THE LARGER PICTURE - DO NOT HOUND THE DOCTOR WITH A "TELESCOPIC MENTALITY" - DOCTORS SHOULD PROTEST!

     Road traffic accidents are common. The injured persons are brought to the hospital (government or private). Doctors attend. Results are unpredictable. If the results are good, the people feel "Doctors did their duty. So what?" If the results are bad, the people get agitated. They feel that the doctors did not even do their duty. Usually this is followed by manhandling of doctors and destroying the property of the hospital. Doctor is neither protected nor respected.  A weak case is filed against the perpetrators of crime and the sympathies of the public lie with them. The harassed doctor and the hospital get no accolades, thanks or good comments.
     You may say "Why a blog on this common scenario?" I will explain. This, I must remind you is an incomplete picture. A telescopic view of a larger picture. What then is the larger picture? A person buys a bus (Bus owner) without any worry about its quality. A driver employed by him drives it as if he owns the bus and the road. An unscrupulous employee at the RTO certifies it fit even without checking it. Road is made by the unscrupulous elements in connivance with the city administration. In the case of a RTA who then is the main culprit? Your guess is as good as mine. I can say for sure one thing - not in the least the doctor. Why then harass him? Because he is the "soft target in the unorganised sector". What then is the solution? Seeing the larger picture and involving the real culprits. If there is a need for expensive treatment and / or expensive investigations naturally the bus owner and the city administration must chip in. Do not they blame the hospital owner if there is a death? Similarly bus owner must be arrested and taken to task. Why does this not happen? I really do not know
     In case of a food poisoning, the hotel owner, cook, building owner, food inspector, and the city adminstration must be tackled and if at all the doctor must be praised and applauded when helpful. Why should the brunt of the burden borne by the doctor?
     Also, I would like to make a clear distinction between the 'error of judgement' and 'criminal negligence'. Not attending is criminal negligence. There is no excuse. Attending but making a wrong diagnosis amounts to an error of judgement. This is. pardonable
     How shall we tackle these issues? Creating awareness is one thing. Forming a SOP is another. If the item you buy is defective, the onus is on the manufacturer and not the salesman. You cannot shoot a messenger however bad the message is. Doctors have to assert their rights. Creating awareness involves many platforms. Honoring of good doctors, appreciating the good deeds, recording the contributions in disaster management are all important steps. Doctors should proactively take credit by using internet, facebook and other similar sites. Petitioning on the Facebook is another option.
     The whole idea is to get credit for the good acts and expose the real culprit. Service clubs and Professional organisations like  IMA must also help. It will take some time for things to change. A change from the telescopic view to viewing the larger picture is the need of the hour. I hope that it will happen pretty soon!

MEMRIES OF MY FIRST MBBS EXAMINATION - SWEET DREAMS OR NIGHTMARE?

     One of my Professors  used to say "Examination is  a botheration to the population of the Indian nation whose main occupation is cultivation." I would like to make a correction - they are so for all nations irrespective of the occupation!
     The most horrible examination I faced was the first sessional exam after 6 months after joining the I MBBS. It was important to be in the top 40 of the class. It meant an entry into the Anatomy Club which almost ensured a pass in the final exam. I felt this should be a cakewalk, for I was the 13 th in the state in PUC to qualify for an almost free merit seat. The books were bigger, the subjects vaster, but the overconfidence brushed it aside. I worked just as I had worked for PUC. I never realised that was not enough. When the results came, I was in for a rude shock. I had scored just 37! Faced with defeat, humiliation I accepted the result and went to the teachers for advice. One of them encouraged me . He said "You can still try. If you score 105 together in the first and the second sessionals, you will get a direct entry to the Anatomy Club and you will become a Prosector which means  you can teach the  juniors the dissection ( you will get one more chance for some dissections) and also get paid for it. It was a win - win situation and I tried really hard. I learent to draw really god diagrams copying from my friend's uncle's diagrams. I did really well and got 69 out of 100 - just crossing the magic figure of 105 by 1 ( a total of 106). I understood what hard work was.
     The final  examinations were considered to be necessary evil. All appeared, only about 30% passed. Going to the exam hall was like going to the slaughterhouse. No one could predict the outcome. When the son of the Principal of Mangalore college appeared fro Physiology at Manipal, where the Dean was the examiner he promptly failed. Neither the Principal (his father ) influenced not the Dean thought of passing him on terms other than on merit.
     That reminds me of my own Physiology exam. "Effect of Atropine on the Vagus nerve and the Heart" was the task It needed to dissect the tiny Vagus nerve and study the effect of Atropine and get a cardiac muscle curve as the proof. It was an examiner's delight and the student's nightmare. With my limited knowledge of finding the Vagus nerve (a white , smooth, glistening hairlike structure),  hampered by my astigmatism, I could never locate it. After the stipulated 60 minutes one had to face the" firing squad" I mean the examiners! I realized at the end of 55 minutes that I had only 1 option.To kill the poor frog! I had to commit the crime in 5 minutes and that too without leaving a trace. I had to think fast. The only weapon I had was the Atropine.I emptied the bottle of atropine on the heart of the frog. After a series if twitches, the frog promptly died and the curve became flat. I washed up the scene of crime and no trace of atropine was left. The army of examiners came to me.  I was so scared. I was sure I would fail. They asked for the graph. I said "The frog died!" The senior most among them said" I have seen these kind of things happen. I fail to understand how the frog died at the correct moment? How on earth did you kill it? I put up a brave front and said "Sir, it must have had a heart attack!"
I answered all the questions. I just passed. Anything was better than failing!
     Anatomy was another issue altogether. Dissections were the toughest party of the examination. Each got 1 part of the body to dissect - selected by lots. The stipulated time was 3 hours. The one who got to dissect the sole of the foot usually went home straight away - that was better than failing after a 3 hour struggle. Luckily I did not get that!
     Histology though a difficult subject to master, was the easiest exam. There was one George, who trained the students in a unique style. He was very good at drawing and anyone who attended his classes would learn to draw well. He would tell us how to recognise each slide without error.  Cover slip broken on the right side - Heart; Cover slip broken on the left side - Lung; Excess stain on the back of the slide - Testes; Slide broken in the right corner - Prostate..... the list would go on. He would show us these peculiarities repeatedly. He had only one request - "Please do not break a slide!" With this 'foolproof'' training,almost  everyone passed!
     Lastly there was Biochemistry - a part of Physiology. It would boil down to 2 questions in Physiology out of which 1 would be a cycle. There would be a 'titration' experiment in the practicals. One had to carefully neutralise something (usually an alkali to an acid). End point was important. The professor always said  "add half a drop more"! I never understood how to add half a drop. The smallest is one drop! Once when I asked this doubt the professor said " Only a vigilant student can do it well". May be I was not vigilant enough. I never understood the half drop concept anyway.
    I did pass tee first MBBS exam in the first attempt! I even scored well! Looking back, that looks incredible!

ON BEING A MEDICAL TEACHER - MY EARLY EXPERIENCES AND EXPERIMRNTS

     Being a good  medical teacher was my life's ambition I had seen a few dedicated teachers during my MBBS days. I recognised the efforts they put in ; the sacrifice they made and the devotion with which they imparted the knowledge. I did not have to look far. I had zeroed in n my career.
     The day I passed my MD, I applied for the job - Lecturer in Medicine. I was greatly disappointed to know that there were no immediate vacancies. I joined a hospital and patiently waited for the vacancy to arise. While working there, I developed interesting in collecting clinical materials - case details, X rays,
 ECG s etc which were very helpful later as teaching aids and for the books I wrote. I also developed a habit of referring to the books and journals.
    The golden day came on 17 February 1982 when I joined a medical college as a Lecturer. I went with a new apron; new shirt,  and armed with knowledge, capped with pride and arrogance (born out of knowledge). Initial years of ones career are 'power driven' - you 'know' everything. From the knowledge stems arrogance and from that comes a dynamic performance. There are only 2 zones - black and white.
 I was ready for my first clinics.
     What followed was unimaginable - the senior students had already attended a clinic by my chief (Dr. KP Ganesan) and left. 4 students were curiously looking at me. They said they were repeaters. There were no organised classes for repeaters. They wondered whether I could teach them. I had taught such students as an intern and as a PG student. I agreed immediately. I took the class well. They liked it. I was extremely happy. I still remember the names of 2 students - Bipin Patel who later become a Physician in the US and did very well for himself. The other one was one Sandra.  For the next 2 months I took clinics for them regularly and all 4 passed (the pass percentage then was 30%). I was thrilled.
     I have taught many batches of UG s and PG s after that. I enjoy using the black board for the theory classes. There has been innovation and modernization in teaching. Power point presentations have replaced blackboards. I personally feel that the audiovisual aids like power points impart  uniformity. They extend mediocracy. Basically it is an exercise in trasferring image(and not necessarily knowledge)  from the teacher to the taught without either one essentially understanding or mastering the topic. A black board is like an empty canvas. It gives immense scope for the teacher to evolve the subject and develop the concept. It is an exercise in transfer of knowledge with a better understanding by both - the teacher and the student.
     The salary of a teacher was unimaginable when I joined. I took home a princely salary of Rs. 250. Daily wage unskilled laborers earned more. Then it was a matter of pride to be a teacher. To survive one had to practice. That is how and why I practiced. Even now my first and only love is teaching. Practice is incidental requirement which I never really fell in love with except the fact that I met people and I enjoyed interacting  with them.
     One or two things have concerned me. Till recently there was no formal training for teachers who teach at highest level -MBBS, MD, DM, Phd. etc. Also no emphasis is given to the 2 major requirements in any field - communication and decision making. Innate skills of communication have to be honed. Decision should be made on rational thinking and common sense rather than using guidelines and protocols alone.
     The later part of one's career is passion driven. One is aware that there is a grey zone( in addition to the back and white ) and many things belong there. One humbly accepts the fact that one could be wrong or more importantly, the other person could be right. Arrogance born out of knowledge (of the early phase of the profession ) is replaced by humility born out wisdom in the later phase of the profession.
     Probably I am now in  the 'passion driven' phase of the profession. I travel far and wide on invitation to take classes and teach PG s and doctors at many CME s.
     I want to emphasize one important point. A good professional remains a student and a teacher all his life.
One need not necessarily have an attachment to a medical college to be a teacher. Teaching any one else at the work including junior doctors, colleagues, even the patients (patient education) makes one a teacher. What is important is to perform the task well and not the title.
     Looking back, I have no regrets.However, the satisfaction obtained by teaching the repeaters and the so called back benchers  (who really need us and our skills)  was infinitely more than that obtained the day I received my 'good teacher award'.
     

MYSTERY OF THE MEDICAL FITNESS FOR A PARALYSED PERSON OR WAS IT IMPERSONATION?

     In the career of a doctor there are some sticky situations. Insurance Medical examination is one of them. This is mainly because the scant respect the administrators and the agents have for the client, medical report or the doctor.  I really do not understand the logistics of this. The payment for the doctor is still about Rs. 100 - while foreign insurance companies pay $ 250 per report! Cheap labor indeed . Again  I do not understand this mentality particularly when the emoluments of the staff are increased almost on yearly basis for their work(?).
     This story concerns one such medical examination a mandatory requirement before any insurance. A person was brought to me for a LIC Medical examination. I did not know the person though he is supposed to have been a well known person. He was accompanied by the ABM (Asst. Branch Manager) and the LIC agent . I requested both of them to identify the person and sign on my LIC diary for the same. I sincerely examined him. I found him feverish and surprisingly a little bit pale which was unusual as he was coming from a good  family. I even commented about it and he promptly said he was suffering from cold.
     The ABM and the agent took possession of the medical certificate, thanked me and left. I forgot about the episode till about 2 monthes later the agent told me in passing that the client died and that the claim (double benefit 4 lakhs for 2 lakhs policy) was promptly rejected by the LIC. I was not concerned anyway. Later I came to know that the party had filed a suit against the LIC. I did not bother about the details. Only when a person from the LIC Udupi division walked in a few days later for the "inquiry". Even then I did not assess the severity of the situation. I thought it was a routine inquiry because of early death which is a standard procedure. I was shell shocked when the person said the LIC had decided to file a criminal case against me. Why so?
     He gave his version. The man was in a hospital admitted for a widespread cancer with spread to the bone, fracture of the spine and paralysis due to compression of the spinal cord. It was highly impossible that he could have come out of the room in the hospital leave alone visiting my clinic on the first floor. I got the implication. I had examined an impersonator. LIC wanted to file a criminal case against me for 'criminal involvement with the client for gain' . I was speechless. They gave me a week to reply
     . I visited my lawyer friend in the evening and explained the situation to him. He heard me out and cooly said, "These things happen. Say sorry. Usually they leave you!" I was really upset. I had not committed the fraud. LIC officials had. To save them they were trying to make me the scapegoat. I sat up the night and gave it a serious thought at midnight when all is quiet and one can think without distraction.
     I hit upon an idea which seemed to be foolproof. I wrote back saying " The person alleged to be so and so who was examined by me on the said date was indeed medically fit. However, the onus of identifying them lies with the persons who introduced him - in this instance - the ABM and the agent of LIC. So please forward your queries and inquiries to these two who in my opinion are hand in glove with the party and are the perpetrators to the crime".
    The tone, and the content of the letter must have annoyed them. The LIC decided to take a second opinion from Nani Palkiwala. They wanted to silence me. I proactively wrote to them that I would be unilaterally proceeding for defamation charges with a claim of 1 crore for the mental harassment from LIC in order to save the fraudsters who were from LIC. The letter had the desired effect. Nani Palkiwala adviced LIC  to lay off and behave. They apologised.  The case was closed.
     The moral of the story is to be very careful at all times. Fraudsters plan the escape roue in advance. Innocent one gets involved unless one is vigilant at all times!
     

THE STORY HOW AND WHY THOMAS WILLIS (OF CIRCLE OF WILLIS FAME) BECAME VERY FAMOUS

     Thomas Willis was a British doctor who was known for neurology and anatomy of the brain-  best known for Circle of Willis
     He was born in 1621.His research would changer the concepts which prevailed before his era. In the pre Willis era, the teachings of da Vinci, Vesalius and Berangario prevailed and brain was thought to be an organ of purification. Willis did a lot of work on Anatomy of the brain. He worked in collaboration with Christopher Wren and Richard Lower. His research in anatomy of the brain  resulted in findings which were unexpected and very different from the views held then. He became famous. But for his research he needed to dissect human corpses. It was not easy to get them and many a time those were obtained by a 'forcible' donation
     Today's story relates to one such episode where the body for research was obtained by a 'forced' donation - one Anne Green, a 22 year old housemaid who became pregnant by the grandson of her employer. She gave birth to a baby prematurely and hid the infant which promptly died. She was accused of infanticide, tried and convicted and was to be hanged to death for the offense.(This happened on the 14 th December 1650)  This was a public ritual witnessed by many. They pinched her and pulled her down by the legs which was supposed to shorten the process and thereby reduce the duration of agonising asphyxia. Her body was pulled by so many people so violently that the court official was worried whether the rope would break and requested the people to leave the body alone. The body was given to William Petty for anatomy lectures at Oxford . When Petty and other doctors including Willis opened the coffin, the 'corpse' was said to have taken a breath. Willis raised the body to a sitting position the doctors opened the mouth and poured hot drinks down. This caused a cough and the doctors began to resuscitate her by rubbing the hands and feet. About 15 minutes later the eyes fluttered. The doctors began bloodletting and applied compression bandages to the arms and legs to increase the circulation (as it was believed then). They put her body on a bed besides that of another woman whose unfortunate job was to keep Anne's body warm. 12 hours after the official 'execution' Anne spoke a few words. After  4 days, she began to eat solid food. After a month, she was said to have fully recovered. Because her her unique resuscitation, Anne was later reprieved of her crime. Anne moved to the countryside taking the coffin as a souvenir. She married, had 3 children and lived for another 15 years.
     Willis married Mary in 1657 and in 9 years of their married life had 8 children 4 sons and 4 daughters. All but 2 children died. Mary expired in 1666.
     This episode made Willis very famous and his success resulted in jealousy from his colleagues. He had to face a lot of harassment He died relatively young at the age of 54. Willis is best known for his circle of Willis which was described before him and he always acknowledged the earlier claims.
     It is rare to find such an extraordinary story in the history of Medicine - No wonder it made Willis world famous for all times to come!

"DAMSEL IN DISTRESS" - A TRUE EPISODE - WHAT WAS THE REASON? HOW WAS IT SORTED OUT?

     Whenever a lady comes for the complaint of vomiting, I remember this episode of a "Damsel in Distress". It was a usual day like any other day. She had taken an evening appointment. She was working in a software firm and wanted an urgent appointment to consult me.
     She came with her mother. Mother was really concerned to the point of being inquisitive. The complaint was one of vomiting almost after each feed. Mother and daughter lived in different cities. Daughter had come to her mother's house because of the complaint.
     After taking an elaborate history, mother hovered around the daughter during the examination. At every step she would ask "What is the diagnosis?" The daughter was uncharacteristically quiet. She spoke little but co operated for the examination. Those were the days before the ultrasound scan became available. At the  end of the examination, I asked for some blood and urine tests. In situations such as these one discretely asks for the pregnancy test - I used to use a code "Urine for H" (which my regular lab understood )indicating HCG which is the basis of the pregnancy test.
     She came back with the reports. She came in alone and said " I insist you do not divulge anything to my mother. I also insist you help me in solving the problem. I know my rights and I demand professional secrecy even from my mother. Then she went out and called her mother in. The report confirmed my suspicion. She was indeed pregnant! Mother asked me "What is the diagnosis doctor?" I had to think fast. I had to tell her something that would closely mimic the early pregnancy. Something that had vomiting as a component. I said "Urinary Infection". Indeed, ascending infection can be complicated by acute pyelonephritis which can present with vomiting ( and fever which can get masked by the partial treatment). Mother seemed to be  satisfied with the explanation. Daughter kept quiet. Both of them went back.
     Next day the daughter came alone. She demanded, "Now that I am your client, you are duty bound to help me. Guide me to a good doctor for the termination of pregnancy". I suggested some name and she went away.She came back after a couple of days and thanked me. She gave a vent to her feelings. She said a man gets away easily and a woman has to suffer and all this  is very unfair. I agreed with her.  I almost forgot the episode.
     After about 5 years, I saw her again in my clinic accompanied by a man. She had come to consult me for something very minor. Anyway, I did my job professionally and did not show any signs of recognition.She thanked me, went out with her husband. Just after she left I observed her handbag. As I was pondering what to do and how to get her back, she suddenly came in. "Doctor, I am sure you recognize me.Doctor, do you remember  I gave a vent to my feelings and had said the boys get away. After going back to work, I gave it a serious thought. I wanted to punish the guywho did it to me. I married him. What better punishment can I give? I wanted you to know that the whole episode had a happy ending.
     I was speechless! I congratulated her and wished her well. How many girls can do this? More should try to "punish" the person responsible. I could not decide who was in a greater  distress. The "damsel" or the "gentleman"?

TRUE STORY - HOW THE GREAT NEUROLOGIST BABINSKI WAS DENIED PROFESSORSHIP- DID IT REALLY MATTER?

     It is not possible to achieve all the ambitions all the time. Can one still reach great professional heights and have a good career? an average man's answer would be a 'no'. But I warn you not to draw conclusions before reading the outstanding story of Joseph Babinski, unduobtedly a great neurologist of all time.
     Babinski was born in 1857. He was a faculty of Medicine in France where the faculty was given only part time jobs and allowed to practice. A university career was possible only after defense of thesis. Aggregation (becoming an associate Professor)  was the next step. This entailed complicated exams. The next would be elevation to the post of the Full Professor (which was partly by selection) and gave a status and enabled one to head the department.
     The time had come after Babinski became eligible for appearing for a competitive examination after completing 2 years of residency. These exams started  in 1802 when the success rate was 60%. Babinski appeared in 1877. He did fairly well in Clinicals (anatomy of trapezius 17 /20 ) and treatment (Burns 20 /20). He did not qualify for aggregation and was promoted to permanent post.in 1879.
     After completing 4 years of residency, Babinski appeared for the Gold medal examination which was mandatory. He did well in the written examination (Gastric mucus membrane ). He qualified for the oral exam but could not appear due to the illness. He was not considered for the gold medal.
      He got employed under Charcot a well respected neurologist at that time. In 1886 he appeared again for the Aggregate exam. He scored  16 / 20 (Hydatid cyst) which was not good enough to appear for the orals. In 1887 he appeared again with Gilles de la Tourette and Pierre Marie, scored 16 / 20 for clinicals and 14 / 20 for orals (chicken pox) and was not admitted. In 1888, in a competition held for 3 possible places Babinski scored 27 / 30 and in orals (sclerosis of the heart) he got 26 / 30  - not good enough for the next step. ,
     In 1893, he   competed for the aggregate and  he successfully completed the exam with a score of 30 / 30 for  written part ( Scarlet fever ) and 19 / 20 for orals (diphtheria with paralysis)., 17 / 20 for cliniclas,, and 30 /30 for the case (Syphilis ).  The idea was to find an able successor to the then head of the chair - Charcot. The competition was between, Babinski, Landouzy, Dejerrine, Raymond and P. marie. Babiski was the preferred pupil. Unfortunately, the arch rival of Charcot - Bouchard- was at the chair of the selection committee. Babinski was intentionally ignored. This story was lapped up by the press and the media much to the discomfort of the education minister who was involved by the public in the controversy. Next opportunity was provided in 1895. Babinski never appeared. He vowed never to appear again. He joined a hospital at la p Petie where he worked for rest of his illustrious career.
     Did Babinski lose anything by being unfairly denied of the opportunity? In his own words, "No" is the answer. His only regret was that he could have influenced the career if he had any. He in fact considered it an advantage not having been invited. He could work at his own pace in his own style.
     What is the moral of the story? One does not necessarily have to be a professor to excel in the field of practice of Medicine.
     Dear friends, do not get demotivaed if you do not achieve what you want to. Still you can do well. In fact, Babinski became world famous for his sign even without Professorship.