Teaching is not easy as it seems

    
      Doctor- Itself means 'to teach'. Now a days I am beginning to understand what it takes to be a good teacher. It requires so many qualities which has to be acquired and earned. Some people have these skills inherent in them. Unlike the school teaching and college teaching, this is a profession where one train the junior to become like him. The junior is going to enjoy the same level of respect and expected to give the same services as given by the teacher. In a fact it can give a competition too.

      There are things which we do due to fear of authority and some other things which we do due to the passion for it. The most important influencing factor for the teacher to teach, is the passion of the student for the subject. In medical profession the student has to take an extra effort to get useful information out of his teacher. Nothing comes for free. The student who take everything for granted is an irritating character for the teacher.

        Another important factor is that the seniors always want their juniors to earn the knowledge. They want them to go through the same striving they went and learn things the hard way. Because early imparting of wisdom does not feel natural and right. But todays generation has got more easier ways of access to knowledge via media and internet. Even then the passion is required.
  
     Although I feel that if someone has worked under me for a considerable time, and he does not know what he is supposed to know, that is my failure. At some point, someone has to strike a balance. A least responsible student with least passion for the subject and patient care can be a headache to the medical teacher. No one can blame him if he do not acquire what he needed to by the end of the course.

     After all, the best compliment one can get in a profession, is when some one good in his field tells that he has been trained by you. So the bottom line is teaching is a good rewarding profession.
 

Surgeon's OCD

    St Luke is considered as the patron of physicians and surgeons by catholic church. But some behaviour peculiar to surgeons make me think we are followers of Apostle Thomas. We don't believe unless we feel it ourselves. This is a job induced obsession.

    Every time when someone comes with a deep wound, the surgeon is restless until he could put the finger inside, rotate and feel the depth and floor of it. It is a part of medical examination, and it has to be done. But even if one doctor in a group feel it and explain, others wont be satisfied until they have their own personal experience.

    There was one patient who came with a 'T tube'. It was time to be removed. Normally it would come out easily on a gentle tug. So the junior most resident tried, it didn't come out, then the next senior guy tried, then my colleague tried, but it didn't come out. Then a weight was attached to it and the patient was asked to move around. Even after the description how tight it was, I could feel my inner urge to try myself. I couldn't resist it. I also gave a try only to find that it was abnormally tight as they described.

     But a many a times, this obsession can save the patient from catastrophes. Counter checking the clinical findings by a senior resident, going through the lab results from original reports and confirming the biopsy results have saved lives and decreased unwanted morbidity.

     

Problem solving is the answer for problem solving

         Two and a quarter year has passed since I joined for post graduate training in general surgery. Although I know the limitations of my knowledge, I notice some development in my problem solving skills. An acquired way of thinking and analysing the data so as to reach a decision or a plan of action. I realised this when, one of my freshly joined junior asked me about a surgical consultation call he got from another department. I asked him whether he assessed the patient. He gave me a look "what am I going to do...I don't know what to do.." I too used to give the same reply till recently. But this made me think what is that thing that caused the change in the attitude.

              It is the basics of science. The algorithm of working out problems. The first step is to talk with the patient and identify the complaint. Most of the time, the complaint conveyed by the nursing staff will be different. Then quantify the complaint. Check for the vitals , objective measurements of well being. Then segregate the abnormal values. This will give us the clue or lead point to the underlying problem. Many a time, it can be found after quantification that the problem is trivial or the surgical solution for that problem might be more weary than the problem itself.
         
               Knowledge about the disease, the treatment the patient is on and the possible complications can give light to what the patient is complaining of. Consulting with the senior person about the problem which not clearly understood helps in creating management strategy for future. That's how the experience matters in medical field. Because every person is different, and no text book can give you ultimate answer for any question. The bottom line is, the more one try to involve in solving patient problems, the more chance that the problem could be solved. So do not try to avoid complaints, but take challenges, enjoy the doctor job.
 

Medical translation: the art of medical communication

                        Although the term hemothorax and rib resection seems nothing unusual to me, a normal person who has left his connection with the subject of biology after schooldays might not understand it even after hours of explanation. That is just with medical terms, but that is the least difficult part. To understand how the operative procedure going to affect the daily routine of the patient is much more complicated. Even three years of residency is little time for the surgeon to assimilate it. But as a surgeon I cannot give the Maingot's book of surgery to the patient and ask them to read and understand about the surgery themselves. There should be an effective way of translating medical definitions and procedures to layman's language.

                     Here I would like to share some of the examples, my professor elaborates to explain things to patients and even the non surgical medical personnel. At this point I have to mention that a surgeon is very different from a physician. A doctor who has never seen or done any surgery after medical school training cannot understand or explain how real life situations are different from text book descriptions.

                   Crossing the road situation 

               A surgery with a described low risk is like crossing a road on a fine sunny day. What are the chances of getting hit by a vehicle or slipping down?

            
 Now for a surgery with a described high risk, it is like crossing the road during a stormy rainy night. The chances of getting injured is high.

             




 



 Ascending the stairs situation

                See...,  undergoing a surgery is like ascending the stairs till the third floor. I will have to do it, the patient have to do it, the attendant has to do it, the child has to do it, the eighty year old grandpa has to do it. You know, the child will run and climb, the grandpa might get breathless by the first floor. This is a simple example to show how the age can be a factor for surgical outcome.

             




    Making Rotti and curry situation

              If the attendant is a person who cooks, this is a helpful example to relate how much athey can rely on experience of surgeon.  " You must have made atleast ten thousand rottis (bread) or around five thousand dishes in life till now. But can you guarantee that the taste of the dish you are going to make will exactly be same as the taste of previous one? "
            That's the same with surgery, the surgeon might have successfully done the same surgical procedure five hundred times.But, the outcome of next surgery cannot be predicted as same as the  previous one.
 

Patient attendant: The real superhero

            I have been writing about the stress which patients and doctors go through. But there is a group of people who are seldom addressed. The patient attendant. Usually it will be the patient’s spouse or first degree relative. It is not uncommon to see a friend or neighbour accompanying a patient.

            To accompany someone sick to a hospital is actually a bad dream. One has to take out all the energy, keep all senses sharp, be quick to respond and keep patience at its height if he wish to get his patient out of the hospital quickly. Treating staff take it for granted that the patient attendant is a healthy person who is responsible for the welfare of the patient. Orders, instructions and directions are thrown at the attendant without mercy. The normal person will take a little time to get accustomed to that treatment.  

            Trouble starts from the registration counter. He or she has to fight for a place in the queue and wait for long hours to get a card. The fight continues for a waiting spot in front of the OP room. Again this person has to come with the patient and without the patient so many times before the patient gets admitted. In between he/she has to work his/her way out to find out where which sample goes, where which x-rays are done and where payments are made. He/ She has to make arrangements for the money, find and bring persons to donate blood and spend sleepless night with the patient.

            In the general ward only one attendant is allowed with the patient, who has to be there all the time. But no bed is provided for them. They are supposed to live on the chair that is provided. Majority of them are also working persons. So the more time they spend here, the more fiscal constraints they are going to face. The mental stress of a person who accompanies a sick patient is unimaginable. Although I don’t have to treat children now, during my house surgeoncy, I have seen depressed faces of people who has to look after sick children. Apart from the emotional attachment, it is about the physical work and stress they have to go through. Many a times, I also feel empty in my armamentarium with some patient symptoms.

            It is not only about money and physical stress, even the relatives of private ward patients who have people under them to take care of physical needs also has to undergo the mental stress. But they are better treated than the common man. The corporates know about this fact and some of them provide a hospital staff called ‘facilitator’ who takes them through these maze of hospital procedures.

But a naïve person can transform to a very good attendant in short time. As a treating physician, I can now identify a trained attendant easily. They ask sharp questions, wait and request for advice or service rather than get offended by the first response. They can easily pick up the lag, a phenomenon seen in any service institution. Unless there is a need from somebody’s side, things get postponed. For example a histopathology report which can be issued in five days might get seven days. By the patient comes with report a holiday will come, then the further test will take some more days. Like that the treatment goes extended. But an experienced attendant plans the things in advance and get the staff done things by persuasion.

            So I like to address them as superheroes, because they are the persons who act extra-ordinarily to bridge the gap between the treating facility and the patient while sacrificing their personal interests.

The never ending sleep

 

I don’t know what to put as a title for what I am going to write. Today morning I was greeted with the death news of one of our patients who was admitted in the ICU. He was a young guy who just touched twenty. An undergraduate student. He was having a normal life till one and a half year back, when he started having bowel symptoms predominantly constipation. Sad to say, none could treat his illness nor find what it is. He died without a diagnosis. He had underwent multiple laboratory and painful tests in this period and finally he ended up in our casualty with complete bowel obstruction.

***scene 1 ***

While trying hard to approximate and close the laparostomy wound on his soulless body, I glanced at his face. He was looking peaceful. It made me recount my first encounter with him while he was alive. He was in agony, he wanted to get rid of the giant nasogastric tube stuffed in his nose. His abdomen was hugely distended and I could see his bowel creating ripples on it.

***scene 2***

“Why can’t you help me to clean this bowl? Whom do you think you are…?” my senior colleague was shouting at the nursing staff, he was at the brim of a breakdown, taking part in surgery after continuous 48 hrs strenuous duty. The male nurse refused to help him with the big bowl which was overflowing with stool removed from our patient. His large intestine was the size of a trumpet and completely filled with semisolid and solid stools which had to be removed. The staff wanted the orderly to come to clean up the mess.

After taking part in his first surgery, I was happy that I chose to become a surgeon. We has made a diverting stoma which we believed to help him out of obstruction and agony. I was proud that we could give him the relief from symptoms, which he could not get from any physician. I was confident in explaining what had we done to him and how it is going to help him after the surgery to his sister. His sister was a well-educated girl. She cared so much for him.

***scene 3***

My colleague who was in charge of his bed for most of the time, told me, that his sister was grabbing his hand and not letting him go after her brother’s death. She was accusing us for doing those procedures, which ultimately relieved him from this world. His father was crying, he was recounting how dearly he looked after his son. The second surgery was done when his abdominal drain started showing pus, which was not expected. On second exploration, we found he had developed perforation of bowel at another site. But his body system had already been crashed that, he never made it to the normal physiological mode after second surgery.

There are things which are hard to explain. Like the loss to that family. The way his dreams were crushed. His eyes were vivid, it said he wanted to live. He wanted to enjoy life. He never have thought that it was his last journey from home, when he left to the hospital that morning. His sister had hope. She believed we could save her brother. But what happened was not expected. But somewhere in my mind I can recollect his face, after the first surgery, telling me he is feeling better.

The surgeon

         My friend and colleague who was actually fond of medicine, but now in the profession of cutting, always tell me that surgeon is an extended physician. A step forward which makes them eligible to cut open and repair the living body. Two years has passed since I joined for surgical training. As I stand at this point, celebrating the new year, somewhere I felt a little pride to be a surgeon.
      
        Surgeon is bestowed upon the permission to operate on human beings and relieve them of their suffering. Well it is not right to say that surgeon treats the disease or eliminates it. What he do facilitates the natural process of healing to take place. Basic principle of surgery whether it be small or big is, removing the dead or diseased part and realign the rest, so that they can stick together by nature's way. Even though man has been able to go to moon and come back alive,  he has not been able to understand the life force. There is no wonder, the people thought life is a power or spirit which is invisible. Even now, when I watch a patient die, I feel that some force or invisible spirit gets evaporated. Like the flickering of a dying flame.

     Surgery is an art when it comes to operating. It includes well planning, judicious selection of patients, procedure and instruments. Like a well trained and talented orchestra, it flows out like a symphony in the operation room. But what makes a surgeon is the follow up. The experience and analysis of the operated patients adds invisible power to the surgeons clinical skill.

     Surgery is medicine when treating patients. The surgeon has the access to all the medicines to keep his patients free of symptoms. But some times patient does not get symptom relief just by medicine and the radiological eye gets blurred that they cannot find a cause to reason the symptom. Then comes the call for surgeon, to open and see what is happening inside. Some times surgery is the answer.