Heal thyself!

Undoctored: The Story of a Medic Who Ran Out of Patients 
Author: Adam Kay

There used to be a time when only the crêmê à la crêmê would be handpicked from public examination scorers to study medicine in state-sponsored medical schools. The competition to be admitted as a medical student was so keen. Entrance would mean assured employment by the State, together with the prestige, perks and elevation of social status to the family that came with it. That is what everyone thought, anyway.

A career in Obstetrics used to be considered quite noble. Doing the work of a stork, being there, and bringing joy via new birth was considered honourable. The team did not mind the long hours and gruelling work conditions, as they were muffled by the lustful cry of a newborn and wiped clean by the tears of joy of a parturient mother. 

Again, it is fulfilling no more.

What was a noble and fulfilling profession became a pressure cooker. A patient walks into a consultation room, wanting hassle-free relief from his pre-existing ailment. He wants 100% relief, not accepting that morbidity and mortality are realities of life. At the same time, he is wary that he may be taken for a ride, given a suboptimal treatment, and, if money is involved, be fleeced of his hard-earned money. 

The medical practitioner, on the other hand, considers the patient a potential legal liability. He must ensure all the ‘t’s are crossed, and the ‘i’s are dotted. He must run a battery of tests to ensure nothing is missed or left that lawyers will later accuse of medical negligence. 

In this background, Dr Adam Kay, a doctor in the ward, found the hard way that the system is toxic. It does not bother the practitioners or the attendants. They are left to deal with their own problems, grief and shortcomings. Dr Kay’s partner had a miscarriage, which he had to deal with himself. The system asked him to put his emotional baggage aside and work. 

He left his overalls and stethoscope for a career in standup comedy and scriptwriting. He soon discovered his true sexuality. In a genuinely comical way, laced with lots of sarcasm, he describes all the going on in his life, good and bad, all in one bag of laughs. Sometimes, he goes philosophical about human life and why we are here. A good read. 

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Burning, burning...

©FG

You tell yourself the citizens of the country sponsored your medical studies. With a fragment of the cost of what you really need to pay, for peanuts, you got a degree. Of course, it was no easy walk in the park on your part, either. All that midnight vigil, the missed outings with buddies and the humiliations at work by seniors later on in life were your sacrifices. You were convinced that your job description would read as crucial as a bomb disposal unit. Your vocation would turn the direction of the country, it seemed. Not to forget the stresses and guilty feelings that haunted you as your patients died in your tour of duty. You can but not complain about your predicament as it was entirely your decision to plunge head in. Some reverence comes with the job, nevertheless.

Those, however, were too few and far between. The same hands that express gratitude to you would be the same ones that point accusatory charges against you. You thought they were placing you on a dais like they do to their Gods, right? When they deified you, they meant you are supposed to be infallible, and when things go south through no fault of yours, they cannot blame God, so they blame you.

If you feel it is unfair to bear the brunt of such responsibility on your tiny shoulders, by all means, move on. They are others who would gladly take over until they, too, burned out.

You are expected to do what you say and say what you do. You are just a spoke in the wheel of life. Others can use you and abuse you. But you cannot. They can be dishonest or lie through their teeth to your face. They can connive to get a big profit out of you. They can make fraudulent claims. No, siree, you cannot do any of that. You are supposed to be the paradigm of virtue. It does not matter if businessmen abuse your good office to enrich themselves. After all, they have their eyes on the money, and you have yours on the soul. So you like to believe...

(P.S. The whole equation gets distorted when the medical studies are self-financed. It is no more of paying back to society but back to the coffers. Sometimes it is an investment. Altruism rarely is in the picture.)

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The lost invisible touch!

Sir Robert Hutchison
Father of clinical methods

A friend, during our stint as house officers, told me about an incident that happened during his medical student days when he was studying in Manipal, India. An American elective medical student had joined the group's ward rounds. The old Professor of Medicine was showing them the correct technique of examining the respiratory system. He laboriously punctuated the teaching rounds by asking basic science questions and snarling occasional sarcastic remarks, for not understanding the basics. He was showing the green medical students the art of inspection, palpation, percussion and auscultation.

The American student, failing to see the point of such a laborious examination of a single patient, raised his hand.

"Professor, wouldn't it be better if we just send the patient for a chest X-ray?" he quipped.

That is the state of medicine now. We have lost the art of practising medicine. It is just about diagnostic procedures and laboratory results. Clinicians no longer use clinical methods to diagnose. If it used to be that laboratory and auxiliary tests were used to confirm or disprove our differential diagnoses, now it is the primary modality of the approach of a patient. 

Pretty early in my training, I did an attachment in a Gynaecological Oncology unit. Its head, an old-timer Professor, once was in a dilemma. As part of the staging of cancer in his patients, he would perform a CT scan. This, he would do after carefully performing a complete clinical examination. The outcome of the scan would enable him to decide on the operability of cases. There was this particular cases where he was in limbo. He was unsure of the stage of cancer. After much discussion, argument and reevaluation, he was convinced that that individual patient had an early operable cancer even though scans were reported as otherwise. After much deliberation, he went ahead and assessed the patient under anaesthesia on the operation theatre. It turned out that the old Professor was correct after all. He proceeded with the surgery, and final histopathological specimen confirmed his clinical findings too.

That was how it used to be. Clinical acumen took precedence over laboratory and auxiliary investigations. Now, lab tests take precedence even over a good history taking. The recent Covid-19 pandemic is evidence of the above. Do the swab test first, then the clinician (or perhaps the technician) would decide the next course of action; whether to operate, treat conservatively or even see the patient. Just quarantine and see the outcome later - If he pulls through what was perceived as a death warrant. 

A recent case that came to my attention recently during my work made me realised that perhaps we are too dependant on lab results. Maybe it is fueled by patient expectations of wanting an instant resolution (diagnoses) and fear of litigation. The need for an instantaneous gratification in all human dealings has permeated all social activities. We do not want our results now, but yesterday.

A 30-year-old lady presented with a two weeks delay of her periods. A urinary pregnancy test showed positive findings (i.e. pregnant). The couple presented at their doctor for a pelvic ultrasound scanning. The examination did not reveal much. As she was asymptomatic, she was told to show up in two weeks for reassessment but to return earlier if she felt unwell.

Just three days later, she returned with slight discomfort over her lower belly. HCG levels revealed 2000 IU/L. This time, a vague mass was seen just right of the uterus. A diagnosis of possible ectopic pregnancy was made and referred to a tertiary centre.

Based on the above findings, at the tertiary centre, Methotrexate was administered intramuscularly to medically treat the ectopic pregnancy. 

Follow-up HCG five days later was 5000 IU/L; adnexal mass still present, uterus empty. After the first episode of pelvic discomfort, she had been symptom-free except for the anxiety caused by the turns of events. 

Another three days later, HCG was 3000; still, uterus was empty, and the adnexal swelling persisted. The patient was well otherwise. 

© George Condous

Seven apprehensive days later, i.e. three weeks after her first consultation, much to the puzzlement of everyone, a small shadow was seen in the uterine cavity of what appeared like a gestational sac with a yolk sac in-situ. A diagnosis of heterotopic pregnancy (concomitant intrauterine and extrauterine pregnancy) was considered, and laparoscopic evaluation was considered.

Being confused with the whole turn of events, the patient decided to opt for 'wait and see' policy. A day after that, she passed out blood clots. She was diagnosed as had a complete miscarriage and was monitored periodically. 

So what happened here? Did the clinicians place too much trust on biochemical results over clinical findings? Perhaps not. When the HCG levels are significant, with the presence of extrauterine shadows and an empty uterus in imaging, it would be negligent to just sit on it. Did the methotrexate cause miscarriage? Possibly not. A high HCG with an absence of visible pregnancy is itself a hallmark of abnormal pregnancy, including impending miscarriage.

In anything that the Covid-19 had taught us, it would be that everybody can be an expert. Armed with statistics and articles to support the assertions, anyone can insist on having found the elusive cure for the ailment. Clinicians, who by nature, like to err on the side of caution, had been accused of selling out the whole human race for self-interests. It seems PhD doctors got the panacea for all woes. Their data analyses and textbookish method of approaching disease make them excellent armchair critiques of what is wrong with the medical services in any country. We all know what happens in the field is not what is shown in laboratory experimentations. But still, it is a free world. Anyone can say what they want. The more one delves into a subject, the less he is cocksure about anything.

Perhaps the demand for wellbeing makes medical services a lucrative business. If before, in the Jurassic era, the doctors would call the shots in the management of patients and the running of medical facilities. The ever increasing expense and the need for state of the art medical equipment make healthcare revolve around breaking even and paying the stockholders rather than being patient-centred. Law of Attraction dictates that the smell of money draws characters of reputable character. Hence, vultures and hyenas of various ferocity started flocking around. Referring to the clinical practice guidelines as their holy grail, these creatures of the dark forces scream medical negligence or even manslaughter whenever an adverse outcome ensues. In hindsight, everyone has 20/20 vision. They think that treating patients is like cooking chicken vindaloo referring to a cookbook.

Like the 1927 movie Metropolis, everyone is just a cogwheel in the big machinery of modernisation. We are mere technicians doing our designated duties for the greater good of mankind as decided by the powers that be - the businessman. The future is not bright, either. After breaking down and digitising our individual tasks, our jobs may be assigned to artificial intelligence (AI). We will be redundant and irrelevant.

This work is licensed under a Creative Commons Attribution 4.0 International License.