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What I learnt as a doctor

Dr.Tandava Krishnan

“Get into the medical course and your life is made”, was the advice often given by elders during our school days. I am currently 36. I got admitted into a medical college 18 years ago on my birthday. To put it simply, half of my life has gone into training and then applying what I have learnt in this field. Throughout my life I had adjectives like hardworking, brilliant, intelligent so on and so forth thrown at me. However, a cursory look at my bank balance makes me wonder if there is any justification for such adjectives! Of course, a lot of people would surmise that bank balance is hardly the correct yardstick to judge a doctor’s life. If clinical excellence and financial success are the parameters to grade a doctor’s success, a 2x2 table can be designed to fit doctors into one of the four groups depending on the presence or absence of the two attributes.(I am not sure if my community medicine teachers in Mangaluru would approve of my application of a 2x2 table!).


Dichotomy in the medical field:  At school, we were taught about the binary system of numbers and I used to wonder as to how so much of information can be incorporated using just two numbers. However, early on in my medical college I realised that a lot of things can happen around two somewhat opposite entities.

Never and always- As students we were taught that in medical jargon, the two words which must be religiously avoided are never and always. Any medical professional who swears by either of these words quickly realises that they do not exist in the medical lexicon. To twist the famous sentence made by Eric Segal in his book “Love story”, “Being a doctor means never getting to use the word never or always!” Similarly words such as best or first also lose their meaning in this field. A teacher once told me,” Every time you think that you have discovered some new idea, just look up in the PUBMED and you will find that many have already been down the path that you have identified.”

Old or young: A doctor is always in a tricky situation as far as his or her age is concerned. The younger ones are labelled as inexperienced and green horns while the older ones are dismissed as old fashioned and out of sync with the latest medical innovations! And there is no way to predict whether in such a situation your age becomes an asset or a liability. Of course, it would be wonderful if a doctor would voluntarily decide the day on which he or she would call it a day like the obstetrician in the book “Final diagnosis” by Arthur Hailey rather than stay out dated and made to feel unwanted like the pathologist in the same book.

Earn late but do charity:  One day I came across a child who needed some tests for the eye. A couple of minutes after the consultation, the mother of that child came back to ask me if the tests were essential and if they could be delayed by a few days. Sensing some hesitation I asked her what the problem was. She explained that the cost of the tests were beyond her means and needed some time to gather the money. I immediately gave her the money and asked her to get the tests done.
A doctor is by default assumed to be financially prosperous. People overlook the fact that a doctor spends more than a decade acquiring the skills and knowledge necessary to practise and/or operate with a certain level of proficiency. Simply stated, a doctor earns his/her first salary either in early or mid thirties.  To put this into perspective, people in other professions have a head start of nearly half a decade over doctors when it comes to earning their first salary.  Even then, what they earn is not always commiserate to their talent. There is a lot of dissatisfaction among doctors about what they get paid. Despite harbouring such a sentiment, a good number of doctors willingly waive their fees when dealing with a deserving patient. In fact, what doctors resent most is a situation where a patient is denied treatment for financial reasons. Some people might find this ironic but the reality is that only a small portion of the medical expenditure actually finds its way into a doctor’s pocket. Whenever a procedure is done, it is assumed that the entire amount is cornered by the doctor. A sizeable chunk of the money goes to the company manufacturing the surgical consumables or medicines. And in the current scenario where corporate entities have made deep inroads into the medical industry (Yes no more a profession!), the remaining profits go into their kitty and not to the doctor. Even with such limitations it is commendable when a doctor does some pro bono work.


Listening to the patient to treat or to console:  As an intern we were once dealing with a perplexing case. With all investigations turning out to be negative and the condition of the patient deteriorating, our unit chief decided to seek guidance from his teacher. The elderly doctor (Professor Emeritus) breezed into the ICU and directly headed towards the patient. He quickly got into a conversation with the patient and after five minutes came to us and said,” This man has calcium deficiency, please supplement him with the same.” When pointed that the calcium levels were within the normal limits, he summarily dismissed them and asked us to give a trial of calcium for half a day and see the results. Surprisingly to us (though not to the elderly doctor), the patient recovered dramatically. In another instance, the secretary of a senior doctor at Sankara nethralaya wondered as to why he needed to spend so much time talking to each patient when there was a huge backlog of patients waiting for his consultation. To which he answered, “There are times when a doctor can do nothing to improve a patient’s condition. In such situations, the least a doctor can do is to listen to their problems patiently.” In the two situations cited above, the common factor was the ability of a doctor to listen and both have their own benefits. In the first instance listening to the patient resulted in the opening up of newer thought processes benefiting the patient. In the second instance, while the situation might sound miserable, a patient hearing of the patient’s woes provides a sense of closure for the patient.

Generic drugs-Damned if you use and damned if you don’t: A well meaning movie actor in a popular show had suggested that doctors shift to generic drugs in the interest of the patient. The idea being that generic drugs are a whole lot cheaper. His intentions are well appreciated but let’s get some facts right. There is a huge margin between the cost price of the generic drug and the printed maximum retail price. This mismatch can be easily detected if one were to buy the same drug from a regular drug store and a store run by some welfare oriented NGO. This disparity militates against the idea of generic drugs being cheaper. Added to that, there are a good number of studies to suggest that the generic drugs are less efficacious than the original molecule. This puts the doctor into a delicate situation. Must he/she prescribe a drug with proven efficacy but higher cost  or use a cheaper (supposedly) drug with dubious efficacy and face criticism from patient for providing sub standard treatment.


Trials and tribulations: Jerome K Jerome in his book “Three men in a boat” wrote about three friends who go out on an adventure trip on a boat. When they try washing their clothes in the river, they realise to their chagrin that it was the river and not their clothes which got cleaner by their efforts, for the dirt in the river was now on their clothes. A doctor is faced with a similar situation while treating their patients. The principle of “First do no harm” must always be in their mind. So how do we protect the patient’s interest? How do we keep our patients from being harmed? By keeping ourselves updated and judiciously applying the knowledge thus garnered would be a politically correct answer. For recent developments, we look up to journals for guidance. The catch here is that in certain situations a clinical trial published in the journal would swear by a particular therapy only to be rubbished by another trial! And then there are some trials which leave themselves open to interpretation in so many ways that the doctor feels like he/she is walking through a veritable maze. In fact it is said that if you torture data, it would confess to almost anything!  In situations where the conclusions are inconclusive, the doctors are compelled to just do nothing, a predicament which is euphemistically termed as “Masterly inactivity”! And we doctors have to actually assimilate these trials and apply them in the best interest of the patient! Facing a firing squad would be a more joyous activity compared to this.   So every time a patient asks us, what is the best option, the candid answer should be, “Don’t ask me mate, for I am clueless!” .But what a doctor would most probably say would be, “Sir/madam, the choice is for you to make, I can only give you options.”

Of brickbats and bouquets: Life for a doctor can be very fickle. Patients can be profusely grateful or abjectly thankless. Early in the career doctors can be easily be affected by both positive and negative emotions of the patients but as one goes along, one realises that both the good and bad have to be taken within ones stride.  I once came across a patient who had poorly controlled diabetes for the past 20 years. As a result he had severe vision loss. When I broke the news about the condition, his first query was, “So how quickly can you correct my vision?” When I told him that visual recovery may not be possible, he became irate and said, “I will throw as much money as you want at your face, Stop being pricy and get on with your job.” When i reiterated my inability to do so he turned violent and I was rescued thanks to some good natured people. As a person, I could chide him for his prolonged negligence of health and his vanity regarding money but as a doctor I must understand the scary prospect he faced of a life devoid of good vision. This fear transforms into aggression for which doctors become easy targets. Sometimes I respond to such patients as a normal person and sometimes I try to be understanding and respond as a doctor. What irks the doctors most is when irresponsible generalisations are made to suggest that doctors are blood thirsty and greedy for money. Adjectives like “botched surgeries”, “killer doctors” used in media with little justification piques doctors but must be accepted with a sense of resignation as an occupational hazard. Sometimes such negative campaign in the media can assume funny overtones. In one such instance a newspaper ran the headline,” Chennai girl gets rupees 1.8 crores compensation for botched eye surgery” (New Indian Express 2nd July 2015). There was a minor anomaly in the headline. The girl had never undergone an eye surgery! The girl had lost her vision because the paediatrician had not referred her to the ophthalmologist at the correct juncture. And when the girl was finally referred, the eye condition was beyond surgical redemption. So much for a botched surgery!
To summarise people aspiring to be doctors must have reasons beyond financial success. As a teacher of mine once said, “Every doctor will have his bread and butter but only the lucky few will be fortunate enough to have the jam too!” Listening to the patient and giving them the greatest priority helps. That clears up the maze which the medical science can sometimes be. Practising medicine like everything else in life is all about perspectives. The same situation can be perceived and hence approached/managed in different ways. There are no dogmatic principles. What is paramount is that the patients get the best possible outcome. And most importantly, we doctors must learn to act as our conscience dictates without fear or favour. I end by reminding all my fellow doctors as well as those who aspire to be one in the future, the immortal quote made by Sir Robert Hutchison

‘From inability to let well alone
From too much zeal for the new and contempt for what is old
From putting knowledge before wisdom, science before art, and
Cleverness before common sense;
From treating patients as cases;
And from making the cure of the disease more grievous than the
Endurance of the same, Good Lord, deliver us.’

 

TK

 

 

Dr. Krishnan is a Vitreo-retinal consultant at Neoretina, Hyderabad.