Non-issue

I thought I was being reasonable and democratic in my management. We had seventeen new lecturers, to be distributed in six units. We have three units with one professor, one associate professor, and one lecturer each. One unit had a professor and an associate professor. The next unit had a professor and a lecturer, and the last one had an associate professor and a lecturer. So I proposed we placed one lecturer in the fourth unit, and two each in the fifth and sixth units. That made three staff members in each unit, as required by the medical council. Then the remaining lecturers were distributed in all units so that each unit had equal number of staff members. Two were extra, who were placed in the first two units by seniority. That put four lecturers in unit numbered one, two, five, and six each, and three lecturers in the remaining units each. The second unit had seven qualified doctors counting a senior resident, while the third unit had only five because there was no senior resident there. We decided to shift the senior resident from unit two to unit three. We then had seven qualified doctors in the first unit and six each in the remaining units. This distribution was unanimously approved by all staff members. I went home a satisfied person. Happiness sometimes does not last long. Mine did not this time. Next morning the head of unit three approached me and said she did not want the senior resident given to her from the second unit. She said she should have one more lecturer, while unit six should have one less. It took me a half hour to do the entire calculation again and show her that the last two units had to be given four lecturers each because they were with only one staff member each above the level of a lecturer. It took me time, but she was somehow convinced that it was a correct (though an unhappy) arrangement. Head of unit two was on leave to grace some conference and so was head of unit six. Today morning the head of unit two came to me and demanded, “I would like my senior resident returned to me and a lecturer from the sixth unit should be shifted to the third unit. All other doctors in my units are new. This resident knows my work style and preferences. The sixth unit head is a mere associate professor and should do with only five qualified doctors instead of six.” “But our distribution is made not for comfort or happiness of unit heads, but to ensure that there are equal number of doctors to treat patients, who go to all units equally” I said. “You have four lecturers, of which one has worked with you for a month already. And your associate professor has been with you for ages.” He made a hand gesture signifying little respect of both of them. That was surprising, because both of them were good. I could not see what a senior resdient would do that an associate professor and four lecturers could not do. One unit head did not want that senior resident and this unit head wanted him, but the situation was such that the wish of neither of them could be satisfied. “I request you to do with the doctors you have. If I reshuffle doctors in a matter of four days without a sound reason, they will develop a feeling of insecurity, which is not good for morale.” “So you won’t do it!” he said and went away in a huff. When I related the story to other staff members, one associate professor made a very valid comment: “I think the whole thing is a non-issue.” It was indeed an non-issue. I would have indulged in self pity if I could, for having to put up with unit heads who wanted personal whims satisfied at the cost of disturbing democratic working, believing they deserved better things than others because they were senior in position, forgetting the primary purpose of the institute was patient care and not keeping senior officials in physical and mental comfort.

Gentleness and Finesse

Normally I do not say something that is not straight. I prefer people do the same with me. Some people don’t get the idea and bug me. If they do, I end up saying something spontaneously, that no I could never achieve by meticulous planning. It is about the same Head of Department, Dr XXX who kept claiming they had as much work as we had, and did it far better than we did. I would not mind it, because I know there can be institutes better than mine, and people better than us. But if it is a make believe, I don’t want to stand silent witness to such claims. This person would say those things every time feeling lousy, and would keep feeling lousy. She would proclaim whatever she wanted in a voice that would do well on a parade ground, both in volumes and authority. She would have something better to say about herself and her people when we said anything about us. The last say on any matter would be hers. I was never in competition because I knew there was no competition. But to suffer silently for whatever time we forced to be in the same room was something I did not need, nor deserve. The last meeting was a time I managed to stay reasonably away most of the time, so that I did not suffer as much as usual. But she did manage to irritate me quite a bit. Then we were served tea. She did not want sugar in hers, and a Dean also did not want any. The Dean shook out a tablet of synthetic sweetener out of a small box and put it into her tea. Then she offered it to this Head of department too. She took the box, and struggled to get a tablet out. It wouldn’t come out. She pressed the box on all aspects, but to no avail. "There must be a button to be pressed" I offered. She pressed whatever that resembled a button, without any result. "You must get this box repaired so that it works" she declared. The Dean was apologetic. "It does act up a bit sometimes" she said. "Here, let me do it for you." The box was returned to the Dean. She held it delicately, pressed it seemingly effortlessly wherever it was to be pressed, and out popped a tablet. She handed it over to the Head, who took it without comment. "XXX Madam, you have to do it gently and with finesse" I heard myself say loudly enough for everyone to hear, though in a friendly tone. The Dean was pleased, because it implied she had gentleness and finesse, which she did have. "Yes!" she enthused. "It is not like the clamps you apply during the operations you perform." She mimed the process of application of a clamp with her hand up in the air, fingers spread out widely like for strangling someone, and then closing her fist furiously around an imaginary clamp. The target of all this kept her mouth shut, an unheard of thing in her life. She prided herself in her appearance, style, and superiority. What transpired must have hit her below the belt. I actually had played without premeditation a masterly move, criticizing her but stopping retaliation by recruiting her senior officer as my ally in the game.

Lost Marble(s)

I thought we were quite sensible and would never lose our marble(s). Just goes how wrong I can be sometimes. Our operation theatres were state of the art. The walls up to the ceiling and the floors were of marble. It used to look good, feel cool, and was durable. Unfortunately the slabs and walls underneath were old and getting older every day. So they undertook repair work that was overdue by thirty years, said the civil engineer. When the discussion got around to what would be put on the walls. “My OT is made up very well, with fine marble and all, and should not be broken up. Repair the rest of the building” the Boss said. “The floor and walls underneath the marble had all but gone, causing all the leakages of water in and out of monsoon“ the architect-consultant told him. “I will remove the marble and repair those.” “You will have to put marble on the walls and floors, of as good quality as the original” the Boss said. “Your existing marble is of second quality. I will put first quality marble” the consultant said. The Boss’ face fell, because the consultant had criticized his marble, and was promising to put better one after repairs. “OK” he said. Months passed. Then they showed vitrified tile sample to our professor and said those tiles would be put on the OT floor and walls. We were aghast. It was against the original agreement. We protested. “The Boss has consented to vitrified tiles” the consultant said. He was the same old one who would say I had signed the plans whenever we found fault with his work. I contacted the other heads of departments concerned and asked them if they knew about it. One did, the other did not. The first one did not want to protest against it. I wrote a letter of protest and left the result to merciful Gods. Perhaps it was divine order that had changed things. The contractor had taken away our original marble and was giving us far cheaper vitrified tiles instead. He must have made a lot of profit in the bargain, both having got good marble and not having to spend on new marble but on a far cheaper substitute.

Higher Institute

It is a matter of pride for me that I work in the institute I work in (bad grammar, probably). I know it is one of the best. There are other hospitals run by the corporation in the city, also with attached medical colleges. But not as good as mine, I feel. When I talk to some others working in those institutes, I gather they feel the same about their institutes as I do about mine. In fact, one of the heads of departments keeps saying every time how superior they are to all others. If I say we are overcrowded, she says so are her wards. If we discharge thirty patients a day, so do they. The story told by people who are transferred to our institute from there is at odds with this story. The hospital looks like one in the developed countries, with large wards and long corridors, all almost empty. The doctor patient ratio is probably better than in the developed countries, not because there are a lot of doctors. Still I don’t grudge that Head of department her feelings about her institute. We met at a selection process recently, and I received a booster of her usual claims. What came as a surprise after the booster was the referral of a patient with genital prolapse from her institute to ours. Genital prolapse is a condition that any gynecologist can handle well. This one was special. She had a rheumatic heart disease with multiple valve involvement, and was on multiple drugs. Obviously she was at a great risk of anesthesia and would require intensive intraoperative and postoperative management. The referral note from that institute said “Refer to a higher center for management”. Such a reference from a poorly equipped and manned peripheral hospital is not unusual. But it was a surprise coming from a tertiary level care center, especially one whose doctors had such an attitude of superiority. I refrained from ringing her up, because she goes on defensive and then offensive when I tell about the transfers to our center from her center. Perhaps they have a phobia of difficult cases, like hepatitis E cases (three cases in last month), rheumatic heart disease (two cases in the last month), severe preeclampsia (three cases in the last month), and some more critical illnesses which involve a lot of work and stress. I had told her to hold on to all transfers until our building was repaired and we had all of our space available to us. I told her we would then take her entire workload. That perhaps was not appreciated very well by her. They continue to send the ‘bad’ cases on a regular basis. What I fail to understand is that if they send their ‘bad’ cases to us, when and how will her residents learn management of such patients and be capable of treating them when they qualify and go into practice.

Influential Brother

She was a girl in her early twenties. She came to us with vague abdominal pain, probably related to bowel upset, but during the check-up we found she also had an ovarian cyst about 7-8 cm in diameter. We performed ultrasonography and a CT scan, and confirmed she had probably a benign cystic tumor. All was going OK for her. But unfortunately she had a brother who was politically connected. So he went to the first citizen of the city and brought a reference note. I had not seen her till then. He met me during my antenatal clinic, and showed me the reference note. “My sister has this condition for which she has been advised an operation.” “That is correct” I said, seeing her examination findings and reports. “But now the anesthetists are saying she must have this X-ray and this blood test.” “That is correct” I said. “Without those tests, we won’t know if it will be safe to give her anesthesia for that operation.” “But those tests should have been done before. Now she will have to wait for another week.” “What has happened cannot be undone” I said. “She must have those tests done. If you want her to undergo further treatment, get those done. If you want disciplinary action taken against whoever who did not advise these tests before, put up a written complaint in my office. I will investigate the matter and take necessary action if required.” He seemed to understand that and went away peacefully. She came again after a week. I saw all her reports and advised a laparoscopic surgery, with readiness to perform a laparoscopy if required. She went away with an appointment for hospital admission. Her brother turned up the same afternoon during my antenatal clinic time and demanded to see me. I could not leave the pregnant women who had queued up for being examined. So I sent a message that he should wait and I would see him after the clinic was over. He sent his visiting card as reply. It said he was a lawyer. I suspected those were intimidation tactics. I told my Registrar to talk to him and ask him to wait for the clinic to get over if he desired to see me personally. She came back in five minutes. “Sir, he said he is connected to a political party which is the ruling party in this city. He said his sister is not married yet and how can she be subjected to an operation by opening her abdomen. He said he has come from the first citizen of the city. So I told him to get the operation done by the first citizen if she knew better.” “You said that?” I asked in amazement. “No sir. I said that part in my mind.” I smiled. That girl would do well in life. I finished the clinic work and called him in. “Doctor, my sister is not married. How can she have an operation by opening her abdomen?” he said. “If that is necessary, it has to be done.” I explained. “She has an illness, and whatever treatment has to be given must be given. We will try to get the cyst removed by laparoscopy, but if it cannot be done, we will open her abdomen.” “But doctor, open her abdomen through a small incision” he said. It had probably to do with her prospects of marriage. “We always make the smallest possible incision” I assured him. “If we make bigger incisions, we have to work more and spend longer time suturing it.” He did not seem to be totally reassured. “You are a lawyer, are you not?” I said. “”Yes.” “Surgery is not like law. In legal practice, longer the case drags on, more the money the lawyer makes.” “No, no!” he protested “I usually try and get quick decisions.” “I know about legal practice. Every time a lawyer appears in the court, he charges the client” I said. “A doctor does not make more money by prolonging the operation. So rest assured, we will make the smallest incision compatible with successful outcome. But if you want some surgeon who will guarantee that the cyst will be removed by laparoscopy alone, I will recommend another doctor. That one makes that promise.” I mentioned a name of a doctor in another hospital of the corporation. I did not say that doctor always kept that promise. He was probably shrewd enough to understand what I was saying. “No doctor. We want her to be treated by you,“ he said. “I will get her admitted in the hospital tomorrow.” He went away, but did not come back. His sister did not get admitted as scheduled, and the OT time slot reserved for her was wasted. Perhaps they went in search of that doctor who would give the guarantee I would not give. I wish her luck.

Lecturer Rain

There were times when out of 6 posts of lecturers in my department, 5 posts were vacant and we were managing with only one. There were better times when we had 2 lecturers. The best times did exist long ago, when we had 6 six lecturers. The administration decided to keep leave vacancies vacant i.e. Without any one appointed on that post temporarily. Then they started keeping maternity leave vacancies vacant too. When they promoted lecturers to associate professors on ad hoc basis, they kept those posts vacant, in case these were reverted. We remained perpetually short of manpower, while the employers kept saving money for salaries. Patient care did suffer, but they (would/could/) did not care. Overworked staff members left, but they (would/could/) did not care. Finally the Medical Council of India threatened to derecognize the institute because there was a shortage of teachers that was not being corrected despite three notices to the institute. They had to listen to the MCI, though they (would/could/) did not listen to slaves their employees i.e. us. MCI said we had a shortage of 18 lecturers. I still cannot believe it, but the administrators advertised these posts and actually filled them up. Like it rains cats and dogs, this time it rained lecturers. We now have 20 lecturers. Some one said we could have a cricket team. If we include the more senior staff members, we will have two teams. Though we do not have a ground, we can always use the tennis court to play cricket. Now we can increase the time spent on each patient in the outpatient clinic, and on other days we can play cricket because the remaining work cannot be increased to fit the time available. You can take a round only for so much time, and you can operate only so many cases per day, especially when we are in transit area for building repairs and have only one table in gynecology operation theater. We won't play cricket though, because I never liked it even as a child. There are some elderly men and many women (all ages) in the department, who also don't like it too. I am grateful to God for answering our prayer of getting required number of lecturers for patient care, but it seems God has overcompensated for the delay in granting our wish. I am not complaining though. God has a reason for everything He does, and it is us mortals who cannot not see it. (Note: some words are optional, put inside brackets because I chose another word in their place. I did not delete them as can be done on a computer, because they are valid and perhaps appropriate too.

Hold Your Horses

“Doctor, the nurse put the needle into my arm and took it out, but did not give me the tetanus toxoid injection. She said get the doctor to write the prescription.” I was in the antenatal clinic, seeing pregnant women, normal and also those with ailments. It is a routine for us to prescribe tetanus toxoid injections and for the nurses to administer the injections. I had not heard of such a thing in the last thirty years. Perhaps the patient was mistaken. Perhaps the nurse had administered the injection, then realized that there was no prescription, and sent the patient to get it prescribed. Post facto prescription is not the right thing to do. But our nurses are good, and the antenatal clinics are quite crowded. Then sometimes they do this to save time. I do not encourage this. But if it happens occasionally, I do not react more than telling the enurse not to do it again. “I will come with you and see what is the problem” said. We went to see the nurse. “Sister, this patient says she has been poked with a needle but not given the injection” I said. “Is that true?” “It is” she said. “Who did it?” I asked. It could not have been her, since she appeared cool. “That student nurse” she pointed with her chin. There was a student nurse from another college posted to work at our hospital because they did not have a hospital of their own and hence no patients to nurse. She was standing outside the injection room, well away from the scene of crime. But at least she had not run away. I called her in side. “Nurse, why did you put an injection needle into this patient but not give her any injection?” I asked. “I put the needle into her arm, when the sister stopped me. She said there was no prescription. So I just took the needle out and sent her to get a prescription written.” “There was no prescription because she did not need an injection” I said. “Do you not check what is prescribed to a patient before giving an injection or medicine?” That concept seemed a little new to her. She kept quiet. Perhaps she was there just to practice giving injections, not the entire nursing process. “Not if the patient goes to court and sues you, then what will you do?” She continued to keep quiet. That concept was also probably a little new to her. I turned to the patient and said “you do not need an injection. No harm has been done. It would not have happened if you had gone away after your check-up instead of standing in a queue meant for injections. No don’t stand in any more queues. Take your medicines and go home.” She went away. I went back to the examination room to see patients. The student nurse followed me after a while and said ”doctor, I am sorry.” “No. Getting an apology from you is not the result I want. If at all, you should have apologized to the patient. I am unlikely to recommend any disciplinary action against you. I would have asked you your name if I had wanted to do so. What I expect from you after whatever happened today is that you will be careful in future and not do such a thing again.” “I won’t do it again” she promised.

Fundal Pressure

I was conducting interviews for appointment of Assistant Professors in my department. There were two other heads of departments from the other two institutes too. But since all the vacant posts were in my department, they wanted me to ask the questions. My questions were aimed to find out who were safe and who were not as far as patient management in emergency hours was concerned. One of the questions was related to fundal pressure given by doctors to help childbirth. We have a strong policy that prohibits fundal pressure. But we keep getting senior residents and Assistant Professors who have been trained in other institutes where fundal pressure is an approved method of management, even if the text books recommend against its use. My question was as follows. “We have a woman at term in labor. She cannot bear down enough and needs assistance. You have three options: forceps delivery, fundal pressure, and a combination of forceps plus fundal pressure. Which one will you prefer?” Candidates trained in our institute knew the right answer to be given, though they may not be practicing it. Those who knew me knew it was a trick question and answered carefully. But I made it a point to ask this question only to candidates not known to me. Some of them answered it correctly, a few said in addition that fundal pressure was dangerous and was not an option. One of them looked quite bright and enthusiastic. He declared he preferred fundal pressure. I did not ask him his reasons for it, but gave him the marks he deserved. I hope he reads my post and learns the right answer.

Father’s Love

The story dates back a few years. The that time Director rang me up. “Dr. Parulkar” the Director said, pronouncing my name without an ‘e’ as usual “we have one Dr. XXXXXX XXXXXXXXXX doing residency with us. Her father is a sercrtary of the Government. He rang up, requesting that she be placed in our institute and not in the sister institute where she is placed currently.” “Madam, we have a set pattern of rotation of resident doctors. One of our APs looks after it, and I normally don’t interfere.” “I know” she said. She should know, because it was she who had assigned that job to that AP as per advice of my predecessor, without consulting me. I had been too glad to accept, because I never wanted to manipulate the rotations, and would not interfere unless there was a manipulation. “See what you can do.” I checked the scheduled rotations, and found that this resident doctor was actually scheduled to be at our hospital. There would be no need of manipulating and causing injustice to another resdient so as to accommodate this one. I informed the Director about it. That should have been the end of it, but it was not. Two weeks later the Director rang me up again. “Dr. Parulkar” the Director said a little apologetically, “you remember the resident doctor whose father had requested that his daughter be placed in our institute? Well, he rang up again. His daughter wants to be placed with Dr. YYY.” I knew Dr YYY was the MS teacher of this resident doctor. I also knew he was quite lenient and generous with allotting operative work.” “Well, the placement schedule has already been displayed on the notice board and its copies have been sent to concerned officers here and in the sister institute. It would invite trouble from the concerned residents if we changed the schedule without any sound reason. I cannot see any sound reason. This resident will be placed with Dr YYY in the next three posts as per rules. It is best she does not request a change now.” “It is all right. I will inform her father about it.” The said resident worked in the department for two years. There were occasions when she messed up like all residents do. I had occasion to correct her time and again. But I did not broach this subject. Then she appeared for MS examination and passed. When she came to take my signature on her clearance, I asked her to sit down while I signed her document. When she tkanked me and got up to go away, I stopped her. “Dr. XXXXXXXXXX, I want to ask you something” I said. She sat down again. “Now you are qualified and have left this institute. Now that I have signed your clearance certificate, I have to hold over you. Now I want to ask you something that you may or may not choose to answer.” She looked at me expectantly. Then I told her about the two phone calls from the Director, and what the Director had asked me to do. “I did not know my father made those requests” she said. “Your father does not know about residency rotations in two institutes. He is unlikely to want you to be placed with a particular unit head specifically, unless you ask him.” “He might have heard me talking about it” she offered. “You are married,” I pointed out. “Do you stay with your parents or in-laws?” “In-laws” she said. “Then how likely is your father to hear you say these things when you go for the occasional visits to his place?” She kept quiet. “You can tell me the truth. I postponed asking you about this until today because I wanted an answer from you without any inhibition.” “I did ask him to see if he could do it for me” she admitted. “A father will do whatever he can for his child. I can understand that. But don’t you realize that when you get something using unethical means, something that is rightfully of someone else, you are doing a wrong to that person?” She kept quiet. “I have wanted to tell you this all this time. Now I have done that. Think carefully about it. If you will change your thinking and refrain from taking advantage of your father’s position in society, it will be a great thing.” “I won’t do it again” she promised, got up quietly and left. That was a couple of years ago. Today I was conducting interviews for appointments of Assistant Professors, when this same doctor walked in. She must have known I would be there. She kept a blank face when she faced us all. It seemed she had been away from the obst-gynec scene for having a baby, and now was back again. I asked her some questions and we gave her appropriate marks. Then the other expert sitting next to me said, “our ex-director asked me to select her when we were conducting interviews for appointment of doctors in that government hospital. I wonder why.” He was talking about the same Director who had rung me up for this resident doctor’s residency placement. “It is paternal influence” I said. I had thought I had changed her for better by my counseling. I did not know whether to feel bad about my inability to change people for better, or to feel good about being able to witness a father’s efforts to help a daughter that continued well beyond her marriage and having a baby too.

FFP Bags in Running Water

She bent into the sink and picked up something held between her thumb and index finger. She handed it over to someone else. I thought she had picked up a mouse by its tail. But I am yet to see a girl do that, definitely not a third year resident in ob-gyn. By the time I had thought these thoughts, she bent in again and picked up another one. I looked carefully and discovered it was a fresh frozen plasma bag. We were in the OT. “Hey, what was that?” I asked. She turned around, not understanding what I had asked. “The sink is dirty, with scrub water, washed instruments water and what not. You must have picked up a lot of germs” I said. She smiled sheepishly. “Wash your hands immediately” I said. While she was doing that, I asked her, “why had you put those things in the sink?” “For thawing before transfusing them into a patient” she answered. I had thought someone had thrown used FFP bags into the sink instead of putting them in red bags for hazardous biomedical waste, to be sent for incineration. “In the sink?” I said, almost in shock. “It is full of bacteria and viruses, many of them pathogens. You will pierce the nozzle with a transfusion set, which wilol put those germs into the bag and then into the patient. Did you not realize that?” “Sir, I did not do it. The anesthetist did it.” So I went in search of the anesthetist. I found him all right. He was a first year resident, barely three months into residency. “I asked the servant for a bowl to immerse the FFP bags in” he said. “He told me there was no bowl, and he told me to put them in the sink.” I spent some time educating the anesthetist and the servant on why such a thing must not be done and went back to my chair. Then I had a sudden thought. I called the resident and asked her, “where do you usually put the FFP bags for thawing?” “In the sink” she answered truthfully. I was aghast. I called my unit Registrar and asked her the same question. “In the sink” she answered truthfully. I was aghast again. I called a senior resident who had been my Registrar in the previous post and was now with the other unit which was also in the OT with us. I asked her what she used to do. “In the sink” she answered truthfully “at times” she added as an afterthought, seeing that I was aghast with the previous answers and having known me for three years. I went to the staff room in the OT complex and told the staff members this story. “Eeek!” said a professor. “I feel like vomiting after hearing this.” Just then her Registrar came along looking for her. So I asked him the same question. “In running water” he said. “Where is the running water?” I asked him. “In the sink” he said. “How can you?” wailed his boss. “Do you put the things you eat in the sink before you eat them?” He seemed aghast at that idea, but was not disturbed a bit at putting FFP bags in the sink. I educated him, and then told the person in charge of holding the labor ward committee meeting to brief all residents on this issue in the next meeting. I could not see why they could not put a bowl under an open tap, and put the FFP bags in that bowl so that they would be in running water. I silently praised the Lord for not giving them the idea that running water was also found in the drain before it joined the gutter. Or perhaps they had that idea too, but it was too much trouble to go up to the drain. The sink was quite nearby and convenient too.

Contribution from Alumni

I have heard that there are quite a few alumni of our institute in USA. One of them came to meet me a while ago, with an American accent and all. He used to look like one of us before he left. He had put on some weight, dressed still the same, but now looked a bit like Ronald Reagan when he spoke. He had a niece studying with us, whom he had brought along to introduce to me. “She is a keen student” he said. “That is very nice. For a change we have a student who is keen. Most of them seem to be happy being in the canteen or on the Katta rather than in classes” I said. “She will attend all lectures and clinics regularly” he assured me. “She is different.” I smiled. “We have formed a group of alumni in US” he said. “We collect some money and send it to the alumni association here every year. Nothing great, just a couple of thousand dollars. Did you get anything from that amount?” he asked me. “They do not consult me about what we need, but supply whatever they think we need” I said. “They had fitted a scrolling board in my department, which scrolled some meaningless text at a rapid rate. We could not change the text to suit our needs. The alumni association office-bearer who was responsible for the installation of the board could not or would not tell us how, nor would she send along the supplier to tell us how. Finally I had to unplug it to save electricity. When they started repairing the building, they took it away. No one in the department objected, because it was not officially given to anyone. It was just fitted in the corridor, which was common property. Such things happen time and again. But since you feel good about doing something for the institute you might continue with it.” “If not money, what would you prefer?” he asked me. “This is an academic institute that needs not furniture or scrolling boards so much as means of education. Medical journals are costly, and we don’t get all the journals we would like to get. You could pay the subscription of any one journal of your choice for our central library” I suggested. “I will see what we can do” he said and gave me a huge smile. It has been two years since. I have not seen him again, nor his niece, nor a single issue of any journal given to our library by his group. I would have known, since I am a member of the library committee.

Muster

The muster in the hospital office is becoming a joke. On one hand there are those auditors who audit the muster so that people are forced to sign in and out on time. On the other hand there are those clinicians who believe in just doing it, no matter how long it takes. They are not so rigid about time in, time out, and timely signatures on the muster. Some of my residents are so overworked that they sometimes do not get time even to sleep. It would be inhuman on my part to expect them to sign on the muster in time. We allow the residents to sign in the muster at any time during the day in office hours. If they have emergency duty, we allow them to sign the next day. We know they actually work and are not away having fun, because their unit heads report if they are missing. But sometimes they do not sign for days together. That is not because they do not have time, but because they are not bothered to sign. We do not allow them to sign for a number of days at one time. Sometimes my clerks are kinder than I and allow them to do so without my knowledge. I turn a blind eye to that because work is being done, and it is not my job to do policing. The interns are relatively free and can very well sign every day. If they do not do so, I scold them because they have to learn some discipline some time. Today morning I was doing some work in the office. I had finished my work and was about to leave, when an intern came along and dug out his muster from the pile of all musters. I decided to wait and see what he did. He did not recognize me even though he was right next to me because I was in street clothes rather than my scrub top and apron. He found his page, and signed seven times. Satisfied, he turned to go away. “Hey, wait” I said “who are you?” He turned around, looked at my face carefully and was taken aback a bit when he finally recognized me. “I am an intern” he managed to say. “Why did you sign seven times?” I asked. “I forgot to sign on three days” he said. “That makes it three days. What about the remaining four days?” “Then I had an emergency duty.” “What about the subsequent three days?” I asked. He had no answer. “Did you forget again on those three days?” “Actually I enter the hospital through the back gate and exit through that gate. So I don't come to this office to sign, it being at the other end of the hospital” he said. The department was in between the back gate and the office and also at this end. But perhaps he thought I would not remember so much about the geography of the department since we were in transit area due to repair and renovation work. I accepted his argument, turned to the clerk and said quite gravely, “What he says is right. Keep a copy of this muster near the back gate from tomorrow so that he can sign.” All three clerks had been watching us quite closely for entertainment purpose. They burst out laughing. I hope he got the message and will sign the muster every day from tomorrow.

Post Facto

It is interesting to see how certain communications in governmental and corporation work are post facto. I received a letter from a government office yesterday. It was addressed to my late father, who passed away 24 years ago. I wrote to the sender about the sad demise of my father and requested him not to communicate with me again. Though 24 years have passed, it still hurts when I think of his untimely death. But the government machinery does not care. It sends out letters based on records as old as 24 years. The point of interest was that it was dated 17 days ago, and wanted me to respond to it within 15 days of the date on the letter, not even the day of receipt. Perhaps we can put that down to inefficiency of people who write those letters, who sign those much later, and others who post those even later. There are deliberate post facto communications too. We see them when we receive notices to attend meetings that have already taken place. Such communications are sent to those who need to be invited to attend, but are not wanted for various reasons. These post facto invitees can rage and thunder, but cannot claim that they were not invited. In fact, it may even be recorded in the minutes of the said meetings that these invitees were absent. That is important when inviters want to make certain decisions without resistance from those who are opposed to those decisions. There are advertisements for posts at the hospital which are to be given only to local candidates. These are placed on the notice boards late evening of the day before the last day for submission of applications. Copies of the advertisement are sent to other institutes after the last date, so that candidates from those institutes cannot attend. I feel strongly about such maneuvers. They had done that to me when I was top of my class, but they did not want me to compete with their local candidates. I did not know about the interviews for the tutors’ posts until after the appointments of those local candidates. I beat them in subsequent lecturers’ post interviews, but that is besides the point. It still hurts that the administrators maneuvered so as to suppress merit.

Malaria & Us

I had read about malaria as an undergraduate student while studying parasitology, pharmacology and clinical medicine. I thought I knew all about malaria. Things evolved a bit over years while I concentrated on Obstetrics & Gynecology, but it being such a common illness, I kept up with the advances because our patients developed malaria anyway, and I had to treat them even if I was an Obstetrician and Gynecologist. But there is something very funny going on. One would expect a consensus on the management of malaria. Unfortunately it is sadly lacking. Everybody knows (I suppose) the dosage of chloroquine for treatment of malaria. We have always treated adult patients with an initial dose of 1 g (= 600 mg base) followed by an additional 500 mg (= 300 mg base) after six to eight hours and a single dose of 500 mg (= 300 mg base) on each of two consecutive days. But some time ago the health department sent us a circular asking us to give it in a funny dosage that I could not find in any text book, recent or old. Perhaps the health department is in the process of publishing a book of its own that it expects all consultants to follow. If so, it has remained in press for too long. I blush mentally at the thought of that dose and cannot put it down here. Then there was the time when I developed resistant malaria. I had taken a full course of chloroquine and was on day 8 of primaquine therapy for vivax malaria, when my fever returned. So I saw an honorary physician in the hospital, who had been my teacher once. He casually looked at my report and told me equally casually to take quinine. I was aghast. With a number of modern drugs available for resistant malaria, I could not see why such a drug should be prescribed to anyone, especially to a professor in the institute. I sought opinion of another physician, who directed me to the ICMR cell which was doing research on malaria. They advised me to take chloroquine and primaquine again, this time from their stock, saying what I purchased in open market might have been substandard. I trusted them and complied with the prescription. I developed a recurrence of fever on day 8 of primaquine therapy. Then I was given mefloquine and artesunate and was cured. I lost a lot of weight, hemoglobin, strength and morale in the bargain. Now the city has so many patients of malaria that there are no beds available for patients in any of the private hospitals. My wife is a physician doing general practice. She told the waiting list for admission into a five-star hospital in town was 320 last week - as if illnesses can wait that long to be treated. In my institute some residents in medicine department follow standard therapy guidelines - chloroquine with doxycycline as primary therapy, and artesunate if it is resistant malaria. There are others who primarily treat patients with artesunate. Some treat ordinary patients with the former and very important persons with the latter. None of them prescribes primaquine for radical cure of vivax malaria. My wife tells me that private practitioners in town are also treating patients similarly, i.e. without primaquine. If we consider the city to be endemic for malaria, then primaquine tgherapy is to be substituted by chloroquine prophylaxis on weekly basis after cure of the febrile illness with one course of the drug. But the city has not yet been declared endemic, and even if it is so, even chloroquine prophylaxis is not being given. I think the reservoir of the parasite is being maintained in livers of patients, and they keep on getting recurrences, increasing their own morbidity as well as creating source of the parasites to be spread to others through mosquitoes. These new patient treated the same way as the older ones add to the city’s hepatic reservoir of malarial parasites. I came across a reference that states that a single dose of primaquine must be given to falciparum malaria patients, so that the gametocytes are killed and the patient does not transmit malaria to mosquitoes who then cannot spread it to other people. I wonder if the physicians will heed this advice in time. What I do to my obstetric patients and what my wife does in her practice is too small to make an impact on the city’s malaria problem.

Freeship Trick

The Government gives freeship to students belonging to certain castes. A freeship means the student does not pay any fee. The Government pays it to the college. I used to get students asking me to sign on their applications for freeships. I used to sign, because they used to be sent by the clerk who did that work. Then one day a student brought a form that was actually legible. I read the contents and realized that I was attesting signature of the student’s parent or guardian, stating that he had signed in front of me. But the parent or guardian used to be at the native place far away from me. The signature was actually to be attested by some authority at the place where this parent/guardian lived. From that day I stopped signing and guided the students to get someone actually present at the time of signing of the form to attest it. Today another student came for that attestation. I patiently asked her to read that form and understand it. She realized I knew what the contents meant. “Who guided you to take my attestation that your parent signed in front of me?” I asked. “Our departmental office clerk” she replied. “Our clerks know me and that I know the rules. They will never advise you so” I said. “Was it the central office clerk who does the work of freeships?” She mumbled something that could have been a yes or no. “By the way, when did you get this form from the office?” I asked. “Half an hour ago” she said. “Then how did you manage to get your parent’s signature?” I asked. “I went and took the signature” she said. “But your home address on the form is of XXXXXXXXX, I said, which is half a day’s travel from here. Your parents stays there. How could you go there and come back in half an hour?” She kept quiet. After a minute of silence, I asked her, “have you signed for your parent?” She nodded her head affirmatively. Then it dawned on me that all the previous students had been signing as their parents, and that was why the signatures were not attested by government officials of the areas of residence of the respective parents. “When is the last date for receiving of the completed form by the office?” I asked. “Four days later” she said. “How much fee will you not have to pay when you get this freeship?” “Twenty thousand rupees” she answered. “How much money will you spend going home and coming back?” I asked. “Six hundred rupees” she said. “Then either send the form home by speed post and get it back by speed post, or go home and get it signed by your parent yourself. Don’t you know that it is a criminal offence to forge someone’s signature, for which you could be jailed? Have I troubled you in any way in the past that you want to take a revenge on me by making me an accessory to your crime so that I hang along with you?” “She shook her head, wiped the corner of her left eye and went away hopefully to obtain her parent’s signature. But I wonder if she went away just to find anyone else who would attest the signature she had forged, so that all trouble and expense of speedpost or travel would be saved.

My Voice

I don’t know why people should stop recognizing me but recognize my voice perfectly. I don’t talk so much, and my voice is not like that of the Big B. The first incident I want to write about took place yesterday while I was sitting at the computer of our typist, making a complex word document with photos of our department in it. The phone rang. Since I had driven the typist away from her workstation, I picked up the phone myself. There was no point in letting it ring next to my elbow waiting for her or anyone else to come to answer it. “Hello, is that Gynec office?” enquired a woman’s voice. “Yes, it is” I said. “Is anybody there?” she asked. I looked behind me and saw that all of the three clerical people were there, and so were two servants and one staff member. “We have lots of people here” I said “whom do you want please?” “Oh, that is you, Sir!” she said. I am Dr. XXX XXX from XXX department.” Wondering how she managed to recognize me, I asked her what she wanted and answered all her questions to her satisfaction before putting the phone down. The other story is even more weird. I was going home after a day’s work, reasonably tired. I take a bus home, because I want to use public transport to save fuel for the future generations (my son is the next generation, along with a lot of others). The bus company (BEST) has recently reserved ten seats for women (originally it was only six) and four for senior citizens on each bus. I reached the seats for the senior citizens and found a vacant one. Since there were no really senior ones (65 and above) around, I sat down in that seat. The bus filled up. People stood in two rows between the two rows of seats. There was a young fellow next to me, pushing my arm with his lower tummy and pelvis. There was a girl just ahead of him. They were discussing animatedly about merit lists and such, which drew my attention to them. I had not seen the fellow before, but the girl had been my student a year or two ago. She either did not notice me or did not recognize me. The bus kept moving rather erratically, braking abruptly periodically, accompanied by an “Ouch” by the girl once, and a “Shit!” by her some time later. After some time, she said to the fellow, “We should tell him to surrender the seat to me.” He murmured somehing, which I missed. “You tell him” she urged. He murmured something, probably asking her to say whatever she wanted to say herself. I looked up and found her looking at me. When she knew she had drawn my attention, she pointely looked at the word “Women” stencilled just above the window where I sat. The implication was that the seat was reserved for women and I should give it to her. “The seat is reserved for senior citizens” I said, looking steadily at her. There was a picture of two old men next to the seat, for people who could read only signs. “The word ‘women’ is left there by mistake by BEST, when they reallotted the seats. It is stencilled on the back of the seat that it is for senior citizens too.” She seemed shaken. After a couple of seconds she said “Sir, if you call yourself a senior citizen, what will happen to us?” “Do you mean to say you are more senior than I?” I asked politely. I knew she had recognized me by then. No one her age calls someone ‘sir’ around here unless that person is her teacher. “No sir” she said, “what I mean is that you are so young!” “No, I am not young” I said firmly “I am old”. I knew she was trying flattery, because no one in her or his right senses would have called me young, with my white hair and all. She smiled. The fellow moved away from me by a respectful six inches, no mean feat in that overcrowded bus. He maintained that distance until they got down from the bus. When they were ready to get down, she turned to me, waved a stylish hand and said sweetly “bye, Sir”. He followed her without even looking at me. When I narrated the story to my wife and wondered how did they recognize my voice, one on phone and the other in person without recognizing my face which has not changed in the last twenty years, she said: “The first one probably recognized you because of your sarcasm and because it was your departmental office. The other one did not recognize your face because you were not wearing your trademark OT scrub suit and apron that you wear constantly in the hospital, but street clothes. She recognized you when you spoke probably because of whatever you said and the way you said it. There must not be anyone else with the content and style of speech like yours.” I did not know whether to feel flattered or hurt. But then she smiled and I decided to feel flattered.

Medical Education Technology

The Medical Council of India has laid down a number of requirements for medical education. One requirement is that each medical teacher should be trained by a recognized institute in medical educational technology. The health university follows the guidelines of the medical council very closely, and also insists that recognized medical teachers be so trained. Our institute has a Medical Education Technology Cells (MET Cell) which charges the sky and conducts these courses for the employed doctors periodically. They give a book authored by its office bearers and friends as course material. I know all about it because they had taken me along as a member to conduct the courses with them, and to write one of the chapters in the book too. They had funny ways of conducting business. They would use terms like cognitive domain that always put me off - I would have preferred simple English words like thinking part. I also did not agree with the concept that a teacher had to use complex techniques to get education into students. A talented teacher just did it. Use of slide projectors, overhead projectors and LCD projectors does help, but cannot replace good old teaching with tools like blackboard and chalk. I finally resigned from the Cell because once they planned a teaching session far away from our center, and went away in a hired bus without me. I had to spend a lot of money and time getting to that center by myself. I did not mind the personal loss so much as the feeling that they did not want me, when my services were free and were offered not because I had wanted to do so but because they had dragged me there to start with. Another reason for resigning was that they had a member who was an academic bully who would ridicule any opinion other than his own, and force the Cell to accept whatever he wanted done. The office bearers resented him but could not do anything about it for reasons best not put here. The MET cell taught that medical teachers must use audiovisual aids for teaching students. The institute obtained the aids, but the department chiefs in charge of keeping those in working order often failed to do so. Finally the teachers were forced to teach without those aids. The Medical Council inspectors confirmed that the institute had all teaching aids like different types of projectors and computers in prescribed numbers. They never checked the functionality of the gadgets. I had a feeling that it was merely copying the Western educational methods without much thought to what was actually needed by our students. So I decided to take an opinion poll. After my lecture to the undergraduate students last week, I asked them if the preferred a dark auditorium with slides projected for teaching or a lighted auditorium with the teacher teaching them face-to-face maintaining eye contact. I had just taught them the latter way because I liked it that way and also because the computer and projector in that Biochem auditorium was not working as usual. “The face-to-face type” they said unanimously. I told them the MET Cell concept and the Medical Council requirements. They just shrugged their shoulders. “Why not the slides?” I asked them. “The teachers just read out the stuff on the slides, which we can also do ourselves with their books” they said. “But a teacher cannot show the photographs of patients or pathology specimens and videos of operations on a blackboard and chalk” I pointed out. “We would like those parts in slide form. But the teaching should be face-to-face” they said. “I always thought so” I said. “Now that 118 students (the number of students present that day) have confirmed it, I will communicate this thought to the MET Cell.” They were happy to hear that. I have not yet written to the MET Cell, because that will shatter the very foundation of what they profess. I can always hope they will read my blog. But whether I tell them or whether they read my blog, I wonder if they will have the courage to write to the Medical Council or the health university, or to teach their course-delegates that they should use teaching aids only for visuals, not for text. I wonder further if the trained teachers will heed this advice because it is always so much more comfortable to read text in slides than to know the stuff well enough to be able to speak it out without help of slides.

The Marathi Issue

The head-office bigwigs decided that all employees working for the corporation must have had Marathi as the higher language in their 10th Standard and should have passed in it. That was because the official language of communication was supposed to be Marathi I the state of Maharashta. A couple of political parties made an issue of it, and that was that. An unfortunate result of the decision was that all doctors employed had to have that qualification. A number of posts of doctors remained vacant because the doctors did not satisfy this condition. A state was reached when the medical council threatened to derecognize the institute due to deficiency of doctors. That there were not enough doctors to treat patients was entirely overlooked by the decision makers and also by the politicians who wanted votes of the Marathi speaking voters rather than from patients who were treated at the civic hospitals. I wonder if even the Marathi speaking voters will vote for them if they realize what harm is being done to them by the concerned politicians. And now we come to the funny part of it. We are supposed to be able to speak Marathi and read and write in Marathi so that we can treat our patients better. But a very large number of our patients don’t know Marathi. So when we communicate with them in Marathi, they either look at us uncomprehendingly, or just tell us they don’t understand what we are saying and ask us to speak in Hindi, their mother tongue. When that happened a number of times, I told them that doctors in employment of the corporation had to pass the standard 10 Marathi exam or their increments and promotions were stopped. New appointment of doctors who did not know Marathi was not allowed. If the doctors had to suffer all this for the sake of the patients, why were the patients not speaking in Marathi? They just smiled apologetically and waited for me to speak in Hindi and get on with their treatment. Then I realized I should not have asked them the questions. The poor souls had nothing to do with the injustice done to not-Marathi speaking doctors. It was not even injustice aimed at them. It was just a political move for garnering votes, and all these were unfortunate side effects of the same.

The Hostel Fiasco

My residents were quite upset. “Sir, this is about our hostel accommodation. They have put us in rooms at the hospital for animals.” “Animals?” I was surprised. “What is wrong with the quarters in campus?” “Sir, you know they have pulled down the new RMO quarters because the building was structurally unsafe. Plus there are a number of extra residents this year.” “Yes, I recall” I said. I had not read anywhere that they had pulled up the architect and the builder who had built the building which had to be pulled down so early after being built. Nor had they pulled up the engineer who had certified it OK after construction. They probably preferred to leave skeletons in cupboards alone. “Sir, the rooms are like animal cages!” said one of them. I wanted to say they could expect nothing else in a hospital for animals, but refrained from saying so because they were quite upset. “Huh?” I said. “Yes, sir. And they have given rooms in campus to non-clinical residents.” That was too much. I thought the hospital was for giving healthcare to patients, and doctors involved with that should be in campus rather than those dissecting dead bodies or performing experiments on frogs and dogs. “I will speak to the chairman of the committee for RMOs’ room allotment” I said. I knew that fellow very well. We shall call him Professor of RMOs’ Room Supply or in short Professor of RRS. I rang him up and he promised to get back to me. I rang him again today, and he came to see me with his deputies and the list of distribution. I called one of the complainants and asked him to go through the list with me. “These rooms are given to residents in Anatomy and Physiology” I pointed out. “They can have rooms outside campus while clinical residents can have those rooms.” “They are office bearers of RMOs’ union. They have to be given rooms because they get the people to repair lifts and geysers if they stop functioning.” said Professor of RRS. “But they have their office to work from in day time. Geysers and lifts are repaired in day time, not at night. And there are geysers and lifts in the quarters outside the hospital too. Are they immune to malfunction and don’t need repairs?” I asked. “Um…. Well! It was agreed by competent authority and passed in RMOs' union meeting” said the professor. “Who is the competent authority?” “It was the previous Director.” “It sounds like the management is scared of the union and strikes of RMOs ordered by the union” I said. “The previous Director used to tell us to do this or that so as not to anger the union.” The Professor had no comment to offer. “Sir, they have given two rooms in two different hostels to one person.” said the complainant. I checked the chart and so did the committee members. It was indeed so. So they called that fellow. “I have not done this” he said. “Someone has done this fraud in my name.” So they asked him to make that statement in written form. “Why have you given rooms in campus to these nonclinical people” I asked pointing to a few names. “They are couples, married to each other” they explained. “We have provision to give married couples rooms in campus.” I was stunned. “That sounds ridiculous” I managed to say. “You are giving marital bliss priority over patient care? Can these couples not have marital bliss in quarters away from the campus?” “Sir, even if we give them rooms outside the campus, it will not make any difference to these boys. Couples are given rooms on floors meant for female residents. By getting them out, we can't give those rooms to these male complainants. Women residents will object.” I was stunned even more. “You mean women residents don't mind married men on their floor, but they mind unmarried ones?” I asked. “Usually it is unmarried men who cause troubles to women, not married men” Professor of RRS said. “Wives of these married men will control them and protect the other women residents on the floor.” This was sounding like a comic show. “By the way, have these couples submitted copies of their marriage certificates?” I asked. “No. They just say they are married and we trust them” the professor said. He seemed to have a wonderful knowledge of law. I turned to my resident and told him, “you find a woman resident and get married to her now! You will get a room here. After residency you can always divorce each other. That is what they do to gain entry into USA.” My sarcasm was not lost on them. My resident grinned while the others ignored me. “As a policy, we have given rooms to all women residents in the campus and males have been sent outside” a committee member said. “It is unsafe for women to walk on the road at night.” Those statements sounded sexist. They also reflected badly on the law and order situation in the city. I hope the police commissioner and the home minister don't learn what this fellow was saying. “Suppose someone mugs him?” I asked. “It is not only women who are assaulted.” “If you want a room in campus, we can send you another hospital in the city by changing your registration to that institute. A person from there will come here in your place” offered the Professor of RRS to the complainant. “I don't want to go to any other institute” said the poor fellow. I have come here on my merit. That institute is horrible. There are no patients to treat there.” “There is no provision to do such a thing anyway” I told the professor. “and you have no authority to offer such an arrangement.” “But why don't you stay away from the campus?” he asked the resident. “I have to attend emergency calls at all times. How will I attend night calls?” “You can walk to the hospital. The place is not very far. Or we will make arrangements for an ambulance to bring you here and take you back” offered the professor. “Sir, it takes two hours to get an ambulance going anywhere. How will it bring him here in a few minutes? Besides I don't think you have the authority to make such an arrangement yourself. Did you not read in the newspaper that there is an ambulance lying around unused in brand new state because people have not been appointed to work in it? If they could not get it working for healthcare, how will they get it working to ferry resident doctors between quarters and the hospital?” I said. “Sir, they have given a room to someone who is not working in our hospital. She is in another institute.” I was aghast at what our complainant had pointed out. The committee members checked out that name and claimed it was as per the letter sent by me to them, giving a list of all residents who would require hostel accommodation. So we took out our file and showed them that her name was not in the list. Then they thought about it and said “the institute she is working in will not give her accommodation when she goes on exam leave. Since she is our student, we give her a room in anticipation.” “You don't give rooms to people who are working here at the moment, and give to people who will be without accommodation after a few months, and when they won't be in our institute even then? Does it sound sensible?” I said. “We always do that” they said. The whole thing was sounding like a grossly mismanaged thing, or there were undercurrents that are not worth mentioning without solid proof. Professor of RRS kept repeating the same things he had said changing the sequence, while the committee members kept silent. I knew there was no progress to be made. So I said, “I know you have worked a lot on this issue. I have pointed out a number of errors and deficiencies in that work. There could be more of them. I suggest you go through the whole thing and rectify all errors. I further suggest you change those policies which are wrong. I am not arguing with you so that three of my residents get rooms in campus. I am fighting for correcting the wrongs in the system, for the benefit of all clinical residents in the institute. What you say is the policy may be looking very fine on paper, and may have the sanction of the highest authority. But if your conscience says otherwise, rectify it. If not, so be it. I cannot do anything further on this issue.” “We will do whatever is possible” the professor promised. The one hour heated discussion ended on that note.

Mistrust

It was during the communications skills workshop that I heard the story from my Registrar. When she had been working as a Houseman, she had been instructed to get the platelet count report of a patient with preeclampsia who was to undergo a cesarean section. She rang up the lab which was on the sixth floor of another building, and got the report of 250000/cmm. Then she washed up to assist for the cesarean section. Towards the end of the operation, the patient kept oozing in the operative field. The Registrar shouted at her that she had been a lazy bum and had told a lie instead of going to the lab and getting the report. If the patient dies, it would be on her conscience. That upset her. So hse feigned illness, washed out after the houseman washed up and went to the lab to get the printed report. It was indeed 250000/cmm. She showed it to the Registrar. She said she actually wanted to fling it on her face, but decency prevented her from doing so. Their relations remained strained for a week or so, but she still remembered the incidence very clearly and the trauma it had caused. After the workshop I asked her to check the HIV test report of a patient that we had sent because I had got a needle-stick injury while assisting my houseman had been operating on her. She called the lab, and came back to tell me it was negative. So I smiled at her and thanked her. She started towards the door, stopped, turned back and said, “Sir, I will get the printed report afterwards and show you.” It seemed to be an extension of the incidence she had related in the workshop just a little while ago. I smiled and said, “I trust you. You don’t have to actually show me the report. A resident would have been tempted perhaps to tell me the report was negative when it was really positive just to teach me, a strict taskmaster, a lesson. But I never thought you would do it.” She grinned at that and went away.

Communication Skills

It is quite important that the hospital personnel communicate with the patients and their relatives and visitors well. A patient gets partly cured (the functional component of the illness) by the hope given by the doctor. The accompanying people are tense and they get assured by people at the hospital if they speak well. Unfortunately they are understaffed, overworked, and dissatisfied due to partial or total lack of equipment, medicines, consumables and investigative facilities. They are stressed and they tend to consider the patients as the source of the stress. Then they don't communicate with them well, which is the beginning of a number of unhappy situations which sometimes lead to violence on the part of the patients' relatives and friends, assaulting hospital personnel and damaging hospital property. Our institute conducted a series of workshops for all hospital personnel, educating them on communication skills. Actually they were didactic lectures rather than workshops, with a minor role-play in between lasting for a couple of minutes. They were good and hopefully they achieved what they were expected to achieve. There was a problem however. They had pooled doctors, nurses, laboratory personnel and servants together. Considering the job descriptions and level of intellect and comprehension of the different people, the course content was not appropriate for everyone at any given time, or in other words, it was appropriate for some when it was not so for some others. They must have their reasons for such an arrangement, which I am not privy to. The workshops are over. But I thought of them today when I heard a woman shouting “Bhimabai, Bhimabai, come here. How many times do I have to call you, eh?” at the top of her voice, and in a tone that indicated Bhimabai (name changed to protect her identity) was a nobody but was being offered treatment as a favor she did not deserve. I was sitting in the doctors' room next to the OT and could clearly hear everything. So I went out and checked who was shouting at Bhimabai. It was an anesthetist. I asked her if it was her who was asking for Bhimabai. She said it was. Since I have no control over the anesthetists, I turned away and went back to my work. I used to talk to senior anesthetists in past when some such thing required to be corrected. I stopped that when I realized it did not achieve anything. Perhaps the anesthetist was unable to attend that workshop. God help her in her practice outside this hospital if she continues to communicate with her patients in this manner.

Emergency Workshop

I have never held a workshop without prior planning, on an emergency basis. But something happened that forced me to. There was the monthly meeting of the Labor Ward committee, which we formed to sort out issues that arose in the management in the emergency room and labor ward. Two senior staff members, all lecturers and all senior residents attend this meeting along with the nurses of that area. The Sister-in-charge told in the meeting that she was quite upset with the way the Registrars spoke with the House-officers. They abused the House-officers, publicly questioning their intellect and humiliating them in front of the patients, relatives and hospital personnel. The asked them if their fathers would do the work the house-officers did not do. Then the house-officers (usually girls doing their first posts) sit in the labor ward crying. Only one Registrar was good to the juniors and civil in her behavior, she said. This behavior of the others needed to be stopped urgently. So I called the senior residents for a 15 minute workshop in the afternoon. It went on for one hour, but the extra time spent was worth it. "This workshop is on communication skills" I said. It is different from others on this topic in that it is about communication between senior and junior residents We shall began with a role-play. I need a volunteer." No one volunteered. So I selected a volunteer, and announced that she would be the Registrar while I would be the House-officer, meeting in the Labor Ward in the morning. "Now talk to me" I invited. She started and stopped. "Go on" I said. She grinned sheepishly, but wouldn't go on. So I went on myself. "Madam, I am doing IPM of this patient" I said holding an imaginary transducer in my hand against tummy of an imaginary patient. "I have not finished my morning round yet." She did not scold me. "Thak-thak-thak--thak-thak--thak-thak-" I mimicked the fetal heart sounds "thak.....thak.....thak.....thak.............thak.............thak........................thak" I slowed the fetal heart rate indicating severe fetal distress, the fetus about to die. She did not panic and say 'don't just stand their, stupid. The baby is dying. Start oxygen.' She just kept sitting there. Finally our Associate Professor intervened. She said she would be the other volunteer, and all Registrars would be the observers who would comment on the role-play afterwards. I stood up afraid of the Registrar and went through the standard dialogues like "Yes Madam, No Madam, Sorry Madam" and performed all tasks with alacrity as guided. The AP did well berating me and shouting and saying the Boss would arrive any minute and scold her for the House-officer's inefficiency. The Registrars were enjoying the show and were laughing merrily. But she did not use the right words. So I changed positions with her, making her the House-officer while I became the Registrar. Then I thundered: "Where is your intelligence, you stupid? If you won't do this work, who will do it, your father?' Suddenly there was silence all around. They recognized the words that they had been uttering so often. The AP was shocked. "I did not know they used such words" she said. "The sister-in-charge of the ward told me" I said. Then I started the discussion. "The Registrar must not be called Sir or Madam" said one. "We don't allow them". I knew they still did it and probably enjoyed it too. The AP invited them to speak on at least one traumatic experience they had had as House-officers at the hands of their Registrars. They told a couple of moving stories. Then I told the story of my Registrar preventing me from going for a breakfast and dinner half the time of my six months of residency, by making me wait for hours before starting work in the morning or evening, so that there would be no time for food afterwards. I had lost 11 kilogram of weight in that six-month period. I also told them of my Lecturer who did not want me to operate as a House-officer for reasons unknown. As per rules, the last case would not be induced after 1:00 P.M. Once there was a case for me and there was time too. But she kept putting the last few sutures very slowly, helped by the nurse who kept giving her tiny pieces of suture material. The minutes were ticking by. Finally I lost my patience and asked the nurse to give a long piece of the suture material. She also did not want me operate because it would mean another 2 hours of assisting. So she said rudely that she would give longer suture material if the Lecturer asked for it. I urged the lecturer to ask for it and she just kept quiet. I did not operate that day too. The trauma of those denials had deeply scarred me, and it hurts even today, 29 years later. The Residents looked at me with empathy. "I suffered as a House-officer" I said. "But I decided then that my House-officers would not suffer like that when I became senior. When I became a Registrar, I managed time such that all of us Residents would be able to go for breakfasts and dinner together. When I became head of a unit, I scrapped the routine of bosses operating every time and the house-officer only if there was a case left and time left. I started the system of giving every one a chance to operate in turns. I may have a lot of faults (I did not believe I had any, but then which human being thinks he has any faults?) but this was one good thing I did that I would like you to do as I did. If you have been troubled by a senior person, do not take it out on your juniors when you have the chance. Break that chain. Be good to them so that they will think that is the way things are done around here and they will be good to their juniors too." We ended the workshop on that note. They mumbled "thank you" and "Bye" etc, and went away. In the eyes of most of them I saw a promise they would do so. I hope they keep their promise.

Experiments in Lecture Management

Life of a medical teacher is dull. Luckily we are clinicians with a flair for research or performing experiments. I try something new now and then to keep boredom at bay. I had a lecture for undergraduate students today. I have seen so many batches of students that I know almost all their tricks of marking their presence when they are somewhere else. It is a challenging task to beat them in this game, and I love that challenge. I circulated the attendance sheet with instructions that it should get back to me in 15 minutes. I knew it would take longer, but my time limit kept them on their toes, so that the extra adrenaline in their circulation kept them awake at least for some time after they had signed their names. Some time later I announced that at the end of the lecture I would keep 5 minutes for a head count, and if the count was less than the number of signatures on the attendance sheet, there would be trouble. By that time two-third students had signed. I told them I would give them five more minutes to complete the job, and also to cancel any proxy signatures they had put. Some of the students developed a malicious glint in their eyes after I said this. So I told them not to cancel signatures of their enemies out of spite, only because they had a chance. Those without a glint in the eyes laughed at that while those with that glint lost it promptly. Finally the lecture was over and the attendance sheet found its way back to me. Then I got a guy in the first occupied row (which was actually the thrid row, the first two being kept vacant so as to be at a safe distance from the teacher for reasons unknown to me) to do the head count for me. I then took opinion of the house which unanimously agreed that I should also get another guy at the other end of the row to do the head count, so that there would not be any error. They finished their counts together, and luckily the counts matched. That was wonderful. All the students including the two involved in the counting liked that and showed their appreciation. After all it would have been quite traumatic to start the count again had the two counts not matched. I myself am quite lousy with such counts. When I withdraw cash from the bank, my count of the bank notes is different every time I count them, if there are a lot of bank notes. There were three minutes to go, when three students strolled into the lecture hall. I asked them if they had come late for the first lecture or early for the second lecture. That confused them and they turned to go back. So I shouted "stop! Don't go away. Come in. I am the next lecturer actually." The students who had endured the last one hour of teaching liked that one too, and showed their appreciation.

The Biochem Lecture Hall

It was my turn again to teach the undergraduates in the Biochem lecture hall. Considering my previous experience when I had tried and tried to get the local people to get the computer and LCD projector to work, and my sense of dejection when my all efforts had failed not only to get this done, but also to contact anyone responsible in the department (they had been away attending a meeting regarding a raise, having a tea break, and some other things), I was not very hopeful it would be any better this time. The only thing I had achieved last time was making another enemy in the form of the Head of that department, who thought my complaint was a far greater sin than her inability to maintain the teaching tools in working order and someone to attend to the lecture hall. I removed the dead bolt on the front door myself and entered the lecture hall. Things were better today from the attendance point of view. There had been 14 students out of 180 plus a few casuals last time. This time there were 118. The attendant was nowhere to be seen. The audio system was not visible. The computer system and LCD projector looked dead. I spent ten minutes looking for the attendant, who was found in one of the inner chambers, with blood shot eyes, slurred speech, a little unsteady gait, a lot of incoherence, and a total unwillingness to get up. I could not make a medical diagnosis of his condition, but it looked like inebriation at 2:00 P.M. My medical colleagues would have perhaps diagnosed a complex syndrome, but I prefer to depend on my clinical instinct. He spent five minutes making the microphone functional, and another three making the fan operative. I could not trust him to start the computer and LCD projector, because I was afraid he would blow them up somehow. The micrrophone was already making a lot of crackling noise by itself. Then he went out and shot the dead bolt home, which I realized when I fiinished the lecture and tried to exit. I had to wait for the next teacher to rescue me. Unfortunately he remained a short distance away waiting for me to exit. When he heard me trying to break the door down by my banging, he and his Registrar came forward and let me out. Our red eyed attendant vehemently denied having locked me in along with 118 students. His sober looking colleague told me the Head of department was in her office and I could complain to her. I decided against that, because I could not increase her enmity towards me no matter how hard I tried. It had already reached its peak. Just then the next teacher's Registrar came out, looking for the attendant to start the computer. I had my first hearty laugh of the day then. It is momemnts like these that keep us sane in the mad world we live in during the working hours.

Letter of Offer

I received the following email from a leading publishing house of medical books. Dear Doctor,   XXX presents classics in Gynecology   Please send us the name of the book you would recommend (Berek/ Telinde/both) & win Principles & Practice of Gynecologic Oncology by Levine & a sample chapter from essentials of gynecology by seshadri absolutely free*   *Offer valid for first 5 replies after your recommendation to students is confirmed by our sales representatives *Valid till 10th August 2010 Regards, Xxxxxxx Xxxxxx Product Manager Xxxxxxx Xxxxx Xxxxxx Xxxxxxx Xxxxx India (Crosses have been put in place of letters to protect the identity of the company and the writer of the email, though in my opinion they do not deserve such protection. You could always Google the titles to surmise who the concerned company and person are.) I wrote back to the company: Does it not look like unethical marketing to you? It does to me. I find it insulting too, since you imply that I cannot afford to buy the book you have offered, and I would do such a lowly thing to get it free from your company.

Kings and Queens in Hospitals

If a lay person is asked who is the most powerful person in a hospital, the answer would be Dean or Superintendent of the hospital. The most powerful person in a given department would be named as the Head of the department. The most powerful person in a given clinical unit would be named as the Head of the unit. But if the same question is asked to a junior Resident doctor in the unit, the answer would be Registrar of the unit. The head office decided we should have training in communication skills. So all employees (class I to IV) and others including resident doctors were pooled together and given training together. Attendance for these training workshop was compulsory. When we compiled a compliance report for this activity, we discovered that a few residents in my department had not attended this workshop. The reason given by the junior resident in my unit was that the Registrar told her to go only after she filled all discharges. By the time the discharges were filled, it was too late. I called her and heard the explanation from her myself. Then I called the Registrar and asked her why she had done this. She immediately said the junior Resident was lying and she had not stopped her from going. There was no way of knowing which one of the two was telling untruth other that subjecting them to a lie detector test. Since we don't have that facility, and it was too trivial a matter for such a major test, I decided to let go. But when the Registrar was not watching, the Houseman said in sign language (i.e. With gestures) that the Registrar had indeed stopped her. I knew by instinct it was the truth. I had known other things this particular Registrar had done in the past. I had caught other Registrars lying to save their own skin and hang the Housemen instead. I knew of a Professor who had prevented the Registrar from going to University examination supervision duty because there was a blunt curettage to be done for incomplete abortion, the the Professor felt too lazy to do it herself. So I told the Registrar that I did believe the houseman. I told her that if she repeated such behavior in future, I would take strict disciplinary action against her. She accepted that and went away. But the Houseman would not go away. She just stood there and started crying in front of me and three other professors. “What is the matter?” I asked her. “Sir, the Registrar will torture me” she sobbed. She was terrified. I knew this was the case, not only because she was crying, but also because this Registrar had treated another Houseman so badly in the past, that that person had reached the stage of committing a suicide. I called the Registrar again and told her, “I want you to understand that if you treat this Houseman badly, or torture her as she is afraid you will, I will report the matter to the Dean and the Ragging Prevention Committee. Please note that ragging is considered a criminal offense and the police take action against such offenders. The punishment is imprisonment and possibly suspension from college.” Then I turned to the sobbing Houseman and told her “if this Registrar troubles you in any way, do not be afraid. Call me and I will handle the problem. Remember that this does not give you permission to misbehave yourself. If you are found lacking in your duties in any way, the Registrar will report it to me.” Then I turned back to the Registrar and told her, “you do not have any authority to punish anyone for anything. You can just report the matter to me, and I will take whatever action that may be appropriate.” There is peace at present. But I don't think I have changed the status of Registrars from Kings/Queens to ordinary human beings.