Beautiful moments in the midst of distress

Wishing you all a very happy new year 2025! As I sit back and think about 2024, I am overwhelmed by how much has happened in the year and how much it has enriched my life. There have been several dramatic twists and turns in the plot called life. One of the most important events that happened this year has been my career change. I vividly remember the conversation I had with a friend who had made a similar career change a few years ago. She told me, "Vijay, it is not going to be easy. But eventually you will get used to the idea that you don't have a regular job anymore. You will find yourself questioning your decision several times. But you will get used to a new normal." Those were indeed words of wisdom. I keep telling these words to myself even today when I question myself for having taken this decision. 

I am now a primary care provider in a rural area. I would not characterise it as a remote area, nor would it qualify as underserved. Compared to when I started working here 15 years ago, today there are more frequent buses and good connectivity by share-autorickshaws. Several small private hospitals have cropped up in the nearby town. The community has also become a bit better resourced compared to 15 years ago. There are days when I ask myself, "What am I doing here? Is my work here relevant? Am I just going here because I am used to this place and it is convenient? Is it time for me to break free of my comfort zone?" When doubts like this cloud my mind, some intense patient-physician interactions happen and they remove the fog. I would like to reflect on the story of a patient I saw in the last month of 2024. 

Mr. P is a cotton garment salesman. He has a huge bundle of cotton ready-made clothes on the back seat of his TVS-50 motorbike and travels extensively in our local villages selling them. On a good day, he earns about 1000-1500 rupees, that is enough to support his family. He is a very religious man. Every year he walks all the way, barefoot, to Velankanni temple, the Church of Mother Mary. It is a shrine located in the coastal area of Bay of Bengal in Nagapattinam district of Tamil Nadu, about 250 KM from where he lives. It is a 15 day walk with rest in the day time and walk during the night times. They go there as a group of pilgrims of 15-20 people in a batch. This time when he was walking, mid-way he developed crushing chest pain and had to call his son to come and pick him up in a bike. Even then he never stopped the pilgrimage and had his son drive him the rest of the way to the temple in his motorbike. As soon as he returned home he came to see me. It sounded like he had an acute coronary event (a mild heart attack). His ECG (a test done to check the electrical activity of the heart, useful to show whether there is or has been a heart attack) showed evidence of a recent heart attack. 

Mr. P is a person who breaks every rule in the medical book. He has been taking treatment for diabetes for more than 10 years now, but eats sweets, and walks long distances barefoot unmindful of the risk of diabetic foot problems. He has developed ulcers of the feet in the past, which I have treated. But he will never stop doing his bare-foot pilgrimage of 250 KM. The day of the mild heart attack, despite having a severe pain and catastrophic health event, he has persisted on his pilgrimage. When I referred him to the government tertiary care centre for a cardiac evaluation he said, "I will definitely go, but not now. I have some work which I must complete. I will go after that." I have learned over the years, that there is no use in instilling fear, threats of dire consequences of delayed treatment, or even invoking the fear of death. Those things don't work on Mr. P. Subsequently he went to the government tertiary care centre and got a coronary angiogram. The test revealed a nearly complete block of three major blood vessels supplying the heart. He was advised to go to a super-specialty centre in Chennai to get an opinion from the cardiologist there. When he came back to see me after visiting the cardiologist in the Chennai hospital, for the first time I saw a dejected and sad Mr. P. 

"The cardiologist says that the vessel blocks I have are not correctable. He says if I undergo surgery it is highly risky and I may not survive. So he has asked me to take tablets and restrict all my activities." His voice was heavy with sadness. For the first time Mr. P had brought his wife along and lines of concern were written all over her face. These are unusual events in my 5-year long association with Mr. P. The cardiologist in Chennai must have meant well when he advised Mr. P to restrict all activities and just take medicines. But for someone like Mr. P, staying cooped up at home is not an option. It will probably kill him faster than a high risk surgical procedure. I spoke to another cardiologist friend of mine and had him see Mr. P. He said his team and he were willing to operate on him. From then things moved very fast. Mr. P got admitted, his sugars were controlled with insulin and within a week he underwent coronary artery bypass surgery. Fortunately he was covered by the Chief Minister's Health Insurance Scheme and the out of pocket expenditure was something manageable by his family. He is now back home and calls me and talks to me almost every other day to update me on how he is doing. 

Patients like Mr. P help me understand that good quality work, work with a committed engagement with the community, and empathetic and compassionate work is always relevant. It need not be in an underserved, unreached area. In the middle of all the sophistication of specialists and super-specialists, there is a need for a quiet family physician who can listen with empathy, understand the patient personally, and make sense of all the specialist opinions and put them in the right perspective for the patient. In other words, every patient needs an advocate and who better than a primary care provider. 

Episodes like this help me overcome the uncertainty of not having a "regular job" and being financially insecure. I know this is a brief respite and I need to work through my uncertainties a lot more. One of the greatest lessons 2024 has taught me is that there will be distress and discomfort in life, but it is our responsibility to look at the beautiful moments in the midst of all of them. I am still a work in progress. I look forward to 2025! Hoping to write more this year! Once again wishing you a very happy and peaceful 2025!