The good doctor and fall from grace

The pressures of being a resident doctor are hard. At 9 am, you start seeing patients in OPD at AIIMS and are meant to continue till noon or 1 o’clock. But you look outside and see a long queue of people still waiting, so there is no chance of going back to the hostel to get lunch, and if you miss the fixed times, lunch will be over. Some doctors, trying to get through the long line, omit the medical history and examination and simply kick the can down the road, that is, they fill out a requisition slip asking the patient to go to the laboratory for blood tests or radiology for an X-ray or an ultrasound. Now the pressure builds on the laboratory and radiology. How can a radiologist write the report without knowing the medical history and symptoms? It’s like working in the dark. If they make it to lunch, they return and start working with their respective specialist in the latter’s clinic in the afternoon. These sessions are vital for them to be able to collect enough medical and case material for their thesis. This goes on till 6 or 7 pm. Earlier, they used to have two years for their MD, but the pressure to collect sufficient material while doing their other work was immense so we extended it by a year. Next, rounds of the ward. If, during OPD, patients were admitted, decisions have to be made on starting treatment. If they need surgery, they need a pre-operative assessment to be made. Out of the 20-30 patients the doctor is dealing with on the round, if several need surgery the next morning, it adds up to a lot of work. All the parameters that the anaesthetist will want to know — urine, hypertension, viral markers, haemoglobin levels — have to be arranged. In my time, we had eight operation theatres at AIIMS. Now there are 16. The resident doctor’s rounds can last till 10 or 11 pm. At any moment, there can be a call from the emergency department to attend to a patient. These long shifts are the single biggest cause of stress. In theory, when the duty list is drawn up in every hospital, the shift is technically for eight hours, but the sheer volume of patients that a doctor has to see, along with attending to patients who are admitted, pushes it routinely into 10, 14, 16 or 18 hours. As one of my colleagues once said, ‘One cannot do anything in medicine well on the fly.’ This is indisputable. When doctors are seeing over 40 patients a day, they know they are practising substandard medicine.

In an ideal world, patients should visit a GP first, not rush to a specialist. Now, hardly any students opt for general practice

If India had created good primary and secondary healthcare systems, doctors would not be deluged by patients. This has been one of the failures of Independent India. For much of their workday, resident doctors are on their feet. Most hospitals, including AIIMS, have no rest area where you can grab a nap. We have yet to work out a way of combining this level of work with a measure of rest and recuperation. A social life is out. This way of living and working is possible only because they are young, their bodies are strong and they are hell bent on becoming doctors. I saw many struggling to cope… It’s a long haul. It begins with five years at medical school. A one-year internship at a hospital, of which six months have to be spent in a village at a primary healthcare centre. Some students love the break this offers them. The downside is the social isolation. Then three years of residency begin. Nine years in total. After this, it’s a question of choosing a specialisation or becoming a general practitioner (GP). It takes 11 years to become a specialist and another 5-10 years before you become a figure that people trust. It caused me great pain when I used to see doctors becoming qualified and leaving to work abroad. We created the push factors. The USA — or other countries — created the pull factors. ‘We have created you. We have spent money on you and kept medical fees low to help you and now you don’t want to pay back to society what it has given you?’ used to be my reaction. As to medical students, both female and male, I have seen the motivation changing. I used to hear: ‘I want to serve my state’ or ‘I want to serve my country’. Gradually, it became: ‘I want to make money. My uncle is a surgeon and he makes a small fortune and I want to be like him.’ Surgery, of course, is at the top of the food chain. Every surgeon I have met has been more arrogant than their medical counterpart. Every single one. They are convinced that they are nonpareil. The word ‘vocation’ disappeared, and with it, the whole system changed. The fall from grace that doctors have had is partly their own responsibility. They abandoned the spirit that infused medicine — the spirit of a sacred duty to treat patients with empathy and with concern for a human life untainted by any concern with reputation, glory or income. I know people think that doctors have to become hardened — or at best dispassionate — to cope with the pain and suffering they see, but that’s not strictly true. To be good doctors, they must have empathy and compassion.

The public should treat doctors simply like any other professional — respect their knowledge, but no extra respect is required for them as individuals

The patient-doctor relationship today is delicate and fraught. How patients feel about their medical interactions really does influence the efficacy of the care they receive, and doctors’ emotions about their work in turn influences the quality of the care. Doctors must not lose sight of how patients feel, how they feel the loss of dignity and identity the moment we take their clothes away and lay them in a bed. The only thing distinguishing them from other patients is the particular illness that brought them to us. That is when selfish doctors can extract favours for themselves but not for the profession or the institution they have promised to serve. I have seen the system becoming more technologically proficient but emotionally deficient. There are cases of missed diagnoses and substandard care that have damaged the trust between doctors and patients. When money becomes the paramount motive, a system of kickbacks emerges. At Sitaram Bhartia, we decided not to take patients on a referral basis… When you depend on word-of-mouth patients, it takes time to build up the funds you need… and that is the price that has to be paid. In an ideal world, patients should visit a GP first, not rush to a specialist. A GP conducts a physical examination and has the whole body (maybe even the whole family) in mind when listening to a patient’s complaint. If a person complains of backache, the cause may be to do with the spine or it may be to do with the kidneys. The patient does not know. But now in India everyone rushes to a specialist, so, having decided their back pain is a spinal problem, the patient goes to a neurosurgeon who is an expert only of the spine and who will start ordering investigations to do with the spine. This leap to a specialist can be disastrous since the neurosurgeon will not even investigate the possibility that the cause of the pain could be elsewhere in the body. The die is cast. The patient might have needed only a few sessions of physiotherapy and some painkillers. But the patient has entered a tunnel. Perhaps the wrong tunnel. I used to keep a film of a chest X-ray in the radiology department at AIIMS. It showed a little nodule in the hilar region, the middle of each lung where the bronchi, arteries, veins and nerves enter and exit the lungs. If I showed it to a chest surgeon, he would diagnose a fracture of the rib. If I showed it to a physician, he would say the same nodule was ‘a lymph node’. The cardiologist? It’s the pulmonary artery. That’s why an examination by a GP beforehand is so important. Before homing in on one organ, the whole body has to be considered. By going directly to a specialist, it means that more expensive technology is likely to be used and the costs of healthcare rise. We have killed the GP in India. It has lost all prestige. Hardly any medical students opt for general practice or family medicine. It differs from person to person but in our society, a specialist is given more social respect than a bachelor of medicine or MBBS. Healthcare is not only dependent on medical care. It also depends on clean water, sanitation and effective sewage systems, in addition, of course, to preventive care. If none of these work, people will fall ill. Some of our best brains have failed to grasp this point. I do not discount ayurveda. I am sure it has uses, but without research and data from random clinical trials, we cannot establish its efficacy. However, I think the Chinese have got it right. In the fourth year of medical school, students have to learn about traditional Chinese medicine. Under the British Raj, ayurvedic colleges were banned and important texts destroyed, but in China, the sources of knowledge remained. We, too, need to include ayurveda in the medical curriculum as it is the only way to encourage the research that ayurveda so woefully needs. If you ask ayurveda practitioners to carry out research of their treatments, they cannot do so as they have no training in research. As a formerly ‘noble’ profession, medicine has slipped. I believe the public should treat doctors simply like any other professional — respect their knowledge which they have spent long years acquiring but no extra respect is required for them as individuals. Good doctors care about their patients. I knew of top surgeons who, the day before a complicated operation, would visit a mandir to pray for a successful outcome. I knew surgeons who, conscious of the fact that a human life is in their hands, prayed more for the patient’s recovery than the family. For me, that is the definition of care. In my ninety-fifth year, it is my wish that the spirit of public service continues to be the guiding force of the medical profession. As Hippocrates said: ‘Wherever the art of medicine is loved, there is also love of humanity.’ — Excerpted with permission from Juggernaut

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