Periya (senior) Doctor

 

Mr. G is a resident of our village and rarely comes to our clinic for some minor ailments. He makes it clear to us that the only reason he comes to our clinic is because it is very close to his home. He takes treatment for his diabetes, hypertension and heart disease in a private hospital far away from our village. Whenever I try to ask him details of his other treatments he retorts, “Why do you want to know those details? My doctor is very good and he will take care of those problems. I came only for this cold. Just give me cold medicines.” We are a small community-based clinic and Mr. G is also a member of our community advisory board. I explained to him one time that it is important to know details of other treatments that patients are taking even if I am giving ‘just cold medicines’. But Mr. G did not want to share any details. 

 

Last week Mr. G came with a dry cough, low grade fever, body aches and headache. This is a season for influenza like illness in our area and I have been seeing an increase in people with these symptoms in the clinic. The commonest reason for such an illness is due to a viral infection. The standard treatment is to give paracetamol for fever and some tablets to reduce the cold. I also prescribe steam inhalation to decongest the sinuses and some hot water gargling to soothe the throat. When I prescribed all this to Mr. G, he said, “Where is Amoxyclav? Why haven’t you written that in your prescription?” 

Amoxyclav is the brand name for an antibiotic. It is given for certain type of infections. If the doctor suspects that the infection is due to bacteria, the doctor prescribes this drug. However, this antibiotic has no effect on viral infections. Most doctors in our area prescribe antibiotics for every fever without evaluating the patient clinically. Some well-informed patients like Mr. G know the names of drugs and that’s why he asked me the question. 

 

“No sir, you don’t need Amoxyclav. It looks like you have a viral illness. Amoxyclav doesn’t work against viruses” I replied. 

 

“Then give me something else that works against viruses. Paracetamol and Cetrizine, I can get myself in any medical shop. I have stock in my home. Why should I come to you.” He was angry and started raising his voice. 

 

“There are no specific drugs for viruses of this kind. The best thing is to use the paracetamol and cetirizine and wait for the body’s immune system to fight and handle the infection” I replied calmly. 

 

“But the periya (senior) doctor in the city always prescribes an antibiotic. He is a much more senior man than you. He is an MD and works also in the government hospital. I trust him. If he gives Amoxyclav it must be right. You just give me Amoxyclav. Don’t worry about anything else…” By now Mr. G was irritable and started talking in a very patronizing tone. 

 

I reiterated that he doesn’t need antibiotics and told him I will not be writing a prescription for the antibiotic. Mr. G was very furious and stormed out of the clinic. This is not new, and we are used to his reaction. But this episode got me thinking. This war against over-treatment with antibiotics and its threat of antimicrobial resistance is a massive one. It is not new, and it is a common phenomenon that all conscientious doctors face on a day to day basis. But the deeper issue is that of trust in doctors and its implications. 

 

Mr. G has developed a trusting relationship with the said “periya doctor” (senior doctor) in the city who also practices in the government hospital. There is a distinct hierarchy of doctors in the society. City doctor > Rural doctor. Specialist doctor > General doctor. Older doctor > Younger doctor. Male doctor > female doctor. (Many times female are not even doctor! They are sister!) Rich appearing doctor (own hospital, wears flashy clothes, drives own car) > humble appearing doctor (works in govt hospital / non-profit hospital, dresses modestly, takes public transport). Cutting doctor (surgeon) > speaking doctor (physician). (Please read the above hierarchy with a generous sarcastic tone. I do not endorse them.) So, when a patient says “periya doctor” (senior doctor) the seniority is based on such hierarchies. People’s assessment of “seniority” of a doctor is quite complex. I can narrate an incident to explain this. 

 

One of our students passed out of medical college and joined post graduation in the tertiary medical college teaching hospital in our area. At that time, he was a young man of 23-24 in the first year of post-graduate training. I am a 48-year-old generalist doctor working in a rural area. I referred my patient to his department for admission in the hospital and treatment for her diabetic foot cellulitis. As I knew him very well, I spoke to him on phone about the referral and wrote a letter to him. The patient went, got admitted, was treated and got better. She came back after a few weeks to visit me. When we were talking, she referred to the young post graduate as “periya doctor” and asked me if I should consult him before doing any changes to her treatment. I understand that the postgraduate is in the process of becoming a specialist and his treatment is a specialist treatment, whereas I am a general physician. But it was funny to imagine the student as “periya doctor”! Why I am saying this is to drive home the message that assessment of ‘periya-ness’ or seniority is quite complex. A young trainee who is a specialist is “periya” compared to an older man who is a generalist!

 

This is just one instance; there have been numerous examples of assessment of ‘periya-ness’ of a doctor based on the other axes of hierarchy that I have explained above. What is most challenging is that this assessment of seniority is the basis for trust for many patients. I have a patient who was started on anti-thyroid medication Carbimazole for high thyroid function of her gland 10 years ago by a city endocrinology specialist. Her thyroid hormone level came to normal within 1 year of starting the carbimazole and remained stable over a 6 month period. So I asked her to stop the carbimazole. But she refused to stop because the ‘periya’ doctor in the city had prescribed it for her. Subsequently she went on to have side effects of the drug and developed low thyroid hormone levels. But still she refused to stop because her ‘periya’ doctor had prescribed it. She also did not go back to that ‘periya’ doctor and continues to take the tablet till date. Trust is such a beautiful thing to have. But it is also dangerous. When our decisions on whom to trust, when to trust, how to form the trust are random and informed purely by our subjective perceptions, it becomes a problem. 

 

Sometimes it is frustrating to be an ‘eternally junior’ doctor. But on other days all this seems funny! I hope I have more days when I can laugh about this!