nutrition - cooking and discussing

We travelled to a place called Chittalapakkam today, where we discussed nutrition first with very small children and then with their mothers. We met in a balwadi or creche. We discussed the importance of fruits and vegetables, drinking milk, and washing hands. After this, we went to someone's home, which was really a hut, and made high-nutrition rotis (indian flatbread) out of wheat flour and gram flour, carrots, spinach, and other vegetables. They were made with minimal oil and and not fried. We took these back to the balwadi, distributed them to the children, and discussed them with the mothers.

It was actually interesting to see what the mothers know. Some know that carrots are high in vitamin A, which is good for the eyes. Others still think eggs aren't good for kids who have jaundice. The level of general education is very low in these communities - among everyone but especially among the women. But the health education is somewhat reasonable in the places that are being reached by the government health centers, which speaks well for Tamil Nadu's implementation of the national health programs.

One program that we saw here was the mid-day meal scheme. Under this scheme, children are fed a well-balanced meal, including an egg, everyday for lunch at the creche and even at the schools, up to the 7th grade, I believe. This serves two purposes: one, at least one good meal per day for the children, lowering incidence and severity of malnutrition, and two, incentive for parents to send their children to school. This is another highly successful program.

good news.

I gave my first good news today to a woman with her first pregnancy. She walked in and handed me a positive pregnancy test stick, asking me to interpret it for her. I told her it was positive, after which her eyes misted over. It was a moment to remember. I then gave her advice on folic acid tablets and proper nutrition and wrote an order for her first trimester scan. It was really something I was happy to be part of. After that I had several small children with coughs and colds, and then we travelled further towards mahabalipuram to a small anganwadi where we measured weights and head circumferences. The weighing apparatus was rudimentary at best, with a spring balance suspended from a ceiling beam, tied to a small rucksack converted into a hammock. The children varied from being well behaved to feeling terrorized by 6 doctors looming over them with measuring tapes.

The area is interesting, alternating between beautiful hotels and resorts and tech parks, with interspersed huts and tiny buildings like the ones we work in. I'm glad to have this brief experience with medicine as it is being practiced in the peripheries.

back in business

It's been difficult to keep updates going when I haven't had much to say, much to talk about. But I saw - and treated - my first cases today.

Rather than try to keep this as a sort of entertainment for potential readers that may or may not exist, I thought it might be nice to keep a portfolio for myself of the cases I've seen and the experiences I've had. If entertaining stories come up, great. If not, that's fine too.

Yesterday was my first day actually seeing patients. I'm working at the Voluntary Health Services, down Old Mahabalipuram Road. It's a dusty little place, with a few old buildings that look like old timey schoolhouses. It was frightening to sit at a desk with a patient seat in front of me. My first patient sat down, addressed me as 'madam' and proceeded to tell me her name. Remarkably, it was the same as mine. I thought that was kind of a cool little sign.

I saw 4 or 5 patients yesterday, all with colds and sinusitis. One woman had what I suspected to be a chronic bronchitis. She had diffuse wheeze and creps heard throughout the chest, with some bronchial breath sounds as well. She complained of 3 months duration of cough with copious sputum production. We interns all had various suggestions, such as bronchiectasis, bronchitis, even walking pneumonia. The medical officer suggested that these all may be zebras. Think simple, he said. Don't suggest investigations you know your patients won'tundergo. So we prescribed amox for a mild LRI, cough syrup, and an aminophylline. And then we sent her home.

What a strange approach!

I wonder, what does she actually have? TB? COPD? Will she get better? Or will she keep taking short courses of antibiotics periodically prescribed by doctors who just want to get the patients to go home?

Another young woman came in and told me that she was diagnosed with "sugar", meaning diabetes of course. She says she hasn't taken medication for one month. Why, I ask. I had to work, she says. The problem is that for her, this is actually an answer. It is valid. If she takes time off of work to go pick up her medicines, she will lose a day's salary. She doesn't come to the clinic until she is too weak to work. I have pins and needles, she says. I am dizzy and weak. Fatigued. We ask her if she's done her blood work. She tells us that she has just given blood and that the report won't come until tomorrow. I prescribe her inj. B complex - for her satisfaction or for my own, I don't know. I ask her to come back with her blood reports tomorrow.

I know I won't see her again.

Death be not proud...

one of the harshest realities of joining the medical profession is that of morbidity and mortality - or in "layman's terms," disease and death. It's not like I had no idea that it happens - I know you people are rolling your eyes and saying to yourselves, what an idiot, of COURSE people die - but that's not the point. Knowing that somehow somewhere someone is dying is different from, say, having a dead body in front of you and having to cut it open. Or walking to the canteen to get a cup of coffee with your Ipod and noise-cancelling headphones and hearing piercing screams from outside the ER, turning and seeing women tearing at their hair and beating the ground. I never know what to do then. I hate turning around and walking away as if I don't care. Because I do. But what am I supposed to do, stand there and stare? Or can you imagine if I actually went over there? They'd see the white coat and shoot daggers at me.

You.
Yes, you.
You have a white coat.
You were supposed to know what to do.
Why is my father/son/husband/brother/friend/lover dead?
Why didn't you save him?

It doesn't matter that I'm a student. It doesn't matter that sometimes there's nothing anyone can do. It just doesn't matter. It's a life, gone. And I wouldn't have an answer.

And then there are those times that I'm walking around campus and the mortuary van almost runs me over. A black contraption that looks like the getaway car in a bad crime movie, it has a way of showing up when I'm in a peculiarly happy mood, as if it's there purely to remind me that people are dying all the time. And I'm supposed to be learning how to save them.

The honest truth is that I'm afraid. I don't know if I'm ready to have a life where it's my job to save people. Where lives are actually in my hands and my decisions may be the turning point between life and death. I know that many doctors feel that way and then they turn out to be perfectly fine at being doctors. But that doesn't change the fact that I am afraid of death. My own death, my family members' deaths, my friends' deaths, my patients' deaths. All of them. Every single one.
I can only hope that given a few more years I will learn to look death in the eye. I will learn to hold the hand of a dying patient and tell them that they will be okay. I will believe it. And I will tell myself I'll be okay and I'll believe it too.

Medicine? For the community? Say what?

How important is it for us to really learn community medicine? Most Indian medical students consider community medicine to be the biggest waste of their time. Bigger, even, than sitting in the canteen discussing the latest movie or the new gossip about the surgery profs.
Today, for a community medicine class on polio, for which India is one of only 6 endemic areas, 29 people showed up. There are supposed to be 144 people in the class. I mean granted, major exams coming up, but still...29? The tragic thing is that even the professors subscribe to the myth that CM is only for the sake of passing the final exam which is mandated by the Medical Council of India. Today's class was peppered with the phrases "this is important for your exam" and "this will definitely be an important question for you", instead of "this will come in handy. Most subjects are taught that way, unfortunately, but at least with other subjects the students tend to realize that they need to know their stuff. Here, no one even dares to think that CM might actually come in handy; that we might someday need to know what the different strategies for polio eradication are.
In a country like India, where 70% of the population and only 20% of doctors are in the rural areas, it can't be stressed enough how important it is for the average student doctor John Doe (or Karthik Subramaniam, as the case may be,) to be thoroughly well versed with the principles of public health and community medicine. So what is it going to take to bring about a change in the student population?
I don't think the problem is one restricted to my university or even to India as a whole. The factors which manage to turn medical students away from community health and public health reform vary from place to place, population to population. Let's take the latest controversy surrounding Indian medical education, for example.
There is talk that there is going to be a new requirement that all Indian medical students should serve two years in a rural health center after graduating, before actually receiving their degrees. This rumor was enough to cause strikes and riots all over India. Government university students proclaimed that as they come from middle class families, it is unfair to ask them to give up 2 years of solid earning potential for the sake of villagers who dont' really need real doctors. Private university students retort that since government students pay so much less in tuition fees, they can afford to give up two years where private students cannot. Nowhere in the discussion, neither in the student dialogue nor in the media, was there a consideration given to India's need for health care for its rural and destitute sick. It appears to be a complete nonissue for people.
There is an increasing shift of perception from healthcare as a public service to health care as a consumer product, a commodity to be evaluated with respect to economic advantage and supply-demand analysis. Of course it's easy to put a moral spin on the whole issue and to say that we owe it to our poverty-stricken brethren and whatnot (which, for the record, is precisely what i believe). And perhaps that works in a semisocialist society like India. But how does that translate to a thoroughly capitalist system like the United States? Is it wrong to tell doctors that they shouldn't be allowed to sell their services to the highest bidder like those who bear other skills? What is it that makes medicine different?

food for thought... I'll be sure to bring this up again soon, perhaps with fewer questions and a few more answers from my side. Ciao for now.

and how are you feeling today?

Yesterday two colleagues and I went to the wards after classes were over to take a case. Normally we go during the day and we have our backpacks and books, and the wards are filled with students like ourselves. But this time it was just us, a few doctors here and there on afternoon rounds, and nurses. We had our stethoscopes around our necks and notebooks to take a proper case history. Of the three of us, I felt the most confident about taking the case, but even I didn't know very much. Something about being there at a time when there weren't very many other students and being there in the capacity of doctors rather than students made me feel somewhat overwhelmed by the whole experience. I felt like I was playing a game of dress-up, not much different from a six-year-old girl wearing her mother's high heels or a 10-yr-old boy carrying around his father's briefcase. It was an awe-inspiring experience, one that made me determined to learn everything I can to become the best doctor I can be. I came home and wrote this poem. Enjoy!

White coats parade through the blinding corridors
Some have faces perched on top
others with patent leather shoes polished to perfection
pink and blue and green scrubs shout orders
codes and meds and labs and scans echo
rattle the walls
Hospital gowns wheel loyal oxygen tanks and IV stands through days and nights filled with coughing and fevers and flat lines
Friends stop coming
Families are too afraid to look
But beds are always full
Every oxygen mask stuck to a nose and mouth
Eyes filled with anguish, faces pale and empty
Those eyes, those faces, turn to me
Grasping hands and speechless mouths plead for answers and ask for hope
But I am not yet a white coat
Nor am I a set of happy pink scrubs
I carry a stethoscope and put my ear to a chest
I dream of hearing answers and solutions and dreams and hopes and souls
But I do not yet have the key
So I hear life
And air
Soon I will feel a wrist and thoughts will come
But for now I walk the blinding corridors
And feel the walls shake
I see masks and tanks and stands and gowns and hands and questions
And I stand in awe
An impostor
A guest
Or perhaps just a traveler
Starting out on a journey
To nowhere and everywhere

The phenomenon of the were-professor

Back in medicine posting now. It seems like we've been on a long hiatus from actually being in the hospital. It's nice to be back in the wards but it is of course a real challenge. To top it all off, we've been posted with the toughest unit in this hospital. They are strict, ruthless, and incapable of being satisfied. It was naturally our instinct to shudder and moan and play the "why me" game. But after thinking about it a little bit, I realized that it's more likely than not that I will have to encounter these people at some point during my stay at this medical school. I'd rather encounter them as teachers than as examiners. Although you can't say they're ever really on "our side", at least their aim is to teach us, not to fail us.
When I first came to India from the States after 16 years in the American education system, I really thought that the professor-student relationship here was bizarre and absolutely unheard of in American medical schools. We stand up when the professor enters the classroom, we only call them sir or madam, we greet them with the humblest "Good morning" we can muster, and we try not to look them in the eye. Coming from a small liberal arts college in Boston where I had lunch with my professors and still send them postcards, I took some time to get used to the way things work here. But considering that medicine is one of those "old guard" professions that don't really change much, a la Patch Adams, I don't think my Indian colleagues and I are alone in this culture of "what doesn't kill 'em will make 'em stronger". Today we had a twenty minute lecture on pleural diseases after which we had a five minute rapid fire interrogation, followed by a twenty minute lecture on how useless today's medical students are and how we will probably become horrendous doctors. I'm not sure if the professors honestly believe that this is the way to turn us into conscientious, studious students, or if they just enjoy taking out all of their frustrations on us. I'm sure there's a rational explanation, but I have to say sometimes it's difficult to see. More on this later. Kidney calls.