Mother’ Love 2

This has bearing to one of my previous posts. Yesterday one of our old employees came to see me. He took my advice on some patient’s problem. Then he asked me if Dr. XXX was in the hospital. This was the same doctor I wrote about in my post ‘Mother’s Love’. “Yes, he is” I said. “Is he all right?” he asked. “He was looking quite OK today morning” I said. “Why do you ask?” “I rang him up the other day. He had told me it was best to call him after 9 P.M. So I rang up at 9:30 P.M. He picked up the phone. I told him I was so and so, and was from his hospital. Immediately he said Dr. XXX did not live there. I told him I knew his voice, and it was him. So he said that was not so, and gave me another number, saying Dr XXX would be there. I don’t know what was wrong with him. Why would he say he was not him?” “When was this” I asked. I was aware of Dr XXX’s phobia for telephone calls from the hospital. “Last month”. “Then it fits. He was on leave that time, and when we called his residence, his mother took the phone and told us he had gone to a place not known to her, for a period not known to her.” “But he was home. I know. I know his voice for so many years.” “You should not have said you were from this hospital. That must have put him off.” “I see! I even asked him if he was all right.” I laughed. One more piece had fallen in place. His mother had really told us an untruth, out of her love for her child (though the child was well above 50) and to protect him from the hospital. Perhaps she did not know what was the nature of the phobia for the hospital, but all she knew was she had to protect the son from whatever he feared.

Trick Question?

Sometimes we take things for granted. For example, we take for granted that postgraduate students will know the undergraduate stuff. I actually planned to ask the undergraduate students this question, but I saw one resident doctor in front of me at that time and just felt that I should check the postgraduates first. So I called all of my unit residents and asked them to write on a piece of paper their names and the year of residency they were doing. Then I asked them, “if we do not clamp the maternal end of the umbilical cord after childbirth, and divide the cord, will the woman keep bleeding from the open end of the cord?” Then I asked them to write their answers on their pieces of paper. To my utmost surprise, they all wrote the patients would bleed through the open end of the divided cord. Some of them stopped the bleeding after some time as the uterus contracted, and the placenta separated from the uterus. I wanted to see if only my unit residents were misinformed, or all of the others were similarly misinformed. So I called all residents from all the other units too, and gave them the test. Out of 22 residents, only one second year resident answered that no maternal blood would be lost but only fetal blood in the placental circulation would be lost. Others answered like my unit residents. Some made their patients bleed through the cord if the placentas were morbidly adherent and did not separate from the uterine walls. It hurt me to know that all of the other 21 postgraduates were unaware that the fetal and maternal circulations did not communicate, and the mother could not bleed through the fetal umbilical cord. I think they all must have known that some time, but never thought about it, and now have stopped thinking about things in general. I don't know what has made once highly intelligent minds now go through the educational process so passively, without any application of the mind.

Antonyms and Synonyms

I was teaching my undergraduate students cesarean section. It was a small group, and I began with a question, "Have you seen a cesarean section being performed?" It appeared that each one of the eight had seen one, but on different patients. I asked the next question, “what was the indication for the cesarean section?" The first guy said, ''It was an elective section." This was the first time I had heard this as an indication. ''I don't think you have understood my question," I said. “A cesarean section can be elective or emergency. I want to know what the indication was." One more guy and one girl independently said their indication was 'elective'. I realized had to get through to them somehow. So I said, "Was there any indication or was it unindicated, i.e. without ant indication?" They kept quiet. "See, if one performs a section without any valid reason, it is unindicated. Were the sections you saw being performed indicated or unindicated?" The question was very clear and I expected a clear answer. However they answered “they were elective." I lost my patience then. ''See, there are antonyms and synonyms. Elective and emergency are antonyms. Indicated and unindicated are also antonyms. But elective and indicated are not synonyms." This was the best effort I could make. But they did not show any indication of having understood anything. Finally I said to myself that they were unlikely to remember school level grammar if they could not remember what they had learnt in first year of the medical course. I stopped asking questions and taught them cesarean section in a monologue.

Lord of the Rings

We have nurses and theater assistants. Both of them assist during operations in the operation theater. That day I had washed up for an operation, and was in the process of wearing surgical gloves. Along came the theater assistant, washed up and wearing a sterile gown. When he started donning surgical gloves, I noticed he had three rings on his fingers, two on left hand and one on the right. I stopped him and asked him if he always washed up with the rings on his fingers. I appeared he did. One of them was of copper, probably worn for good health. The other Two either had ornamental value (gold and precious stone), marital value (wedding wing) or religious / magical value (charm for good luck). I got one of the medical students to take a photograph of his hands on his cell phone. The assistant kept on hiding his hands, but I somehow managed to get the student to snap a picture showing the rings clearly. I did not plan to show the picture to anyone. I just wanted to scare him so that he would not repeat this mistake. Then I explained that he had to wear no rings while washing up, because microbes would remain between the rings and the fingers and in the rings too. I sent him away to remove the rings and wash up again. He did so. On my next operation day, he washed up with me, and he did not have any rings on his fingers. I was happy. But my happiness was short lived. The chief nurse of the theater washed up for the next operation. Not only did she have a ring on one of her fingers, but also a religious thread around the wrist. She said the ring was too tight and would not come off. She did not say anything about the thread. I asked her not to assist for an operation if she could not get the stuff off. Today she did not have the stuff on when she washed up. So I was curing one person per week. It was not as if these people did not know they should not wear things from el bows down while washing up. I think it is a combination of laziness, fear of losing valuables like rings if removed during the assisting job, fear of not wearing religious threads at all times, and fear of failure without the lucky charms on their person. I mentioned this to one of my junior colleagues who worked in my unit before getting promoted to head a unit herself. She said, “Sir, it is not only with these people. A professor of surgery had come to our operation theater once to manage a surgical problem in one of our patients. He washed up with a band-aid on his finger. Now he heads a superspecialty department.” I was stumped. If such highly qualified people who definitely knew the principles of surgical asepsis and antisepsis very well behaved in this manner, it would be but natural that their juniors would behave similarly too.

Influenced Treatment

It was one of those busy days. I had just finished the wards and was going through the pile of paperwork, when two guys walked into my office. They were tall, stout, round around the middles, and used to walking into offices to get their work done. The stouter fellow looked like a policeman in civil clothes or a village politician in a Marathi movie. “What is it?” I asked them. “This patient’s treatment” the stouter of the two said, and shoved a case paper in front of me as explanation. I took the paper and read the clinical notes. I had seen the patient in the outpatient clinic two days ago. She had pelvic infection and adenomyosis both. I had put her on a course of an antibiotic and an anti-inflammatory drug, and called her with investigation reports after a week so that a hysterectomy could be done on her if the infection was controlled and the reports were normal. “She has been given the right treatment” I said. “Now what else do you want?” “We want her to undergo the operation now”, the guy said “we cannot wait.” “But she has an infection. It must be cured before any operation can be done on her” I said. “Otherwise the infection will get worse and her life will be in danger. I had explained that to her.” “We know additional commissioner Mr. XXX. He is a family friend”. Additional commissioners can have family friends, but they don’t land up in a hospital for poor patients. Even if they do, the fact cannot alter the course of their treatment. I knew this particular additional commissioner and liked him too. But that was not the point. “That is good. Now give her this treatment, and bring her to see me on the next outpatient day.” The guys went away, but it seemed they would return soon. They indeed did so in half an hour. “We went to see the Dean, and we have this note” the stouter guy said. I had no time to waste, but I wanted to settle this issue. “Come in. Sit down” I indicated a couple of chairs. “Let me see what the note says.” He handed me the note and sat down with a victorious look on his face. He seemed to know how to handle government and municipal employees. The note was written by assistant medical officer who sat next to the Dean’s office. I read the note. ‘This patient is known to additional commissioner Mr. XXX. Please give her appropriate treatment”. “OK!” I said. “So can she have the operation now” he seemed pleased with himself at having handled me properly. “The note says I should give her appropriate treatment. So give her the medicines I have prescribed and bring her to the outpatient clinic next week” I said quietly. He could not believe his ears. Finally he managed and got up to go away. He turned around near the door and said, “I have met many people, but not anyone like you. You stick to what you say the first time.” There was some sort of wonder in his voice. “That is because I say the right thing the first time, and it is not in my patient’s interest to change it. Please remember that everyone cannot be managed by bringing about pressure of influential persons, and it not always in your interest too.” It is more than two years since. That patient has still not come to the clinic. Perhaps she went back without treatment. Perhaps she underwent hysterectomy with someone else and had a flare up of her infection. It is just another of those loose ends that remain so.

We Get What We Deserve

“Sir, did you hear Dr XXX got selected for promotion as Associate Professor?” “Huh?” I could not hide my surprise. “That too with just 5 years of teaching experience, going ahead of another lecturer who has 10 years’ experience.” “How?” I asked. “That post is reserved for that category.” “Ah!” I said. “Sir, but it is not fair.” “…” Who was I to comment on fairness of the constitution of the country? “Sir, how can they promote someone who perforated the jejunum during laparoscopy? Jejunum! Lower bowel, I can understand. But jejunum?” There was some point in what this lecturer was saying. The upper bowel perforation is not expected during laparoscopy. “But we had one associate professor perforate the jejunum during laparoscopy too. That patient died. And that AP was not there by virtue of reservation” I pointed out. “Sir, there is more. This one had perforated the ileum at 4 places and the sigmoid colon at one place during an MTP perforation of the uterus once. One uterine perforation, four ileal perforations and one sigmoid colon perforation in the same case?” “We had an Honorary Professor with us who had perforated the uterus at six places during an MTP. That one was of open category. This can happen at any one’s hands” I said. “Sir! Did you know this lecturer had put a Sims’ speculum into a patient’s rectum for cutting a suture that had passed through the rectum during suturing of an episiotomy?” I was dumbstruck. One could pass a proctoscope into the rectum, but a Sims’ speculum was beyond anyone’s wildest imagination. I wondered how that poor patient had withstood that. ‘Hats off to someone who could think of this one and carry it out too’ I could have said had it not been that painful to the poor patient. “Well, I cannot comment on the wisdom of the selection process. It is the system. But I will say one thing. The society gets the doctors in public sector it deserves, just like it gets the government it deserves.” I think the complainant must have found my logic unbeatable, because he went away without saying another word.

Social Justice

Space Crunch

I went into the labor ward wearing slippers meant to be used only in the labor ward, leaving my shoes outside. I saw three patients in the ward and came out. Some woman had left her footwear parked right on top of my shoes. There was plenty of space around my shoes, but for some reason she had chosen my shoes instead. I am a little particular about cleanliness, and this act of someone putting the undersurface of her footwear on the upper surface of my shoes left me upset. It was quite obvious from the size, shape and design of the footwear that it belonged to a woman. I politely inquired who the footwear belonged to. There was no answer. Finally I called the sister-in-charge of the ward and asked her to find out who the culprit was. She asked all student nurses, and doctors in the ward. The answer was negative. The owner had to have entered the ward recently, since it had been left over my shoes in the ten minutes I was inside the ward, and it was quite warm, like one recently taken off one’s feet. I was further upset because no one would own up her mistake. I requested the sister-in-charge to keep one of the pair in a secure place, and the other right where it was, and to inform me when someone asked for the missing one. I went about my work. After an hour and a half, I rang up the ward and asked the sister if the owner had been found. She said no. So I left my number with her, and requested her to ring me if anyone asked for the missing one. She rang me up after half an hour and told me she had found the owner. It turned out to be a first year resident doctor called Dr. Queta (name changed for maintaining anonymity). I asked the sister to put that doctor on the line. Our conversation went something like this. I: Good morning Dr Queta. Dr. Queta: I am sorry Sir. (Bad manners! She did not wish me good morning when I wished her one.) I: Dr Queta, why did you leave your footwear on top of mine? Dr. Queta: Sorry Sir, it won’t happen again. I: That is for the future. But I want to know why you did it. It is not a very nice thing to dirty someone’s footwear. Dr. Queta: Sorry Sir. I won’t do it again. I: But how will I know that? I suggest you put your name’s sticker on your footwear. Then I will know it is yours. I am coming to the labor ward. I will check your footwear for that sticker that time. Dr. Queta: Sorry Sir. I: Which unit do you belong to? Dr. Queta: XXX unit (name masked for maintaining anonymity). I: Uh! I remember a time when the same unit’s registrar had thrown down my clothes from a hook in the operation theater and put hers there. When I asked her why she had done that, she had said she had not known those were my clothes. I had told her that she should not throw down anyone’s clothes, not just the department head’s. You shouldn’t put your footwear on top of anyone’s footwear. Dr. Queta: No Sir. I: OK, go back to work. I wonder what drives some of the residents to show total disregard for other people’s things. Is it a simple space crunch, is it the pressure of the work, or is it robotic behavior, or is it a feeling that there is no one more important than them?

Idiot or Psychopath?

It is true that the hospital building is being repaired, and we are in a transit area. It is also true that the transit area will be repaired and renovated at a later date, and is at present not at its best. But it is also true that our annual budget is Rupees twenty million. So if the toilet’s door bolt gets damaged, it is no big deal to have it replaced. We have enough carpenters to do the job. Still I found that the bolt that was damaged and used to come off when pulled was replaced with the trocar pointed stainless steel inserter used for inserting subcutaneous suction drains. It is normally so sharp that it can enter one’s hand on the palmar aspect and come out of the dorsal aspect if so pushed with moderate force. Some ingenious soul put it in place of the bolt, the pointed end outwards. So when anyone tried to bolt the door shut after going to the toilet, the inserter would pass into one’s hand. I noticed it without getting poked by it. I took it out and asked the theater assistant who had done it He was clueless, or at least he said so. I asked if they had at least autoclaved it first. He said that was unlikely. So whoever it pricked would also be at risk of getting something like HIV or hepatitis B, if the patient on whom it had been used had any of these illnesses. I cannot imagine why someone did such a thing. Either that person is stupid. I sincerely hope so. I hope so because a stupid person is far less dangerous than one who is intelligent and malicious, bordering on being a psychopath. To have someone like that put it there to hurt others intentionally is something we all can do without.

Quotation Business

We have a complex procedure for purchasing equipment. If it is costly, tenders are invited, and big bidders bid for supplying the equipment. If it costs in thousands or less, quotations are invited, and smaller bidders quote. Tenders are advertised in leading newspapers, while quotation notices are put on notice-boards and telephones to usual dealers. We had asked for stainless steel trays for labor ward. The stores head clerk sent me all quotation papers for scrutiny and approval of the purchase. We had asked for big trays and small trays. There were three quotations for small trays, Rupees 2100, 2200 and 2300 from three different companies. There were three samples, which were not labeled and they looked identical, manufacturer’s stickers included. There were three quotations for big trays, of Rupees 9600. 9700 and 9800 from three companies. There were no samples. I was asked to state if the samples were satisfactory, and if the price quoted by the lowest bidder was reasonable and as per market rate. It is the normal tendency of a head of a department to state that the lowest bid was satisfactory and reasonable, and recommend the purchase from that bidder. I had my doubts. So I called a known vendor and asked him the prices. This fellow had supplied us equipment of good quality in the past, when I had made the purchases through a grant, getting three quotations from different vendors without involving the stores personnel. He quotes Rupees 330 and 2300 for a small and a big tray respectively. So the lowest bids to the stores were 6.3 and 4.1 times the market rate. I wrote this remark and returned the papers to the stores, asking for fresh quotations for the trays. I am yet to hear from the stores again.

Comprehension Failure or Short Term memory Failure?

I experimented with the undergraduate teaching process a little. I wanted to see how much attention they paid during the teaching session and how much they comprehended. Since they never made any notes while we taught, one had to presume that they either already knew whatever we taught them, or understood the stuff so well that they did not have write anything down. When I started a small group teaching session, I told them they would sit for a small test at the end of the session. I told them a correct answer would get one mark, a wrong answer would get minus two marks, and no answer would get zero marks. They did not disagree. I taught them at a speed at which they could understand everything. I asked questions in between and answered those questions myself if they couldn’t. They had some difficulties, which I solved. There was that guy who kept turning the angles of his lips down and nodding his head throughout the session, as I have seen actors in American films do, to show that they knew what was being said better than the person who was saying those things. He was not just a ‘nodder’, but a ‘superior nodder’. For those who don’t know what a nodder is, let me state that a nodder is a person who nods his head much more than an ordinary person does during a teaching session. I gave them a break of five minutes after the session, during which I composed five multiple choice questions, each with a single correct answer to be chosen from four possible answers. I collected the answer books and corrected them immediately in front of them. I returned the answer books without reading out the marks aloud. That was meant to avoid embarrassment for those who scored badly. They promptly checked out one another’s marks anyway. Out of maximum five marks, the ‘nodder’ got -3, others got -1 or zero, and one of them got 1. The ‘nodder’ turned out to be a pseudo-superior-nodder’. The others were terrible. I had really asked quite simple questions based on what I had taught them barely 5 minutes ago. It reminded me of the Dean asking me about a large number of students (more than 20) failing in obstetrics gynecology in the University Examination in the previous batch. The explanation for these doing so badly was perhaps the explanation for those failures in the University Exam too. If any of my readers is a pure educationist and will tell me exactly what is wrong with these presumably bright young students, and how to correct the problem, I will be much obliged.

Ad hoc troubles

It started with promotion of one of our lecturers to associate professor’s post on ad hoc i.e. temporary basis, being reverted to lecturer level for one day every month. In case a permanent associate professor was appointed by selection, this one would be reverted to lecturer’s position. That was good for the concerned person. But it was bad for the department, because the Dean said he had to keep the lecturer’s post vacant by law, so as to be able to fill the associate professor’s post as soon as one was selected. So we had one lecturer less to do emergency duties. We also had one lecturer less for maintaining our recognition by the medical council of India. I suggested that the vacant lecturer’s post also be filled on ad hoc basis, to be terminated with one day’s notice when required. That was refused as something that just could not be done. In due course the medical council sent a team for inspection of the college and hospital, and found a deficiency of not one but 18 lecturers in our two hospitals attached to our medical college. Though a number of them were in the other hospital we still needed to not only fill up two posts that were vacant, but also had to create a few new ones and then fill them up. To add to our woes, two of our lecturers got selected for ad hoc promotion to associate professor’s position. Now we would have an additional deficiency of two lecturers, taking the tally to twenty. When I met the Dean in a meeting not related to this issue, I explained the situation to him. The Dean maintained that he had to keep these lecturers’ posts vacant by law, so as to be able to fill the associate professor’s post as soon as one was selected. ‘But what about our recognition by the medical council?’, I asked. ‘We already have a deficiency, and this will add to it.’ He mulled over it briefly and said, ‘I am thinking of filling these up on ad hoc basis’. I wish he had done that with the promotion of the first lecturer, so that we would have had an extra working hand for all these months in between.

The Solution

The students' lack of interest in the overall education process is something we all have been unable to correct. These statements of the staff members should illustrate this point. “They don't seem to be interested.” “Their body language speaks volumes about their interest. The slouch, they shuffle.....” “They don't seem to have a spark inside them.” “Their parents must have pushed them into medicine.” “They seem to be going along the course to wherever it will go.” Indeed, I have been discouraged as a teacher to see students arrive slowly, what my people 'trickling in' with neutral if not downright disinterested faces. The boys staying at the hostel ('Hostellites') get up late and arrive for wards or operation theaters late or not at all. That day one guy came late and gave a reason for his late arrival 'I am a Locallite and I overslept. So fellows staying at hostel give that as the reason for oversleeping, and those having their residence in town give that as the reason for coming late. God help them. But today I found a solution to this disinterest. We have a workshop on 'Emergency Medicine' going on for the last three days. The students have registered for it by paying Rupees one thousand and five hundred each. Every morning I find students with bright faces, well bathed and dressed, wearing badges around their necks and smiles on their faces, eating snacks at the college gate, talking animatedly near the gate, or shouting jubilantly in the nearby auditorium. As a teacher I have not seen any medical student in campus at that time of the day, and never in such enthusiastic form. Now I know what will get them interested them in education. We have to call the standard education process as a workshop, a different workshop every day. We have to charge them on a daily basis instead of charging fee at the beginning of the term. The fee needs to be hiked so that we can give them breakfast and lunch every day. We have to give them badges with their names on them to wear around their necks. And then, we have an entire batch of interested students, rearing to go!

Clampless Cervical Polypectomy

Every now and then we get a patient with a leiomyomatous polyp growing down from one of the lips of the uterine cervix, sometimes big enough to come out of the vulva. A natural tendency of many residents is to put a clamp across its pedicle, cut it off and then replace the clamp with a transfixion suture of delayed absorbable suture material. The pedicle is often thick, and putting a clamp on it is not a very good idea because there are high chances of the clamp cutting through or the ligature slipping. We prefer to perform clampless polypectomy in such cases. We make an incision in the mucosa covering the pedicle of the polyp, about 5-10 mm from its origin. Then we cut through the pseudocapsule of the leiomyoma, and dissect between the leiomyoma and the pseudocapsule. If it is not possible to dissect at the base, we divide the pseudocapsule through the length of the leiomyoma, and then dissect the leiomyoma out of the two halves of the pseudocapsule. Then we excise the redundant part of the mucosa and the pseudocapsule. Hemostasis is achieved by electrocauterization. Finally we approximate the edges of the mucosa with interrupted sutures of No. 1-0 delayed absorbable suture. The advantages of this technique over the clamp technique are: 1.No part of the pedicle is left behind. 2.The reconstructed cervix looks much more normal. 3.Complications like the clamp cutting through the fleshy pedicle and the ligature slipping over the smooth mucosa are avoided. We have done a large number of cases using this technique, and have quite satisfying results.

Education at a Price

The new batch of students appeared to be sincere, if not interested. Eight of nine students posted in my unit were there on day one. That was unheard of in recent years. The ninth guy had gone home, they said. I was quite happy with those eight and taught them with interest for two days. During the second day’s teaching, in a minor break, they informed me that six of them were going to attend a workshop on emergency medicine for three days and would not attend the teaching sessions we held for them. I had not received any such letter from the medicine department, and was curious. “You six must be planning to go to the USA” I said, “such things are considered important for gaining entry into that country”. They kept quiet. I was right in my guess. “Is this a paid thing?” I asked them. “Is the charge something like Rupees 1000/-?” “Rupees 1500/-” they corrected me. So here were undergraduate students paying such a princely sum for learning emergency medicine that should have been taught to them in the course of their standard undergraduate teaching without any extra charge. And they wanted to miss the standard teaching in Gynecology and Obstetrics that they had already paid for as part of the fee paid to the college. “But I cannot stop education of the remaining two students because you will be away for three days” I said. “We will continue to teach them, and you will miss that. I would like you to meet the course coordinator and ask him to send me a letter with the Director’s approval, so that we don’t mark you absent on those three days. If you cannot get that, we will mark you absent. Then you will have to deduct three days from the number of days you have bunked for your personal reasons including personal happiness.” They kept quiet. They had understood exactly what the rules were. “You seem to know the basics of Medicine, since you plan to do a course in emergency medicine, which is not included in your curriculum. Shall I ask you two questions? If you answer them correctly, I will let you go without being marked absent.” I knew I had no authority to any such thing, but I wanted to test them. I had a feeling they would not be able to answer those two simple questions I had in mind. Nobody said no. I distributed six pieces of paper to them as answer books, and asked the questions. “The first question is on the treatment of malaria with chloroquine. Why is the dose funny, like 4 tablets stat, followed by 2 tablets after 6 hours, and then two tablets a day for 2 days? Why is it not something like 1 tablet three times a day, as most other drugs are given? The second question is how is brain death diagnosed?” I sent them away to write their answers and come back. I was confident that they would not cheat by copying one another’s answers, not because I knew of their integrity (I hardly knew them) but because I knew they would not know the answers and there was no one nearby who would tell them the answers. They came back dutifully after 5 minutes. “Give me the answer books” I said. They hesitated. “Have you written your names and roll numbers on them? If not, please do so. Otherwise I will not know which answer book belongs to whom”. They hesitated further, but made no attempt at writing their names on the answer books. “Are they blank?” I asked. They nodded. They were right. There was no need to distinguish between the answer books when all of them were blank. I collected them and said, “I will keep them. They will prove useful when you take another test later.” They kept quiet. “Considering the fact that you have been unable to answer two basic questions in Medicine and still propose to take a course in advanced Medicine, I have nothing further to say. I rest my case.” They permitted me to rest my case and did not put up any fresh arguments. I was upset because of many things. There was nothing wrong with them wanting to do a course in advanced Medicine. But they should do it when they learned Medicine, not in the time allotted to another subject. They also had to know basic medicine before taking advanced courses. They should be doing courses because they loved that subject, not because it would help them go to USA or some other exotic destination. But if they loved the subject, they would have answered at least one of the two questions asked by me. They were spending their parents’ money, which some of them could afford, but perhaps some did not and still somehow managed because the parents believed that was essential for their wards’ education.

Give Me 42 Ranchos

Three representatives of the resident doctors came to meet me today morning. They apologized for being late for the eventful lecture that did not take place yesterday because they were late, and they kept trickling in like they into the canteen at lunch time. “OK, I accept the apology” I said. But they would not go away. I looked at them with a question mark on face, silently asking what else they wanted from me. “Sir, it was an important topic. We want you to teach us that”. “No, it is not possible. I have made that timetable taking into consideration the existing schedule of clinical meetings, holidays, and days convenient to the teachers concerned. Now there are no free slots left until the series gets over.” They continued to look at me, hoping I would give in. But I could not give in because there indeed no free time slots to teach them. “Besides, I am disturbed by a few things. You all seem to have a lack of interest in the education they get or are offered. Your walk is sluggish, your movements are lethargic, and your looks are of disinterest. You seem to be going through your residency waiting for it to run its course, rather than enjoying what you do, and what you learn in that process. You do not show any enthusiasm for seeing new things, doing new things, and learning something new every day.” They kept quiet. I don’t know whether what I said to them registered or they were just waiting for the old man to get his feelings out of his chest. “You seem to be spending your time doing things because you have to do them, rather than because you want to do them, and because you enjoy doing them. You don’t seem to be reading your books, and when you do, the effort seems to be aimed at passing the exams rather than acquiring knowledge that you will cherish. You seem to be like the average students in the movie ‘3 Idiots, and not one of you seems to be like that fellow Rancho in that movie”. Mention of that movie seemed to kindle a spark in their eyes. At least I am hoping I saw it. “Actually I don’t want one Rancho amongst 42 of you,” I said, “I want 42 Ranchos in my department. I promise I will teach you if I see that change in you”. They went away after that, to become Ranchos, I sincerely hope.

My Heart Bled

I guess I have seen so much pain and suffering in my 29 years as a doctor, that pain and suffering would not touch my heart again as it does a non-medico’s heart. But they do. I have seen so much trouble added to suffering of poor patients by neglect of duty by those employed for that express purpose, that I thought nothing would hurt me any more. But I was wrong. It is usual practice to send blood samples to the laboratory in the hands of patients’ relatives that it may be put down as standard operative procedure (SOP) on the website of different departments. A few days ago I was sitting in my office when I happened to glance up from my work and happened to see a very old man shuffling towards the laboratory just beyond my office. He had a small bottle with blood in it, and a form of request for a blood test. There was something in the way he carried himself, bent with age but still proud and moving with a purpose. I left my work, got up, and went out. I stopped him and asked him, “What do you want, Sir?” “I am taking this blood sample to the laboratory” he said. “Did they not have any servants in the ward?” I asked. I knew there were servants in all of my wards, but their physical presence did not guarantee they worked as required. “I don’t know,” he said. “The nurse said it was urgent, so I brought it myself. It is my daughter’s. She is in labor.” Since he had reached the laboratory, I did not stop him. After all, he was a father trying to do his best for his daughter who seemed to have some emergency, and delaying him would trouble him further. He went into the laboratory, while I rang up the ward and asked the nurse why she had sent the old man with the blood sample. “Sir, we have only one servant. The sweeper is absent for last one week. The servant has gone to the laundry to get linen.” I had no solution to the problem of servants not reporting to duty, servants not being sent in place of absent servants, and servants on duty not doing their best at all times. I had no administrative control on them, and our complaints were not addressed by those who had these powers. The Dean who was in office that time had wisely shook head and said ‘yes, something must be done about the servant problem’ has superannuated and used this stepping stone to go even higher. I have not been able to get the old man out of my mind ever since, and thought there could not be anything worse than that. I was wrong again. Today I was rushing to a meeting, when I found a middle aged woman limping horribly while pushing a wheelchair. There was a sick man on the wheelchair, probably her son. She was taking him along the long corridor somewhere, probably back to his ward after getting a radiograph or ECG done. Every step of the way seemed to be painful for her, and still she was hurrying as much as she could. Perhaps he was due for some sort of treatment and it was already late. I wanted to stop her and push the wheelchair, but I had no time. And how many wheelchairs would I push every day? I wondered where the servant of the concerned ward was, and what he or she was doing. I also thought the patients’ relatives were not complaining because they at least had stretchers on trolleys and wheelchairs to move their patients, or they would have to carry them on their shoulders or backs to wherever.

The Tragedy of Postgraduate Teaching

I had planned the lecture series well. The time had been kept between 4 and 5 P.M. so that all residents except a few in the emergency room would be able to attend, since the routine operations and outpatient clinic would be over by that time. The teachers had been against this because it was beyond their duty hours. But when I explained the need that the residents could not attend lectures between 3 and 4 P.M., all except one teacher had readily agreed to teach at that time. The topics were suggested by the residents themselves; probably those they found difficult or important or both. I had made attendance compulsory, just in case anyone did not feel like attending. A post-test was scheduled after each lecture, so that the residents were forced to pay attention, just in case anyone decided to sleep or dream. I wound up an important meeting and reached the venue exactly at two minutes to 4 P.M. There were only 6 residents there. The number gradually increased to 15 by 4:10 P.M. and 36 by 4:25 P.M. I asked them their reasons for coming late, and only four had been busy in the emergency room. All others had been doing something else or nothing, and still had been late for the lecture. I got quite upset that the very residents who wanted lectures on these topics and for whom we were teaching beyond our duty hours. I had spent quite some time preparing for the lecture, as one normally does. I had spent two hours making five sets of questions papers, each with 10 questions in different order, so that they could not write the neighbors’ answers and get away with it. I decided to give them the test, and the results of their test are as follows. Yr Number of Candidates with Marks 0 1 2 3 4 5 6 7 1 0 1 4 4 3 2 0 0 2 2 1 2 1 5 0 0 3 3 0 1 2 2 1 1 0 1 No one had 8, 9 or 10 marks out of 10. Only 4 had 4 out of 10. Two had 0 out of 10. The third year residents had the lowest scores, though they were scheduled to sit their MS examination in 3 more months’ time. I was extremely discouraged by their attitude as well as performance. One may say they could not be expected to answer questions without being taught on that topic. That would be correct except for the fact that the questions were based on theory taught to undergraduate students, and practical training they received practically every day in the outpatient clinic. I left them without teaching them a single thing on that topic. I further told them that the lecture series would be cancelled, since they did not seem to be keen on it and it was forced on their teachers anyway; unless they submitted a letter signed by them all stating that they really wanted the series, and would be present for all the lectures before their teachers arrived to teach. It remains to be seen what they do. In the meantime I am feeling very much down, and as tired as after running a half marathon.

Unhealthy Practices

The poor fellow was running with two small bottles of blood samples in his bare hands, and test requisition forms in the other. Taking blood samples to a laboratory is a job done by a person employed to do it. He goes to all wards and collects all blood samples on his trolley. Here was an intern trying to do it. I stopped him and asked him what he was doing. He was reluctant to stop, his attention outside the door. But he did stop and said “I am taking these blood samples to the fellow with a trolley, who has gone with the other blood samples”. “Do they not supply you with gloves?” I asked. “Don't you know better than to handle blood samples without gloves? Have you not heard of HIV and othe blood-borne infections you can catch by handling blood without protection?” He did not answer that question. Instead he said “That fellow is in the next ward. I have to give him these samples.” I let him go, because if he missed him, he probably would have to go to the laboratory himself. Why the servants would not do the job is obvious – they don't want to work if they can avoid it. Why the sisters under whose control they are don't make them work is perhaps less obvious. They might be afraid of something. Why the administrators who control the servants won't make them do their work is perhaps fear of trouble from the servants' union. I asked the concerned unit residents why they had made that fellow do a servant's work, and they had no answer. I also asked them why they had not educated him about safety measures in handling blood, and they had no answer to that one also. Finally I asked them to see to it that they they did not make doctors in training do servants' work. They promised to do that. All this was being watched by their boss, who was in his street clothes taking ward round with them. He appeared aloof, as if he had nothing to do with all this. I asked him if he did not even have an apron as was required. He immediately said “I couldn't find one. I looked twice.” I was aware that he always came up with an excuse, like school children do. I was also aware that his aprons were very much in the bundle in which all aprons of staff memebrs are kept after they are returned by the laundry. I had seen them while getting mine. I just made a gesture of hopelessness. “I will look again” he said and went away. He came back in one minute wearing an apron. I did not ask him how he found one when he had failed on two previous occasions. I knew he would have said “it has just come from the laundry” or some such thing. The previous time I had found him telling untruth like this in connection with a resident doctor and confronted him, he had thrown a tantrum, said a lot of irrelevant things, had developed tremors, and I had got worried he would perhaps break a vessel in his head or something. It was not worth it, bexcause his tarck record showed he had never changed for better. What troubles me is that the residents working under such a person may also pick up such traits, which will be detrimental to themselves as well as to the institute.

Professor of Repair and Renovation

Actually the architect and the contractor were hand in gloves in the matter of repair and renovation of our building. They were seriously behind schedule, and wanted to find a scapegoat. They thought I would do well as one. Maybe they got the idea from one of the coordinators who had tried to do the same to me during the reign of one of the past Deans. “We cannot work because the entire ground floor is full of stuff that the user department has not shifted out" the contractor said. I was the head of the user department. The statement was wrong because the contractor had supplied people to shift stuff out of our vacated department to a godown he had build, under instructions from the architect. “We handed over the premises to you," I said, "and you were to shift stuff out to your godown." "The godown is full. It was decided in the Dean's meeting that the user department would find place to put the stuff” he said and flashed a paper in front of me.” ''That is not my job," I said. “Don’t say it is not your job” shouted Professor of Repair and Renovation (who is actually a professor of one of the paraclinical departments, but has devoted his life in the institute to the building repair and renovation” “Please don’t shout” I told him firmly, partly because he was shouting right into my right ear, and partly because I don’t like people shouting at me, definitely not when I am right and they have no authority to shout at me anyway. He stopped shouting. "I don't have any authority to use any space in the campus unless it is given to me. Show me the paper.” The contractor handed the paper over. It had nothing to this effect. “There is no mention in this document that I had to find space to store the stuff while you repair the building” I pointed out. “No, it was said but was not written down” said the contractor. Either he was dumb and did not understand procedures, or he thought I was dumb. Who is supposed to decide where to store stuff? Call that person" I said. The Professor of Repair and Renovation (we shall call him Professor of RR in short form) knew who it was, and that person was then duly called. I wondered if he knew who that person was and why he wanted me to say it was my responsibility. Either he was dumb, or he thought I was dumb, or that he could just bulldoze me by shouting at me. The concerned administrator came and when he learnt that the work was stalled for a month and a half, he asked why he was not informed a month and half ago? “Let it go, man” said Professor of RR. "Now let us find a place to keep the stuff.” While they set about finding a place to store our stuff, I wondered if Professor of RR was also hand in gloves with the architect and contractor, since he seemed quite keen to cover them up, while as a person devoted to this work he should have known the problem and sorted it out as soon as it came up, or at least informed our department’s professor of repair and renovation to have it sorted out. Before thy decided to go out and look for space for storage of the stuff, I broached the subject of their running the water and drainage lines right through the middle of our operation theater roof. The architect said it could not be changed. Our department’s professor in change of coordination of this work said, "If it cannot be done, let us keep it that way and move on." "No," I said, "you will retire in two years and me in five and a half years. That we will not be here to suffer from a water leakage into the theater is not justification for allowing it to happen. As head of department, it is my duty to see that things are done the right way, so that there is no trouble in future." That quieted him. Just then the Director arrived. When he was through admonishing the architect and the contractor for tardy work, I explained my problem to him. He firmly told the architect that the pipes had to be relocated to the outside wall. “But what we are doing will ensure there is no trouble for 7-8 years", the architect said. “NO, we want work done that will ensure no problems for 20 years," the Director said. “You cannot say there will be no leakage until the monsoon or something like that." That was exactly what I had been saying all along, and the architect was ignoring me. But he could not ignore the Director, and meekly agreed to do the needful. Later in the course of the on-site round, our Professor of RR kept finding fault with my logic and reason-based approach and kept telling me I should change the way I worked. He kept telling me we had to do work that others would not do, so that the project would progress. I could not see the logic behind it. It would be more appropriate to make people do their own jobs. If I had to do those, I would have to leave my own job to others like this professor did. Finally I got bugged and told him, "See, I do my job using my left brain." "No," he immediately contradicted me probably out of habit, "you should use the right brain.” I was nonplussed. “No, never," I said, "the right brain is only for forwarding e-mails to other people." This was I think a good one - the architect whose inadequacy I had just exposed grinned all over his face. As an afterthought, I feel perhaps he disliked this Professor of RR even more than he disliked me because he bugged him every day while I bugged him once in 3 or more months.