What internal medicine taught me

Internal medicine is supposed to be an intense rotation; it’s a little — neigh, a big chunk — of everything. Some gastrology, some pulmonology, some neurology. As students, when you are keenly learning how to perform various physical examinations on their patients and are keeping an eye out for findings leading to a correct diagnosis, you realise — again — what a miracle life really is, what a miracle our imperfect bodies are. From palpable livers that point towards hepatomegaly — a term used to describe an enlarged liver — to negative reflexes that make you think of neurological lesions. Add these up and you can not but help think of the million other ways a physical mishap could have wrecked your life. Does a realisation of gratitude hit you then? In another episode of an existential crisis, you also conclude that life is pretty funny, and pretty crazy, because amongst all the emotional turmoil that you ride through, behind all the sleepless nights spent tossing and turning in bed with a deep sense of loss giving you some good ol’ chest pain, there definitely is some grand Plan running your machinery – a Plan so complex and so perfect that a feeble mortal like you can not comprehend even though you’ve given the next couple of generations some incredible physics theories and mathematics formulae. What an amazing terabyte of intelligence and intellect we have, isn’t it?

 

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Ziauddin University Hospital, KDLB

 

 

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The history of pain

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Photo credits: https://www.instagram.com/ax2mir/

Taking histories, writing them down, presenting them to your consultant — quite a tedious task as seen by us future doctors. But it’s so much more than that, isn’t it? Your narrative collides with that of the patients’ — like two meteoroids falling together, their paths colliding for a nanosecond in the eternity of time itself.

You’re taking a history of pain – any kind; abdominal, arm, any part of the body. You have a checklist in your mind that will help you reach a diagnosis and swiftly answer the consultant when he asks you to enumerate the differentials.

“Where do you have pain?”
“For how long have you had it?”
“Did the pain start suddenly or gradually?”
“Does it travel to any other region of your body? Yes? Where?”
“Tell me more about this pain. Does it feel like someone’s stabbing you? Or it’s a kind of heaviness in this area? Or it’s throbbing?”
“Does it get worse when you move about? Is it relieved by taking meds?”
“On a scale of 1 to 10, how bad is it?”
“Does the pain come with anything else? Any nausea or vomiting?”
And a couple of other questions like these.

As a future doctor learning the basics, every time I see these patients, I wonder if aching hearts ought to be healed this way, too?

“My heart and soul are aching, doc”.
“Umm, I’ve had it for a while now. Ever since my son died”.
“It started suddenly. Like a strong current rising within my chest. Like something stopping me from breathing”.
“Yes, it travels all the way into the depths of my soul and then down to my legs. I feel very weak then. Like I can’t stand on my feet, you know?”
“It’s all of that, doc. It’s throbbing sometimes. And sometimes it feels like a heavyweight is placed on my chest”.
“Yeah, it does get worse. When I walk out of my room and I see his baby clothes lying in the laundry because nobody has the courage to pick them up, or his toys peeking at me from behind undusted furniture”.
“I came to you for the meds, doc! Make this pain go away!”
“1 to 10? I don’t know. Sometimes it’s 3, sometimes it’s 8. And sometimes, it’s 11. I don’t know”.
“Yeah, it comes with loneliness.”

So many pieces all at once,

in the blink of an eye,

in half a breath,

in a fraction of a second –

a little hole here, a bigger one there

because this is magnificent beauty; this wound

where the light enters you.

Koi tou hai jou nizaam-e-hasti chala raha hai

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Photo credits: https://www.instagram.com/shehrozkhan_/

It’s strange isn’t it, how our narratives unfold? It’s a very surprising journey from the expected to the unexpected, from realising — with an existential jolt — that what we need is superior to what we want. It’s very simple, but like all simple things, we realise it after the hour is gone. I thought I needed ‘that’ when in fact, what I needed was ‘this’. The criss-cross of our narratives makes a beautiful patchwork on the map of this universe and takes us to lands that we hadn’t even dreamt of. And this is a realisation that I’m struck with every time I look back and gaze at the paths that I’ve walked, the people I’ve met, the stories I’ve lived, the reflection of Eve that I’ve now become.
It’s a realisation that calmly overwhelms me when I stand up in front of the patients — the responsibility of a future physician beginning to weigh more than the stethoscope hanging around my neck — listening to their story of how the pain doesn’t let them sleep at night, that they’ve had it ever since their eldest child graduated, that they never bothered to get it checked before, that it’s a pain that comes and goes at odd hours. And this is a realisation that will hit me many times during my life. And I’m glad it will. I’m glad it will because the journey ahead really does seem exciting because of the uncertainty. A year ago, I would have said ‘despite’ the uncertainty. But now I’ll say ‘because of’ the uncertainty. Yes. To survive patriarchy, to survive the game of broken hearts, to survive through the harsh seasons, it’s best to become friends with this uncertainty because I know I can’t win the battle of life otherwise.
I don’t want to kill the stars to get to the moon.
So I’ll hug stoicism like an old buddy and whisper to myself the words of Muzaffar Warsi, as sung by Ustad Nusrat Fateh Ali Khan, “Koi tou hai jou nizaam-e-hasti chala raha hai”.
(Someone is there Who is managing the order of life).

Yes, Someone is there.

Sailing in the sea of medicine

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“He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all.” – William Osler

Back in the third year of medical school, I had always eyed myself very apprehensively as a future physician. How do you connect the dots leading from signs to symptoms and put your finger on the diagnosis? How do you, then, jump from that diagnosis to the treatment?
Wow, doctors really are magicians, no? No.

They aren’t.

They — or let’s say we — are as much human as you. This process of healing patients is as much of a journey – a landmark on our timeline – as much as it is for them. To know what to ask your patients, how to ask your patients, when to ask your patients — that in itself, requires more patience and tact than we had imagined.

History taking is another add-on to a doctor’s reflexes. But these reflexes could not have developed had it not been for our patients. We — future physicians — apprehensively walk up to patients in the ward and churn out the well-rehearsed words, “Assalam Alaikum! Mera naam Arfa hai aur myn fourth year ki student houn. Aap jis jis takleef ki vaja se yahan aeye hain, kya uske baaray myn chund sawalaat kar sakti houn?” (Hello! My name is Arfa and I’m a fourth-year medical student. May I ask you a few questions regarding your sickness?) They lovingly give you their consent. “Bohat shukriya!” (Thank you!) And you go on with your checklist. And when you’re done, you graciously thank them. Do you know what they say then? “Shukriya, beta! Khush raho! Acha acha parho aur qaabil doctor bano!” (Thank you, child! Study well and become competent doctors!).

And that, dear reader, is when you know why you are there — wearing a white lab coat, a stethoscope hanging around your neck, a notepad and a pen in your hand, a stressed brain trying to process all the information that you have just gathered, a thirst for knowledge in your soul, and the compassion and enthusiasm of youth in your heart.
Yes, that’s when you are reminded of why destiny willed you here.

That laughter is still ringing in my ears. Can you hear it, too?

 

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Photo credits: Haniya Ather (https://www.instagram.com/lemonandscotch/)

It’s a chilly winter evening and you’re cuddled up in the warm blankets, jumping from one radio channel to the next when suddenly your fingers pause and so does your heartbeat. It’s that song, the one that reminds you of those carefree summer days playing hide-n-seek with cousins, the one that reminds you that you’re in the prime of your youth with all the blessings in the world and yet, you still complain – in impolite language – when your Wi-Fi service slows down. You get what I mean, don’t you?
It was one of those ordinary days. We walked into the male ward of Karawan-e-Hayat, a psychiatric hospital and rehabilitation centre located in Keemari.

 

He was a 46-year-old male, well-built and tall; self-importance evident in his fine walk. We’ll skip the clinical diagnosis and focus on the fact that despite delusions of grandiosity and hallucinations, a brief conversation with him – bits of which you’ll be reading below – gave us an insight that we – intelligent people pursuing a noble profession – totally and unapologetically lacked.

 

“Kaisay hain aap?”
(“How have you been feeling, Mr M?”)
“Bohat khush raha houn. Bohat izzat aur shohrat milli Hai Allah Ta’ala ki taraff se.”

(“Been very happy! God has blessed me with a lot of respect and stardom!”)
He looked up towards the roof and said, “Allah woh hai. Waahdahu la shareeka lahu.”
(That is God. He is One and He has no partner with Him!)
.
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“Aapko lagta hai koi aapko nuqsaan pohancha raha hai?”
(“Do you think someone is trying to harm you?”)
“Nahin. Jou Allah par yaqeen rakhta hai, Quran aur namaz parhta hai, unko kon nuqsaan pohunchata hai? Khuda sabka Hai; Allah, Bhugwaan, God!”
(“No. The one who believes in God, follows the Holy Book, offers his prayers, cannot be harmed by anyone! God is everyone’s; Allah, Bhagwan, Jesus’s God!”)
.
.
“Do you ever feel very happy? Like you’re on top of the world?”
“kaisi baatyn kar rahi hain aap doctor sahiba? Myn koi King Kong thori houn. King Kong tou sirf Allah ki zaat hai!”
(“What’re you talking about, doc? I’m not King Kong! Only God is the King Kong of this world!”)
.
.
We asked him what he thinks has happened to him – “Yeh meray aur meray Rabb k darmiyan hai. Mujhe aur meray Rabb ko pata hai k meray saath kya ho raha hai, kyun ho raha hai!”
(“This is between me and my God. Only my God knows and I know that what is happening and why it’s happening!”)
.
.
“Kya aapko lagta hai k mazhab ki taraf rujhan kissi beemari ka hisaa hai?”
(“Do you think so much inclination towards religion is part of your condition?”)
He pointed towards two boys with beards, “Tell me, is an inclination towards religion a disease?” He looked at me in the eye and said, “You’re wearing a headscarf, are you sick?”
.
.
It wasn’t minutes that passed with the flow of time in that huge room; I was measuring time by the passage of one striking realisation after another: are we merely bowing down to a God because we’ve been born into non-atheist families without really feeling Him within ourselves, within each one of our red blood cell that completes its life of 120 days to be replaced by a new one, within the heavy thumping resting underneath our ribs? When struck with a misfortune, have I ever exhibited a strong faith in this Mystical Force that has so perfectly set the mechanism of my body – a body that we proud, intelligent humans are still discovering – and that has so perfectly embellished the timeline of my life with all these emotions that so finely define the meaning of my existence? Have I ever shown the same confidence in a God who has been much kinder to me than perhaps to this unfortunate patient struck by what medical jargon calls ‘Schizoaffective Disorder’? Have I? Have you?

 

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Photo credits: https://www.instagram.com/unmaderhyme/

As I try to recall and relive those moments of existentialism – the deep look that the patient was challenging me with – I am at a loss for words; my vocabulary fails me, my brain – the ever ‘logical’ brain – mocks me. How can I ever rationalise the truth that so harshly slapped us all, so hard that perhaps, we failed to even acknowledge the pain? Really, though, how can an interest in the Unseen Being that so perfectly manages the machinery of the known and the unknown universes, the fascinating play of time, the lives of so many humans and animals, be called a ‘disorder’? It’s only when you’re sitting in a room with grey coloured walls and a few plastic chairs, facing a healthy looking man living in a psych hospital, that the absurdity of your own notions maliciously laughs at you and your life philosophy.

That laughter is still ringing in my ears. Can you hear it, too?

Long before the oceans dry up, the lone traveller struggles to reach the shore

 

 

 

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Photo credits: Younis Bazai

 

Chaque homme porte la forme entiere de l’humaine condition.
Each of us bears the complete stamp of the human condition.
– The first principle of psychiatry as proclaimed by Michel De Montaigne in 1580.

 

Unbothered by the quick feet shuffling around her, carrying unknown faces down the corridors of what she has learnt to call her ‘home’, this young lady was lost in a world of her own. She paints a sad picture and reminds me of long, lonely hallways with high roofs, warmed by the yellow of the afternoon sun. A sad, sad nostalgia. The silence in the psychiatric hospital is as calming as it is unnerving; like the reminder on our cell phones that we keep snoozing because we just can not bring ourselves to finish the task. Did I like it there? I can’t be sure. It was another world altogether, mirroring how vicious the real world out there – the one I came from, the one where I felt safe – can actually be.

What if these people are far, far saner than we are? What if their insanity is a very welcome escape from the social rules and norms that you and I are bound to since birth? Is this sanity a burden that we earthlings will be carrying to our graves? Maybe somewhere far away, lying deep within the heart of another galaxy in another universe, is a world inhabited by beings where people like us home in institutes like these?

So I went home that day – relishing the warmth of the sun on what was supposed to be a chilly December evening – watching the traffic slip away as busy men and women rushed through life occupied by thoughts of their electricity bills and crippling taxes. And when I walked into my room, I wondered why I hadn’t noticed the slow spin of the fan. I wondered what it’s speed was. And then I opened my notebook and stared at the white pages holding a catharsis that was just a few days old:

Breath by breath the memories shed themselves,
uncovering the heart within; the statue dismembering.
Long before the oceans dry up,
the lone traveller struggles to reach the shore –
away from the embers of the world,
towards the awaited smile.

Truly, ‘So which of the favours of your Lord will you deny?’ (55:38; The Quran)

 

 

 

Human life is pretty fickle; its fragility a truth as ancient as the human civilisation

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As a successful doctor, you not only need to keep yourself updated with the latest medical guidelines while simultaneously retaining that which you learnt in medical school aeons ago, but you also need to be equipped with the presence of mind to deal with crises of all sorts – attendants who are angry and possibly violent, in a state of denial, uncooperative, and even threatening.

The first reaction to a loved one’s death is almost always that of shock, followed by denial of the unfortunate event before being proceeded by grief. What the doctor needs to remember, however, is that the deceased was not the grieving family’s patient, but a very, very important part of their life. Patience, empathy, and compassion are the only tools that can help a doctor communicate to the attendants – as clearly as possible – the reasons leading to the patient’s demise. Words like ‘cerebral infarction’, ‘non-ST elevated myocardial infarction’ – are Greek to them. Using simple language and an easy-to-understand analogy along with a gentle explanation of what the term ‘palliative’ care entails, can help avoid unpleasant incidents where the deceased’s family may unfairly blame the doctors, inadvertently creating a ruckus in the hospital.

A very important – and yet, easily forgotten – clause of the Hippocratic Oath entails: ‘I recognise the special value of human life, but I also know that prolonging life is not the only aim of healthcare.’
What a lot of patients and their families also do not understand, is the fact that often – especially in our set up – they head to the hospital once the disease has progressed to a stage beyond that of a quick recovery, or when there are a few asymptomatic comorbids. In such a scenario, there’s not much a doctor can do except choosing between ‘management’ and ‘treatment’, and often, ‘symptomatic treatment’. Unfortunately, a lot of home remedies that are often the first option chosen by quite a few patients tend to aggravate the situation, further complicating the doctors’ job. All these factors combined – doctors are always treading on a fine thread that asks them to make quick, one-minute moral decisions pertaining to patient health, patient and hospital safety, and sometimes, even cost-benefit analysis. But the important question, again, is whether to save a life – no matter how physically or emotionally compromised – or the quality of that life. What would you want? A few more years of bed-ridden breaths haunted by persistent nausea and weight loss as a result of the chemotherapy needed to cure cancer, or, a relatively easy, pain-free few more days spent reminiscing with your family?

Another important clause that is forgotten amidst the glory of doctors, is this: ‘I will promote fair use of health resources and try to influence positively those whose policies harm public health’.
How many doctors – out of sheer goodwill – do not charge their patients on rounds in hospital wards if all that they do is having to check the lab reports, a task that the medical officer has already performed? How many doctors weigh their patient’s financial situation before helping them decide the best course of treatment? Or how many doctors in power stand up to the unfair health practices and extortion of money that some private hospitals shamelessly engage in? How many stand up to the varying prices of diagnostic tests? These are questions that quite a few healthcare professionals and policymakers have yet to answer.

All in all, human negligence is very much possible and doctors are also humans, hence, remaining vigilant during your care is not only a good idea but extremely necessary. But let us also remember that human life is pretty fickle, its fragility is a truth as ancient as the human civilisation itself, and there’s not much that we fallible beings can do with our limited intelligence in the face of good, ol’ mother nature.

Are we alive? Or thoughts that drift away from a God we’ve never seen but Who never fails to side with me?

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To watch the soul depart from its cage of mortality is akin to watching – that too live – a tragic reminder of your own death; how one day, we’ll leave behind everything, everything, and head to a land unknown. It punches you right in the heart and the room around you begins to shrink and you are scared; you are scared of what is to come.

When I saw our first patient die right in front of us, mocking any amount of medical advancements my seniors could boast of, I was overcome by both grief and disgust. After long years of rigorous clinical practice, writing the death note in a patient’s file becomes a part of your routine. It’s like watching a news channel broadcasting the death statistics of a natural disaster and exclaiming “Oh, only twenty casualties!” And then you remember that you definitely need to discuss yesterday’s sale at your favourite outlet with your fellow doc. Life doesn’t stop for anyone and there’s no room for sentimentality in a room full of medical equipment like a ventilator and a defibrillator, and well, perhaps the dead human body holds no dignity anymore, does it?

As I walked out of the I.C.U., I battled with myself – what sort of a doctor will I be? Will I actually do that? Or will I mourn those I couldn’t keep alive? It was in that moment – the heartbeat of my moment – that I decided: a small prayer for the deceased and their family and a relevant reminder to cherish the people in my own life and to take out the time to appreciate their presence in my life, was what I’ll do. And as I made this resolution – trying to calm the rising turmoil within – I was reminded of the lyrics from the song ‘Standing Outside A Broken Phone Booth with Money in my Hand’:

We sit outside and argue all night long /
about a God we’ve never seen /
but never fails to side with me… /
Am I alive or thoughts that drift away? /
Does summer come for everyone? /
Can humans do what prophets say? /
If I die before I learn to speak /
can money pay for all the days I lived awake /
but half asleep? /
A life is time, they teach you growing up /
the seconds ticking killed us all /
a million years before the fall…”

Really, though; are we alive? Or thoughts that drift away from a God we’ve never seen but Who never fails to side with me?

 

The healthcare dilemma

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“In any case, seeing care for certain groups as an excessive cost reflects an arguably perverse way of thinking about health care in terms of human need. […] In other words, care for the sick is an economic burden only in healthcare systems where profit is the bottom line and public services are underfunded and politically unsupported – that is, systems in which only market logic is considered legitimate.” 
― Julie Guthman, Weighing In: Obesity, Food Justice, and the Limits of Capitalism

The history of the human existence takes us through a course that brings to our attention – albeit, much to our distaste – bitter truths that make us uncomfortable as we sit in our well-furnished homes drinking tea from expensive cutlery. Or as you go about tending to sick patients in a hospital clinic.

A twenty-six-year-old female attired in clothes that hung loosely from her frail body and clearly pointed towards recent massive weight loss walked into the pulmonology clinic of a public sector hospital in Karachi. She was accompanied by her old, tired father and a mother who seemed to be trying her best to fight their unfortunate circumstances. Her signs and symptoms suggested pulmonary tuberculosis and her disinterest in her health, a lack of desire to live. Why would a woman so young lose all interest in life? The resident on duty – a young woman herself – wondered. Her silent query was answered when the father later came up to her with involuntary tears in his eyes, asking her if a High-Resolution CT (HRCT) was very expensive and if he’d be able to afford it with his monthly salary of Rs 12,000. He had, after all, his daughter’s medicines, the house rent, the groceries, his own travel expenses, the monthly bills – amongst other things – to consider. The mother also told the resident that her daughter was a divorcee – an unforgettable, highly punishable social status, eh? – whose son had also recently died. That explained the young woman’s behaviour: the end of a marriage is the end of the world, says the society.

“My heart skipped a beat, Arfa,” the resident later told me as she narrated the encounter. “The tears in that helpless father’s eyes shook me to the very core.” She did all she could; directing the family to a government hospital from where he could get the tests done free of cost.

As I heard this sad tale of many a common man in our country, a million thoughts raced through my mind. Social and economic inequity, the ‘burdensome’ status of women in our country and why economic empowerment and independence is a much-needed survival tool for women, the negligence of a basic human right such as healthcare.
All of us are guilty.

We spend thousands on fine-dining at expensive restaurants but haggling over fruits and vegetables and clothes with street vendors is just a habit. One of those vendors could be earning a mere twelve thousand rupees. Let’s walk in his shoes for a bit? Imagine having to make important decisions like choosing between getting whether to pay the house rent or to get your daughter’s medicines.
The common man here dreams big for his sons but saves up for his daughter’s dowry instead; after all, the son will support him in old age while the daughter is supposed to go to another home. Survival in this vicious world is a skill that we all must be equipped with. And this ‘we’ constitutes of women as well.

Artists, writers, poets, and all those affiliated with the social and electronic media are under trial here: a country where every household has access to a television and a mobile phone; where political talk shows and morning shows are a daily feature, a lot of social awareness can be achieved if creative brains work the right way. Yes?

The ‘little’ tragic mistakes

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As doctors – someone who goes through long, gruelling hours of learning the secrets of the human body – we often tend to underestimate the importance of paying attention to the small details when we are dealing with the gross realities of what is presented to us as pathologies.

One small mistake, one act of negligence that is the sad result of a tired body working for hours at a stretch, one incident of forgetfulness; and you, dear Doc, could have put someone’s life at stake.

An X-ray of a female documented as ‘Mr Sarfaraz’ instead of ‘Mrs Sarfaraz’ could lead to an embarrassing situation for both the patient and the doctor.
A female patient whose OBS/GYNAE history is left undocumented after a huge ‘MALE’ is scribbled across the relevant section, in the ER of one of Karachi’s well-reputed hospitals, could result in a near-fatal treatment or management plan because of missing out on important medical information.
Forgetting to check the blood pressure of a known case of a hypertensive patient while taking their history in an OPD, is sheer irresponsibility.
Writing down the wrong file number on a sample of fluid collected from a bronchoscopy, perhaps, could lead to some disastrous misdiagnosis.

It’s these little details – the seemingly easy tasks that require less of an effort than retaining important drug side effects and pharmacology – that could rob someone of their smile. And it is these little details that we so unjustly underestimate.

Having heard of so many tragic ‘mistakes’, I am still naively surprised at how our doctors and future doctors haven’t yet realised that in a profession such as ours, acts of negligence like these incite the suicide of the very ideology that attires us in this white lab coat. But here’s some food for thought for our education policymakers: starting a clinical skills class early on in the five-year-degree could hone our future physicians’ skills so perfectly, that double checking facts and following basic health protocols would become an innate feature of their personalities by the time they are ready to take the Hippocratic Oath. After all, old habits die hard, don’t they?