Drained and defensive: the poignant crusade of a fatigued healer

 

 

I finished reading the book “The Liver Doctor” by Dr. Cyriac Abby Philip. The book title says it is a collection of stories of Love, Loss and Regeneration. The title is an interesting pun, because the liver is the only organ in the body which is capable of regeneration. If a large part of the liver is damaged and only a small part remains, it can actually grow back and regenerate fully. In fact when people’s liver gets damaged, they undergo liver transplantation. Someone else donates a small part of their liver. This donated liver is only a small bit, but then in the recipient’s body it regenerates and forms a full big liver. 

 

To give you a little background, Dr. Cyriac Abby Philip is a hepatologist or a liver doctor. He specializes in diseases of the liver. He works in Kochi, Kerala. He is a very famous doctor by practice. Actually, he is more famous as a social media celebrity. He is very active on X (Twitter) in which he posts incisive and sharp posts against Ayurveda and dietary supplements and herbal medicines that are promoted. He says that these are untested and non-evidence based treatments and are harmful to the liver. He has been subject to a lot of criticism for his anti-herbal and anti-Ayurveda comments on X. He has also been part of high profile court cases where big companies like herbal supplement manufacturers and Ayurveda pharmacy companies have sued him for writing against them. This is his first book. I bought the book with a lot of curiosity and anticipation because it promised to have a lot of patient stories. Patient stories are very insightful and they can teach us a lot as practicing doctors. I like reading patient narratives. Not only this, an artists My Lan, based in the UK has illustrated the various patient stories that the author has written. The illustrations are brilliant. They are all pencil sketches, but capture the story vividly. The promise of patient stories and the brilliant sketches made me buy the book. 

 

Right from the first chapter, the book reads very personal. It is clear that Abby Philips is giving an inside view of his clinic, the various events and episodes that take place in it, his thought process and his innermost feelings. Abby Philips comes across as a very serious physician with a lot of empathy. When he loses a patient, he breaks down emotionally. He takes refuge in the solitude of his shower where he cries his heart out. He takes the illness and suffering of his patients personally. He shares their pain, their sorrow, their suffering and doubts intimately. He reaches out and touches their lives personally. He forms strong bonds with his patients. He makes friends with his patients’ relatives who stay in touch with him long after the patient has passed on. When his treatment fails, he considers it his personal failure and mentally torments himself in the private confines of his room. He loses sleep over his patients. I could relate to a lot of things Abby Philips does. A superficial read makes him come across as the ideal doctor. But there is something deeply and clearly not alright with his approach to clinical medicine. At several points in the book, I was feeling ashamed of myself as a doctor, and was questioning my own detachment from my patients’ suffering. “This man is literally crying with his patients and breaking down with every failure. I am not doing anything of that sort. Am I a good physician? What am I doing wrong?” I found myself questioning my clinical methods and the relationship I have with my patients. I think there is a difference between clinical empathy and emotional contagion. If I empathise with my patient clinically, I would feel “I understand your pain. I know this is very hard. I am here to help you”. On the other hand, “Your suffering is now my suffering. I am breaking down with your grief” is emotional contagion. The patient’s suffering has become contagious and has affected the doctor. The doctor is absorbing the patient’s trauma and mirroring it without drawing healthy boundaries. I could sense a lot of such unhealthy contagion throughout his narrative. In one of the chapters when Abby Philips describes the death of a patient from alcohol induced liver disease he write, “A woman lost her husband, two young girls lost their father, and I lost a patient who had etches himself into my heart – into a scar I now carry. Three lives shattered, and nothing could ever fill that voice…..That day, as I rode home, hidden from my driver’s gaze, I ate three small laddus in silence at the back of my car. The sweetness that filled my mouth, unable to cloak the heaviness in my chest. I fell asleep, mid-journey, only to be awakened at my doorstep, still lost in thoughts of life, death and the helplessness in between.”  I found this paragraph and so many similar paragraphs throughout this book indicating a serious problem in the way the doctor connects with his patients. I am not judging him or calling him wrong. But I am not sure if doctors are supposed to feel this way to be effective. Compassion and empathy do cause pain and suffering to some extent, but this book left me feeling that the practice of medicine is a painful and sad endeavor, which in my experience it is not. 

 

Dr. Abby Philip is strongly opinionated against ancient systems of medicine like Ayurveda, herbal medicine and the profit driven dietary supplement industry. A dominant narrative in this book is stories of harm to the liver caused by Ayurvedic medicines, herbal medicines and dietary supplements. Abby Philips talks about how he systematically and meticulously unravels these heinous crimes with the support of modern evidence based medicine and sophisticated laboratory investigations and valorously saves the lives of the innocent patients who made wrong choices. Most of these narratives are over-dramatized for effect. Fast paced racy thriller series will abruptly end one episode with a cliff-hanger so that audience are pulled back to view the next episode. Abby Phillips does this, he abruptly introduces a chapter break at crucial points, probably for the dramatic effect. But being a practicing clinician who handles numerous patients who take herbal medicines, Ayurveda and Siddha medicines in addition to my own prescriptions, I know that each of the examples he cites in his book are extremely rare. Unexplained and unanticipated dangers and harms of drugs and treatments are not uncommon in modern medicine either. I had a patient, a middle aged woman, whom I started on a sulfonylurea drug, commonly used for diabetes and within a week she developed a dangerous skin allergic reaction referred to as Steven Johnson’s Syndrome that disfigured her very badly. I know SJS happens with sulfa group of drugs from studying pharmacology in medical school, but it is extremely rare that we don’t expect that to happen. Neither did I completely stop using sulfonylureas because of this episode, not do I warn every patient I put on sulfonylureas that they could get a permanently disfiguring skin condition. What I am trying to say is there are so many unknowns and uncertainties in every field of medicine. Any modern medicine practitioner who claims to be under full control of their patient’s bodies and its function is only fooling themselves. It would help for doctors to have an open mind to complementary and alternative systems. Pitching modern medicine as the only ‘scientific method’ and the only ‘rational method’ and everything else as quackery is not well informed and is immature. Unfortunately the entire tone of the book is a crusade against complementary and alternative medicine. 

 

The overall impression I got from reading the book was that the practice of hepatology in a super specialty centre induces deep despair and hopelessness in the doctor. Why should the practice of medicine be so sad? Why should a doctor feel that Death is his constant companion and friend? Why should a doctor view Death as failure? Why should doing an omental biopsy (a highly risky procedure) in a terminally ill woman be important if not for saving her life, at least to know what killed her? Why should a doctor mirror the emotions of a son losing his father, a father losing his little daughter to his own life and panic? 

 

I think Abby Philips’ highly intense empathy bordering on emotional contagion is the reason for his parochial mindset towards complementary medicine. He is demonstrating a trait called tribalism, where he fiercely protects the modern scientific method and opposes complementary and alternative systems. This comes from empathy fatigue, as result of constantly suffering from heart breaks and emotional trauma when his patients are ‘harmed’ by the complementary systems and he saves them with his ‘modern approach’. It has created a tunnel vision that has made him dismiss the positive side of complementary and alternative systems.