Letter from Chennai

This is the way the world ends. Not with a bang but a whimper.

––T.S. Eliot, The Hollow Men, 1925

Not With A Bang But A Whimper

Sunil Pandya’s musings on his (not yet complete) retirement^[1] prompted me to share with you the experience of my complete exit from the profession. Early in 2020, I remembered that I had first registered with the then Madras Medical Council as a qualified medical practitioner in February 1959, and had thus completed 61 years in the thick of the action, as a clinician, a teacher, an administrator, and a clinical researcher. Over the years, I had gradually shed my responsibilities, first of renal transplantation in 1996, when I passed my patients on to one of my colleagues and stopped doing more renal transplants. I do not remember when I first gave up administration, but it happened suddenly one day when I was sitting and filling up for the umpteenth time a meaningless form from the National Board of Examinations, and I thought to myself, why am I wasting my time on this unnecessary task? I picked up the telephone, called my Chairman, and said I wished to be relieved of the responsibilities of running the renal unit as its chief, but to continue as a consultant nephrologist. I suggested that the responsibility and the title of Chief Nephrologist be passed on to my former student and the nephrologist next in seniority in the unit, Dr K.C. Prakash. With some hesitation the Chairman agreed to relieve me of the administration, but wanted me to retain the now empty title of Chief Nephrologist, which I have held to this day.

A brief digression on the National Board and its forms. The Board should obviously take all care in deciding that a nephrologist and his unit have what it takes to be a postgraduate teacher of nephrology. I believe that after that first inspection, no further forms or inspections should be necessary. The unit should stand or fall on its record. How many of its students have passed their examinations, and what have been the publications from the unit? A nephrologist may fill his annual survey with glorious achievements, but if after 5 years no candidate from his unit has passed the examination, he is not competent to be a teacher and recognition should be withdrawn. On the other hand, if a number of his trainees are deemed by the examiners to have an adequate knowledge of nephrology, he is obviously doing the right thing, and even if he has fewer books and journals than the inspectors deem necessary, he is a competent teacher and should continue to have Board recognition.

Over the years, I have shed my responsibilities in dialysis and then in critical care nephrology, passing each to one of my colleagues who had some special interest in that area. Finally, when I turned 80 some years ago, I gave up all inpatient care, and confined myself to outpatient consultations. These still gave me a full day’s work, from 10:30 a.m. to 5:30 p.m., often extending to 6 p.m. or later. I also remained active in the teaching programme of the unit. From the very beginning of the unit, we have been accredited by the National Board of Examinations to prepare candidates for the examinations in nephrology, and while the Board in its wisdom decided at some stage that I and others of my age were no longer competent to teach or examine candidates, I continued to teach the students who were now accredited to my colleagues in the department.

So why do I now want to give up even this limited work? Being a teacher requires a mastery of the literature, and over the years I have spent some hours every day trying to keep up with it. The advances in nephrology have been amazing. We know so much more about the intricacies of renal physiology, and there are great advances in therapeutics too. A practitioner may not need to master all of them, but a teacher certainly needs to. What is more, at my great age, patients and other nephrologists had a perhaps mistaken idea that my opinion would be the last word, and I often had patients who came to me after having consulted leading experts elsewhere, often referred to me by one of them. I could rely entirely on my personal experience, but I needed to have some idea of recent developments elsewhere if I was to be genuinely able to give the last word. I found myself lacking the enthusiasm to spend the hours poring over the literature, and I thought it better to retire when people asked why, rather than wait till people asked why not. I did not want to be other than first rate, as a consultant or as a teacher. My wife was at one time Chief of Laboratory Services of Apollo, and later Senior Consultant Pathologist when she decided to relinquish her administrative duties. She decided to retire along with me, and we asked to be relieved on 31 March 2020.

The Chairman threw a grand dinner to acknowledge our services to the hospital. This dinner was a few days less than 2 months from the date of our retirement. Many wondered why it was so early. Was it just the most convenient day in his hectic round of activities? Perhaps he was prescient. My unit, and many of my students from the neighbouring states, wanted to bid goodbye closer to the actual date of my departure, and planned to send me off with a bang, the unit on 28 March and my old students early in April. And then a virus intervened. All social plans were off.

There is a fundamental difference between the doctor–patient relationship with respect to surgeons and physicians, and particularly to nephrologists. Most patients go to a surgeon for a particular problem. He operates and rectifies the problem and most often the patient does not have to see him again once his rehabilitation is complete. The patient remains eternally grateful, but there is really no reason for him to come to the surgeon again, so they may never meet. In the eternal feud between surgeons and physicians, we caution patients to keep away from surgeons because they are like bandits; they wear masks, they wield knives and they take away all your money. Surgeons respond that the physician treats, but only the surgeon cures.

We often say that dermatology is the best specialty because the patients never die, they never get well, and they do not wake you up in the middle of the night. Barring a few renal patients with acute renal failure (11% of mine) or with a reversible nephrotic syndrome (4%), the majority of our patients will never get well. They have chronic diseases that will ultimately lead them to dialysis or transplantation, and our efforts are directed at keeping them going as long as possible and delaying the day when they must enter the dialysis unit. Even the 15% who are apparently cured are advised to have an annual check of renal function since they could develop chronic changes later, and many of them come back to me for this check. After my first few years in nephrology, when I worked to establish maintenance dialysis and transplantation in India, I have devoted all my efforts to keep my patients away from the dialysis unit.^[2] I have been reasonably successful in this endeavour, and so have thousands of patients who come to me over and over again, who keep in constant touch by email, and who are no longer my clinical subjects but my close friends. I informed all of them by mail or in person that I would not see them further, and many of them tried desperately to get an opportunity to see me just once more before I left. The virus intervened again. Many of them with flights and train journeys booked had to stay home as their journeys were cancelled, and only a few could make it to the hospital. And further, the hospital administration and my colleagues decided that the risk was too great for a person of my age, and I was banished from the hospital even before the date of my retirement.

My patients and my students have sustained me and kept me working and teaching for all these decades, and I have left them, not with a bang but a whimper.