STEPS to improve the experience of being a doctor

I was watching the episode 4 of Satyamaev Jayate (The truth prevails) (for those of you who do not know about it, it is a recently started much publicized talk show conducted by the celebrity actor Aamir Khan in India, addressing various issues that face today’s India). This episode really got the debate going because obviously though it had some truth to it, it was not the complete picture.

As I was thinking through this, I was struck by the fact that doctors are the most vulnerable group in the health care industry, be it in the United States or India. Doctors are at the disposal of everyone else in the ‘hierarchy’ of healthcare industry. Patients can sue them for bad outcomes or even without justifiable bad outcomes, employers can fire them for no reason what so ever, and if they own their own practice, they can get drowned in their own debts with all the ever-increasing overhead costs, and the public can criminalize, ridicule and metaphorically crucify them. It is true there are corrupt doctors, there are greedy doctors, and unfortunately so for the rest of them that are not. I am all for an outspoken criticism when the situation calls for it (like  the criticism of health care that I think is well deserved and long overdue), and recognize that passionately fighting back at the critique is only going to protect the rotten and corrupt parts of the healthcare system. So we should let the spark grow because that is the beginning of the road to a fairer system. However, we should be mindful of what we could do to amend the broken parts on our side.

It is important for us doctors speak up in this is the age of connectedness, age of social media, where every one ought to have a voice. This is a thought process to address the issues that might prove potentially problematic, not just from the legal standpoint, but also from patients’ perspective. Here are some issues that I thought were important ways to address them. This is mostly what we learned during training, but so often forget to practice

Speak up, Team up, Educate, Protect yourself, Support – STEPS

1. Media misrepresentation of doctor-pharmaceutical relationships – This may be different in different countries. My experience says, it is probably a worse problem in India. There have been many regulations to disconnect the big pharma companies from doctors. However, we are missing the elephant in the room, the real and bigger problem, that lies in the high-end ties and relations between corporate lobbyists & ruling powers. Whenever and wherever you see this kind of content, debate the issue, draw the attention to where the real problem is. ‘Mounam sammati lakshanam’. (silence is a sign of agreement) If you keep quiet, it is not considered polite, but counted as guilt. And if you think you are in a slippery slope with a pharmaceutical company, seek help and get out! You will not regret it. Someday, we will have to use the same medications & treatments and we should be able to do so without worries.

2. Doctors are overworked – Bring up such issues in meetings and devise a plan for work hours and schedules. when you cannot work anymore, please stand up and say, “I am done for the day, I cannot work anymore” and leave. It is better for everyone. Although easier said than done, I have to admit. An alternative would be taking at least an hour break, either for some quiet time or a slow lunch which should revive you enough to keep you going for the rest of the day.

3. Doctors have lost trust – Again, bad events, bad outcomes get more publicity and taint the image of doctors in the public eye. Gain trust of your patients. Inform, educate, communicate, obtain consents  — can’t be said enough. Show them their lab values, normal ranges, abnormal ones, graphs of trends, images and point to where the pathology is. Ask them to get an independent second opinion from another doctor of their choice. If it is different, discuss with the other doctor. It is ok if your first opinion was wrong on second thoughts. Do not forget to inform patients about risks, of everything that you do with their bodies. They have a right to know. Tell them what you are going to do, before palpating their breasts, or pressing on their bellies, or even listening to their lungs. Tell them what you find (sounds ok or looks fine) because they will be anxious about what you are going to find. Give them the assurance that you know what you are doing and if you do not know something you will find out. At the end of a visit, always ask if there is any other question you can answer for them. Do not leave them wondering what you are thinking. This may seem too trivial but very important contributors to what patients think of their doctors and how much they trust them, Convey to them that you are only as perfect as them and definitely care a big deal about their health. Remind yourself everyday that you and your patients are in the same team and are not opponents in a game where your win must mean patients’ loss. Work on gaining trust from your patients not by doing what they want, but assisting them with your expertise and help them make the best decisions for themselves. Tell them what they are entitled to know, instead of sugar-coating the talk and giving false hopes for incurable conditions. Keeping them informed of some bitter truths only makes them better prepared to face their struggles.

4. Employers giving you bad feedback based on what they ‘say’ they heard from patients about you. (while in fact it might be a purely administrative decision). It is a more malignant world than you think. An employed doctor does not have any protection against such kind of accusation, even when it is false. Unfortunately employed physicians are also the ones that depend on feedbacks for their future employments and growth in their careers. Do not let this affect you. Regardless of the kind of practice you have, provide patients with a website address (like vitals.com or health grades.com) where they can provide feedback, so you don’t get falsely accused of bad care. And with good feedback, you attract more patients and retain the ones you have.

5. Support your professional community. Do not discuss the perceived medical failures of your colleagues, or any other medical professional in front of patients. Firstly, you might not even have enough information only based on what patients tell you, that the care they received from another doctor was either wrong or unnecessary. Even if you know it is true, your objection has to be brought up with the other doctor and not with the patient. By not doing so, you are setting up a fertile ground that breeds mistrust. This where communication comes in handy, again. Obtain medical records, consult other physicians involved in your patient’s care. The time spent will save you time and even expenses sometimes.

Even after all this, it is not a cake walk being a doctor. It is quite a walk though, and we have to make the most of it!

Hilton head island

After living in temporary apartments, with stuffed clothes still in suitcases, traveling like there is no home I finally found a job & place of my choice. Before making the big move, we needed a weekend break to revive our spirits from the almost nomadic past year and strengthen our endurance through the next few weeks of chaos.

Remembering hilton head island (supposedly the second largest barrier island, the first being long island) in south carolina that my sister-in-law had mentioned a while ago, we thought it would fit well into our schedule since it was not too far. It was a weekend filled with unlimited fun on this shoe shaped island. Just short of 3 hours by car, it was a quick drive from our place. Densely covered with trees (one of the tree cities in USA that has held its name for > 9 years!) spanish moss-covered live oaks, palmettos, pines and red cedars. lots of flowering plants I don’t know the names of, is a perfect welcome layout for visitors. Fell in love with it, just like that!

An exhilarating morning run on the beach right behind where we stayed, then an opportunity to take a camera shot of the sunrise was kind of foiled by a thicket of black clouds hovering in the eastern sky. It was beautiful nevertheless. The clouds seemed to disperse upon its grand arrival. As the rays pierced through the dark clouds they seemed liked they were bleeding crimson at their edges. The birds gliding in the mosaic of orange and bluish grey background created a sight to watch and left me craving for a pair of wings. It is amazing how sunrises and sunsets can never cease to be wonderful. To watch the red fruity star emerge or vanish as you are watching feels like a new experience every single time you watch it. It is one of the very few things that makes you pull over on a highway while you are driving. (other than police :p)

We made use of the well-defined bike paths and the kind bike rental shopkeeper offered (without asking) to let us have the bikes all day for the price of 3 hours. Not enthused enough we said, “meh, we might return it in less than 2 hours”, but I guess they knew better. We didn’t come back until night. We rode on the beach with our little one in the kiddie ride, watching all the jelly fish washing ashore, sand castles that other kids were busy building, people trying to take a bite of the beautiful day in their own way. Some reading, some walking with friends, some playing with their dogs (who seemed like they were having the most fun), some having a quiet time, pensive and in deep thoughts, some alone, some with a baby in hand, paused to give a friendly nod as we rode by.  We rode along the nice little plazas tucked into and in between giant tall tress. Ponds and lakes with aningas having a sun bath, milky white egrets in tranquil waters, turtles resting on grass and alligators just being alligators. Dinners with live music (with a surprisingly well-behaved kid!) sitting outside just made the food more delicious, not to mention our friendly neighbor who sat at the next table and kept asking how each one of our items tasted. We willingly took that extra minute to relish and review it for him. He must have been confused with the menu, and looking for some live instant yelp, I guess some parts of the bike paths were lined with wooded lots with huge, i mean really huge homes. We wondered what kind of people lived there and if the kids in those houses knew the ‘rest’ of the world.

And we did not forget to play in the sand and sea water! and my daughter taught me how to become a mermaid  We played so much that we literally immersed ourselves in it! Highly recommended, get yourselves into it!

the kid enjoyed the pool most, no surprises there. since the ride in the beach was too hot & boring for her she took a break in the kids sprinkler area while we rested from our exhaustive ride against the wind. Restaurants and food are irrelevant to her since food was not an item on her schedule of events. Except when it was either an ice-cream or a popsicle.

I have often noticed, when I have such joyful escapes, as the pleasure soars high, a fleeting sense of anxiety silently arises, suddenly knocking me into an extremely sober mood, almost to the point that the joy dwindles away into oblivion, but this time I managed to grab it back and held on to it tightly, because I needed it, very much and dearly.

Finally we returned, rejuvenated, and only craving for more. Not being able to plan for vacations far away and for long time due to messed up schedules (adverse effect of our professions), this was just right. I think such weekend getaways are much more rewarding than the long annual vacations. Like the power naps, just enough, right in the middle of busy.

After a long break, I wanted to come back with a happy post. more sober ones will follow, they are waiting to be let out of the closet

2011 in review

The WordPress.com stats helper monkeys prepared a 2011 annual report for this blog.

Here’s an excerpt:

A San Francisco cable car holds 60 people. This blog was viewed about 2,600 times in 2011. If it were a cable car, it would take about 43 trips to carry that many people.

Click here to see the complete report.

Mommy Doctor

I wore my white coat as my daughter watched me.
It was one of those days when you need to make quick weekend rounds and there is no one to watch your little one. So she tags along, stopping in nursing stations, drawing on paper or typing randomly with a big colored font on MS word, being entertained by and entertaining people around in return.

As I buttoned up, she said, ” you are a nice doctor”
I gleefully replied back- “really? why do you say that?”
Because you are a mommy doctor. you take care of people who are ill (‘abbi patients’ is the word she uses) and also me.
I wasn’t quite sure how to react to this, because, I always have a nasty guilt pricking me from inside, that she should not be following me at my work place for more reasons than one

I do get an occasional & infrequent “you cannot bring her into this area or that area etc” from an angered staff member. It only makes me feel more helpless and angry at myself and at the person who says that

But reflecting on the consoling words my daughter had just said, there are indeed lot of things that I borrow between the roles of being a mother and a doctor.

When my little one becomes too hard to manage, I use the “be empathetic but stay detached” attitude that helps a great deal from getting frustrated and maintains my calmness to either listen to her “grievances” about why the box is not closing with a pencil upright in it or some such frustration of her own that she is not able to handle herself.

On the other hand, I have patients, who just will not listen. period. Then I have sometimes used a stern and angered advice- and a short story about what would happen if they don’t listen to medical advice. I see the same changes in their facial expressions when I talk about consequences as I see on my little one’s when I tell her what would happen if she doesn’t brush her teeth

There are occasions when patients are upset that the doctor is not available when needed. All they need is few kind words & caring gestures and they will be happy people again. Just like my daughter. How many times has she complained that I just don’t listen to her. My patients might feel the same.

This is not to say, mommy doctors are better at these skills, nor is it an attempt to put my daughter in the same basket as my stranger patients. But only to say both roles have so much in common, not only in execution but also in the rewarding feeling when the relationship pays dividends in the form of improvement in health habits or personalities. They may not last long, they need hard work, patience and are heartwarming at times.
More importantly, when everything else seems sour, I seek solace in my interactions with my daughter  and with my patients. I seek warmth & comfort in them just as much as they do with me. They help me become a better mommy & a better doctor

The soldier’s wife

She looked at him, eyes wide open, scanning every inch of his face, trying to lock it in her memory. She wasn’t sure when she will see him next or if she will even see him again. She muttered something, tried to hold her tears back. She couldn’t recall what she spoke but she knew where her tears had flown on his neck, as she hugged and waved him goodbye. He stood their like a rock, motionless, face devoid of expression. And that dreary cold look made it harder to see what was hidden behind. “Was this a battle, or was this an escape? Or was it a soul lost in the intricately knotted world?” her thoughts were so blurred out she was trying to clarify whether those questions were meant for her instead. Her heart sunk further into an abyss as she wondered for what greater purpose she was being abandoned time and again.

 

All she remembered of their togetherness were those moments of separation, the agony of which made anticipation of a reunion dreadful. The constant awareness of his absence brought a pain stronger than the euphoria of seeing him. Closing her eyes to get away from that terrifying thought only brought her closer to it. She fluttered like a dainty flower in the cool breeze on the seashore, her heart jumped with joy at the sound his voice, she felt happy and content with him around, she had given it all. She knew enough to fall in love but could never know enough to stop. In her mind he was perfectness, embodied. He was her yardstick to measure the world and everything fell short.

What is it that she wanted from him? What is it that she couldn’t find on her own? What was that sense of incompleteness? Her world was struck with drought, the mind was barren with him gone & far away. But she had to learn to fight it, like a soldier’s wife, just like every other soldier’s wife. For, the whole world was waiting for him.

But until she saw him again, she had memories, that she celebrated, moments that she lived again, happy thoughts she nibbled on, pleasant dreams she got lost in. She had hope in her thoughts that died faster than the flicker of fireflies

 

It was about time again. Time to go through this one last time, for she had done the unthinkable. She planned to poison him. She walked away relieved that she will now be free from the torment of separation. No more reunions and no more separations. The Weltschmerz had engulfed her and transformed her into a self possessed demon. Fear clouded her conscience, anger drowned her love. But an accidental slip of fingers was enough for a quick turn of fate. While she was convinced she couldn’t leave him and so he had to, her subconscious mind had laid out different plans. She had passed on her burden. It was now his turn to ask questions that would never be answered. Was she lost and restless? Was it a battle or an escape? Was she left helpless by the reckless world? His sweaty hands and fingers trembled as he frantically searched her desk, looking for clues as to why this happened.

She was a soldier’s wife, who had fought well but had lost.

The ugliness and beauty of crime and punishment

I have been thinking about this for a while now and I came across more such things and of course only more questions…

Article #1 with pictures of people sentenced to death with their last meals (their last wish).

Article #2 about how this ‘luxury’ was taken away since it was abused by one person.

Article #3 about how a father escaped for protection, with his molested his girl child, instead of hurting or even killing the offender.

The first article brought a sense of deep sadness. What they did to deserve that punishment, I had no clue. But I wondered if any conceivable crime be large enough to deserve killing in return. In all likelihood the pictures were taken at a different time than their last meal, but somehow, the association made it look extremely disconsolate.

Our  aspiration for fairness and justice in this world, comes inherently. We fight for rights, we hail justice, celebrate equality. It does not have to be a heinous crime. It could be simpler(?) things like lying, dishonesty, bullying, apathy that we live through everyday. We punish people for such behaviors guided by these above evil motives. Actions with criminal intent are punishable, and the offenders are fined, sent to jail, sentenced, executed. The punishment is proportional to the ‘size’ of the crime. The purpose of ‘punishment’ is either based on goodwill that those actions should not be continued (for the benefit of all), or for defending ‘justice’ and for a sense of power or victory by claiming non-surrender to the other party’s oppression/manipulation presumed or judged to be due to evil motives.

Although it is only intuitively agreed upon that this sort of payback is necessary for smooth running of a society, there is something very awful about one particular kind of punishment. That is execution or death sentence. To punish a person by killing, the crime must have been of equal degree. Assuming all such crimes were with wrong motives, when a person dies for punishment (caused painlessly) does it even qualify of punishment? In fact, a painless death is a desire in life that one could only wish for. It probably qualifies as punishment either because of the offender’s anxiety about his/her death, or because, there is a loss of what s/he potentially could have ‘enjoyed’? But paradoxically, death actually removes one from that suffering or desire to enjoy.

Firstly, the goal achieved with this as I can see it is that the rest of the world has got rid of this life and is presumably better off without him/her alive. But is it really the case? Research shows, that executions do not really decrease more of such crimes (It is reportedly also more expensive) . Makes one think, there should be more to these kind of crimes that go way beyond what is considered ‘normal’ human behavior. So many of the murders and slaughters are done by people with abnormal brains, minds and thinking. They have pathology that can be potentially corrected.  If the criminal is nothing more than a victim of his/her diseased brain, execution as a punishment loses ground since punishing a diseased person for his/her disease is not a lesser crime by any means.

Secondly, it is often argued that, the killing gives a sense of closure to the victim and families thus making it, not only justifiable but also a necessary thing. The person who actually ‘kills’ does not know the criminal. (s)he is merely making a living with this job. Do the victims/’s families actually feel a sense of closure after the death of the offender? Especially so if the person ending his life is neither enraged nor affected by the death? Or is it that they feel closure because they are supposed to? Is that the only way for closure? What would you prefer? An offender who realizes the wrong, confesses, repents and suffers or one who walks to his deathbed cold and unaffected? If the answer is the former, this also makes the argument for execution somewhat weaker.

It is probably not difficult to teach our minds to think that a life taken away cannot be an answer to a crime, but should we do that?

Easier said than done. Would I think differently if I was the victim or a loved one of the victim? Probably yes. There are enough articles like this too, but will give article 3 for example. It was about a father who did not harm his daughter’s molester but instead he ran away, grabbing his daughter from him and informed the law enforcement officers. The description of a person being raped, or murdered or abused itself enrages one to the extent that you feel that if you were there you would have killed or severely injured the criminal. The father probably would have received (more?) public empathy if he had killed/severely injured the offender.

Will the rage that surges within ourselves when we see such crime, remain strong if we were to learn that the murderer had some surgically reparable brain lesion, or some chemical imbalance that could have been potentially treated? With so much advancement in neuroscience, can all such heinous crimes be attributed to some ‘malfunction’ of the brain? What other than a diseased brain can lead to abnormal behavior? There could be pathological conditions that are still undefined and undiscovered. When is an action due to ‘pathology’? In other words, when is it a disease? And when is it punishable? For if it is indeed not under the individual’s control, it should be treated and managed but not punished.

Once we are convinced that somehow killing for murder or killing for any reprehensible crime may not be the most morally superior thing to do, can we extrapolate the same logic to our daily lives? Can we or should we simply forgive all harm that is done to us? It may be a colleague stepping on your toes or backbiting you. Or it could be a friend who might be abusing you for his/her benefits.There is always a need for justice to be done not only in situations where people get killed, but also in situations where our egos get killed or our prides get hurt. Who would like to be fooled twice? Once when they get fooled and again when they forgive?

This brings us back to the roots of human nature. Just as inherent as our sense of justice and morality, we have within us, a revengeful self, that doesn’t surface up until we are victimized ourselves. Or we are able to empathetically step into the victims’ shoes. While it seems easy to uphold the moral value of forgiveness when you are an onlooker, it is quite as difficult to do so when we are the victim. It is not only about self protection, but a sense of relief when people hurt us get hurt. It is about letting ‘fight’ define the situation when ‘fright’ or ‘flight’ are enough for defense. The sense of revenge plays an important role in our lives that the sense of ‘morally right’ rides over what would otherwise be ‘morally wrong’. Explicitly marked or not, we protect our ego dearly all through our lives, establishing ones own stance in this world. Speaking of our day to day lives, can we rationally convince ourselves that, ‘an eye for an eye’ strategy cannot solve problems? Can forgiveness come without an apology? What will it achieve, other than more harm to self? How can one be forgiving if that only means giving away his/her ego, pride and identity? If forgiveness doesn’t yield repentance?

While I was writing this all up, I came across the article #4 which went against all my thinking about revenge and forgiveness. Does one lose the ego, pride & identity by forgiving? Or does it get revived?

The halloween scare!!

We have used up this planet like no one else. We cut down trees. We cut down animals. We chased them out of their dwellings. We invaded the coldest ice covered regions and the hottest desert regions. We infiltrated the air and we stirred the ocean. We settled down, we multiplied and then multiplied again. We invented fire, electricity, we discovered gasoline and coal. We made plastic. We multiplied the ways we used up this earth. We fought, we divided, we killed, but we multiplied again. Wherever we stepped, we destroyed. We thought this earth is for us and we for our children and our children for theirs. While we think we should leave the best for our children, we are leaving the worst. We are leaving the worst not just for our children, but for all those that will ever live on this once beautiful planet, until it gets completely destroyed, by the flames started by its own inhabitants for light, for power, for life. Animals extinct, birds falling dead, fishes wash ashore with mercury and plastic in their guts. Ecosystems destroyed due to climate drifts and shifts.

Is there a way to come out of this harrowing whirlpool?

Because, this halloween, nothing can be scarier than the horrifying fact we are gifting our next generations a planet that is getting more toxic and uninhabitable.

Do what you can!

Use less of the planet!  Every opportunity you get!

Reuse what you can!

Heal the planet! spread the word! Every bit counts!

Let’s not trick! Treat our next generations!

Happy Halloween!

Vitamin D: The sunshine vitamin

Being a nephrologist, I deal with bone disease related to chronic kidney disease on a daily basis and vitamin D is a major player in metabolic bone disease patients with chronic kidney disease. Also, I have been frequently asked about this by many people, so I thought it might be a good idea to put some relevant information together for a quick reference.

In June 2011, the endocrine society published recommendations for daily intake and optimum levels, based on extensive literature review. However, these are not based on

large randomized controlled trials (which haven’t been conducted, so far)

With whatever evidence we have, these are the take home points:

Main source for Vit D is diet, but very little present, except for oily fish. Another important source is UVB radiation, which converts 7 dehydrocholesterol to pre-vitamin D3 and then D3

Plants have vit D2 more like a pre hormone than a vitamin.

Vit D (either 2 or 3) gets hydroxylated at the position 25 in the liver (cyp2r1 &  cyp27a1), stable and half life is 2 wks.

Then, hydroxylated at position 1 in the kidney cyp27b1 (also present in other tissues)

This is the active form of vitamin D.

Measurement:

When serum levels are measured the 25 hydroxy form is measured since it is more stable, concentration about 1000 times more than the 25 hydroxy form

The hydroxylation at position 1 depends on PTH (parathyroid hormone), FGF-23 (fibroblast growth factor-23), Calcium, Phosphorus

Recommended daily doses of Vit D:

Age upto one year: At least 400 IU/day

1 year and older:  at least 600 IU/day However, at least 1000 IU/day of vitamin D may be needed to raise the blood level of 25(OH)D consistently above 30 ng/mL

19 to 70 years: at least 600 IU/day

>70 years: at least 800 IU/day of vitamin D.

In adults (>19 yrs) at least 1500 to 2000 IU/day of supplemental vitamin D may be needed to keep 25(OH)D levels above 30 ng/mL.

Pregnant and lactating women need a minimum of 600 IU/day of vitamin D; 1500 IU/day may be needed to maintain blood levels of 25(OH)D higher than 30 ng/mL.

“Obese children and adults and children and adults on anticonvulsant medications, glucocorticoids, antifungals such as ketoconazole, and medications for AIDS need at least 2 to 3 times more vitamin D for their age group to satisfy their body’s vitamin D requirement,”

Tolerable upper limits of vitamin D, which “should not be exceeded without medical supervision,” include the following:

• 1000 IU/day for infants aged up to 6 months,
• 1500 IU/day for infants aged 6 months to 1 year old,
• 2500 IU/day for children aged 1 to 3 years,
• 3000 IU/day for children aged 4 to 8 years, and
• 4000 IU/day for everyone older than 8 years.

Of note all recommendations are only for bone health. No recommendations for ‘purported’ benefits of Vit D (for cancer, cardiovascular health) since they are mostly association studies.

Exposure to sunlight:

In fair skinned people: 10 minutes in mid day sun with no sunscreen (when UV index is < 3) is enough to produce about 10000 units of Vit D. This holds good provided the clothing is minimal exposing about 50% of the body. which essentially comes down shorts and tank top

In darker skinned individuals: the time required may be more.

Also note: darker individuals have lower risk for than fair skinned for skin cancer, so they probably could expose themselves longer in order to get the benefits of the natural vitamin D

Sunscreen recommendations

New FDA rules regarding sunscreen:

Sunscreens will carry a broad spectrum label- to indicate that it covers both UVA & UVB radiations

The SPF indicates protection against UVB only which is responsible for sunburn, skin cancer, and vitamin d production in the skin with sun exposure

While UVB affects only the outer layer of the skin, UVA enters deeper layers, 30-40 times more prevalent than the UVB, and linked to tanning and skin aging and skin cancer as well

Now, the highest SPF products can claim is 50+ since value above that are not meaningful in terms of protection

They can carry labels claiming to prevent cancer, only if SPF is higher than 15

Water resistant sunscreens will have to undergo testing, and labels have to specify time of protection in minutes for swimming/sweating

Manufacturers have one year to comply with these rules

Too much noise and lost poise

I was flying back home. A headache was looming around the corner as I sat down on a small connection flight. It looked more like a modest greyhound bus with wings attached. I put all my bags aside hurriedly preparing for a short nap that I thought would be enough to take care of the hovering headache. Knowing myself from before, more often than not, my headaches are from missed meals. And that day I was especially hungry even though I had binged on some crepes just an hour before.

I wouldn’t be writing this up if things went on as planned. Unfortunately, I had some loud passengers, especially a woman behind me. May be louder due to my heightened sensitivity to sounds. I got so bitter, I could kick one of those people out of the plane. I easily consoled myself to remain a low profile, no-problem-variety citizen.

I had no interest in speaking to anyone. But I had to tell them somehow. I closed my eyes with my scarf, closed my ears with my palms. The thought of swooping down to hide my head inside the seat back-pocket brought a smile even in that pain. But I couldn’t keep the situation appear funny for too long. First it was a “please” expression, which I thought I managed too bring on my face pretty well. They did not seem to care. May be they did not even notice. The seat belt sign went on, and I suddenly grew fearful of the next hour having to deal with this noise. That was it!  I could not take it anymore. I lifted my hand and waved frantically at the air hostess drawing every one’s attention. I suddenly became nervous about the whole scene. I requested if I could change my seat, request denied until plane takes off.

Since the discreet communication did not work and my headache did not show any signs of subsiding,  I resorted to the impolite way to make them realize their imprudence. I gave her the “how can you be so uncourteous?” look. After waiting on the runway for what felt  like several more hours, the plane finally took off, only a few minutes late. I got up and luckily I found a few empty seats at the back with people either quietly reading or sleeping. It felt good to be away from all the noise.

But I did not forget to give a resentful glance at the woman who I thought, knew that she was being too loud and did not care to be accommodative.

We were total strangers, we cared zilch about each other, had zero interest in each other’s lives. But even so, don’t we all follow a general rule of  ‘we accommodate for each other’s needs’  in public places? The rule of  ‘I don’t really care about you, but I will accommodate for your needs’ . But it doesn’t always work because 1. That rule is so vague and 2. It is always the other person that needs to follow the rules.

Would it be different if it was my friend instead of a stranger? Or would I react differently if I was that woman and I had another passenger giving me those  ‘angry glances’. Or would it be different if I did not have the headache and I was actually interested in listening to their discussion?! does ‘they can do it’ translate to ‘they should do it’ despite the potential harm & little or benefit to self. Does the freedom to exercise one’s rights overrule the responsibility to do no harm?

I have also been on the other side of the line, when my kid was too noisy and I had to cut a sorry figure in public for not knowing how to deal with it. But that would be a slightly different situation, since it was a kid with no or little knowledge of all these nuances of social life.

The headache went away and when I was my saner self, I thought I could have been more polite myself. A small headache was enough to bring out my “evil” side. May be we need to be more empathetic towards the seemingly resentful people we encounter. I wondered if there should be rules of behavior for each of these tweaked situations so we are all just following rules instead of having to go through the moral torment  of right & wrong, the ambiguity of freedom and rights as understood in our social and not so social lives. What would you have done?

An octogenarian perspective

I had picked up Emily’s patient to help her out, since one of mine was a ‘no-show’. The patient, Mr. Martin was in the infusion room getting an IV infusion . Not wanting to waste time waiting for him to finish, I decided to see him in the infusion room. Luckily, there were no other patients in the room and a computer to access his medical records was right on the table next to his chair. The conversation turned out to be one that I would remember for long. Within a few minutes, Mr. Martin had vented enough to give me glimpses of  his toughened mind, tempered thoughts, emotional vulnerabilities.He had pulled me into his world briefly by revealing some of the victories and losses of his life’s battles.

As I logged in to access his records, I introduced myself and hoping to start up a conversation, asked him how old he was.

Mr Martin belonged to the healthy looking octogenarian kind, even though he had dealt with his fair share of health problems. He actually looked younger than his stated age, not only going by his vigour and confidence, but also by physical appearance. He was neatly dressed, had maintained a good physique despite his physical disabilities.

Confidently he said, ”Oh yeah, I want live for another 10 years, atleast. Not that I have any major project like building an empire or something but I now have a reason to live which I did not have before. You know, I am a capitalist..” And he looked at me for a reaction as if it was my turn to tell him what I was..

Me: Well, I am not quite sure what I am. I have conflicts in my mind when I see huge discrepancies in wealth. I feel deeply empathetic towards people who struggle for even basic necessities, while others enjoy an exuberant lifestyle

Him: “I am empathetic too, but if I become a socialist all I do is give away everything and nothing will be left for me. And they won’t even be helped. You need to strike a balance while being aware of the discrepancies & maintaining your empathy. You need to cut a path for yourself” I couldn’t tell if he was trying to change my opinion or was trying to defend his..

Me: Yes may be you are right. Because if you don’t have wealth, you can’t hope to get it from other “empathetic” people.

Now his eyes gleamed, happy that I got his point. “Exactly. I am not wealthy or anything but I have worked hard for what I have”

Me: I think you should stop taking the Magnesium tablet

Him: “Well that is good. Are you a doctor?”

I smiled, Why? are you having doubts? (I remembered that just a couple of days prior to this, another patient had mentioned his difficulty in identifying people in hospitals, since doctors, nurses, nurse practitioners, PAs all dress & look the same)

Him: “No, I can tell people easily. I was just checking if you are a pharmacist since you are adjusting my medications”  he then spoke to me in Spanish

Me: I can’t have a conversation in Spanish, I barely know a few words.

Him: “Well, I can talk to you in French then”. he smiled. for me it meant that he was looking for someone he could talk to. (needless to say, he lived alone)

Me: I am sorry I don’t know French either. I can speak hindi if you want to (note to self, my fall project is (has been forever) to learn Spanish or French)

Him: “No I don’t know hindi, I haven’t been that far yet. I have gone up to turkey, I have flown over india, not in a plane but a bomber. He looked at me with pride as he mentioned bomber.

I was busy gathering data to make my assessment and he probably wanted me to stop it & listen to him.

I can take care of Pakistan in a minute for you, if you wanted. Prrp! , (he snapped his fingers) in a second!” with a delightful expression on his face.

by now I had realized this was going to be a long conversation.

Me: oh no, I wouldn’t want that.

He probably noticed I am not freely entering into a dialogue. and sternly said, “I only have thirty minutes because I have to leave for another appointment” implying he doesn’t have time for me either.

Me: Looking at his infusion, told him that it was unlikely he would be able to get out on time, but I would try my best to finish up my part as quickly as possible.

I was being drawn into this converstation already and I did not mind at all, since I had time & also some interest in listening to this man who seemed enterprising

Yes I know that too, he grinned. “I feel better already. I probably take too many of those water pills. (which I found out was true) he was taking it more frequently than prescribed).

He continued, ”I once saw an Indian movie in Paris that my wife took me to. She looks more Indian than any of the Indians that I know of. It was a totally new experience. The only other thing remember about that day was that the Egyptian movie was terrible.

Even while I was grazing through his chart, I could notice a sad tone in his voice when he said, “I don’t remember many thing s from the past but this one I remember very well”

I tried to perk him up a bit,

Me: I am glad you enjoyed the Indian movie, do you remember the name of the movie or the actors

Him: No, I only remember the costumes and the intensity of those scenes. He lifted his arms trying to probably describe a scene or something… but he couldn’t. aah yeah, and those actors can’t kiss. It was evident he remembered those moments somewhat vividly, though he did not remember any details of the movie

Me: Has anyone talked about dialysis to you?

Him: Yeah, they were talking about getting me a tube osmosis or something

Me: Sorry could you please repeat that again?

Him: You see, I am not trained in medical field but I am a well educated person, you know. I understand somethings well. If there is a membrane, I guess the exchange has to be osmosis.

I wasn’t sure if he was annoyed or offended by me asking him to repeat.

with a discontent tone, he continued, “We all are stuck here. We should not even be going to places where we are not supposed to be. Do you know our blood boils when we go to 50,000 feet? we have only 40 secs to live if that happens. Now you will think I am a crazy old man”

Me: No not at all. I would be happy if my brain works like yours when (&if) I am your age.

Him: I know. With a brain like mine, I sometimes cannot handle it myself. I get up in the night & start talking to myself. I become restless.  I have been to great heights, there is no sky and it is definitely not blue, it is just dark, black. I have seen the curve of the earth’s horizon. He was showing it with one hand as a plane and with another the curvature of earth’s horizon.

Me: Wow! That must have been a nice experience. I have only seen it on videos.

Him: Not entirely. You have a pressure helmet and you are under stress, but it gives you a different perspective

I was juggling between this conversation and my assessment and documentation. I had managed to squeeze in a physical exam while asking him a few more questions. Everytime, I tried to pull him back into a ‘medical’ conversation, he would pull me back to his side, so to speak…

Me: How long have you been on this medication?

Calculated & told me the duration,..

Him: When I moved here, I got my wife’s ashes and my medications in the front seat of my car. When I checked the next day, the medication was gone. I mean, somebody so slick?! What would they even do with that? Stealing other people’s stuff. Goddamn people. Oh god, I don’t even know what religion means anymore. he was sad again, actually sadder it seemed as his words dissipated into an angry mumble.

Now I had to stop typing and had to take a pause, since I noticed he was getting intensely emotional, remembering his wife

I tried to distract him, after hesitating for a second, since it was a delicate situation

Me: Hmm, are you a non religious person?

He had already rcovered, I thought

Him: yes. I do believe in god but I am too educated to believe in rituals and customs if that is what you mean. And I believe in god only to the extent that I think that is the only way I will ever see my wife again. Oh well, whatever… People can do all sorts of things if that helps them get peace. I don’t have an objection to that. May be it will help their stress & “hypertension”. He raised his eyebrows skeptically.

I asked him about one of his malignant medical condition.

Him: They put me on hormone injections so I don’t have testosterone in my body. Now I am a woman. I have breasts, I have a belly, I shave only once a week. I don’t know what I am anymore. I cannot control my emotions sometimes. you know, I cry like a baby sometimes. You probably have more testosterone than I do.

wanted to say that it is ok to cry and that everyone cries, but I kept it to myself

My colleague Tanya entered, wanting some info. She respectfully nodded her head as he looked at her, trying to make an assessment in his own mind.. he seemed to like her

Him: “You are pretty”.

She giggled “Oh! no one has ever said that to me”

Me: “Oh come on, that can’t be true

Colleague leaves after a brief exchange of some information with me

Him: See how easy it is to connect with someone? Well, She was actually pretty. If you can breathe, you are pretty.

Me: hehe, yeah may be you are right, I nodded as I continued with my work, trying to finish it up.

Me: So you had an infection in your bloodstream in the past? There was too much past medical history for me to browse through

Him: Oh yes. Can you believe I am still living after going through all of that crap? btw Do you know Ms Leena? she works at the regional hospital where I was admitted

Me: No

Him: She was ‘one of a kind’ person. She is a doll. She is young. well, everyone is young to me at 80 y of age. She is gay. She does not have a sex (gender) she is just a good person. You would have loved to meet with her.

Me: I see.

Me: OK I have made some changes to your medications. And ordered some labs before your next visit. Do you have any questions for me?

Him: Thanks for getting rid of some of those medications. So, are you going to help me live another 10 yrs?

Me: Oh sure, I will try my best. why 10? may be 15…

Him: Who knows, I had less than 30 minutes to live about ½ h ago. (pt was hypotensive and had received  some fluids in the clinic)

Me: I enjoyed the conversation with you. Could I please get your permission to post this on my blog?

The nurse had disconnected the IV lines by now.

We shook hands and then as he got up, he said,

“Sure, anything you want to do. You know, I don’t talk with everyone like this. I felt a positive feedback from you. It was a pleasure talking to you. How do I pronounce your name? how do you spell it?

Me: M as in Mary…, A as in apple…

he wrote it in a small book and he walked out with a sluggish & fragile gait with the help of his walker, dragging his tall statured, weathered self. He must have been a robust and handsome man in his prime days, I said to myself

I get to meet with many old lonely people during my day’s work. This one caught my attention today, mainly because of his resilient attitude which was incongruent with his weakened body, cold & random at times, yet wise & thoughtful, all while trying to deal with his loneliness and shortcomings. At 80 he seemed to have almost come to an agreement and had made peace with a disconsecrate view of the world he is living in.

I have written this from what I remember of all the relevant (or should I say irrelevant?) parts of our conversation

Names, patient information have been changed to protect privacy