Self care

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 to support her during the cardiac procedures. She is not comfortable seeking help from her bother and sister’s children as she feels it is inappropriate to ask them. Mrs. AK is a widow living with a 24 year old daughter who is developmentally delayed and she is the sole caregiver. Both these women work as daily wage laborers and bring money home daily to manage food and other essentials. When I started talking about a cardiac procedure, they both broke down and could not even imagine going through something like that. The temporary plan is to intensify medical treatment for them and gradually work out a plan to get them to see a cardiologist in a tertiary care hospital with the support of the community. 

 

I saw a bank employee, Mr. AA yesterday somewhere in between these two women. He is a 48-50 year old man, with diabetes, and hypertension. He was accompanied by his wife and daughter. The main complaint was the man had cough with expectoration for more than a month, and he was bringing up blood in his sputum. In a patient with diabetes, tuberculosis is a definite possibility. The sad part of the story is, the last time I saw him was a year ago, when he had come for the same complaints. We had done a sputum test and chest X ray and detected pulmonary tuberculosis. He started medications for it. He got the treatment in the local primary health centre and never came back to us for follow up. His wife, with a voice full of concern, told me “He completed the TB treatment after you started us on it. Then he started drinking alcohol heavily. Because of alcoholism, he stopped diabetes medicines. Overall he stopped taking care of himself and now it looks like the TB has come back”. He was sitting as though the wife and daughter were talking about someone else, totally uninvolved in the discussion. Twenty years ago, I would have been appalled by such indifference and such self neglect and would have gone ballistic with the man. But such self-neglect and disrespect to the body is so common, partly fueled by ignorance and partly by the indolent nature of chronic diseases and by strong pull by competing priorities like alcoholism. I can handle such behaviour with a sense of clinical detachment now, not sure if that is the best thing. We have initiated the process of testing for pulmonary TB and getting the treatment process moving. Alcoholism is another major problem that needs to be addressed. 

 

As I was returning home from the clinic and the thing that struck me most was the stark contrast between the two women and the bank employee. Gender is such a major determinant of health seeking behaviour. While my concern about the two women was about how to get them to a hospital to see a cardiologist and get them on the right treatment pathway, the concern about the man was how to protect him from alcohol and self-neglect. One of the women is socially isolated, one burdened with care-giving responsibilities of a daughter with disability that they cannot get the medical care that they need. Neither of them have anyone to care for them, accompany them to a hospital or support them during their treatment. The man has a supportive wife and daughter who are worried and concerned about it, but he does not want to take treatment. He abuses and violate them daily. It felt unfair that the support was available in one case, but was not respected, and no support was available in the other cases. If only I could swap the families and contexts of these people! All three scenarios are frustrating in their own way. 

 

I was having a discussion with two erstwhile students and current friends regarding other patients over the weekend. The discussions were heated. One of them, a very intelligent young man with strong ideological positions, pointed out that doctors themselves self-neglect all the time. They are taught to never care for themselves. They are chastised for taking self-care time. I had once told him “self care is over rated” in another context. He quoted me and asked how could self care be over rated, if self neglect is the root cause of most of our frustrations in clinical practice. I was reminded of this conversation yesterday when I was reflecting on the story of Mr. AA. While it was easy for me to get frustrated at how uninvolved he was in his treatment for diabetes, hypertension and tuberculosis, I never considered how I am handling my own frustration in treating Mr. AA and my own sense of helplessness in dealing with Mrs. S and Mrs. AK. I came home took a cool bath, had comfort food and settled down with a book I had been wanting to read for a long time Kadal Pura by Sandiylan.