Skills passed down through ages

It was a Monday morning. I was feeling very low. Nowadays Mondays mornings are invariably associated with a low mood and a sense of worthlessness. I was questioning many of my life choices. What am I doing in my life? Is the kind of medicine I am doing relevant anymore? Is there a space for community medicine in today’s world in the semi urban spaces where I practice? There is a hospital or a clinic every 500 meters in these areas. The public health system is also aggressively going door to door and bombarding people with tests, medicines, health messages, vaccines and everything else from the public health armamentarium. There is almost no elderly person in any of the areas where I practice who does not have a bag full of medications. The other day, one elderly man pulled out a box full of Tolvaptan tablets and said that he has been buying it from the pharmacy and having it regularly over the past 2 months. Tolvaptan is a sophisticated drug used for those with a hormonal condition that leads to reduced sodium levels in blood. It is quite expensive. This man was taking it over the counter without a proper prescription based on an old prescription that was given to him several months ago. I am just sharing this example to tell you the level of medicalization that exists in the communities where I work. I sometimes feel silly about the work I do. On days like this Monday, I feel frustrated by the fact that I travel so long and spend so much time and efforts, not even sure if any of this has any impact on people’s lives. 

 

I entered the clinic in Tiruvallur with a long face. As soon as I entered, I went to the table, placed my bag on it, and opened my laptop. My laptop is my safe space. It is my platform of high productivity. It is my portal of entertainment. It is also the world into which I disappear and hide when I am feeling extremely low and non-social. It gives me an excuse to ignore the people around me. When someone is seated in front of a laptop and immersed into it, there is a sense of legitimate purpose and an appearance of being busy with a ‘do not disturb’ signal automatically rising on the face. I take refuge in this and try to avoid people and compose myself when I am low. 

“Sir, shall I set up the clinic in your room? Will you start seeing patients?” the staff nurse in charge of the center asked me. 

I got out of my short respite and flashed a fake smile at her. The fake smile is one thing I have practiced and perfected over the years. The fake smile is a powerful tool. When the whole universe seems to be going wrong, and when everything seems to be poised to destroy our peace, deep breath and a fake smile are the only two tools that always come to my rescue. The fake smile prevents us from reacting the way our inner instinct asks us to, which is shout at the person in front of us. The added bonus is that those who do not know us well won’t recognize that the smile is fake. But when the person knows us well, they may recognize that the smile is fake, but that is also good, because they might have by then learned that it is time to move away and give us our space. This staff nurse is of the first category and so she smiled back at me. I put away my laptop, packed up my bag, let out a silent but huge sigh and walked reluctantly towards the out patient room. 

 

There was a huge crowd of patients sitting just outside the consultation room. I had an overwhelming wish for the floor to crack open under my feet and fall through the crack and disappear. But those things happen only in cinema. I walked into the room and started seeing patients. 

 

A 65 year old man walked in. His face was in a frown and his nostrils were flaring out. He was breathing heavily. With a lot of difficult he walked in and sat in front of me. He was obviously breathless as he complained,

“Doctor…..i am unable to breathe. At night…..unable to lie down…..no sleep….no fever….cough is there…..body pains….” It took a lot of effort for him to even complete the sentences. 

It sounded like he had a lung problem. I always have a fascination for the respiratory system. I remember in my final year MBBS, I got a long case of respiratory system for my clinical exam. In our times they used to say that if you get a central nervous system or a respiratory system case in your MBBS exam you will surely fail. This is because the examination of the patient to evaluate both these systems can be quite complex. I got a patient with bronchiectasis and managed to perform a thorough and detailed examination and presented the case and passed the exam. I attribute my fascination to the respiratory system to this validation of my skills in examination. Subsequently also, whenever I have come across a patient with problems in the respiratory system, I have always made detailed efforts to examine and evaluate the patient. So it was a good thing that the first patient required an examination of the respiratory system. I requested him to strip his shirt and started my examination. This shook me up and activated my lethargic Monday morning brain. One more thing I have noticed is that when I examine patients so closely and in such great detail, they are immensely satisfied by it and feel like they are being given special attention. Many good things were happening. I was getting out of my Monday morning blues, the patient was feeling satisfied with the detailed attention, and I was making a slow and steady progress towards the diagnosis. 

 

After almost 15 minutes, I came to a diagnosis of fluid collection in the right side of his chest also referred to as pleural effusion. This man had diabetes. It was possible that this pleural effusion was due to tuberculosis. The center where I work does not have an x ray facility. I sent him with the driver to a nearby private clinic which has X ray and also gave him money to pay for the X ray. When he came back the X Ray showed massive right sided pleural effusion. This is not the first time that my clinical diagnosis has been confirmed by imaging test. It is also not the first time that I have made a correct diagnosis of a respiratory problem. Therefore, there is no reason for me to be elated. But I was. I felt a sudden high running through my entire system. Immediately felt guilty about it as I was feeling high about a patient’s suffering. I felt like a fresh MBBS graduate making his first independent clinical diagnosis.

 

Subsequently my mood lightened up for the rest of the clinic. I was less grumpy and more engaged in seeing patients. The past three days, I have been thinking of the process of clinical examination and arriving at a clinical diagnosis. The four steps of a thorough clinical diagnosis – inspection, palpation, percussion and auscultation – are seldom used nowadays. We still meticulously teach our students to perform these tasks on patients. They religiously purchase the clinical examination kits which comprise a stethoscope, knee hammer, tuning fork etc. and carry it to the ward during the clinical postings. We teach them how to do each of these procedures. But when it comes to actual practice, I don’t see many doctors use any of these skills nowadays. I have heard sad stories from patients, friends and relatives who say that their doctor barely touches them. The intimacy of the connection provided by close inspection, palpation, percussion and auscultation are relics of the history of medicine. One clinical examination that is still done is the auscultation with the stethoscope. Even that has more of a ritualistic role than a role as a diagnostic modality. These ancient historical procedures have been replaced by cutting edge technology, imaging procedures, and laboratory tests. But that day, my entire diagnosis was based on listening to that man’s story, observing his breathing, talking, and performing the classic clinical maneuvers from so long ago. That was the reason for my excitement. Not only was I excited for myself and the diagnosis I made, I was excited at the power of the age old wisdom of clinical examination that has stood the test of time over the centuries. The same methods of great doyens of medicine like Osler, Rangachari, Misra, KV Thiruvengadam, N Karunanidhi, Bennet passed down the generations and working upto 2025! The feeling was a heady mix of thrill, excitement and humility. As I sit back and bask in the warm glory of the feeling, I am grateful to the Universe for giving me this chance to practice the craft of medicine!