Residents' Quarters

I was a resident doctor between 1980 and 1983. In the first year as a house surgeon, I shared a room in the residents' quarters with another resident doctor. Then I became a registrar, and had a room of my own, not shared with anyone. It had an attached toilet and bathroom too. Even if I spent the whole day and some part of the night working, I had my own room to go to, to scatter my books and read them when I pleased, to sleep without disturbance of the room partner's activities when there was time to sleep, to keep my things without worrying anyone would touch them, to go to the toilet and bathroom without having to stand in a queue. In 2010, there are more than 50 residents in my department while there were only 18 in the period from 1980 to 1983. Residents who have completed their residency but have not appeared for their exams (which are usually 2 months after the end of their residency) continue to occupy their rooms officially. They have demolished one hostel building because it was certified unsafe for occupation. Surprisingly it was the newer building, while the older building continues to be solid and dependable. New one will bve built in due course. New residents who come from all over our state as well as from other states in the country have no place to stay in the campus. They have to stay at a place where I would be reluctant to let my son stay if the situation arose, and definitely my daughter if I had one. I hear the boys stay on the ground and first floor, the girls on the second and third floors. There are no toilets, bathrooms and wash basins on the first and third floors. They have to walk down one floor to attend to those needs. The girls take a taxi at 10:30 P.M. to go to their rooms and another in the morning to go back to the hospital. I am scared as a third party, so I can imagine how scared their parents must be. I spoke to the professor who is in charge of the committee for residnets' quarters. He said it would be sorted next year. God be praised.

Stretches in Office

They repaired the college building and renovated the offices too. Instead of the old arrangement of tables in a row with chairs behind the tables for the office clerks and standing spaces in front of the tables for visitors including us doctors, the put up cubicles with tables and chairs inside for the office clerks and standing spaces in front of the tables for visitors including us doctors. It was supposed to be like corporate offices, I suppose. Unfortunately there was a mix up somewhere and the heights of the cubicle walls was nearly 5.5 feet. So the people standing outside have now to stretch their lower limbs and stand on their toes in order to catch a glimpse of the people inside the cubicles, and maintain that position to carry out any conversation with them. The office clerks may be happy because they suddenly have a privacy they never had before. No one can make out if they are manning their stations or are away, just by glancing into the office from outside. Theya re unhappy because the single ceiling fan does not provide any breeze that can reach inside the cubicles. The thickness of the walls of the cubicles is about a foot or so. They will probably stop bullets if there is war or terrorist attack. But they have taken away precious floor space. The offices used to look decidedly untidy and dirty in the past. Now they look decidedly discouraging and unfriendly. One advantage of the arrangement is that it makes visitors perform lower limb stretches, which helps loosen those seldom exercised joints, builds those seldom exercised muscles, and may increase height of those whose epiphyses have not yet fused.

Unusal Ovarian Tumor

A 65 year old woman presented to us with a huge distension of the abdomen for two months. She had had two cesarean sections in the past, the two scars starting froma point above the pubis and diverging through an angle of 5 degrees towards the umbilicus. Clinical examination revealed a 36 weeks' size ovarian tumor. It was confirmed by ultrasonography. We scheduled her to undergo a laparotomy after she was somehow made fit for anesthesia after 1.5 months. The anesthetists said they would give anesthesia only if a ventilator was kept ready for her. That was tricky, since there is always a great demand for ventilators in our institute and we have had to postpone operations of high risk patients a number of times because all ventilators in the institute were in use. Luckily one was available for her on the day we proposed to operate on her. Unfortunately I was asked to attend a meeting and could not operate on her. I asked my juniors to operate anyway, but they did not, because my lecturer did not know how to perform an omentectomy. I was upset, because there would be no guarantee that a ventilator would be available the next week. The woman was indeed lucky. It was available. I operated on her. She was lucky again, because had they opened her abdomen the previous week in my absence, my lecturer would not have been able to handle the situation. The tumor weighed 12 kg. It extended to the pelvic floor below, liver and spleen above, and the flanks on the sides. It was adherent to the anterior abdominal wall on the left side, the small bowel posteriorly on the right and retroperitoneum on the left. I removed the entire tumor, the uterus, tubes, ovaries, and omentum. She had hypotension for two hours (systolic blood pressure of 80 mm Hg, but she recovered well.

Volatility in Residency

Volatility in Residency is something that does not make sense to me. One would think that if a doctor opted for a particular subject for his or her postgraduation, he would be quite enthusiastic to learn everything that could be learned. There being no way better than working in management of patients, one would expect these residents to work as if possessed. Well, it is not so, and that is what does not make sense to me. There is a trend towards just disappearing from work, without telling a soul about it. The said resident just ceases being seen around some time during duty hours. The mobile phone is switched off. The local guardian does not know where he/she is. The parents are emphatic they have not heard from the resident. The boyfriend, fiancé, or husband as the case may be, also does not know the whereabouts of the missing resident. The co-residents and staff members are worried stiff because the city has its share of crooks and the girl-resident from another part of the country might be in a bad situation. Or she might have been under stress and might have done something like perhaps a suicide. The administration is informed about the disappearance. After a couple of days, it is learnt that the resident is safe with a friend, having gone away because she did not feel like working or something to that effect. We had this girl who would just go away on a Sunday morning, even if she was on duty. She would regularly do the disappearing trick. The psychiatrist said it was due to difficulty in adjusting to the stressful environment of the hospital. We had another girl who would disappear similarly. One morning she was woken up by her roommate for going to the wards and working. She got ready and went back to sleep. The roommate woke her again. She left for the ward, but never reached it. After the usual sequence of events, she was found three days later with her brother in a remote town. She said she did not know how she reached the airport. Since she was there, she purchased an air ticket and reached her brother’s place. The parents did not know all this. This week two girls did the disappearing trick. Both seem to be OK at present. That they don’t have the responsibility expected of a doctor on duty is upsetting to me as a head of the department. That they don’t care to inform their near and dear ones is upsetting to me as a parent myself. That they don’t care to inform their friends is upsetting to me because it reflects on their poor social quotient and I cannot do anything to help.

Age To Become a Doctor

It was a meeting called by ther secretary of health, and many of us were asked to attend. It was concerning changes proposed in MCI. Basically it was to get opinion on three types of changes, and to help select one of them. However there was a big communication gap, what may be called a communication divide, and people went there hoping to suggest a large number of changes in MCI. It was to be an opportunity of a lifetime, and if we did not avail of it, all would be lost. The organizers restricted speakers to opting for one of the three options, and prevented them from making any other suggestions. After the whole thing was over, one of the professors near retirement said something which appealed to them. He said, “ My son is in an engineering college. What he learns there is same as what medical students learn in medical colleges. He learns structure and function of machines. They learn structure and function of human body. I think the age at which students join a medical college is very small. They are immature, and not fit to learn medicine. They need to spend a year on psychology, communication skills and such. Then they will be able to break news about a patient's death to the relatives. When I was a 23 years old intern intern, I was told to tell relatives of a patient about his death, and I did not know how.” I was aghast. Students join a medical college at the age of 17 or more. When they become doctors, they are 23 years old, which is long after they become mature to break bad news to relatives. In fact, they are mature at 18, when they are allowed to vote. By the time they complete their bonds and postgraduation and subsequent bonds they are 30 years old. By that time more than one third their life is over. By that time their engineer friends have been earning for 9 years. In my opinion it is extreme cruelty even to consider adding one more year to their period of education. Even if it were a just idea, I wonder why the professor had to wait till his age of retirement or until after his son's admission to an engineering college to discover this.

Attitude 11

It happened while I was on vacation. One of the patients transferred to us in labor underwent an emergency cesarean section for placenta previa. She was found to have partial placenta accreta. The obstetrician managed to remove all placenta and control placental site bleeding with underrunning sutures. Postoperatively she developed abdominal distension which kept on increasing. An ultrasonic scan showed a large hematoma in the left broad ligament. A CT angiography was done, which confirmed the presence of the hematoma, without any vessel bleeding actively. She was explored immediately thereafter, 4 days after the cesarean section. At laparotomy she had a clean abdmonen and pelvis. There was no extraperitoneal hematoma. The abdomen was closed. When I met a senior staff member from the department of radiodiagnosis, I gave this feedback. That person said “if two radiological examinations (USG and CT) showed a hematoma, it must be there. How can it not be there?” I said there were 4 senior witnesses, just so that a claim of negligence in noticing the hematoma was not made. She said “perhaps it was dissolved and absorbed due to medication.” I wanted to know which medication would achieve it, so that we would give that to all patients like this instead of exploring them. She had no answer. So I said the problem was in her department, and she better sort it out. She immediately went on the defensive and said, “it is always easy to put the problem in our department.” I was stunned. That a visual diagnosis should be claimed to be wrong believing two imaging modalities, and that no effort should be made to correct the error were two different things, both of which were beyond comprehension.

Date… Anyone?

I was busy in the outpatient clinic seeing new as well as old patients. There was one whom I had advised a transobturator tape insertion for urinary stress incontinence and a posterior colpoperineorrhaphy for a rectocele and perineal defect. She came back with reports of investigations we had advised. She was seen by an intern. She wrote the patient had come for a date, and sent her to see me. I was surprised why a middle aged, married, parous woman would come to the hospital to find a date. I actually suspected that it was for an appointment, not a date. So I called that intern and asked her if she saw anything wrong with what she had written. She couldn’t. I asked her the name of her school (school as in school, not medical school). She was confused by that question, but still told me a name which was unfamiliar. So I probed further and discovered it was an English medium school, not a vernacular one. Then I asked her why she thought a patient would go to a hospital to find a date. She thought for a while and blushed when she realized her folly. She had literally translated the patient’s request for an appointment for her operation from vernacular into English. I asked her to tell me her name, which she did. I explained I planned to put it on my blog, and that she would soon be famous. Though she dared not say anything to that one because I was almost thirty years her senior, and also Professor and Head of the department from where she would have to get a completion certificate, the look on her face was enough. I will not disclose her name here (I wouldn’t have, anyway!)

Phobia in Obstetrics & Gynecology

One would think phobias were in people and were described in Psychiatry. There could not be any specifically in Obstetrics & Gynecology. Well, it is there in all branches of Medicine, especially in the surgical lines, in all people in all wakes of life. I am writing about Obstetrics & Gynecology because that is my specialty. It is phobia for HIV. There is reason enough for the phobia. There is no guaranteed cure for the disease, and it can spread to the doctor on contact with the body fluids of the patient. But we have to do what we have to do – treat patients. There should be no place for a phobia. But it there all right. We had this fourth year resident, who had this phobia, but would not admit it. It was our Gynecology operation day, and it was her turn to operate. The patient was HIV positive and was scheduled for an abdominal hysterectomy. She said she would rather not do the case, because she was not very confident of performing an abdominal hysterectomy. So my Associate Professor said it was all the more reason she should operate and get more experience. We always assist residents, even if they are qualified. There was no way out, so she finally did operate. But she kept asking the Associate Professor to do whatever she thought was tricky. At one stage they told me the posterior pouch was obliterated by dense adhesions and it would best to perform a subtotal hysterectomy. I offered to help separate the adhesions, but they said no. They finally performed a subtotal hysterectomy. We had this Lecturer who was quite senior. There was a HIV seropositive patient who needed a cesarean section. He did not want to operate on her. I always do whatever my juniors cannot do or will not do. But he would not say why he did not want to operate. Since he could not get anyone else junior to him to operate, and since he dared not tell me to operate without any reason for his reluctance, he started the operation. But he sent for me soon. I reached the OT. The baby had been delivered. He said there was a tear in the lower segment close to the bladder, and he did not know what to do. It was a small tear, and I was sure he must have dealt with far worse cases. I washed up, dissected the bladder away and stitched up the tear. I asked him if he would be able to deal with such a situation in future, since I had shown him how. He could not say no. Then I asked him if he could do the remaining operation as usual. He could not say no. SO I left him and he completed the operation. Luckily for us or him, he got a transfer to another institute soon after. Then we had that Associate Professor in another unit, who came to the OT with band aids on both the hands for cuts, he said. There was a HIV seropositive patient scheduled to undergo hysterectomy that day, and in the opinion of the unit Professor, that was the reason for the band-aids, not any cuts on the hands. There was that same Professor who had another HIV seropositive patient who required a hysterectomy. She tried to send the patient to a laparoscopic surgery workshop, but they did not want a seropositive patient. Medical treatment could not be given because the patients had large leiomyomas which would not respond to medical treatment. So the patient was finally scheduled for an abdominal hysterectomy, and another Professor heading a junior unit was called to operate on the patient. He consented for the sake of old friendship, performed the hysterectomy while our professor observed, pricked himself accidentally, and then took the prescribed course of chemoprophylaxis.

Pathogens? What is That?

When I got selected me as a lecturer, they sent me to the most peripheral hospital, saying that was the pattern they followed for IAS officers too. They had lied to me, so that they could accommodate someone lower down on the merit list in the topmost institute. They had sent orthopedics number one to the topmost institute and the last candidate to the most peripheral institute. Both Gynecology and Orthopedics interviews had taken place on the same day. All candidates selected in interviews conducted after that day were treated the same way as they treated me. SO be it. The reason they sent me there was for me to improve that hospital, they said. I believed them. There was need for improvement. Soon after joining that hospital I found out that the used surgical gloves were washed, dried, and powdered for reuse. It was done because the funds available were low and disposable gloves would not fit in the budget. What was upsetting was that the gloves were never sterilized. The servant would spread them on the floor, roll them in talc also spread on the floor, fold them neatly, and then put them in a drum meant for an autoclave, but which never saw the inside of an autoclave. The doctors and nurses in the hospital had been using such gloves for conducting deliveries, suturing episiotomies, applying vacuum and obstetric forceps, and performing blunt curettage for incomplete curettage. This had been going on probably from the day the hospital started years ago. The most surprising thing was that none of the patients developed any infection. I talked to the people concerned, and started getting the gloves autoclaved. I got transferred to the central institute after ten months. I hear they have gone back to the original practice some time after I left. The other day I found a second year resident suturing an episiotomy without a cap, mask, sterile gown, and without a sterile drape on the patient. The gloves were sterile, because we insist on that. It seems that was her usual method of working, and no patient had developed any infection in the one year she had been working as a resident doctor. I talked to her and found out she knew about microorganisms and principles of surgical asepsis and antisepsis. I extracted a promise from her that she would follow all those principles meticulously hence forth, but I doubt she will keep her promise. I have finally understood I can change only myself but never the rest of the world. The world has to feel the need for a change and has to change itself. In the meantime, since episiotomies are not gaping in both the peripheral and the central hospital, I wonder if the pathogenic microorganisms actually exist or it is just a lot of hype created by manufacturers of things required for preventing infections, and by pharmaceuticals manufacturing antibiotics. Just joking :-)

Paradox in Medical Education

A student goes through a lot of effort and competitive examinations to become a doctor. He studies day and night, attending school and coaching classes or private tuitions in the tenth standard to get good marks to ensure admission in a good college. Then he bunks college lectures and attends coaching classes and private tuitions to get good marks in common entrance test to get admission into a good medical college, and if that is not possible, any medical college. He studies 5 or 6 books minimum per subject to ensure a good score. Once he enter a medical college, he bunks classes and wards, does not attend private coaching classes or private tuitions, reads maximum one book per subject (that too the smallest possible, perhaps a guide or one bordering on a guide) to pass with 50% marks. Then he spends one year of internship solving multiple choice questions as preparation for postgraduate common entrance test, not doing what he should be doing as an intern (i.e. application of what he is expected to have learned as a medical student). As a postgraduate, he spends two years and 9 months working as a resident doctor but reading practically nothing, and then three months (the period of exam leave) reading whatever everyone reads to pass the postgraduate examination. There is something seriously wrong if he makes his best effort in the twelfth standard and the worst in the course of his medical training. What is even worse is he refuses to understand this and change for better even after counseling.

Rat Race to Medicine

A close family was visiting us today. Both the parents were doctors. The elder son was in the twelfth standard, gearing up for the entrance test for admission to the medical course M.B.B.S. He had joined a prestigious coaching class for getting coached for the common entrance test he would have to sit after the twelfth standard exam. “The pressure of the studies is too much” said the mother. “He is feeling toxic”. “It was so at the time of our son’s exam too” my wife said. But he had opted for engineering, not medicine. “Our don has no time to do anything else. His teachers at the class are very strict. When he did not do well in a unit test, the teacher confiscated his cell phone. He returned it only after he reached top grades 15 days later. He was right. Our son used to be glued to the cell phone all the time.” “Now he is not glued to it?” “No. Not after the cell phone has been confiscated again” said the mother. “Again?” “Yes. His grades dropped after the phone was returned. Now it won’t be returned for three more months, and that too if he tops the class. We agreed with the teacher. He cannot finish studies if he is distracted all the time. He has to read six books for each subject, besides the notes given by the coaching class. He has to solve multiple choice questions from three books. Each question’s answer has a reference to one of the six books.” “Is he studying the subjects in first or is he studying them by solving the questions?” I asked. It appeared it was both ways, but more by solving the questions. “But then he will be a trained expert at solving the questions rather than a student with an in depth knowledge of the subjects” I said. They agreed. “And where is the joy of learning?” They had no answer to that one. “The teacher wants him to drop mathematics and take psychology for the board exam. He gets three days after all other papers to prepare for it. It seems it is a scoring subject.” I was stunned. Giving up mathematics for psychology, a subject one has not been exposed to ever, only for getting into a medical college? It was indeed a rat race, and we had not realized when we had turned our beloved brats into those rats. These same people would later study multiple choice questions rather than learn medicine for getting admission for a postgraduate course. I was thinking of the famous movie ‘Three Idiots’ and its message when our guests left.

Psychiatric Illness in Obstetrics Gynecology

There was that upsetting news in the newspapers sometime ago about resident doctors in another institute revolting against a professor. All revolters were women and amongst a host of allegations was one on sexual harassment. It seems they had appealed to the human rights commission too. The truth of the matter is not known to me. But it brought to mind painful memories of a time now long gone. Early eighties was not a time when people were aware of human rights and measures to control sexual harassment at workplace. We just believed everything was as it had been in our upbringing. Perhaps there would be some bad sheep, but not where we were. I must have been quite naïve. (Recently one of my told me I was very naïve. How she understood this is beyond me, because I thought I put up a very professional and shrewd appearance. I think I did not change at all over years.) We had this Associate Professor, who is now retired, but still around somewhere. She must have been 12 years senior to me. She seemed to be like everyone else, until one day she changed my opinion. I was assisting my boss for some abdominal operation. There was another assistant by my side. We were both reasonably tall and it would be difficult for anyone to see over our shoulders. We had wooden platforms for short people to stand on and see over the shoulders of the assistants. This Associate Professor came into our OT and stood on one such platform behind me and leaned forward to peep into the operative field. I belonged to a culture where men didn’t touch women and women didn’t touch men freely, unless they are very closely related. I was shocked when she put her front against my back, without even a hand in between. I did not know what to do. She was Associate Professor while I was a mere resident doctor. I dared not tell her that I would move away so that she could see better. She moved away after a couple of minutes and I went back to assisting. I was sitting at my desk that evening. My batch mate and neighboring resident noticed my pensive mood and asked me what the matter was. I told him. He started laughing. I asked him what the matter was. He said she was known to do that regularly. He further said her husband used to do that or more to women residents in another institute, and that it must be some psychiatric illness in the family. I had studied psychiatry as an undergraduate student, but had not heard of such a familial illness that affected husband and wife who were not blood relatives.