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