Lessons of a Medical Lifetime

Lessons of a Medical Lifetime

Dr C.J. Vas

Lesson 1-Wonders Never Cease

Mr. S., stout 48-year-old Caucasian married man, father of three young children, was in a hospital bed in August 1960, lying depressed and unable to breathe due to a collapsed lung. He was told that his lung cancer was inoperable and that his condition was unlikely to improve with the available radiotherapy which would, therefore, not be used. During the following ward-rounds, he heard a discussion between the two consultants and the house physician (H.P.) revolving around a recent article in a medical journal reporting that four patients had improved after the administration of a new drug—methotrexate, under similar conditions. Serious side-effects were, however, also reported. The medical team decided to give it a try if the patient agreed, even though the results were likely to be disappointing.

Well, the patient thought he had nothing to lose; he might improve albeit for an unknown period and the doctors did promise that they would care for him to the end. On the other hand, the Chief was exceedingly sceptical and would have nothing to do with the experiment. He finally made up his mind with his own personal interest and that of his family uppermost in his mind.

The drug was injected and the treatment protocol followed carefully by the H.P. but nothing new or untoward was observed. On the fourteenth day after treatment, the H.P. was greeted, on entering the ward for his morning round, by cheers and shouts from all the excited patients that Mr. S. was remarkably better, breathing well and that he was able to take a few steps which he had not done for some time. A quick examination confirmed the improvement. After a while, Mr. S. returned to his family and work for over a year and a half.

The H.P. thinking back many a time about the brave Mr. S., kept reminding himself of what he was told as a student: Once a medical student, always a medical student until you are six feet under or up in flames. How true!

Lesson 2-Unbelievable, But True

Mr. P. an amiable 62-year-old man, was unfortunately severely affected by the 'shaking palsy' so well described some 200 years ago by a simple but rather observant English general practitioner, James Parkinson. He stuttered away and had to be fed because his hands and legs shook like mad. He prayed for a cure or at least something that would reduce his persistent disability.

On a routine visit to the hospital, he was shunted, or so he suspected, by the compassionate Consultant Neurologist who had been seeing him for many years to a young Registrar sitting in a room apart. "Well," thought Mr. P., "old Dr. MJP cannot take it any longer and he has passed the buck to a raw hand,” but he would wait and see. Much to his surprise, the young Reg. talked of a new drug which he wished to try on the patients tremor. It was explained that the drug was said to be very good for the control of tremor according to some Italians but this was not certain. And, of course, every new drug appeared at first to be effective until it had been tried for some time and experience gained. Moreover, it did have side-effects. The only way, said the Reg., the precise effectiveness of the drug could be determined was by a 'double blind cross-over' trial where the drug was tested against the effects of simple and innocuous saline. In the experiment, neither the doctor nor the patient would be aware of what was being injected - either the drug or saline. Nevertheless, the rest of the conditions of the experiment would remain identical. The pulse, respiration and blood pressure would be continuously monitored. Finally, after all the patients were studied, the 'key' of allocation of 'treatments' would be broken and then the good and bad effects of the new drug versus saline could be compared.

The patient having volunteered consent, the clinical experiment, which was one of so many undertaken by physicians over the years to advance medical knowledge, was commenced. Consenting Parkinsonian subjects were randomly and alternately given the new drug or saline intravenously, unknown to both the doctor and the patient in a special area where machines recorded the pulse, blood pressure and breathing continuously under the watchful eye of the young Reg, whose emotions could not be observed through the cap, mask and gown that he donned. At the end of the study, the new drug was found to be undoubtedly effective in suppressing human tremor when it was injected intravenously. But-and there are always 'buts' in such work--there were a few individuals whose tremor was not affected by the drug, and our amiable Mr. P. was one of them. Disappointed, he suggested that another experiment with a double dose of the drug be conducted if the drug was safe as advised by the manufacturers. The Reg. agreed to a further ‘random double blind’ study using a double dose of the new drug and saline.

Mr. P was the first experimental subject in this second drug trial. The

Reg., all togged ootg cap, gown and mask went about the task with practised thoroughness but he soon developed jitters. Perspiration dripped down his face. back and legs and his pulse raced. Mr P's blood pressure was seen to fall from 160 mm of mercury to 110 mm after the ‘test injection’ and it continued to fall. The Reg. decided that should the blood pressure fall to 100 mm, he would promptly abandon the study and instead administer medications to boost the pressure. Fortunately, that stage did not come and our poor Reg. breathed a sigh of relief. On the next turn around, Mr. P. did very well and did not develop any untoward complications. The Reg., his friends and his mentor, the good old Dr. MJP, all agreed that there was nothing blind about the trial with Mr. P. in view of his reactions. To their utter astonishment, the "treatment key" later revealed that the drop in blood pressure seen in Mr. P. had occurred after the injection of saline and not the double dose of the new drug.

Such surprises are not uncommon in clinical research and are unbelievable at times. Nevertheless, trial and error are an essential component of a physician's way of life provided of course the patient is taken into confidence, the advantages and dangers made clearly known to the patient and his or her relatives and the voluntary consent of the individual obtained. This is essential for progress in the field of medicine.

Lesson 3— Ethics and Conversion Hysterics

 Physicians and psychiatrists have for long known that the dividing line between 'conversion hysteria and malingering’  is an exceedingly thin one. It is well known for instance that a patient with a 'hysterical paralysis of a limb may also have a loss of sensation. Indeed, it has often been demonstrated that one may pass a needle through the skin without the patient feeling it; and, moreover, without any sign of bleeding on removing the needle! At times even the expert can make and often does make a mistake. What matters is the attitude of the concerned doctor. The following examples will provide some insights into the problem.

A tall and big 45-year-old married woman was brought to a Hospital with a dense left sided paralysis of the arm and leg accompanied by loss of sensation in those limbs which had occurred two days earlier. She was escorted by her husband who was well-mannered, small and moved about quietly. After a detailed examination by a young physician, the patient was told that she needed to be admitted to the Hospital for treatment after investigation which would include blood tests, a lumbar puncture with a needle in the lower back and examination of the fluid that would be collected through the needle and a few other tests. The lady was incensed that her word could not be accepted and that she had to be investigated. She then sat up suddenly and stated that she could not possibly enter the Hospital as she had to stay at home to look after her husband who had a brain tumour excised only three weeks earlier! Later, it transpired that the patient was a well-known hysteric who frequented the department of neurology and psychiatry for treatment sessions.

 A thirty-year-old married lady frequently complained of severe cramping spasmodic pains in the abdomen. Detailed examination and investigation at different times failed to provide a clue to the diagnosis. Various forms of treatment were quite ineffective. After some months, an astute physician after examining her in the throes of pain told her that he would give her an injection of a new imported drug which would certainly relieve her of the pain. He did. The drug was 'distilled water’ and the pain disappeared in less than minute. The  patient jumped up, embraced the doctor and then knelt to kiss his feet in appreciation of the wonderful treatment. The pain never returned and she never did know what she had been given.

A ten-year-old boy was admitted to a Hospital with a short history of paralysis of both legs together with a loss of sensation from the lower chest down to the feet. Examination and investigations failed to find any cause. A young watchful medical intern saw the boy occasionally sitting up and even standing by the bedside at night. The intern encouraged the patient to talk and continue his activities whereupon some psychological disturbances came to light. Later, the intern reported his findings to his Chief during the ward rounds and concluded that the diagnosis was that of conversion hysteria or malingering. The Chief was most upset as he had postulated a diagnosis of tuberculosis or a tumour and had called in the neurosurgeons to help. He then decided that he would teach the young brat a lesson. He called for a red hot metal spatula and applied it to the patient's leg. The boy jumped out of bed with a yell and ran out of the ward!

Conclusions: An ethical doctor needs to be humble enough to admit his mistakes without being spiteful to a patient. There is also a great need to be continually aware of the cultural reality affecting the patient i e. hysterics in India are terrified of procedures involving the application of needles but this is not so abroad.

Lesson 4 Intellectual Honesty in Research

 At a well-known Hospital, a highly-respected 'clinical scientist' presented clinical data about a rare group of metabolic and genetically-determined disorders which could be only identified by the performance of an unusual biochemical test which had not until then been performed in the country.The presentation was excellent and some others tried to use the same test for diagnostic purposes in other undiagnosed subjects. Enquiries about when and where the test was done were referred to the assistant by the ‘clinical scientist': and, the assistant, claimed ignorance and referred the queries back to the ‘clinical scientist'. Persistent and investigative enquiries subsequently revealed that the tests had never been done!

A sad reflection on the medical scientific community!

Lesson 5—The Business of Medical Practice

The practice of medicine was said to be a vocation but many now increasingly believe that it is a pure and simple business with its own marketing strategies, discounts and commissions, consumer and legal problems.

Recently a young physician, with an enviable academic record and a highly rated M.D., decided to enter medical practice in a posh suburb of Bombay. He was advised to visit all the general practitioners in the area and to leave his visiting card. This he did: walking and climbing in well-lit and dilapidated buildings while visiting all sorts of doctors-M.B.B.S., G.F.A.M., homeopaths, ayurveds and R.M.Ps.--about 200 in number.

At the end of his prolonged tours he was exhausted and depressed. Almost without exception, the general practitioners were only interested in one issue: What commission would he give them? On being asked their requirements, the responses would vary between 40 and 60 per cent. Not one of the general practitioners was interested in his academic record, experience, the services that would be provided or the centres and hospitals where he worked. What a sad reflection on the medical profession which is said to be bound by a Code of Ethics of the Medical Council of India which prohibits the payment of commissions or kickbacks. The only silver lining to this exercise in futility was that this young physician now practises medicine without paying a single paisa as commission.

What can one do to bring back ethics into medicine? The medical profession would be well advised to sort itself out soon. Or else, some external agency will impose unpalatable norms.

Lesson 6-Treat, but Above all do no Harm

 A century old maxim still guides the profession as it should. This was exemplified by a neurosurgeon who when faced with a deeply-unconscious patient with a haemorrhage on one side of the brain was honest enough to say to the relatives, who were tardy in agreeing to an operation, that where there was life, there was hope. When they did later agree, the medicalttendants were not at all enthusiastic to intervene. However, surgeon persisted and operated. The patient remained unconscious for two weeks and then made a slow recovery. When seen some nine months later, she walked a little slowly but would talk sensibly with frequent emotional breakdowns.

On another occasion, an old man aged 80 years was brought to the Hospital having been in a stuporose state for a week. On examination, he was found to have huge tumour which occupied more than half the cranial cavity. It was accompanied by a great rise in intracranial pressure. A neurologist and a neurosurgeon could see no way of helping the patient medically or surgically. Indeed, as it was thought likely that the patient would perish if operated, they were happy to let the patient be taken home by the relatives who were against surgery and who had expressed a wish that he die at home. The patient died two days later . This was another example where the doctors and his relatives did not persist officiously to keep him alive.

Lesson 7—Private Hospitals: The Modern Pharisees

 A poor patient was admitted to a 'charitable or free’ bed in a private hospital under the care of a specialist for treatment of a serious illness. He was seen by many experts and all manner of treatments applied but to no avail. He died. His relatives were so impoverished by the expenditure involved that they could not settle the hospital charges. Yet, they had to as the hospital authorities would not release the body for the funeral rites unless all the bills were paid as laid down in the rules of the institution. What could be done? While praying for help and inspiration, the relatives quite by chance met one of the experts, who was unknown to them, but who had once seen the deceased. They asked for advice. The expert informed the hospital administration that he would personally guarantee the payment of the dues by the relatives within three months. And, the body was released! The dues were settled within two months without any prompting.

A creditable role for the medical 'expert' but would the private charitable 'hospital constitute a modern pharisaical institution grounded on sound business practices? Is this what modern medicine is all about?

Author's Note: All the "Lessons” described above are based on actual events but the details of those involved have been deliberately modified to provide anonymity.

Compilation of professional reminiscences of specialists - edited by M.V.Kamath and Dr.Rekha Karmarkar