January 06, 2012

The Doctor's touch- a ritual in need of a revival

How many of you have visited a physician and got sent straight to the laboratory for an investigation or have been prescribed medicine or a CT scan without the doctor laying a finger on you? If your answer is yes, dear reader, be assured that you are not alone. It was a thought provoking video that arrived in my mail a while ago which inspired me to pen this article. Dr. Abraham Varghese, professor for the Theory and Practice of Medicine at Stanford talks about the transformative power of the doctor’s touch, the transcendental power of the human hand, of the ritual of physical examination.  He is a firm believer in the old-fashioned physical examination of patients, the bedside chat and the power of informed observation.
              Let’s take a look at the scene today. It is not uncommon to see patients being operated upon the wrong limb, having unexpected drug reactions because of wrong prescriptions and suing doctors as a result. In an era where, time is money, patient welfare seems to have conveniently been put on the backburner. A patient is nothing more than a statistic in a drug trial or profit spreadsheets. The higher your insurance coverage, the more expensive are the investigations ordered and the more expensive are the drugs prescribed. Did you know that the average time that elapses when a patient is talking to his doctor before being interrupted by the doctor is 8 seconds? We have witnessed the gradual corporatization of healthcare in India.  Medicine these days is generally not a non-profit venture. Hospitals are watching their profit margins and that means putting pressure on their doctors to see more patients in less time, order more tests, and generally make themselves and their practices financially not just viable, but highly profitable. Technology, data, metrics and the entire gamut of evidence based medicine devices have been touted as being a means to the end of the goal of cure. But in today's era of corporate healthcare do these means justify the end? My answer is no. In fact it is a vicious circle. With information explosion, and doctors who neglect the importance of conversation, patients sue and file litigations and to escape this, doctors have come to excessively rely on laboratory investigations and now practise what is infamously known as defensive medicine. Hiding beneath the cloak of modern laboratory investigations and the plethora of electronic apps available on smart phones and ipads has become quite common for doctors who do not trust their own capabilities or are plain incompetent.
        Let’s examine this issue from 2 perspectives. From the perspective of the patients, they come to the doctor filled with uncertainty and hope and fear; and the clinical response, if determined purely by complex sounding laboratory investigations, however medically accurate,  without any physical examination , the visit to the doctor may be emotionally insufficient for the patient.  Sometimes, all that the patient wants is for somebody to listen to them, empathize and understand. From the doctor’s perspective, I'm sure most physicians would love to spend much more time with patients. But there are only so many hours in a day. If we spend twice as long with a patient we will need exactly twice as many doctors. Healthcare is already becoming a huge burden on our economy.  The solution for example, perhaps would lie in not running to the cardiologist when you get the flu   and instead go to a general practitioner who is equally capable of treating your flu. This would allow a cardiac patient in greater need of the specialist’s time to avail the necessary attention and care.

   Cicero once said, “The competent physician, before he attempts to give medicine to the patient, makes himself acquainted not only with the disease, but also with the habits and constitution of the sick man." When I went to medical school, my professors in a bid to drive home the importance of observation always stressed that the diagnosis of an ailment in a patient begins the moment he/she walks in through the door of your clinic. I strongly agree. There is nothing more soothing for a patient than to have a comforting presence, a patient listener who empathizes and puts a warm arm around the shoulder when he/she is confiding their darkest fears and being completely vulnerable. A thorough physical examination of the patient is a kind of ritual and as such should be cultivated. To be touched from head to toe gently and thoroughly, to look at the patient while he/she is  talking about their symptoms or stories , to look for those subtle uncommunicated signs in their body language, to hold their hand and tell them you understand and it will be okay- this is what builds the doctor – patient relationship.  The greatest offering our patients give us is their absolute faith and trust. Touch, observation and conversation are 3 vital elements to establishing a successful doctor-patient relationship.  Taking the time to spend a few extra minutes taking a thorough history and examining the patient saves time in the long run and offers information unobtainable by the gamut of tests. Don’t get me wrong. Touch should by no means inherently trump rational analysis or technology. I definitely believe technology has a powerful role to play in the improved diagnosis and treatment of our patients. What I am against however is the obsessive reliance of the healthcare community on powerful diagnostic tools completely neglecting the patient as a whole. The existence of such powerful diagnostics tools does not invalidate the doctor using his senses to get some idea of what to look for in all that data.
 Technology should not deny the patient as a human being.  No doubt laboratory investigations serve as a valuable tool for diagnosis, yet as physicians we must not forget that unlike the corporate honchos sitting in their plush offices and counting profits, patients are not statistics, they are human beings. Without the ability to unflinchingly gaze at your patient when they are most vulnerable, touch, show compassion and empathize, we are doing our patients a great disservice. The clarion call of the hour is to return to our roots, to revive the dying art of history taking and the ritual of physical examination, to amalgamate the best of both worlds- a humane approach and technology for the betterment of our patients.  Without this humane approach, we physicians would cease to be "healers" in the true essence of the word. Let’s use our humanity or what’s the point of having it?

June 13, 2011

Antigua - Land Of Sea & Sun

My better half at Shirley's Heights

At the carnival

Me at Devil's Bridge

Nelson's Dockyard

Sir Viv Richard's Cricket Stadium

View of the Harbour from Shirley's Heights

View from Fort St.James

View from Shirley's heights

Sunset at Shirley's heights

Two years ago, if someone had asked me, if I’d ever heard of an island called Antigua, I’d never  for the life of me ever have been able to locate it on a map. But life works in mysterious ways. One and a half years later, here I am living in this traveler’s delight, enjoying work with pleasure and penning an article about this tropical paradise nestled in the Eastern Caribbean, called Antigua.  So, dear readers fasten your seat belts and let me take you on a fascinating ride into the land of sea and sun.
   Antigua & Barbuda forms part of the Leeward Islands of the Lesser Antilles, separating the Atlantic Ocean from the Caribbean Sea.  Antigua is about two thirds the size of New York City. Its capital is St John’s. From the title, one would gather that it has several pristine beaches. I wonder if you’d be able to guess the number of beaches in this idyllic island.  30…60…90….180…hold your breath, Antigua boasts of a whopping 365 beaches, one for each day of the year. And to think that if you’ve seen one, you’ve seen them all would be a definite misjudgment.  So the challenge posed to a visitor is not how to gain access to the best of them but simply how to locate the beach that suits one's taste. To name a few, along the Northwest coast we have the Dickenson Bay and and Runaway Bay for those wanting the resort beach experience.  Along the east coast is the Half Moon Bay, now a National Park and a good choice for a family outing.  As their tourism promotion campaign punchline goes, beaches are just the beginning. 
        For many of the tourists who mostly arrive on cruises, the first stop has to be St John’s Cathedral whose magnificent ornate towers dot the skyline of the capital city, St John’s.  The capital city has several shopping areas that boast of fine dining and shopping. Be sure to watch out for the beautiful handicrafts that make beautiful souvenirs. For those interested in the early history of the island, there is the Museum of Antigua and Barbuda, housed in the colonial Court House. The museum displays both Arawak and colonial artifacts recovered from archaeological excavation expeditions on the islands.
       English Harbour, Antigua's graceful and evocative historic district, is focused on the fifteen square miles of Nelson's Dockyard National Park. The dockyard was built to provide a base for a squadron of British ships whose main function was to patrol West Indies maintaining Britain's sea power .The harbour served as the headquarters of the fleet of the Leeward Islands during the eighteenth century. Though abandoned in the nineteenth century, it has now been restored, and is the only Georgian dockyard in the world. To get a sneak peak into life aboard the ships in those days, one can visit the museum housed in the same vicinity.
       Further above the harbour, is my favourite spot - Shirley Heights, where one can view the partially-restored fortifications of the harbour's colonial observation post. On a weekend, we go for a long drive and watch the breathtakingly beautiful sunset and restful waters from Shirley heights.  If lucky to be visiting on a day when the skies are clear, we get a panoramic view of Guadeloupe Island to the south and the island of Montserrat with its still active volcano to south west. Shirley Heights Lookout is home to the 'biggest and best' party on the island every Sunday for the last 25 years with the famous steel band or reggae playing at different times. Fort James is another destination that affords a breathtaking view of the surrounding harbor.
       Another one my favourites is Devil's Bridge. Not for the faint hearted! Just kidding, Devil’s bridge was called so because a lot of slaves from the neighboring estates use to go there and throw themselves overboard. That was an area of mass suicide, so people use to say it had to be the handiwork of the devil. The waters around Devil's Bridge are always rough and anyone who falls over the bridge is said to never have come out alive. So says the exciting legend.  Actually, this is an example of sea water erosion. It is a natural arch carved by the sea from soft and hard limestone ledges of the Antigua formation, a geological division of the flat north-eastern part of Antigua. A bridge was created when a soft part of the limestone was eroded away by the action of the Atlantic breakers over countless centuries.
          What makes Antigua unique is that apart from sightseeing and shopping, it offers tourists myriad options for activities for all age groups.  On land one can revel in hiking, golfing, biking and birdwatching while the more adventurous can go ziplining in the rainforest tour. The sea will beckon you as you enjoy parasailing, surfing, kayaking, deep sea fishing, diving and snorkeling. I must mention here the enchanting 'Stingray City' which, fringed and protected by its own reef makes possible an actual swim with the stingrays. The unbeatable scenery and pristine coral reef encircling the area enhance this amazing experience, second to none in the world. Antigua sailing week is home to the world’s top five regattas and is the premier sailing destination in the Caribbean.  For the high flyers, there are chartered helicopter tours too.
      How can I forget the Antiguan Carnival? Beginning in the last week of July to first week of August, it is a commemoration of abolition of slavery in 1834. Ten days of music, dance and revellery, it is the best time to visit as you can join in the spontaneous fun that surrounds you. Each of the troupes will be setting up Mas Camp – a base where beautiful, colourful , intricate costumes are prepared and where the troupes start marching from on the first Saturday of Carnival – on their way to Carnival City to officially open Carnival. Carnival Culminates in a massive street party called J’ouvert (meaning day break) on the following first Monday in August. The dancing literally goes on all night and stops mid morning. . It is a blend of steel pan music, calypso and jam bands playing the hottest music on demand! An indefinable party atmosphere envelops the city as all age groups shed inhibition and come out to frolic and have a good time. In every sense of the word, it is a riot of colours.
     My description of Antigua will be incomplete if I fail to mention the icing on the cake in Antigua. It is the warmth and friendliness of the people which is the soul of this tropical paradise. Gentle and fun loving, they’re always around to help with a smile.
                                      A wonderful saying goes, “A thing of beauty is a joy forever”.  This suits Antigua perfectly. Unscathed by the scourge of industrialization and pollution, her timeless beauty serves to soothe and heal. She will touch your soul and make you want to come back again and again…..Truly, the Land of Sea and Sun! 


May 27, 2011

The Good Samaritan

As I sat browsing through the news articles, something suddenly caught my attention. The heartwarming saga of the endeavour of a young male to give back to society, to do his bit for the downtrodden, by setting aside a portion of his income to teach the underprivileged children. MG Jayaprakash – someone who showed us how to walk the talk.  Truly, a beacon of hope in an increasingly self centered world. I wouldn’t be exaggerating if I’d say, to those kids, he is the Good Samaritan.  And while I read his story, I couldn’t help reminiscing about my rendezvous with a Good Samaritan. I regret I never had the chance to ask her name but if she reads this someday, I will be happy. So here it goes…

It was the year of 2010. We were flying to Mangalore for Xmas and I was super excited as I was going home for the first time after entering into wedlock. I was going to be seeing my parents after a whole year which seemed to me nothing less than eternity. And of course, I was looking forward to family weddings, quality time with cousins, kuswar and   lots of pampering. Anticipation was at a crescendo as we boarded the flight to Gatwick on December 17.

December 18 - It was then that the nightmare started. Unprecedented snowstorms ensured ours was the last flight to land that morning . Our next flight was to be boarded from Heathrow but with no road access we were stranded at Gatwick for the night. British airways were kind enough to put us up at the Hilton.

December 19 – Once, we checked out of the hotel at 12 noon, we went to the Gatwick airport to ask BA to get us a hotel at Heathrow, (BA had told us the previous day that they were giving us only 1 day accommodation in Gatwick and that we have to come back to them the next day and they would give us a hotel at Heathrow since our flight for India takes off from Heathrow.)  To our disappointment   after waiting with four heavy bags of luggage for over 7 hours at Gatwick, we were told by BA that there are no available flights till the 24th of December, so we have to fend for ourselves and find a hotel and BA will reimburse us later. Once we reached Heathrow, we took a chance and asked the BA desk at Heathrow whether we could get a hotel. To our surprise they booked us into another Hilton franchise at Heathrow for 1 night. We however took our luggage and boarded a bus to reach this Hilton Hotel that BA had given us.  After getting down from the bus, we had to get onto a train to reach the hotel.

It was in the train that disaster struck. Tired, weary and hungry, pondering over the next course of action, we began our journey. In due course, we arrived at the station. A pretty British   lady helped us get 1 suitcase and 1 handbag off the train at the Bracknell station but to our horror, the train doors closed and Neville and I were left in the train with the rest of the luggage.  We got off the next station which was deserted. We found an intercom and buzzed for help. The helpful officer at the other end of the line told us that he couldn’t see anyone with the bags and no one had called it in yet. A land where we knew no one, biting cold and frayed nerves. We were at our wits end by now because it was 8pm, we had not had our lunch and despair all around. And then we heard a voice over the intercom again. We were told that a lady had just called in about the incident and she would be waiting for us till we got back to Bracknell. Needless to say, we had tears of joy. For that was the first good thing to have happened to us since that morning. My chivalrous husband lugged the remaining bags over numerous stairs until we got to the opposite side and boarded the train again. Having alighted at the designated point, our joy knew no bounds when we saw her. The kind lady was still waiting with our bags. We were overwhelmed that people like these still exist in the world as we know it today. We profusely thanked this wonderful woman. She gave me a warm and comforting hug when we narrated our ordeal. We said our goodbyes. Finally we took a taxi and reached the hotel. We slept at 1am that night.

December 21 – Many frantic phone calls and dashed hopes later, at 2am that night, we had our second Christmas miracle. My ever helpful brother in law and cousin managed to get us tickets for 22nd. At 4am, we packed our bags and reached the airport by 7am. We finally boarded our flight and safely reached home and walked into the loving arms of our families.

      This incident is an exemplary demonstration of the parable of the Good Samaritan from the Bible, played out in real life. This inimitably beautiful parable has such profound but simple truth. It makes every man the neighbor of every man. Secondly, reflect on the conduct of the priest and the Levite. We see that they were heartless, but they did not see it. We do the same thing ourselves, and do not see that we do; for how many of us have not known of many miseries which we could have done something to stop, and yet have turned a blind eye or been content to be an armchair critic because our lives were unaffected?

 I somewhere once read that true religion teaches us to regard every man as our neighbor; prompts us to do good to all, to forget all national or sectional distinctions, and to aid all those who are in circumstances of poverty and want. If religion were valuable for nothing but this, it would be the most lovely and desirable principle on earth. While we might have differences of opinion as far as religion is concerned, and while we are steadfast in our belief about what we consider to be the truth, still we should treat each other kindly, aid each other in necessity and should thus show that religion is a principle superior to the love of sect.  The thread that binds us is humanity and must not be put aside because of a difference in opinion.

    Martin Luther King often referred to the story of the Good Samaritan. In "A time to break silence" he says, "On the one hand we are called to play the Good Samaritan on life's roadside; but that will be only an initial act. One day we must come to see that the whole Jericho road must be transformed so that men and women will not be constantly beaten and robbed as they make their journey on life's highway. True compassion is more than flinging a coin to a beggar; it is not haphazard and superficial. It comes to see that an edifice which produces beggars needs restructuring".This is exactly what individuals like MG Jayaprakash are doing; being the change they want to see in the world. Lip service will often be paid by those who say it most often but obey it the least. The clarion call of today is to not let our kindness be marred by apathy, forms of worship or a bigoted attachment to what we deem to be most precious but to be the Good Samaritan with little acts of kindness in every little way we can in our little lives.