There's more?!?

The intern in me is almost two months old right now. I’ve seen what seems like a buzzillion patients & it’s taken all that I thought I'd learnt from my practical exams pretty well into a shallow grave. Let me elaborate…

The first rule in a clinical exam is ‘Be thorough… or the examiner will be thorough with you!’. We got about 45 minutes with each patient& we spent every agonizing second asking, “What else?” This generally meant that our histories were long and arduous & there was always something jotted down on our sheets using which you can present the case differently to the examiner. That doesn’t mean we twisted the facts, just that we were thinking creatively.

Anyways, so I’m 2 months old now & one of the first things I’ve learnt not to ask is: “What else?” This statement is usually followed by an endless rant of nonspecific complaints that makes me wish I was studying abroad, because then I could add some anti-psychotics, anti-anxiety meds in their prescriptions & they’d take them without batting an eyelid! I’m not saying that there isn’t anything wrong with the patients, but some act like little sissy babies at times. “Doctor, I’ve had throat pain since last night”, “Sir, I have fever since this morning”; sounds familiar?

A large number are chronic malingering (Yes, I spelled that right, google it!) cases & yes, they need some psychiatric help. But, given that Indians regard most psychiatrists as “पागलों का डॉक्टर”, I’d doubt they’d follow through even if I could find them some help! Over the course of the past few weeks, I’ve realized some are even hoarding up medicines, selling unopened bottles out in the wild. Patients ‘classically’ come with ‘classical’ complaints & if they don’t see a pill they recognize, they brew up a storm!

The system is flawed because quite a few cases that legitimately require extra help are surrounded by a superfluous cloud of “symptoms”. One may argue that I’m being impolite or callous & am miserly with my skills. But, I have the perfect example to illustrate just how many patients don’t require much help:

Last week, I was handling a Gynac OPD with a dental intern. The front desk didn't what "Gynac" meant turned my cabin into a general female OPD. We started receiving a steady flow of patients with similar musculoskeletal complaints. Was around 4pm when the dental intern asked why my prescriptions were becoming so predictable. I just smiled as I was just about to start writing the prescription of a new patient complaining of abdominal discomfort. I’d already finished with all my relevant history when the following conversation took place.

Me: So, any other complaints that you may have?

Patient: No, none at all

Me: You’re 45 years old, no joint pains?

Patient: Yes, now that you mentioned it, I have knee pain

Me: Do you get an electric current like pain in your thigh or buttocks?

Patient: Yes, how’d you know?

Me: Any problem in moving your shoulder?

Patient: Yes, it hurts when I move it. Can you please give me something for that too?

Me (to dental intern): Can you please jot down the same prescription as my last one? I need to take a break.

Dramatic exit

I, Gynaecologist

I was taking a personal day about 10 days back when my phone flashed a call from some random landline. Before I proceed, I must stress that interns are petrified to take calls from unknown numbers lest they be called in for some work. I had managed to get that personal day after a lot of hassles & was truly worried that I’d been found out. But, the optimist that I am, “what’s the worst that could happen?” rang through my head. I picked up the call & it turned out to be from my Dean’s office (D'oh!). Here’s how the conversation went:

Dean’s Secretary (DS): Hello, Doctor, I’m calling from the dean’s office (Gulp). I just wanted to confirm your participation in the camp this weekend.

Me: What camp? I’m in my rural posting today. I haven’t been informed of any camp

DS: Well, I have your name right here with one of your co-interns. There’s a camp this weekend that you’ve been selected to go to. I don’t understand why you haven’t been informed yet, but I need a confirmation from your side

Me: You can’t be serious! This is the first I’m hearing of this. I’ll call back after I call my department.

Fast forward a few seconds:

PSM Dept: Yes, you’ve been selected for the camp. I’m surprised you haven’t been told yet (Duh-huh!!). Anyways, you’ve leaving this Saturday

So much for my optimism

“I hereby do solemnly swear to uphold the Intern’s code which clearly states that I MUST NOT pick up calls from unknown numbers. May Hippocrates bless my broken soul. Amen”

To cut a long story short, we left that weekend for a camp near Junnar, a part of Pune district. The camp was being organized by an NGO & as such had requested residents from almost every specialty (or so I thought. More on that later) from three different hospitals. My friend and I were the only two interns from medicine. The dental college has sent over their own interns but also a lecturer for additional expertise.

If there’s something I absolutely love about trips is the travelling. The winding ghats have a way of playing Russian Roulette with our inner ears but it usually spares me just enough to enjoy the journey. There’s this amazing thing that one sees when moonlight and high-beams light up the countryside. Ever noticed the thin line of demarcation where your headlights stop lighting up things besides the vehicle? The trees, shrubs just disappear into the darkness as you make your way through. It’s a brilliant way to relax, introspect, get your thoughts in order. I just wish my camera could've captured things the way I saw them. 

We left the next morning for the site of our first camp. Was disappointed on our way; the landscape seems so uninspired during the day. The one positive was that we got along royally with residents from other colleges. We joked that while PSM from other colleges had sent senior residents, our dept apparently trusted us interns far more than we earlier assumed. We went so far as to spread word that we were in our post-grad. I don’t need to tell you no one bought that crap!

The setting of the camp was straight out of a movie from the ‘70s. Dilapidated school, classes without fans, decorated walls, outdoor restrooms, a lot of greenery, but strangely hardly anyone around. The doctor-patient ratio for the 1^st hour seemed to stagnate around 25:1, a number that perhaps the camp wouldn’t be too proud of. Some wise character had apparently spread word that the camp was going to start at noon!! Large cards prominently displaying OPD names were being nailed to each classroom door when the camp incharge shouted, “Doctor, you’re in charge of Gynac today”. Now, I’m not one to shy away from situations like these; still wearing a confident look, spring in my step I made my way over to “MY” OPD. Right then I heard the same woman shout out that I’d be running the OPD with a dental intern. I heard a large thud that I swear I assumed was my jaw hitting the ground! “Wacky stories to tell back home”, I thought; things couldn’t get any funnier than this.

While I think I’ve polished my Marathi tremendously over the course of MBBS, my peers seems to think I’m delusional about it. Not unexpectedly, not a single patient I saw that day was able to converse in Hindi. I’d had a lot of practice the month earlier in my rural posting so I decided to power through this as well. Thankfully the dental co-intern empathized with me & helped me out a lot. But, at the end, even she couldn’t figure out what some of the patients had to share. Some of the phrases I’ve heard loosely translated from Marathi were: 

Water doesn’t flow on my body; 

My gas stones are causing problems; 

My body is slipping out from my body. 

I’d dare anyone to figure out their hidden meaning in the comments section. I D-A-R-E you !

Knowing I’d be lost among a sea of specialists in the other OPDs, I chose to volunteer to run OBGY the next day as well. Not a smart move on my part, since the front desk was forwarding all females with any complaint over to Gynac. Most cases seemed to be the ubiquitous low backpain, tingling numbness, giddiness, & lest I forget, the “generalized weakness” pandemic. Its times like these that really make me wonder where the thrill of practicing medicine has disappeared. But ever so often there came a woman in genuine need of someone’s help, where I could really “counsel” a patient. I could do little for most given the limited repertoire of drugs at my disposal but it was a learning experience just figuring what went wrong and why. Overall, I saw over 150 patients over two days, referred a few for further evaluation & made a “bus-load” of friends. Quite a productive weekend, but it hurt to know that I’d rejoin the regular rotation in PSM at 9am the next day especially since I reached back home at 3am! The life of an intern...

Story Of The Village Witch-Doctor (Part II)

I feel drunk but I haven’t been drinking

My first few hours at the HIV Center centred on a lot of clerical work. Patients came & went, I asked about any new complaints they had, had a good look at follow up cases of those with infections & made the necessary entries in their files. A few patients moved on this way. Then came this particular chap whose medication was changed the previous month as the government had no stock of his regular meds. He complained of tingling numbness down his legs, inability to hold his fingers steady, a constant headache & then, “the feeling of being drunk” all the time. Now, I’ve seen a lot of alcoholics & malingering patients over time, but this guy wasn’t either one of them. My senior intern quickly remarked, “So I should continue the meds, right? Who doesn’t want the feeling of being drunk without drinking?”. The patient didn’t see the lighter side of the comment. The fault lay with this drug Efavirenz. I saw hoards of similar patients with the same nervous system complaints. The in-charge went so far as to claim it was a bad decision to let this drug stay in the HIV program, but we don’t really have a large pool of meds to choose from. Every year, HIV meds are stupidly distributed to those who do not need it. Patients have even faked their CD4 counts to be eligible for free high dose meds from the government, not realizing they’re doing themselves more harm than good. The virus continues to spread, to evolve, albeit at a pace medicine has failed to match. So here I was distributing Efavirenz to patients who didn’t actually need the drug; started on it just because the government failed to stock the regular supplies effectively. Years later when their regular meds fail, these patients may not even respond to Efavirenz because the short-term treatment in the past has made their infection resistant to the same. What do I know? I’m just an intern filling up files.

Why me?

It was my third day at the center when a 40 something local man came into our room. He had been newly diagnosed with HIV while his wife tested positive. Now, his wife may be in the window period of infection where tests are false negative. But, to be sure that she doesn’t contract the infection from her husband in the event she’s actually negative, we had to explain that they needed to avoid sex or at least use condoms for a few months. I thought the conversation would be fairly straight forward until he asked, “Why me? I’m a knowledgeable man. I knew everything about HIV and how it spreads. I’ve never visited sex workers. Why me?”. It would be very easy to assume he lied about the sex workers or has been doing drugs, but no man would be as traumatised if he knew why he had this disease. His history suggested he’d taken multiple injections in the past few years. But he’d never seen the new syringe being removed from its packing, nor the destruction of the needle after. He fell prey to some idiot’s satanic scheme of reusing syringes and needles. The sad part was that this isn’t a new phenomenon. One may assume that such things are restricted only to remote villages like this one, but that couldn’t be farther away from the truth. Just a few years back, we heard of a doctor from Nair hospital finding a repackaged syringe in a store around Mumbai Central. Public care under government undertakings are soft targets so we fight back with “trick” syringes. Once these collapsible syringes are used (drug/vaccine drawn in & pushed out), any further effort to use again results in the piston breaking up. Ingenious!

There’s something very tricky about a public-private partnership in medicine. Often, the institute is held ransom to the guidelines issued by government authorities often randomly or based on utter bullshit (case in point above). Meds don’t reach on time, there’re patient targets to be met, patients don’t follow up, tests aren’t made available on schedule. One thing I learnt is how far a person is likely to go to conceal their HIV status. Every medical center has a “Catchment Area” of a few kilometres radius from where they usually get patients. But, in the case of HIV, patients would travel from remote regions and come to our center to avoid the risk of being spotted by someone lest they visit a center around their residence. So, while our catchment area for the cold and flu are quite small, that for HIV far exceeds it. But I was glad they came to such a center, where they placed patient “care” above all else

Story Of The Village Witch-Doctor (Part I)

So I’m barely 20 days old in my new ‘Dr.’ avatar & the time had come to smuggle me away to a land far far away from Bombay; a curious little village called Ganeshpuri where I would be employed in a Medical Center specializing in HIV care. Although this center was a collaboration between an NGO and my parent hospital, the latter did not run it. Its importance lies in the fact that these guys meant business, so no funny business! (I apologize for the silly jokes, more to follow. Sorry again) 

               

Even before I left for the rotation, there was controversy. Interns decided to go on strike demanding a hike in our stipend (Info here). Although I whole heartedly supported the cause, I was dreading the fact that I may have to go to this place again next year to compensate for the holiday I took on the day of the strike. After a lot of cajoling & emotional blackmail by friends, I decided to brave the dreaded “Repeat” as we call it. Collective spirit turned to agony that afternoon when I realized that a few dim-witted doctors (has a nice ring to it) had attended their postings that day. I was mad partially because they didn’t join in for the strike, partially cause I was damn jealous they got their attendance. But, I digress.

               

Ganeshpuri is a little town, on the outskirts of Bombay. I woke up at 4.30am that morning, caught the drowsiest (hopefully not inebriated) cabbie around for a ride to Dadar station. In my shameful stupor, I had miscalculated the time, reaching an entire 30 minutes before the train; I lugged my baggage over to the platform right to the other side of the station (regular passengers will know where Virar Fasts arrive). Picked up a thick TOI & I was set for the next 75 minutes. 

Met my fellow intern at Virar, made a few calls to figure out where I would find the all-important shuttle to my center. I’ve never been to Virar earlier, & felt absolutely timid seeing the sheer number of people trying to get into southbound trains. I was extremely anxious not to miss the medical shuttle to Ganeshpuri; failure would mean an additional hour spent hunting down & then travelling in local ST buses, being marked late, getting shouted at & not being assigned any work for the day. Twenty minutes, a long walk, short run & a lot of panting later, I was snugly seated in the shuttle.

“Yes, intern, you need to go to the HIV Center. Get your luggage & move on”. Before I say anything else,I must state: I had a lot of luggage! Surprisingly I found a familiar face in a college senior who was also posted there. He led me first to the living quarters where the most inviting plate of noodles awaited.

Off to the HIV center then... Part II coming soon.