A book DEAR PEOPLE..sample

Dear People, Once upon a time, doctors were considered akin to God. The stethoscope was revered and their healing touch was discussed far and wide. The doctor-patient relationship was a pure bond, unaltered by technological interference. Don’t get us wrong; there’s much to cheer in the way we live today, but a lot is still elusive. Times have changed and from being thought of as divine, doctors are now routinely assaulted and hospitals vandalised. There are many discouraging stories of the strained doctor-patient relationship in the media on a daily basis. Widespread distrust exists between both, patients and doctors, such that it almost feels like people are at war with their healthcare providers. The reasons are plenty and maybe they can be best addressed by a deep introspection by both doctors and patients. Let us begin by telling you our side of the story, the doctors’ perspective. Millions dream of becoming a doctor one day. As did we. It remains one of the most coveted career options for young people globally. The journey is not easy, and only a select few are able to fulfil this aspiration. It takes more than a decade to become a super-specialist and a lifetime to understand and master the art of healing. This is probably the longest that any professional needs to train. But, learning about the human body and mind is merely one of its many facets. Medicine is also about connecting with people, getting them to trust you, reassuring them of recovery, and being with them in their most difficult times. In that respect, medicine isn’t an absolute science and at the end of the day, doctors too, are only human. When we graduated from medical school, we believed that we would diagnose with honesty and treat with compassion and kindness. We thought that we would have the knowledge and power to be able to cure each and every patient of their illness. What we didn’t know was that the idealism developed in medical school would not teach us the frailty of medicine and the challenges staring at us in the form of real-life patients. Unlike machines that are standardised, human beings do not come with a user manual. Each person is different from another. Despite the technological advances, our predictions of a response to a certain therapy are still not, and can never be, absolute. The complexities of medicine are not easy to decipher and, thus, despite best efforts, no doctor can promise a foolproof final solution. Doctors often fail, and that’s a burden we learn to live with. Does that mean we wish ill for our patients? No. None of us would intentionally harm them. Of course, like any other profession, there are some black sheep in medicine too. But it may be myopic and self-destructive to paint the whole profession in the same colour. While we lament that doctors who used to be treated like gods are now mercilessly assaulted, we don’t wish for doctors to be accorded the status of a deity at all. No doctor is or can ever be God! Still, even today, a lot of doctors are revered. However, they lead a life of veneration and often are expected to be all things at once: empathetic listeners, clear thinkers, skilled practitioners, conscientious individuals and altruistic healers. The expectations that society has from its doctors require them to be almost superhuman. As doctors, we fight two of the fiercest enemies of mankind—disease and death, and while we may succeed in defeating disease, death is inevitable. Impossible expectations may thus weigh us down and even though we strive to do our best, we might often fail to meet expectations. It’s at times like these we must make an attempt to remember that doctors are humans too! The altruistic idea of healthcare which places a doctor above all others in society also interferes with the doctor’s ability to make a good living. People might believe that medicine is not just a profession but a calling. Sadly, many a times, money is the root cause for discord between patients and doctors. While quality healthcare is expensive, doctors often complain of a general unwillingness of the people to pay, even those who can afford it. Many people do not think twice about spending money on recreational activities, but they resent spending money on medical treatment. Even if healthcare is considered an essential service, there is an unreasonable expectation of philanthropy from medical practitioners. The truth remains that even if medicine is a doctor’s calling, it is also their livelihood. Doctors pay commercial rates for rent, electricity, water and staff salaries. They pay as much income tax as other professionals and private medical practitioners do not receive any sops from the government. At the end of the day, doctors, too, need to support their families, educate their children, and fulfil their basic desires and wants. Even if human life can never be valued in money, there’s a fee for every service. Or, just as money can never make up for the loss of a loved one, the service of a doctor who saves a loved one is also priceless. While one of the biggest allegations against good doctors globally is their high fees, the truth is that most doctors are empathetic towards patients who find healthcare unaffordable. However, the problem is much deeper than the way it is understood. India, for instance, has one of the lowest per-capita expenditures on public healthcare in the world. Blaming doctors for the high price of healthcare is like blaming a pilot for the high cost of air travel. Clearly, it is not something that is completely under a doctor’s control. The problem is systemic and being the face of medicine, doctors often bear the ire of the disgruntled public. It also goes back to how students become doctors in India. Today, many privately-run medical colleges often operate under political patronage. These institutions are prohibitively expensive. Hence a discussion on the cost of healthcare must also delve into the cost that individuals are paying to become doctors, without which, an economic discussion is non-tenable and indeed non-sustainable. In the 1980s, healthcare in India was mainly run by the state. Once the Indian economy liberalised in the 1990s, the market trends changed. Yet, healthcare in India has been forced to retain a quasi-socialistic structure. It appears at times that India is confused. On the one hand, healthcare is expected to be a basic, fundamental human right while on the other hand, India has one of the lowest allocations of funds for healthcare in the world. While more and more rules are being pushed on to govern private healthcare, which caters to almost 80% of the patients in India, government hospitals and medical colleges lie in a seemingly perpetual state of decay. Healthcare is a complex subject and no healthcare system in the world is perfect. Regardless of whether people are under state-administered healthcare systems like the National Health System (NHS) in the UK where the waiting time to see a specialist may range from weeks to months, or the insurance-run private healthcare system of the US, people, everywhere, are unhappy and want more. Today, statistically, people are living longer and better lives than any other time in history. Modern science has proved its capability of altering the course of life. However, a little more than a cursory glance can take us closer to the truths lived and experienced by doctors. In the 1980s, for instance, in India, healthcare was brought under the purview of the Consumer Protection Act (CPA). This by default rendered patients as consumers and doctors as traders. Even though the intention was to hear cases of medical negligence, such as when doctors operated on the wrong limb or inadvertently left a mop in the abdominal cavity during surgery, there is a deluge of consumer cases in the tribunal today. Yes, defaulters should be punished, but the scope of it being misused because of the vagaries of medicine cannot be denied. The status quo has led doctors to become defensive. This often poses the Hobson’s choice for doctors—Do you order tests and risk being called corrupt, or do you not order tests and risk being called negligent? If we are prepared to know what lies beneath the surface of a doctor’s life, we will uncover how alarmingly unprepared we are to deal with the complexities of this profession. Medicine cannot be compared to any other profession because here, lives are at stake. We face unparalleled expectations while helping people live a life as far away from health complications as modern medicine would allow. This means mastering vast medical knowledge that in itself may be incomplete. It also means acting with speed and swiftness, bringing to the fore other doctors, nurses, and laboratory technicians, in situations that might need hours of thinking. In doing so, doctors must also show patience, empathy and genuine concern. A doctor’s job encapsulates all of the above, but certain incidents have made us evaluate the patients’ responsibility towards their own health. Sometimes, patients fail to realise that along with rights, they have as much (if not more) responsibility towards their own health. Without that, the doctor cannot even begin to do his/ her job. This responsibility towards our health may mean taking care of our diet and exercising regularly but it also means making full and fair disclosures to the doctors, which would allow them to decide further course of treatment. Dr Shome once had a patient who met with an accident and suffered multiple facial fractures. The patient had already been operated on multiple times and had come in for another facial surgery. Surgery under general anaesthesia means that the patient must be ‘nil by mouth’ for at least 8 to 10 hours prior. Despite receiving clear instructions, the patient had a glass of milk an hour before the surgery. As the surgical team wasn’t informed, it led to aspiration of fluid into the lungs during the surgery. Within 30 minutes, the patient’s vital parameters started dropping. An emergency chest X-ray was performed in the operation room, and it showed that the patient had aspirated the milk into the lungs, leading to a complete shutdown of the lungs. When we informed the parents, the first reaction of the patient’s mother was to blame the medical team! The patient had to be kept in the ICU and eventually recovered completely, without any sequelae. But we kept thinking to ourselves—shouldn’t responsibility be a two-way street? Shouldn’t patients take some ownership of their own health? Similarly, we have patients whose post-surgery recovery doesn’t go as planned. Multiple factors can contribute to this, but sometimes, patients do not find it important to disclose crucial details, like addictions, to the medical team. For instance, if there is smoking, drinking and drug abuse post-surgery, how can the surgical team ensure uneventful healing of the wounds? We have had numerous experiences when patients complain that post-surgical wounds aren’t healing and disclose their addictions to tobacco, alcohol and drugs, only after repeated and persistent questioning. Healthcare is a complex web of choices with uncontrollable outcomes. And when things go wrong, we as humans tend to look for easy targets. In the age of social media, it is very easy to point fingers at someone without any evidence. This leads to increased disappointment and discontentment in the medical and patient fraternity. Thus, the doctor-patient relationship is becoming ever more disillusioned and disheartened. Trust, of course, is also a two-way street. Like patients and their families look for doctors who they can trust, doctors also want to treat patients who can be trusted. Breach of trust can be from either side and the repercussions are equally strong. More than anything else, today, the relationship between doctors and patients seems to have been pushed into being defensive and it has almost become, a ‘Us vs Them’ situation. Take a moment to think: Aren’t doctors today, too, a part and product of the system? How can subjecting them to a different ideal be fair? Unfortunately, from trust, we seem to have moved to disbelief, doubt, and plain rejection of what the doctor is saying. Doctors are fallible like all human beings, and they should not be subjected to an ideal they cannot necessarily live up to. Doing so has resulted in an unprecedented change in the doctor-patient relationship globally and it’s upon us now to think of a way forward. A new world order that takes into cognisance the needs and demands of both doctors and patients. Three years ago, we started thinking about this. Must it really be, ‘Us vs Them’? We began to talk to doctors from multiple specialities and patients from across India and the world. The issues, we realised, are complicated with no easy answers. The problems are systemic with solutions a few years ahead of us. However, we realised that as doctors and patients, we all do have stories to tell. Stories of triumph, stories of success, stories of humility, stories of concern, stories of love and sometimes even stories of failures. We both strongly felt that these stories needed to be told. That is how the idea of putting this book together came to be. This book is a collection of heartfelt stories by doctors and patients across the globe. It is a peek into our lives which are closely intertwined together, the predicaments and ethical dilemmas both doctors and patients face, and most importantly it is about the changing metrics of the doctor-patient relationship. We believe that the time has come to initiate a conversation, as there is an ocean of positivity waiting to be discovered. We feel this book needs to be read by doctors and patients alike and the masses as well. We hope that instead of just pinning the blame on someone, both parties will start donning our thinking caps. It doesn’t have to be, ‘Us vs Them’. Both doctors and patients need to realise that they cannot survive without each other. This book is also about the modern experiences of doctors and patients—about what has changed and hasn’t, about recording that change and reflecting upon a way forward. Immediate solutions and answers might elude us but we aim to launch a conversation on what it means to be a doctor in today’s world and what a doctor-patient relationship must be. And that is why we wanted to conclude this book with a manifesto—a statement of rights of both doctors and patients that must be followed to build a society that’s far more tolerable and less treacherous than it currently seems to be. We are immensely grateful to His Holiness, the Dalai Lama for blessing this book with the foreword. At the end of the day, medicine is about love, kindness and compassion, and there can be no one better than His Holiness to talk about the crucial need of reviving these values for doctors and patients. While we are the editors of this book, it would have been impossible to come this far without the contributions of our authors. We are deeply indebted to all contributing authors for making this possible. This has been a beautiful journey and a great learning experience for both of us. We sincerely hope that this book does justice to what we set out to do. We would also like to thank the patients who have contributed their stories and brought in balance. We are extremely grateful to Bloomsbury for seeing merit in publishing this book and thank them for their support. Last but not the least, we dedicate this book to all our patients. Together, let us try and turn a new leaf. With love, Dr Debraj Shome and Dr Aparna Govil Bhasker Dear People, ‘I learnt the hard way that one might obtain a medical degree in a short time, but becoming a great doctor is a lifelong commitment and endeavour.’ Dr Altaf Patel The Evolving Doctor-Patient Relationship in the New Millennium When I started my career as a young physician, I had an incomplete and incorrect impression that saving lives was my calling and passion. If I were unable to save a patient, I would drive home wondering what else I could have done. Often, there was no answer. If ever there was an answer, I would chide myself for not thinking about it sooner and be overcome with a horrible feeling of guilt. After a four-decade-long tug-of-war, where the Almighty kept pulling my patients from above and I from below, I am wiser and understand that death is a natural sequel to life, and doctors are only humans at the end of the day. Nowadays, success is measured in strange ways. We tend to measure the success of a person according to his/ her wealth, not intellect, charity or empathy. As for me, I used to measure my success as a doctor by the number of patients I saved and failure as the number of my patients who died in a month. This was probably my biggest mistake. Medicine is not an exact science. In this field, a doctor’s success must be measured by his/ her ability to tread in troubled waters. Medicine was and will always be an art, and the doctor should know when to wait, and when not to. His/ her clinical decision-making must be astute. Addressing therapeutic options and adding, subtracting or changing doses of drugs cannot be learnt from a textbook. I learnt the hard way that one might obtain a medical degree in a short time, but becoming a great doctor is a lifelong commitment and endeavour. About 35 years ago, when I had just started off my career, I was treating a cancer patient when I discovered that the disease had already spread to his lungs. It was confirmed in the chest X-ray but when I examined him, the site of the primary cancer eluded me. My colleague was equally confused. This was before the advent of sophisticated imaging techniques like ultrasound and computed tomography (CT) scan. In the morning, the attendant senior physician arrived and I gave him the patient’s history. It took him just about a second to ask the patient to pull down his trousers and I was stunned to see a testicular tumour glaring at us. After the rounds, I casually asked him how he was so quick to arrive at a diagnosis and he told me that two decades ago when he was a resident, he had faced a similar situation. It was then, that I realised that physicians in India rarely look at testicles. Ten years later, I went for a home visit to examine another patient for lung cancer. This too was before the advent of CT scan and we had scheduled a bronchoscopy. When I examined him and looked at the chest X-ray, it seemed to me that this was not a primary but a metastatic tumour. In a moment of déjà vu, I asked him to pull his pyjamas down and lo and behold—there it was: a testicular tumour. I asked him why he did not bring this to the notice of the cancer surgeon at the premier cancer institute where he was being treated. He told me that he felt shy; so I wrote a note to the doctor. I heard from the patient two days later that the cancer surgeon looked at the note and examined the testicles, after which he lost his temper and asked him to never to come back. Some doctors believe that they are God and often behave arrogantly. The patient then insisted that I treat him. In those days, chemotherapy was in its infancy; I read about the treatment and proceeded to treat him. He made a surprisingly good recovery and was so happy that over the next six months he brought every conceivable cancer patient to see me professionally, though I insisted that this was not my domain or speciality. Today, however, medical science has advanced. We have newer drugs, imaging techniques and life-support systems such as ventilators and dialysis machines in our armamentarium. These were not available a few decades ago. Today, both patients and doctors don’t want to let go and the patient is kept alive with the fervent hope that things will get better. Prolonging lives is a costly affair and makes it terribly expensive for the patient and the relatives at times. When things do not go our way, families of patients often express annoyance and dissatisfaction at the mind-boggling expenses coupled with the loss of a loved one. No wonder such stories make it to the media, with news of a deceased patient’s relatives occasionally assaulting doctors. Hence, it is always prudent to discuss the cost of treatment at each step on the road of therapeutics. This, I think, is one of the biggest hurdles in the doctor-patient relationship. The problem runs deeper as a lot has changed over the last few decades. There is a dearth of government-run medical institutes and existing medical colleges are not able to cater to the thousands of youngsters who aspire to take up medicine as a profession. It is only once you start studying do you see that it’s impossible to get through the voluminous study literature and it takes a while to realise that no one can really master medicine. By then, the fees are already paid and it is too late to have second thoughts. It’s also disconcerting that medical education has become superlatively expensive and many private medical colleges charge exorbitant sums of money as tuition fees—far beyond the reach of an average Indian family. Many students opt for private medical colleges and pay a huge amount of money on their medical education. These so-called capitation fee colleges are the scourge in India and deny a poor person an equal opportunity for education. On the other hand, a student who has spent large sums of money for his/ her education will obviously try to recover it as soon as possible. This commercialisation is the biggest blow to the doctor-patient relationship. I remember the late 1990s when medicine had fallen under the purview of the consumer courts. To be treated as a trader, I thought, was demeaning to the profession. Even more problematic was the fact that the doctor would have to face a judge who had little knowledge of medicine. In response to this, there gradually emerged the concept of defensive medicine. This literally means doing every single test in the book to show that one is not negligent and, unsurprisingly, the repercussions are ultimately faced by the patients as this eventually bleeds the patient’s pocket profusely. Medicine is complex! I remember a young nurse who underwent surgery under spinal anaesthesia. A common complication of this was a persistent post-procedure headache. This is often addressed by hydrating the patient, making postural changes and administering analgesics—all of which were done. In two days, she was no better and a blood test and a CT scan of the brain were finally ordered. To my surprise, she turned out to have a brain haemorrhage! Which judge in this situation would condone a 48-hour wait-and-watch policy if the patient went to court? If we are extra-cautious we are blamed for over-investigating and if we avoid getting tests done, we may sometimes be termed negligent. As doctors, we battle this dilemma on a daily basis. While discussing the commercial nature of medicine, it is also important to understand young doctors’ perspectives. Once a student graduates, he/ she either goes in for general practice or may choose to specialise. Specialisation and the subsequent super-specialisation take away another five or six years of the prime years of a medical student’s life. One is already in their mid-30s by the time they are done with their studies. Then comes the responsibility of marriage and children. During the initial years of private practice, the most distressing feeling is going to work every day without knowing what one is going to earn. Patients who take appointments may not appear. Many who come for consultation may not be able to afford the fee and, finally, everyone expects a discount when it comes to their health. Then there is the great balancing act between income and expenses; every doctor in this country has to face this at some point of time in their career, except those few who are inherently wealthy. This brings us back to the question: What ails the doctor-patient relationship today? From a time and age when the family doctor was involved in every big and small decision of the family—right from marriage to other non-medical problems—what has happened today? There is a lack of trust between doctors and patients. Patients who enter the hospital today are more worried about the cost of treatment. The lack of desire to develop proper clinical skills because of the accessibility to sophisticated investigations may often be the order of the day, and too much emphasis may be placed on reports instead of applying proper diagnostic logic. Not that the current doctors can be blamed for this—after all, we only reap what we sow. The fear of courts, the advent of litigation and the practice of defensive medicine have increased the reliance on diagnostic tests, at the sad expense of clinical skills. After all, a judge may want evidence and a CT scan is far better evidence than a doctor’s clinical judgement and gut feeling, which are abstract tools to a judge at best. I often wonder what the science of medicine is all about. Is it about brilliant innovations, is it just about prolonging life or is it about making life more comfortable? The day is not far when research in genetic engineering may enable us to order customised children on the internet, much like online food delivery today. I guess it is all of the above, but most importantly, it is about empathy. Empathy is the crux of medicine and that is probably why the curriculum of the Royal College of Physicians lays great emphasis on empathy in their qualifying exam. During this examination, one whole practical station deals only with how the student conveys bad news to the patient’s family and how he/ she explains the various possibilities gently, but truthfully. Medicine is about understanding and trying to walk with the patient through various choices and therapeutic options in what is probably the most difficult time of their life. The art of medicine is all about love for our fellow human beings and that is one of the main reasons why the doctor-patient relationship has survived for thousands of years and will remain strong in the future as well. Dr Altaf Patel is currently the Director of Medicine at Jaslok Hospital, Mumbai. He was an honorary professor of medicine from 1977 to 2007. He is a medical columnist for many mainstream newspapers like The Times of India and Mumbai Mirror and has many research publications in national and international journals. In his free time, he enjoys reading, travelling and swimming. Did You Know? The cost of medical malpractice lawsuits in the US has risen more than 2,000%, since 1975, to $ 26.5 billion in 2003, according to Tillinghast, an actuarial consultancy. And to what end? A study of malpractice suits in New York by the Harvard Medical Practice Group found that plaintiffs had actually been injured by doctors’ negligence in only 17% of cases. Those patients with small claims often cannot find a lawyer to represent them while those who win find their lawyers have swallowed half the payout from the doctors. Source: https:// http://www.economist.com/ united-states/ 2005/ 12/ 14/ scalpel-scissors-lawyer Dear People, ‘Not only is it important for doctors to never give up on patients, it’s equally important for patients to never give up hope.’ Dr Anil N. Suchak and Dimple Mishra Never Give Up When I was 17 years old, I accompanied my father for his talk on the Bhagavad Gita, swadharmai, work ethics and how to conduct a good life. He made two points that made a deep impact on my impressionable mind and have stayed with me since then. First, ‘Few people are fortunate to become doctors. It is the noblest of all professions where we get the chance to help people in pain and relieve their suffering’. Second, ‘We should treat every patient in the same manner as we would treat a member of our own family.’ I grew up to become an anaesthetist and critical care specialist and in a career spanning 37 years, my professional life is rich with countless memories—some outright hilarious and some heart-breaking. Of course, like any other profession, in medicine too, one must take cognisance of the financial aspect, career goals and job satisfaction but being able to alleviate pain is unlike any other happiness. When we see our patients do well, all the years of study, hard work and sleepless nights melt away. An elderly lady was admitted to the ICU with heart failure and was put on the ventilator. As her doctor, I apprised her relatives that her condition was critical and unstable. They were initially saddened but seemed to accept the situation a bit too hastily. They asked me if the end was near as they would need to inform their near and dear ones accordingly. Since I do not believe in ever giving up on a patient (like most doctors), I said that was not something I can assert and that we should pray for her to get better. The next morning as I walked to the ICU, I saw about 30 to 40 people dressed in white, waiting outside. My heart sank and I went inside thinking that the inevitable had transpired. A visibly shaken resident medical doctor ran to me as I entered and begged me to give him the day off. I reassured him that I would take care of the relatives and gently break the sad news to them. What he said baffled me and relief washed over my face. He nervously stuttered, ‘Sir, the patient is actually improving and I have no idea what to tell these premature “mourners” who’ve gathered outside. Please let me go home.’ I looked at him and had a really difficult time maintaining a straight face. I asked him to leave and told him I would deliver the good news to the family. I went outside and explained to the relatives that their prayers had been answered and good medical treatment had worked wonders. The patient was now much better and out of danger. After hearing this, all the people clad in white miraculously disappeared. In a few days, the patient got better and went home hale and hearty. Even today when I think of this episode, it brings a smile to my face and I am thankful for the occasional lighter moments in our stressful profession. However, a doctor’s life is rarely a collection of amusing anecdotes. In 2001, an earthquake devastated Kutch in Gujarat and within minutes, the misery was broadcasted on national television. I decided to garner help and quickly put together a team of doctors. We packed our ambulances with whatever medical supplies we could manage and left for Kutch. Ten doctors and a medical staff of eight people accompanied me at literally a moment’s notice. We stopped at a petrol pump at Dahisar in Mumbai and bought whatever supplies—packaged food and water—the adjoining shop had. The owner was, therefore, curious to know where we were going. As soon as we told him the purpose of our journey, he refused to accept any payment from us. His kindness was heart-warming. The next day, we reached the village of Bidada in Kutch and after acquiring permission from the collector, we began to render our voluntary services. There were hundreds of injured people, critical patients and dead bodies all around us. It was inexplicably miserable to see the suffering the people had to go through. The casualties were coming in at such a breakneck speed that the doctors, interns, and volunteers worked around the clock. No one slept for more than three to four hours, that too in tents and in parked vehicles. As there was no electricity, generators were procured and whatever petrol and diesel was available was being brought to us by volunteers. Various organisations, NGOs and hospitals were sending medicines and supplies from different cities to cope with the huge number of patients. Like a factory assembly line, the OT was working relentlessly. But nothing could stop the mass cremation of those who had succumbed to nature’s fury. We worked non-stop, day and night, for 15 days. After that, we decided to shift around 40–50 critical patients to our hospital in Mumbai and flew them to the city along with their surviving family members. Airlines provided their service free of cost. After removing the aircraft seats, almost 15 patients could be accommodated in each carrier. Following the principle of ‘triage’, we decided to focus our attention on the few patients who needed multiple surgeries and further rehabilitation. For the next three months, we housed these patients and their families with us, provided them with all medical help, food, clothing, boarding and eventually arranged their transport back to Kutch. The reason I share this particular story is with the hope that the next time you hear of some unsavoury incidence of malpractice by a doctor, you would take it with a pinch of salt and understand that it is probably a one-off occurrence, as unfortunate as it may be. There are all sorts of individuals in every profession, including medicine. We are all humans. I have learnt my life’s biggest lessons both as a doctor and a patient. I’ve realised that not only is it important for doctors to never give up on patients, it’s equally important for patients to never give up hope. Doctors, after all, want their patients to recover and live healthy lives. In 1987, I was diagnosed with chronic hepatitis C, which progressed to cirrhosis of the liver by the turn of the century. By 2006, the cirrhosis of the liver had advanced to end-stage liver disease and my general condition had started worsening. I was advised to undergo a liver transplant at the earliest. A year later, I decided to undergo a liver transplant and my surgeon, Dr Subhash Gupta, was optimistic about the outcome. In a 23-hour complicated surgery, 850 grams of the donor’s right lobe of the liver was resected and transplanted into my abdomen. The diseased liver from my body was removed and explanted. My surgery was extremely difficult as there were multiple adhesions in my abdomen. It took Dr Gupta and his team almost nine hours just to be able to get to the liver. This is a classic example of a doctor with the ‘never-give-up’ approach. Dr Gupta was persistent and did not think of abandoning the surgery at any point in time. It is due to his optimism and confidence in being able to see my surgery through that I am here today, recounting the story of my life. Later, once I recovered, I came to know that during surgery I was bleeding profusely from all organs and more than 60 bottles of blood were transfused in those 23 hours. The histopathology report of my liver also showed two tumours in addition to the cirrhosis of the liver. Both tumours were cancerous. I feel fortunate that the surgery happened at the right time before these tumours could spread to other organs. As I regained consciousness, I became aware of the multiple sounds of the various machines I was hooked on to. Post-operatively I was put on a ventilator. I could feel the various tubes inside me—the urinary catheter, nasogastric tube, multiple IV lines, central line and arterial line, among others. As I had an endotracheal tube in my throat that was connected to the ventilator, I could not make any conversation. I was closely watched and monitored by the team of doctors and nurses in the transplant ICU. I underwent frequent blood tests, ultrasounds and doppler tests as and when required. It was important to assess the functionality of the new liver at every step. Since I could not speak, I learnt to communicate with the doctors and my family members by blinking my eyes once for ‘yes’ and twice for ‘no’. However, I eventually realised that I needed to relax and allow the ventilator to work in order to conserve my energy and recover. There was no point in fighting the life support systems. When my endotracheal tube was removed in a couple of days, I knew, that I was going to survive this. Subsequently, I was put on immunosuppressant medications so that the new liver was not rejected by my body. Three days after the surgery, I started experiencing hunger pangs. I was started on a liquid diet, followed by semisolids and then a normal high protein diet. While I thought everything was going smoothly, a complication occurred. There was a biliary leak from the transplanted liver. Bile started collecting in my abdomen and almost 1.5 to 2 litres of bile had to be drained on a daily basis. This went on for three days and finally on post-operative day nine, I was taken up for a re-surgery. A hepaticojejunostomy was performed. This surgery took six hours. I went through tremendous pain, sleepless nights and emotional trauma. Finally, I recovered, but for weeks after that, blood tests were conducted to monitor the levels of immunosuppressant medications and I was kept under a close watch. I visited the hospital every other day and waited my turn like any other patient. Here, I was not the medical director of a well-known hospital or the practising anaesthetist and intensivist. I was not the man in control. I personally experienced the travails, difficulties and challenges that are faced by patients and their families in a hospital. Liver transplant gave me a new life. After my surgery, my mission has been to spread as much awareness as possible on the subject of organ donation and transplantation. This is a novel science developed over the last couple of decades and even now the awareness about transplantation is very low as was evident when a gentleman dropped into my office five years later. He was visibly upset. His wife had slipped into a coma due to liver failure. I told them that a liver transplant was her only hope. I explained to them about the importance of finding a donor as soon as possible and counselled them about the expenditure involved in undergoing the transplant. They asked numerous questions and understood everything. Once they understood that the liver regenerates, both the husband and his brother were willing to become the donors. I guided them regarding all the necessary arrangements and connected them to the doctor who had treated me, Dr Subhash Gupta, Unfortunately, the patient had a unique condition called the ‘situs inversus’, that is, all the organs in the body were situated in the opposite location like a mirror image. But Dr Gupta’s persistent efforts meant that the transplant surgery went well. About a month later, a young woman in her early 20s walked into my office. After introducing herself, she bent down to touch my feet. I was really surprised and extremely moved when she thanked me for saving her mother’s life. It was then that I found out what had happened: I had assumed that the donor was the husband or my young visitor ’s father when, in fact, her father and uncle were both rejected as donors and she was the one who donated a part of her liver to her mother. She was a young business management student and I couldn’t help asking her if she had any concerns about having a large scar on her abdomen. ‘Sir, my mother gave birth to me; she brought me into this world and is my life-giver,’ she said. ‘I have just given her a small part of my liver.’ I was overcome with fatherly pride and happiness when I heard her answer. Such cases are reminiscent of the principles that I have followed in the 39 years of my medical practice. Never refuse a call from a patient. In fact, I spend time taking down a patient’s history and educating them on keeping records of their previous illnesses. I not only try to regularly update my medical knowledge, I always give an accurate and honest picture to the family, no matter how critical the situation is. Over and above all, my biggest learning has remained what I heard from my mother as a 17-year-old: Few people get the opportunity to alleviate pain and when you do, never give up and treat your patients like you’d treat a family member. Never stop learning, never stop believing and never give up! Dr Anil N. Suchak is an anaesthesiologist and an intensivist. He is the medical director of Suchak Hospital, Malad. He has been a member of IMA for the past 37 years, performing various roles from being a member of the managing committee to Vice President of Mumbai (West) to being the joint secretary. He heads the Mumbai branch of The Divine Life Society and is the trustee of a school. He formed the Indian Liver Foundation to increase awareness about liver transplantation and organ donation. Through this foundation, he has advised hundreds of patients. Being a cancer survivor and having undergone a liver transplant himself this is his way to express his gratitude and giving back to society. He has also been the recipient of the Lifetime Achievement Award given by the Association of Medical Consultant. Dimple Mishra is a professional Interior Designer and Interior stylist since 1986. An active member and functionary on the managing committee of the Indian Liver Foundation; in her spare time, Dimple contributes towards the written word, she is a published writer and loves to blog about her tryst with the subtle during her fascinating travels. Did You Know? A doctor juggles between lots of roles—from being a physician to a provider at home and finally being a member of a family. It’s tough to be at all the places and be everything at the same time. For some doctors, patients are the first priority. They love to serve humanity and this is the reason why they chose medicine as their career. In a poll conducted by Curofy, asking doctors what their first priority is, patient’s, family or economic independence, out of 1,820 doctors who responded, 60.4% said that they prioritise their patients over everything else. Source: http:// health.cxotv.news/ 2016/ 07/ 01/ selfless-service-2-out-of-3-doctors-prioritize-patients-over-family/ Dear People, ‘While doctors must adhere to their duty of caring for patients, we must not forget that doctors, no matter how skilled or competent, need care too.’ Dr Aniruddha Malpani The Night I Nearly Killed My Patient Many years ago, I was a junior resident in the obstetrics and gynaecology department at a very busy public hospital in Mumbai. As it is one of the most renowned teaching hospitals in the country, many patients with serious and complicated illnesses were referred to us for emergency management and complicated cases which meant conducting over 7,000 deliveries every year. As junior residents, work was never-ending and we were perpetually sleep-deprived. Of course, sleep deprivation was a part of a resident’s life as our seniors strongly believed that we had to be trained in keeping midnight vigils—a traditional occupational hazard for obstetricians. Like most Indian medical institutes, the teaching programme was fairly unstructured, and we followed the traditional ‘see one, do one, teach one’ approach. During night hours, the unit was managed by the senior registrar and the two of us, along with a senior house surgeon, were responsible for overseeing all obstetric patients who were admitted from 4 pm until 8 am the next day. I would often be on duty for three or more continuous nights as numerous critical patients would be admitted under our care. As the junior-most doctor on the team, I was responsible for all the drudge work and monitoring the patients. On one such night, a 28-year-old woman, pregnant with her first baby, was referred to us from a private hospital. She was in advanced labour and had severe pre-eclampsia. Pre-eclampsia is a potentially dangerous pregnancy-related complication, which is characterised by high blood pressure, discharge of protein in the urine and severe swelling over of the feet. The registrar and the senior house surgeon did an emergency caesarean section. Once the baby was safely delivered and the patient stabilised, they went to bed, leaving me to monitor her in the ward with the instructions that I was supposed to give her enough intravenous (IV) fluids to ensure that her blood pressure was maintained. The patient was tired and drowsy after her surgery, and so was I. Throughout the night, I would meticulously check her vital signs, and every time her blood pressure was low, I would pump in IV fluids, to keep the blood pressure (BP) within the normal range. Unfortunately, her pressure kept dropping and according to the instructions that I had been given, I ordered the nurse on duty to pour in large quantities of IV fluids to maintain her BP level. I was so focused on making sure her pressure level was normal, that I failed to realise that I was making a cardinal mistake. All the extra fluid we were pumping into her was getting trapped in her subcutaneous tissues, causing her to develop systemic swelling. I was following the orders at a spinal level and was not experienced enough to be aware of the risks of overloading a pre-eclampsia patient with so much fluid. In the morning, the senior houseman came to check the patient and was aghast to find that in my attempt to keep her BP in the normal range, she had received over 12 litres of IV fluids—in less than six hours. Her entire body had become grotesquely swollen because of the fluid overload, and she was having immense difficulty in breathing. Due to the severe swelling in her throat, it was impossible to intubate her and we had to perform an emergency tracheostomy (a procedure conducted to allow air to enter the lungs) and transfer her to the intensive cardiac care unit (ICCU). She was put on a ventilator to aid her breathing. She had a stormy course but, finally, recovered and was discharged in a couple of weeks. I still have nightmares when I think about her. It was only later that I found out that patients with pre-eclampsia and pregnancy-induced hypertension are known to have leaky blood vessels. Because of this, all the fluid that I was giving her was leaving her blood vessels and getting trapped in her tissues. I was mercilessly and publicly berated for my incompetence by the senior house surgeon, registrar and professors. The punishment for my indiscretion was being forced to monitor patients every night for the remaining three months of my residency. At that time, I felt guilty and accepted that I deserved the punishment meted out to me and accepted it quietly. I kicked myself many times for not knowing more about how to manage a patient with severe pregnancy-induced hypertension and was extremely grateful to God that the patient had survived despite my ignorance. Residency can be cruel and, for a long time, I was ostracised by my colleagues and treated like a pariah for having nearly caused a patient’s death since this would have been a blot on the hospital’s reputation. There was no one I could talk to about what had happened and why, and I had to bottle up my mixed emotions—of fear, guilt, shame, anger, embarrassment and humiliation—through the remainder of my residency. At that time, I needed emotional support and professional reaffirmation from my seniors and teachers. I needed to be told that, regardless of my mistake, I could be a good doctor. But I was abandoned and left to fend for myself. The moment my residency was over, I moved to another hospital, to try to erase these unhappy memories. Most doctors have had similar experiences, where they have unknowingly made a mistake that may have caused harm to their patient. A lot could have been done to protect this patient at many different levels, and this is what we need to focus on. The reason for the error was not just my ignorance; it was also the fact that what I was doing was not supervised and there was a lack of proper infrastructure. Things would never have come to this if there were protocols for the management of pregnancy-induced hypertension in the hospital. The patients who would come to us were severely ill and should have ideally been in an intensive care unit (ICU), where an experienced clinician would provide 24-hour supervision. The woman should never have been left on a bed in the ward, under the care of an inexperienced house surgeon like me, no matter how well-meaning or sincere I may have been. Unfortunately, most teaching hospitals are run by junior, inexperienced and unsupervised residents and this is one of medicine’s dirty dark secrets. A secret that doctors never discuss in public. I was never given an opportunity to discuss this case, and the other residents were not given a chance to learn from my mistakes either. Even worse, no changes were made to prevent this episode from recurring. The harsh truth is that all doctors make mistakes, and this is a part of their learning process to become a doctor. Medical errors will continue to happen until we bring them out in the open, talk about them and learn from them. However, most doctors often suffer from a ‘God complex’ and making an error is extremely shameful for them. This shame is sometimes so powerful that most doctors never come forward to talk about any error that they have made. It is impossible for us to admit to a mistake. We tend to pick the best of the best as medical students, knowing that the medical system is not for the faint-hearted. There is no place for a ‘good enough’ doctor—you must be excellent, which means there is absolutely no margin for error. Being perfect is not easy and, sadly, sometimes it may mean hiding your errors from the fraternity to maintain your flawless image in their eyes. Doctors are not alone in harbouring these expectations of perfection from themselves. Patients too envisage their doctors to be perfect. As doctors, we are trained to take charge—to be the captain of the ship. And we must take personal responsibility for everything that happens to a patient in our care, whether or not it was our fault. We are responsible, and the buck stops with us. When a complication occurs, the first feeling that envelops us is one of sadness that someone is suffering. Then emerges a feeling of shame that we may have actually caused that suffering, followed by the fear that somehow this will lead to us being ostracised, sued and humiliated publicly. Next comes the anger, because you feel lonely and wonder why the system is not supporting you in this really difficult time. A combination of all these emotions eventually leads to panic. It’s important to remember that medicine is an ambiguous science and as doctors, our knowledge and experience is never enough. We face uncertainties every day and, at times, despite our best intentions, errors may happen. Patients are undoubtedly the victims of these unforeseen ‘errors’ but after an error, we also need to take care of the doctors and nurses involved. They, too, as my experience has shown, can be the ‘victims’ of these unexpected and unanticipated medical errors. Any doctor will tell you that a precise diagnosis is the first step to resolution for a patient but what they won’t admit is how important a supportive and nourishing environment is for a doctor to work well. While doctors must adhere to their duty of caring for patients, we mustn’t forget that doctors, no matter how skilled or competent, need care too. Dr Aniruddha Malpani is an IVF specialist. He founded the world’s largest free patient education library, HELP at healthlibrary.com, and has authored numerous books. He pioneered the use of innovative technology to educate infertile couples using cartoon films, comic books and e-learning. An active angel investor, Dr Malpani invests across all domains and admires entrepreneurs because they have the potential to change the world. Did You Know? As per the Indian Medical Association (IMA), physicians’ suicide is almost a public health crisis in India. According to a report published in the Indian journal of psychiatry, 30% of Indian resident doctors suffer from depression and 17% have contemplated suicide. Long working hours, taxing medical training, violence against doctors and the stress of saving lives are some major factors that push doctors to the breaking point of burnout. Source: Grover, S., Sahoo, S., Bhalla, A., and Avasthi, A. (2018). ‘Psychological problems and burnout among medical professionals of a tertiary care hospital of North India: A cross-sectional study’. Indian Journal of Psychiatry, 60( 2): 175–188. Dear People, ‘Grief is not a

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