Thursday, April 12, 2012


Yes and I state that high tech. investigative medicine has in many cases taken over clinical medicine and in some cases caused irreversible damage to both the medical practitioner and the patient.
The topic of this debate is actually most appropriate and relevant to my present status as a teacher in a new budding post graduate training institute. All these years I have worked in mgm hospital. Working in this hospital is like working with one hand and foot tied. We have been told to deliver 21st century patient care using vintage equipment and facilities. Despite that most of us have made a success of our work thanks to our clinical skills. What we lacked in equipment we made up by keen observation, thorough examination, compassion and care for patient and experience. Our work in MGM has enabled many of us to become better physicians in outside hospitals where we work.

With the advent of medical students since last year, I along with my senior colleagues have become painfully aware of the deficiencies in the trained doctors who have joined as residents. This trend is a worldwide trend has lead to an editorial in the Texas Heart Institute Journal by Herbert L. Fred who has defined such specimens as Hyposkilliacs.  I quote "I call this malady hyposkillia—deficiency of clinical skills. By definition, those afflicted are ill-equipped to render good patient care. Yet, residency training programs across the country are graduating a growing number of these “hyposkilliacs”—physicians who cannot take an adequate medical history, cannot perform a reliable physical examination, cannot critically assess the information they gather, cannot create a sound management plan, have little reasoning power, and communicate poorly. Moreover, they rarely spend enough time to know their patients “through and through.” And because they are quick to treat everybody, they learn nothing about the natural history of disease." These sound harsh words indeed but if we reflect on them they are indeed true. Before the seniors start gloating, I must quickly add that we too should share the blame. In a book by Groopman titled How Doctors think? the author while observing clinical rounds was shocked by both the lack of depth of his students questions and equally by the fact that rarely did attending physicians explain the mental steps that lead them to decisions.

However, some may say that this situation is there not because of the high tech modern medical facilities but has come about because of the particular individual, who has reacted to the system. I beg to differ because it is human to take the easy way out and in this materialistic acquisitive world, where time is money both students and teachers are becoming increasingly mentally lazy. Hyposkilliacs become proficient in ordering tests, interpreting numbers, analyzing images and calculating drug doses. The barrage of information is so huge and the analysis so complex that in fitting the whole jigsaw puzzle the patient is forgotten. How many times residents refer to patients by the result of tests or cot no or subject, the term made famous by Bollywood's Munnabhai MBBS. He held a mirror for our profession when he protested his seniors calling the patient a subject. Rounds are taken by no touch techniques and even the simplest of ailments which may be cured by simple remedies are treated after a barrage of tests. While this is not the subject of the debate today, I can state with authority that a large number of these tests are unnecessary, of dubious use and their results lead to faulty treatment which often harms the patient rather than does him good. Besides they have the not so insignificant side effects  of burning a huge hole in the pockets of patients and bloating the profits of the modern medical high tech. industry.

Let no one conclude that this old man wants to live in the past and does not recognize the value of modern high technology medical facilities. I believe that in a country whose media created  image is of a super power but which is at the bottom of the Human Development Indices, it our responsibility to utilize scarce resources responsibly. We owe it to ourselves and our patients to train ourselves and use what I would like to call critical thinking. Medical treatment and bedside medicine has traditionally been based on systematic steps, beginning with patient listening to "His story" or history taking, which serves the purpose of creating a bond of caring between doctor and patient and helps development the important component of critical thinking. The next step is a thorough examination and recording of findings. Our seniors always said "what the mind does not think the eyes can never see" and their experienced eyes noticed things we never saw. All this leads to a working diagnosis and an plan of treatment. Pertinent investigations which enables one to diagnose and plan the treatment must be ordered. Communication with the patient and with our juniors explaining the rationale of our thinking and the methods by which we arrive at our conclusions are of critical importance. And if we want to restore modern medical care from a mere science to an art form which it was then we need to construct every storey of the building from its foundation upwards and any step missed along the way will lead to disastrous consequences and an assembly line of hyposkilliacs. Critical thinking is the seed from which innovations and discoveries sprout. Today, I wish to pay homage to one such thinker Dr. BB Joshi who was a giant nurtured in the soil of this institute. A kind word, smile, compassionate touch and genuine concern for the patient and reassurance of proper care cost nothing but are far more critical to a patients well being than all the tests and gadgetry and the attendant anxiety created by their use in patient care.

In conclusion, I wish to thank and pay homage to all my teachers and gurus, from whom I have learnt and who have instilled in me the values of ethical compassionate medical practices, good bedside manners and judicious use of modern high technology medicine harnessed to the service of the IP who is really the VIP of modern medicine. I also wish to apologize to my fellow colleagues and students for harsh words. However, a teacher of mine said the words NEENDAKANCHE GHAR SHEJAR ASAVE. Our critics must be our neighbors and it is in this spirit that I request to take these words.

Tuesday, April 10, 2012

Thailand Travelogue

My family and me went to Thailand on March 29 to April 8, 2012. Some musings and observations.

While we all thought our Mumbai airport privatized is world class we were relegated to gate 1A terminal 2 from which some low profile air flights depart. There were mosquitoes galore, and we did not know what to mind our boarding passes or our bodies. The opening of the BKK airways plane with mosquito repellant spray could not quite repel the resilient pests from Mumbai who were determined to take a free ride to Bangkok.

Why do airways serve dinner at 2am?? Just to feed us and mark as fed. Why does hindu veg meal always have paneer? Vegans of the world must start a petition to serve us vegan meals every flight.

All over the world immigration officers are glum stern and slow. Security in Thailand is very tight too.

We went to Phuket, pronounced Pooket and not Fuket to avoid any double entendre. Tourist destinations all over the world are same, full of touts like our own Goa, They tried to sell tours, cheap only one day offer and a time share offered a free ride to hotel plus one tour thrown in for free(conditions apply) listen to their ragas and buy a time share. Luckily we realized there is no free ride.

While Thailand has great roads and tourist infrastructure, it remains an Asian country dressed up to please tourists with plastic smiles and dolled up girls.

Andakira Hotel in Patong bay area, great hotel though not on beach, top notch facilities, recommended. Staff courteous and good but language always an issue.

Thai boxing a rage, night clubs on Bangla road etc. we saw young girls dolled up. Thai women seem to be very hard working; we saw street food made by them, one woman show, cooking, and waiter cleaner cashier all by herself working from 6 pm to 6 am. Amazing by all standards.

A Buddhist nation predominantly, but ironically pork and beef eating, they do not even know vegetarianism. However slim and trim people, reasons I guess hard work, no wheat lots of greens, rice noodles eaters, but they digest any meat and sea food of any kind too.

Natural beauty abounds, superb white sand beaches, scenic locales, from  and James Bond movies, we really enjoyed the long tailed boat cruise. We also saw Buddhist monkey cave temple. Very good Buddha reclining statues and lots of monkeys in serene green sylvan surroundings. We saw a muslim fishing village, signs of islamization of buddhist country. Religion declines due to the followers all over the world and vacuum taken over by islam. Rock stalactites stalagmites seen by canoe a thrill. Pristine mangroves, a treat to see.

Thailand Phuket especially really international destination, we saw French, English, American, Australian, Chinese, Japanese and Bangladeshis. All kinds, we vote for French as most friendly and nice easy going jovial guys.

Krabi island less crowded than Phi Phi island but our tour guides not up to mark, though not lacking in effort. One French guy got hurt on coral but first aid kit inadequate, no gloves and deep cut, we had to dress and send guy to hospital. So ortho surgeon useful on trip. An Iranian girl had a shoulder contusion treated with cuff and collar and NSAIDS too. Also saw a local thai girl on trip to Krabi with a right side birth brachial  plexus injury, erb’s palsy. Wrist fused, ulnar claw. Told her to send xrays etc by mail, maybe we can give her some function.

Traveling with my daughter Delna is slow and we have to be careful as she can get lost. So we went to a small Elephant island safari, complete waste of time and rip off. Elephants made to perform like circus animals, unnatural and the ranibaug like elephant ride quite useless. Orchid garden and fresh fruit were few flowers half dead and two bananas each. Please do not waste ur money or go there.

Then we went to Felixresort Kanchanaburi, historical town made famous by the fictional movie based on true story Bridge on River Kwaii. The war memorial cemetery, JEATH museum(acronym for death represented by nations Japanese conquerors and oppressors, Englishmen POWS and victims, Americans and Australian troops who were allies in war and Thai the conquered nation. They were all against norms made to construct the death railway with many bridges and tunnels to connect Thailand to Burma and then to conquer India. The troops POW’s and indentured labor suffered and gave up their lives in large numbers and finally destroyed the bridge and delayed the Japanese invasion so that we survive. Saw a natural Buddhist cave with seven rooms, limestone caves but I think monks live life of luxury, hardly any asceticism, smoking and beef and pork eating monks, were told they no not drink. Small mercy indeed. Inside statues of Hindu Gods too. Ganesha.

We visited Tiger temple Buddhist temple to walk with tigers. Despite internet reports by animal right activists to boycott the place since there were accusations of animal trading, our curiosity and desire to see and touch the majestic animal got the better of us. While initially the site of the majestic animals walking around excited us, we soon realized that the majestic cats were only looking majestic but were tame pussies in front of the monks and trainers. We wondered if they were drugged. On asking a monk, later he told us that majority of the 102 tigers in the temple were born in the temple. The cubs were separated from mothers and nurtured by monks and were given a collar and leash early in life. So they felt that the humans were almost their mothers. They were fed and exercised but never made to hunt for food. In short the nurture got the better of nature and the animals became a means of commercial exploitation and show pieces like circus creatures. Maybe no cruelty, but what can be crueler than programming an animal to perform for life, out of his natural habitat. This is not tiger conservation according to me.

Thai roads great, traffic in Bangkok probably as bad as Mumbai, not much lane discipline but no honking. We need to learn. Streets very clean on main roads but a garbage producing society, no awareness of plastic bag recycling, bottled water galore. Toyata commuter running on LPG or CNG very smooth and excellent tourist vehicle.

Bangkok appears to be a great shopping destination. But the Buddhist temple and four pagodas worth seeing. Golden Buddha temple real gold, Reclining Buddha huge statue but Gold colored. Typical Buddhist thai designs porcelain kind of work on pagodas representing powers of the Kings of the Rama dynasty from our very own Ramayana. Present King 84 years old with grand palace. Victory monument, parliament building democracy monument all grand structures, but nothing to write about. We decided to concentrate on retail therapy and give floating markets a slip. Women’s clothes really good, cheap and vfm.

Malls all over the world are the same except bigger or smaller. They cater to the human greed and need to get more for less, without realizing that all we get for more or less has to be left behind for free. The cost of clothes maybe lesser than in our motherland but the carbon footprint of stuff made one place, stitched another, sold and going to another land makes all this costly for all of us. Point to be pondered upon.

Like the sky train monorail experience was very nice. Smooth swift small trains. Ac comfort hope mumbai has the same too.

On Saturday we went to Chatuchak the weekend market to strike more deals get more for less. Daisy my wife very satisfied with her buys. We finally went to the hotel to leave for amchi mumbai smug with satisfaction carrying memories of Thailand and stuff to boast about.

Suvarnabhumi airport huge with a big relief of Amrutmanthan. Thailand has lots of hindu symbols but is far removed from indian culture. Two words we learnt Sawadee for welcome or swagatam and kop kun ka for thank u.

We reached mumbai and sat in a meru cab tata indigo xl cab. more spacious than all the toyotas. home is great but we need to really improve in infrastructure and our people need to learn discipline and civic sense. We will get there but we have miles to go.

While the whole trip was very good cannot pinpoint a highlight or defining moment. Thailand a great tourist destination, has its plus and minus points, not spectacular but certainly value for money.