DOCTOR IS NOT FOR SALE

Once I had a very rich actress as a patient and she could not maintain her appointments due to her poor time management. So she came up with a grand scheme. She would pay me a salary equivalent to my total income- provided I should be available to consult with her whenever she needed it. Another patient had the similar idea- except she said she was a very poor person and had no one to take care of her husband (who had dementia). So could I please come over and be with him and counsel him at home while she could finish her shopping, chanting, parlour visits etc? She would pay me whatever hourly charge was due at that time. Another time I recommended a female companion for an elderly woman to be recently discharged from hospital (depression). This patient came from a very rich family but lived alone. So I advised them to call someone to give the patient company and take care of her house while she recovered. Patient's family had the great idea that I could go and stay with her and they would arrange for a servant to do the housework- they had a grand mansion and I could consider it a good 'all expenses paid' vacation. They probably thought people who live in smaller houses are unhappy and dying to live in mansions at any cost.

Patients make odd requests and qualify them with 'I will pay you extra'. The ridiculous part is: our colleagues are not above making such demands. Once I had refused to do therapy for a patient who had very poor compliance and was perpetually late for appointments and also harassing me on phone. He lived in a hostel because the family could not tolerate his misbehavior. A senior Psychiatrist called me and told me in these words "Patient wants to see you. It makes him feel better. Please see him at his hostel. You may charge him for it". I could have murdered that Psychiatrist at this outrageous comment. Another colleague, "Dont you want to become a rich Psychiatrist, having famous and powerful patients? Then you start with seeing this patient whom I am about to refer to you. Go to the girl's house, counsel her there and charge whatever you seem fit. The father is a rich colleague, he will pay. Dont get fussy about boundaries and contract, etc". A number of General practitioners had an idea to take booking charge from patients and arrange my consultation in their clinics- they would negotiate with me on patient's behalf for fee and convenient timing. 

Then there are people who need medical certificates, prescriptions and treatments as per their requirement- I have to just write whatever they want and they would pay me whatever I want. One son wanted me to go to his parents house and arrange for their shifting to hospital because he was very busy in his office- I would be paid whatever the charges I want. One father wanted me to check into an Ayurvedic spa as roommate to his daughter, who was psychotic and refusing Psychiatric treatment. I once refused to meet a patient because he was stalking me and making sexual remarks during session. His mother could not understand why I was so sensitive to it 'because being a young adult male he has his needs and that is why he is in therapy. And we are paying you for it'.

All these requests are made by desperate people who are in denial of the nature of their problems. These people feel that everything should be bought. Its true that much can be bought; Some other person has done the needful where I refused. A Psychiatrist works with emotions, within limits that are psychological. Doing whatever the patient requests, for money is counterproductive to therapeutic outcomes. No therapist or Psychiatrist can do for the patient what has to be done by the family only- like taking decisions, convincing for treatment and telling where they are going wrong. If you are too scared or indifferent to communicate with your own family member; no Psychiatrist in the world can help. In your attempts to undermine healthcare professionals by throwing money at them, you lose their respect and definitely only a certain kind of person will work for you- who has not the values or courage to tell you what is wrong- which is the key job of a Psychiatrist.

Besides, I find it humiliating that people would believe I would do anything for money. If my initial refusal is met with further haggling, I usually tell them to meet another Psychiatrist. I fear to imagine what would have happened if I had followed the advice of my colleagues mentioned above? I would like to keep my work technically and ethically sound. My work is only a part of my life; my life other than my work is full and happy. I am very clear that I can help people with my experience and expertise; I am not for sale.

A Psychiatrist on COVID unit

As I mentioned in my previous posts, I was able to join this great team without much trouble. My worries about endurance, adjusting with colleagues etc turned out to be...just worries.

I observed that the key issue with all patients was autonomic instability and maintaining vital parameters was the main task being done. Second was to prevent further infections. I attempted very earnestly to learn all that- and came to the conclusion that it was not worthy pursuit considering that my posting was only a fortnight. I decided to concentrate more on the things that I could already do so that I could make a true contribution to the team efforts. Organising the day's work, taking down notes, finding out details of clinical history or talking to resident doctors and talking to patient's relatives were the things I started with. In a couple of days, I progressed to diagnosing small clinical issues and addressing them- like whether a patient is getting dehydrated, having acidity feeling and the like. As the different wards are segregated according to the treatment facilities available, we have to match the patients case with the wards and then admit them. Soon I was able to take these decisions.

Simultaneously I was continuously observing the course of illness in patients. The unit was completely supportive of mental health interventions. So I checked the pharmacy and luckily all basic medications were already present there. In this hospital, we have a 'cubicle' system. It consists of a transparent cabin, in which the health professional is seated. Patients are outside the cabin and communication is through intercom. This was a very good facility for primary assessment. I decided that every patient should be screened by brief mental status examination at the cubicle. Then I went inside wards in the PPE to screen patients who were on oxygen therapy and could not come to cubicles. Now the hospital has hired full time counselors, who will do the screening and supportive counseling. 

I found that none of the COVID 19 patients were on antidepressants. The other surprise was that none of the patients had reported or found to be having signs of alcohol or tobacco withdrawal. A small minority were on anti epileptics and anti psychotics. Psychological distress was more common in women than in men. Majority of the patients reported feeling frightened and sleepless and apparently breathless on the first night of their hospitalisation. They reported feeling much better physically as well as emotionally on the second day itself. Sleeplessness, palpitations, restlessness and worrying continued in a small minority of patients. These were also patients whose vitals were taking longer to stabilise. All these symptoms were of recent onset and not fulfilling criteria for diagnosis. Few patients had symptoms amounting to depression, generalised anxiety or dysthymia. In another hospital, I had found that a number of patients became anxious at the time of their discharge- this was accompanied by destablisation of their vital parameters. Most patients in this hospital were however eager to go home and lengthening of hospital stay due to anxiety was a rare scenario. One patient suffered lasting cognitive deficits.

The task force had recommended using Melatonin for sleep. But I found that insomnia was always accompanied by anxiety and restlessness. So I preferred to use low doses of clonazepam, amitryptiline and relaxation training. Patients were thinking a lot about the disease and most of them needed proper information about the virus, disease, vaccine and so many other things that keep appearing in the media- and reached patients through their phones. Almost all patients were baffled by their infection and preoccupied with determining exactly when and how they got the infection. Facilitating acceptance and moving towards recovery was required. We also reached out to family members in some cases- addressing their mental health needs as well as advising them actions to facilitate patients recovery. One patient with special needs required behavioral intervention- he was being non cooperative with treatment because of unfamiliarity and cognitive limitations.

So here we are- at the very beginning of doing mental health interventions in this COVID unit. Patients appreciate that we enquire about how they are feeling and give them some solutions to their immediate problems. I have decided on a policy of short term interventions to facilitate recovery from COVID19. It is difficult to tell whether the emotional issues will persist.The patients with clinically diagnosable conditions will be referred for further evaluation and treatment in the community.

Any Psychiatrist who wants to be a part of the COVID intervention will have to work closely with the team to understand COVID19 as well as the treatment approach. The protocols are different at different places. For example, this COVID unit treated only mild and moderately ill patients. In units treating more severe cases one can expect more mood instability, delirium, cognitive problems, grief reactions- due to greater use of steroids, toxic antivirals and higher mortality.  Ideally, one will need to spend a few weeks working full time and getting familiar with the team members and the disease. The Psychiatrist will need to brush up basic knowledge about respiratory, cardio vascular and Gastro intestinal physiology- including Circadian rhythms, correlation with menstruation. We need to refresh our knowledge about history taking of symptoms of these systems. Also we need to read up about the common drugs used and the thinking behind how short term interventions are done and when long term interventions are required. Along with the full pathophysiology of COVID19 (as it is being discovered and understood).

If given a few months more here, I could understand the full picture of the physiological issues and how they correlate with mental health. I could look at how patients do after recovery. My present level of knowledge is nowhere near what is required to realise the ambitions I came here with. I will continue to supervise the mental health interventions. I will also visit part time and try to solve clinical problems. Still I know its not like working full time and being there when the learning opportunity presents. I guess, I have to accept this to be the best deal under the circumstances.

A Psychiatrist and the Pandemic

As soon as the Pandemic was declared in March, I closed down my clinic and readied myself to be summoned for duty. But nothing happened- life continued like a vacation for me, while my colleagues from other faculties sweated it out in the hospitals. I had been messaging them and reaching out to tell them I was available to consult- through phone, in person- whatever way they thought necessary - for patients and colleagues. But people did not reach out and patients all preferred tele-consultation. I dont mean I just wanted to go to hospital anyhow- but I want to say that I recognised that I could not avoid going to hospital.

One reason that I was ready to work in hospital was 'survivor's guilt'. I felt that I was letting down my colleagues while they had to bear the entire burden of the disaster. Second reason was my thinking that Psychiatry is very important and legitimate part of medicine and that like everyone else, we needed to be an 'active' part of the pandemic response. My nature is to be deeply involved in anything that's happening around me. I felt rather left  out of the Pandemic party because I was at home mostly and my Psychiatry consultations were also down to a trickle.

I have often heard mental health professionals complain that the gap in treatment is because our non- Psychiatry colleagues fail to refer patients. This is mainly due to their inability to suspect and diagnose mental health issues. I could not see how this ability would be developed overnight due to Pandemic. Thus if we mental health people really believed that we should reach out to all those who need our help, we would need to go out there and find them ourselves.  I saw that mental health professionals were talking a lot about the expected increase in need for support and intervention due to the Pandemic. Webinars, helplines and tele- consultations were being publicised on every available medium. My personal thinking is that all this is fine for Psychologists and counselors. Psychiatrists being medical professionals have to show up,learn and implement the medical interventions where patients are.  I also felt that one could make a reasonable contribution to any COVID unit, if one tried. The real role of a Psychiatrist is that of a doctor. Its ironical that we complain about Psychiatric interventions being neglected but are not showing up on site to handle them when the need arises.

I had never been comfortable with tele-consulting and after seeing few patients through video calling, I was convinced that it is a very inadequate method for evaluation. Maybe the patients felt better by talking through the video call (that is to be determined by asking them); but I was never happy with the evaluation. I was disturbed by the thought of completely abandoning hospital visits for fear of infection. I felt that we need to be ready to don the PPE and visit patient for evaluation if the situation so demanded. A blanket withdrawal from 'in person' consultation is not feasible. In the initial days of lockdown I had suffered sleep disturbance and anxiety and I dont consider myself as invincible; so I also wanted to remain in touch with hospital to avoid developing a phobia.

In January this year, I was reflecting on the fact that my work had become very routine and dull. I wanted to inject some excitement into it by taking up a few months of regular general medicine work. I love the energy of hospital wards and enjoy the intellectual stimulation of solving a medical problem.The Pandemic seemed a perfect chance to get this plan going.

The complications of the 1918 Flu pandemic had lasted for decades. I estimate that it could be similar with COVID 19. It is a completely new disease. I needed to learn everything I could about it.  I dont like to become an armchair expert. The correct way to learn in medicine is one the job- means by managing patients under supervision. I was looking for an opportunity to work on a COVID unit so that I could actually watch personally how the disease appears and evolves at every stage in a good number of patients. I wanted a chance to witness its physiology first hand. I wanted to be able to understand what every patient went through during the disease phase. I did not want to settle for the poorer option- of my frontline colleagues selecting only a few for my evaluation (maybe missing some). I wanted to experience myself, what kind of emotional and physiological difficulties patients were going through. I wanted to be able to formulate a plan of intervention- most importantly I wanted to be able to decide for myself where the threshold for Psychiatric intervention should be. I wanted to become an expert on COVID related neuropsychiatric disorders.

Very Ambitious indeed!

I didn't have any illusions about my limitations and risks. As I have a limited hours medical practice, I was not sure of my physical or mental endurance for long hours. Having functioned independently, I  was also doubtful of my ability to blend in with a team of younger folks. Its been 15 years since I left hospital quarters and my tolerance for that ambience and food was also doubtful. And the practical aspect of how my family of four would adjust with me suddenly 'going on the frontline' and missing in action at home. But these concerns could be tested only when the time came and not in advance. My fear of infection was reduced by my thinking that I could learn to manage the risk like my colleagues working on the front-line. I had no real concerns about it beyond confirming the availability of good quality and quantity of PPE and meticulously studying the precautions.

With all this on my mind and a great eagerness in my heart I kept waiting. But the call did not yet come.

Frankly then, I became quite desperate and volunteered myself to work on the COVID unit. I am much relieved that I was accepted without much fuss. And my learning journey began....

NOT ALL POKER FACED

You dont LOOK like a doctor'- thats what I get to hear when I am smiling and having fun or just very nicely dressed up or wearing my cooking Apron. Why? How is a doctor supposed to look like? Always serious, stoic and poker faced? Not at all. Doctors are the most sensitive, artistic, fun loving folks full of life. See any type of the arts- music, dance, writing, sculpture, acting, painting- you will spot at least one doctor who has achieved professional level accomplishment- in addition to their medical work.

In BKC Covid hospital too, we are trying to live our lives- with balance and optimism. So when a group of special needs folks had to move in for treatment- Dr V and her team made it their business to enliven their wards. After their hours of grueling duty, this group of consultants, Resident doctors, nurses and paramedical staff made lovely artwork to decorate the wards. Patients are thrilled!

A little while later, a group of performing arts enthusiasts has popped up. Music, dance, pictures and other lovely art is posted on this group. Everybody gets a moment of entertainment and reprieve from their mundane duties. An impromptu send- off for a loved colleague is celebrated with a grand cake and some emotional moments are witnessed.

Its Eid coming. And I see mehendi designs on some hands. Somewhere there is a little bit of mehendi is found and I get my share of the mehendi design- in two minutes flat- a little celebration by the way. Dean Sir makes the time to spend with folks celebrating 'on the job'. These doctors didnt go home to be with their families to celebrate even when the option was available. They did their duty and guess what- one doctor's family even had several boxes of yummy desert delivered to all of us.

The folks working here are really committed to getting all their patients recover and will not abandon their posts till their work is completed. But they do it with passion and positivity. We smile and laugh and not lose a chance to appreciate art or celebrate an occasion. Life is lived in its moments. No one understands this better than doctors.

Such a time .....

This young man is in hospital. Now he needs to go home because he lost his mother to the virus and there is no one else to perform the rites. Yesterday a husband, himself not keeping very well, had to take leave from hospital to cremate his wife.Last month an entire family was hospitalized. The 90yr old patriarch passed away. His 70 year old son was heartbroken..he had cared for his father till now. But now for the final journey he couldn't be with him.Mothers weep or simply become quiet and thoughtful, when we talk of children. Their children are at home, far from them. On TV I see an old age home with a plastic curtain that has sleeves. Its meant for children visiting their parents to hug them, the plastic acting as a protective barrier. 

Some of these are patients. But all of these have happened to doctors. Of living away from home. Of missing children. Of being unable to hug their parents. 

This is such a time

How long the pandemic woes?

Just read about the recurrence of cases in Spain. Looks like covid is going to be with us for a very long time. This brings to the fore a number of questions, which need to be thought about. (Only pertaining to healthcare)

Covid treatment facilities 

Presently the treatment is being done at public hospitals, private hospitals and dedicated covid hospitals. Public hospitals are overwhelmed by numbers because they didnt have much capacity to begin with. Private hospitals are going bust because of increased costs on one hand and capping of charges on the other. And covid hospitals are not working to capacity yet.

Treatment of other disorders 

Other obviously important diseases like monsoon fevers, medical emergencies and surgeries have become difficult to manage because the hospitals are occupied by covid patients. Medical issues like knee replacement,  plastic surgeries, dental problems are prone to be seen as 'luxuries' and completely sidelined. In reality, delay in treatment of these will cause lots of suffering, worsening of the problem and complications. Space needs to be urgently created to start proper interventions for these issues.

Work and livelihood 

In Mumbai at least, the age distribution of medical professionals is very peculiar. Most of the healthcare system in private hospitals is managed by doctors above 50yrs. Public hospitals have younger doctors. But they are all into covid duties. Older doctors in public healthcare have been forbidden to work due to risk of coronavirus infection. Older folks in private practice have been forced to work for their livelihood and government compulsion due to which many have died and there is much fear. Largely medical professionals have not been paid their salaries on time. 

So fear, financial problems,  lack of work, overwork are the avoidable problems being faced by doctors. Plus most private hospitals are facing a financial crisis and may close down in the near future.

What is possible? 

We need to compartmentalize the pandemic and deal with it and that according to me is the only solution. For this to work, following needs to be done

1. Strengthen the covid hospital 

Presently the hospital is mostly empty. Patients need to be directed here instead of occupying private hospital beds. In any case the care is about the same and patients will be saved a great deal of money.

There is severe shortage of healthcare professionals in the field hospitals. Generosity from private sector, expanding telehealth services and creating part time positions is urgently needed.

2. Release private hospitals 

Private hospitals should be released from the compulsion to treat covid patients. They can go back to treating non covid issues. Patients will be served by getting all necessary treatments and private hospitals can be saved from financial collapse.

3. Public hospitals 

Senior doctors in public hospitals should start teleconsultation.  Non affording patients stuck in lockdown at different places can avail of their help.Midcareer specialists should take over the respective departments and start treatment of patients with comorbid covid. For example conducting emergency surgery of covid patients or deliveries etc. This way risk to patient is minimized and the academic program can resume. 

PS

Every medical professional in Mumbai must recognize the covid field hospital as a blessing as it is the only exit strategy available to us. All of us must contribute as much as possible to its setting up and smooth running, with or without payment. Otherwise we are all going to remain in infinite deadlock treating covid which is totally draining our resources and will be unable to return to our usual work. If all of us work by rotation, contributing few weeks time, it can be managed.  It  is quite feasible to take leave from practice for short duration. For now we are also in a position to gain respect because we can contribute voluntarily as per our choice and convenience. However there will come a time when doctors will be publicly shamed for not coming forward and forced to work on unfavorable terms. 

Salute the young...

 a strapping 6footer and just finished his graduate medical studies.  He works at the field hospital for covid patients.  Due to his young age and provisions of the 'Epidemic diseases Act' Govt has posted him to do the most difficult job of actually implementing the treatments for patients.Between duties he lives near the hospital. Though the facilities are above average, I wonder how it must feel for a young fellow to be away from friends, family and food of choice for such a long time...and not out of choice.

He brings along his studies on an Ipad and reads when he is not with patients.  Like the typical doctor, studying and preparing for an exam or simply to understand what is happening to his patient.  He shows great concern for his patients and reports to work enthusiastically. We sent him off to the ward duties..6 hrs is the maximum.  I see him after 6 hours...this erstwhile picture of youth and vitality is soaked to the skin in sweat, face is flushed, pupils dilated and he somehow staggers to the couch. Wearing ppe and working in the hot Mumbai weather has reduced our young Rambo to a tottering wilted rag from heat exhaustion. After he takes rest and fluids and in an hour's time he is asking if he should go back in the wards. For now, I tell him its not needed. So he settles on a chair with his ipad..back to studying.

And there is Dr S. She had a bout of food poisoning this morning. Her mother sent her some homemade food and she saved it to eat over few days. By afternoon she is back in hospital,  ready to don her ppe and dive right in. I am scared, this wispy young doctor...will she be ok? She belies my worries does a wonderful job of it. Dr R wants to check each and every of the 100 patients under her care personally and we are trying to teach her to take it easy...its teamwork and some patients are to be checked by the staff nurse and reported to her. Dr K has a misleading soft voice and demeanor and does great work.

Dr D has a medical condition which requires surgery on Sunday. So he works till Saturday evening.  Dr S has a gynec hormone issue and is going through painful period pain..but she pops a pill and dons her ppe. Only upon seeing her rather pale and drained out after half time, we are able to prise out of her what she is going through.  And then too she insists on staying for duty and has to be practically evicted to go and get some rest.

Dr D is a trainee in Psychiatry. For the last 4 months she has been on covid duty, far from her studies and patients. Neither she nor her colleagues are complaining though. They try to catch up on studies through zoom sessions with their faculty professors. Dr A, the resident from the ENT department is trying to practice her examination skills on the covid patients who complain of throat aches. Are they not worried about the time going? About their education? Marriage? Must be worried, but they are all taking it philosophically as an opportunity to learn and grow as people. 

Dr M is an exam going Resident dr of a superspecialty branch. Without the pandemic disruption, he would have been fully qualified and minting money in private hospitals now. He completely and peacefully immersed in work and doesn't show a hint of disappointment.  He has been lent out to the covid hospital on a resident dr's salary. He treats patients, makes protocols, coordinates with families and set up every system here. Young and married..such are many drs living here and going about the work with absolute dedication. 

And so on. All the drs here have the traits mentioned. These drs are young and yet demonstrate oodles of sincerity,  stoicism, wisdom, confidence,  sense of responsibility and competence in their work.  Our response to the covid pandemic is entirely riding on these young shoulders. The qualities they have cannot be taught and I can clearly see...some people are meant to be drs and it shows from young age.

I am so proud of them and honoured to work with them

Thinking of the Earth

Before the coronavirus pandemic started, there was a lot of concern about being environmentally friendly.  As countries went into lockdown,  the air became cleaner and wildlife experienced more freedom. 

In my neighborhood, we had started some waste management practices like segregation and composting. Unfortunately they stopped during lockdown and dont seem to have resumed.  People are using larger quantities of water with soda bicarb. So thats leading to water wastage and probably changed composition of sewage. 

Medical facilities are using non biodegradable materials for ppe and created a huge amount of waste.  Due to fear of infection people prefer to eat in disposable single use dishes using plastic cutlery. And everyone prefers bottled water to refillable RO.

The pandemic has taken a toll on the economy so that now environmental concerns are not going to be given due importance in planning businesses and development..all possible resources will be put at service of recovery and development. 

In the best of times people find it jarring to hear about environmental issues.  When safety from infection and recovery from poverty are of such concern, there is going to be little opportunity for the environmentalists to have their say. Environmental degradation and climate change have caused this series of misfortunes. But will we learn? And is there a way to be environment friendly in this pandemic? 

Day one

Finally I acted on my desire to contribute my bit and started my 'covid duty' in Mumbai.  My workplace is a temporary field hospital. I visited this location for exhibitions earlier...but now it is a fully equipped hospital. The general mood here is optimistic and calm.This reminds me of NIMHANS. And I feel at home immediately. 

After my orientation and induction, I am still wondering how will I be of help here? 

But in a while I witness a lengthy phone conversation of Dr S. A family member has phoned him to report concerns which include behavioral problems.  Dr S quite confidently reassures him of a solution 'because now we have an experienced Psychiatrist with us'. Both Dr and family member are happy that patients problem will be addressed. 

For ppe, there is no shortage, it fits well and it doesn't feel hot at all. Though I know after several hours in ppe...it will get bad. The ward is huge and disorienting. Patients are in nightclothes and carers in ppe. The whole feel is like walking among clouds due to fogging of face shield with rainbow halos around each lightbulb.

As I finish my evaluation my throat gets strained due to louder than usual speaking. I was quite anxious about doffing. And rightly so because the space allotted was small and much of taken over by discarded ppe. Duties were changing, so a large crowd doffing simultaneously undoing the safety efforts of previous hours.

The administration has suddenly decided to change the accommodation of Drs causing disquiet. So it takes us several hours more to sort it and head to base camp.

Starting Covid Duty

I am a mid career Psychiatrist and have joined covid duty at bkc.

I had been already told good things...but the people who told me are very gentle non complaining types. So I wasn't so sure.

Now that I am here I can clearly see that very good work is happening here. Its very safe. People get along well. Arrangements for stay are outstanding. And patients are improving nicely. 

They train you for the work. And because of clear protocols and helpful nature of experts on team...one gets to make a contribution irrespective of subject of specialization. 

I am happy to have decided to join. I will recommend this to other drs like me.

For all the nice things...there is a real shortage of drs and the salaries are not coming on time. The first issue is to be solved by more of us stepping in. And I think it is best to keep salary as lowest on reasons to join..if you can afford to do so.

Hospitality. ...no thanks

In May my friend told me..."my Drs changed a lot. Today I phoned him for an appointment and he answered with a detailed mssg about services and payment for same...all to be done in advance. I have been with him for 10yrs and this seemed jarring."  I think some of my patients are feeling the same. But there is a reason for this change. 

The whole of April I had been very understanding taking patient calls advising them and sending prescription on phone;on occasion even going in search of a postoffice to mail prescription.  For all my troubles and understanding..a shocking number of patients thought they didn't need to pay. A lot of them did not even qualify my reminders with a reply. And those who did felt consultation fee was not warranted for few minutes conversation. 

I dont buy all these arguments. My clinic is open and I am willing to do consultation there. I am even available for emergency consultation at my hospital. But it is patients who choose to prefer teleconsultation. It requires more effort on my part...in terms of concentration and data use to download the reams of test reports that patients forward. Plus I have bills to pay and salaries of 3 employees. 

I decided I am done with the haggling. If any patient wants my advice they must pay me in advance. I am done with pursuing them for fee and then haggling over the amount. Through this I have been giving concessions to those stating economic constraints...but there will be no discount on account of 'i dont think so and i am patient so you are my servant ' philosophy. 

It was notable that illiterate folks with poor economic status paid up immediately after an honest communication about their issues. It was the highly educated iit iim phd and richie rich class of folks who defaulted on payment and haggled on the amounts. Plus they still keep demanding facilities...now i am to download every payment app that they have...send prescription only through the app they have and do facetime through whatever apps they have....schedule consultation when  they are not working from home...list is endless.  

As Salman Rushdie commented...we folks focus too much on the wedding and neglect the marriage. 

So do our patients who focus too much on hospitality from the doctor and neglect treatment. 

I can only wish such folks 'All the Best' and hope that they go to another Psychiatrist.

Its such a joy to help someone in need. My patients always appreciate my help and we dont talk much about money ever. But teleconsultation has shown me that the talk about money can turn ugly. I am not enjoying it.

ONLINE SCHOOLS and HOW GROWN UPS GOT BUSTED

For more than a decade now, we have been preaching to parents and kids about the harmful effects of electronic devices. The last revision of Diagnostic and Statistical Manual has come up with the new diagnosis of ‘Gaming disorder’. Special deaddiction departments like S T O P at NIMHANS, Bangalore have been established to treat disorders related to excessive use of electronic devices.

Then COVID 19 happened.

Now we are all for ‘ONLINE EDUCATION’ and what about the children’s health and safety? The excessive enthusiasm for online schooling has uncovered the double- standards that we grown-ups have- we change our positions when it suits us. Is it really so? Or it is a time for us to understand the finer points and reconcile with the situation?

ARE ELECTRONIC DEVICES SAFE?

The short answer is ‘NOT SAFE’.

Electronic devices harm children’s body, eyes, brain and personality. They can cause chronic health problems like obesity, depression and cancers.There is ample and unequivocal evidence that electronic devices are not safe for children because of their physical and psychological immaturity and that they have a greater vulnerability to the general harmful effects.

Guidelines clearly recommend zero screen exposure till the age of 2 years. Thereafter exposure should be minimized to few short spells on a weekly basis and can be upto an hour daily by the teenage years.

AND ONLINE SCHOOL

I am much happy about the Maharashtra Govt Guidelines which has said no online schooling for children upto the second standard. Thereafter the SOP recommends upto 2 hours daily till standard 8 and then 3 hours daily for high school students. This is touching the limit of safety.

I guess- the way to understand it is to compare it with the danger of attending school in person on one hand and complete break from learning on the other hand. (other modes of learning like home schooling are rarely possible in India).  In India, there is a great pressure for school and academic performance- mainly parents find that school keeps children busy and out of trouble. And if they see children doing school, parents feel more secure about them. So authorities are generally under pressure to start the schooling process somehow or the other. In reality, if children do not go to school for one year- and work only on sustaining their previous levels of learning- nothing drastically bad will happen. They may need to work harder next year though. This is especially true for kids below 12 years. But it will lead to massive amounts of parental stress, economic distress for educational institutions and administrative headaches when schools resume. So, the easier way out is to start school by whatever means available- and online schooling is an elegant and attractive option.

Electronic gadgets are still unsafe for children and my hope is for the online schooling hours to reduce further for every age group and that children should have the sessions only few times a week instead of everyday.

HOW TO ENHANCE SAFETY?

If we accept that online school is necessary due to overwhelming circumstances and that it is a temporary option, then we need to work on enhancing the safety by minimizing the risks. In our culture we are accustomed to feeding children special diet with almonds, milk, etc if they are attempting something that requires more strength, concentration. If children are weak or vulnerable as during illness, then too we feed them special foods and arrange special comforts for them. This situation is similar- it requires a greater concentration alongwith constant risk of damage to health to do online school. Therefore certain special measures should be taken.

11.

CONTROL DOSE

After online schooling, teachers should be careful to give homework that does not involve further use of electronic devices. Parents also should insist on children making handwritten notes and assignments. After school, children should not be allowed to use electronic gadget-based activities to relax. Further learning like tuitions, art classes etc through electronic media should be minimized. Child should be given access to only one device at a time.

For this to work, even parents will need to set an example through their own behavior.

2.      PHYSICAL MEASURES

Good ergonomic charts demonstrating proper seating and distance from screen can be downloaded and displayed next to the child’s work station. Proper seating arrangements, light source, desk for writing, noise cancelling ear muffs, etc should be provided. Child should be reminded to follow the safety precautions until it becomes a habit.

Attention should be paid that child will suffer no ill- effects to eyes and vision, hearing, neck-back and posture, hand and shoulder while being at online school

3.      IMPROVE HEALTH

Children should be encouraged to build their health and immunity through healthy habits. These are balanced diet, adequate fluid intake, regular vigorous physical exercise, hobbies and recreation, good restful sleep at night and social interactions with family (and friends through phone calls)

HOW TO DO IT?

The best way to implement and habituate safe online schooling is through adequate supervision of the child. In the beginning, parents should sit next to the child and attend the school without participating or interfering in the schooling. They should observe the child and give cues about posture etc- so moulding healthy habits. It also gives idea to the parents about what else needs to be provided. Slowly parent can do their own tasks quietly sitting near the child and later can leave the child to attend school by himself/ herself for short periods of time. Completely leaving the child alone while he/ she is on the screen is not recommended.

I can offer no solutions in this blog to parents who are unable to implement their plan because child does not listen to them. They will need to consult good books or counselors for guidance.

NEGATIVE TRENDS

Unfortunately, all schools are not following the SOP given by Govt. ECA has in fact stated that pre- schoolers must be enrolled in online schooling ‘without pressure’. But how will they protect the young eyes and brain from screen radiation and risk of addiction and hyperkinesis- that they have not mentioned. It is for the parents to choose not to enrol children in schools following this guideline.

Some schools have 6-7 hrs of online school daily with or without homework that requires further use of electronic gadgets. I can only feel sorry for the kids and parents of such  schools- they don’t have a choice but to comply with such unhealthy schedules.

Education, school and learning are extremely important. But a little delay or slack will not kill the child or his/ her future. We need to temper our desperation for school with the knowledge that electronic gadgets exposure is basically harmful to the child. With this thought in mind, we must design the online school to do what is absolutely essential only. 

COVID PANDEMIC- A mental health condition

A pandemic occurs when a disease spreads across large populations across countries, races and continents. When COVID occurred in one person it was an infectious viral disease. But when it transformed into a pandemic it has become a behavioral problem- the cause of the body damage in individuals is the virus but the cause of spread is the people’s behavior.

CULTURAL FACTORS

India has been a crowded country for ages. And we have practiced social distancing in the form of ‘UNTOUCHABILITY’. I am absolutely against untouchability and regard it as a blot on our culture- but the point is- it can be done. So also the hygiene measures- we have myriad of purity rituals. And the mask use- we have imposed the purda system on women for centuries. So overcrowding and poor resources is a difficult but not impossible problem to solve. According to me the real problem is a lack of understanding. People have not been able to understand the nature of the problem and hence their response is lacking.

In general, we are a culture with a poor habit of reading.  And the illiterate folks have a major disadvantage on that front. With literate people, the information that gets attention should be to be religious or have some ability to elicit shock or amazement. A disease that can be controlled by simple measures of behavioral change- no that information is not likely to be consumed or believed. The only way to overcome this issue is to involve community leaders and repeat the information.

POOR COMPREHENSION

Among seniors, my personal experience is that due to ageing factors- there is considerable impairment of judgment. So even now, when I got out, I see a very large number of seniors- some even unable to walk- out in the open. Their masks are barely there. Upon enquiring if they had to go out due to being alone- most said they were out due to boredom and also a feeling that they did not need to fear death. Is this silent suicide? But its definitely a form of poor comprehension.

Younger folks with anti social traits, hyperkinetic nature and intellectual challenges also find it difficult to follow precautions. These are the cases of the infamous ‘corona parties’ in the US. Youngsters who don’t feel the empathy for seniors and do not take precautions like wearing mask- citing flimsy reasons like inability to exercise outdoors wearing a mask. The complex comprehension of risk vis a vis individual rights is missing here.

IMPAIRED JUDGMENT

 I would say the key element of dysfunctional behavior is an impaired judgment. Many folks with absolutely zero symptoms of mental illness can have a poor judgment. I see impaired judgment more in the community than in my clinic. Especially folks who are highly qualified or have a good financial or social status are prone to believe that they have nothing to fear from anything that is essentially killing the poor and those who are in contact with them. They are happy with banning domestic workers from their premises and then they don’t believe in following any precautions. . It is harder to modify their behaviors because they are up to date with google research and alternative medical philosophies- plus have a tendency to take offence easily. The problem is- that the virus is highly opportunistic and any small slip-up can lead to infections.

MENTAL ILLNESS

The pandemic also increased the stress levels in all. People who had some vulnerability in the form of prior mental illness or a genetic pre disposition- they did develop the symptoms of mental illness. This would not have happened without the pandemic situation- not definitely in such large numbers in such a short period of time. So this is another the dimension of the behavioral impact. But unless the person is in a manic episode- where the person leaves caution to the wind- most people with mental illness will be socially withdrawn and the infection part of the pandemic reduced. Manic episodes are extremely rare. So mentally ill people did not contribute to the pandemic at all.

CONCLUSION

In countries where people were able to practice sustained behavioral change, they were able to control the pandemic earlier and more robustly. But where the people’s judgment was impaired due to various reasons- they didn’t practice healthful behaviors and the virus has moved in for the kill. Just as the infection is spread by the asymptomatic and the pre- symptomatic virus carriers- it is amply aided by those mentally impaired people who don’t have features of mental illness- but whose judgement is clearly impaired. Thus covid is an infectious disease but covid pandemic is a mental health issue.

DUTY...that never was....

I spoke to a friend DR TS a Psychiatrist. Sometime last month, he received an email asking him to join for COVID Duty. He got ready with the idea of contributing to the fight. But he got stumped when he discovered he had been assigned ICU management.

Now Psychiatrists are medical doctors, but after internship we did not get any much practice in medical interventions. We can do a good general and neurological examination and give intramuscular and intravenous injection if the occasion so demands- but beyond that we rely on our better equipped colleagues. In today’s world ICU management is beyond just TPRBP (Temp, pulse, respiration and blood pressure monitoring) which was the key thing when we did our training in general medicine. Of course, we have the general idea and having practiced rigorously in internship- a few weeks of good training may improve us. But I humbly admit that we cannot handle ICU for COVID patients.

So DR TS wrote back to the administration explaining the situation. He offered to work in screening out patient departments and in quarantine centres- where Psychiatrists can really do a good job. That was a month ago and no body’s replied to his email yet.

I felt DR TS was somewhat disappointed that he came so close to doing COVID duty and still missed the chance.  Its true, when so many people are calling helplines and all they need is reassurance- Psychiatrists can definitely play a role. A number of suicides have been reported in COVID wards- the mental health problems must be a lot. 

I think, the administration is so overwhelmed and also ignorant about medical issues- these things are getting missed. Meanwhile DR TS is recounting his experience of the duty that never was….

CAME AWAY INSPIRED.........

It occurred to me this morning that an Anaesthetist colleague of mine, DR SV, must have some idea of the COVID duty. Turned out that she had just returned from doing her posting of the COVID duty and talking to her today was a revelation.

Her initial reaction upon being served the posting was of being confused and she called her classmates for more information. Someone told her that Physicians and Anaesthetists were to be called first and therefore she had got her posting now. When she went there, the treatment centre had not even started functioning. The first 2 days were just spent assessing the facilities and requisitioning equipment. So far being done by non- medical people, she had to step in to advise them and they cooperated whole- heartedly. They began receiving patients on day 3. Patients who had improved and needed further care were being referred here and the facility filled up quickly. They were a group of herself and 3 Physicians functioning as team leaders of the 1000 bedded facility. Other team members were fresh medical graduates, fresh nursing graduates and newly recruited helpers. So the team leaders also worked on assigning duties, training the staff and setting up of systems to implement treatment protocols.

Clinical management consisted of a hub and spoke model with tech assistance. Patients being distributed in about 28 wards- the ground staff would be assigned to their care dressed in complete PPE. Team leaders were required to take clinical rounds in PPE and monitor continuously through remote feed given by cctv in each ward and continuous input through phones- at that time they did not need to be in PPE. Any indication of patient worsening or clinical doubt, they had to don the PPE and step in again. Dr SV mentioned that it was continuous work and significantly stressful due to the continuous monitoring and talking to give inputs. Considering that each dr was seeing 250 patients, this is really a feat of medicine!

The physical experience of wearing the PPE was very unpleasant- she being posted during the worst weather weeks of end May- starting June. Since then the weather has improved considerably. Everyone was cooperative and calm and went about their work diligently. The arrangements for healthcare workers were good. There was no shortage of PPE and the they were of high quality. Arrangements for stay, food and transport were comfortable. She did not choose to stay over. But others who did were not reporting any problems  with the accommodation provided, she said. And the administration has taken all documents to process her remuneration, so it will be coming.

As I spoke to Dr SV, I realized that she went in there with a good attitude. Considering that she arrived when nothing was in place yet, she didn’t think of complaining. She just saw what was needed to be done- and did it. She and her team organized the place and had it up and running. Her whole description of the experience was very matter-of-fact and completely devoid of any complaints. In fact, she expressed great satisfaction that she could contribute. Her concerns mainly those of a working mother- how can I be looking into the kids online school, will he be ok, etc? In closing she mentioned that she had not looked into the matter of the salary as yet- she considered that this was her duty and she may not even pursue it much.

Since 4^th May, when the COVID DUTY notification appeared, I have been getting lot of negative feedback about how things were going. Some of the descriptions were downright scary and I was thinking if its even safe for Doctors anymore. I called Dr SV with these fears in my mind and came back inspired.

ANGEL- only of that moment

Last Sunday, a friend called me. His father’s oxygen levels were falling steadily and there were no beds available anywhere to hospitalize him….could I do anything to help? A lucky chain of events followed and we were able to hospitalize him and now the patient has recovered and is back home.  My friend appreciated me by calling me ‘an angel’. He is my good friend and I know his regard for me doesn’t depend on anything I can do or not for him. But whenever I get effusive thanks for a life saved, I remind myself – ‘its only for that moment, the next moment I could be condemned as the Devil incarnate’. Such is the experience of a doctor.

Nothing special really….

Most of the times when folks come to me for a problem, I know exactly what is to be done. Because I spent all my life learning about it and practicing the same. For the common man, it is a rare experience. The fact that I can give an accurate prognosis and guide them seems amazing to them. As a Psychiatrist, I have the advantage of having some communication skills which makes things that much smoother. Even when there is uncertainty, I am able to prepare the person for it.  When things go as I had suggested they will…..they think its miraculous and I have some special powers. Its nothing special really. Completely within the abilities of any doctor.

Angel for the day

For most doctors, things work out, especially if the patients are sensible. (which is the case for every doctor- otherwise why would they be in business still?) . On the such occasions, I have taught myself to be humble and say to myself ‘its not me who is the angel; its just the chain of events that made me look like one’. Therefore, yes I feel very happy and gratified for the compliment. But I know tomorrow is different and I am not an Angel.

Devil incarnate

I am not perfect and sometimes things go wrong in unexpected ways. Many years ago I prescribed medication to an 18 year old in a Manic episode. It appears that the doses were inadequate due to which he was up the whole night making his father prepare endless portions of instant noodles. Next day the exhausted father called up his family physician who told him that the medication was extremely dangerous and could have killed him. Bass- the next call was to me and cursing me to all kinds misfortunes- I was the Devil incarnate to him. More recently, after the lockdown my patients and their relatives suddenly began to call me up at all odd times of the day and night to discuss covid. I could understand their stress and anxiety- but being only human I could not answer all of them. Plus some of them needed more than few words of comfort- and this being the professional service I provide, I asked them to pay me. I was faced with their disappointment, disgust and people designated me as the Devil (who is after money)

Learning…

People cant understand what we doctors are upto. They find it unfair that we can earn through spending 20 mins of examining them- a process that seems so simple and not at all heroic. For Psychiatrists its worse- pay for talking? Well, that’s the issue. If it was only about spending time with the patient or merely talking to them why would you come to us? So many folks to spend time with and talk to- free and willing. The difference is- that we worked extremely hard all our lives to understand what is happening to you and are trained to make it look smooth and effortless- if every consultation is like Munnabhai scene where we get histrionic and appear to do heroics- imagine what would happen to your blood pressure? So even if it appears cool and effortless there is a massive amount of hard work that’s gone to make it that way and it saves your life. Its not miraculous but its definitely worth the money.

So we doctors- well we are a shameless lot. But we cultivate that quality under the euphemism of ‘Equanimity’. Call us Angels, call us Devils- after few moments of feeling something about it (though not showing it on the face at all) we just let it go and move on to the next thing on our schedule. Drs cant afford to take these things seriously, not for themselves and not for those few wise patients who value them.

COVID- Times. SCHOOL FOR THE CHILD

A large part of the child’s day is spent in school and in completing learning tasks assigned at school. School is the place where the child finds stimulation, companionship, security, self esteem and a sense of identity. School is a habit that must be cultivated and sustained. Consistent school attendance throughout childhood not only equips the child with skills and knowledge to pursue a means of livelihood- but it also promotes the child’s development which is critical for survival in the real world. It is therefore to be expected that children will be worried about what is going to happen to school in the context of the covid epidemic.

In the initial days all schools were kept closed and it was easy to explain to children of all ages about the whys and hows of the situation. By now, children are missing their school and their friends. In some places where schools have been re-opened both parents and children are frightened of going to school. They are afraid for themselves and afraid of bringing home an infection that can harm their valued family members like grandparents who live with them. In a way, children are happier to stay at home because their schedule is less demanding now and being around parents is (mostly) comforting. Children want to know if its really necessary to go to school now? Cant they postpone it by a bit and go when they feel safer?

For some children school provides a refuge from difficulties at home. These difficulties may be in the form of poverty, hunger, poor quality of physical surroundings, lack of facilities like toilets and lack of space. Immediate challenges from family such as abuse, living with a person with difficulties (like illness/ disability/ etc) and burden of housework and caretaking. These children look forward to school for more than just learning.

Schools also provide a strong sense of self esteem and identity. The different rituals followed by a school- like appointing students to committees, making them captain of school groups etc promote ambition and striving among students and provide role models. Celebrations of national festivals, competitions in different categories are things that children enjoy and add to their confidence. Children benefit both by participation and spectatorship.

A school means all these and much more to the child….and in lockdown they are missing it mostly and relieved from it somewhat. People who want to plan about school should really do a survey about what children are missing because their schools are closed. This ‘customer experience’ should be considered before making the plan of schooling during covid so that children feel attracted to the experience.  

SURVIVING COVID- A recovered Dr's account

I heard,read,talked about the covid pandemic, till it hit home. Till I exeprienced it myself it was something that would happen to someone else, not me. Denial helps us to keep anxiety at bay but denial also keeps reality at bay.

First when my 78 years old  father was diagnosed as covid positive, l already developed my first  bout of fever spike. Getting a bed for my father was a task in itself , with me lying in the back seat of the car shivering with chills, helpless, not knowing whether my father would be shifted from a non-covid to a covid hospital or what awaits me in the next 20 days.

With admission of my father in a  a covid hospital, and simultaneously my symptomatic condition progressing, slowly time started seeming unreal. Father's condition was deteriorating and mine too. My husband, Sujit transformed our bedroom to ICU. Talking to physician friends, whose immense help and guidance helped him to sustain me at home for almost 9 days. Then on the 10th day, my condition deteriorated. I was in such a fogged state of mind with my father's condition going downhill and my own general medical condition seeming to go downhill. Finally sujit decided to get me admitted. He and his close friend drove me around in the car calling doctors, friends anf acquantainces in search of a bed for at least 6 hours . I was sitting like a dead body in the car listening to the concersations these two were making  trying desperately for a bed  Finally a friend (Dr Vikrant Shah) managed to secure a bed in Surana hospital in chembur. I remember myself sitting at at around 2 am or so, on a chair at the hospital gate, totally unaware what part of Mumbai it would be. Iin the darkness and  silence of the night I wondered if I would just probably sit there forever.  Sujit did the formalities of getting me admitted. As no relative was allowed inside the hospital premises, finally a wardboy escorted me inside the hospital, leaving behind my dear ones, as if I am entering some unknown strange place totally secluded from the rest of the world. I turned back to Sujit  and our friend again and again and bade them goodbye with weak gestures till they disappeared from my sight.

The moment I entered the hospital building at around 3 am, a ppe donned exhausted doctor standing at thhe elevator enquired about me. He took my history in short, and that was the first time I realised i could not speak a word without getting breathless. I had not spoken for so many days due to fever, bodycahe, dullness that I didn't realise that I was breathless. The doctor patted my shoulder and said not to worry, told the wardboy to take me to my room, told me he would meet me in the morning.

It was around 3:30 am. 27th may 2020

I was kept in a single room. The staff came, put iv, checked all my parameters, took blood for testing. The rmo Dr. Vikas came and attended to me. It all seemed unreal. I was put on oxygen. That morning I tried to sleep but couldn't,  but felt safe that I was in a hospital.

From next day onwards, as things started sinking in, as I got more aware of my breathlessness,I started assimilating things around me, inside me,  my being alone in a hospital , with no one by my side, with no one to hold my hand, no one to put hand on my forehead, an altogether different reality started developing. And the last straw on camel's back was the news that my dad passed away.

I felt the gravity of one singular reality, being alone, unable to breath, face to face with death,my dad's, my own. As evening light seeped through the huge window of my hospital room, I started experiencing darkness more intently than ever. Light was sustaining me to face my fears in the daytime but as night approached, the fear of death and darkness would a start a dance in my mind ,an eternal dance of life and death.

My ears would crave for the slightest human existence around me. The staff going about  doing their tasks outside, someone talking down the road, someone's steps approaching my room. I realised how important human company is, especially in a situation where uncertainty rules  and one is on the verge of life and death and all alone. That night I sudeenly woke up startled, at around 1 am and panicked. The oxygen mask , my saviour seemed like someone holding my mouth, not allowing me to breathe. A panic attack...I called the nurse and the staff of the hospital stood beside me holding my hand and I shall never forget that comforting touch ever in my life. The staff was in ppe, I didn't know the person, I knew only one thing, I have someone to hold my hand when my morale, mental strength, physical strength had hit rock bottom. All barriers of self and other disappeared. A feeling of calm dawned upon me.

My treating doctor Dr Sameer had been so encouraging throughout my journey that I cannot thank him enough. He himself used to be exhausted when he would come at around11 pm for his rounds. But relentlessly, without a  frown of irritation or annoyance he would encourage me to do the prone awake position to improve the perfusion of lower parts of lungs, guide me through the progress I am making and then talk to Sujit on phone to give him the updates of my progress. What  a blessing he had been through out this journey I made! I ssurrendered myself to my doctor. I trusted that whatever he would do would be the best for me and i don't have to worry about any medical apsects of mine. In fact, I deleted the fact from my mind that I am a doctor. I was just a sick living being wishing to live.  I experienced first hand how doctors are the frontline warriors in this pandemic along with  their team of nursing staff. How their lives need to be protected with right protective gears and why it is so necessary for the concerned authorities  to provide them with the utmost care and protection.The nobility of the profession struck me really hard and respect  for my fraternity grew multifold.

As I was suspended in the interim of life and death, the most striking realisation was that of kindness. How much love and kindness the world is filled with! People came forward to provide us with any support we needed, friends went out of the way to provide us with help in a very difficult lockdown situation, the hospital staff, right from the wardboys, mavshis, nursing staff, the canteen, the doctors took the responsibly of not only their respective tasks but went ahead beyond the call of their duty  to keep the morale of patient up so that they don't lose  hope.

How each every and every fibre of the fabric needs every other fibre to hold the fabric of humanity!

Gradually as blended with the surroundings, I started rooting myself in my one and half year long insight meditation practice. The mindfullnes practice teaches to witness everything eight in this moment, as it is, without judging. I started centering myself in the present moment, just witnessing what is happening niw. If i an breathless now, i am breathless. If ihace pain, i hace pain. If I am scared, I am scared. Nothing less, nothing more. Buddha's words used to ring in my heart 'In what is seen, there is just the seen. In what is heard, there is just the heard. In what is sensed, there is just the sensed. In what is thought, there is just the thought'. I held dearly to this 2500 years old wisdom. It's  nit that I was not scared, at times, fear did step in, but I was no longer scared of fear. Mind used to wander, chatter, think about untoward consequences but I used just witness those  and not draw any conslusions from that. I was being in the rawness of the present moment, not bothered about what arises in it. What arises, passes away.

It was a nightmare but it taught me more than a pleasant dream. It taught me about the kindness each one of us carries inside us, all the tilme, about  compassion, an innate human trait, an absolute contrary picture that we are made to believe in today's  times that world has lost love and kindness. 

Humans shall survive this pandemic greatly because of it's ability to reach out and help others with kindness and compassion, and that's  an absolute need of the hour.

It's  my humble appeal to each and every person to be responsible about one's own life as well as life of others, to stay safe themselves and help those who are in need.

It's in the worst of times that the best in humanity shines through the darkness and brightens up the world.

This pandemic may be the worst the world has seen in a century but I am also hopeful that this pandemic will see the best in the human species, the common singular foundation of which rests in kindness and compassion. And I am sure there would be many individuals like me all over the world who would have witnessed kindness in their own life right through all the uncertainty of sickenss, dying and death and would carry the light of kindness ahead to brighten up other's lives.

I write this as I await my discharge from the hospital in a day's time. I have been off oxygen mask since more than  a day now, without any discomfort or breathlessness. Sice three days cyclone Nisarga had changed the weather and from my window, I watched gushing winds, a downpour, grey skies. Today I look out the window, my only bridge to nature outside, and see bright warm sunlight hugging the trees, water-drenched leaves reflecting golden light, butterflies fluttering around merrily and a magpie robin singing. The cyclical nature of rain and sun, pain and pleasure reminded me of one thing, the joy of life.

Post-discharge

After coming back home and settling in the small comforts of home, I realised that I am not all well yet. I am able to do my daily tasks but breathing is still a bit laboured. I am continuing spirometry exercises. I have started my daily meditation  practice. I have started doing breathing exercises like pursed breathing exercise and abdominal breathing exercise. I am eating well, resting  well, sleeping well and taking the medicines prescribed by doctors. I am allowing my body to heal, keeping my mind calm. Now things  will take it's own course slowly. Our body has it's  own innate intelligence, what Alan Watts calls "innate intelligence of an organism". If we don't  meddle with it too much, and if we listen to our body and mind quietly and calmly, this 'intelligence' helps us at every step. 

Schooling in COVID- Summary of concerns

SCHOOLING DURING COVID PANDEMIC- CHALLENGES AND POSSIBLE MEASURES OF MITIGATION

A WRITE UP FOR THE STUDENTS OF THE STATE OF MAHARASHTRA STUDYING IN SCHOOLS OF THE STATE BOARD

                              

INTRODUCTION

Schools in Maharashtra have been closed since the second week of March 2020 due to the COVID Epidemic. This period was the least challenging as decision regarding impending exam was taken immediately and then schools took a break for vacations.

Several documents about maintaining safety from the CORONAVIRUS have been issued by various authorities. They can guide the measures for safety from virus. This write- up is exclusively about the issues related to child mental health- namely learning, development and prevention of mental illness.

STAKEHOLDERS AND POSSIBLE CONCERNS

1.      CHILDREN- Learning, Socialisation, co-curricular activities

2.      PARENTS- Safety, academic challenges, motivation for schooling, child minding

3.      TEACHERS- changed modes and teaching methods, job security, financial security, safety

4.      SCHOOL ADMINISTRATION- Safety of all, logistics of organizing, maintaining financial stability, ensuring compliance with regulations

5.      AUTHORITIES- ability to foresee and plan, be fair to all stakeholders, timely action

6.      MENTAL HEALTH PROFESSIONALS- prevention of mental health disorders, prevention of detrimental psychological reactions in all stakeholders but particularly in children, ensure adequate learning outcomes in children, maintain developmental trajectories in children, promote resilience and learning of coping skills

CHALLENGES

1.      Extreme heterogeneity of school settings- rural, semi urban and urban. And accompanying culture and priorities

2.      Wide disparities in facilities in schools- space, time, teaching aids

3.      Lack of examples that can be followed or at least used as a benchmark

4.      Children are low priority group and education is low priority sector and in context of pandemic and economic chaos- their importance has further gone down

APPROACH

1.      Children’s well- being must be the first priority

2.      All stakeholders should get a fair consideration. However, in case of conflict of interest, the child’s well being must be given precedence

3.      Guidelines should be timely and time bound. They need to be revised periodically to ensure gradual return to normal

4.      Feasibility should be considered

5.      All schooling methods should be considered

6.      Based on literature available about children’s health, development, learning and related areas

MITIGATION STRATEGIES

1.      Adjustment of syllabi

2.      Adjustment of pace of teaching

3.      Multiple modes of teaching- live online, recorded video, etc. should be flexible and contextual

4.      Consider greater contribution of parents and siblings including home schooling

5.      Modify role of schools as mentors and guides rather than only directly imparting education

6.      Include indicators of irregular school-work and learning problems

7.      Provide for assessments and remediation of learning problems

8.      Consider reasonable concessions for all stake holders