in unfair, unjust allegations because everyone wants free healthcare.
PS: There are greedy doctors and hospitals, like in every other profession. This article is not about them. It is wrong to advise patients unnecessary procedures / tests to achieve financial targets. This article is to explain to the society that target setting is essential for any hospital where recurring investment in new technology and maintenance is also the responsibility of the owner.
Please share unedited.

The Customer and The Patient.

The Customer and The Patient.
© Dr. Rajas Deshpande
“I have seen the patient. In my opinion she has multiple lesions (injuries) in her brain because her nerve fibre coating is destroyed. You will need some tests, and an MRI of brain.” I told the family.
Affluent, educated and polite. Patient, her parents, brother and an uncle.
Then there followed a 30 minute viva. All of them asked me questions about her medical condition. They had extensively googled, and had over fifty questions about the causes, types, her symptoms, diet, lifestyle, job, exercise, physiotherapy, marital life, treatment options all over the world and what not. I am proud of my patience, but when the questions started repeating, I politely reminded them not to.
This disease being my specialty, I was only too glad to be able to answer every question. As I wrote down the investigations, they looked at each other as if they had planned a surprise for me. The brother went out and brought in a huge bag. © Dr. Rajas Deshpande
There were consultation notes of at least 5 other neurologists, two from my own town. Repeated tests were done. Four of the five had diagnosed her correctly, and had also written the standard tests and management.
“We were very upset at the earlier neurologist. He did not have time for consults at all. And she was not happy with his attitude. So we wanted to know if he was right. That’s why we didn’t mention it earlier.” said the mother.
I kept my poker face on. As all tests were already done, I reviewed the results and wrote them the treatment plan. There was further screwing about the side effects of the medicines (I want your personal number in case I have side effects) etc. © Dr. Rajas Deshpande
The father spoke. “Yes Doc. I am working as a senior govt. officer, and we have free tests and medical consultation. If you want to repeat any tests, we can get them done at any hospital at low rates”.
They got up. I noticed that the uncle was fiddling with the smartphone. Alarmed, I asked him, “What is that? Were you recording?”
“Yes doctor, we don’t remember the conversation so we keep recording every time we meet anyone” he said without any change of expression.
I lost my patience but did not react. I was not scared of the recording, but they had to know it is wrong to record an informal conversation without the doctor being aware. But there was no time. Outside, they fought with the receptionist about my fees, and demanded that they be included as govt employee category (which has to pay @ 52 Rupees as a specialist consultation fees).
I declined. The first consultation and a second opinion can be free for such govt patients, not the whole medical hopping and shopping.
The next patient came in. a lively and smiling software professional with her father. He had obvious signs of Parkinson’s disease and was having too many side effects of medicines. As I changed his prescription and informed him of possible complications, he smiled and said “I am in your hands, Doctor. I know you are not God, but you are like a God to me. I accept all the risk. I know my illness is not your fault. Do what you think is best for me. We are not very rich, but we will try and do whatever you say”. © Dr. Rajas Deshpande
The first case went down in my mental diary as a “Customer”. The second one as a “Patient”.
There is a lot of difference that the doctor has to opt for when dealing with these two categories. In case of an arrogant, suspicious, accusative patient / relative, the doctor automatically turns his medical safety switch on. These patients will require more documentation, longer consults (hence more fees), more tests (courts always ask for proofs), safest, low profile medications that may take longer to act, and lowest reassurance. That because a simple “he should get better” is being recorded and “you said so“ will be questioned in future. So the doctor, even when asked in front of the patient, has to frankly tell all the bad possibilities about the patient’s illness. That further depresses many patients, especially the elderly and anxious. Most of these “offenders” are usually continuously dissatisfied, whatever you do for them.
One cannot put a gun to a doctor’s head and then expect him / her to be loving, compassionate and perfect. As many doctors will have realised, medical optimism is dangerous. © Dr. Rajas Deshpande
The doctor wants the outcome for each patient to be the best too: which doctor would like to be a failure?
One can easily deduce that the patients will also make such categorisation as “Doctor versus Businessman”. That is true too. But the difference is that the “Businessman” doctor is still an educated, qualified person who is trying to do good to the patient in most cases.
A judge can knock his hammer and shout “Silence” and punish the misbehaving. A policeman will lock you up if you misbehave or offend him. A minister or a government officer will have you thrown out by his security. A performer or a musician will not tolerate disturbance. There is no other profession where you tolerate insults and demeaning behaviour. © Dr. Rajas Deshpande. The nobility of a doctor (or a nurse) is that he / she will still try to do good to their offender.
Once the complete and genuine trust is felt, most doctors go out of the way to help the patient. Many will never realise, but almost every doctor has over hundreds of non paying patients: relatives, other doctors, teachers, poor patients, maids etc., hospital staff and many more. Add the forced free patients: politicos, govt. employees, and the pseudopoor.
Every “Doctor” wants to treat “Patients”, and this sacred relation still exists, although waning. I feel it is more of the doctor’s responsibility to improve this relationship. For their own good, as much as for their patient’s good.
As for the “Customers and Businessmen” mentioned above, I think they complement each other, and the true “Doctors” and “Patients” should avoid both of them.
© Dr. Rajas Deshpande