Vulvar Dystrophy Story

"I have a patient" my wife told me "who is 62 years old. She has white raised white lesion on the labia. It does not go away on wiping, feels firm and irregular. There is no pain or itching."
"It sounds like vulvar dystrophy" I said. "It will need to be biopsied. If there is vulvar intraepithelial neoplasia, she may require a simple vulvectomy."
"Vulvar dystrophy? Is that common?" she asked.
"No. I have not seen any patient in 35 years, despite the busy outpatient clinic."
"Then how do you know?" she asked.
"I have seen picturs of the condition" I said. "That is how I function. I keep the knowledge about rare conditions in my head ready, waiting for a case to turn up."
"Who shall I refer her to?" she asked. She was nice enough not to doubt my diagnosis based solely on her description, and despite not having seen a single patient.
"Send her to a dermatologist. Skin biopsy requires Keye's biopsy punch which dermatologists have, but gynecologists don't."
The patient was reluctant to go to a civic hospital. So she sent her to a dermatologist with a note saying that the patient had a vulvar dystrophy and would need a biopsy. The patient was send back by the dermatologist to my wife, with a note stating "the patient has a vulvar dystrophy and needs a biopsy."
My wife was surprised, and so was I when she told me about it. We could see no point in the specialist repeating what the family physician had written and sending the patient back. So my wife referred her to a gynec oncologist at a multispecialty starred hosppital nearby.
"They are willing to do the biopsy" she told me later. "But they are going to charge 28000 INR for it."
"28000 INR?" I was aghast. "That is too much for removing a tiny bit of skin under local anesthesia."
"They wanted 55000 INR. When she told them she was not well affording, they checked her bank passbook and finally lowered the price to 28000 INR after a great deal of haggling. She does not have that kind of money."
"Send her to my hospital" I said. "I will get it done."
I am proud to say our dermatologists performed the procedure the same day without any hassle and she went away happy. I am still wondering why the starred hospital wanted so much money, when it is required to treat 20% patients free, as per agreement with the civic body for getting various tax exemptions and land on nominal lease. Even if I write to the civic body, there will not be any change. I know it, because there has been a lot written on it in the newspapers, and still no improvement has taken place.

Vasectomy and Weight Lifting

She was a young woman who came to use for a sterilization operation. She had two babies and did not want any more. She was a housewife. Her husband had a clerical job in an office. I counseled her about the risk of failure, and also about the methods of performance of the operation, its complications, and the pros and cons of the operation as compared to the male sterilization operation.
“I would be best if your husband underwent a vasectomy rather than you undergoing a sterilization operation” I said.
“No, not my husband” she said.
“Why? Is there any problem?” I asked.
“He is the only breadwinner in our family” she said. “Suppose he cannot lift heavy weights after the operation?”
“But he has a clerical job, which does not involve lifting heavy weights” I said. “Anyway vasectomy does not impair the ability to lift any weights.”
She kept quiet. I had heard that excuse from many women in the past. They probably talked to one another and had concluded that it was a standard and foolproof excuse.
“It does not lead to loss of libido or impotence too, if that is what you fear” I assured her.
“Yes, doctor. But suppose it happens? Then what?”
“It is your husband’s concern” I said. “If he understands there won’t be a problem and wants to undergo the operation, why should you resist?”
“Because if he gets the complication, we both will suffer” she said. That was unbeatable logic, though the presumption underlying it was totally wrong.
“OK. We will perform a sterilization operation on you, provided you accept the higher risk for yourself” I said.
Husbands of some of them fear loss of libido and resist vasectomy. Mothers in law of some of them fear the same for their sons and resist the operation. Some of the women fear loss of physical power in their husbands, others fear loss of sexual power in their spouse. Some others want the protection from a pregnancy in their own body, rather than in the spouse’s. No matter what the reason, there is widespread resistance to vasectomy, and there seems no hope that it will change.

Postoperative Resolution of a Patient

She weighed 86 kilograms before we operated on her and removed her uterus. The specimen did not weigh more than 300 grams. So weight was practically unchanged. When I examined her on the next day, she was comfortable in bed, and was OK surgically.
"You are all right" I told her. She seemed happy it that.
"What will be the first thing you will do after going back home?" I asked, though it was too early to be talking of going home.
She looked at me uncomprehendingly. I smiled at encouraging her to answer that one. We continued like that for half a minute. Then she understood.
"I will reduce my weight" she said.
I was surprised. That was the answer I wanted, but I had not thought she would read it on my face. "Was it readable on my face?" I asked the Resident Doctors. They did not say anything in response. Probably they had spoken to her at length about the problems of obesity, both for her and for them (from the patient care point of view), and that too in no uncertain terms.
A week later this patient went home and we had another, weighing 103 kilograms. We performed a cesarean section on her for fetal distress. The baby weighed 3 kilograms. So she had a full 100 kilograms weight of her own. I did not have the heart to ask her the question I had asked the previous woman, because I knew she would get even fatter, what with the nutritious diet and supplements given as a routine to all women after deliver in our society (provided they have the money required for that).

Promises Are For Not Keeping

One of my past students needed something from me. He said he would call me again in a couple of days, by which time I would get the information. He did not call, but I did. Then he said he would visit me. We fixed a day. I planned my schedule and kept it flexible enough so that I would be able to accommodate him whenever he came. He never did. He did not call to cancel the appointment, apologize for not being able to come, nor for rescheduling it. I did not call again to see what had happened, because I realized he belonged to that group of people who do not realize that promises are meant to be kept, and they are expected to communicate and explain if they cannot keep their promises.
This started me thinking, and I started remembering a lot of people who have done this before. There was that Professor of a superspecialty, who had said he had received a number of medical eBooks of different specialties on a DVD and would give those to anyone who wanted to read those.
"I would like to borrow these books" I said.
"Of course. I need to get them on another DVD and give you" he said.
I called his office and residence a number of times. It has been three years since that conversation took place. I am yet to see a single book, though I have given up on it, and I do not want any too. I purchased all the books I need. This came up again when one of our Associate Professors said the other day "Dr xxxx (the same person quoted above) said he had a DVD full of ebooks. He said he would give the ebooks to anyone who wanted them."
"Did you get any" I asked.
"No."
"So he does that to many people, not just me" I said. She smiled with understanding.
I plan to ask my psychiatry colleague which personality disorder it is, in which the subject volunteers to do or give something, and just does not do it, no matter what.

Tragic Death of a Colleague

One of our senior colleague from another civic hospital passed away suddenly due to a massive heart attack. There had been no history of ischemic heart disease. I was stunned when I read about it in the newspapers. He has been just two years older than me. A nice person, liked by all. I reached the hospital. One colleague met me and said “Sir, did you read about the tragic death of Dr. xxxx xxxxx?” I was surprised because the smile on that colleague’s face belied the words uttered.
“Yes, very tragic” I said, thinking perhaps the facial muscles of this person did not know how to express happiness differently from grief. Some time passed. Another colleague who was on leave arrived for some work. That one had not had time to read the newspaper and had not known about this tragedy. When I told her about it, she said “how surprising, isn’t it? He must have been just a couple of years older than us.” Actually they were the same age. I was stunned by finding a smile on face of this colleague too. Was it an inability to show a sad expression, or a happiness that death had passed one by and visited another person?
When I read the other newspaper in the evening after the day’s work as I normally do, I read a journalist stating that this death highlighted the fact that doctors have long working hours, irregular meals, stress of work and hence they get heart attacks. It must be the journalist’s way of generalizing things about doctors without actual knowledge. Most of the senior doctors do not fit in this description. It is appropriate for young doctors in training and at the beginning of their professional career. I do not mean this about the colleague who passed away, God rest his soul in peace, but about most of us. The truth is that doctors do not eat healthy, exercise, and use methods to relieve stress that they tell their patients to do. I am witness to meetings of doctors where fast food and dangerous food is consumed in large quantities and with relish. I know very few doctors who go to gyms or engage in outdoor activities that can be considered cardio exercises. I have set up a gymnasium in my department, which is never used by any resident doctor (poor people probably have no time and energy to exercise, I suppose) and by more than 90% of staff members (who have the time and energy, but probably not the desire). Perhaps they use other gyms or fitness centers, but no one looks fit and rearing to go, as they seem in the TV serials on doctors. I fill confidential history sheets of all employees in my department every year. There is a question about their health, and I have to state if their health is good, OK or bad. Since they do not have a health check up and submit the report to me any time, I have no method of knowing about it. I just say it is good, because I have no evidence that it is bad. Then one day one of them passes away suddenly and we retrospectively realize it was bad. I wish the institute takes the initiative and makes health check-ups compulsory. After all, a doctor passing away is a loss not only to his or her family, but also to the institute and to the society.

Blessed Ring

That patient looked not so well off, which is what one can say about many patients coming to this hospital. But she had three rings on her fingers. I had examined her, made a diagnosis, and prescribed appropriate treatment. But I was curious about the rings, remembering the three rings worn by one of the characters in the movie 'Three Idiots". I had a feeling these rings had to do with superstition.
"Are these rings just ornaments or something more?" I asked her.
"These two are ornaments" she said, pointing towards two of them. "This third one is blessed by God."
"Blessed by God?"
"It is for good luck, good health and keeping away evil" she said.
"have you always worn it?" I asked. "You have been unwell for quite some time. Did the ring not help?"
"All treatment taken from other doctors failed. Now I have started wearing this ring after that."
"For how long?" I asked.
"I started wearing it when I came to this hospital" she said.
"She is wearing this ring to protect herself from us and our hospital" I told my Registrar. She just smiled.

Blood or Red Ink?

The Resident Doctors have a lot of work to do, both clinical and management. They wear aprons which have reasonably sized pockets. These pockets are always full of stuff that they would need any time. There are sometimes red stains on the aprons, not necessarily on the pockets. When these stains are after they have worked in the labor ward, they can be presumed to be caused by contact with patients' blood. We have standard procedure laid down for action after a contact with blood. But the poor guys and girls are so overworked that they just ignore these stains and the SOP.
"Is that blood on your apron pocket or is it red ink from a pen in your pocket?" I asked one Resident Doctor when I saw a good sized red stain on her apron.
"It is blood" she said. Probably she did not have to consider the ink option because she did not carry a pen with red ink in it. We encourage they fill the discharge summaries of patients using red ink for headings and important parts, and blue ink for the remaining information. But I did not press the point.
"Is that blood HIV positive or negative?" I asked.
She looked at the stain carefully, gave a half smile and said, "It is probably HIV negative."
"At least put some hand wash solution on it until you change your apron" I said. I did not press that point further too, hoping she would have got the message. I would have liked to call her to see me after half an hour to check if she had changed her apron, but I did not do it because it would add to her busy schedule and take away whatever little free time she would have found.

Minglish

I am feeling a little adventurous today. The best I can do when I feel so is to make a new word and try to make it stick. If Hindi English is called Hinglish (distinct from the Queen’s English and also from Americal English), why not called ‘Missed English’ Minglish?
This question brings us to another question - what is ‘Missed English’? This is a newly described entity, unlikely to be found on Googling, and also not on Wikipedia. It is English used by people who have missed the true meaning of what they say in English, who use those words for something altogether different. A couple of examples should make it clear.
“Doctor, I have a great difficulty in passing bathroom” a patient said.
“Making bathroom?” I asked. The patient had the entire sentence in vernacular except the word ‘bathroom’. I have translated the sentence into English for my overseas readers and also for those who are local but cannot read local languages.
“Yes, bathroom.”
“What is making bathroom?” I asked, because I had to know the symptom so as to be able to make a diagnosis of her condition. She explained elaborately, and finally it dawned on me that she meant defecation by saying making bathroom. Perhaps she thought it was indecent to use that word, or even the word ‘toilet’, and preferred a decent word like ‘bathroom’. I would have thought she would have used that word for micturition at the most, because I could not imagine how anyone could defecate in a bathroom. Over a period of time I realized that she was not alone in the the use of this word in this manner. A number of women in our outpatient clinic, coming from the same educational and socioeconomic strata used that word similarly. That was ‘Missed English‘.
Another example of this phenomenon is use of the word ‘Operation’.
“We need to perform a small operation check your pelvic organs” I explained to an infertile patient. I was talking about laparoscopy and hysteroscopy.
“No, Doctor. I don’t want an operation. How can I get pregnant if you perform an operation on me?” she said in vernacular.
“What do you mean? This operation is to find out why you have been unable to get pregnant” I said.
“Operation is done to prevent a pregnancy” she said. It dawned on me that she was referring to a female sterilization operation. In her world, that was the only operative procedure performed on a woman.
“What you are calling ‘operaion’ is one of a few thousand different operations. It is called sterilization operation. All operative procedures done in operation theaters are called operations. Do not worry. We do not propose to sterilize you” I said and then explained what the endoscopic procedure was all about. I have encountered many more women who believed the word ‘operation’ meant sterilization operation performed as a permanent method of contraception.
I suppose what I mean by ‘Missed English’ is clear to the readers. The compulsion to use English words instead of known and trusted vernacular words has some psychological reason like a desire to appear knowledgeable or as smart as those who speak English. I hope the readers have no objection to calling ‘Missed English’ ‘Minglish’. It may not make its way to the Oxford Dictionary. But so what? I get at least the happiness of having created something unique and original. :-)

Awesome Teacher Student Ratio

A teaching institute is assessed from multiple aspects. One of them is the teacher-student ratio. Higher the ratio, better the teaching status of the institute. It is obvious that if there are fewer students for a teacher to teach, he will be able to give better attention to the students and the learning process for the students will be enhanced. from this point of view, the medical council and the health university make it mandatory that for postgraduate teaching, the teacher-student ratio should be one, i.e. for each student there should be one teacher, or a teacher should not have more than one student. It is not so for undergraduate teaching. While we get 16 postgraduate students per year, we get 180 undergraduate students per year. The number of teachers remaining the same, the ratio cannot be 1 for undergraduates. For clinical postings, they put less than 10 students per unit if there are 6 teaching units in the hospital.
But my students achieved the seemingly impossible. The other day, when the civic body elections were held, only one student turned up for education, the others preferring to stay home rather than go vote or get educated. So our teacher-student ratio became one. And then a day came when they achieved the impossible - they made the ratio infinity. No student turned up for education. The ratio being number of teachers divided by the number of students and the number of students being zero, the ratio became infinity. The mathematical explanation for those who have not studied maths is that any number divided by zero gives the answer as infinity. Ours is probably the only institute on record with such a ratio. Perhaps we could apply to the Guinness book of world record! :-)

Elder Sister

She was a middle aged woman. She presented to us with abnormal uterine bleeding. We found that she had two small leiomyomas in the uterus.
"Doctor, do I have to have my uterus removed surgically?" she asked. She had been advised that by someone else.
"There are different treatment options" I said. Then I explained them to her.
"What if I just wait?" she asked.
"You could do that. If you remain symptomatically OK with medical treatment, and you get menopause some time soon, your leiomyomas will regress" I said.
"But when will I get menopause?"
"It tends to happen at about the same age in sisters and their mother. Do you have an elder sister?"
"Yes."
"Is she menstruating?"
"Yes."
"Well, then it seems difficult. Hoe old is she?"
"Ten minutes older than me" she said.
"Ten minutes?"
"Yes. We are twins. She was born ten minutes before me."
I was taken aback. I had not expected her to have a twin sister, and then say the sister was elder by ten minutes. She had missed the whole point of my question, but still, technically she was right. You think you have seen it all, then you are suddenly proved wrong.

One Glove per Patient

She was a thin and frail woman. She had come to our outpatient clinic for minor gynecologic complaints. She probably did not have a serious problem, judging by her symptoms. But still she was anxious. That was possibly because she had no way of knowing the gravity of her problem. The nurse gave her position for an examination.
“Doctor, do you change gloves after examining one patient before examining the next patient?” she asked me when I approached her for an examination.
I was surprised. No one had asked me this question before. I had never thought that using a fresh glove for each patient could have any alternatives. She was not just anxious, but terrified.
“Yes, we do” I assured her. She then got examined, diagnosed and treated. She went away happy.
When I narrated this story to a few colleagues, they were not as surprised as I was at her question.
“We had that professor, who went on to win the prestigious ‘Dhanxxxxxri” award for his contributions to gynecology. He used to examine all patients in the outpatient clinic with the same glove” one person said.
“Was there an acute shortage of examination gloves?” someone asked.
“No! He did that deliberately.”
I was surprised at that. “That would transmit infections from patient to patient” I said.
“He must have known that. But still he did what he did. The patient must have heard of such practices.”
“No one stopped him?”
“Honorary doctors used to be like God in those days. Who would dare to correct the honorary head of unit?”
“We had a unit head who examined patients without gloves” another person said.
“Huh?”
“Yes.”
That sounded reckless too. Not only did that person infect patients since his hands would not be sterile ever, but he was exposing himself to the risk of getting infections from patients.
“We should stop such practices” I said.
“Nobody does such things any more, Sir. These stories are from the past.”
“Hm…” I said.

Troubleshooting Endoscopy Display

We had developed a method of using a computer with a video capture card in place of an endoscopy monitor, so that we could both see what we were doing during endoscopy using a CCD camera, and record the operations as videos. It turned out to be just 40000 INR while a high definition endoscopy monitor would cost 175000 INR or more. It was working out fine, until a few days ago, when it started periodically showing blurred images, reversing colors so that green looked orange and orange looked red. Endoscopic surgery could not be done safely any more.
I got the electronic engineer to look at the system. He checked it. We used another camera. That did not work too.
“I cannot find the fault” he declared. “Most probably the computer is at fault.”
I got the computer engineer to look at the computer.
“Perhaps the color display is faulty” he said.
So I started MS Paint and drew lines of different colors. Green looked green and orange looked orange. I showed him previous recordings of operations, and they looked fine. “Color display is OK” I said. “There is a problem with the video capture.” He went away, because he could not do hardware repairs. I got another video capture card from home and fitted in the computer in place of the old one. It did not work, though it was working fine in my home system. So it was not a problem related to the card. Then I checked the device manager and found that the video capture driver was corrupt. I removed and reinstalled it. It remained faulty. The computer engineer tried to install it and failed.
“Let is see if there is a better driver on the net” he said.
“I think it is a problem in the motherboard” I said. “The old driver was working fine in the past. Why would it not work now? We have tried to install it from the original CD as well as from a copy of the CD. Both got installed but did not work.”
He went away, because there was nothing further he could do.
Then I checked the camera on an LCD projector and it worked fine. So the fault was indeed with the video capture part of the motherboard. No I have two options. Either I use a television set in place of the monitor, or I get a new LCD projector and project the operation video on a screen while we operate.
“Sir, it was a good idea to test the camera this way” said the Associate Professor in charge of endoscopy equipment.”
“Yes. I like the algorithm myself too” I said.

Rule Master

“Sir, I am unhappy.”
“What happened?” I asked. If I could help it, I would not have anyone unhappy in my department, because unhappy people achieve far less than happy people, and if life was not about being happy, then what was it about?
“Do you remember I had asked the administration for xxxxxxxx?” (the Xs are put here to maintain confidentiality).
“Yes. Did you get an affirmative answer?”
“The first paper was held by the head clerk after the administration had sanctioned it. When I sent a reminder, the head clerk kept that paper too after the administration sanctioned it.”
“Was your demand actually sanctioned?” I asked. “As I recall, though it was a perfectly reasonable and legal demand, the civic chief a few years ago had declined such a request to someone else.”
“Well, the administrator had just signed on my request and marked it for the head clerk.”
“That is just direction for the head clerk to take action as per rules” I explained.
“Yes. You had said that before too. So I took the head clerk and that paper to the administrator and asked for clear directions on the issue.”
“Did you get what you wanted?” I asked.
“No. The administrator said my head of department should grant me what I asked for without bothering the administration.”
“I would do it if I had that authority” I said. “I cannot because it is not in the civic service rules.”
“That is what! The administrator said you stick to rules very rigidly. You should set some rules aside.”
So my staff member was unhappy because I would not break some rules to oblige that staff member.
“Look here. You saw what happened to those who set the rules aside in the Sara Sahara scam? They spent a long time in jail. You saw what is happening to those who set rules aside in the Armymen’s Adarsh building scam and 2G spectrum scam? Do you think it is fair to me to ask me to bend rules so that you will get what we know is legally yours, when a better option is to ask the civic chief to grant what you want, and if he won’t, take legal recourse?”
“Um….”

Laparoscopic Stress Test

I was surprised. The senior faculty performing laparoscopy was trying to fit the end of the fiberoptic cable to the gas insufflation inlet on the operating laparoscope. Laparoscopy, like many other procedures is quite mechanical. The steps are fixed, and not difficult to remember. After some time, it becomes a subconscious activity, like breathing and walking. I had seen some residents trying to achieve the impossible - what I just described, or connecting the end of the gas insufflation tube to the receptacle for the fiberoptic cable. But to see the same being done by senior faculty? The error was corrected after a few attempts, without anyone drawing the gynecologist’s attention to it. I thought about it, and understood. The said consultant was under pressure and was allowing it to distract him from the work at hand. Perhaps such a thing would not happen with more experience.
Then I thought about the residents who committed the same mistake at times. It was not as if they did not understand what should be connected where. It was probably because of tension.
“It does not fit there” I have to say. “It goes to the other receptacle.” Then they correct themselves, but without a word or even an apologetic smile.
I have also seen some of them putting the telescope in place of the trocar in the cannula and putting their eye to the eyepiece before connecting the fiber optic cable and switching on the light. When they do not see anything inside, they look outside the telescope to find the cause of the failure to see anything.
“You cannot see anything inside the peritoneal cavity until you switch on the light” I advise them. They do it without a word or even an apologetic smile.
I always wondered why they would not show any response to my advice and just correct themselves. Now I know. It is the tension of having to perform the operation, expecting either unknown complications, or criticism for errors. Laparoscopy is a stress test for sorts for them.

The Magic Shirt

I was not shocked, but definitely more than surprised. I had not thought any woman would hold my arm (other than my mother when I was small and my wife when I grew up and married her). I did not think so because of many reasons. First of all, in our culture women do not do so. Then no woman had done so when I was young; so the chances were quite small that anyone would do so now. The third reason was that I had never done so to any woman (except the two mentioned above), so no woman should want to do such a thing to me. The fourth reason (some people would put it higher on the list) was that I had always behaved maintaining a certain distance from people, and people had reciprocated. Why would anyone change anything now?
“This is a nice shirt” said one of our junior colleague, who had left the institute long ago, and was attending a function in our institute. She held my arm for a few moments after saying so. A number of staff members were present, but no one said anything.
When I narrated this to my wife, she laughed and said, “it is the effect of the shirt I bought for you.” She had bought that shirt, which was quite different from my choice.
“I hope it is not catching or something” I said. “Anyway, I did not reciprocate in any way.”
“I know you would not” she said.
The next time it happened in a wedding party. One of our relatives, herself a doctor, grabbed my arm ( I don’t recall if it was the same one or the other one) right in front of my wife and a lot of other relatives. She held it almost until I was ready to break her grip. I was wearing the same shirt. She had not done any such thing any time in the past.
“I think we should dump the shirt” I said to my wife. “what with people grabbing my arm …”
“It is a nice shirt. You cannot throw it away” she said.
“Perhaps I may wear at home” I said.
“No way. It is for functions and outdoors.”
I kept it hidden for a long time. Today I had to attend a meeting, where 5 or 6 specialists from different fields were going to interact. We had had a few meetings in the past, and knew one another. My wife found that hidden shirt and suggested I wear it. I good husband takes all suggestions of the wife on such issues seriously, and I complied.
“Oh, hello” said one of the specialists. “This is the second time we meet!” She was as old as I was, or perhaps older.
“We have met more than once before” I said with surprise. “I have been attending meetings with you for the last two years or so.” Then I had a thought. “Perhaps you did not notice me then.”
“Oh, um… uh…that is not so” she mumbled.
It was that shirt again. She had not noticed me because of my knowledge and technical expertise in the past. But she noticed me when I had that shirt on.
My readers may think I am loony, not wanting to make the best use of an almost magic shirt I have been gifted. Well, I could not do it before, and I won’t be able to do it now or later. I could give it away to someone who could put it to better use, but that would hurt the feelings of the person who gave it to me. Tough situation, what? :-)

Rediscovering a Student

I was conducting a meeting of the PCPNDT committee. We were scrutinizing proposals for new registration as well as renewal of old registration.
"Sir, there are these two proposals. They have not applied in time, and they are refusing to pay the late fee. What shall we do?"
"You have to seal the machines as per the act, if they are no more registered" I said.
"They are demanding that we ask the PCPNDT committee rather than refuse them ourselves."
I checked the two proposals. Both applicants were very senior consultants, making a lot of money. There should not have been any need to try and save money. Anyway, they had to pay as per the act. So I wrote my remarks on their proposals, advising them to pay the late fee. Some time later, the person in charge came to meet me.
"Sir, there is one doctor who says she was your teacher."
"My teacher?" I was surprised. "I myself have been a teacher for thirty years. My teacher would be very old."
"Her name is x x xxxxxxx."
"Yes. She had been one of the bosses when I was a student and resident doctor. What does she want?"
"She has not applied for renewal of registration in time, and now she does not want to pay the late fee. Despite explaining the PCPNDT Act to her, she refuses. She is going to speak to you, you being her student."
"I don't think I can break the rules, even for my teacher. By the way, she said she did not like me as a student, for reasons she may not like to discuss with you. Why would she want my help now?" They all laughed. I had not said that to make anyone laugh. I had said this because I had truly been upset. This same person had attended our celebrations for our institute having completed 80 years three years ago, had promised to do something within her power to upgrade our department, and had not done it.

Representing Respect

'Congratulations to Dr. x x xxxx Sir for becoming president of xxxx.'
Someone had put up this notice on our blackboard near the entrance, and also on another one near the staff room.
"It is perfectly fine to put up such a notice" I said. "But I cannot understand putting 'sir' after the person's name. That is not good English."
"The residents always do that. They write 'patient seen by xxxxx madam or operated on by xxxx sir' on official records" our Associate Professor said.
"It sounds like 'Honorable xxxxx ji xxxxx saheb, which people who lick xxx do in our politics, to please the boss."
"That is because they are not assessed for their command on languages, when they opt for professional courses."
"They could always read good English and improve themselves" I said. "I think this does not have as much to do with poor command on English language, as on their attitude of licking xxx for favors. In the case under discussion, it is evident from the fact that the said professor became president of the xxxx long ago, while they have put up the notice today, just a day prior to the end of his long leave."

Anything for the Maid Servant!

"My servant’s wife is coming here from the native place" one of my distant relative was saying to me on the phone. "She has a prolapse problem. I would like you to treat her at your hospital."
"OK. Send her to my outpatient clinic when she arrives" I said.
"This servant is a special one. He has been with us for years."
"I understand" I said. "We treat all patients well. I will give personal attention to her treatment."
The patient arrived in due course. She had a genital prolapse. I advised an operation, and tests for fitness to undergo the operation. The patient ans her husband went away.
"We are a little busy right now, preparing to go abroad" I got a call from that relative the same evening. "We will get those tests done in a few days."
"She can have them done free at my hospital" I said.
"No. I don’t want her to stand in queues there. I will get them done in a private good laboratory near our house."
"OK" I said. It was wonderful to see that people cared so much for their servants.
A month passed. These relatives went abroad. The servant brought his wife to my outpatient clinic.
"Where are the reports of her tests?" I asked.
"I have to get them done in this hospital now" he said.
"But your employer said she would get them done from a private laboratory!" I said.
"She said so, but told me to get them done here after they went abroad."
I kept quiet. A week later they came back with the reports. Her hemoglobin was 7 g%, far lower than safe for undergoing an operation.
"She has to take treatment for her anemia for a month or so" I said. "If the tests had been done a month ago, we could have treated her in the meantime, and she could have undergone an operation now."
"Yes. But madam would not let me bring her to this hospital for tests until she went away. She wanted me to keep working all the time, not spend a couple of days away from her house."
I kept quiet. Both of us understood the situation very well, and nothing would be achieved by voicing our thoughts. I operated on her in due course and she recovered well. But I still think of her husband’s employer whenever she or her husband come to me for any treatment. The said employer is fine in the meantime - no divine justice seems to have been done as one would expect in a novel or a story.

D&C or Something

She was a young woman who had come to our clinic for infertility. My Registrar had seen her and had advised investigations.
"This girl works as my maid servant" said the Head of one of the paraclinical services, pointing towards that woman. "Her investigations have been done."
"Let us see the reports" I said. I checked the reports. They were fine. The next step was to assess the pelvic structures fallopian tubal patency.
"She has been advised hysteroscopy and laparoscopy by your resident doctor" she said.
"That is correct" I said.
"I don’t want you to mess up her pelvis. Can you not do something else?"
"Why?" I asked. "That is the best procedure for her at this stage."
"She looks after my house. I cannot have her away for rest after the procedure."
So the motive was not to get correct treatment to the woman, but to show her that she had arranged for good treatment for her, and keep her working.
"I cannot think of anything else" I told her.
"Can’t you do some D&C or something?" she asked. The patient was standing by, not understanding a word of the conversation.
"D&C is not useful, and hence an unnecessary and harmful procedure. I do not recommend it" I said. I wanted to add that D&C would probably mess up her pelvic structures even more than endoscopy and that too quite needlessly. But I refrained from saying so. It would not have made any difference, I knew.
"OK. I will talk to her and see what can be done" she said and took the patient away.
You must have guessed, they never came back. The Head of that service either took that patient to someone else to get a D&C done. That was 25 years ago. The said doctor retired from her job ages ago. I have seen her periodically in some functions of the institute, heard people speak of her with respect, but could not feel any respect for her myself.

Silence Zone

The civic body has wisely decided that the space around a hospital should be a silence zone. there are boards around our hospital warning people not to sound the horns of their cars, so that patients are not disturbed.
"Sir, the nurse cannot hear which instruments we ask for when we are operating" an Assistant Professor complained.
"Why?" I asked.
"Sir, they have that students' function on the tennis and basketball courts. They have put up amplifiers and speakers as tall as I am. they are playing music with heavy drums and such. The nurse has to be good at lip reading if she has to know what I am saying."
"Only if you do not wear a mask when you operate" I said. He smiled.
"This problem is annual" I said. It has been going on for ages. Medical students and their teachers both have to understand this, but they turn a blind eye to it. Cultural festivals are essential for comprehensive growth of the students, I understand."
"Hmm ..."
"I will speak to the administrators" I said. I did and they promised to speak to the organizers. I continued to run the OT with sign language in the meantime, wondering why I had to complain every year? Or perhaps the silence zone was for motorists and people around the hospital, not people within. The sound diminished after a half hour, and restarted. Perhaps they thought the OT was over, and ward patients did not matter.

Reverse Silence of Residents

The English language has some quirks of its own. One of them is to include letters in the spellings of certain words, but omit them during the pronunciation of the words. These letters are said to be silent. It was done in the 15th century by scholars of English to remind people (as a nationalistic gesture) that most of the words in the language originated in Latin and Greek. For example the word 'doubt' was spelled as 'dout' then, taken from French 'doute', but had actually been derived from Latin 'dubitare'. So they put a 'b' in the spelling, but kept it silent. There are many such words. The purpose of this article is not to write on English grammar and hence I refrain from giving more examples.
Our Resident doctors show a reverse trend these days. Then tend to leave out letters from spellings of English words when they write clinical notes. Perhaps it is the influence of the modern texting when they send SMS on cell phones.
“pt. and husbnd r staying 2gether” wrote my House officer once on a patient's case paper to record that they were cohabiting. She passed out and is now probably a consultant somewhere. What happens when they practice the art they have learned could be a new trend in clinical practice and record keeping. I dread the possibility of some patient filing a case in a court and such case papers are submitted there as evidence.
“.... there is occlusion of the inular artery” read a report of CT scan of head of a patient who had a cerebrovascular accident in the past. My Registrar presented it to us on ward round.
“I think there is nothing called an inular artery” I said. “It must be 'insular.'
“It is in the patient's printed report” the Registrar said, pointing to the conclusion of the detailed report.
“Let me see the report” I said and read the description. The word in that part was 'insular' and not 'inular'. “Look at the description” I said, “which shows the correct word. It was probably a typo, unless you think it was the correct spelling and the 's' was silent in the spelling of the word.” He looked at me blankly. “Like the spellings I find in case notes of Resident doctors. Letters are missing, and verbs are often missing. Don't you remember lines like 'vaginal incision made, uterine vessels clamped, and uterus removed?”
If guys could blush, he would have. Being a guy, he offered me a smile instead.