Why do Indian doctors refuse to work in villages?

This post was originally an answer in Quora for the same question

This is often a derisive topic among the general public, the politicians and the doctors. I also feel that people talk and pontificate without knowing ground realities. People expect altruistic qualities from their other countrymen while they sit and criticize everyone including doctors. So for those willing to understand what the issue is here are a few reasons why doctors are refusing to work in rural areas.

Infrastructure
The government hospitals in big cities like Bangalore, Kolkata, Mumbai, Delhi, Chennai, etc themselves are not the among the best in infrastructure. Even the basic infrastructure already present is poorly maintained. Most days in a month the CT & MRI scanners are not working. This is more like a rule than the exception.  So too the instruments, microscopes, endoscopes, cautery machines and expensive diagnostic equipments suffer from the same fate. If for some reason something stops working, then it wont be fixed till the end of the year or sometimes never at all. This is the story in big cities. So expecting any kind of infrastructure in a rural set up in India is like day dreaming. 
There are hardly any drugs that are supplied to the Primary Health Centers (PHCs). At the most you would get one huge carton of Paracetamol and a 5 cartons of Diclofenac injections (painkiller) and 10 cartons of Sterile water injections (yes water!) and many more cartons of syringes to inject these. These are highly inadequate to run any kind of village health program. When antibiotics are required, even when the patient can afford (rarely) to buy there is not a medical shop for the next 20-30kms (the nearest town). How would a doctor who has put in so many years getting a medical degree feel in this situation when he can't even treat the people around him. When people do not get better how will they trust him/her? 
Some people would say why not refer? I worked in some villages 20kms from Mysore during my rural postings during internship. When we want to refer, the patient doesn't even have money to take a bus to the city. We would sometimes have to pay from our own pocket or even take them ourselves to ensure they go. If a patient with a simple throat infection has to be referred to the city for treatment it shows the dismal state of our rural healthcare. Imagine the plight of that helpless doctor in these circumstances.

Personnel
The recruitment for the PHCs is from the state public service commission (PSC). In Karnataka, one of the more prosperous states in India more than 50% of the slots remain vacant. Why do you think? The corrupt officials running the KPSC always recruit less even when enough applicants are present since keeping the demand high is very good business for them. The going rate of bribe in Karnataka for a PHC doctor's job right now is around 1.5-2 lakhs. The job has a listed salary of Rs. 30,000 - 42,000 pm! Many of the applicants are recruited on an ad-hoc basis streching from 6 months to 2 years and then the whole process starts again. Giving permanent jobs reduces the officials' black revenue.

Now we have one politician who wants to win the next election. Who can he target? Oh the new medical students graduating out of medical colleges!!! Give some speeches of doctors only making money in cities and not serving the poor, put in some fines, threaten their PG seats and the job is done. If not the media does the rest. After a year of this forced labour where the doctor is given no agenda nor help to set up anything in a village,  he's just kicked out in the open. If that student really wants to serve the villages for a few more years he has to put in all the efforts I mentioned in the previous paragraph. Will any sane man do this? I fail to understand who is benefiting from this futile exercise?

Then comes the specialists and superspecialists who are posted in the peripheral community health centers without even basic infrastructure or even a semblance of an OT. You won't get gloves, linen, sterile instruments or even clean bed in these hospitals. My oncologist friend served his 3 year govt bond after his post graduation in a remote village in Tamil Nadu. He spent everyday of those 3 years referring patients to the city, most of whom never reached there. Forget chemotherapy and radiation the medical college he served in did not even have pharmacy to buy drugs. My Orthopaedic (bone) surgeon friend served a year in a community health center doing everything from delivering babies to making house to house visits of every panchayat leader in the villages around. There were no mid-wives even. He hardly fixed a bone the whole year because there was not even material for the cast. He could not even buy it himself because his salary never came and he quit after a year. How is this stupidity helping improve rural health? Is this the best use of the specialist's expertise?

Administration
I have many of my friends working in PHCs. There is a huge hierarchy in the government medical service where too many people in the middle are hardly working. The doctor assigned responsibility of a PHC is not given autonomous control over the running of the same. 50% of his/her time is spent in CYA* in the administration rigmarole set up by their superiors to escape blame for anything wrong that happens. Rest of it is spent in seeing patients, managing lower level staff, putting up with all kinds of nonsense from the villagers, inspecting the whole village for any risks of Dengue, malaria, gastroenteritis etc. and of course getting frustrated at the system. Even the staff under him is not under his control. He cannot even fire the group D staff of the PHC he is supposed to be heading. There is so much administrative burden on this one single man and he's not even trained to do that. He just has to jump into this dirty puddle and learn to swim by himself. All he really wanted to do was help treat people in the rural areas.
*CYA- cover your ass

No scope of progress
There is no clear career trajectory for a doctor working in a rural area. They may get some reservation in the PG entrance exams but if you continue to do primary health care in the villages you don't go up the ladder at no time during your job. You will keep doing the same job at 60 what you were doing at 25. There is no mentor, forget that- not even someone bothered whether you are progressing. How would you feel to be an intern throughout your life?

Security
Forget it. I won't even speak about it. We can't seem to protect the doctors in the cities how will we even think of those poor village doctors?

Pay
I put this in last, lest people would comment how inconsiderate thinking about paying a doctor. I don't have an issue with the salaries posted but I am bothered by how they pay. 
Let me give you an example to explain. Four friends of mine are serving in PHCs in very remote villages where no doctor wants to go. They are working there because it is closer to their home. They haven't received their salaries since 6 months!!! They have a protest about this for one day and the media vultures eat them up. I know people expect doctors to be so altruistic that they should work for free but which job in the world gets done if you don't pay people for 6 months at a stretch? 
You demand why this happens and they say this minister has to release the funds and that official has to sign the papers, so it takes time. 
So how do govt employees like Bus conductors, Bus drivers, bank officials, group D and other govt officials like IAS, IPS, IFS get their salaries on the 25th of every month without this "inevitable delay" ? 
Because if you don't pay these people on time they won't turn up to work next day. Simple as that.

I'm sure there will be people disagreeing with everything that I've said above and then go on to complain about the rampant corruption among doctors, commissions they receive and sub-standard care of someone they knew. There are many people in India who are like an ostrich with it's head in the sand and thinking everything is all right. They expect solutions to fall from the sky. If they can blame it on someone else their job is done. But I would like someone to suggest how anyone would be able to improve the situation in rural areas without putting the onus on unpaid, ill-treated and frustrated doctors. 

Can someone suggest a good enough solution? 

"OMG!!! How can they ask that?"

Eulogy to Dr. APJ Abdul Kalam

The first time I saw Abdul Kalam in person was when he inaugurated the free school built by JSS Mahavidyapeeth- A Hindu religious institution which owns my Alma Mater- JSS Medical College, Mysore- in 2002.

That in itself speak volumes of the kind of unsurpassed respect he commands across all of India without any barriers of politics, religion or politics of religion.

Before this visit I had only heard and read about the "Missile man of India" from the TV and newspapers. I was was in 1st year of my medical school. We were all supposed to attend the the inauguration but all of us went there happily to hear the great man talk. He spoke to all present there- school children to college professors- in his usual child like demeanor. He asked about 10-12 school children to ask him some question. He was very impressed by some deep questions.

One child asked him.
"What is the most dangerous weapon in the world"
He thought about it for a few seconds and replied,
"Ignorance"

I remember this like yesterday even though it happened nearly 13 years ago. He absolutely nailed it with just one word. This is the kind of impact he has on our consciousness. An unapologetic dreamer, inspiring grandfatheresque figure and an optimist who breathed positivism with every word that he spoke.

Why was he so universally loved and celebrated?

He removed all the useless fluff from the presidential office. He made the president more approachable. He actually lived the life of the first citizen in it's true essence. At the same time he elevated the office of the President from the ceremonial rubber stamp it was perceived to be before he took over. He gave the office purpose and a stand.

In a country bereft of visionary leaders he truly proved to be a leader. Among all the chaff we had a gem. Whether it was his India 2020: A Vision for the New Millennium or his very famous lectures he was always a man thinking of how we can change rather than complain why we haven't. He put his point across with such an innocent charm that we were taken by him. A scientist- Statesman- Patriot that India badly needed at the time.

"A developed India by 2020, or even earlier, is not a dream. It need not be a mere vision in the minds of many Indians. It is a mission we can all take up - and succeed." -APJ Abdul Kalam

I've read his books Ignited minds and his autobiography- Wings of fire.

Very simple in the prose that it almost seems like a high school kid has written the books. But the ideas in the books were so powerful that it can shake the whole nation. He writes about his early struggles as a scientist in ADE, DRDO and finally in ISRO. How he overcame failures to finally make India a nuclear power to reckon with.

“Thinking is the capital, Enterprise is the way, Hard Work is the solution”
― A.P.J. Abdul Kalam, Ignited Minds: Unleashing the Power Within India

“Your children are not your children. They are the sons and daughters of Life's longing for itself. They come through you but not from you. You may give them your love but not your thoughts. For they have their own thoughts.”
― A.P.J. Abdul Kalam, Wings of Fire

He taught us to dream despite our limited resources and assured us that only our dreams can take us forward and make us do more than we are now. I wrote a poem after reading his book- Wings of fire about dreams.

I do not want to list out his scientific contributions which are so well known already but would like to mention that he had a significant role to play to get the India-US nuclear deal pass the parliamentary test. Like a true patriot he managed to convince a populist leader like Mulayam Singh Yadav to support the deal, which finally went through.

He supported something very close to my heart: education. A boy, distributing newspapers in Rameshwaram eventually reaching the highest office in the country was only possible due to education and he understood that all too well. His love and dedication for children was fueled in no small measure by this basic understanding of his.

"Black' Colour is Sentimentaly Bad". But "Every Black Board Makes The Students life Bright - A.P.J. Abdul Kalam

A lot of people become heroes after they die but here we had one while still alive and yet we couldn't have enough of him. I would end this eulogy for Dr. A. P. J. Abdul Kalam with this quote he made us all repeat when he gave his speech 13 years ago. I still remember it like yesterday......

“Learning gives creativity
Creativity leads to thinking
Thinking provides knowledge
Knowledge makes you great.”
― A.P.J. Abdul Kalam

Lee Kuan Yew. A great man and deservedly so.

Lee Kuan Yew, the founding father of Singapore died today of natural causes. He would have been proud of how he has left his country.

Lee Kuan Yew (LKY) will be remain a great leader even if he wasn't the most popular leader outside Singapore.

If one has to appreciate the work that was done by him one has to live in Singapore for sometime like I had the opportunity to. I lived in Singapore for about a year and completely enjoyed my time there. This one year gave me the opportunity to examine why Singapore was so successful. Coming from a country like India which got independence much earlier than Singapore it is just incredible how he converted a third world country to a first world in a single generation. This kind of feat is not matched by any leader in world history.

Of course he did not do it alone. There were other leaders too. Also LKY crushed his rivals and was not kind to dissent in his own party or even others. He ruled Singapore with an iron hand. This might seem untenable to a European or American but Singapore needed that kind of a leader in 1965. Otherwise it would have slowly degenerated into a banana republic like Zimbabwe or Myanmar. He was the leader that Singapore needed. 

When I lived in Singapore I was saddened by how India could have been as developed if not for populist and socialist Congress Party. Jawaharlal Nehru could not for all his greatness become as great a leader as LKY. Far worse he left a poor legacy in Indira Gandhi and her dynastic politics to send India into political and economic ruin. Where did India miss the bus when we got our independence in 1947? 

The difference was the vision that LKY had for his country which none of our Indian leaders had. As examples I would just mention 3 instances of his great vision. There are many more but these are instances which stand out for me.

1. Drinking water Independence
During the world war II,  Singapore was offering strong resistance to the Japanese invasion and even destroyed the bridge connecting Malaysia to Singapore. Japanese cut off their water supply from Malaysia and Singapore surrendered within three days. This may seem inconsequential but LKY took a lesson from this and built the Marina Barrage where water flowing into the sea was collected in a dam like entrapment. In 20 years time the salt water reservoir became drinking water and now Singapore is completely self sufficient in fresh water requirement. Some would have called LKY a mad man then but now you can't hear anyone laughing

2. Public Transport
Singapore got it's Mass Rail Transit (MRT) in 1987 and India got it's first Metro in 1984. Today singapore has the one of the best and cheapest forms of public transport in the world and India is struggling even in the biggest cities. To see how we in India literally missed the bus we have to realize that one had to wait till 2007 to see a Delhi metro materialize and we still haven't seen the Bangalore metro become a reality anytime soon. We were 20 years too late.

3. Human capital.
LKY realized quite early that he was not going to achieve much without any natural resources so he made Singapore the point of business for all of Asia. He created human capital. He made English one of the national languages and that gave Singapore linguistic currency to deal with the west. He did business with everyone who gave them business. China, Malaysia, North Korea, Myanmar....it did not matter. That was a very astute move for a small country to do to improve economy and avoid war from neighboring countries.

My admiration for LKY stems from the way he built a country from nothing and which now has one of the fastest growing economies and a strong currency. No Singaporean today wants to settle down in another country but several in India are dying to....and that says a lot about LKY as a leader and statesman and how far Singapore has come since 1965.

How should a medical student use his Internship?

I got asked this question on Quora

How do i make best use of internship during MBBS in India?

It got me thinking as to what internship meant to me. I finished my internship nearly 7 years back so maybe now I have better perspective on what it meant back then. I answered and I thought it would be a good idea to share it here as well.

How should you spend your internship?
Most of my seniors said study hard for your entrance exams since its so hard to crack them. I'm sure most interns would study anyway as a default. I wouldn't stress on that aspect.

I would say use your internship to prioritize your career goals.

What do you want to be?
Sometimes this question is asked too late in a medical student's life.

To prioritize your medical career you need to use your internship as career sampling. 

More than knowing what to take as a specialty you should know what not to take.

Few things I think might help you in that

1. Keep an open mind. 
Never get bogged down by other people's opinions about what you should do. What you do is your business not your uncle's or neighbor auntie's.
2. No work is too small.
Take up every role that you come across. Cleaning a colostomy tube is as important as putting in the colostomy tube through surgery.
3. Respect the patient.
Work towards making them better always and try your best not to hurt them.  Always remember that patients are your best teachers so give them as much respect as you would your teachers.
4. Take ownership of your patient. You might be just an intern who follows your unit head's orders but the patient is still yours. Try to create a personal bond between you and your patient. It always helps you and the patient. Both sides get what they want.
5. Medicine is art. 
Work hard in the wards. Your books will only take you so far but the warfield (wards) is where you learn the craft. Never belittle any ward procedures. IV lines, central lines, urinary catheterization ,repair of emergency lacerations..... You never know what you will come across in the wards. These skills you can never acquire or experience later. I did one central line during my internship and that experience was exhilarating. Being an ophthalmologist now I'll never do it again so I'm thankful I did it then. Wards and patients will give you all the inspiration you need to propel you towards a speciality.
6. Make your peace with death and disease.
Until you reach internship you never realize how much death and disease of your patients can affect you. This is because you will have a personal investment on the patient. You will sometimes feel helpless in the face of mortality and morbidity but that is necessary.
7. Find your role models.
It could be anybody you work with and even your own batchmate who has probably figured it out better than yourself. One is never short of people to look up to.
8. Recognize the wrong people. 
You will come across people who are not good at their job, people who insult and look down on their colleagues and juniors, people who are unethical and so on. Identify those people and make note to yourself never to be like them. Do not let a bad doctor ruin a good speciality option for you. I didn't have good teachers for ophthalmology in my medical school but I didn't let it spoil my opinion of ophthalmology.
9. Maintain your sense of wonder
I feel we need to find wonder in what we do and work towards what we want to be. I would advise the same during one's internship. Never lose that wonder.

Defense is the worst form of Offense

Whatever I may do,

A fault,they will surely find.

Wherever I may live,

The world is still not colour blind.

Raghuraj S. Hegde from the poem Blackie

Over the past month or so I have been really worried as to how dangerous the world had become. Two incidents have much to do with what I feel right now. 

One is a seemingly funny comedy movie "PK" released last month in India to rave reviews and incredible Box office collections. It supposedly makes fun of age old superstitions in India (Disclaimer: I havent watched the movie yet). This movie has somehow caught the fancy of self claimed protectors of Hindu culture who have denounced the movie saying it insults Hinduism and promotes 100 other blasphemous things. It would have been good if it had stopped at that but no. They had to burn posters, set vehicles and theaters on fire and also file frivolous litigation in courts. Fortunately no one has died as yet because of this movie (at the time of writing). The presence of  Hindu fundamentalists, radicalists and anarchists have been denied by the Hindu majority public for a long time. Those who don't yet believe that they exist are living in middle earth. What distresses me is not that these fundamentalists exist but that they have active support from educated and informed Indians. I found this out when the discussion about this movie was brought to Facebook, Twitter and Quora. I realized many of my old colleagues, classmates and acquaintances hold a very strong opposition towards other religions. These people have passed out of the top universities, seen the world around and yet they have such a narrow view of their own religion and other religions. Many of these people started openly posting anti-Muslim or anti-Christian status updates and jokes online forgetting so many of their acquaintances are from any of the many religions in India. Any opposition from many people were ridiculed as either "sickular" or "selfish" or "blind" or "emasculate" . These people were steadfast in their hate for other religions. They claimed that Hinduism has been insulted long enough without anyone protesting and that was because Hinduism is a tolerant religion. From the vile I saw in online media Hinduism was anything but tolerant. I know it is not true. I am a Hindu by birth and proud of it. I do not see it as a religion but as a way of life. Hinduism is one of the few religions in the world which gives you the freedom to be an atheist but still belong to the religion. I presume most of these Hindu fanatics do not realize how open minded Hinduism has been and will be. You don't need 10,000 people burning posters and effigies to protect a 5000 year culture. It can stand tall on its own.

The second incident was the assassinations of cartoonists and editors of 'Charlie Hebdo' by a few of misguided French Muslims. This has again started a debate as to how this came to happen. Commentators wrongfully point out that the Charlie Hebdo bought it on themselves by publishing blasphemous cartoons over the last few years and that this would have happened sooner or later. They also go on to say that all this would not have happened if the magazine was more respectful of Islam.

Really? I mean are we even considering this argument?

As a citizen of the world and living in a democratic country I would want to have my own opinion and not things thrust upon me as politically correct. If not anything I should have the right to be offensive. Weather I choose to use that right is another matter entirely. As long as my words,writings and forms of expression do not harm anyone I have the right to say it.The 2006 article by Christopher Hitchens explains it so brilliantly here. If our only aim in life is not to offend anyone then we would see something like this in the future.

Anything you say is offensive to someone else so what should you do? Should we just stop talking or expressing? One is just waiting for the other to be "offensive enough" to start any of the following- protests,tearing posters, rioting, frivolous court cases, mass murders and genocide. If our attitude remains to encourage the above and stifle all forms of expression then soon enough we would be no different from people in China, North Korea or Saudi Arabia. 

How can you be even sure any harmless thing you say is not offensive to someone else. You can never be careful enough. If you as an individual find something unacceptable or offensive choose not to promote it, watch it or even publish it. Tearing up posters, burning movie theaters, killing cartoonists and policemen isn't going to change anything. Every religion deserves the right to be criticized or praised in the same measure. I don't believe that religion should not be debated or discussed. How else would we improve our religion to suit our modern world. If we had not debated or discussed religion we would still be practicing all the weird old practices of our forefathers. As a Hindu I have the right to question my religion and so does a Muslim or a Christian. We have to see the merits and demerits of religion as one sees himself and not how a particular religious organization decrees we see it as. If we are scared to question we will not progress. All I want to say to these people is. Thank you. I can think for myself. Please respect my intelligence.

Raghuraj Hegde

Life of a 21st century doctor!

The medical science has seen a sea change over the last century.....more than what has been achieved in the previous 5 centuries put together. The change has been for the better for patients as people are getting cured of diseases which previously had no cures.

In this state of change to expect the medical profession not to change is simply naive. I would like to enumerate the good, the bad and the ugly of the medical profession in general and the joys and challenges of doctors in particular. This is in no way a negative or cynical post. It is more of a perspective of how things are and how it is going to be.

Medical Education

Over the years the field has grown leaps and bounds and this being the era of super specialization.....now doctors are moving on to micro specialization. It has become harder for students to keep up to the whole gamut of information which keeps changing every few years so "specialization in minutiae is inevitable" is  the new world order for doctors. I agree with this in principle but the path to specialization especially in India is difficult, unrewarding and involves a lot of factors unrelated to your capability to be a good doctor. First on the list comes low pay right from the time a medical graduate passes out. This pay never reaches the amount appropriate to his/her level of expertize all through their career unless he/she indulges in any wrong practices or his/her family owns a hospital. Second is the high cost of medical education not only monetarily but in the quality of life a medical student has to endure throughout his student life. An equally capable professional in another field is pretty much well set by the time a doctor can come out to practice and by which time the doctor has a mountain of debt and an unforgiving society. There is very little incentive for a student in India to join the medical profession unless their family owns a hospital or have unending disposable income to spend. This puts the profession beyond the reach of the middle class since there are no returns for the incredible amount of mental and financial investment required from a doctor. So is it any surprise with the quality and character of the doctors of the new era. The brightest and smartest don't want to become doctors since it's simply not reasonable for a middle class family to sustain a medical student. This makes way for corruption and only the people with the insane amounts of money can become doctors in the new era. Are these the kind of doctors you want to trust your lives with?

Those fortunate to be bright enough enough to secure a government medical/ residency seats which they can afford are treated so shabbily by the system. They are often put up in slum like living condition in hostels with bug infested rooms, mosquitoes and the works by government colleges. They are often made to work 80-100hrs a week resulting poor nutrition and low morale. A lot of them end up sick and in extreme cases even dead. On top of that, the added danger of flash mobs assaulting the emergency doctors on call. The general feeling is the residents are often disgusted with the system and with their seniors for perpetuating this unfair system. This is how the brightest in the field are treated by the society. Some links below which might give an idea of how big the problem is.

https://in.news.yahoo.com/why-indian-doctors-fear-for-their-lives-043955469.html?fb_action_ids=10202670862286429&fb_action_types=og.recommends&fb_ref=facebook_cb

http://www.dnaindia.com/mumbai/report-who-takes-care-of-doctors-in-bmc-run-hospitals-2029755

The specialist doctor problem

These days everyone wants to be treated by the specialist. To a lay person it might seem like the most correct thing to do and may feel that super specialist is very accomplished hence also the most capable to treat his disease. In practice however it is a huge waste of resources. In most patient surveys around India and the world 80% of the sickness can be treated at the primary healthcare point. The consequences of making the cardiologist treat a common cold is that the patient is wasting a cardiologist's expertise and overpaying his consultation as well. People don't realize the importance of a general practitioner or general physician in their healthcare. This discourages newly minted medical professionals from taking up general practice. It is just not viable for them. What is the government doing about this problem. They are completely ignoring the issue and like they have treated primary education, they are treating primary healthcare with the same disdain. They aren't hiring permanent staff for their rural areas and those hired are paid salaries once in 6 months. They are forcibly making new residents serve in rural areas. This again is a huge waste of valuable resources. Orthopedic surgeons are doubling up as midwives and delivering babies in rural areas since there are no other doctors. How will this change our primary healthcare in anyway? GPs are not
average doctors as people would like to think. They have a different set of skills than a super specialist. While a super specialist is restricted to a very narrow field of medicine the GP is trained to look at the patient as a whole. More amazing diagnoses is made in a GPs chamber than a neurosurgeon's. But in the new era this important medical community is dwindling.

Quality of life of a Doctor

I'm not saying it is the toughest job on earth but a doctors life now is harder than it has ever been. Very few vacations- no money during student life and no time once you are practicing. 
Family suffers. My father is a doctor and all through my childhood I resented the fact that we took so few family vacations and that my father was never there for the most important events in school or others. All the while he was working day and night to make ends meet and ensure that we, his children get the right education, amenities and taken care of. This made sure that I was a reluctant doctor for the most part of medical school. I eventually found my calling and was "reformed" but it was a painful journey nonetheless. 
It is going to get worse for the future generations. There is this underlying myth that doctors make a lot of money during their careers which is really not true. I had a conversation with a friend from the money making tech industries and he had this to say

"Doctors can't contribute enough financially to the nation to command higher salaries. A doctor ONLY saves lives but engineers,financial analysts and CEOs create wealth which they distribute among themselves."

This is how much value saving lives commands. I was angry at what he said at first but later realized this is how the money creating industries think of doctors: overpaid and untrustworthy. Life and death can't be quantified in stocks and bonds and hence that is not enough. It made me sad as to how this came to pass and this perception is precisely what the next generation of doctors will have to work against. 
Governments post newly minted doctors into rural areas on compulsory postings but on temporary jobs. It is cheap labor for the exchequer, vote banks are taken care of and they don't have to bother about a permanent solution for a complex problem like rural health. 

What these people don't realize is that by having this attitude they will ultimately increase healthcare costs and then everybody suffers.

This inability of the society to acknowledge their altruism will be the reason to discourage the next generation of brilliant students from taking up this unforgiving profession. Doctors are no more demigods or authorities in their field. Their medical decisions will be altered by arm twisting untrusting patients, fear of malpractice suits, defensive medicine, target hounding corporate hospitals, a populist government and an inefficient law system. All this stress while their family still suffers from the lack of their time and money.

http://www.kevinmd.com/blog/2014/11/wish-knew-advice-spouses-doctors-residents.html

Doctor and patient relationship

To a doctor who is just starting out I would say this: ' Your decisions will be questioned at every step. You cannot dismiss patients like you are doing a favor to them. You will have to get down to the level of the patient and sometimes lower'. It will be a big let down in a doctor's life that they keep having their motives questioned every day of their professional lives. I think this is for the better as the doctor community has been too arrogant for far too long. They spend so little time with patients giving the excuse of long patient lists and surgeries. I think this is why people are so distrusting of what we do. Doctors of the new era have to respect the "new patient" who is educated, informed and has 1000 questions. There will be unreasonable patients just like other professionals have unreasonable clients. You have to approach it like how other professionals do. 
Any drug that you prescribe you should know all the side effects. Any surgery that you do you should know all possible complications. Ignorance is never an excuse anymore. It is your job to know. Never be dogmatic and steadfast about your decisions or opinions. Learn humility, patients appreciate that. State your professional opinion clearly before educating your patient about his/her disease and give them more than one choice when possible. Let patients take ownership of the decisions that need to be taken. All this takes time and you would be well advised to give it to them in the first instance or you'll be forced to give it in court. This sword of Damocles hanging over your head seems very unfair when all you wanted to do was do your job well. There is no point complaining about it and we have to make peace with our present day realities. If we want to be counted as professionals we have to be accountable. Period.
Also you need to connect to every patient you meet. For you will have several patients but for a patient you are the only doctor at that point of time. Learn more about your patients and make them feel like you are their doctor rather than make them feel they are your patients. There is a world of a difference in that.

http://mattandjennimurray.blogspot.sg/2014/09/in-defense-of-doctors.html?m=1

http://www.buzzfeed.com/lukelewis/16-doctors-on-the-dumbest-patients-they-have-ever-treated?bffb

Doctors and the media
Doctors in India are the vilified lot and not for small reason due to the unrelenting attitude of the media to slam doctors at every given opportunity. Media misuse their privilege to become just the loudest voice in the room. Most of the popular channels give out gross wrong health advice, unhealthy diet fads and advertisements of dubious cures. If that was not enough we have enough doctor slamming shows like Satyamev Jayate. Shows like these invite doctors and patients to discussion forums and post recording heavily edit the discussion in a very biased fashion to suit only their pre determined point of view and to create sensationalism to increase the TRPs of their shows. Doctors are the favorite punching bags since doctors in India have no voice. They don't form vote banks since they are an educated community which can't be swayed by politicians. They don't have a lobby to fight these instances of injustice since doctors in general don't make enough money impact the finance of any political entity. The Indian Medical Association and its state counterparts sometimes have token protests against these wrongs which not surprisingly never gets reported in the media. Doctors in hospital emergency rooms get beaten up every other day almost in all instances for no fault of theirs. This almost barbaric treatment of junior doctors in hospitals across the country are never reported in the media and if reported would highlight "some mistake" on the part of the treating doctors and never anything defending the doctors. This is because in most instances these assaults on doctors are perpetuated or encouraged by media persons. And strangely if there is any instance of a doctor strike  protesting archaic quota system of medical education, low pay or assault of doctors in hospitals, the same  media will come raining down on the doctor community of holding people's life at ransom. What I'm sad to see is that people don't realize that doctors are not anarchists.They would be more happy treating patients rather than be in protest rallies and fight lathi charges. If they are forced to do these things one has to realize how desperate and frustrated they are with the system. Nobody else is fighting for them and doctors have no choice but to protest in what little way they can. It is sometimes heart rending to see doctors who are on hunger strikes still running emergency clinics in these protest areas since they don't want people to suffer.

Doctors and Doctors

Over the years in the medical profession I have seen as a young doctor trying to make a mark that doctors work against doctors. There is too much professional jealousy and Godfather complex in the doctor community. There is a culture of disrespect which is passed on from the senior doctors to the junior ones. A senior doctor would not bat an eyelid before running down his junior colleague or rival in front of the patients. When you can't respect your own profession how can you expect the patient to respect it. Doctors cannot treat their junior colleagues like slaves at their beck and call. If you don't respect your colleagues the feeling will be mutual. So the first step in the new era will be to respect for everyone from medical student to super specialist. While we are at it there should be respect for everyone concerned with your patients....every person in the health delivery system forms a vital cog in the machinery. The future of healthcare is in creating effective teams rather than hierarchy. Nobody would believe me now but things will change in the near future in India to prevent hierarchy from setting into a system. Only when you remove nepotism , favoritism and godfathers from the picture will we gain a meritorious medical community. Mentors are the need of the day. Only if the present stalwarts mentor the next generation of doctors will there be continued value of our art. But if these stalwarts are insistent on running their personal fiefdoms then its a bleak future ahead.

Finally the joys of being a doctor

Being an optimist has helped me still enjoy my profession in a positive way despite the injustices that are being done to doctors in India. Its been a very long road from being a reluctant doctor to an empathetic doctor and this journey has taught me a lot of lessons. 
One of the joys of being a doctor is having the power to change a person's life and livelihood with one accurate diagnosis and appropriate treatment. A doctor may not move nations or even sometimes not even impress the patient he's treating but power to positively impact another person's life is incredible to say the least and I suspect is the reason why doctors still continue to perfect their art and science. Doctors may not make millions of dollars like lawyers, engineers, management consultants and businessmen but the value they give the patient with their work is not measure able with any material affluence.

The 10 best books I have ever read!

There has been a recent trend on facebook which has gone viral- to name 10 books which have impressed the person being challenged.  The book lover in me was enthused by this challenge.

Since the earliest time I can remember, books have been an integral part of my life and have at various times entertained, stimulated , educated and made me feel amazed at the world around me.

Here goes my list:
1. The Salmandra Glass by A. W. Mykel
2. A Prayer for Owen Meany by John Irving
3. Life according to Garp by John Irving
4. Kane and Abel by Jeffrey Archer
5. The Fountainhead by Ayn Rand
6. The Godfather by Mario Puzo
7. The Outliers and What the dog saw by Malcolm Gladwell. (They are one book inspite of 2 titles)
8.The day of the Jackal by Frederick Forsyth.
9. Waiting for the Mahatma by RK Narayan
10. The kite runner by Khaled Hosseini

And I'm the one of the biggest fans of PG Wodehouse, Agatha Christie and Jeffrey Archer. Wodehouse is the best comic writer in the world, Agatha Christie is the queen of detective stories and Jeffrey Archer is greatest short story writer ever. Since I can't fit in all their books into this list I've nearly excluded them all since they have a pride of place in my heart. It doesn't take a genius to figure out that this list above can't be exhausting for a voracious reader like me.

My list is wacky in the sense that they don't follow any particular genre and that's down to my reading habits as I read anything from newspapers to trashy magazines. My hunger for the written word is insatiable and incurable. The unintended (at least in my case) yet positive aspect of reading is that when you enjoy it, over time you become extremely well informed about current world issues and have a modern outlook and logical opinion on most topics. This gets you into any conversation with all kinds of people and that is a huge advantage in life.

Hope and Heartbreak: two sides of Retinoblastoma

I recently read an article "The Zimmerman family story" by Dr. Mary Louise Collins .....She is the daughter of world renowned Ocular oncology researcher Dr. Lorenz Zimmerman. She is an Ophthalmologist herself and she had written an article on Retinoblastoma from a personal standpoint in relation to her family. It has been published as an editorial in a scientific journal. The link to the article is below.

http://archopht.jamanetwork.com/Mobile/article.aspx?articleid=1844006

She talks about how her father Dr. Lorenz Zimmerman got interested in Ocular Oncology and went on to do pioneering work in Retinoblastoma research. Not only her father but several members of her family were responsible for landmark discoveries in the understanding of this disease. Tragically Retinoblastoma struck Dr. Zimmerman's family when his youngest son,Larry was diagnosed with the disease. Dr. Mary goes on describe how her parents courageously decided to go ahead with experimental treatment and had to fight several in the establishment to do so. Fortunately the treatment cured their son of the disease. Unfortunately the disease was to strike again on Dr. Zimmerman's family when Larry's daughter Perry was diagnosed with the same cancer. Dr. Mary then goes on to describe how the research done by her family gave them courage to fight the establishment which in turn helped change the lives of their own family members and the millions of kids worldwide.

What struck me about this wonderful article was it was scientific in content but from the heart in form. Dr. Zimmerman family struck me as both tragic and fortunate. Tragic due to the multiple times it was struck by the horrible cancer. Fortunate because the family was at the forefront of cutting edge research and at the best position to understand the disease and decide upon possible treatment. This is a wonderful article which I would recommend everyone to read.

But recently I saw another side of this terrible cancer. A 4 year old kid from Indonesia had come to us more than 8 months back with classical signs & symptoms of Retinoblastoma. It was diagnosed as such despite the child being out of the usual age group for retinoblastoma. But the parents strangely rejected our diagnosis and proposed treatment and went doctor shopping in Indonesia until they found a "doctor" who debunked the diagnosis and started treating it as something else injecting useless drugs into the eye. We came to know about this since the parents returned with the kid about 2 weeks back to our hospital. The kid by now had multiple metastatic cancer aided in no small measure by the criminal injections of the that Indonesian quack. We still offered the parents an aggressive treatment protocol which may yet save the child but the parents listened to us and disappeared again next day. This is the heartbreaking world of Retinoblastoma and I'm sure this happens in most parts of India as well where this dreadful cancer has to fight superstitions, parental denials, costs, cultures, quacks and witch doctors.

These are just two stories on opposite sides of the spectrum. There are many more stories between and beyond them as doctors fight this dreadful cancer.

What is Ophthalmic Plastic surgery?

“It’s better to do a dull thing with style than a dangerous thing without it.”- Charles Bukowski

What is Ophthalmic plastic surgery or Oculoplasty? I often get asked this question when I tell them what I'm specializing in. Most people are not aware that such a speciality exists  including majority of medical doctors. They ask me how can you be an Ophthalmologist and a Plastic surgeon at the same time. It's a tedious exercise explaining it to people what my work comprises and one which makes my wife make fun of me when I explain because she's heard it so many times. I thought it would make sense to pen it down. Here it goes....

Ophthalmic Plastic Surgery is a subspecialty of Ophthalmology which deals with the orbit (eye socket), eyelids, tear ducts, and the face. It also deals with the reconstruction of the eyelid, the eye socket, and surrounding structures. Lately as a natural progression this branch has been getting into Facial Aesthetics in a big way in the form of Brow lifts, facelifts,Botox, fillers and Facial Rejuvenation.

The subspecialty of ophthalmic plastic surgery was born in the mid-twentieth century in the United States at the conclusion of World War II. The art of oculoplastic surgery, however, is centuries old, bearing its roots in antiquity in India,the Far East, and Europe.

The various procedures that have evolved over centuries can be divided into several general categories: reconstructive, restorative,and cosmetic.  Oculoplastic surgeons have perfected, refined, and pioneered new techniques of lacrimal surgery, ptosis repair and blepharoplasty, orbital surgery, lid malpositions, and flaps and grafts. With the close relationship of this speciality with Eye Cancer and eye reconstruction after removal of tumours,  Oculoplastic surgeons are de-facto Ocular oncologists. Since the treatment of the above conditions often requires multidisiplinary approach the possibilities of this field are endless. It also requires good working relationship with other specialties and to create a valuable team to treat the patients.

Oculoplastic surgery became recognized as a unique subspecialty of ophthalmology at the end of World War II. Numerous orbital and periocular injuries were treated by general ophthalmologists without prior training or exposure to ophthalmic plastic surgery. More often than not, trial and error were keys in developing these procedures. Among the earliest pioneers was Dr. John M. Wheeler who established a full practice based on oculoplastic surgery. He is known as the father of oculoplastic surgery. His student Wendel Hughes was the next major force in this field. Further Hughes' students Alston Callahan,Byron Smith and Crowell Beard propagated this field across the world. This group of Oculoplastic surgeons went on to found the American Society Ophthalmic Plastic and Reconstructive Surgeons(ASOPRS) in 1969. This was the first such society in the world for oculoplastic surgeons. Later more such societies got formed in other parts of the world. Europe (ESOPRS), Canada (CSOPRS), Asia-Pacific (APSOPRS) and even India (OPAI).

It is a relatively less known specialty. ( I myself did not know about it till I joined residency). There lies the challenge in this field and also the greatest opportunity to grow. The specialists in this field are there in it only for passion since the other sub-specialities in Ophthalmology are much more rewarding monetarily. This sub-speciality is quite hard to master yet it is incredibly satisfying. I am honoured and privileged to count myself among these stalwarts. Like I said the possibilities are endless and there is so much work to be done....

References:
1. Smith and Nesi's Ophthalmic Plastic and Reconstructive Surgery
2. Local Flaps in Facial Reconstruction by Shan R. Baker and Neil A. Swanson

The curious case of the Tilted Buddha

Was intrigued on a recent trip to Bhubaneshwar when I saw a sculpture of a tilted head of Buddha and I asked the significance to the sculptor. He couldn't explain me the significance and me being me went on to check why the Buddha's head is tilted. It all comes to one of the quotes apparently attributed to Buddha.

“When you realize how perfect everything is, you will tilt your head back and laugh at the sky”- Buddha

What it apparently means is this:

Since everything is but an illusion,
Perfect in being what it is,
Having nothing to do with good or bad,
Acceptance or rejection,
One might as well burst out laughing!

I don't really know whether Buddha actually said that and that inspired this tilted version of Buddha or its is just down to coincedence. Nevertheless its interesting.

From Oculoplasty and back

“Just don’t give up trying to do what you really want to do. Where there’s love and inspiration, I don’t think you can go wrong.” —Ella Fitzgerald

Its been an incredibly long time since I've been active on this blog. Partly because I have been busy and mostly because I haven't been inspired to write in a long time. I was in Bhubaneshwar sometime back and it has kind of brought me back to a place where I almost gave up on Oculoplasty as a career. In my earlier blog posts I had professed immense interest in Oculoplasty and haven't really updated what happened afterwards. Its a huge story worth a potboiler at the very least (ha ha I'm kidding). Well I wont bore you with all the details.

But something incredible happened in the end of September 2013. I got an offer letter from National University Hospital, Singapore accepting me for their Orbit and Oculoplasty clinical fellowship program. I had applied to NUH after my residency  just like the many other institutions I had applied to. Somebody there had seen a spark in me and selected me. I was ecstatic and that hunger to get into the fellowship kept me from giving up during the protracted paperwork process to start my fellowship.

I'm now more than 4 months into my fellowship and its been an amazing experience till now and I feel I'm in the best place that I could be. I have finally found a mentor who could really shape my career the way I would want it to go. I'm learning new things everyday and things I never thought I'll be doing.

I'm training in navigational surgery of Orbital fractures,small incision endoscopic browlift, Aesthetic procedures, attending orbital fracture implant courses and a myriad things I hadnt even imagined I would be able to do.  I realize that i'm at the forefront of technology and innovation in my field here in Singapore. The real challenge will be to use the knowledge and training that I have gained here into a place like India where there are always impediments to one's growth. A lot of it is economic and most of the rest of it is politics and nepotism that thrives in my profession in India. I sometimes worry that I'm getting spoiled by all the high tech gadgetry that I see here in Singapore and I fear becoming obsolete in India. Also I'm recently married so to get the kind of solid support from my wife has been comforting but I understand the sacrifices she's making for my career and it sometimes troubles me.

But after a lot of reflection I realize that the basic emotion here is "Joy". Joy in what I am doing despite hectic schedules of this fellowship and finding happiness in an equally important marriage at the same time. This beats every fear that I'll ever have. I figure that if I'm enjoying what I'm doing I'll find a way to make a living out of it.

The witty patient!!

Lot of our daily practice in our clinics would involve seeing patients,making quick diagnoses and discussing various treatment options. We do sometimes joke with our patients to make it a more comfortable environment but most of our work though intellectually stimulating is not so much humorous. So just yesterday one patient of mine impressed me with her quick wittedness so I thought I just had to share it here:

A lady came into my clinic with red eyes and red angry lower eyelids. It wasn't fitting into any particular diagnosis other than allergic dermatitis.
So on repeated questioning she finally confessed that she arm twisted her dermatologist to prescribe her bimatoprost for getting long eyelashes.

Bimatoprost is an anti glaucoma drug whose side effect is long eyelashes. So drug companies and cosmetologists have started using this side effect as a cosmetic tool. But another side effect is it can cause allergic reaction which was the case here in this patient.

I explained to her that the eye drops  have caused her allergy.
Just then my boss walks in.
She says to him "Doctor we just discovered what caused my red eyes"

"What would that be?" My boss asked not knowing the whole history of this patient

She replied with a straight face

"Vanity"

The puzzled look on my boss' face was the funniest thing I have seen in a long time!!!

Living in a Fish Bowl!

“When a man is denied the right to live the life he believes in, he has no choice but to become an outlaw.”
― Nelson Mandela, Long Walk to Freedom: Autobiography of Nelson Mandela

We often believe that the information that reaches us is always the right information. why wouldn't we? We are not living in China where information is censored by the government nor is there any dearth of information with the world wide web which has largely been free of any restrictions till now! I recently understood the perils of listening only to one side of the story for too long. Over time that one side of the story is perceived as truth.

Last month I was working in a hospital which has international fellows coming in from different countries to train in specific disciplines and then go back to their countries to use that training. I had the good fortune to meet one such fellow from Palestine who was working in the same department I was. We shared a common love for the sub-specialty we were working in and over discussions of ophthalmology we also discussed a whole lot of international politics too. The information junkie that I am I was only too happy to know about stories I would probably never ever hear about.

The stories the international media feeds us or even the Indian media feeds us is that Palestinians are a group of people governed by terrorists and that Israelis are always the victims of Palestinian intolerance. We’ve been fed these pro- Israeli stories so many times that we believe it as fact. But the true picture is not so straightforward.

I do not want to go into the whole history of Israel- Palestinian conflict which is extensive and most of which is available on the internet. I want to talk about stereotypes and misconceptions created by international media. It’s interesting to note that Israel is a country that was formed only in 1948 on Palestinian land and now ironically it is the state of Palestine that is not recognized by the UN. The British who  ruled over the Palestine area could not handle local tensions between Arabs and Jews so after the world war II out of a sense of compensation for the Holocaust granted the formation of the state of Israel.This in turn resulted in the large immigration of Jews into the Palestine area hence making it a Jewish majority. The Israelis have been fighting the Arab countries ever since and the conflict with Palestinians have continued to this day while Israelis have peace treaties with Egypt and Jordan.

As an impressionable teenager I read with tears in my eyes the story that Anne Frank was narrating so calmly in her autobiography. The Holocaust was a truly horrific episode in Jewish history. The 1972 massacre of the Olympic athletes was tragic as well (Steven Spielberg made the movie ‘Munich’ from this episode, who incidentally was the director of the Holocaust movie ‘Schindler’s List’). I had concluded after reading so extensively about Jews, about the tortures and concentration camps during the Nazi regime that Jews were the most oppressed race in the world and that anyone who are against Jews are inhuman by default. But i failed to realize until I met this Palestinian doctor, how instances of injustice to the Jews have been documented over the years in print, broadcasting and movies but the Palestinian stories are somehow elusive to all of us. I’m not belittling the Holocaust nor am I endorsing the terrorist attacks on Jews. I want to shed some light on the other side of this Israel-Palestine conflict.

You would be surprised to know (I was too) that Palestinian territories are landlocked territories surrounded by Israel and people from these areas are not allowed to go towards the sea by Israeli authorities (though it is only 40km from their border) and all the Palestinian borders are controlled by Israel including its borders with Egypt and Jordan. There are no airports in Palestine and anybody wanting to leave the country will have to go through Israeli airports for which you would need loads of paperwork and permission. There are two Palestinian territories, the Gaza strip and the West bank but these are separated by Israel and hence have two different governments with no common governing mandate and ruled by different political outfits. A Palestinian from one territory is not allowed easy access to the other territory hence both these territories are mutually exclusive and independent of each other.

Despite being highly educated there are limited employment opportunities in Palestine hence many Palestinians choose to live and work in Israel. Israel is a developed country while Palestine is barely there due to restriction of Palestinian border trade by Israel. Palestinians who chose to live in Israel are forbidden to marry, have a family or even ever visit Palestine again. Even this Palestinian doctor i met works in Israel in a Christian hospital. He lives near the border with his family and makes the daily to and fro journey from Palestine to Israel just to earn his livelihood. His wife too does the same to work in some telecom company in Israel. All these journeys and checks to have the right to have a family!!!

But the most touching story I heard from him was this. His elder sister married and emigrated to Australia with her In-laws in 1987.Since 1987 she has never been able to visit Palestine again. So she decided to visit her country of origin with her two kids last year. After landing at the Israeli airport she was stopped at the border check point. She and her kids were Australian citizens with Aussie passports. The Israeli authorities told her that her sons had the right to pass the border but since she had been a Palestinian before 1987 she would have to produce a Palestinian ID to do the same. His sister and her kids had to return home without visiting anyone from their family. My Palestinian friend has not seen his own sister for the last 25 yrs!!! These stories are not exceptions but these are commonplace instances in that region.

This is like a goldfish living in a fishbowl…. despite seeing everything the goldfish can never go out of the bowl nor can it hope any other goldfish to give it company. Its life is governed by the rules of whoever feeds the goldfish and not by what the goldfish wants. If you make them live like goldfish is it any surprise that they retaliate in a violent way? Humans were not meant to be in a fish bowl nor are they goldfishes.

When he spoke about the whole situation there was no anger in his voice, only sadness.Sadness over all the Jewish friends he has lost over the years, over the misconceptions that dominate all over the world about Palestinians, about all the family members he can never see and how their freedom to live life the way they want it is not there but no one knows or cares about it outside their country.
His words at the end were very profound, “No Palestinian ever killed a Jew in the Holocaust yet today it is we Palestinians who are paying the price for it.”

P.S. just check out this one article i found on the net which can be said mildly anti-Israel…. its by Arindam Choudhury of whom i’m not a huge fan but in this case he seems to have got his research right!

http://www.thesundayindian.com/en/story/when-weapons-are-to-be-tested-the-gazas-become-the-casualty/44225/

The Surgeon Conundrum

“From inability to let well alone; from too much zeal for the new and contempt for what is old; from putting knowledge before wisdom, science before art and cleverness before common sense; from treating patients as cases; and from making the cure of the disease more grievous than the endurance of the same, Good Lord, deliver us.”

Sir Robert Hutchison, 20th century physician, British Medical Journal, 1953

I often hear descriptions of famous surgeons as “great”, “amazing””, “brilliant”,etc. and wonder how those adjectives get decided. The corollary used in describing a surgeon is somewhat akin to a performing artist or an athlete. The problem with such an approach is unlike an athlete who can be assessed by statistics or artists who is assessed by cultural expertise of common people, a surgeon does not lend himself to such assessment. A surgeon does not have a publicly available success rate statistic nor do common people have any expert knowledge of surgical procedures to know if a surgeon is great or not.
Is surgery so hard? Yes and No.
YES because one needs to put in years and years of study to even have the opportunity to hold a scalpel and from then on has to practice relentlessly for many more years to actually master the surgeries in his/her specialty. For that relentless pursuit the surgeons usually have to sacrifice the prime years of their lives to this task, having no time of their own, decreased social and personal life and often living under debt or their parents’ financial benevolence for a little less than half their lives. 
NO because its not magic. Most surgical procedures have certain established techniques which if practiced over many years become second nature to the surgeon. So if you know the rules you are set. Of course it goes without saying that you would need a certain level of aptitude and intelligence to learn the complex machinations of the human body,decent memorization ability and a whole load of patience but essentially surgeons are human beings like the rest of us. Only that we surgeons are the lucky ones among humanity who get to wield the scalpel to help humanity as a reward for all those years of hard work.
Skill can vary of course like in any profession, they can be excellent, good, average, poor and miserable. Skill, we surgeons are often told is what separates the great from the rest and yet there are many average skilled surgeons doing incredible service to mankind which many highly skilled surgeons could not.
So does mere skill of a surgeon decide his greatness? Here its a big no. From what I see from the inside of a surgeon’s world, having started my surgical career 3 yrs back, the greatness of a surgeon has to be measured beyond just skill. Like my Professor in college used to say, “ Any fool can operate,even that cobbler on the street or that OT technician, maybe even skilfully but what should separate you from those fools is that you should be able to judge what surgery the patient needs or if he needs surgery at all?” (he had more colourful words to say, this is the watered down version of it, LOL). I recently heard an amazing perspective from a very famous surgeon (he’s a brilliant surgeon by the way) : “ The reason older experienced surgeons do lesser types of  surgical procedures than younger newer surgeons is not because they are any less fearless or capable than the younger ones its because they are tempered with the wisdom of what works and how well. The ability to cut down on trying too many things and to bring more efficiency and longevity to surgery is what experience brings”  These are two different perspectives with a converging opinion on the importance of clinical judgement of a surgeon being paramount!
Doing too much or doing too little? Where do surgeons draw the line?
For that the “art of judgement” is the crucial quality of a surgeon. I sometimes feel we as surgeons are often guilty of “surgical over-aggressiveness” . There are times when doctors operate when in hindsight just waiting would have done the trick. Sometimes when a medical treatment would be far more beneficial than a surgical one. Other instances when after surgery the patient is worse off than before. It’s not to say these doctors have any vested interests to operate. They mostly always want to help the patient and often in their zeal probably do too much. Sometimes its more harder for the doctor than the patient to accept that nothing more can be done. But again in trying to solve the “doing too much” problem, surgeons should not fall into the “doing too less” trap which so often happens in many hospitals these days where patients aren't demanding or in the know. There are several instances when doctors just chooses to delay instead of taking that acceptable risk to operate since they don't want to be responsible for somebody’s poor surgical outcome. Some don't even refer to a specialist who is capable of doing the surgery with lesser risk. In the end such a patient’s surgery is not done at the correct time resulting in handicap or he/she succumbs to the disease. This attitude is worse than the “doing too much” phenomenon. As an example i distinctly remember one little girl of 5yrs who came with multiple metastatic cancer to my hospital when the original small eye tumour which was detected a year earlier was not operated by the doctor assuming it to be benign. A clear case of doing too less and the experience is so heartbreaking for everybody concerned.
There are no definite answers to most surgical decisions because medicine is a field where results cannot be predicted with pinpoint accuracy like a mathematical model. But surgeons have to take these calls everyday and no one else can do it for them.The surgeon’s judgement sometimes lies between life and death of a patient so its not as simple as people believe it is. I am happy to say with full confidence though that for the most part more good than bad gets done in the full balance of things. The ability to do as much as possible to help the patient yet never letting one go overboard is a balance every surgeon should aspire to attain and this balanced judgement is what makes a surgeon truly GREAT.

What women want…

Before you mistake this for another sexist diatribe against the female sex by a testosterone charged male, let me clarify its no such thing. To the contrary I want talk about how society is oblivious to what women want. News channels these days are filled with “human interest stories” of sex crimes, rapes, assault, domestic violence, etc. on women and children all over India. It is as if there is a sudden epidemic of perversion and sexual frustration by men India-wide. I see a lot of people on these TV channels and outside say this is due to western influence –their clothes, relationship concepts and habits. It is as if sexual crimes never existed in India before. Well what the TV channels are gladly ignoring in their project to create this “breaking news” phenomenon is that these crimes are not new events in Independent India. The perverts,the sadists, the paedophiles were always there but we as a society never acknowledged them. We protected them among lies, cover-ups and  false family honour. Every time we see some new report on a ghastly crime, we as a part of society give an appalled shocked expression, shrug it off and move on believing such things are rare events in civilized society. The real fact of the matter is the problem lies in the mindsets of society as a whole. The sad part is the crimes are not as surprising as the comments by leading political figures and officials in law enforcing agencies. These politicians and the police are supposed to be representatives of our country’s people and if they think thus by projection the country also thinks like that.What do they say?

“The woman who got raped was wearing a mini skirt, was an alcoholic and a prostitute. She tempted that rapist to rape her. She had it coming”
“ The man’s affection for the child has been misconstrued as child sexual abuse. There are no paedophiles in India. It is a western phenomenon”
“ Women should know how to dress decently in order not to get raped”
“ Women should not work in offices after dark so that they will not tempt rapists at night”
“ The western influences are ruining the culture of our country. Women should not dress in western clothes, should not drink, not use mobile phones and internet, not have male friends,……(list goes on)”

If these statements shock you then you really haven’t been reading the news lately. There are many more such banal statements being given on a daily basis.I don’t know who was asking for their explanations but nevertheless they did provide their distorted logic for public consumption. What is unfortunate is that these statements are coming from not just religious fundamentalists,policemen and politicians but from some members of the National Commission for Women. If people appointed to safeguard interests of women (who are women themselves) think like this then really women in our country have no hope. I think the actual rape has happened in the brains of these commenting people.

The ploy to put the blame of rape squarely on how women behave is an old one. They will tell you men don’t have any control over their sexual craving and its only natural that they will rape someone who will sexually arouse them. They believe that the onus is on women to avoid rape. It’s like saying that any man can become a rapist if present in the given circumstances which commonsense should tell us is not the case. Chivalry and gentlemen have not died in this world and not all men are rapists if it even needed to be said. The rapist will rape anyone without regard to looks,clothes,behaviour, age and sometimes even gender. Instead of acknowledging this problem these people will try to put morality and culture into the equation. Aside from the fact that I don’t think two hoots about the culture of our country (much less ruining it), there is no credence to the belief that it is somehow ok to rape a sex worker or a lady who drinks or a woman who wears revealing clothes. It is behind this belief that rapists, sadists and paedophiles in our country find shelter in. If society acknowledges that the crime is committed in the minds of rapists rather than due to situational happenings, only then something can be done to curb these crimes.

Women in our country should be free to wear the clothes of their choice, work in professions they want to, go to any place at any time,to eat and drink whatever is legally allowed to all citizens AND STILL NOT GET RAPED. That should be the societal standard and not primitive ideas of these dinosaurs called politicians and policemen who are probably living in a cave.

The idea that women are respected in our country is a myth. Except in certain pockets where women find a pride of place, in most places in India everyday we see women being insulted, abused and exploited. The IT boom and corporate culture has improved the stock of women in our country. We find that more girls are getting educated and making a living for themselves than the previous generations did. But societal prejudices still remain and the behind those signs of progress among women hides an ugly truth. A truth nobody is willing to acknowledge : “Society still considers women as inferior to men.” These men and women( the voices of society) who give statement after statement believe that its always the woman’s fault (even some in the NCW think so).Unless this mindset is not corrected no law will control these savages committing crimes.

The media which is supposed to be the progressive voice of our country is as regressive as can be. Recently we saw footages from a Guwahati based news channel showing images of about 20 men molesting and stripping a 17yr old girl. This episode teaches us two things. ONE: People who would seem normal are the people capable of such serious crimes. There are no signs to separate these savages from society as a whole. TWO: There are no ethics and sensitivity left in the media. While seeing the video we are also listening to the cameraman actually encouraging the molesters to go further in their ghastly crime despite futile pleas by the girl to leave her alone. The reporter of that news channel even has the gall to interview the molested victim and ask her personal details immediately after the incident. Then they broadcast it live all over India and say they actually helped identify the culprits while actually they were just creating a TRP raising story. They did not even try to help the poor girl. This is how depraved our media is. Its not just one news channel, every news channel in India broadcast it without any shame. The identity of that girl was flashed like a sign of victory thus destroying the last shreds of humanity. The govt. did one better (rather worse), they sent some elite high brow delhi socialite women who claimed to be from the NCW who conducted press conferences along with the victim. Even a molestation is treated as platform for politicians. What law will these politicians bring in when they themselves behave worse than those molesters.

This is not to say some good work is not going on. The child abuse bill and domestic violence act are some examples of good legislation. But unless the powers that be change their prejudicial stand point no law can be enforced to actually decrease such crimes.

feel free to read what western media thinks about the rapes in India:
http://www.slate.com/blogs/xx_factor/2012/10/26/rape_in_india_a_sexual_assault_spree_in_haryana_brings_out_the_crazy_in.html

Lessons learnt in Kolkata

Three years spent in Kolkata has been an experience which changed the way I looked at life. Here are few of the lessons i learnt in Kolkata.
Lesson #1: There is no clear distinction between good and bad people.
People who are good hearted are not good in every aspect and they will still do the wrong things sometimes so that it suits their situation. While they say there is something good in everyone, I found out this to be untrue. There are genuinely bad people in this world and they have no guilt nor remorse in what they do. People who do good are not necessarily rewarded and people doing bad things get away scot free despite everybody knowing it. In Kolkata i met some of the best human beings as well as some of the worst products of humanity. I met people who genuinely cared about others and others who would use people to further their own agendas. This was one of the first lessons I learnt while I was here.
Lesson #2: Integrity is the only currency in the world...without it all the money, fame and achievements count for nothing!
Integrity is the first virtue people lose when they want to get ahead at any cost. The cost? putting other people down, lobbying, flattering their superiors, scheming to achieve an advantage over their peers, losing friendships and trust in order to get ahead. I’ve seen them all during my 3 years in Kolkata.  Some of these people might even go on to tell you there is no other way to be successful in today’s world yet there are people with impeccable integrity living dignified lives even today.  We should do our job the best way it can be done and everybody else play their part. Often times others don’t play their parts but that should never lower our ideals and integrity. Our purpose in life should never be affected by the bad things other people do! If you keep your integrity(and whatever you stand for) despite all temptations and rewards to lose it, you have something to be proud of about your life! Everybody keeps a safe distance from people with integrity and will think twice before they mess with them. Not only that all your achievements have incredible value as its all yours and not dependent of somebody else’s generosity. I would like to quote Ayn Rand who is an authority on these matters.

Honesty is the recognition of the fact that the unreal is unreal and can have no value, that neither love nor fame nor cash is a value if obtained by fraud—that an attempt to gain a value by deceiving the mind of others is an act of raising your victims to a position higher than reality - 

Ayn Rand

Lesson #3: The best punishment to people you don't like is to ignore them.... you can live in peace and it drives them nuts!!!
Heh! Heh! This is a practical lesson I learnt while I was in Kolkata. With time I came to know that it is impossible to  change somebody’s view/opinion/behaviour/attitude if the concerned person does not respect you. No matter how many logical arguments you may produce to prove that what they are doing is wrong they will never move from their position. So when it comes to these people I preferred to give them the “silent treatment” which worked wonders. It drove those very people so crazy that they straightened up to doing things how i wanted them to. If they didn’t mend their ways i at least had the peace of mind since didn’t have to talk to them.
Lesson #4: Genuine interest is key to most things.If you haven't got wonder in your life you have very little else.
During my residentship i saw many residents- senior and junior who took up Ophthalmology even though they were not interested in it and took it since they did not get the subject of their choice. They were in various degrees, uninterested, critical of the subject and mostly non-working due to it.I am a moderator in an online career guidance forum for doctors and I met several people who joined ophthalmology and were regretting their choice. I took up Ophthalmology since I was interested in the subject and once I started my residency I was totally hooked. There was no looking back. For me Ophthalmology was the best subject in the world. I was initially pained that all the above people did not see it that way but slowly understood why. Ophthalmology is a tough subject to like if you are not interested. It involves learning a new set of skills quite different from what medical students are exposed to during their undergrad period. So its a paradigm shift in their learning process. Also in most medical colleges (fortunately not mine) in India they give very little surgical hands on experience to residents of Ophthalmology. This may contribute to them being frustrated but mostly it is because of lack of interest. We all have to make compromises in life at some time or the other, but I feel even when we compromise we should choose a path which we will go through till the end. Again interest is the most important thing.
Lesson #5: There are no born surgeons. The surgeon who does not work hard to improve is the bad one.
When I first started my residency my biggest fear was whether I'll be able to do surgery competently.I did not want to play with human eyes to humour myself. But surprising even myself I did turn out to be good enough. I had a good reputation among my colleagues and my teachers regarding my surgical skills. But surgery never came naturally to me or probably I was a slow learner. I did struggle to fit in initially and due to peer pressure I did go through some periods of depression. But I picked myself up and worked hard to improve myself. Reading about surgery I found out was the best way to improve your technique and minimize your complications. Watching live surgeries and videos by experienced surgeons was the second best way.  My boss was the biggest inspiration behind me. Every time I had a set back he was the one who motivated me. He said to me “If i could learn eye surgery at the age of 37 yrs, you being so young have a lot going for you”. I did improve and did quite well eventually. So every time I wanted to learn a new surgery I read extensively about it, assisted in many surgeries and watched many videos. This was the philosophy I tried to inculcate in all my juniors with varying success. A lot of people want a short cut in everything. But surgery is such a field that there are no short cuts. You have to do the long haul or not do it at all. So whenever I saw any of my juniors not willing to work hard even for their own selves it always disturbed me. But those who were willing to listen did very well. I feel a slow but careful surgeon is better than a fast, over-confident and talented surgeon. The ideal surgeon is the one who is open to constructive criticism and advice from seniors and teachers while remaining confident about oneself. He should leave his ego when operating and be sensitive that he’s operating on a human body. He should always work hard to improve his skills in every way possible yet be prudent enough to understand that complications happen in the best of hands and our goal is to minimize our complications and not to eliminate them. This was my career defining lesson.

Lesson #6: A doctor's life is tough but it's an uniquely gratifying experience! Doing good is easy if you want to do it.
My friends in other disciplines would have me think that Ophthalmology is not a satisfying branch since in most cases we are not battling to save patient’s lives. But I beg to differ because sight is as precious as life itself and saving vision of patients is as satisfying as saving lives. In fact since we see very few deaths in our practice we have happier lives. When I was doing my residency I was exposed to the abject poverty of patients in West Bengal which is much more grave than in Karnataka. It was tough for me to handle initially but gradually I learnt how to give efficient care to the appropriate patients. I learnt to listen to patients problems (not necessarily health related) to help them make the right decisions for their situations. I tried to reduce their hospital spending by effective means. I sometimes went to great lengths to convince my superiors to take timely decisions. It was a great management lesson for which I did not need to go to a B-school to learn. In the end I found that if you truly care for your patients, have empathy towards their varied problems and have respect towards them you will find a way to help them in the best possible way.
Lesson #7: Never compromise with personal relationships…friends and family.
Always stand up for people close to you despite all odds. In their time of need you should be their biggest asset. You may sometimes stand to lose your footing supporting them but in my experience it’s been worth it. When you are in trouble you’ll see how they will come for you.  I am blessed to have the most amazing friends wherever I have lived and my family has been my pillar of strength all my life. Friends and family are the most important people for you in success and in failures.
Lesson #8: Positive attitude cures a lot of bad luck!
This is my lifelong aspiration. To see the positive side of things. To believe that there are no wrong turns in life, only new roads to find. Anything that happens to us which may initially seem like bad luck may be an opportunity to do something different. There will be plenty of people who will say some things are impossible. They will discourage you from pursuing your dreams. They are all liars and are people who lack  vision. Belief in what you do is paramount, so if you believe in something never give up half way. Go the whole distance and  you'll see you were right!