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