Prayer

Those people who read my blog have enough of everything required for a reasonably good life, or they would not spend time reading blogs. I wish they continue to be happy. But I also wish the New Year sees others who don't have much get at least enough to meet their survival needs.
There are many who have so much they don't know what to do with it.
May the New Year see them do something that will make a difference to others.
The world has evolved to the present state with the help of those who thought differently and dared to do differently.
May the New Year see many more such people do their thing.
The world has many differences between people, which is causing much grief to many people. The differences are unlikely to go away.
May the New Year see more people who will talk people into being tolerant to those with differences.

I could wish for many more things. But expecting too much in one year is not wise. I think I will leave the rest for the years to come, hoping this New Year sees at least these wishes come true.

New Cause of Hypocapnia

A famous psychiatrist conducted a workshop on stress management for us. He told us the following story.
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I always knew anger was bad for physical and mental health of the person who got angry. But I decided to avoid getting angry only recently. Actually I had planned to practice it and even conduct a workshop for Resident Doctors on anger management. I had collected a lot of theoretical as well as practical material for it. But somehow it remained to be done. Implementing those ideas in my own life also remained not done. Finally I decided to do it. I even made a video for teaching anger management.
One of the techniques that was easy and effective was deep breathing. I liked it. Whenever someone did something that would make me angry, I started breathing deeply. That calmed my anger. I was happy that I had managed it. But there is one Resident Doctor who is very good at making me angry. Something or the other keeps happening in the hands of this person. One day so much happened that I was deep breathing almost continuously for quite some time. So much so that I started feeling faint.
"I am feeling faint" I thought.
"Naturally you will feel faint if you hyperventilate for this long" an alert part of my brain said. "It is due to carbon dioxide washout. It is hypocapnia."
"Yes. I realize that" I thought. "I got rid of my anger, but at what cost."
"Is it not better to be hypocapnic rather than angry?" that alert part of my brain asked.
"Not really" I thought. "I must use other methods to control my anger, at least until this particular Resident Doctor completes residency and moves on. Or very soon I will have no carbon dioxide left in my body."
One good thing that came out of all this was that I discovered a new cause of hypocapnia - aggressive anger management.

Did Or Might Have?

This story is from another anger management workshop, where one speaker told this as a part of the exercise set by the person conducting the workshop.
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It is all in the manner of speech.
I prefer to say what I want to say or at least what I have to say. There is no hiding from it. Most of the people do the same thing. If they don't want to say something, they keep quiet. But not everyone is so. See the following example to know what I mean.
"Why did you do this?" I asked one resident doctor who had goofed up big time in patient management. Luckily we had been around and not allowed things to go wrong.
"But I did not do so" she said.
"But you did. People saw you do it" I said mildly. I have learned finally that anger harms me rather than the person who makes me angry. So now I try and not get angry.
"I did not do it intentionally. It might have just happened from me" she said.
"Ah!" I said. It looked like a case of someone using this person like a puppet. She probably could not help what happened. "But I don't think you did not know what you were doing. Would you not go to sleep in some corner of one of the wards during emergency duty, where no one could find you? You would even switch off your phone so that you would not be woken up."
'I did not sleep like that" she said indignantly. "My eyes might have shut on their own."
"And you lie to save yourself many times" I said. It troubled me saying all those things. But they were true complaints, and they caused trouble to patients and her coworkers.
"I don't lie" she said. "Some untruths might be slipping out of my mouth."
I gave up. "OK. You can go to your work" I said.
"But when ..."
"See, I have managed not to get angry because I am working on it. But now my breaking point is approaching. Go before I get angry" I said.
She turned and started going. She stopped twice in the six feet distance to the door, turned around and opened her mouth to say something, saw the look on my face and finally went away. I congratulated myself on having maintained my cool, and also thanked her mentally for the training session in anger management she had not conducted on her own, but had somehow been instrumental in its occurrence.

Merry Christmas

Hey!
Wishing You All......

How People Paint

It was not actually an experiment, but turned out to be one anyway. I was having trouble filling color in black-and-white vector graphics, as I wrote in my previous post. I managed somehow, and the result was as shown below.

Then I spoke to someone much younger than me (but an adult). He offered to find a solution to my problem. So I sent him the same original graphic. He returned it in five minutes, saying he had no problem filling it up with color. He ran Windows 8. The result was as follows.

This post is not about the version of Windows one runs. It is about painting. I am aware an actual snail does not have colors as shown in either of the illustrations above. Both look nice, and I cannot decide which one looks nicer. Both of us ended up painting the eyes blue. Some psychologist might interpret the use of different colors differently. My own interpretation is that there is a child in each of us, and that child loves colors and filling colors in drawings, and in the mind of each the color of the same object can be different.

(Acknowledgement: I have used a black-and-white drawing from the following web page of ClipArtBest.com, which gives free images for use. The coloring and write up are my own.
http://www.clipartbest.com/black-and-white-cartoon-animals)

Black-and-White To Color Trick

Sometimes you have a black-and-white image that you want to be colored. There are actually two types of images - vector and raster. The vector images are easier to fill with color. You just have to use the fill or flood tool of a Paint program. You select a color with a color picker tool, click on the fill tool button, and click in the middle of the area you want to fill. It gets filled instantly. At least, that is the theory. In case of raster graphics, there are no such well defined boundaries around areas you want to fill. You need a more powerful graphics program like Gimp. It puts a transparent later over the original, and you paint in it using a brush tool. It is easier with a specialized tool like 'Black Magic', which does the same thing, but without you having to actually insert a transparent layer.
A problem with the Paint programs is that if you open a black-and-white image, the software recognizes it as a black-and-white graphic, and replaces the colors you choose with shades of gray. Gimp and Photoshop do the same thing. You can actually see the color palette, select a color of your choice, and then you end up watching a shade of grey where you wanted color. The only way to beat the software is to open a new blank image, which is a color image by default. Then you paste your black-and-white image in it. Now the color palette is enabled and you can put whichever colors you want in it. This works with both the Paint programs and more advanced ones like Gimp and Photoshop.

(Note: this one is applicable for those who run Windows XP like me. It is OK on Windows Vista and higher. I am unwilling to upgrade because Windows XP is otherwise working fine for me, and I don't want to throw away good money.)

Repairing A Potato Peeler

I wanted to take up woodcarving as a hobby. It would have given me satisfaction from doing something with my hands, other than delivering babies and performing operations, which I do for both happiness and making a living. The main problem was that I could not find any woodcarving tools in the local market. I gave up that idea because there was no way to make it work. But if I had those tools, I would have been able to at least repair our potato peeler much more easily. It was a simple instrument, with a metallic peeler fitted over the end of a cylindrical wooden handle. The metallic part remained fine, but the wood rotted inside the grip of the metallic part, and the handle came off. I tried to fit it again, passing small nails through them both. But the rotted end of the handle would not hold the nails. I could not find another piece of wood that would fit in place of the old handle. I had no tools to shape any other piece suitably.

Then I had an idea. I reversed the handle, so that its other end would fit into the metallic part. But it was broader than the cylindrical base of the metallic part. I had to shave off the extra portion so that it would fit. I was back to my old problem - no tools. I knew it would be a lot easier to buy a new one. But there would be no sense of achievement in it. Besides, the ones available in the market have flat plastic handles, which do not sit well in the fist when you peel potatoes. Luckily I had another idea. We have this machine that we use to sharpen our kitchen knives and scissors. If it could grind metal, why would it not grind wood? I tried and it did that very well.

In the figure above, 'A' shows the metallic part (golden colored) and the handle. Please do not say the other end of the handle does not look rotted. I had to spend a very long time making these 3D drawings. To show one end of the handle rotted would have taken ages. 'B shows the upper end of the handle ground all around such that the cylindrical part of the metallic part would fit over it. 'C' shows the two fitted together. I passed two small nails through the base of the metallic part and the handle within it. 'D' shows the finished potato peeler.
A note of caution for those who want to try this out. Try to fit the base of the metallic part over the handle periodically as you grind it, so that you do not make it too thin. If it gets too thin, you will have to find a new handle and start all over again.

How To Give Away Free eBooks?

This is something that I need advice on.
I have written two eBooks recently, mainly for resident doctors in training. They might help medical students too. They are in PDF format. Their front covers look like this.

I want to give these free to anyone who wants them. The problem is I don't know how to do that. Perhaps there is some place on the internet where I can upload them, and give a link so that people can download them. I would welcome people to give them to anyone who wants them, just so long as one does not print and sell them. The idea is just to let people learn what I learned the hard way. I cannot email them, because that would take away a lot of time, in which I could do something else that also might help people.
If anyone can suggest how I can do this, I will be obliged. Please email me.

05-01-2015
A kind soul advised me to put them on Google drive. Thanks to him/her (did not reveal identity), now you just have to click on the image of the book and the ebook will download. Open it in any PDF reader.

The 7.5 Size Gloves

Our surgery professor used to tell this story.
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It was not a great way t start a busy outpatient clinic.
"Where are 7.5 size gloves?" I asked the attendant.
"Sister has not given any" she said.
"Sister, why do we not have 7.5 size gloves for examining patients?" I asked when the sister arrived on the scene after I called her.
"The stores clerk said there were no gloves of that size" she said.
"So what did you do about it?" I asked. "I cannot examine patients for four hours with smaller gloves."
"What could I do?" she asked.
"You could have let me know then, rather than I discovering it now."
There was no pint in calling the stores clerk. It was 9:00 A.M. The time of arrival of the clerk was 10:30 A.M., and the expected time of arrival was not before 11:00 A.M., if one went by past experience of other clerical personnel. I called the administrative office.
"The person who looks after the purchase of gloves has not yet arrived" I was told. "I will tell her as soon as she does."
"Do I not work until then?"
"........"
"In an emergency, I have used even size 6 gloves. I have put left hand glove on my right hand and worked too" I said. "The economy of this place has made me do that a number of times. But this is not an emergency. I have to see patients one after another. I cannot do that meaningfully with my hand in cramps.  Since I am head of the unit, I have to see my share of all patients, plus all patients that my juniors want me to see and opine on. If you cannot supply gloves, we will have to prescribe a pair to each patient I examine."
"I will try and get 7.5 size gloves from somewhere, and see that new ones are purchased" I was promised.
Some gloves were brought from a place that had stopped functioning for last 6 months for reasons other than nonavailability of gloves..
"Sister, if you do not get gloves in future, write a call to the purchase officer and ask for permission to prescribe gloves to patients. She gives us gloves or she gives us a permission to prescribe them to patients" I said.
"Yes, Sir" the sister said.
This method seems to have worked. I get gloves of 7.5 size now quite regularly.

Innovative Blood Pressure Control

Life is so full of surprises. Who would have thought a resident doctor would come up with such a novel way to control blood pressure of a patient?

I found the patient in the ward where we keep patients in early labor. She was lying down with her head on a sphygmomanometer. It was a little surprising, because it must have been quite uncomfortable for her. It was a mercury type instrument, housed inside in a long, flat metallic box. To balance a head on such a narrow thing must be difficult. It must have been painful too, since it was hard. Other problems with leaving it on the patient's bed were making it non available to other doctors, and breaking it by accidental fall.

"Who has left the sphygmomanometer on the patient's bed, under her head?" I asked. None of the resident doctors answered in the affirmative. I repeated the question and got no response once again. They must have thought that would beat me. They always believe the Bosses believes the patients are dumb and do not ask them any questions. I am different. So I asked.

"The doctor checked my blood pressure with it and forgot it here" the patient said as she got up.

"Which doctor?" I asked.

"This one" she said, pointing the doctor out. So I asked the doctor, "why did you leave it there and not own up when I asked?"

"But I had taken it back, because it belonged to another unit" she said.

"So you think the patient brought it back and kept it under her head and now is lying to me?" I asked. Actually telling me the truth - that she forgot - was so much easier and time saving. But perhaps face saving was more important to her than time saving.

"......" she said.

In the meantime I noticed that the patient had decided that we had finished talking to her and was back to her lying down position. She had carefully positioned her head over the hard, long, narrow, metallic box. Whether the frown on her face was due to the pain of labor contractions or the pain caused by the box was difficult to opine on. That suddenly gave me the idea.

"She seems to believe the instrument is for controlling the blood pressure. Have you given her the idea that putting her head on it controls her blood pressure?" I asked.

"......."

Since she would not answer, I have no way of knowing the truth. But the patient seemed quite upset when they took the sphygmomanometer away from her.

Threat of DNA Analysis

It was an old trick they used to get away from work.
"Sir, we have a problem. The water supply to the labor ward shuts down once or twice a week regularly" the sister in charge of the labor ward complained to me, while I was taking a round of our patients in that ward.
"That sounds familiar" I said. "Where is the problem?"
"There is enough water in the  underground tank. But the inlet of the overhead tank is shut off."
"That is usually operated by the electricians who run the water pump" I said.
"We asked them. They said they were not closing the inlets. Someone else was doing that."
"I know who is doing it" I said. "The servants in the gynecological OT used to do that on my OT day because the operation list used to be big. If they shut off the water, there would be no list. Which meant
they did not have to work. I found that out and got it sorted out. The problem has not recurred for many years. Now one or more of your servants has learned the trick. Call the senior servant. I will talk to him."
The servant was duly called.
"I understand the water supply to our labor ward is shut off by someone" I said. He kept looking at me, confident that I could do nothing to catch the culprit. "The servants in the gynecological OT used to do that on my OT day" I continued conversationally. He kept looking at me. "I fixed that problem. It did not happen again after that."
That shook him up. Fixing gynecological OT servants was no small feat. If I did that, I must be good.
"Now I am warning you and the other servants. If this happens again, I will get DNA analysis done on the inlet valve of the overhead tank. That will catch the culprit. Then I will lodge a police complaint for interfering with work of the civic hospital. You understand the nature of the complaint and the consequences, don't you?"
It seemed he understood the consequences very well. I went away.
"Sir, will you really do that?" someone in the unit asked me.
"Well, no. We do not have funds to do such a test. I have just frightened him. Knowing my academic reputation, he has believed me. They won't do that again. Actually they could have beaten the trap by wearing gloves while doing this, just as they do while cleaning the ward. But he does not know that and I am not telling him."
In the next two months, the water supply to the labor ward stopped only once, but was soon restored. It was either accidental, or they decided to do it just to try and prove that they were not totally beaten.

Novel Solutions From a Printer

I wrote a book entitled 'Differential Diagnosis and Management Options in Obstetrics and Gynecology' a few years ago. Its two editions were sold out. Then the publisher did something funny. He did not reprint it, nor did he ask me to revise it. After 2.5 years, I thought it was time to revise the book. So I asked him, and came to know all this. The publishing house was quite big, and every time I communicated with it, there would be a new manager who talked to me. There was no explanation why this had been done. They had also printed my last edition on such horrible paper, like one used by tabloids, that it turned yellow after some time, and orange after a few years. They had no explanation for that too. They had no remedy for the loss of goodwill of the book and financial loss to me. I was unhappy with the publisher and decided to change him.
He gave me the publishing rights quite amicably. I think he was just not interested in publishing books any more. I revised the book. It was different from conventional books. It was in landscape mode. Each chapter was covered in just two pages facing each other. There would be an algorithm (flow-chart) on the page on the right side, and explanation of the algorithm on the page on the left side. A reader had to hold the book open, and read the pages alternately to understand the contents. Unfortunately a few algorithms got so big, that they encroached on the lower margin.
"See if the printed pages will look OK" I told my new publisher. He asked his printer to check it. Then he got back to me.
"The printer has three novel solutions to the problem" he said.
"What are they?" I asked disbelievingly. I could not find a single solution to it, and this person had three!
"The first is to remove some parts of the bigger flow-charts" he said.
"No. We cannot remove any matter" I said. "The stuff would not make any sense if we removed any matter from it."
"The second solution is to make the font smaller for those pages" he said. "It will be a reduction. You understand reduction?" he asked me, thinking reduction was a very technical term used by printers.
"I understand 'reduction' I said. I have been reading and writing in English for ages. I have written 21 books so far, all in English. We cannot reduce the font. I have used 10, and any smaller will not be readable easily."
"OK. The third solution is really novel. The printer says the book should open up and down instead of side to side. The spine of the book will be transverse, not the usual longitudinal." He meant like a laptop, I thought. For those of you who cannot visualize this idea, here is an illustration I whipped up.

A is the one he had suggested, while B is the way my book was to be.
"We cannot do it" I said. "It will still put matter in the lower margin. The other reason is that God has made our hands one on each side of the body. So it is comfortable to hold the book open sideways. To hold it open in up and down position will strain the hands and cause fatigue. A laptop remains open by itself, while a book won't."
"So what can we do?" he asked.
"Either we print it as it is, or we just put it in electronic format. to be read on laptops, tablets and smart phones."
I cannot sell eBooks" he said unhappily.
"OK. Then I will give it free to whoever wants it" I said.

Pedunculated or Sessile Polyp?

I was in the second year of my graduate course studying pathology. It was then that I learned that all tumors that grew from any surface either had a stalk or pedicle, or did not have one. Those with pedicles were called pedunculated and those without were called sessile. A little later I studied Gynecology. I learned that leiomyomas arising from the outer or inner surface of the uterus could be pedunculated or sessile. A pedunculated mass arising from a mucosal surface was also known as a polyp. This information has an important bearing on the management of the tumor. A benign pedunculated tumor can be removed easily by dividing its pedicle. A sessile tumor cannot be removed so easily, and has to be dissected out of its bed. All this information is quite basic, and is required to be known by the graduate and definitely the postgraduate students.
We were in a clinicopathologic meeting, attended by our doctors as well as pathologists. One case was being discussed, who had a polyp of the uterus.
"Polyps can be pedunculated or sessile" a Professor from the other department said.
There was a deadly silence among both gynecologists and pathologists, at least those who were paying attention or not dozing. No one said anything for quite some time. Then the resident doctor who was presenting the case started where he had been interrupted. The meeting moved on.
"Has she/he* gone bonkers?" someone said after the meeting. "How can she/he make such a statement?"
"She/he is known to make such statements. That is how God has made her/him" a knowledgeable person said.
"But what about the students taught by her/him? They will remember that and get in trouble in exams" a third person said.
"They don't pay attention to the teachers. They read books for their education" a fourth person said.
"I hope she/he has not written a book and if she/he hasn't, is not planning to write one" a fifth person said.
"I think she/he was not concentrating, and said polyp in place of a leiomyoma" I said. That sounded correct. It also fitted in the behavior of the person concerned.
(* She/he is used to protect the identity of the person concerned).

Dig Deeper

"Sir, we have received the histopathology report of Mrs. XXXX" my Registrar said.
"What about it??" I asked. We got such reports of all our operative cases. There had to be something unusual about it for her to say so.
"It says 'material inadequate. Do a deeper curettage'".
I remembered that patient. The material had been scanty when we had done a dilatation and curettage. But that had not been due to any lack of effort.
"I remember. The operating surgeon had done a really good curettage, despite which  there was hardly any material" I said.
"So what shall we do?" the Registrar asked.
"The endometrium was atrophic. So there was no material. We cannot get any material if we repeat the curettage and curette deeper as the pathologist has suggested. We have to treat her condition appropriately, based on her symptoms. Let her see me when she comes to the outpatient clinic the next time."
The Registrar went away. This was the second time someone had erroneously told us to dig deeper into the endometrium. This time it had been an Assistant Professor of Pathology, while I was Professor and Head of my department. The first time it was the Assistant Professor of my department while I was a first year resident doctor 34 years ago. That patient was young. She had abnormal uterine bleeding.
"Admit her and do her endometrial curettage" the Assistant Professor told me.
I did that. The patient came for a follow up. Her histopathology report was 'proliferative endometrium'. She was still bleeding. Instead of treating her with appropriate medicine, like a progestin, the Assistant Professor said, "you have not done a good job. Admit her and do her endometrial curettage again."
I knew I had done a good job the first time. But there was military discipline in the civic hospital. So I followed orders and repeated the curettage. The report was still the same, and the patient continued to bleed.
"Can't you do a good curettage? I am telling you, do a GOOD curettage" the Assistant Professor said.
So I admitted the poor woman and did a good curettage a third time. The third report was ' endometrium in prolifeative phase. Bits of myometrium seen.' When the Assistant Professor saw that report, she said, "I think you have done a good job. Though she is still bleeding, don't do a curettage again. She cannot afford to lose myometrium. We will treat her medically." I don't know what treatment she gave to that patient. But I do know that she did not teach me the right management of such a patient, probably because she did not know it herself. I had to learn it from her mistake, and by reading books on my own.

HIV Therapy Misinformation

One woman came to our outpatient clinic demanding a laparoscopy. This seemed unusual.
"Why do you want a laparoscopy?" I asked her.
"I want to have another baby" she said.
"But why laparoscopy?"
"When I could not conceive, that nice doctor XXXX performed a laparoscopy on me and I had a baby. Now I want another."
"OK. But I don't think you need a laparoscopy. Did he tell you to have a laparoscopy again?" I asked.
"He does not want to treat me" she said shortly.
"Why?" I asked. This was getting weirder and weirder.
"Um... I am HIV positive" she said.
I was taken aback, for a number of reasons. That a doctor should refuse to treat her because she was HIV positive was not OK. Then he had advised her a laparoscopy, when she had conceived and had a baby. So that advise was also probably not OK. The main thing was that she knew she was HIV positive, and that she could get AIDS and die some time, leaving behind children who would be orphans. The fact that she came to a civic hospital indicated that she was not well to do. How would she provide for two children?
"The risk of transmission to the baby was substantially reduced but not eliminated totally with drugs administered to the mother" I said."You have a baby Why not take good care of that baby rather than have another one, when that baby can get infected? Besides, if your disease progresses and your life is cut short, who will raise your babies?"
"The person at the therapy center  has told me that with medicines for HIV, I can have a normal life span" she told me.
"OK.Are you going to buy your own medicines?"
"No! Government gives these medicines free" she said indignantly. Poor woman did not seem to be reading the newspapers and did not know that government healthcare schemes worked at times and did not at other times. For those who do not believe me, read the following news in Times of India that appeared just two days ago. For the last one year, medicine kits given by the same agency to pelvic infection cases are not available. The medicine kit given for vaginitis by the same agency has been available for a few days and not available for most of the days in the previous year.`
Stock-out hits HIV treatment across India

"OK. It is good that you trust you will get an uninterrupted supply of the drugs you will need. I will treat you to help you get a baby. But We will not perform a laparoscopy. From your history and examination findings, I don't think that is required. It is a dangerous procedure that can cause serious complications at times. We never do it without proper indication"
She looked at me suspiciously and went away. She reappeared after half an hour with another woman who said she was a social worker in the agency that gave HIV drugs.
"Why are you not performing a laparoscopy on her?" she asked me. "She will have a normal life span with medication and raise her babies well."
"That is good. Perhaps you will tell me why patients are dying in the medical ward with AIDS?"
She just looked at me. She probably knew a few lines that she was supposed to tell patients, but not the hard facts of life in a poor country. Or was she forbidden to talk about those hard facts?
"Anyway, it is good to know that patients are doing well in your opinion. We will treat this woman's infertility, but we will not do a laparoscopy because it is not required and doing an unnecessary operation on her might pose a threat to her life. Let her follow up in our infertility clinic and we will treat whatever problem she has got."
They went away. That woman never came back. She would not believe me probably because she wanted to believe what she thought suited her best. No degree of wisdom and explanation from me would convince her otherwise.

Novel Contraception

Usually the histories of new patients are written by the resident doctors in the outpatient clinic, and then the patients go for a clinical examination to senior doctors. But there was a big queue for history taking and no patients for examination. So I went to write a few histories. There was a 24 year old patient, who had come for a check up because she had missed her menstruation by 5 days. After asking about the complaint, menstrual, obstetric, medical, surgical, and personal history, I asked her about her use of any contraception.

"Yes. My husband uses condoms" she said.

I had known that most of the couples coming to our clinic were not very regular in their use of condoms, when they used condoms at all. So I asked, "when does your husband use condoms? Does he use a condom every time?"

"No, not every time" she said. "He uses only during my menstruation."

"What does he use at the the other times?" I asked when I had recovered from the shock I experienced.

"Nothing" she said.

 Poor woman, I thought. No one has taught her that contraception is not required during menstruation. Poor woman, also because no one had taught her husband to leave her alone during her menstruation.

Chronic Adrenaline Rush

My life was quiet and peaceful when I was a kid. I managed to get the top rank in school without too much effort, and I did not feel it was a great achievement. Probably the other kids took is easy much more than I did. Even in premed it was equally peaceful. Then I joined a medical college and I changed without knowing about it. There was so much to learn and it was fun too. Thinking back, I realize it was a high that lasted throughout my graduation and postgraduation. It became a habit. I would not walk peacefully even when there was no urgency. I would hurry to wherever I had to go. If there was anything to do, I would start doing it and be at it like a man possessed until it was done. I joined as a Lecturer and progressed to Professor and Head of Department's position at that same pace. The pressure at work, some of it inevitable from the profession I had chosen, some created by administrators who could have done far better but did not know how, kept the pressure on me. It became a habit that made a slave of me even in my personal life. Even when it was exercising or going for a walk, it was always a part of the hectic schedule, to be rushed through so as to be able to go to the next chore.  Now it is 39 years since I entered a med school, and I don't remember any time when it has been different.
The other day I went out to buy a couple of things. After the first purchase, I went on looking for the other thing I needed. I could not find what I wanted. But it was a day different from the other days. The roads were less crowded. There was less noise, fewer obstacles while walking, a pleasant breeze in place of the usual heat and humidity. Walking was not just an unavoidable unpleasantness, it was refreshing. It was at that moment when I realized what I had been doing. I had been on a chronic continuous adrenaline rush, which would continue until it exhausted me. Then I would rest awhile, let the overworked system recover, and plunge right back in. I suddenly understood the meaning of those forwarded emails which told me to stop to feel the breeze, to smell a rose, to listen to a bird sing, to watch a sunset.
I hope those who read this post don't have to do what I somehow did. I understand it is difficult with the rat race on. I just hope they find a method of finding a few moments to feel the breeze, to smell a rose, to listen to a bird sing, to watch a sunset.without any other thought in those moments.

To What End

I was on my way home from the hospital. A very senior consultant boarded the bus just as it was about to leave, and sat down next to me. We chatted a little, about the same things two medical persons chat when they meet occasionally.
"Dr XXXXXX had come visiting recently" the consultant said.
"The preventive medicine person?" I asked.
"No, no. Anesthetist. She was in the same batch as you, she said."
"Oh, yes" I said. I remembered. The name had not made sense at first because I remembered her by her maiden name, while this consultant had referred to her name after marriage.
"How is she?" I asked conversationally.
"Oh, she is fine" the consultant said.
"Is she not in New Zealand?" I asked, straining my memory.
"Australia" the consultant said.
"What does she do?" I asked. There should have been no reason to ask. She should have been practicing anesthesiology. But some of the doctors I had known who had migrated to US had changed their specialties. One had gone from cardiac surgery to radiology. Another had gone from cardiac surgery to gynecology. Another had gone from gynecology to family medicine. Perhaps this one had changed her specialty too.
"She teaches in a school" the consultant said.
"Um..." I was confused. "A medical school, you mean?"
"She teaches children in a school" came the answer.
"But why?" I asked.
"She thought her child would do better in Australia than in India. She did not want to go through residency again in Australia, because she would not be able to give time to her child if she went through the residency".
I kept quiet. I thought of the 8.5 years spent on medical education, finally wasted. I thought of the national resources spent by the government so that she could get subsidized education, now wasted. I thought of loss of one more doctor for my country which needed doctors badly. I thought of the rumors of parental influence used to get her a couple of gold medals over other students who were considered more worthy then.  To what end was all that? I thought and then could not think any more.

Reverse Trend in Hysterectomy for Cervical Cancer

For those who don't know, hysterectomy means surgical removal of the uterus. When the body of the uterus is removed and the lower part called cervix is left behind, it is called as subtotal hysterectomy. In general it is recommended that the cervix be not left behind, because a cancer may develop in it at a later date, and then the treatment of that cancer becomes difficult. Only in difficult situations does one leave he cervix behind, such as when the urinary bladder or rectum is densely adherent to the cervix.
That woman came from a place in north India. Some surgeon had removed her uterus.
"Why was a hysterectomy done on you?" I asked her.
"The doctor said it was the beginning of a cancer in the cervix of my uterus" she said, and showed me her case paper. "But he did not remove the cervix." I checked her papers. A subtotal hysterectomy had indeed been done for cervical intraepithelial cancer.
"But if it was done for the beginning of a cancer of the cervix, the cervix had to be removed" I said with amazement.
"Yes, doctor" she said tearfully, "but he did not remove it. It seems they do hysterectomy like this on all patients there."
I checked the doctor's prescription. His degree was MS in general surgery. I could not understand why a general surgeon would perform a hysterectomy these days. It was the job of a gynecologist.
"Doctor, save me" she said. "I have two small children."
"Don't worry" I said. "We will remove that cervix. It does not look like it is cancerous." It wasn't. I performed a vaginal removal of the cervix. It was a little difficult, because the abdominal structures were stuck to its top, and they had to be protected during its removal. Later on when I related this story to a friend, he said,
"If a young woman has cervical cancer and she desires to have more babies, they perform a radical removal of the cervix and keep the body of the uterus behind. This seems to be exactly opposite. The surgeon removed the body and left behind the cervix which he believed to have a cancer."
"Yes. This is a reverse trend in hysterectomy for cervical cancer. I hope he does not get any more patients like this."

Crying Baby and Mother

This was the experience narrated by a visiting surgeon, not unlike some we also see.
_________________________________________________________________________________
I was waiting near the north window for the first operated patient to be wheeled out of the OT before the second one could be go in. We have this huge window on the north side of the OT, which spans almost all of the wall. The view outside is breathtaking, with a couple of huge trees, a lawn below, the tennis court in the background, and no sounds to mar the view. I must admit the 'no sound' business did not apply that day. A child was crying incessantly outside, and I could hear it. I looked down at the lawn. The child was standing alone, back towards me. His mother was squatting down, looking at the child. She had nothing with her, not even a bottle of water. She tentatively extended a hand towards the child. The child backed away a couple of steps and continued to cry, standing stiff. She waited for a minute or so, and extended her hand again. The child moved back by another two steps and stood crying. After another minute she got up with seemingly great effort and took a step towards the child. The child moved back as before, and cried and cried. Finally she extended her hands offering to pick up the child. The child ran towards her. She picked the child up and put its head on her left shoulder. The child clung to her, not crying any more. She wiped her right eye and cheek with her right hand. She must have been crying. The child became alert and picked up his head from her shoulder. She immediately put it back on her shoulder. She probably did not want the child to see her crying. Then she wiped away tears from her left eye and left cheek. With the wet hand, she wiped the child's eyes too. There was no handkerchief, but the child did not seem to mind They stood there, just holding each other. After a minute, an elderly man stepped forward. He did not look much better off than those two. He offered a small fruit to the child. She noticed this, and turned around, possibly to make the child see what was being offered to him, and possibly to hide her tears from that kind man. The child saw the fruit, took it, and held it in his tiny hand in wonder. The kind man went away. The mother and child moved to a spot I could not see from that window. There were a couple of small shrieks after that, but no more crying. I could not change and go down to see if I could help in any way, because the next patient was already being given anesthesia. By the time I finished for the day, there was no one on the lawn. When I reached the hospital the next morning, I could not see the child and his mother anywhere on or near the lawn.
I don't know why they were in the hospital. I don't know where the father of the child was, or if there was a father any more. I don't why the child was crying, nor do I know why the mother was crying. I don't know where they are at this moment, and what is to happen of that child in future. All I know is that there is a lump in my throat every time I think of the crying child and mother, and the lump does not go away. I don't even want to think of the thousands of such children and their mothers who cry every day, because there is nothing that I can do to stop them from crying.

Educational Resistance Movement

It is a new movement. You won't find it on a Google search or any other search.
I had thought students wanted education. After all, that's what students become students for. Well, a number of students apparently do not seem to think so. They probably just want to get a degree, so that they can make a lot of money to live happily ever after.
I may sound harsh when I say so. Well, I am upset at what happened. That should explain my harshness.
It was my observation that resident doctors did not read much (lack of time? Lack of energy? Lack of motivation?). When thinking about it, I had a novel idea. We publish about 10 interesting case reports every month in our journal JPGO. These articles are written well, after a good amount of research by the authors. Residents did not get to see such cases, not in any one unit they work in. They did not read the journal (lack of time? Lack of energy? Lack of motivation?). So I thought I should make them read it, which would enrich their experience and make them better doctors. I decided to put multiple choice questions at the end of each issue, based on the articles published in that issue. I coded a web form and put the questions in it, each with a radio button for each of the four options for each question. I arranged to have the residents type their names and year of residency in that web form. I arranged for a print facility so that they could print the completed answer sheet and submit them to our office. My colleagues liked the idea. We decided to give the reidents internal assessment marks based on their performance in these monthly tests. They could read the articles while then answered. It was to be like an open book examination. The idea was to just make them read.
The outcome for about 10 residents in each unit is shown below.

Unit	Activity
1	All residents answered honestly.
2	Only one resident took the test.
3	Seven of them cheated. They made one answer sheet and everyone copied it.
4	All except one resident cheated. Only one person made answer sheets for all residents in the unit. They submitted their own answer sheets.
5	All residents answered honestly.
6	Only three residents took the test. They were honest.

The cheating was easy to spot. The concerned residents had the same score, and the same answers wrong. The technique of cheating was found out by questioning. The explanation for cheating, after repeated questioning, was "Sorry, Sir. It won't happen again."

I am feeling sort of numb inside.

"Why do you insist on making them learn if they keep finding methods to avoid learning?" I was asked. "You are just making yourself unhappy."
Did I do that because I was stupid, stubborn, or a hopeless dreamer? Definitely not to trouble them, as some of them probably believed.
"I do that because I believe it is my Karma to do that" I said. I was a teacher. Was it not my Karma to teach and make them learn?

Abdominal Distension - Different Approaches

I don't know which of the following three stories told in a story telling competition that was held during my residency is the best.

Story 1
This one happened when I was doing my residency in Obstetrics and Gynecology many years ago.
There was a 23 year old woman with acute abdominal pain. The surgeons had decided she had a lump in the abdomen that was excruciatingly painful. She was admitted and put on the operation table. It was the middle of the night and they were waiting for an anesthetist. She was screaming with pain so much, that they left her in the operation room and sat at the table outside. Suddenly her screams stopped.
"Go see if she has died or something" the Registrar said.
The houseman went in to check and came out on the double.
"She ...ah..."
"What?" the Registrar asked, suddenly worried.
"She is OK. The painful abdominal lump is gone, and there is a baby between her legs. I don't know what to do about the umbilical cord that seems to be going inside her."
The woman was spared a laparotomy by a busy  or tardy anesthetist. The surgeons had not realized she was pregnant and in labor.

Story 2
The woman was 8 months pregnant. She had a valvular heart disease and was in early cardiac failure. We sent a call to the cardiologists. The cardiology Registrar saw her and advised some cardiological tests. He also advised an ultrasonography of the abdomen.
"A cardiologist wants an ultrasonography of the abdomen?" I asked, surprised. "This is the first time I have seen this happen. Please ask him why he wants one."
My Registrar asked and informed me about it.
"He wanted it to see if there was any large mass or fluid in the abdomen, that would compromise her breathing and cause breathlessness."
Of course she had both a large mass (the fetus) and fluid (amniotic fluid) in her abdomen, just like all pregnant women have.

Story 3
The woman was admitted in the medical ward with severe anemia. Her hemoglobin was 4 g/dL (normal range is 12.5 to 14 g/dL). We received a call from the medicine residents. My Registrar saw her and reported back to me.
"The patient is 35 weeks pregnant and has severe anemia."
"OK. What did they want from us?" I asked.
"Actually their professor asked them to do an ultrasonography and send us a call at the same time. The professor thought she had a uterine fibroid, which was causing the anemia."
"Fibroid causes heavy menstrual bleed loss, while a pregnancy causes amenorrhea (absence of menses)" I said. "You can actually feel the baby at such an advanced stage of pregnancy."
"The professor felt it was a fibroid" my Registrar said.
If we could diagnose a heart disease, anemia, pneumonia, and cirrhosis, the medicine guys should be able to diagnose an advanced pregnancy, I thought. Well, the 'should's may be very well justified, but that does not make them real.

P.S. (29-11-2014)
There was another patient who was single, admitted in the medical ward. She was there for investigations of hepatosplenomegaly. The got an ultrasonography done on her as a part of the diagnostic work up. It showed she was 8.5 months pregnant and had no hepatosplenomegaly. It goes to show that they do not read my blog, or read it just to get angry if there is anything that they think is criticism rather than praise. Well, I praise them for managing so many patients so well despite being understaffed. The purpose of writing such posts is not to criticize, but to try and avoid such happenings in future.

Civic Doctors The Sweepers

The following conversation was picked up on closed circuit camera, at the source of the circular asking doctors to sweep floors of the hospital for 2 hours every week, starting 1.5 hours after going off duty.

Clean India Campaign and Us

It seems the Boss of the country has launched a movement for clean India. Perhaps people expected‘ clean’  to mean non corrupt. But it seems it is physical cleanliness, not the other one we just referred to. The thing percolated down, and the civic Boss ordered the same thing in the civic body. The circular received by everyone states as follows.

Every XXXday, all officers and employees will clean the offices and their surroundings between 5:30 P.M. and 7:30 P.M. An observer will come from head office, and will see to it that people do this cleaning. There was furor over it. The doctors burst out as follows.

"The National Boss started it as a voluntary service. This seems to be a compulsion!"

"Naturally. If the civic Boss makes it a success, he will reach Delhi in some time."

“Who is going to wait from 4:00 P.M. to 5:30 P.M. doing nothing? Does he not know our duty gets over at 4:00 P.M.?”

“Who is going to do a servant’s job? Why is the big idea?”

“If doctors do servants’ job, what will the servants do? Doctors’ job?”

“If they fill up all vacancies of servants, they will not have to ak the doctors to do the cleaning.”

“The patients and their visitors throw things about and make the hospital dirty. We have to clean up after them or what?”

“I employ servants to clean our house. Now I have to do that work here as doctor?”

“Will the servants’ union assault us because we take away their jobs?”

“The premises are clean. Do we have to throw garbage around and then clean it? Like they did in Delhi, and the State Boss did in State headquarters?”

“Why can they stop people from littering, instead of asking us to clean up after them?”

‘It is not a part of my job description. I will file a writ petition against the civic Boss who has ordered this demeaning work be done by us.”

“We will be the first group of doctors in the world who do sweeping, dusting and stuff in the hospital.”

“What will they do if we don’t  do this stupid work? Sack us? Then who will treat patients? Sweepers?”

“Do we actually have to do this, or do we just pose with brooms for taking pictures? Like those politicians?”

“Sir, why are you not saying anything?” someone asked me.

“I have asked the Boss to clarify some points about this business. I am waiting for the answers. In the meantime, I have designed a new instrument for use by the civic doctors. It will look like this.”

“What is it?”

“It is a stethoscope and a broom combined together. I am going to call it stethobroom. All civic doctors will buy it. If I take out a patent for it, I will make enough money so that we can all employ private servants to do this cleaning work in the hospital in our place. Perhaps even enough so that we can all retire and leave the patients’ treatment to the sweepers.”

Another Virtual Oxytocin Drip

When I write about another oxytocin drip, it implies I must have written about it before. I have not called it 'virtual' when I wrote about it before, but it was indeed a virtual drip. You don't actually have to know about that one to understand today's post. But if you are curious, you can find that post at this link.
It was during a departmental meeting when I heard of this virtual oxytocin drip. It was observed in that civic hospital that the Boss' Boss publicly declared as the best of the three civic hospitals. The reason cited was that it delivered so many women, and nothing went wrong. That 'nothing went wrong' was a statement that should have been taken with not just a pinch of salt, but with a sack of salt. Anyway, someone has said 'the boss is always right'. Then the Boss' Boss must always be right, and more than right or more right, or whatever.
"We got over of this patient who was herself a lawyer" one senior senior staff member said. That hospital had a system in which they handed over all patients in the labor ward were handed over to a new unit in the morning. That way the previous unit was free to go away. "Her indoor paper said she had been on an oxytocin drip. When asked about it, she confirmed she was receiving an oxytocin drip, as she had been informed by her doctor. But there was no intravenous line, and no intravenous infusion of anything had been given to her. When asked if she knew what an oxytocin drip was, she said she did not know."
'It was a virtual oxytocin drip' I thought.
"May be she was being given oxytocin through gas' someone joked. 'Perhaps they called some doctor 'Gas' over there' I thought.
"Why did you come to this hospital?" this doctor asked her.
"To get good treatment' she said. 'She must have heard someone like the Boss' Boss' I thought.

Cat Falls for Teddy

Our housing society has a big garden, and a lot of free space. There are a few people who feed cats.Accommodation and food bring cats and cats bring (by reproduction) more cats. One of our neighbors recently took to feeding a stray kitten. They have converted a regular window into a French type window, and they being on the first floor, the kitten has free access to the house from adjacent roof of a shop below. The kitten often plays on the roof and sleeps on it at night.
The last weekend we witnessed this neighbor out of the window on the roof of the shop. There was a huge teddy bear on a weather shed near the roof, presumably of the neighbor's daughter. It had been there for about a month. He was trying to retrieve it using two long sticks. It was fun to watch, as he struggled using the sticks like two huge chopsticks, trying to hold the teddy, like one tries to hold food with chopsticks. It was heard that he had been to China for a long time, but he did not seem to have picked up the method of using chopsticks. The teddy remained where it was. Finally he pushed it down to the ground and asked the sweeper to bring it home. The spectators dispersed (meaning we went back to our work).
The next evening (yesterday) we found that the teddy was back on the roof, and the kitten was curled up next to it. I managed to take a snap of the two together.

Today morning I checked up again. Now the kitten was asleep on the tummy of the teddy. I managed to get another snap.

"It looks cute" my wife said.  "It must be nice to curl up next to something furry and warm like the teddy. The kitten must also love sleeping on something so soft."
"Yes. The kitten seems to be in love with the teddy" I said. "It must have stolen the teddy from their house the previous time too. When the neighbor took it back, it stole it again."
"It is possible" she said. "The other possibility is that the neighbor's daughter must have given it to the kitten and told her daddy that the kitten took it. She is very kind to people and animals."
It remains to be seen when the daddy goes out on the roof of the shop again and retrieves the daughter's teddy.

Innovative Hat Camera

Most of the open surgical operative still pictures and videos are shot using a camera that gives a line of vision that is somewhat different from that of the operating surgeon. The line of vision of the surgeon is the best, because he chooses the best one to operate well. When I worked on an atlas of operative techniques, the camera was held behind and by the side of my left ear, and when the operative field was to be photographed, I would move to the right and the photographer would move the lens of the camera to where my eyes had been before taking a picture. I positioned the video camera at a suitable angle when I shot operative videos. But I remained dissatisfied. When I explained my requirement to my son, who is a software engineer, but also a gamer, he understood the need immediately. There is such a view when one plays 3D games.
"Get a good webcam and fix it to the forehead" he said. "That will give you the view you need. You will not be able to zoom, but otherwise it will be very good."
That was a brilliant idea. The main problem was finding a method of fixing it to the forehead. I asked my wife to lend me her ENT examination mirror. I fixed the camera to the head strap of the mirror and wore it around my head. The view was good, but the weight was too much. I returned the mirror and tried to think of another solution. Google glass was a theoretical option, but not very practical because it was not available in the market at home, and it was terribly costly anyway. A few days passed, and suddenly I had an idea. A 3D image of the idea is shown below.

I took a hat with a visor. It had an adjustment band at the back. I hooked the webcam in that band and wore the hat back to front. It was a little wobbly, because the band was not designed to take that extra weight. So I put a big rubber band around my head, passing over the handle of the webcam. It fitted perfectly, the angle of inclination could be adjusted as required, and the images were excellent. I shot with this assembly about 100 pictures of different instruments and surgical knots for a new book I am working on. It was a bit of a bother when both of my hands had to be in the picture. But there was no one to help. So I placed the laptop near my foot and clicked the left mouse button with my great toe when an image was to be captured. It worked like a charm, except that toe business. I suggest you get an assistant for that purpose, unless you are a Yoga expert and can bend your lower limb joints impossibly.

My Virtual Twin

There is a theme used by many Hindi movies. There would be twin babies, and they would get separated in some calamity. Then they would grow up independently, and meet one day as adults. Such movies were there when I was a child, and I suppose they are there even today.
I know no such thing happened with me. But I met someone today, and I thought, 'my God, if I had a twin, she would have been like this.' I had gone to the bank. The teller asked me to wait. She was an elderly woman, thin, fair, and and with good manners. It was not this description that prompted me t think what I said I thought. While I was sitting on an adjacent bench and waiting, she said in voice that carried,
"Krapash.....Krapash ....."
Krapash came on the third call, which was louder than the first two. He was another employee of the bank.
"What?" he asked.
"Phone...." she said.
"For me?" he asked.
"Yes, for you. You think I would call you to take a call that was for me?"
I wanted to laugh out loud, but managed to stop with a grin. 'My, God, she thinks like me, and talks like me too' I thought. I finished my work, came home, and told my wife enthusiastically, "Hey, listen. There is a new teller at the bank. Elderly, thin, fair."
"What about her?" she asked.
"You know which one?" I asked.
"Yes," she said calmly, "she speaks exactly like you."
"You know that too?" I asked.
"Yes" she smiled.
"If I had a twin that got separated when we were babies, she would have been like her" I said.
"I know" she said.
 I remembered a story, which I had told my wife before. When I ask patients 'when did you get your last period or some such clinical question', some of them ask me back,'who, me?' If I am not overworked or stressed, I say 'yes, you'. But if a lot of them do it to me on a single morning session, I point to another woman standing or sitting at the other end of the waiting hall and say, 'not you. I am asking that woman over there'. Then they get the hint and do not ask 'who me' again. I remembered another story. When I get a call while working in my office and the caller actually wants some other person or place, I say 'this is not him or the place. Some of them are insistent. They ask 'then where has the call reached?' I lose my patient then and retort, 'does it matter where it has reached, when it definitely not reached the person you want?'
I know some of you out there want to advise me to take a course in having patience. I am unlikely to do so, but thanks for the suggestion anyway.

A Neat Trick

We prefer to have no pests in the house. Unfortunately pest control does not take care of everything. We have a balcony garden with thirty plants. Plants bring ants. We are careful not to spill food particles anywhere so as to avoid attracting ants. But they come for something else - water. There is no stopping them.
We fill up water in a container, drawn through UV purifier, instead of switching it on every time we need water. Unfortunately the ants discovered this cache one day, and spread the word. I don't know how they do it. Perhaps they do it vertically genetically. Generation after generation of ants started entering our water container. They would be found swimming on the water surface in large numbers. They would form groups and swim together, like the gymnasts do in Olympics. Here is a picture, in case you do not believe me. We wondered why they would not drink water and go away. They must love swimming, we thought.

We had to throw away that water and fill fresh water again and again. We do not believe in wasting water. But we do not believe in drinking contaminated water too. Then I remembered a story of a patient of my wife. He ran a small home laundry business. He had plenty of rats, not by choice. He could not afford to let the rats destroy customers' clothes. So he kept food for the rats in a dish every night before retiring. The rats ate that food and went away without damaging a single garment. We decided to try that on the ants. We started keeping a saucer with water in it next to the large water container. The ants stopped entering our water container. But they would not swim in the saucer too. We were stumped, though happy that our water was protected. When my vacation started, I decided to find out exactly what was happening. I watched the saucer. The ants would climb into the saucer, drink water, climb back down and go away. They would not stay in the house and trouble us, or get pest-controlled and killed.
"They could not climb up the steep sides of the water container and fell in the water. They can climb out of the saucer" I explained to my wife.
"Good" she said.
"This is great," I said. "not just good. Now we know something about ants that no one else did so far. We have protected our drinking water. We are doing good work by providing water to thirsty creatures. That is increasing our Good Karma. We are also saving lives of those ants who would have drowned. That is increasing our Good Karma even more."
"I hope you are not going to write this on the net" she said, not greatly pleased that our Good Karma was increasing.
"But I am" I said. "It will help someone else out there who has the same problem, but has not yet found the solution to it."

An Offer That Hurt

"Sir, I want to see you for something important. When can I?"
"Sure thing" I said. "This Wednesday would be fine." He/she was my student, who had done MD some years ago. He/she had opted for running a coaching class for aspiring college students rather than practicing Obstetrics Gynecology. He/she was doing very well, probably much better than contemporaries who had gone into private practice. I wondered what he/she wanted from me.
He/she came on the Wednesday fixed for the meeting. Preliminaries over, he/she came to the point.
"Sir, I am expanding."
"That is nice."
"I want you to help me" he/she said.
"Huh?" I was surprised. "Your business is teaching college students. How can I help you?"
"The syllabus is changing. A lot of work has to be done... teaching sets, question and answer sets... I cannot do that alone."
"But you must have assistants" I said. I had an idea where the conversation was going, and wanted it to stop before it did.
"You could do a part of the work. The money will be good."
I was speechless.
"But I must tell you, I need the work done a certain way. Professor XXXXXXXXX had joined me to do this work. But he/she could not do it the way I wanted it. So I had to tell him/her to go."
I knew about this. This professor, a superspecialist in a surgical branch of medicine, had indeed taken up that work, possibly because the money was good. I had heard it had not worked out. Now I knew one side of the story.
"Thanks for the offer" I said. "But I am afraid I cannot do this. I don't need the money. I am making enough to eat four meals a day, commute to work and back, and buy the essentials for living. But even if I did not, I would not do this. I became an Obstetrician and Gynecologist because I loved that subject. I don't want do anything else in life. Best of luck."
He/she went away. I was hurt, not because I had been insulted, but because perhaps I had failed as his/her teacher in instilling in him/her the love for the subject that I had taught, and the values I believed I instilled in all of my students.I wondered where I had appeared inadequate so that he/she believed that I would prefer to do something else to make more money as he/she had done. Or was it the wealth he/she had amassed that gave him/her the idea that he/she could make that offer to me and I would accept it, and if I did not do well, he/she could ask me to go.

The One Who Chaired Many Chairs

"You see that person?" someone murmured while I was trying to suppress my seventh yawn of the morning. We were in the middle of a meeting called by a government agency, and the time was being put to (good or bad) use by dignitaries on the dais making speeches. I looked in the direction pointed at.
"Yes. What about him?" I asked.
"You don't know him?"
"I do. But what is it that you want to say about him?"
"I don't know why he is here. But it cannot be for an academic purpose."
I knew him. I could understand why this speaker said that about him. I kept quiet.
"You know he chaired many important chairs?"
"Huh?" I said.
"Dean of this college, Director of that institute, Director of some obscure department of the university, Dean of that third institute, then chair of his specialty in a fourth institute and so on."
So that was the chairing-many-chairs business.
"That is impressive" I said.
"You must have read about the financial scandal he was in before some minister bailed him out."
I recalled reading that in a newspaper a few years ago.
"I remember a story about him. Want to hear it?"
A story seemed a lot more interesting than the repetitive speeches coming from the people on the dais.
"OK" I said.
"A number of people were called to the university for some work. Both of us were there. When the clerk asked him how he had reached the university, so that he could pay the traveling allowance, he asked the clerk what transport was permitted. The clerk said first class railway fare or taxi fare. So he said he had traveled by railway - first class. The clerk asked him for the railway ticket, to be submitted to the accounts section. That got him in a fix. He thought about it a bit and said he would not take any traveling allowance, without giving any reason for it. The clerk managed to look puzzled and I managed to look not embarrassed for my one time teacher. I knew he had no first class railway ticket, because he had not traveled by first class."
"Ah!" I said. I understood that he was trying to make some money. "What did you tall the clerk about your travel?" I asked just to avoid discussing the embarrassing topic any further.
"I said I had gone there by bus, and gave him my one rupee ticket. The clerk looked embarrassed at the idea of paying me one rupee as travelling allowance. He asked me to keep it and paid me a princely sum of fifty rupees."
The bus ticket to the university located at one end of the town costing only one rupee suggested it must have been about thirty years ago. This person asking for one rupee seemed unreal.
"That must have been thirty years ago" I said.
"Yes. In thirty years his dishonesty has increased manifold as he chaired chair after chair. I am afraid to be under the same roof as him."
Suddenly I was afraid to be on the same academic platform as him too. I managed not to say 'me too'. But it was tough.
(Note: read he/she and him/her in place of he and him respectively. That is to protect the identity of the person concerned. Normally I do it as I type. But this time I did not do it because someone told me it makes reading the article less interesting.)

MTP Act Versus Right of Women

The MTP Act in India is quite clear about who can have an abortion (MTP) and who cannot. There are a number of conditions listed in it. If the woman has any of those, she can have an abortion. If she does not have any indication from the list and an MTP is performed, it becomes a criminal abortion, for which both the doctor and the patient are at risk of punishment as per the Act. But usually the doctor goes to jail and the patient goes free, unless some mishap like death has drawn the attention of the authorities to that abortion.
The act is liberal. If the couple has been using contraception and the pregnancy has resulted from a failure of that contraception, an MTP is permitted. If a couple says it has used contraception, one has to believe it. No proof is required. So virtually anyone can have an MTP.
Once we had a series of meetings, which was aimed at improving the functioning of the PCPNDT Act and MTP Act together. A few specialists and a few NGOs were called. I was invited as the local specialist. The representatives of the NGOs were quite vocal and they had very strong opinions. One of them said,
"We have good cooperation from XXXX hospital. Whenever a woman goes there to have an MTP, the doctors in that hospital do it. But some other hospitals are not so cooperative. They trouble those women about the indications."
"What do you mean?" one specialist asked.
"See, it is the right of a woman to have an MTP. If she wants it, it must be done" the activist NGO representative said.
"Even without a valid indication?" the specialist asked.
"It is the right of the woman. She cannot be denied that right."
"But the MTP Act is quite clear about the indications for an MTP" the specialist said. "One cannot just have an MTP because one does not want the baby."
"That is what I meant by saying that some doctors are cooperative while others are not" the activist said. Turning to me she asked, "what do you do in your hospital?"
"We do MTP when they require it" I said. I knew there was no point in arguing with her. That would just make me her enemy in her mind.
"Good" she said. So I had said what I wanted to say and she heard what she wanted to hear. Good use of ambiguous language, huh?

Hail Those Independent Minds!

We have an outpatient case paper for women attending antenatal clinic. It is something like a printed spreadsheet. All one has to do is to fill in the blanks under appropriate headings. It makes sense to do so, because one can always check what the previous readings were, and note if there is a trend, like weight gain or increase in fundal height. A sample of that case paper is reproduced below.

It did not work out as was intended by the civic body which gets these papers printed. So I gave strict instructions that all parameters should be checked and written in respective columns. It still would not work, so I kept giving the same instruction again and again. Still I find the following variations repeatedly, involving faculty and resident doctors equally. On a given case paper, when the patient has been seen by different doctors on different days, there is utter chaos.

1. Some of them move the columns showing fetal size (by date, clinically and by USG) one column to the right. So the successive readings are not one below another.
2. A few of them move the columns showing fetal size (by date, clinically and by USG) one column to the left. So the successive readings are not one below another.
3. Some of them do not fill rows horizontally. They write the three parameters one below another in three paragraphs.
4. One of them has a unique style. There are only two readings in place of three. One is written on the left half of the paper, the other on the right half, in a huge letter size. No one has any clue about the heading of either of them. It looks like the following. It does not serve the purpose it is supposed to serve, and wastes a lot of paper too.

                                

All this stresses me out when the patient comes to me for a check-up the next time. The only solution to this problem is to stop going to the antenatal clinic, like a number of senior faculty in many hospitals did and do, or take voluntary retirement. At the moment I have chosen to take the stress and keep working, because working is what I got to do.

Curse of Illegible Handwriting

When there are many doctors running an outpatient clinic, and the same patient is seen by different doctors on different days, illegible handwriting can become a great problem. This is the situation in a civic or government run hospital. As head of the service, I have to see all patients who need a senior to see them, and I also see a lot of others in the course of the clinic. When the previous records are not legible, I get stuck. Sometimes I have to ask my resident doctors what the written records are. They usually can make out what I cannot, like a pharmacist can read doctors' prescriptions when doctors cannot do so. There was one particular resident who would not improve her handwriting despite measures like counseling, sweet talk, admonition, and threats of disciplinary action. Finally I did a Google search and found out the reasons for an illegible handwriting. They are listed below.

1. doesn't have the inclination or time to write legibly.
2. laziness.
3. thinking faster than fingers can move to write.
4. emotional stress.
5. hysteria.
6. dishonesty: hiding intentions behind poor writing.
7. an illness resulting in muscular impairment.
8. alcohol or drug abuse impairing physical or mental vitality.

I think reasons 1 to 4 were most likely in the given case, 5 a remote possibility, and 5 to 8 unlikely. The good part of this exercise was that I knew the reasons behind the bad handwriting (while I had believed the reason was genetic, poor training or bad luck). The bad part was that there was no solution to the problem. The only thing that could be done was to call that resident every time I could not read what she had written, trying all the time not to get stressed.

Too Difficult Patients

"Sir, we had a patient who was too difficult" an Assistant Professor from another unit told me. She just refused to let anyone examine her."
"What do you mean by 'refused'?" I asked.
"She screamed, threw tantrums, was violent, the works."
"Why?"
"God knows. A number of people were required to restrain her so that a brief examination could be done."
"And then?"
"She delivered. She was completely quiet and docile after the delivery."
"Remarkable" I said.
"Did you experience any such thing?"
"Yes" I said. "Quite a few times. When I was doing my residency, there was a woman who refused to be examined. She was calm, firm, and in control. No tantrums. No screaming. Just refusal to be examined."
"So what did you do?"
"We told her that she would have to go to another doctor if she did not want to get examined."
"So she agreed?"
"No. She would not go away and she would not get examined too. Finally she delivered. Three days later she went home."
"Must be a psychiatric illness."
"Probably. We learned much later that we had to make psychiatric reference in such cases. There was another patient who behaved similarly. Her relatives threatened to break down the hospital if she was examined."
"Then what happened?"
"We had a smart Associate Professor.He checked her pulse, touched her tummy, and declared she needed a cesarean section. She submitted to a cesarean section and went home with a baby in her arms and two scars, one on her uterus and the other on her abdomen."
"Poor thing."
"By that I trust you mean poor doctor" I said. "Then there was one who would get up from the labor cot and hide under it, or run out of the labor ward. Then there was a smart doctor who was a patient herself. She delivered in the sister institute. She knew they would start an oxytocin drip for her and then take her up for a cesarean section. So she went to the toilet, locked herself in, sat on the commode, and came out only when she was about to deliver."
"That is unbelievable."
"Yes. They come in many types."