My philosophy of medicine

    

 
This is it. This is the thought that started this blog. 

One evening, coming back from work with all the self doubt and insecurities that comes with being a freshly passed out doctor being thrust into the unfamiliar surroundings of a new hospital, new guidelines and rules, I realised that I had become ‘institutionalised’. I was too used to following orders, protocols. Sure, I had been taught how to examine, diagnose and treat, but the algorithm of a large 1500 bedded hospital had lulled me into working at an (almost) spinal level. 
As I worked through the first few months of my ICU tenure in this 200 bedded hospital, I learnt that I would have to come up with my own algorithms. I learnt that its not about being right all the time, but being wrong the least number of times. 

And I made my own rules. As I’m nearing the end of my ICU stint, and going into more unfamiliar surroundings (again!), I realise now more than ever that what I need to take with me, apart from my knowledge of medicine, is my philosophy of medicine. 

This is how it goes:

1. First, do no harm. 

2. Do not prolong life when chances of survival are bleak. 

3. Involve family on ventilator decisions early. 

4. History, history, history. 

5. Constantly read. Ask for help. Choose only after knowing the available choices.

6. Empathize. But don’t let it cloud your decision making.

7. Worry. About patients, treatment decisions and how much of what you’re doing will work. It helps.

8. It is necessary to be impatient to get work done fast and get fast results. But it also necessary to be patient in order to give the patient time to respond.

9. Consider this. You are imposing western standards of practice, western philosophies of life, family and social norms on an environment which may be of eastern mindset or western mindset or a mix of both. So take your time. Learn how to go about things the cautious way, the aggressive way, the respectful way, the minimalistic way, the least painful way.

10. Make your own protocols. 

11. Put the patient’s wishes above that of the family’s.

12. Question everything. Patients, colleagues, current medical guidelines, the sensibility of medical decisions, and the rationale behind applying textbook (or trial) conclusions to individual case scenarios.

13. Think about what you don’t like in the current medical scenario you are working in and what you want to do to change it. It is as important to know the solution as it is to know the problem.

Fifty Shades of Brave

Every backache has a story. 

Actually, this is only a partial truth. Every patient has his or her story of their affliction. But its the ones with the low backache, where both diagnosis, and treatment are dependent on listening. 

So many of them are women. Some actually have medical causes for their pain, like a vitamin deficiency, or osteoporosis. But the treatable cause is only a fraction of the problem, and there always is the real, yet abstract element of loneliness, or a diminished feeling of self worth, or world weariness, that manifests itself in these very nagging, painful symptoms. It is an established fact that depression, a disease of the mind, can have signs of the soma (body). 

  

There will the old Mohameddan lady who has ‘bone breaking back pain, mungi (pins and needles) sensations down her legs, and constant thakaan (fatigue).’

There will be the otherwise sprightly maushis in my hospital who keep asking me what’s wrong with them, why do they keep getting tired, why are they plagued with this backache?

And I know, when they come to me, that my most important job is listening. Tales of children now grown up and busy. Their experience of the daily drudgery of existence. Stories of domestic violence, of a life spent in seva- of the in laws, the kids, the husband. How they handle two jobs and whatever other hardships life throws at them.

So I listen. At times like these, I am thankful for my dual roles of being a woman, and a doctor, because both these roles bring with them that very essential quality- patience. 

And I wonder. Can being a woman be such a thankless job?

Aequanimitas

Dr. Smriti Khanna

There is a clear, untouched, beautiful memory I have about St. John’s Hospital. It was a crisp, something-in-the-air  day, the kind only the combination of Bangalore and St. John’s campus can produce. I was in my second year of M.D. Medicine residency, with a miraculous day off. I had just finished lunch (at lunchtime!) with a friend. Things were already looking good.

St. John’s has a research wing, one of the best in the world, most of which I am sorry to say I have not explored. It’s a stone’s throw away from the hospital and the college buildings, but the minute you enter that part of the campus, the cacophony of the hospital and the restlessness of the college falls away, and you’re left with a sense of calm.

I digress. It was a fine day, I was walking with a friend. We came to the History of Medicine museum, a building I’m pretty sure I had passed many times until then, but  hadn’t noticed. The only reason we went in this time was because there was a felt doll exhibition by a French lady (she does them every year, her name is Francoise Bosteels), and we had time to kill.

The doll exhibit was beautiful. It occupied the centre of a large room on the first floor, and it was only when we were about to leave that I glanced at the rest of the room. Pushed to a side to accommodate the exhibit were shelves upon shelves of old dusty books. I gasped (I really like books). Then I turned to look at the walls. They, all of them, were covered with paintings, or copies of paintings, of old medical and surgical procedures. There was Sushrut doing what is possibly the world’s first plastic surgery. There was Laennec, using the world’s first stethoscope .

I don’t remember all the books I looked at, flipped through and exclaimed multiple times over, in that museum. There were old research volumes on animal experiments (ouch). There were the first editions of books I have studied the 23rd edition of in MBBS. There were books I had heard only awed whispers of but never seen before.

This is when the theory of relativity kicked in, and I lost track of time.

I don’t know how, but I soon (or much later?) found myself, on a comfortable couch, with yet another huge dusty tome. The cover read-  The Principles and Practice of Medicine by William Osler.

It was the first edition (published in 1892). I sat there reading it, and it would have been like reading any other good book of medicine, except- it wasn’t. It was magic. I can describe it no other way. William Osler was a legend, and the list of medical phenomena named after him is unrivalled, some of which are very strange (consider this). I had been hearing of him since I had joined medical school 8 years ago, although I hadn’t come across  a book he had authored until then. To suddenly read words he had written, things he must have taught his students who then went on to teach their students, and so on- and which had then come to me, somehow- it was surreal. It was surreal, and it was time travel. The strange thing about medicine is how much has changed and how much has remained the same, which is why reading contemporary truths in old books, or perusing illustrations that generations before you have seen, admired (I’m looking at you, Frank Netter) and sniggered over(I’m looking at you, Bailey & Love), feels like you’ve touched the feet of the old masters and come back to the present.

Sir William Osler has a large body of work, but there is one essay, called Aequanimitas ,which was delivered as a valedictory address, that I can never forget. It speaks about how, about all, a doctor should have calmness of spirit, a veritable ‘equanimity’ which should guide him throughout his career. He writes, ‘Imperturbability means coolness and presence of mind under all circumstances, calmness amid storm, clearness of judgment in moments of grave peril, immobility, impassiveness, or, to use an old and expressive word, phlegm.’

I would recommend reading the essay in its entirety. It’s unbelievable how much it holds true, even today, more that a hundred years later, not only for medicine, but for any career you wish to put your heart into but not lose yourself in.

Love Happens.

Decoding medical school. The first of a series by Smriti.

I’ve been meaning to write about the journey of the practice of medicine, and I realise it will be incomplete without a general overview of the course and its materials.

Medicine is actually the most colourful amalgamation of pure sciences there is. For example, these are the subjects we study in MBBS.

First year is the most descriptive answer to the question ‘Who am I?’ It starts with anatomy. This involves a complete dissection (theoretical as well as practical) of the human body. Concrete distinctions are made as to what is a nerve, a vein, an artery. Anatomy tells us the complete structure of the human body.

Now we come to the functional aspect. This is physiology. Here we learn how anatomical distinctions are not absolute, and how organs work together so that the body operates as one individual.

We also learn biochemistry- actions at a cellular level which enable the body’s structure and function to work.

Second year is about everything that can go wrong.

Pathology- what happens when structure and function misbehave.

Microbiology- how bugs can affect us, from single cellular viruses to complex segmented roundworms.

Pharmacology- the science of drugs and their interaction with humans.

Forensic medicine and toxicology- violence, poisons and a miscellany of ugh stuff.

The last two years is spent studying the practical sciences- what to do with a cataract, how to help with childbirth, when to treat a disease with drugs and when to operate on a patient. We spend more time in the ward than in the classroom.

This is followed by a year of interning in different departments, where the job description can involve anything from ordering food for the residents to doing minor surgeries singlehandedly.

Somewhere, in these five and a half years, (if you’re lucky) love happens. It may be in the form of a spark on a quiet day in the library, or it may be a gradual allurement over the years.

And just like that, you know what you want to do. All your life. For me, it was internal medicine.

Dr. Smriti Khanna