Written by Dr. Harish K Rao

Physician burn out is today an alarming issue in the medical field.

Not that it has not happened before, but after the pandemic, it’s now an epidemic itself. Many eminent doctors have quit lucrative practices and joined ashrams of famous gurus to provide free service and thereby attain peace.

I was recently asked if I don’t feel the stress of practice or how I manage to carry on in these stressful times. The answer is obvious and even though I do, I learn and manage. Medical practice is perhaps the most uncertain of professions and today with high expectations from the society and the patients the stress is only worse. But then, how do I carry on with apparent equanimity that I do?

I, perhaps, have been lucky to have some very nice humans as patients during crucial periods of my career, who taught me lessons that have endured and helped me carry on.

I always teach my students that as doctors we must possess behavioural traits that are absolutely necessary to be in practice. A doctor must be absolutely honest. A dishonest doctor is a threat to society. He must always be punctual, keep his word on the appointment made because patients life could depend on it. He should be patient to the point of being stoic. Empathy is a quality without which no doctor can practice. As a budding doctor I was brash and cocky, but my interactions with patients changed all that and I learnt some valuable lessons.

The first lesson in honesty was taught to me by a patient when I was an intern. A school teacher Mrs. T. was a regular inpatient of our medical ward. She suffered from asthma and had to have inpatient treatment often. It so happened that we admitted her on our OP and tested her, treated her and then discharged her as she improved a couple of days later. She had to be readmitted the very next OP for an exacerbation of symptoms. Those days our hospital was the only free hospital available to the poor in the nearby area. Since she was discharged only a couple of days ago, instead of repeating her blood and urine tests, I simply copied her previous reports onto the case sheet. Next day when we were on rounds, my chief asked me about the reports and I glibly reported what I had written on the case sheet. The patient who could speak and understand English immediately informed my chief that I had not done the tests but faked them. I was severely taken to task and then punished with continuous extra duties till my posting was over. After this humiliation I resolved never to be dishonest and sincerely apologised to the patient and thanked her too for teaching me a lesson in honesty. Never have I tried to fudge records after that and now I disclose everything to the patient before and during treatment. That way I have stayed out of trouble and gained a lot of trust from my patients.

Today, the biggest grouse of doctors is that patients don’t show any gratitude towards them. It was not always like that. Mr. K, a poor tribal from a neighbouring district came to our hospital with a large inguinal hernia. I performed a standard inguinal herniorrhaphy as per prevailing practice. The wound healed well and the patient went home happy. He came back a fortnight later for a follow up and everything was fine. After he was given his prescriptions, just before he was about to leave, he called me to the coffee room in the OP and made me sit on the chair and then knelt in front of me pulled out a small packet made from crumpled newspaper from inside his shirt and offered it to me with a delighted expression in his eyes and asked me to open it. Inside it was a fistful of cashew nuts in bits and pieces extracted from raw cashew nuts by burning the shell. Then he implored me to eat it. I took a few bites and told him it was good. On hearing this, tears of joy brimmed his eyes. So, when patients now show disaffection with me today for no fault of mine, I remember Mr. K and carry on as there are others who will be grateful for simple services rendered.

Mrs. MS, was referred to me one rainy evening with acute abdomen that looked like a perforated hollow viscus. She had had a previous cholecystectomy and was irradiated for carcinoma of cervix. I treated her conservatively as the investigations done at the time was not conclusive. She seemed to improve the next day and I started her on clear fluids by mouth, only to see her become worse.

Immediately, I got a contrast CT abdomen done, which showed a leak in the bowel but could not localise it. I operated on her and could initially not find the perforation but the abdomen was full of the contrast given. So I searched a second time but still could not find the culprit. Just before closing, I decided to check a third time, in  the mesenteric border and I located it in the jejunum, a pin-hole sized opening! I closed the perforation and abdomen and sent the patient to the post-op. For two days she seemed to improve and then I started her on orals again, but she promptly developed pain and nausea but continued to take liquids by mouth.

On the fourth post-op day I got a call from the nurse saying that fecal matter was leaking from her vagina. To my horror, I found it was true and it was a massive leak. So, I decided to reopen her. This time I requested my senior colleague for assistance. On opening I found most of her bowel had completely necrosed and we had to take it out leaving behind a small stump of small bowel and bit larger remnant of colon. We brought the loop out as a fecal fistula.

Post operatively, I explained to the patient what had happened and told her that she was unlikely to live. To my surprise, this rich widow of 74 took the news calmly and requested me to inform her only son who was in New York. I obliged her and requested him to return home.

Those days it would take time to arrange for a return and I was asked if could somehow keep her alive till he returned. I couldn’t promise that. But the woman continued to express faith in me and stayed in the hospital. Each time I visited her, she would ask me to feed her a gulp of water before I left her after rounds. Initially I did not understand why, then I realised that she was following an age-old Hindu custom where a dying person is given water to drink just before breathing their last to help them with their final onward journey. This is expected of very close relatives. Since her son was yet to arrive, she must have decided that I was good enough to be her last relative. She died a week after surgery on the day her son landed in India but had not yet reached the city. Yet, despite all that she had survived, she never complained or expressed displeasure or anger at me but treated me like her son! It is this woman who still inspires me to do something for my patients even when things seem bleak and hopeless. This is a lesson in gratitude and acceptance I’m grateful for.

Today, the transactions between the patient and doctor is purely commercial. It wasn’t like that when I started my practice. We were very hesitant to charge and treatment was easily affordable for any patient. Mr.V was referred to me for multiple swellings all over the body. I diagnosed a kind of lymphomatous disorder in him and advised a biopsy. He agreed and I performed the procedure and charged him Rs.350. Subsequent visits were free. The pathology report said it was Hodgkin’s Lymphoma. Those days there were no chemotherapeutic facilities available here and I advised him to visit Tata Cancer Centre in Bombay. He went for the referral. One early morning, a few weeks later I got a call on my land line asking me when I would be available at my clinic. It was Mr. V and he was calling me from the bus stand where he had just arrived from Bombay. As I was about to leave home, I told him to come straight away. As I reached my clinic, I saw that he was already waiting outside. As I opened the door, he entered and before I could ask him anything he pulled out an envelope from his pocket and handed it to me. I asked him what it was and his reply is still etched in my mind. “Sir, this is a small token of appreciation. I understood the value of your treatment after going to Bombay. Just going out and then re-entering a consultant’s clinic costs money and I have paid you only once for all the treatment and advice you have given.” Then he added, “I think you are not aware of the value of what you are doing.” While I was certainly delighted to hear that, it only made me ensure that I don’t commercialise my practise. And so, I never became a millionaire from my practice but the trust I have gained from my patients is priceless.

There are several such patients whom I have come across and to whom I am grateful; who have highlighted some facet of human life that is largely being ignored today with consequent effects of disputes and violence. During times of stress or hopelessness it is these people who inspire me to carry on and do good to others. 

For, what is given will return in equal measure—you reap what you sow.         

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