He is a fervent, and eloquent, evangelist for the art of healing as distinct from the science of cure, a continuous student of the humanities. This arguably accounts for his reputation as India's best diagnostician. He is the colossus of Breach Candy Hospital. When he walks through the corridors of Parsi General, people reverentially stand up. He has mentored thousands as Professor of Medicine at JJ. He is perhaps the last of the legendary physicians. And he is as passionate about Mozart as about the symphony of the human body. Interviewing Dr Farokh E Udwadia is equally elevating. Excerpts from a long conversation.
Karkaria: You are quite the Renaissance man. The importance of the humanities recurs in all three of your 'lay' books, including the imminent Tabiyat – Medicine and Healing in India and Other Essays (OUP).
Dr Udwadia: I can't emphasise this enough. A study of the humanities gives you a wider perspective. After all, we exist in the world, the environment interacts with us, isn't it? And if you want to know exactly how a human being works, you will be much better off if you had a good idea of the humanities. Read poetry, literature, and you get a good idea of what suffering is. If you can appreciate your patient's suffering, your response to his disease is much better.
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/ctn_outbrain_ads.cms?adcode=video_ad&msid=62676135&secid=17371530&templateName=articleshowpotime:17As for history, doctors should at least know that of their own profession. All of us stand on the shoulders of discoveries of past greats, who had no access to the modern technology that has swept over us today. This also gives us another essential quality, humility.
Oh absolutely. I consider it the most important of the arts. Music has unquestionably shown that it helps the healing process. Even in the World Wars, soldiers convalesced better when they listened to music. Now it is being scientifically understood how it acts on certain parts of the brain, which perhaps control the immune response of the body to disease.
Personally, it gives me a feeling of relief, of satisfaction, and ennobles the spirit. Great music is a great blessing. I'm passionately fond of it.
So let's talk of your related passion for the 'art of healing' as distinct from the science of cure.
Medicine is an equal measure of art and science. Curing and healing are not exactly synonymous. Curing is science intervening to get rid of a disease or infection. But healing involves the whole mind-body complex. That's the important distinction. There are conditions which you cannot cure, but you may be able to heal a fair amount of anxiety and discomfort. Not uncommonly, the problem is more in the mind, and that is where the art of medicine comes into play. Sometimes you cure and you heal. Sometimes you cannot cure, but you can heal to some extent. Sometimes you can heal when there is no real physical illness to cure.
What's the missing link in medicine today?
Medicine has lost its path because it's so enamoured of machines and technology. The doctor relates more often to these than to the patient. He's making his diagnosis in the laboratory rather than at the bedside.
So, is the famed 'bedside manner' now on life support?
Not yet, but it's really neglected.
It's ironical, then, that advances in technology have led to a decline in the profession.
If there's one reason for this decline, it's the lack of empathy, or deep caring. Today, the doctor fails to realise that unless he listens to the patient at length, and examines the patient carefully, only then can there be the doctor-patient bond which lies at the core of medicine. Particularly in a very sick patient who almost has an antenna which senses genuine empathy. When that happens, there is faith, and it's amazing how much faith can heal. It dwells within the mind which influences the body. If a patient comes with a cough and cold, whether you give empathy or not doesn't matter. Fortunately, most diseases cure themselves, sometimes even in spite of the doctor.
But in a patient who's seriously ill, empathy is critical because it builds faith, which can make the difference between life and death. The patient feels 'My doctor says I'm going to get well, I believe in him, and I will get well', and that influences the body. No one knows exactly how, but it does. It's equally amazing how that patient's antenna will not respond to pseudo-empathy.
Is the doctor's own machine-dependency irreversible? We can't wish away technology.
No, but we have to keeping stressing the importance of being close to the patient, of knowing that there's another, older side to medicine. After all, have science and technology ever been able to take a good history from a patient? Or take the place of a good physical examination? No! It's important to realise that your eyes, ears and hands can sometimes detect what no machine, no technology, can.
Tell us more about deploying all the five senses. I was blown away by what you wrote about listening — to 'recognise the blowing diastolic murmur of aortic incompetence'.
You'd miss the diagnosis of very early Parkinson's if you didn't look at a patient's face, or notice the way he walked into the room. Or a child with high fever may have few purpuric spots — blood spots which point to a serious illness.
Do you find yourself making involuntary diagnoses even in social situations?
Vera, my wife, despairs when I remark 'X is showing signs of ankylosing spondylitis.' Or 'That's early Parkinson's'. Yes, I make these wry comments and am oblivious to the more normal stuff when we are among people. But it's not that I don't notice a pretty face!
Everybody doesn't have access to a great diagnostician like Dr Udwadia. In complicated cases, we need a good GP to tell us what kind of specialist we need. But the good GP is becoming extinct; every doctor wants to go into a money-spinning specialisation.
The shortage of good GPs is tragic. He may not make the money of, say, a neurologist, but he has a very satisfying life. You can't equate happiness with the amount you earn.
But that satisfaction would only come if he were being the 'good GP'. If he listened and examined, as you say. Today, he starts writing out a prescription even before you've finished describing your symptoms.
The old GP never did that. He asked you probing questions, looked at you, listened to you, and stood by you. And he was pretty good. You must remember that when specialisation started, those great individuals who did neurology or cardiovascular or respiratory disease, were great general physicians too. Meaning, they were well-versed on a whole gamut of diseases. Until very recently, all these specialists had a large general ward and a small speciality unit. Today, you get your MD degree and lose touch with everything except your speciality. Medicine has become compartmentalised, that's the sadness of it. The heart specialist looks only at the heart. He doesn't factor in the body in which it resides, and that there might be other things wrong there. Some ailments are straightforward. A tear in the retina will be set right by an eye specialist. But otherwise, it's important for a specialist to be aware that besides the brain, heart, kidneys and lungs, there's also a human being. You can't treat merely the organ.
Tell us about the lacunae in teaching today.
Inevitably, there's more to learn, so much more time must be spent in classroom teaching it. Genetics is an important allied science now. As are biochemistry and biophysics. Those who come to do a sabbatical with me from abroad say they, too, have little time left to spend in the wards. As students, that's where we learnt the most.
How does the ward teach more than the classroom?
Medicine is learnt at the bedside. It is never learnt from books. I could hand you a huge tome on medicine and ask you to study it for two years. You'd be able to answer everything from it, but would you be a good doctor at the end of it? No. Why? Because you have had no contact with patient. The mind influences the manifestations of the disease differently in different patients. That's the most important thing. The response of the patient to a disease also varies, as does the compensation that the body makes to help itself recover. His response to the disease will depend on his genes, constitution, mental state, sense of well-being, strength and such. Even his geography. That, the book will not tell you. That you will only learn from the patient. You need to take a good history astutely because different people interpret what is happening to them differently. One person might say, 'I have a little pain here, doctor.' If you keep at it, you might realise that he is underplaying things because he is the stoic type. When you examine him, it might emerge that it's not just 'a little pain'. Or another man, who may have very little the matter with him, may cry out, 'Help me, doctor, I'm in terrible pain!' So, many different things have got to be taken into consideration. A disease may be differently tinted by the attitude of the mind. An anxious person will have exaggerated symptoms. That's why your best teacher is the patient, the more [information from him] the greater your knowledge. And, of course, you've got to keep learning and realise 'this is where I went wrong, why I went wrong, what should have been done' so that you can keep improving.
In your 2004 convocation address at Banaras Hindu University, among the hallmarks of a great physician — competence, humanity, honesty and integrity — you included 'charity'. Why?
If a poor person comes to you and says, 'Sir, I can't afford your fees', you must not say, 'Then I won't examine you.' There's a famous quote on this: 'Don't enter the temple of science with the heart of a moneylender.'
Tell us more about medical ethics.
Beneficence is the most important; doing good to the patient. That's not limited to your medical intervention. It extends to his inner being. That is where humanism and humanity come in. Second is patient autonomy. But that often comes into conflict with beneficence. So good medicine is a balance. Sometimes the patient thinks that this is what he wants to do, but beneficence says 'No, this is dreadfully wrong. He is going to kill himself. For example, a young man comes in with severe pneumonia — blue, breathless and very ill. But, because of his dislike or fear of hospitals or doctors, he refuses to use the breathing machine he urgently requires. I know that he'll die in a short while without it. I try and explain that, but he is adamant. Patient autonomy says he doesn't want it, but beneficence tells me if I want to do something for this patient, to the point where I might have to save him, he needs the machine.
How did you convince him?
I didn't. I just asked my attending doctor to sedate him immediately, intubate and ventilate. He recovered after a fair amount of struggle because we wasted about 15-30 minutes trying to persuade him, by which time he was almost pulseless and pressure-less. And, when he did survive, he distributed sweets as a thank you. This is how it is. In a critically-ill individual, beneficence prevails.
Sometimes you have to be paternalistic. A patient with a long-standing problem of the colon had been treated medically. But it ruptured, leaked and caused an inflammation inside the peritoneum. That's a fatal condition. She too said, she didn't want surgery. I said, 'You decide, but this is necessary'. Here again, empathy comes into play. If a patient comes to believe that you are doing this because you care for what is happening to her, she will listen to your advice.
But when it comes to a chronic patient — say, one who has cancer — and he's absolutely against chemotherapy, I tell him I cannot promise that it will cure you, but it will certainly extend your period of quality living. Think about it, ask others, but don't take a hasty decision. If he comes back and tells me, 'No, doctor, I still don't want it', I will respect his decision.
You've also included justice in ethics
It's about doing the right thing. Sometimes it is not possible to do exactly the right thing. Then you do what is the least wrong thing. At JJ, we had a tetanus ward with nine beds and two breathing machines. Sometimes five or six people needed one simultaneously. Do I give it to those who are most ill? But, how do I know that those who are less ill today will not become more ill tomorrow, because this is an acute disease?
Isn't tetanus always fatal?
Even with severe tetanus, people can live. We started this ward and we —that is, all my boys and girls working 'round the clock — brought down the mortality from 100 percent to only 18-19 percent. I'm talking about severe tetanus.
In your decades of practice, was there ever a 'Eureka moment', an epiphany?
All I can say is that you often come across patients who surprise you. You're thinking along a certain line, and you find that no, you were wrong. But the important thing is to admit that. I used to tell my students at JJ, 'After you've written down the patient's history and the findings from your examination, add what you think is wrong with him'. So then, when all the tests have been done, and the diagnosis turns out to be different, you can't fool yourself. If you don't admit it, you'll never learn. If you do, you'll tell yourself, 'Ah! The next time this happens, I won't make that mistake'.
Is death the ultimate mocker of medicine's hubris?
No. Is there any other certainty in life? Death is the only certainty. So you have to take it axiomatically. Unfortunately, modern medicine, very often, wants to fight death to the very last. This is what is called cultural Iiatrogenesis: A physician-made condition. Ivan Illich, a professor of sociology in Mexico, wrote a fantastic book which I made compulsory reading for my registrars in JJ. It is called Medical Nemesis. The second edition was called Limits to Medicine.
But isn't it tempting to play God?
Oh no. If you do, you will never be able to draw the line. You must do whatever you can within the realms of reason, and that's important. That comes with experience. You do not want to prolong the act of dying, but at the same time, you can't write off the patient saying 'he's so ill so let him die now'. The more you live as a doctor, the more you realise that people you thought were going to die, sometimes get up and walk out of the hospital. And the people you think are almost certainly going to live, leave the world. That's the uncertainty of life and also the uncertainty of medicine.
Your views on euthanasia are conservative.
Active euthanasia — giving something to a sick patient with the express purpose of killing him — is unquestionably, in my opinion, morally wrong. Because you lose the respect for life, and that is the basic tenet we live by. A great man, a great doctor was trying to sum up the essence of the ethics in which a doctor should work. He kept writing, and cancelling. Then one day, while floating down a river, he saw a beautiful sunset and wrote, 'Suddenly the words I was struggling for struck me. They were 'reverence for life'.' You know who that was? Albert Schweitzer, a great, great doctor who spent his life in an African village looking after really ill people, with very little equipment. He said, if you have reverence for life, you have everything going for you. Then you're good, you're kind, you have empathy, you're truthful. Everything emanates from a reverence for life.
Is your most difficult moment telling a patient that there's no hope?
You don't ever tell a patient that. Even if he's dying, he will not want to talk about it. But abroad, they have 'death conferences': The doctor sits with the patient and his relatives, and says, 'You've got lung cancer and you're going to live for this long, so you better set your affairs in order'. Here, a patient would change the conversation, or not speak at all. And I personally don't see the point of it. He feels, 'I know my illness has reached a stage where I'm going to die, but I just might live a little longer than everyone thinks.' Why should I extinguish that faint glimmer of hope? Of course, I'll tell the whole truth to the relatives.
This said, there are a few patients who have discussed this at length with me once they know the end is at hand, and it is a fascinating discussion — what they feel, what they say. They ask questions, to many of which you have no answer. But whatever you say in reply must be something that uplifts them, never something that would disturb them. To the question 'What is there after death', I'd rather say, 'It will be better than what is there in life'. And that's what I honestly feel.
You believe in a life after death?
I do. Of course, no one has come back from the dead to tell us about it, unfortunately. But for me, it's a deep belief. That there's some other power which is perhaps directing you. And that power will continue after death.