Between thoughts and words

  During a recent discussion on the dynamics of doctor patient relationships, we were talking about professionalism and professional boundaries. When practicing medicine in underserved rural areas, professional boundaries are blurred. The other day, a patient with a chronic skin condition whom I was treating in my clinic, saw me in the bus on my way to the clinic. He lifted his t shirt then and there to show me his skin rash over the abdomen. That is one extreme of how loosely defined professional boundaries are. How does the doctor balance being connected with the patient, maintaining good rapport and relationships, being sensitive to the local culture, and at the same time maintaining professional boundaries? I can make sure that I don’t breach professional boundaries with my patients, but how do I handle it when patients liberally transgress the boundaries?    Mr. M was a 65 year old man with cancer of the voice box. He was treated in a government regional cancer hospi...

Mr. R is a 29-year-old man, a cab driver who lives in a village near our clinic but operates out of Chennai. He finished his bachelor’s in mathematics from a private arts and science college in Chengalpet, and after hunting for jobs for several months, decided to drive a taxi for his living. He has been working as a cab driver for 7 years now and has earned a decent amount to build their own home in the village. His mother, younger sister and he live in the house. His sister has just finished her bachelor’s in education from a private college and is preparing for exams to get into the government service.   Mr. R came to our clinic about 3 years ago. While on a long trip of more than 300 KM on the road, he had developed severe breathlessness, profuse sweating and palpitations and had to stop driving and rest for a few minutes. It frightened him and so as soon as the trip was completed, he came home and the very next day came to our clinic to see me. He looked tired and his face was ...

Every Tuesday I meet with the community health workers who are the face of our community health program in the rural area where we serve. They are an enthusiastic bunch of 10 people from the local villages, 8 women and 2 men. Hailing from modest backgrounds, they are workers with excellent people skills, cool conversationalists and go-getters who can accomplish tasks assigned to them with perfection. Every Tuesday when we meet, we start with greetings and the broad opening question, “How are you all today? How has the last week been?” Some days they are silent and take time to warm up and start talking, on most other days they just start talking about the activities of the week, the challenges they faced, the unique problems they solved and the doubts they have regarding their work. Our meeting room is the noisiest space in the office and sometimes we end up disturbing the work of others in the office. But, I think this dynamic and vibrant discussion space has been one crucial factor t...

Yesterday there were two women who came to the clinic. Both of them had chest pain which was disturbing them. They had diabetes and hypertension for a long time and were taking medicines for it. Both came alone to the clinic, and were in obvious distress. I did ECG for both. One, Mrs. S showed features of long term heart disease that remained unrecognized and unattended (which happens often with patients with diabetes as they do not have symptoms) and the other, Mrs. AK showed a heart disease condition that is recent in onset. Both these women were relatively young (in their 50s), and so prompt consultation with a cardiologist, coronary angiogram, and treatment would be the next steps in their care pathway. But there was no scope for all this in either of their lives.     Mrs. S lives alone as her spouse left her for another woman many years ago and she doesn’t have children. She has an older sister and brother, both of whom are unwell and cannot accompany her to the hospital ...

      “I am having severe neck pain doctor. I have taken all home remedies that were suggested to me. But it is not going away,” said a demure young woman. She was the 68 th  patient of the day. The complicated and memorable patients always seem to come to the clinic towards the fag end. Is it a pattern? Or am I vividly remembering them because they came last? The brief interaction with her left a deep impact. I was thinking about her for a long-time last evening.    Mrs. L must be all of 24-25 years of age. She must be about 5 ft 4 inches tall, thin built, pitch-black hair well oiled, parted in the middle and worn as a plait. She also had a bright  kumkumam  dot on her forehead, it was not the typical dark maroon color that most women in the area wear. It was a light red to orange colour dot, commonly worn by women belonging to the Irula tribal community. We have a practice of routinely collecting information about caste in our clinic case record...

I was not feeling very well yesterday. It has been this long-drawn cough, cold which had morphed itself into a sinusitis and headache. As soon as I wound up clinic around 1.30 PM, I decided to leave for home. My friend, a physiotherapist had come to clinic and whenever he comes, I hitch a pillion ride on his motorbike till Chengalpet from where I take the train home. But yesterday was not a routine day. Early in the morning, I got a call from the wife of one of my long-term patients and good friend. He had been fighting for life in a critical care unit with complications of chronic kidney disease for more than a week now. He passed away early yesterday morning. This was running in my mind throughout the day. I was conflicted between going to to their home and going home to get some rest. I decided I will go home. I got on to my friend’s motorbike and almost reached Chengalpet. Throughout the ride all I could think of was the man who had passed on and his family. So somewhere just befor...