‘DOCTOR, TALK TO ME!’

From time to time, voices from the past beckon to us and provide wise counsel. Here is one such example.

Mr Anatole Broyard had served as an editor of the New York Times Book Review. He was also a friend of the celebrated columnist Mr Max Lerner. (In passing, may I recommend to you Mr Lerner’s book?1 You will be richly rewarded with his insights as this master of words describes his cancers and heart disease. While recommending Mr Broyard’s essay, Mr Lerner described it as ‘a classic plea for the kind of communication that is so rare’.) But there is much more in Mr Boyard’s essay2 than just communication.

The first two sentences of the essay captivate the reader. ‘I found that I had difficulty urinating. I was like Portnoy, in Portnoy’s Complaint…’ You will recall Portnoy, the literary creation of Philip Roth, and his fixations on his male member.

Mr Broyard was found to have cancer of the prostate that had spread to the lymph nodes and lower spinal column. He succumbed to it after a little more than a year of the diagnosis.

In this essay, Mr Broyard described how one educated and highly literate individual searched for a competent doctor. As he was being treated, just as his physicians studied his illness, he studied them. We are the beneficiaries of his findings and suggestions on how he would have preferred their interactions to turn out.

He describes the qualities he looked for. He wanted a doctor who had successfully survived the scrutiny of rigorous critics outside the medical profession. He sought earned respect that had provided the doctor a status. By knowing how to live, his physician could be expected to look after the lives of others. He cast around for a person ‘with a furious desire to oppose himself to fate’. He confesses a partiality towards charismatic physicians, combining ‘a dash of magic’ with medical ability. ‘I would like a doctor who is not only a talented physician but a bit of a metaphysician too, someone who can treat body and soul…Soul is the part of you that you summon up in emergencies.’

His father, an anti-Semite, preferred a Jewish doctor as the latter considered the loss of a patient to be bad business.

His own expertise in the use of words left Mr Broyard particularly sensitive to the way his physician used them.

‘My ideal doctor would be my Virgil, leading me through my purgatory or inferno, pointing out the sights as we go.’ (In Dante’s Divine comedy, the Roman poet, Virgil, serves as a guide up the Mount of Purgatory.) He expressed a partiality for Dr Oliver Sacks. ‘I can imagine Dr Sacks entering my condition, looking around at it from the inside like a benevolent landlord with a tenant, trying to see how he could make the premises more liveable for me. He would see the genius of my illness. He would mingle his daemon with mine; we would wrestle with my fate together…He would see that my sickness has purified me, weakening my worst parts and strengthening the best.’ (Dr Sacks wrote the preface to Mr Broyard’s collected essays on his illness.3)

‘I would not demand a lot of my doctor’s time; I just wish that…he would give me his whole mind just once.’

Physicians are commonly cautioned against being emotionally involved with their patient. Mr Broyard disagreed. Bemoaning the fact that most physicians do not delve into the inner being of the patient, he stated, ‘I would like to think of him as going through my character, as he goes through my flesh, to get at my illness, for each man is ill in his own way. Proust complained that his physician did not allow for his having read Shakespeare…A doctor’s job would be so much more interesting and satisfying if he would occasionally let himself plunge into the patient if he could lose his own fear of falling…Every patient invites the doctor to combine the role of the priest, the philosopher, the poet, the scholar. He expects the doctor to evaluate his entire life, like a biographer.’

The patient’s illness is a routine incident on the physician’s rounds but ‘for me it’s the crisis of my life. I would feel better if I had a doctor who, at least, perceived this incongruity.’

The reticence displayed by physicians dismayed him. The title of this essay was occasioned by the fact that his doctor ‘…did not talk very much – and when he does, he sounds like everybody else. His brilliance has no voice – at least not when he’s with me. There’s a paradox here at the heart of medicine, because a doctor, like a writer, must have a voice of his own, something that conveys the timbre, the rhythm, the diction and the music of his humanity, that compensates us for all the speechless machines…Whether he wants to be or not, the doctor is a storyteller, and he can turn our lives into good or bad stories, regardless of the diagnosis.’

He is aware of irrationalities in his expectations. ‘To be sick is already to be disordered in your mind as well.’

In the end he let his unconscious tell him what he needed. Introspecting, he recognized that for the doctor to be interested in him, he had to prove himself interesting. When he showed nothing but a greediness for care, nothing but the coarser forms of anxiety, it’s only natural for the physician to feel an aversion. ‘There is an etiquette to being sick.’

The last paragraph sums up the feelings that prompted the title. ‘Not every patient can be saved, but his illness may be eased by the way the doctor responds to him—and in responding to him, the doctor may save himself. But first he must become a student again; he has to dissect the cadaver of his professional persona; he must see that his silence and neutrality are unnatural. It may be necessary to give up some of his authority in exchange for his humanity, but as the old family doctors knew, this is not a bad bargain. In learning to talk to his patients, the doctor may talk himself back into loving his work. He has little to lose and much to gain by letting the sick man into his heart. If he does, they can share, as few others can, the wonder, terror and exaltation of being on the edge of being, between the natural and the supernatural.’

If this account should stimulate you to learn more from this author, look no further than his collected essays on illness, life and death.3 Writing about this book many years later,4 two authors commented: ‘…His words are still an excellent means of presenting the humanities as the source that inspires human experiences.’

CHAOS, IF NOT MADNESS IN THE WORLD OF INDIAN MEDICAL EDUCATION AND CARE

When political calculations form the principal yardsticks for planning and executing changes, meritorious criteria fall by the wayside. The consequences can be disastrous.

Budgetary allocations for public health and welfare

The state of Maharashtra consistently reduces its annual allocation for public health. When inflation is considered, the decline is even greater. The effects on existing government medical colleges and hospitals are obvious. Once at the acme of medical education and care, they are now worn out, run down and in dire straits. The few departments that continue to retain standards do so against odds. In contrast, the private medical colleges, set up for profit by powerful politicians, flourish, flush with funds generated by astronomical fees charged to medical students.

Inspections by monitoring authorities in Delhi have government teaching hospitals now mimicking the private hospital chains. Teaching staff are transferred from other hospitals to that under inspection so that gaps in professorial and other ranks are not evident. Inspection completed; the teachers are returned to their parent institutes. Non-functioning equipment, generally poor maintenance and lack of well-planned and comfortable hostels for students, resident doctors and nurses are other examples of the deficiencies at many of these teaching hospitals. Several campuses are in disarray.

Under such circumstances, the Government of Maharashtra has announced a proposal for the construction of medical colleges at 14 locations!

Blatantly overlooked are fundamental principles.

A new medical college and hospital must be of a higher standard than the best of those existing in the state. The rationale for this expectation is that founders now have available to them experience (local, national and international) and the best of present expertise and technology.

The soul of such institutions lies not in concrete, steel and equipment but in the minds and hearts of those forming its staff members. When present colleges lack teachers and hospitals lack clinicians, where are the new institutions to obtain its experts? We have no reserve pool of competent, dedicated and willing teachers. As noted in earlier editions of this letter, even the new All India Institutes of Medical Sciences are struggling to fill their ranks.

The healthcare system has medical colleges and their hospitals at the apex of a pyramid. What about the rest of this edifice, especially its base formed by primary health centres? These humble clinics are expected to be self-sufficient and efficient. My conversations with interns working in them at present are disheartening. The medical officers in many of them are self-serving and incompetent. Drugs and other supplies are pilfered so that when the poor villager or tribal seeks succour, she is asked to buy necessities that should be rightly supplied free of cost. The less said about surgical procedures carried out in these centres, the better.

Systems for referral from primary to secondary to tertiary centres and vice-versa are tragically inadequate. The newspapers are full of accounts where no ambulance is available to take a seriously ill person or a woman in advanced labour to a competent centre. Deaths have followed such failures. The stock reply by those in power to reporters enquiring into cause and solution has been, ‘We are looking into the matter.’ No action seems to follow.

DEEMED UNIVERSITIES AND OTHER SIMILAR MEASURES

In 1947, the University of Bombay had an exalted reputation in India and abroad. Medical colleges affiliated to it were likewise respected.

Much water has flown under the bridges since. In 1998, the state government detached the medical colleges and affiliated them to the Maharashtra University of Health Sciences. Private medical colleges were permitted to flourish. Those expecting that these ‘developments’ have raised standards and the reputations of our medical institutions should be classified among bird-brained dreamers.

As though this multiplication of bureaucracy and catering to rich and powerful politicians were not harmful enough, since 1956 medical colleges are now enabled to set themselves up as ‘deemed universities.’ The term, itself, raises a question.

A university is defined as an institution that provides the highest level of education, in which students study for degrees and in which academic research is done. To be deemed ‘university’, an institution should have a consistent, long-term reputation on standards, especially regarding teaching and research. The patriot would hope that our universities will strive to attain the reputation of their counterparts in Oxford and Cambridge, England and, across the pond, those such as Harvard and Yale.

As far as I can tell, Maharashtra has at present, eight medical deemed universities, all of them in the private sector. I wonder how many of our deemed universities truly meet the definition of university in the previous paragraph.

Clarity dawns when one seeks the reasons for seeking distinction as a deemed university. These have the right to set their own standards, design their own courses, award their own degrees and decide their own fees. They are, in theory, to be monitored by the Universities Grants Commission.

I tried to learn of the performance of deemed medical universities. There is no separate portal for it, all deemed universities being lumped together. The performance portal can be accessed at https://deemed.ugc.ac.in/PerformanceMonitoringOutcome/Home/Index. From 2016 to 2018, the total number of publications from all deemed universities hover at the same level, around 25 000 per year. There is no note on the quality of these papers.

Information on detailed assessment of each of the medical deemed universities from 1956 would yield much food for thought.

NEED FOR SCIENCE JOURNALS IN INDIA

There is a crying need for good journals promoting and spreading reliable information on advances, development and techniques in science in general and medicine in particular to our lay public.

We have excellent examples abroad which can serve as models. Scientific American, Popular Science, New Scientist, National Geographic, Science and Discover are some examples from the English-speaking world.

India does have a few noteworthy publications. Current Science was founded by such stalwarts as Drs C.V. Raman, Birbal Sahni, Meghnad Saha, Martin Forster and S.S. Bhatnagar. It published its hundredth volume in 2011. It frequently features essays, book reviews and news items on medical topics.

Science Reporter was launched in 1964. While the coverage of medical topics is somewhat sparse, it has the praiseworthy SciencSpark—a blog where youngsters from the age of 15 years are encouraged to contribute.

Resonance saw the light of day in 1996 and is aimed at undergraduate students and their teachers. The medical sciences do not feature in its core subjects.

Some specialized journals are of interest to the lay public as well and among these, we can list The Journal of Bombay Natural History Society (published since 1883) and Sanctuary Asia (published since 1981). As their names suggest, they focus on nature, wildlife, conservation and natural history in general. The former journal had eminent medical experts on their editorial board from time to time, especially when the study of nature in general was very much within the domain of the physician. Some examples: Dr G.A. Maconachie, Dr Lt Col K.R. Kirtikar, Dr Mrs Edith Pechey-Phipson and, more recently, the virologist, Dr A.N.D. Nanavati.

A notable venture in the private sector failed for the wrong reason. Science Today (launched in 1966) was edited by Mr Surendr Jha for the Times of India group. His own academic interests and dedication soon made it popular. He successfully sought contributions from leaders in the field. As was later noted with other journals published by this group as well, academic success did not impress the owners. Lack of what they considered important—burgeoning advertisements— eventually forced closure of this journal in 1992.

Two magazines published by pharmaceutical companies and distributed gratis to physicians had large followings, when they were shut down.

Ms Geeta Dethe was earlier editor of Medical Times. She then took over the production of Pulse, produced by Sandoz Pharmaceuticals (later Novartis) in India. It carried interviews with eminent doctors, featured the history of medical colleges and institutes and generally informed us about history, medicine and, of course, pharmaceuticals. Ms Dethe lives in Pune.

Housecalls was published by Dr Reddy’s Laboratories and edited by Ms Ratna Rao Shekar. It followed a pattern like that used by Ms Dethe but had the added advantage of resources for the editor and select reporters to travel not only to different parts of India but throughout the world for interviews and on fact-finding expeditions. Its accounts of the development of medical colleges and institutions were more detailed. Historic photographs were obtained from senior professors and archives. An excellent artist converted photographic images of edifices into paintings. Individuals featured in biographical essays ranged from Drs K.S. Sanjivi, Prakash N. Tandon, the Aroles, Farokh Udwadia, Badrinath, P.K. Sethi, K.C. Gangwal, and Indira Hinduja to Madan (Laughter) Kataria, Kaveri Nambisan and Hemant Morparia. Each of these pen portraits was accompanied by photographs of the individual, members of the family and the institutes where they worked. An invaluable feature in several issues was the essay on ancient Indian medicine and its principal figures by Dr Bhanu Shankar Mehta, historian based in Varanasi. Were these to be collected and published, the resultant volume would constitute an important source of reference for medical students and others. Ms Shekar now writes and publishes books and essays and edits another journal from Hyderabad.

I am unaware of the reasons for their closure. They had served an important function, all the more relevant as they could be accessed even by those lacking funds.

I do hope bound volumes and stray issues of the two magazines referred to above are available in our medical college and institute libraries.