Doctors on the move

The other day I saw a white van speeding by on the next track of the CA 78 highway. It said ‘Your friendly neighborhood doctor’ (Spiderman like) or some such thing. Well, it was a surprise, and I wondered, is the work of physicians going to get distributed, close to the need, finally, with home calls etc coming back into vogue? Seeing that close on the heels of the computerization and outsourcing moves, it sounded like a great idea, actually.

Years back, when we were kids, we had a Dr-mama - Dr Balakrishnan Nair at Calicut who used to come if the patient at home was too weak or sick to move or was a small kid. Otherwise we took a horsecart (or were there noisy autos then? – I forgot) or some form of conveyance to his ‘Karunakara Nursing home' on Wynad road.

Calicut medical College records these things for posterity though I myself was recounting of the mid 1960’s. The1930s and 1940s saw the heydays of Family Practice in Kozhikode. In1930, Dr VA Raman established Ashoka Hospital - perhaps the first private hospital in the region. Meanwhile, Dr A Balakrishnan Nair in the north of the city, Dr A Narayana Sami in the central town area and Dr CK Menon to the south had laid equal and honourable claims to the patient clientele of Kozhikode, despite the lack of facilities for inpatient hospital care: recalls Dr Ramanathan and Dr Madhavan Kutty. It was only later that Karunakara Pharmacy established by Dr A Balakrishnan Nair, an alumnus of Calicut Medical College, started offering inpatient care. Dr Ramanathan adds - The general practitioner was a jack of all trades — friend, philosopher and guide. It was a hectic schedule with home visits. There were few women gynecologists. I had to attend to deliveries too, including in remote areas in Wynad.

This was the history of medical services in Kozhikode, with the medical college coming up in 1957 or so but then, I recall Dr-mama arriving at Chalappuram, asking questions about maths, homework, other relatives and their well being, the politics of the country, discussions about his children (doctors themselves) and so on. The Nair/Menon community out in Calicut was pretty well connected and inter-related, so everybody knew everybody else.

That was family practice - Do you remember those scenes from early movies, the doctor comes to the bedside, this briefcase held by a male member of the patient’s family, standing beside him with arms crossed and great respect writ on his face. The doctor asked for some water which he boiled using a small pot & spirit lamp taken out of his leather bag, to sterilize his syringe. Distilled water for injections came from those small ampoules that he broke using the mini saw ‘aram’ (just the other day I found out that they have a new tool - a plate with a hole through which the ampoule top is inserted and snapped off– though not as interesting as the original one, it is probably faster & safer). After drawing out the water, he injected it through the rubber cap of the antibiotic or whatever was in the bottle, then shook it vigorously and drew it out again with the syringe for the injection. As a child, I recall holding out my hand for one of those mini saws or ‘arams’ after the doctor’s work was finished. Later when my dad, a doctor himself came back to Palakkad after a stint in the estates, I recollect seeing the very scenes even more often, and I remember helping him now & then with cutting the head of those ampoules and lighting the spirit lamp.

After he was done, Dr-mama stopped to drink some tea and eat chips served out from the ‘bharani’ filled up recently from Maharaj’s at SM street Then, the Dr would get up to go. The ‘karanavar’ of the house (my valiachan) would stealthily go near him and slip the ‘fees’ into his hands (I have never understood this stealth – as though it was dishonourable). Dr-mama would consign it to his pockets without a look at how much it was and the leather bag would be carried by another adult male in the family to Dr-mama’s car. Sometimes he left a sample syrup or something for the ailment thus avoiding the need to go and find it in the ‘Palms’ medical shop across Karunakara Nursing home (I think it was only later that Karunakara Pharmacy came into being to supply the medicines).

From those days medicine came a long way in Calicut. Clinics came up; though there was the big medical college hospital it was 5-7 miles away in Chevayoor. Then came the primary health centers, private hospitals, specialty hospitals, the diagnostic centers…Now you even have the 5 star hospiplexes (Honestly - I made that word up just now ) – hospitals that will soon become like cinema multiplexes with all kinds of stuff – 5 star rooms, shops, hotels, in room TV entertainment, on demand movies…and what not.

Appointments were then the rule of the day since the clinics started, but I can say that to this date I have not seen a place where I have met the doctor on time. Whichever be the country the aspect that time is irrelevant is writ on the honorable doctor’s profession. Probably right, I guess, because when you are in with the doctor, at least I have always much to ask and understand. But then, sitting in the reception, being prey to all those germs floating around and sick and glum faces looking at you is not fun. Here in California, the clinic states that anybody who has a cold or flu has to wear a mask out of consideration to others. But we have a new breed these days. They are called PA’s or ‘physicians assistants’ who become kind of ‘quasi’ doctors after a two year course. They cannot be sued, I believe, so cost the clinic less, and are quite popular. The PA’s take care of mundane ailments or less complicated patients. From personal experience, I can say that they are equally good.

In England, these clinics are called surgeries. The NHS works in a completely alien fashion and you can chose to meet a nurse for small issues and a doctor’s appointment for routine check up’s can be many days away, when you call in to fix one. Meeting a specialist (unless an emergency) requires a reference and a long wait and getting a dentists appointment is even more time consuming, many months of wait actually. Private insurance can help jump the queue for surgery, otherwise it is free. UK still requires doctors & nurses to do some home visits.

Today outsourcing is the name of the game with diagnostics outsourced across continents, clinical trials are done in India (I saw a very negative Tamil film on this called E) and China, with even diagnosis getting outsourced. Thus from the days of home visits, we have transcontinental visits. The days of telemedicine are here… You could for example call the Auyurvedic specialist in Kerala and get a diagnosis and advice on what to do with hair loss. But that is not exactly what I meant by telemedicine.

Telemedicine typically involves physicians using interactive video and/or store-and-forward consultations to treat patients. Interactive video allows medical specialists to directly communicate with their patients who are in another location, using television monitors and specially adapted equipment. Store-and-Forward techniques include physicians sending pictures, x-rays, and other patient information directly to the computer of a specialist. After reviewing that information, the specialist then sends the diagnosis back to the local doctor, who treats the patients and provides follow-up care. Telemedicine may be as simple as two health professionals discussing a case over the telephone, or as complex as using satellite technology and video-conferencing equipment to conduct a real-time consultation between medical specialists in two different countries. Well, it has come a distance from ancient days of African villages sending smoke signals to keep visitors away from a sick village!!

Interestingly, it is in India that we have already utilized advanced forms of Telemedicine since 2001. The efficacy of telemedicine has already been shown through the network established by the Indian Space Research Organization (ISRO), which has connected 22 super-specialty hospitals with 78 rural and remote hospitals across the country through its geo-stationary satellites. This network has enabled thousands of patients in remote places such as Jammu and Kashmir, Andaman and Nicobar Islands, the Lakshadweep Islands, and tribal areas of the central and northeastern regions of India to gain access to consultations with experts in super-specialty medical institutions. More details of the ISRO project can be found here.

So will computers & satellites take care of our medical needs? Will robots like Da Vinci that I wrote about earlier replace surgeons? Will nanobots (tiny nano sensors or devices placed into the blood stream) go through our bodies (also delivering minute amounts of medicine at the right time to the right place) and constantly report the health of the individual to a computer and will the computer dictate predictive & preventive maintenance as well as corrective actions to our bodies? I think all the above will happen in our life time just like many of us have already undergone laparoscopic (keyhole) surgeries.

But will all this provide the same comfort and confidence that you would get from the reassuring words of a doctor in front of you? Probably not! And so, for that reason and probably since it is a niche business by itself, some docs are getting back to visiting patients. Today you have mobile doctors in UK, USA & many countries, flying doctors in Australia etc. But will we see the reemergence of eminent Dr-Mama’s? I doubt it.

Tailnote - I cannot leave this subject without taking a dig at doctor’s infamous handwriting …

There is always a question about a doctor’s handwriting in the patients mind. He peers at it and can hardly make out the drug name (this is valid mainly back home & some other countries – here we get it off computers as a print out with the doctor checking his/her hand held device sometimes to come up with the drug names and then to input it into the key board). As he presents it to the pharmacy, the guy at the till takes one look and screams out the names to the boy who is on the ladder to search it out. Then he transcribes to you the codes e.g. 3 t.i.d. pc or t.d.s pc as ‘three tablets per day after meals’ and the such.

Why is it a scrawl on the prescription and one that only a compounder or pharmacist can understand? Apparently this bad handwriting kills over 7000 people a year due to wrong transcription by today’s pharmacists.

Well, I do not know the reasons, but the assertion that doctors have bad handwriting holds an honoured place in traditional lore. According to conventional wisdom, doctors write in a code--a self righteous chicken scratch that is decipherable only by experienced pharmacists and, with luck, by each other. A study was conducted and the results were - The handwriting of doctors (mainly related to letters & not numerals) was no less legible than that of non-doctors. Significantly lower legibility than average was associated with being an executive and being male.

Today the problem coupled with strict health & safety requirements in any countries require that the prescription is printed out or emailed to the pharmacy.

Why is it that the prescription has an Rx on the top left corner even today? What does it mean?

There are various theories about the origin of this symbol - some note its similarity to the Eye of Horus, others to the ancient symbol for Jupiter, both gods whose protection may have been sought in medical contexts. But in reality it means ‘prescription’….

The word "prescription" comes from the Latin "praescriptus" and is made up of "prae," before + "scribere," to write, so that prescription meant "to write before." This reflected the historic fact that a prescription had traditionally to be written before a drug could be prepared and then administered to a patient.

What other codes are used? Quite a few are used, Check these links for details. (One, Two)

What is QD and QOD? QD means ‘every day’, QOD means ‘every other day’ (alternate days). But OD means ‘right eye’ so imagine what happens if the Q looks like O!!!
Some cartoons on the subject
Pics - Thanks to ISRO & various sites

Comments

Interesting post, Maddy. I too recalled my boyhood days when the family doctor used to call on.

By the way, I think I knew Dr.Balakrishnan Nair, who was a client while I worked as BM of Syndicate Bank in Calicut during 1992-94.

The handwriting of the doctors, while many reasons can be quoted for it's miserable nature, is to be deplored. I was shocked to see that in US alone over 7000 die a year from the illegible scribblings called prescription of drugs or medicines.

Regards,
Rada said…
As the diagnostic equipment have become more sophisticated, has the physician of today lost some of those skills himself? Gone are the days when a doctor could simply feel your pulse, listen with his stethoscope and with a few basic checks declare what was wrong with you with an almost 90% accuracy.

These days when you go to a hospital with even a simple complaint, observe how many tests they order before they even actually examine you! Talk about protecting oneself with belts and suspenders! And even at the end of all this, chances of wrong interpretation and hence wrong diagnosis abound!
Krishna Vattam said…
Congts.Reads like an excellent story bridging the past with the present.A loveable piece.Krishna Vattam
What a charming post - and how beautifully you have captured the role of the doctors then - and now. Very interesting. Some of the Doctor's names were familiar to me, but only as names for I married into the Calicut family and went there only in 1967, when the family doctor was a Matthew Zacchariah.
But my husband reading that bit of the post was very excited and pleased because he recognised all the names, and knew most of the doctors mentioned.
Anonymous said…
Hi Maddy

Another piece of brilliant writing!Thoroughly enjoyed this one.
Telemedicine,Telehealth,Telecare-welcome to 21st Century Medicine.Guess computers and technology will continue to build up on its already fast growing influence on the way modern medicine is practised-and to be honest, it's not entirely bad. You can now send by email scans from one hospital to another in a matter of a few minutes and get a
2nd opinion within the same day. In the past films had to be posted or delivered by person and one had to wait for days to get that 2nd opinion. Teleconference between specialists in different parts of the planet, remote monitoring of heart rate and BP as well as your aged relatives,controlling your environment by using just the flick of a finger or by eye lid movements by a severely disabled person-the influence of technology goes on!

Alex
And yes, nice new photograph!
Anonymous said…
Computerised 'scrips' have helped to reduce prescription errors due to illegibility in many countries such as UK and US.In fact some of the in built software programmes will warn you of a serious inter-action between medications or an actual contra-indication when you prescribe a new medicine for someone already taking a few.The daily checking of drug cards/sheets of inpatients by hospital pharmacists have also helped. Yet 'iatrogenic' errors continue to happen!One wonders how many such deaths still happen in India where there is no control on prescription or dispensing!

Alex
Anonymous said…
Maddy

Doctors handwriting-come on mate, it's not much worse than that of a lawyer,engineer or a Uni professor? But I agree that it has far more serious consequences.
Many of the medical terms have been derived from Latin and Greek and pharamacology has its fair share of it.
QDS/QID/TDS/TID/BD---
BD- is that Before Dinner or twice daily?! [BD=Bis In Die=Twice a day].Many doctors still prefer to use these old Latin abbrev instead of just writing legibly in clear English- TO BE TAKEN TWICE DAILY AFTER FOOD.

Alex
harimohan said…
dear maddy
luckily iam having a foot in both boats working in a state of art computerised johns hopkins run hospital and also being a physician trainer in the hospital information system and also running a cosy family clinic in india ( my wife take cares of it )with personal rapport with patients for past 20 yrs
sending a poem i wrote on computerisation in my hospital here to all physicians (sorry for this long comment ....up my alley )



The computer for us be it day or night is a mirror
We need to be careful as to make no error
HIS shows us all of hers and his
And no details can we or do we miss



Patients and patients are seen in digital format
Be they young old thin or fat
Don’t ever think they are reduced to mere numbers
For to us they are like our family members



And so we start the day by opening our inbox
Like an eager child opening his Xmas socks
We do get surprises of summaries to sign
And at time results that are strangely benign



Our mail box fills and flows
And Some of them do make us glow
Jobs to be done and rotas on call
Like eternal shopping in a big mall



And then we rise from our screens
To face our patients and preen
To knock their chests and listen to their ailings
And come back to our screens for the mailings



Orders we give in power forms
Requests we make by the usual norms
Virtual treatment is a distant reality
The day it does it would be a pity



Every progress has its disadvantages
This has been told for ages by all sages
we need to use the best and throw out the rest
So don’t you look at your computer as a pest



Don’t we get our results in a jiffy
Though at times they do get us into a tiffy
We can see our ultrasounds and ct s live
And doesn’t it help us in our knowledge strive



Change comes with time
And we are the harbringers of reason and rhyme
So smile and grin and look at your computers
And clear your soul of all its bitters



Happy HISSING…………..Dr Harimohan
.
Very nostalgic posting! You missed out Dr.AG Nair, the brother of Balakrishnan Nair. Incidentally, none of them was a product of Calicut Medical College. They were all trained in the Calicut Medical School which functioned in Mananchira (behind the RDO office) till after the second WW and awarded LM&S diplomas.
I would like to add another bit - the concoction called 'mixture' (either carminative or soda sal) which was the standard medicine served in green squarish bottles with the dosage marked by bits of paper artistically cut and pasted on the bottle. It used to be as effective as the modern capsules in curing us of the many ailments!
Sunita said…
Maddy, it was very interesting reading this particular post because my father worked at the Calicut Medical College around the mid-late '60's before he shifted base to the Trivandrum Medical College.
I remember scenes when the parents of his patients (he was a paediatric surgeon) would come home hoping to show their gratitude by bringing small gifts which were promptly returned. I suspect some of them found out his weakness, though, because I never saw him return a gifted puppy or any other animal!
calicut said…
http://www.cmc.edu.in/golden%20jubilee/kozhikode.htm
The above link takes you to a good summary of medical history of Malabar.
PN Subramanian said…
Very interesting and informative post. Thank you sir.
gauri said…
Nice one, Maddy. Had to read it in parts, but I finally did :)

The scrawl - yes, it is so legendary - even today, I consciously check if a prescription is legible, and it never has been. Almost like it's not fashionable to prescribe with clear legibility.

You think it started in old times because local quacks (& pharmcists) didn't want laymen to figure what medicine is a cure for what disease? Else people would just figure out, and wouldn't need the doctor anymore :D Sounds like a conspiracy theory to me ;)

g
Maddy said…
Thanks Guys & gals for all your comments, I truly appreciate it...

Murali - This Dr ABNair I think stopped practice in the 70's & retired. But as you said the statistics are strange, I was shocked myself..

Rada - problem is Litigation and loss of the 'awe' the profession carried. In the past, a doctors word was gospel. As the clan multiplied, the awe vanished. Then it was the insurance companies, litigation together with people who made investments in diagnostic equipment who influenced the process.

Nevertheless, let me quote from Erich Segal's doctors - Gentlemen, I urge you to engrave this on the template of your memories: there are thousands of diseases in this world, but medical science only has an empirical cure for 26 of them. The rest is ....guess work.

Thanks Raji & KV...I am glad you liked this..As for the photo,thanks, and I think I will now pen a blog on how I lost my 'moustache'.

Thanks Alex..very accurate as always with your insight!! BID is twice a day.

Hari - that was a nice one, You should tell us more about your Arabab hospital experiences. You make them quite humorous & interesting.

Thanks CKR for putting up the link. Mine has been changed. So this helps. And yes, I recall AG Nair as well. ah the carmicide mixture was a cure all!!

Sunita and PNS - thanks indeed. You should see what patients bring to doctors in the Malappuram - Manjeri area. They are the ones with real gratitude...without limits.

Gauri - May be you are right. Because in the old times it was necessary for a learned person to have a good handwriting.
Happy Kitten said…
Some of us souls still retain the "awe" for that profession....

and then it is always the friendly doctor who listens to the patient that is liked by all.. somehow his medicines will work ...

during my growing up years it was the clinic attached to the Tea Estate and it had only a Compounder (sp?) and a nurse.. but then he was akin to God to all the workers while my Mother was happy curing most of our ailments with her homemade concotions.. and when he did visit us he never failed to use the syringe!
Kichu's Corner said…
Respected Mr.Maddy,

I thank you for remembering and my Grand Father Dr. Balakrishnan Nair on your blog.

Your blog is simply amazing and full of so much of valuable information - God bless you Sir,

My I request you to kindly visit my FB page on him https://www.facebook.com/pages/DrA-Balakrishnan-Nair/192957197437703 & also request you to kindly post your valuable comments there.

Respectfully
Balakrishna Gopinath
balakrishnagopinath@gmail.com
harimohan said…
wonder if dr balakrishnan nair is same physician whose son is
dr venugopal opthalmic surgeon ?
talking of handwriting once when i could meet Ruskin Bond up in the Mussorie hills he commented on my handwriting and called it a typical doctors one !
coming from him that was a compliment