The Games We Play

I had done well. A grateful Mr Smith. A bottle of wine and that nice, warm feeling you get when all ends well.

Mr Smith, the smoker. 40 plus a day and no less.

Mr Smith, the keen jogger. 6 miles a day and no less.

Mr Smith, the man who had just crossed the milestone of 50 years.

Life was good for Mr Smith, but lately this had been disturbed by those odd twinges of pain in his chest, which had resulted in three hospital admissions. Each time he had gone through the same ritual: rushing ambulance, siren screaming, light flashing. Serial ECGs. And ouch! Those numerous needles and cannulations. And each time after a stay of few hours in hospital he had been sent home with a little discharge note: “Non-cardiac chest pain. ECGs, Troponins normal.”

The ritual was getting boring and Mr Smith anxious.

“Why doctor, have I not seen a cardiologist after so many hospital admissions?”

“Because, the chest pain was not from heart?”

“How can you be so sure? How can those doctors be so sure? You are not the specialist.”

“Um..you are worried about heart attack…um…smoking….”

“Lets not go there doctor. Will you please refer me to see a cardiologist?”

And I did.

Dear Cardiologist,

This man has presented three times to the hospital with chest pain and on each occasion all investigations were normal. He is lean and fit and runs 6 miles everyday. His biggest risk factors are his age and smoking. The first one no one can help him with. As for the second he does not want any help. He is very anxious about these episodes of chest pain and has requested your valued opinion.

Thank you.

The good, wise cardiologist knew the secrets of his trade well. He made Mr Smith run on the treadmill.

A few minute on the treadmill for the man who runs miles everyday. Cakewalk.

The verdict: “Fit, no cardiac problem.”

A verdict from a specialist is special and means so much.

Mr Smith was happy. Satisfied.

But what if, what if there was a slight abnormality on the exercise ECG? Remember what happened to George W Bush? And what about the biggest modifiable risk factor for Mr Smith? Has he been falsely reassured?

Mr Smith, the running steam engine bellowing smoke on the street.

Oh, what a silly way to trouble my little brain with all these mundane worries.

Time to go home and enjoy the wine.

_________________________

On the Bush story:

Huffington Post

The Washington Post

Live Science

A blog post by Dr Richard Bogle, cardiologist on a recent paper from the COURAGE study that questions the wisdom of stenting  narrowed LAD, a lesion commonly known as a “widow-maker”. Head versus Heart, Emotion versus Science

The Coronary Artery Entrapment Dr Bernard Lown reflects on how medicine has transformed from a humanitarian profession to a costly technocracy.

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Kunti Bai

The lampshade was swinging gently, casting a penumbra on the ceiling of the old, dilapidated World War II army barrack that served as the Health Centre to the neighbouring residents. The residents were mostly from slums and in the Delhi of late 1990s more and more slums were springing up everywhere. An old fan whirred in the background. It was the end of a long summer day.

June in Delhi can be stiflingly hot and the air, in anticipation of monsoon, can become so thick with humidity that you wish for a pair of gills rather than lungs. But, the beads of sweat on Dr Joseph’s forehead were not just from the heat and humidity. The stench from Kunti Bai’s clothes, the last patient of the day, still wafted in the air.

The condition of Health Centre was poor, as were the patients that went there. There was usually not much to offer apart from a parcha, a prescription, for this tablet or that. But people nevertheless queued up noisily and gratefully accepted that valued piece of paper. Did they have money to buy the medicines prescribed or indeed if they really needed that tablet or tonic, or was it the poverty and deprivation that needed addressing? Human brain is good at blocking out such troubling thoughts and growing up in India is often a good education in that.

In those days I would meet Joseph at the Centre every Saturday evening and we would walk to the nearby Sardar’s Dhaba that served cheap whisky and the most exquisite tandoori chicken. We were both in agreement that this was good for our soul and eagerly looked forward to those happy Saturday evenings.

Despite the stench and heat in his office, that evening, I could immediately sense that Joseph preoccupied with some thoughts. He acknowledged me with a gentle smile, “You know I have had an amazing experience today.” He went on to tell me about Kunti Bai. She had presented to him a few weeks ago with her fist pressed against breast bone, “It hurts here doctor babu.” Joseph ascertained that the pain was usually on eating solids, which seem to take an inordinately long time to pass through her gullet.

Joseph, the dedicated and ever resourceful doctor, concerned that there might be something nasty going on with Kunti’s gullet had managed to arrange a gastroscopy for free with a gastroenterologist friend of his. Much to his relief nothing nasty was found.

He reassured Kunti, “Bai its all fine. Nothing to worry. Eat regularly and all will be fine.”

Kunti’s reaction startled him. “Babu, why does it keep hurting like this,” she asked tearfully.

Joseph was used to seeing these dislocated, isolated new migrants to the throbbing metropolis that Delhi had become. Sensitised as he was to the many traumatic experiences of relocation and the distant, often demeaning, harsh realities of the daily life in a metropolis, he touched Kunti’s hands and gently asked, “What is hurting you? Why do you hold your chest like that?”

A wall of silence met his questions, but not for long. Soon tears rolled off her eyes as she narrated the story of her family loosing their land in her village. Then she had to leave her family behind to earn money and ended up in Delhi. Got married to an alcoholic, who regularly abused her.

“Could this be causing the pain?”, she asked tears still rolling from her eyes.

“Perhaps”, he replied, his mind furiously thinking which social worker or charity would be most supportive and helpful for Kunti.

“Doctor Saab, thank you. You have listened to me as nobody ever has. Thank you again for all the help”, Kunti left refusing any further help.

“I just can’t understand why she refused help”, Joseph said guiltily over the glass of whiskey. He seemed to blame himself for her refusal to accept help. It was then the cleaner from the Health Centre turned up. Predictable as we were, he knew where to find Joseph.

“Saab, I found this bag in your room as I was cleaning it.”

Joseph immediately realised that it was the ragged bag that Kunti came with. It felt curiously heavy and we could not resist the temptation to check its content. Out came one prescription after another, results of one barium swallow after another. We could find at least 3 different endoscopy results. All were normal.

The whiskey was already having its effect and the brain felt too tired and exhausted.

“Can you please take this to Kunti’s shack and return it to her?”, Joseph requested the cleaner softly.

Kunti’s behaviour was baffling and I admit feeling angry at her and sorry for my friend. My friend’s trust and care felt betrayed. It did not make sense. She had no money and was doctor-hopping. Managing to get investigations that she no longer needed. Probably also refusing help that she needed. All this to what avail?

With years Kunti receded from memory and the life went on.

Jhumpa Lahiri in her Pulitzer Prize winning book Interpreter of Maladies has a story “The Treatment of Bibi Haldar”, which brought back the memories of Kunti Bai. Like Kunti, Bibi Haldar suffered with a mysterious ailment. It is a story of a lonely, destitute woman’s life. “Apart from my X-rays, I have never been photographed,” she says. Likewise Kunti Bai had X-rays, but never had that metaphorical photograph, which might have helped to understand the person that she was. “Treatment” in the title refers both to that prescribed to cure her condition, and the way she was treated by her family and by her community. I cannot help but wonder what treatment Kunti Bai ended up getting.

There are many layers to the dialogue that happens between a patient and the doctor. Indeed, as John Launer writes in Therapeutic Dialogue there are more people present in the conversation between a doctor and patient, all struggling to make sense of each others’ stories, to the best of their ability.

It is inevitable that the stories that a patient brings to her doctor will have more players than present in the room. It can be difficult for the doctor to sift out “medical” from “non-medical” if indeed that is possible. This can be frustrating, but I think it is something to celebrate.

Iona Heath writes: “Illness begins as a subjective sense of bodily unease, an experience of the functioning of the body as being not quite right. It is often very intangible and the sense of unease arises not just from what we have come to recognise as disease but also from other forms of distress including tiredness and unhappiness, misery and grief.”

I, like many of my colleagues often struggle with what can be regarded as “non-medical.” But, I do not think that we can ever really escape that. I cannot agree with that meagre view of humanity that many people seek medical labels to have an “easy life” on benefits.

I have beliefs which may be naive and foolish. This may change over the years, but so far my years as a doctor has only strengthened my belief in humanity. At the same time I have realised the limits of my imagination, which prevents me from better understanding the conversations that take between doctor and patient.

I am still learning.

Happy Holi!

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Sam

As a medical student I thought if I knew the textbook well I will be fine. Hours were spent desperately trying to memorise all the mundane terms, definitions, classifications. The path to nirvana was in book.

Books gave me the vocabulary. I could doctor-speak. But it did not take long to realise that there is a lot more to caring. Still a young doctor I realised that I had to be able to relate to my patients. And that came surprisingly easy. I felt that warm glow within and realised that I will be fine.

Sam was a lively young teenager with all the awkwardness not-a-child-any-more and not-a-grown-up-yet brings. He had a passion for cricket, but was also increasingly curious about girls. He liked to talk about them and the opportunities to do so were getting more frequent. His chronic leukaemia was in a blast crisis and this meant that he was spending more and more days in hospital. I often wondered whether these frivolous chit chat during chemotherapy sessions made my life easier for the writing was on the wall. We began preparing each other. And I felt that intimacy with Sam, his father, mother, sister that only grief brings.

Yet, when the end came it was sudden, too sudden. Expected, yet completely unexpected. It was over in a matter of few minutes: a massive bleed somewhere in his upper airway as we were happily chatting. He drowned in his own blood and I could do nothing. That was horrible, but it was the rage of father that was even more unsettling. His grief turned into anger. Sharply and pointedly directed towards me.

Many years have gone by and I kept trying to understand what happened then. Why was he so enraged at me? I kept hurting.

No longer a young doctor, I think that this was a different type of emotion: a father’s attempt to hurt me to ensure that we were both hurting. After the weeks of extreme intimacy that we had shared it was perhaps only appropriate to hurt and grieve together. Another lesson they don’t teach in medical school.

We are emotional creatures capable of occasional rational thinking. Perhaps I am just rationalising, but I know that I will be fine. I hope Sam’s family also found peace.

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The Menace of Specialism

Dear Doctor,

Thank you for making me see this pleasant man. While X-ray shows a moderate degree of arthritis he has the most beautiful set of knees. I remember enlightening this man last year that he may stake a claim for a new set knees only if he remains in pain despite maximal analgesia. You failed to try anti-inflammatories and have instead asked me to see him again. He has told me that anti-inflammatories were not tried as he has a history of bleeding gastric ulcer that nearly killed him a few years ago. I gently reminded him that I deal only with knees and for problems like that he needs opinion of a different specialist, namely gastroenterologist. This pleasant gentleman kept moaning how his knees were making it hard for him to care for his wife with dementia. Again, that is a wrong problem to tell me about. I am a knee specialist, but I think he and you should be contacting social services for that.

We had a rather animated 30 minute discussion. I have clearly explained to this man that my conscience does not permit me to offer knee replacement until he has done the sufficient amount of suffering. At this point this pleasant gentleman let out a loud cry and stumbled out of the room holding head with his hands. I think, he has suffered a subarachnoid haemorrhage and believe that he should be referred to the Emergency Department. I leave that decision in your competent hands.

I have made arrangement to see him in three months.

Yours sincerely,
Mr Knee-Expert

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Cancer Myths, Hypes and Hopes

Here is a concept as half baked as it comes. On the big C word. I have pondered for a while on this and wrote what follows a while ago. But that did not go down too well with colleagues and I hesitated to share. A concept should be regarded as a work in progress and hence half baked and should be discussed openly, with respect and restraint. I acknowledge Straight Statistics for much of what follows.

Cancer care statistics are frequently used to bunk or debunk a healthcare system. It is a very complex area and consequently allows sufficient room for the tabloids and politicians to argue their points of view.

Guardian had this headline:

NHS cancer figures

This was based on a study by Prof Colin Pritchard in the British Journal of Cancer that showed that the NHS in England and Wales had achieved “the biggest drop in cancer deaths and displayed the most efficient use of resources among 10 leading countries worldwide.”

This is the conclusion based on mortality data.

Cameron and Lansley’s attack NHS was based on the study in The Lancet by Prof Coleman that was based on the numbers who survive cancer rather than who die, i.e., survival. They had concluded that “survival had improved in all the countries studied, but was persistently higher in Australia, Canada and Sweden, and lower in Denmark, England, Northern Ireland and Wales.”

Many have noted that Denmark also employed GPs as gatekeepers and concluded that as NHS restricts patients from referring themselves directly to specialists it will never be able to match the performance of other systems. This is an inference not directly supported by the data, which needs cautious interpretations.

Consider this graph is from the Lancet paper:

ColemanLancet-lung_mortality

This would suggest that while mortality from lung cancer in falling amongst men, it is worsening in women. And this is not only in UK, but worldwide. Surely we should getting all the feminist groups and women together to protest against sex discrimination!

Indeed, that is not true. Lung cancer mortality in women is rising as the incidence rate in men has fallen rapidly while it is increasing in women. This is because more men than women have stopped smoking. The survival rates remain the same for both sexes around 10% throughout the 25-year period from 1980-2005.

ColemanLancet-lung_incidence

According to Dr Laura Woods and Prof Michel Coleman from the London School of Hygiene and Tropical Medicine, same team whose paper was used to trash NHS, there are 3 main measures in cancer epidemiology:

  • Incidence
  • Mortality
  • Survival

Screening, early detection, increased awareness are among the factors contributing to increased incidence. Intuitively, catching it early should result in better care, better outcomes. One big disappointment has been that evidence is hazy for most cancer. A lot of people find this upsetting, but that is what the data is suggesting. This “war on cancer” may have resulted in overdiagnosis and overtreatment and there has been a flood of articles on this in BMJ and elsewhere recently. A recent book by GP Dr Margaret McCartney The Patient Paradox: Why sexed-up medicine is bad for your health a very readable primer on this topic of great importance.

Indeed, in their BMJ paper, BMJ 2011; 342 doi: 10.1136/bmj.d3399 (Published 9 June 2011)

Coleman et al had concluded:

The question has long since ceased to be whether such unacceptable differences in cancer survival exist. The question is what the underlying mechanisms are and what can be done to improve the outcomes for patients with cancer in the UK.”

This is clearly a very complex area. Some say science is better at allowing better questions to be asked than providing answers. Some of the questions that arise in my mind are:

- what factors influence cancer care in UK?

- what can I as a GP do to improve care?

- what is the role of deprivation?

- what can be done to reduce the risks of getting cancer?

In The Emperor of All Maladies Siddhartha Mukherjeewrites “Even…‘most fundamental measure of clinical outcome’ – death – was far from fundamental. Death (or at least the social meaning of death) could be counted or recounted with other gauges, often resulting in vastly different conclusions. The appraisal of diseases depends…on our self-appraisal. Society and illness often encounter each other in parallel mirrors, each holding up a Rorschach test for the other.”

Patients presenting with symptoms and red flags need appropriate work up. But, we should still be open to what we might be missing out in the pursuit of diagnosing cancer earlier and earlier. It might be a lot more than what we suspect.

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In Our Name

This is such a wonderful movie. In life’s experiences trauma comes easy, coping can be hard and often victims may even lack the insight to their situation. Fear of stigma does not help.

This is my take on the film:

The gurus of medicine have always expounded that a good doctor sees the patient’s plight through their eyes. So here I was facing her, leaning just slightly forward, facing her fully with a hint of head tilt mirroring hers. I was even trying to match her breathing pattern. I felt her sadness, her anxieties, her fears. By the end of the day I was also feeling her paranoia, but was too anxious, too afraid to discuss with anybody, lest I am judged unfit to practice. In pain, lost in the isolated landscape of human suffering.

That can be your doctor too.

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Florence’s Symptoms

One thing that often frustrates me is the difficulty in trying to understand my patient. This happens more frequently than I would like to it to be.  More worryingly it often passes under my radar of self-awareness. It can be hard to resist the relief of giving a “diagnostic label” and treat that label.

What follows is an extract from a book that has been a great solace and inspiration. After a hard day this has helped me recharge my soul and return to work the next day rejuvenated. Thankfully, most patients I see are nowhere as daunting as Florence. Or, may be they are and it is my lack of imagination that is the limiting factor.

I hope you will find it inspiring as well.

 

 

“I am Florence’s mother, I am a paranoid schizophrenic and she is too. This is her husband, whom I despise. What do you mean by telling Florence she cannot see another doctor?”

Florence’s list of symptoms by the end of sixth week of visits included:

Headaches

Double vision

Itching ear canals

Deep pain in her throat

Shortness of breath

A dull chest pain

Fullness after eating

Pain with menses

Burning on urination

Difficulty urinating

Painful

Bowel movements

Constipation

Difficulty swallowing

Pain on swallowing

Aching lower legs, arms, thighs, and shoulders

Periodic nausea

Dark urine

Painful intercourse

Irregular menses

Crawling sensations under the skin of her face

Intolerance to several foods

Dizzy spells

Spots in her field of vision

Abdominal swelling

Swelling of her hands and feet

Red blotches on her neck

Hair falling out

Weak spells but no loss of consciousness

A feeling of impending doom

Sensations of being hot and cold

Tingling sensations in her legs

Decreases in visual acuity that would come and go

Episodes of severe abdominal pains

Loss of energy and tired feelings

Feeling sick all over

She told me early that she was absolutely convinced that she had a very rare disease that was beyond medical science. I…kept telling her, “I do not know what is wrong with you…yet.”

I never told her that “nothing was wrong” with her. I also resisted the common course of telling such a patient that the problem was “all in your head.”

There were at least two other prevailing strategies for dealing with patients with many symptoms. The, first, and the most dangerous, was to make a diagnostic error and assign a false diagnosis to the patient. The other common way of dealing with these patients was to make up an innocuous diagnosis and assign it to them. What I was attempting with Florence was to abandon all these common approaches, stay completely honest, and see where it led.

I now had a very long list of diseases I knew she did not have, and in some sessions, I would read the list very slowly to her. I would go on and on in boring details, dragging out my list of absent diseases.

Then one day as I was going down the list of diseases I knew she did not have, she started to laugh. She laughed, and laughed until her eyes were watering. I waited. After she collected herself, she said, “Okay, this is getting ridiculous, it’s ludicrous, that’s what it is. It’s ridiculous.” She looked very puzzled and sat there saying nothing, staring out of the window.

I must have waited ten minutes. I could hear Sapira in my mind’s ear. “Hold out…hold out…use pauses; let the patient speak first whenever possible.” it was like holding my breath too long under water. Then she said, with some hesitation, “I need to think. I’ll see you next time,” and she left. This occurred at the end of ninth month.

The next time she came in, she looked very different from any time before. “What do you think you have?” I asked.

“I think I have lice under the skin of my body, and I know they are eating my hair follicles.” She blushed and looked embarrassed.

I asked her what test she thought I should do to prove the diagnosis right or wrong. She went on to tell me that she wanted me to biopsy her skin and find lice.

“What else might convince you that lice infestation was the one and only disease that you have or would convince you that you do not have lice? What can I do that would do that for you?”

She thought for several minutes and said, “Treat me for lice and I will be satisfied.”

After much thinking and soul searching, I came to a decision. I had pharmacist prepare a very dilute solution of Qwell lotion. On the next visit, I wrote her the one and only prescription I had written for her in the nine months I had been seeing her. I suggested she apply the lotion to her whole body twice daily for ten days. I did not want her to miss a spot, so I spent some time telling her exactly how she should apply the liquid. I put myself into whatever mental gear I thought might increase the potency of the placebo, if a placebo was going to work here.

She smiled as I handed the prescription to her, and then she said, “But you do know, don’t you, that you must treat again in two weeks to kill the eggs that hatch after the first treatment?”

Florence returned with her husband. Both were all smiles. She looked like an entirely different person – confident and very outgoing. She often deferred to her husband, who thanked me again and again.

Both talked about their future. He was going to go to graduate school, in geology, I believe. She would finish her Ph.D. In history and had a job lined up with the university library research department.

We did not talk of any symptom nor did I ask Florence how she felt.

Adapted from:

Image

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