I always had a feeling that the branching off of pulmonary medicine from general medicine deprived us of the ‘lungs’ we needed to ‘breathe’. The lungs maketh the body and the body maketh the lungs.
After some contemplation, I decided to pursue senior residency at the Government General & Chest hospital in Hyderabad. I would get to see all things lungs – TB and its shenanigans, autoimmune disorders always spark a unique curiosity and interest in me, bronchoscopies, biopsies and so forth. Or so I thought.
I reported to work on a Monday, met my professor, a short stout man with quite a few accolades to his name. He also famously, pioneered the establishment of department of pulmonary medicine in Gandhi medical college & hospital in 2016. Standing on the shoulders of giants, I thought. I was asked to look after patients in the male TB ward in his unit. I nodded excitedly, signed the required papers and jotted off.
The environment in the hospital area is one of the best in the country. The archaic and British-era buildings were retained, as they were so well built with excellent ventilation, that over the years, very little modifications were required to keep it functioning. The patients also get to enjoy a wide variety of flora around the ward. Calming and comforting from their ‘consumption’.
As much as the hospital premises deserves high praises, the clinical work inside was nowhere near. For starters, every patient had empirical TB. Inspite of looming biases, even if in a TB-endemic country, in the state nodal TB centre, in a TB ward, it is quite unlikely that all patients admitted there had to have TB. The simplest questions I asked myself were – What are we doing for our patients? Are we giving them our best? Is the disease burdening them or are we burdening them with 6 months of antitubercular therapy? What if this is not TB?
I gently prodded some of the PGs with these questions – the responses I received were answers which were static and killed off any meaningful conversation quickly – “these are clinico-radiologic features of TB”, “the patient has a close contact at home”, “they don’t collect their sputum properly”, “in my experience, this is TB” and so on. Being a curious cat, I immediately asked myself – what are these clinico-radiologic features? Surely, there must be a few mimickers we may be overlooking. What is the risk of transmission of TB from a close contact? What can we do to make patients collect their sputum properly? A gentle pitch for a quality improvement programme to improve sputum collection was met with indifference and was quickly brushed off. A quick stat-check at the DOTS centre was alarming – In the month of November 2021, 693 patients were started on antitubercular therapy, of which only a measly 93 were sputum positive. A paltry 13%!
In an ethical dilemma, I asked myself – what is happening ? And why is it happening ?
Are the treating doctors there, inhuman ? No. Are they ethically and morally, corrupt ? No. Are they working hard enough? Yes. So, what else could be culpable?
Like most things in life, problems do not exist in a vacuum and are often greyed out in the background. In fact, one of the most difficult steps in tackling a problem, is to identify the problem – clearly and succinctly. It is the same for practice of medicine too – making a clear diagnosis and instituting therapy on the best available evidence, is an elusive force.
For me, there are several principles which dictate my method of practice, however the 3 most important principles to me are – curiosity, empathy and a sense of duty-mindedness. Applying these 3 to the above scenario, curiosity drove me to ask the right questions, curiosity made me aware of the shortcomings of our system. Curiosity made me human!
Empathy made me understand the burden of the disease on the patient, empathy made me understand the burden of treatment on the patient, empathy made me understand their goals, go deeper into their life stories, their hopes and fears. Empathy made me human!
Duty-mindedness always made me ask myself – are we doing the best we can for our patients? Am I getting a good balance of curiosity and empathy? Duty-mindedness made me human!
Humanities are neither an isolated entity nor do they exist in a vacuum. Just like the internet of things (IoT), there is an internet of behaviours (IoB) too. Humanity, curiosity, empathy, gratitude, fear, anger, frustration, relief and satisfaction are all interconnected. My principles spontaneously inculcated humanities in me. A friendly, hand-on-the-shoulder chat with several PGs there, gave me a profound insight into their lives, into how they practice medicine and what their aspirations were. Almost all of them had their own governing principles, almost all of them had an awareness and insight into what was happening and why it was happening. A common theme emerged – their desire to learn and be curious was not being met largely due to a deference to authority. Months and years of indifference can render the best of us inhuman, indifferent and stoic. On some days, even I find myself detached and indifferent. However, now that I’m a young consultant myself, with a few independent powers in clinical decision making, I get back on my feet quickly. However, for PGs and junior doctors, it may not be the same – out of the box thinking is shunned, curious questioning is castigated, uncanny ideas are discarded. Consequently, young enthusiastic minds may not see the light of the day and retort to a system of learning that does not breed curiosity, but rather indifference.
I firmly believe, humanities are a direct manifestation of a scientific temperament, and our prime focus should be on encouraging a sound scientific temperament and an attitude of healthy skepticism. Only then shall we see a snowballing effect of humanities.
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