The subject of ‘ethics’ should have enough importance to be the ticket to your own graduation ceremony.

28 September 2019

“When will this end?” It finally has. Hope so.

My Internal medicine rotation has drawn an end, also turning the final pages to the chapter of what we have called ‘Ziauddin University’ for the last five years. It will be, undoubtedly, pretty magnanimous to call them pretty decent. But that’s for another time (read: post).

Dabbling with the most common ailments – malaria, typhoid, dengue, diabetes – was personally not as exciting as getting to explore the humanistic aspect of medicine and interacting with professors who commendably accredited enough significance to this side of healthcare.

Prof. Dr Ejaz Vohra, former Dean of Postgraduate studies at Ziauddin University and one of the professors I was rotating with, is known amongst the student body for his admirable efforts in trying to promote narrative medicine as an emerging field.
Dr Vohra has organised monthly seminars where he has encouraged the students and house officers to present and discuss excerpts from literature that ties together medicine and the human stories that we so often do not hear over the presenting complains of our patients due to a dearth of something as basic and as essential as empathy, compassion, and kindness.

That, and my own personal experiences as a student, a patient’s attendant, and an almost doctor (am I even ready?) have ascertained one thing: the vicious cycle of ‘I-had-it-rough-so-shall-the-younger-ones’ does not stop at diabolic social norms and customs usually handed down in the ugly disguise of ‘tradition’ from one generation to another, but also plagues our professional circles where one side chooses to override the other. We not only need to talk about uprooting this thorny bush, but we also need to take practical, effective steps to do so. The subject of ‘ethics’ should have enough importance to be the ticket to your own graduation ceremony.

Actions speak louder than words. Let’s get going, shall we?

 

There are six weeks left until five years of this journey comes to an end.

10 June 2019

The man looked really, really, really angry. Clad in a plain white shalwar kurta, he held a slip of paper in his hand, waving it around frantically. We had just reached the orthopaedic OPD – a good sixty minutes late because we knew the consultant was never punctual – and were prepared to wait for another hour till the clinic would begin.

“I will report you in the media! What nonsense is this! I’ve been waiting for an hour for this doctor to show up! Why have you written the time 2 PM here when he comes late? Is our time not valuable?? You charge us an exorbitant fee and make us wait for hours at an end! This is ridiculous! I will make a video and circulate this on social media! ”

We quietly crept back into the clinic. Crept back, yeah. Because we knew that man was right. We knew how valuable his time was. Maybe he had taken a leave from his workplace to especially bring his patient here. Maybe he had travelled a great distance to get to this hospital. But maybe none of that was true and he was just tired of waiting. Because time is valuable. Whether it’s his or ours or the very respectable doctors’.

There are six weeks left until five years of this journey comes to an end. I’m not very sure about how I feel. Ecstatic? Relieved? Accomplished? Scared? Apprehensive? Anxious? Maybe a little bit of all or simply none of these. But my heart is only beating to one realization – as we walk on this thin rope of life, we owe every human being we meet the sincerest form of dignity, respect, compassion, and kindness.

Just six weeks left. I will keep praying that all of us – every single person I’ve shared that lecture hall with – graduates with a kind, kind, kind heart. Amen.

 

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Does a balance even exist?

This post first appeared on Sehat Kahani.

So I’m a young female medical student hoping to graduate this year. The future doesn’t seem bleak. It does, however, seem confusing. Clinical or academia? How does one find a sub-speciality that allows you to earn well as you enjoy what you do, and also leaves you with enough time to enjoy summer beach trips with the family and soulful winter evenings with a book, all as you proudly break down the barriers set by the patriarchy?
In an attempt to put to rest similar concerns shared by the female workforce, I had a little tete-a-tete with two female doctors gracefully doing it all.

Dr Iffat Zafar Aga, the co-founder and CEO of Sehat Kahani and a happy mum of two had a very practical approach to making the work-home balance stress free.

How do you manage to give time to your kids along with the work? Are there days when you miss a PTM or a school event? If yes, do you experience any guilt? How do you deal with it?

So it has been the most difficult journey as a working mom who is equally passionate about her kids and her work. I generally like to start work very early, heading to the office as soon as my daughter is off to school, and then getting home by 5 so that 5:30 to 9 PM is when I can spend time with her. Her bedtime is usually when I start working again since being an entrepreneur there is no end to it. I have missed and forgotten the parent-teacher meetings and felt bad about it, but then that is how you cope with it.

How do you ensure cooperation from your husband and family on the bad days?

I don’t have any family here except my husband who is generally a big support. As much as I may hate it, my biggest support is a very old trusted maid. She has been with us for years so I trust her. Thankfully, my husband has always been supportive. It’s all about being kind and understanding and helping each other out by cooperating. He often works for late hours and I also work from home and take care of his parents, so if I ever need help, he’s always there.

Any things in particular that you keep as a backup? For instance cooking on the weekends, keeping a planner so nothing is forgotten, a trustworthy house help?

Oh, yes! All of these. Saturday is my household chores day when I shop for the coming week’s grocery, plan the meals, etc. Like I mentioned before, an old trusted household help has been very supportive. I also think that as working mothers, we ought to start training our children from a young age. I have two daughters and the elder one knows that she is not allowed to go out with the driver, she’s not even allowed to speak to him, she knows that only her Mama or Baba and the Auntie (household help) can help her change clothes. Similarly, she knows that she has to talk to me about the day’s happening at home and school, that way we avoid a communication gap that has become a threat for most parent-child relationships.

Dr Sameeha Aleem, a clinical psychiatrist and also a cheery mum of two, astutely observed that it is the will to continue that matters, and it is the contentment on the faces of her patients that makes it all worth it.

What should a working woman’s – especially a doctor’s – support system look like? What sort of support do you look for from your husband and your family?

Choosing who to marry goes a long way in helping a female with her job. If both spouses understand the importance of sacrificing one’s time while the other is at a crucial stage of their career, then it works well.
A female doctor should ideally have a lot of emotional support from the husband, and appreciation and encouragement from her parents and in-laws. She shouldn’t be made to feel guilty for choosing to continue her profession as she loves and cares for her family. Small gestures from the husband like doing the dishes, taking turns in making dinner, matter and makes one not regret their choice of profession and spouse. It also allows the couple to spend quality time together without letting the gender stereotypes bitter the relationship.
In all of this, having the ability to build strong relationships is what helps the most. Friends are really, really, important, they are the light at the end of the tunnel. I try to meet my friends in between my clinics at least twice a month, saving in advance to plan these outings.
Taking out time for yourself is very important. How do you do that?
I stand up for my alone time and try to reduce impingements on it by others. Spending quality time with children is my ‘me-time’. Bedtime storytelling is more therapeutic for me than anything else! And post-bedtime is when I get to unwind by treating myself to a good book.

That brings us to the main issue. As Dr Iffat points out, “Most healthcare institutes, despite having a big infrastructure, lack daycare services for working mothers, hence excluding a large number of women who could have worked but in the absence of the family’s support, they are left with no option but to quit work. A very important part of the support system also requires making the men of our society attuned to the idea of working women, be it the husbands, the fathers-in-law, the fathers, or the brothers. This will go a long way in ensuring their much-needed cooperation.”

Dr Sameeha very wisely summed up how empathy, kindness, and respect should colour up our lives – “an ‘either this or that’ situation shouldn’t be created for her. An unhappy mother can never raise happy children.”

 

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Left: Dr Iffat with her family.                             |                 Right: Dr Sameeha with her family.

 

Economising as a young doctor

This post first appeared on SehatKahani.com.

You meet a young man or woman preparing for their medical college admission test and you exclaim – with indulgence – “Aah! You want to save human lives!” Yes, they do! But they also wish to save their own – and the lives of their families – by bringing enough bread and butter home.

A lot of young, disheartened doctors are seen struggling to make ends meet. While there is no denying that the state ought to pass a legislation to set the bare minimum pay of a house officer in accordance with the graph of the economy – keeping in mind the difficult work conditions that they have to face, especially in the public sector – a little smart thinking and an ounce of discipline at our end can also help in surprising ways.

If you do not look at the experience of your elders with a wise eye seeking counsel, you will have made the biggest mistake of your life; that’s what I heard growing up. So why not ask the doctor herself on how to live a life of financial security?

“By modifying our lifestyles, we can easily save up! We need to curb those irrational impulses. I do not have to go to that Khaadi sale every time I pass their outlet. Dining out every week when I can eat simply at home also seems an extravagance that I can do without,” says Dr Sameeha Aleem, a clinical psychiatrist and a mom of two.

“Would it matter in the long run what brand we wore or how fashionable we were? Money spent on experiences like watching a movie or going for a walk along the beach makes one more happy than spending money on fast food frequently or buying the makeup that I don’t even have time to put on,” she shares.

So what’s the real deal?

“Pay yourself first! Google suggests setting aside ten per cent of your monthly salary regardless of your income. So if your salary is Rs 30000, set away Rs 3000 as soon as you receive your pay. You may put the money in a monthly committee and when you receive your share from the committee, you can buy a gold biscuit worth Rs 54000. You may sell it later when the price rises. Alternatively, you can book a small property by beginning with a down payment of one to two lakh and later pay monthly instalments. It is especially very important for the empowerment of our girls. You can also buy foreign currency with just Rs 10000 and get it cashed when the value rises. We as doctors need to save for our retirement right from the nascent stages of our career – look ahead into the future while being grounded in the present.

Most importantly, live on a budget. Calculate where you spend the money. That way you can cut down on many expenses. For instance, my credit card was the major culprit – unnecessary shopping from sales was eating up my savings.
Set goals. I haven’t shopped for clothes in the last year, utilising and redesigning the old ones because I wanted to save for a trip.”

So a little discipline and a little more determination can get you to economise in ways that you will not resent. You will, instead, thank your younger self as you reap the fruits during a rainy day, or simply when it’s time to pamper yourself.

Hopefully, our generation of young doctors will begin to enjoy cosy chats over homecooked Chinese as a weekend speciality and discover that a simple old wristwatch tells the same time as the latest one that bores a hole in their pockets.
Did I hear an ‘amen’ to that?

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An empathetic doctor, or empathy for a doctor?

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The picture has been taken with consent.

 

An empathetic doctor, or empathy for a doctor?

My ENT rotation for fourth-year ended last week; the crazy schedule that it saw me dealing with, however, did leave behind a few worthy lessons, like the importance of patience while communicating with patients, and some intelligent understanding at the patients’ end.

Doctors – especially in our part of the world – are also under the constant shadow of suspicion. From the ‘useless’ and ‘unnecessary’ tests that they are accused of prescribing to the truckload of medicines that they weigh you in – the majority of the population will always double-check the doctor’s diagnosis and management plan with a source that they find a bit more reliable – Google.

While it’s good to educate oneself and be aware, it must be noted that Google is a search engine that links you to often inauthentic information. Very few sites – like Medscape – carry up-to-date information and are hence, used by the doctors themselves. Years of hard work and a precious youth spent over amassing all that clinical knowledge cannot contest the incomplete knowledge that one can gather from a few reads of an internet article, without any prior background knowledge of the complex workings of the human body. Every disease has a different prognosis, a different course. Every patient responds to every disease, every drug differently. How so? Because factors like age, gender, biomass index, race, co-morbids (other pre-existing diseases), and personal history matter more than we give them credit for. So yes, every patient certainly is a different story and that is exactly why bedside learning is highly encouraged.

One of the many problems plaguing our society is the unfortunate fact that unless its the pending electricity bill that threatens to cut off the power supply, our people will not pay immediate heed to any problem at hand. The majority will not head over to the doctor unless the disease has progressed to a stage where not much can be done. Be it a recurrent pain in the ear or a suspicious lump in the throat – a visit to the doctor is always the last option. How so, I wonder, can the doctor treat a disease that has already progressed – due to mere negligence on the patient’s part – to a stage where it can only be symptomatically managed and not ‘cured’? Yes, it’s the ‘too late’ scenario here that needs to be considered before harbouring unrealistic expectations from another human who has spent years studying from various resources, training for over thirty hours straight every three days irrespective of birthdays, weddings, festivals.

Similarly, a single medicine can be used to treat multiple signs and symptoms. Often enough, a medicine’s side effects are used to achieve the desired result. For instance, Ventolin (Albuterol) is a drug used commonly to prevent and treat difficulty in breathing, wheezing, shortness of breath, coughing, and chest tightness, caused by diseases such as asthma and chronic obstructive pulmonary disease (diseases affecting the lungs and airways). One of its side effects is hypokalemia, low blood potassium levels. So if the doctor deems it safe, he/she may prescribe a dose of Ventolin inhaler to a patient with high levels of potassium in the blood. In such a situation, a seemingly harmless Google search will only confuse the poor patient or his family simply because of lack of prior knowledge and understanding. It must also be noted that every drug interacts with another and often enough, they work together to achieve the desired result – lesson learnt: it is very important to take the medicine as directed by the physician. As is with antibiotics, leaving a dose as soon as the symptoms disappear only makes matters worse because the drug needs to act on its target for a specified time period for it to completely eradicate the cause and to also prevent recurrence. Failure to do so always results in the patient coming back to the doctor with the same disease – often worse – and almost always holding him/her responsible.

Another important thing to remember – and what many patients and their families have reservations over – is that laboratory or radiology tests are important investigations that help present a clear picture of what really is going on inside the human body to cause the signs and symptoms that the patient can experience; only then, can a definite diagnosis, and hence, an adequate management plan be reached.

While it’s definitely true that the healthcare set-up has become notorious for exploiting patients, that is not always the case. Some basic primary-level science teaches us how complex the intricate, interlinked system of the human body is – so how can ‘fixing’ an abnormality in this complex system be an easy task? The different subjects taught during M.B.B.S. – anatomy, physiology, biochemistry, pathology, pharmacology, behavioural sciences – are all deeply interconnected which is why the modern curriculum is structured around a module based system – the cardiovascular system, the respiratory system, etc – that helps build up a strong understanding of how the human body really works.

If only half the population understood some of the above, it would ease the lines of frustration on many a doctor’s forehead as they try to reason and counsel patients and their families.

So the next time you feel unwell, do not – for your own sake – delay consultation with a good doctor. And when you do consult one, remember that they, too, are humans in need of some empathy!

 

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This picture has been taken with consent.

 

 

 

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.

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.