क्रुतीशीलता

"गुरुजी, नवे वारे वाहू लागले आहेत हो" आटपाटनगरच्या राजाच्या रुग्णालयांतील राजवैद्यांनी जाहीर केले. "आमचे जुने ठोकताळे आता बहुधा मागे पडणार."
गुरुजी राजवैद्यांना चांगले ओळखत होते. ते जरा तिरकस बोलत आहेत हे त्यांच्या लगेच लक्षांत आले.
"ते कसे काय?" गुरुजींनी विचारले.
"पूर्वीसारखे र्वैद्यकशास्त्र आले की झाले असे हल्ली उरले नाही. नव्या दमाचे वैद्य आणि जुन्या दमाचे पण केस काळे केलेले वैद्य व्यवस्थापन वगैरेच्या कार्यशाळा करून येतात. क्रुतीशीलता (ज्याला management मध्ये proactivity असे म्हणतात) वगैरे मुळे रुग्णांवर उपचार अधिक कुशलतेने करता येतात असे ते म्हणतात."
"म्हणजे काय ते नीटसे कळले नाही" गुरुजी म्हणाले.
"गुरुजी, क्रुतीशीलता म्हणजे पुढे काय होणार याचा विचार करून आधीच योग्य ती पावले उचलणे. अतिशय योग्य अशी संकल्पना आहे ती. आता आमच्या क्रुतीशील वैद्यांनी काय केले ते पहा. आमच्या एका रुग्णाला आंतडे अडकण्याचा विकार झाला होता. ती दोन महिन्यांची गर्भार पण होती. शल्यक्रिया करून तिचे आंतडे सोडवावे अशी विनंती आम्ही शल्यक्रिया करणाऱ्या वैद्यांना केली. पण त्यांनी कार्यवाहीत विलंब केला. तिला जंतूसंसर्ग झाला. रक्तांत दोष निर्माण झाला आणि रक्त गोठण्याची प्रक्रिया थांबली (ज्याला disseminated intravascular coagulation किंवा DIC असे म्हणतात). पोटात गर्भाचा म्रुत्यू झाला तरीही हा विकार होऊ शकतो. पण तिला तो विकार आधी झाला आणि नंतर तिच्या गर्भाचा म्रुत्यू झाला. कालांतराने तिची शल्यक्रिया झाली पण ती दगावली. माताम्रुत्यू अन्वेषणाच्या वेळी शल्यक्रिया करणऱ्या वैद्यांनी असा मुद्दा माडला की गर्भाच्या म्रुत्यूमुळे तिला तो रक्ताचा विकार झाला. आणि त्यामुळे ती दगावली."
"यांत क्रुतीशीलता कोठे आली? उलट निष्क्रियता दिसून आली" गुरुजी म्हणाले.
"गर्भ म्रुत झाल्यावर पांच आठवड्यांनी हा रक्ताचा विकार होतो. या रुग्णामध्ये आता गर्भ मरेल अशी परिस्थिती आली आणि शल्यक्रिया करणारे वैद्य क्रुतीशील असल्यामुळे हा रक्ताचा विकार आधीच झाला. निदान असे त्यांच्या म्हणण्यावरून वाटते. हे क्रुतीशीलतेचे उदाहरण असावे" राजवैद्य म्हणाले. "मी भरल्या बैठकीत तसे सर्वांसमोर म्हणालो देखील."
"मग ते काय म्हणाले?"
"काही नाही. गप्प बसले."
(Keywords: proactivity in medicine)

अब्रूवर घाला

फार फार वर्षांपूर्वी आट पाट नगर होते. नगराचा राजा मोठा द्रष्टा होता. नगरवासी माणसे ही आपली लेकरेच आहेत आणि त्यांच्या हिताचे रक्षण करणे हे आपले कर्तव्य आहे असे त्याचे ठाम मत होते. त्यांच्या भल्यासाठी त्याने अनेक गोष्टी केल्या. त्यांतील एक म्हणजे त्यांच्यासाठी एक सुसज्ज रुग्णालय बांधणे. हे रुग्णालय त्याने इतके सुरेख बनविले, की तिथे उपचार करून घेण्यासाठी देशोदेशीचे रुग्ण येऊ लागले.
दुर्दैवाने येणारे सगळेच रुग्ण सुसंस्क्रुत नसत. बरेच जण शाळेत गेलेले नसत. गेलेच तर त्या शाळेत सामाजिक वर्तन वगैरे शिकवत नसत. शिकवले असले तरी त्या वेळी टपोरीगिरी करणे, मस्ती करणे, गप्पा मारणे इत्यादी गोष्टींत काल व्यतीत केल्यामुळे त्यांच्या सामाजिक वर्तनात बरीच त्रुटी राहून जात असे. घरातला कचरा बिनदिक्कतपणे रस्त्यावर टाकणे, रस्ताने जाताना नाकातोंडावर रुमाल न धरता शिंकणे आणि खोकणे आणि खाकरा रस्त्यावरच थुंकणे, नाक रस्त्यावरच शिंकरणे आणि हात दिव्याच्या खांबाला पुसणे, तांबुलपत्र चर्वण करून त्याच्या पिंका कोनाड्यांत आणि रुग्णालयाच्या भिंतींवर मारणे अशा प्रकारचे वर्तन ते नित्यनियमाने करत असत, आणि त्यांत काही वावगे आहे असे त्यांना अजिबात वाटत नसे. या घाणीमुळे आपल्या आप्तेष्टांचे आजार बळावतात याची त्यांना जाणीव नसे. अरे, असे करू नका असे कोणी म्हटले तर 'अरे ला कारे' करणे हा त्यांचा धर्म झाला होता. काही जण तर शिवी्गाळी आणि मारहाणी करायचे. रुग्णालयात नेमलेल्या सुरक्षारक्षकांनाही ते जुमानत नसत.
एके दिवशी दोन स्त्रिया आपल्या आप्ताला भेटण्यासाठी रुग्णालयात आल्या. त्यांनी बरोबर आणलेल्या खाद्यपदार्थांचे वेष्टन जमिनीवर टाकले. सुरक्षारक्षकांनी त्यांना असे करताना पाहिले व हटकले. गुन्हा कबूल करण्याऐवजी त्या दोघी उलट भांडायला लागल्या. आपण असे काही केलेच नाही असे त्या म्हणाल्या. सुरक्षारक्षकांनी आपली क्षमा मागावी, अन्यथा आपण कोतवालाकडे जाऊन सुरक्षारक्षकांनी आपला विनयभंग केला अशी तक्रार करू आणि त्यांना तुरुंगात डांबू अशी त्यांना धमकी दिली. स्त्रियांच्या अब्रूवर कोणी घाला घालू नये म्हणून राजाने केलेल्या कायद्याचा गैरवापर करणे हाही आपला हक्कच आहे असे त्यांना वाटत असावे. सुरक्षारक्षक सटपटले. त्यांनी रुग्णालयाच्या मुख्याला बोलावले. मुख्य हुशार होता. समजुतीने बोलून काही फायदा होत नाही हे पाहून त्याने बंदचक्रमुद्रण (ज्याला हल्ली क्लोज्ड सर्किट टीव्ही असे म्हणतात) सर्वांसमोर त्या दोघींना दाखविले. सत्य बाहेर आले. दोघींची वाचा बसली. अवाक्षर न काढता दोघी वळल्या आणि निघून गेल्या.
"दंड न करता त्यांना जाऊ द्यायला नको होते" असे सुरक्षारक्षक म्हणाले.
"तुरुंगात जाण्यापासून वाचलात त्याचा आनंद माना. बंदचक्रमुद्रण नसते तर तेही झाले असते. महाराजांनी रुग्णालय बनवले ती मोठी चूक केली असे आता वाटते आहे."
"माझा संबंध नसताना बोलतो म्हणून माफ करा" हा सर्व प्रकार बघणारा एक साधूपुरुष म्हणाला. "आपण म्हणता ते मला योग्य वाटत नाही. अशा प्रकारची तामस विचार आणि वर्तणूक असणारी माणसे असतात म्हणून सत्कर्म करणे सोडून द्यायचे नसते. ज्यांच्यासाठी सत्कर्म करावयाचे त्यांची लायकी आहे की नाही यावर सत्कर्म करावयाचे की नाही हे अवलंबून नसते. सत्कर्म करणे हा आपला धर्म आहे म्हणून ते करावयाचे असते."
"साधू महाराज!" असे म्हणून सुरक्षारक्षक आणि मुख्य यांनी साधूपुरुषाला दंडवत घातला.

त्यांना सलाम

आपत्कालीन उपचारांसाठी रुग्णालयातील नवा विभाग सुरू झाला तेव्हा तिथे सगळी मोकळी जागा होती. एखाद्या प्रगत राष्ट्रातील प्रगत रुग्णालयासारखे ते दिसत होते. ते प्रगत होते यात काही शंकाच नाही. या रुग्णालयाच्या आवारात आपण असतो तेव्हा आपण एखाद्या प्रगत राष्ट्रात असतो, असे मी आमच्या निवासी डॉक्टरांना नेहमीच सांगत असतो. हळूहळू हा विभाग भरत गेला. अतिदक्षता विभागात खाटा उपलब्ध नसल्या की आमचे अत्यवस्थ रुग्ण या आपत्कालीन विभागाच्या अतिदक्षता विभागात ठेवावे लागतात. गेल्या काही दिवसांत असे बरेच रुग्ण आले. त्यांना पहाण्यासाठी खूप वेळा तेथे जावे लागले. दाटीवाटीने मांडलेल्या खाटा, दोन खाटांच्या मध्ये ठेवलेल्या रुग्णांना इतरत्र नेण्यासाठी असणा~या ट्रॉल्या आणि त्यांच्यावर ठेवलेले रुग्ण, तश्याच स्थितीत त्यांना लावलेले वेंटिलेटर, त्यांचे असंख्य नातेवाईक, या गर्दीत तुलनेने अगदी अल्प असणारी डॉक्टरांची आणि परिचरिकांची संख्या बघून धक्का बसला. गेल्या काही वर्षांत लोकसंख्या इतकी वाढली आहे, की गरीबांची संख्या इतकी वाढली आहे आणि त्यामुळे इतके रुग्ण येथे आले आहेत हे लक्षात येईना. एका टेबलाजवळ दोन तरुण डॉक्टर बसून येणा~या रुग्णांना बघत होते. अतिशय गंभीर आजार असणा~या इतक्या रुग्णांना ते कसे उपचार करणार हे मला कळत नसले तरी ते इतके दिवस हे काम कुशलतेने करत आहेत, त्या अर्थी सारे काही ठीक असणार असे धरून चालायला हरकत नव्हती. जागा, डॉक्टर आणि परिचारिका यांची संख्या खूपच वाढविली पाहिजे हे प्रशासनाला कळत नसावे, कळत असले तर वळत नसावे, त्यांच्याकडे आवश्यक निधी नसावा, आणि असलाच तर त्याचा विनियोग इतरत्र करण्याचे ब्रुमनपाने ठरवले असावे. काही असो, ही गरज पूर्ण होणार नाही हे नक्की. इतक्या कठीण परिस्थितीत कुशलतेने रुग्णांवर उपचार करून त्यांना बरे करणा~या त्या तरुण पिढीच्या डोक्टरांना आणि परिचारिकांना सलाम.

The History Hiders

Medical history is different from usual history. Apathy to the latter in student life is widespread, probably due to students hating the need to remember whatever happened exactly whenever. That cannot be said about medical history. Usually patients remember something about their past medical problems, though very few produce documents related to their treatment. Some of them leave their old papers at native place when they come to us for treatment of a new condition. Some of them leave the papers home, which is somewhat better since they can get them at the time of the next visit. Some of them get angry with the diagnosis of their condition and tear up all papers. After they repent, they go to a new doctor, and the whole diagnostic process has to be started again, including all tests that they had got done and had lost by tearing up the reports. Some women have some medical condition before marriage, and they hide it from the groom and in-laws fearing that the marriage will not take place if they know about it. They hide it from their doctors after marriage fearing that the husband and in-laws will learn about it from the doctor and the marriage may end in a divorce. Recently we had a patient who had undergone a major abdominal operation about four years ago, long before she married. She was pregnant when she came to us. She had no papers of her past operation, because her mother had torn up all of them. The mother did this because the daughter eloped with her boyfriend and got married to him without her parents' wish. Now we were stuck, not knowing what had happened inside her abdomen, and how it would affect her current pregnancy.

I have seen a new trend in the last 15 days. We had three patients, who hid their past medical history from us.

1. The first patient had high blood pressure, for which she was taking treatment from a private practitioner. She came to us with toxemia of pregnancy. She hid the history of this treatment from us and kept taking her pills on her own. She had seriously high blood pressure during childbirth, which we managed somehow. When she was ready to go home, she was seen taking her own pills, and when asked, she said nonchalantly, 'that is as per my other doctor's advise. I am managing that part on my own. So I did not tell you.' She obviously did not know about interactions of medicines, and possible serious effects of her condition on her pregnancy.
2. The second patient was a diabetic. She hid the history that she had convulsions in past. We managed her diabetes during pregnancy and delivered her successfully at term. She had tonic and clonic convulsions immediately after delivery, which could not be explained by her medical condition, and the doctors on duty were alarmed because the convulsions could be due to any of a large list of conditions, most of them serious, and they were prepared for none of them in this patient. It was discovered afterwards that she had this condition in the past. It was lucky the baby did not have any problem and both the mother and the child went home fine.
3. A resident doctor from another specialty brought his mother for uterine leiomyomas. We advised her to undergo surgical removal of the uterus. They hid the history of angina from us, from the anesthesia outpatient clinic doctors, and our OT anesthetists. She revealed it when she was on the operation table and was being administered a regional block. We all almost went into shock, thinking of all the bad things that could happen to her if we operated without diagnosing if she had ischemic heart disease. There was dispute among the son, husband, daughter, and patient on whether she had undergone a stress test. Finally it emerged that she had not run on a treadmill for the test. I had to take her out of the OT, get a cardiology opinion urgently (*which the son managed well, including a stress test) and then operate on her. Luckily she did not have ischemic heart disease, or we could not have operated on her without getting it treated first.

I am quite worried by this new trend. I appeal to all my readers to spread the word that patients should not hide their past medical and surgical history from their doctors, for any reason.

King's Healthcare Management Strategy

You must have read my post on the very good and kind king, who reigned centuries ago, and started a hospital for the poor people to give them state of the art healthcare. If not, read all about it here. The population of the kingdom increased because of the excellent healthcare given at the hospital (low death rate caused that). So he had to start three more such hospitals. The king did not want all the hassle of managing these hospitals himself. So he decided to appoint a master manager. The system he developed was so perfect that it went down in the history of the country as one which would remain applicable for ever. Its outline is as follows.

1. The king appointed the oldest courtier (अमात्य) in his court (दरबार) for doing this work, believing the oldest one would be the wisest one. This was based on the universal belief that people gathered knowledge and wisdom as they aged.
2. The oldest person in the king's court (दरबार) could be from any specialty - carpentry, plumbing, oil well drilling, pothole filling, trading, jugglery, gossiping, politicking, and whatever else one could think of doing. This was a democratic process of giving equal opportunity to all.
3. The master manager was required to make decisions on everything, including medical decision making, procuring medicines and equipment, human resource management, discipline and whatever else that happened in the king's hospitals. This made the management truly 'out of the box', the likes of which could not be found anywhere else in the world.
4. The master manager was guided constantly on all matters by the elected representatives of the people. This made the healthcare truly democratic, where the people could decide if they should have their appendices out, or H1N1 tablets in, whether they should have cesarean section or abortion, whether the healthcare providers really understood what they were doing, or people knew better.
5. The master manager had his own coterie, whose most important job was to praise his actions, and criticize everyone who had other thoughts on that matter. This helped identify stupid people who could not make out which side of the bread was buttered. The master manager could then devote his time and energy to improving such people.
6. If not so knowledgeable healthcare providers from obscure corners of the kingdom told patients to go to these big hospitals and get specific treatment, the patients expected exactly that treatment, irrespective of whether the specialists thought that another form of treatment was better. Peoples' representatives and the master manager had full powers to take the specialists to task for not doing what people wanted done to themselves.
7. The master manager automatically acquired special powers after appointment to that position, so that he could decide who was in error without inquiring into the matter. This shortened the process of inquiries and reduced costs tremendously.

We have reproduced the principles of the system here so that people in other countries can appreciate the wisdom in it.

Intercom Substitute

I have to be grateful to the civic administrators for encouraging and promoting my intellectual development and innovative thinking abilities. I know I have probably not managed to achieve much in both areas, but that is not due to any fault on the part of the administration. Let us consider the example of our intercom system.
We have in the institute an intercom system that has so many phone terminals, that no one can remember even 5% of the numbers. Fortunately they provide us with a list, which is correct in about 85% cases at any given time. After the building was repaired by heritage architect hand in glove with a world class contractor (should I have said 'jointly' instead of 'hand in glove'?), the intercom system was never the same as before. One by one the terminals stopped working. For one week now, 99% terminals have been dead. They would not be repaired because of one of the following reasons (I don't know which one, and knowing that would not help us anyway)..

1. The hand in glove duo had been paid fully. That probably did not leave them any incentive to work on the same things again.
2. The duo did not work on the same thing twice, just like lightening does not strike the same place twice.
3. Local engineers could not repair it because they had no layout plans or circuit diagrams (or whatever) required for repairing the network. The duo did not and would not (despite requests) hand over the diagrams.

To add insult to injury, a divine thinker in administration sent us a Fatwa that mobile phones must not be used in operation theaters. This was akin to the situation आई जेवायला घालेना आणि बाप भीक मागू देईना in Marathi, which translated freely into English would be 'mother would not feed us and father would not let us beg'. I hope you understand the father figure was the duo, and the mother figure was the divine thinker. You must understand that a father figure can be a duo in civic world, because anything is possible in the civic world. To overcome this problem, I thought of a solution, which many of you must have played with as children.

The contraption consists of two styrofoam cups, their bases joined by a strong thin string. One person speaks into the cup while the other person puts the other cup to his ear. Then they reverse roles. This system has a number of advantages.

1. Cost effectiveness: the styrofoam cups are thrown about by visitors everywhere in the campus, after they drink tea or coffee from them. Thus there is a free supply of free cups at all times.
2. Using the discarded cups can be counted as participation in PM's swachh bharat abhiyan, which the civic body has forced the employees to participate in.
3. The string comes with stationery supplied by the health university for conducting exams. I have to admit the supply is often short, and civic body may have to buy some string. But it is far cheaper than telephone wire.
4. The design is simple, and can be mastered by anyone who can do anything with their hands. Surgeons probably would do better than physicians. The patients who need occupational therapy can be given this task, combining their therapy with social service.
5. Repairs are not required. These contraptions are of the 'use and throw' type, which is the strategy on disposable medical instruments in all the developed countries.

There are some disadvantages.

1. There is no scope for anyone to make money in tenders etc.(Oops! Should that have been in the list of advantages? It must be my old age which is confusing me.)
2. If pigeons sit on the string (after getting tired of flying in our corridors), sound transmission can be interfered with.
3. If any unscrupulous person decides to eavesdrop on any conversation, he just has to put a hook on the string, and fix a styrofoam cup at the other end.
4. Connecting two terminals around bends may be difficult. But the civic administration has a few people who are very good at driving employees around the bend. They can tackle this problem very easily.

I am not going to suggest this to the civic body, because their strategy is to ask people who make brilliant suggestions to conduct a pilot study on their suggestions. They might even get angry with me for interfering with their utilization of the budget earmarked for intercoms. They can read my blog, and use my idea as their own. It would be a win-win situation. They would get credit without having to make any efforts, and we would get functioning intercoms.

What To Do If Great Chief Is Dumb

You may have a senior officer who is dumb. If he/she knows he/she is dumb, it is OK. If he/she believes he/she is better than Archimedes in intellect and Covey in management, you can do any of the following, as recommended in ancient Indian text चाणक्यनीती.

1. Bang you head against the wall until you break your head (does not solve the problem, just provides you with something to do).
2. Tear your hair out until you go bald (comment as above).
3. Pray he/she gets a heart attack before you do (it is not cruel or unethical, it is just survival instinct. Prayers of this nature usually do not work, but there is no harm in trying).
4. You sell your soul to Satan for a greater price than he/she did (dangerous, not recommended. Satan may not want your soul in preference to the one he has already got, anyway).
5. Change job (best solution, unless you love your current job. There is no guarantee the Chief at the new place won't be as dumb or dumber anyway.)
6. Flatter the Chief's abilities (don't ask which ones, just do it).
7. Bribe the Chief (greed has no limits anyway).
8. Take voluntary retirement (tempting, huh? But that is running away).
9. Believe in fairy tales or Hindi movies, where the good guy wins in the end. (It does not happen that way in real life.)
10. Ask some agony aunt what to do (agony aunts give good advice sometimes).
11. Laugh it off. Don't you know idiots will be idiots? (the best solution).

Getting Reimbursement From The Civic Body

A great quality of the civic body is its ability to hold on to money that belongs to others legitimately, but found its way into coffers er... treasury of the civic body.. If one accidentally pays any money into the treasury of the civic body when there is no occasion to do so, the civic body understands that this man has no understanding of the value of his money, and goes all out to protect his money in its treasury. This is done so well that no matter how hard the man tries to get his money back, the civic body does not let go. I thought this was its behavior with other people, but not with its own. The civic body has another great quality. It does not discriminate between its own people and others. It treats all people the same way.
We have this ultraviolet water purifier that I got installed using our own funds. But once something is given to the institute, it belongs to the institute. So this water purifier became the property of the civic body. It needed annual maintenance, which we expected the civic body to pay for. I asked and the engineer told me to go ahead, pay for it, and he would get my money paid back to me in due course. I trust people until they prove themselves not worthy of that trust. So I trusted the engineer and spent my own money to get the maintenance contract into force. A month passed, but there was no sign of any reimbursement. So I asked, and was told by the clerk that the proposal was lost. Two clerks of the engineering department kept batting me from one to the other department, until I lost my cool and asked them if they thought I was like the common man who had to run from pillar to post to get anything done. Then they told me to submit our office copies of the reimbursement proposal. I did that. After another month and a number of reminders, they passed it and sent it to the cash section, from where we had to collect that measly amount -  rupees 1650/- They did not pay me for another month, saying they did not have any money. I wondered how it could be so, considering the fact that the annual budget of the institute was more than rupees 2000000000/-. So finally I called the  head clerk in the cash section and asked what the problem was.
"We don't have money" she said.
"Despite a budget of  rupees 2000000000/-?" I asked.
"No, Sir. We had some money in between, but I asked the concerned clerk to pay a small amount to every creditor, so that everybody got some of his money."
"All except me, when I actually work here and the others don't?" I asked. "If you cannot afford to pay Rs. 1650/- at a time, at least pay Rs. 10/- per day, so that I get some of my money at least" I said. My sarcasm must have shown, for she immediately changed tack and said, "OK. I will pay the entire amount somehow. Please send someone."
If you think I got my money right then, think again. I got it on the third day after that. It has been a great learning experience for me. I hope this post helps people learn from my mistake instead of learning the hard way.

Oxygen Administration At 50%

Administration of oxygen used to be with a rubber catheter in past. A thin India rubber catheter would be attached to the oxygen tube, and the other end of the catheter would be passed into the patient's nose. It would pass into only one nostril, but the oxygen would reach the nasopharynx and then go down the trachea into the lungs when the patient breathed. The administration system evolved. Now oxygen is administered with a face mask or nasal prongs when the patient is breathing on her own.
We saw a patient in the waiting ward during our ward round. She was lying comfortably in bed, and was conscious and doing things on her own, including breathing. She was receiving oxygen through nasal prongs.

The curious thing about her oxygen administration was that only one of her nasal prongs was in a nostril, while the other one was outside the other nostril.
"This woman is receiving 50% oxygen" I said. "That coming out of the other prong is creating an oxygen-rich environment near her face."
One of the residents moved forward and corrected it. Nothing was said to the patient. I could have done it myself, but then the residents might not have noticed that something was amiss.
That tube has to be in both the nostrils for you to receive adequate oxygen" I told the patient before moving on.
The following are possible reasons for this curious phenomenon.

1. One prong accidentally came out.
2. The prongs were irritating the patient's nose, and she removed one to improve her personal comfort and kept the other one to honor the doctor's effort at treating her.
3. The patient believed it was just another gadget they used in the hospital, and had to be worn around the head, like a necklace is worn around the neck.
4. The patient might have seen or heard of oxygen-rich environment being used in some beauty parlor or something, to rejuvenate the skin. (I made this one up. There might not be anything like this. But it might happen, once someone reads this post and thinks it is a good gimmick.)

I did not try to find out, because I have found out that neither the patients nor the doctors give the right explanation. It does not matter that I did not find out, because I had seen it for the first time in so many years and statistically it is extremely unlikely that I will see it again. This post is just to make readers aware that they should be aware of things that can go wrong in patient management and they should be on the lookout for the unthinkable too.

Win-Win Situation in Education

An old classmate came visiting the other day. His daughter was studying in final year, which was probably the cause of the visit. After an initial patter, he came to the point.
"Students are not taught these days the way we were taught, huh?" he said.
"What do you mean?" I asked.
"Lectures are not taken at all" he said.
"Did your daughter tell you so?" I asked.
"Yes."
"But we are very particular about teaching students" I said. "If a lecture is missed due to any reason, we reschedule it."
"I did not mean your department. Teaching in your department is meticulous. In XXXXXXX department, not a single lecture has been taken in last one year."
I thought about it for a while.
"Is it same in the other departments?"
"Most of them."
"Why do you not tell the Boss? I am sure he will want to improve things."
"What? Then the concerned departments will victimize my daughter."
"But the head of XXXXXXX department gives adequate attendance certificate to all students. I know, because eligibility for appearing for exams is jointly checked by all departments."
"Zero out of zero is 100%" he said. That might be inaccurate mathematically, but was logical.
"And all teachers keep complaining that students do not attend their lectures" I said.
"That is true for many students, especially when they have exams of other subjects" he said.
Then it dawned on me. It was a win-win situation. The teachers got to not teach, and the students got to stay away from lecture halls and still got required attendance certificate.
"Do you expect me to tell the Boss about this?" I asked.
"Umm..." he said, "that would be nice."
And make enemies of all those teachers? I suddenly recalled a few faculty who came to me time and again and indirectly urged me to fight their battles for them. 'Fight your own battle' I wanted to say, but decided not to.
"I will have to tell him your name" I said.
He thought about it a bit.
"I think my daughter will self study" he said. "Let us not bother your Boss with such trivial things."

The 7.5 Size Gloves

Our surgery professor used to tell this story.
_________________________________________________________________________________
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.

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.

Maneuver The Idiots

There was a circular about a new medical college that the civic body wanted to start. It seemed the building was ready. There was already a hospital, now renovated, to be attached to the college. There would be an inspection by the Medical Council to decide if the college could be allowed to start. What remained was to employ people to run it. The circular stated that existing doctors-teachers in the medical colleges would be transferred to that college, and the posts that became vacant due to transfer of these doctors would be filled up in due course. They had asked the aspirants to attend a meeting. There was a huge rush, and many people had to stand during the meeting. There was no concrete decision about who would be finally transferred there. I had a few questions, which I asked the Boss, because I was concerned about continued recognition of my institute.
"What happens if Medical Council holds our inspection between my faculty is transferred and new persons are employed? What if the new people are not employed at all? After all, many of our posts remain vacant for years."
"The civic Boss has promised that these posts will be filled up. So they will be filled up" I was told.
"But why not fill up the posts in the new medical college directly? Why take away our people and fill up our posts later on?"
They have decided to do it this way. Trust the Civic Boss."
I definitely trusted this, until I heard about the court order during another meeting, where people were voicing their grievances to the Assistant Civic Boss, in presence of Boss and Boss' Boss.
"We are not getting promoted to Associate Professor and Professor" the people complained.
"We cannot promote anyone. There is a stay on all such appointments by the High Court. It has been there for many months" they were told.
'Ah!' I thought. 'That explains why they won't employ new teachers directly. They are ordered by the High Court not to employ any teachers. But then how were they going to fill up posts made vacant by taking away our faculty?'
When I voiced my concern to a knowledgeable person, he said, "this is called maneuvering the idiots."
"Who are the idiots?" I asked.
"Those who believe them" he said.

Healthcare Workers and Election Duty

"Sir, can they call us, laboratory technicians, for election duty, can they?" the person in charge of the lab asked me.
"You have already been called, I read in the newspapers today" I said. "The election commission is a constitutionally established federal authority. It is autonomous. It can do whatever it wants as far as conducting elections is concerned. If its order is refused, it can jail people. Its chief draws salary like the judge of the supreme court of India, I hear."
"But how will we do lab tests for patients if we have to go on election duty?"
"I understand it is judicial or quasi judicial. Don't you know that law is blind. It is evident from lady justice wearing a blindfold, as shown in court scenes of our Hindi movies . That blindness must prevent the people in the commission from seeing that healthcare is more important to people, especially poor people who seem to make a major part of the population, than the election process." someone said.
"But how will we run laboratory services on those four days our technicians go on election duty?" the lab person asked desperately.
"Well, you obviously cannot. The newspapers have strongly criticized the decision to call lab persons for this duty. If that decision is not revoked by the election commission, you will have to stop laboratory services on those days."
"But our patients will suffer."
"I know" I said. "But I have no power to do anything to resolve the problem."
A week passed after the initial call was sent out, and they did not revoke the order. The lab person was right. The patients did suffer. The tragedy was that no one seemed to care. Social activists, NGOs, media, and even politicians remained silent on that issue. It seemed like the poor people had lost the will to protest, or even to survive. Others probably had other things on their minds.
"The next thing will be doctors being called for election duty" I said to the Boss during a meeting.
"They have already been called" the Boss said.
"What has the biggest democracy in the world come to?" said that someone who had criticized this decision so vehemently just a week ago.
No one answered the question, because it was a rhetorical question.

Superspecialty Focus

"Doctor, they have sent me to you from the cancer hospital" the patient said. I was surprised. Usually we sent them patients for management. This seemed to be an exception.
"What is the problem?" I asked.
"I have white discharge and pain in lower abdomen" she said. It looked like pelvic infection and vaginitis.
"Do you have itching of the private parts?" I asked. It may seem like a little too personal question. But it is essential with the symptom of white discharge, and no patient of ours has found it embarrassing.
"Yes" she said.
So it looked like I was right. I examined her and confirmed that she had both of those conditions. I gave her appropriate advise and prescribed her specific medicines to cure her conditions.
"Why did you go to the cancer hospital?" I asked her.
"I had this white discharge, and my local doctor said it could be cancer" She said.
"Show me the reports from the cancer hospital" I said. She did so. They had checked her Pap smear, done a test for Human Papilloma Virus, and performed a cervical biopsy. Thus they had ruled out cervical cancer and referred her to a gynecologist. They had spent a lot of money, specialist time (clinician and pathologist included) both of which were wholly unnecessary. All of their and the patient's troubles would have been avoided if she had gone to a gynecologist primarily.
When I narrated this story to a friend, he asked "why did this happen?"
"That happened because a superspecialist is very focused on his work, and cannot see beyond. Then he misses out a lot of things that a specialist or even a family physician would pick up more easily."

Administration Par Excellence?

I was asked to conduct a preliminary inquiry of someone by civic administration. A part of an inquiry process is to call witnesses to the event under consideration and take their statements. When the witnesses are working in some department or a section, inquiry officer has to write to the head of that department or section, and ask him/her to send the witnesses for making statements. For that inquiry, I needed to get the casualty medical officers (CMOs) as witnesses. So I wrote to their head, whom we will call Deputy Boss.
"Ring up casualty and tell them to come for the inquiry, in addition to sending this letter" I told our clerk-cum-typist (CCT). The inquiry had to be postponed because the health university sent people for an inspection of the institute on that very day. Se I sent another letter to Deputy Boss and got the CCT to ring up casualty again, informing them of the new date and time of the inquiry. The CMOs came at the appointed time, and the inquiry was conducted. A month passed. Then both of my letters came back.
"Joint Chief Personnel Officer - do the needful" was the instruction scribbled on each letter by Deputy Boss. The Joint Chief Personnel Officer had returned the first paper with the remark, "this does not concern my office", and had returned the other paper without any remarks. Someone had remarked 'file' on the first paper at the end, which probably meant 'put it on file'. Both papers had been put in the box of my department, from where our servant had brought them back to me.
When I had to see Boss for some urgent work, I took these papers along and showed them to Boss and said, "Deputy Boss does not understand that he/she had to instruct the CMOs working under him to attend the inquiry. He/she sent the papers to a third person, who had nothing to do with it."
It so happened that Deputy Boss walked into the Boss' chamber just then.
"Dr. XXXXX, you have to instruct the CMOs to attend this inquiry, as is written in this letter" the Boss said. "You have delayed the inquiry by your action. Now instruct them to attend the inquiry."
Deputy Boss looked blank.
"The inquiry is over" I told Boss. "We called the CMOs and they came to make statements. I have shown you these papers just to make you aware of how things are done in the civic offices, affecting smooth functioning and causing undue delays."
"Next time do things properly" the Boss told Deputy Boss.
Deputy Boss kept looking blank.
'The future looks bleak', I thought, 'if there will be a future at all.'

Beats Me

I believed I usually knew why people did what they did. Now I am not so sure.
We have resident doctors who join for a three year postgraduate degree course. A part of their training is to do some research and write a dissertation. The health university has laid down deadlines for all stages of the dissertation preparation, such as one for sending the topic to the university after getting approval from institutional ethics committee, one for starting work, one for submitting the finished dissertation to the university after getting approval from the teacher. The students are supposed to work on the topic for 2.5 years. What I have noticed is that a vast majority of them do not submit a topic to the university by the deadline. In fact, there are a few who have not submitted the topic yet, while they are expected to submit the finished dissertation in another 3 months and 10 days. The teachers are after them to do the work, but it just does not happen. I know of residents who take three months to respond to each letter from the ethics committee. The health university had been tolerating all the delay. But it has sent a notice recently that the residents will have to put in extra terms to work on the dissertations, if they do not do the work in time. Even that does not seem to have worked.
"Why do they do this?"one of my colleagues asked.
"They must be very busy working" someone said.
"There are eleven residents in a unit where there used to be three in the past" someone else said, "and still there would not be such delay in the past."
"They procrastinate" someone said.
"Yes. We are wondering why they procrastinate" the first person said patiently.
"They think it is not important" someone said. "They know they will finish it somehow, and the university will not object."
There appeared to be some truth in it.
"Some of them are stinking rich. They don't care" a knowledgeable person said. "They just need a degree to go back to their ready nursing homes."
"But such persons are few" someone else said.
"Why do you think they do this?" someone asked me.
"Perhaps their priorities are different. Perhaps they are distracted by other things." Then I said something I had never said before, "my most honest answer is 'Beats me!'".

Elective Deaths

We received a circular from the Boss' Boss about maintaining operation theater data in each OT. It said it was sent as per instructions of Boss' Boss' Boss, i.e. Boss of the sender of the circular. A format for the maintenance of the data was attached in the form of a table. The first row of the table (containing the headings of the columns or data fields) is reproduced here as an image.

There were instructions that information should also be included on how many operations were done by each employee. The data was to be reviewed by heads of departments and Deans, and corrective steps were to be taken as required. It seemed the Big Boss had started something really commendable. Knowing the reasons why operations got postponed, one could take measures to prevent such an occurrence. Knowing which employees did a lot work did not help those employees in the form of a raise or bonus, but knowing which ones were drawing salary without actually doing much work would help putting them to work. The Big Boss had given good instructions. But while preparing the table, someone had goofed up.
There was a heading 'Elective Deaths' which stumped us all.
I called the  Boss' secretary and said the circular was not clear to us.
"It has come from the office of the Boss' Boss" I was told by way of an explanation. "I will call that office and get an explanation." I got an answering email in the afternoon. The heading 'elective deaths' was as it was before. I called a meeting of all faculty.
"Can deaths be elective?" someone mused.
"Euthanasia is not legal in our country" a second person said.
"Even if it were legal, one would not operate to give death to the patient. There would be no guarantee that the patient would die due to the operation" a third person said.
"A doctor saves lives. We all do. Even non-doctors understand that. Who would have thought doctors in the civic hospitals handed out elective deaths to their patients?" the first person said.
"The Big Boss must be IAS. The Boss' Boss is not a medico" a fourth person told us, though we knew that already.
"IAS persons would not make such a mistake" I said. "I have talked to the Big Boss in a meeting. He is just brilliant and very capable. Perhaps it was the clerk who goofed up?"
"That may be so" a wise one said.
I wrote to the Boss "I have not understood the meaning of 'elective deaths'. Some of our operated patients sometimes die. But none of the deaths are elective. Kindly obtain an explanation.'" I am yet to receive an explanation.

Double Whammy for Gynecology OT

"Sir, the intercom telephone connection in the Gynec OT is dead" a staff member complained to me.
"I know" I said. "I have been communicating with the electrical engineer for more than two months. He cannot do it."
"Then who can?"
"He said he would have to call the contractor who did the job" I said "and he seems unable to do so."
"But how do we communicate with the blood bank, intensive care units, wards, and other specialty doctors when there is an urgent need?" that person asked. "We have to change into street clothes to go out and make the phone calls."
"I can see some patient getting seriously ill or worse, because of this delay" I said.
"They have banned the use of mobile phones in OTs, or we could have used our mobile phones" that person said. It was true. Boss' Boss had taken out a circular to that effect, so that people would concentrate on work rather than talk on mobiles. Someone had said that time that they should make the intercom system functional before implementing such a rule. Well, policymakers will be policymakers (like they say boys will be boys).
"So no intercom, and no mobile phones!" that person exclaimed in frustration.
"It reminds me of a saying in Marathi" I said. "आई जेवायला वाढेना, आणि बाप भीक मागू देईना. Its free translation into English would be: mother does not feed us, and father does not allow us to beg for food. So be it. I have written a complaint against the electrical engineer to the Boss, explaining the whole situation, and suggesting getting outside help if the work cannot be done in house" I said.
"So what happened?"
"The Boss had referred the matter to the same electrical engineer for doing the needful."
"Huh?"
"Yeah!" I said.

Managing Files Without Extension

Our administrative office sent me an email with an attachment, which had been received by that office from a government office. It had to do with some healthcare related matter, since it was sent by a healthcare related agency of the government. I downloaded the file and tried to open it. Windows informed me that the file was of an unknown type and Windows did not know how to open it. So I checked the properties of the file. The file type was 'File'. It had no extension.
I informed our administrative office that the attachment could not be opened. But I could not let it go just like that. I could not believe that the government office people could make 'File' type of files that they expected doctors to read. So I gave it '.doc' extension by renaming it. Then I tried to open it in Microsoft Word. Word expressed an inability to open it. So I changed the extension to '.pdf' by renaming it again. My PDF reader opened it promptly.
As luck would have it, there was a goof up by the government office. They had not called me to the meeting at all. They had called the head of another medical college Obstetrics Gynecology department, but had written the address of the college as 'Parel', which was where my institute was located. We could call it a double-goof up, something on lines of a 'double-whammy'. One was sending the invitation to a wrong person, and the other was to remove the extension of their file, so that no one could read it. I could read it, only because I could read the mindset of the people who made that file and knew what they would do, though this was the first instance of it in my life.