Letter from Chennai

MAKKALAI THEDI MARUTHUVAM (MEDICAL CARE-SEEKING PEOPLE)

On 5 August 2021, the Makkalai Thedi Maruthuvam (Medical Care-Seeking People) scheme was launched by the Chief Minister of Tamil Nadu. The most significant part of the project is to screen everyone in the state above the age of 30 years for diabetes and hypertension and provide treatment either in the Primary Health Centre or at home. Workers also screen for carcinoma of the breast and cervix in women and provide palliative care and peritoneal dialysis for those who need either. I believe that the most important and effective part of this scheme, with the maximum cost-benefit ratio, would be the detection and treatment of diabetes and hypertension. The scheme now covers only those above the age of 30 years. A study was done of a sample population and a report was published recently. I recommend that everyone interested in the project should read the report at https://spc.tn.gov.in/makkalai-thedi-maruthuvam

As would be expected, coverage was greater in the rural compared to urban areas. I believe that it would be better to establish the scheme in the rural area and only after that to attempt extension to urban areas. Since the report only covers a minuscule proportion of the population, it does not give the reader a clear idea of the actual working of the project and the results achieved. I would like to make a few comments. One survey is excellent for study purposes, but to actually achieve an impact on the population, it is essential that effective treatment should be provided and the survey should be repeated periodically. While an annual survey would be ideal, I think it would be impossible to achieve for an entire population. Perhaps, once in 3 or 4 years would be practical. The health worker should monitor the patient once a week and may make minor adjustments in dosage of drugs. A doctor should see each patient once a month till control is established. Thereafter, an annual visit may be enough.

We have not been told what drugs were used. Clearly, the drugs should be cost effective, for the project should be affordable, as the scheme, once started, should be permanent. Tamil Nadu is the first state to take up such a scheme and deserves every credit for its initiative.

I am only sad about one point. This kind of a prevention scheme was first taken up and run with excellent success for 25 years by the Kidney Help Trust of Chennai. The prime mover of the project received the John H. Dirks Award in 2005 from the International Society of Nephrology as it was judged to be the best prevention programme in the world. The two persons who had the major role in carrying out the project have retired, are in Chennai and are ready to render any possible advice and assistance to make the programme effective, but the Government has made no effort to involve them in its working.

ON PAIN OF DEATH

I have always admired oncologists. They work in a field with a low success rate and have to sustain the spirit and overcome depression, not just in their patients but in themselves. An oncologist in one of Chennai’s hospitals treated a lady with an advanced cancer with chemotherapy and palliative care. Her condition deteriorated after discharge. Her son was dissatisfied with her treatment. He took an appointment to see the doctor, entered his room, locked the door from the inside and stabbed him several times with a kitchen knife. He then attempted to flee but was caught by the hospital staff, and presumably, the law will take its course. The doctor is fortunately recovering after surgery.

I was one of the first nephrologists in India. Most of my patients came to me having tried every possible system of medicine unsuccessfully and therefore often in moribund condition. They would also have exhausted all their resources. Dialysis was very expensive, and often administered too late, so the success rate was poor, but at that stage was the only option available. I believe that it is essential to discuss the pros and cons of the procedure in great detail with the patient and the immediate family and to disclose the results of one’s own unit honestly. I remember quoting a success rate of 75% for some procedure and being told, ‘But the other doctor said he could get better than 95% success’. My answer would always be, ‘then you should certainly go to him, because I do not get that success rate’. One has also to stress that 75% or even 95% success means 25 or 5% failure. This discussion would require a great deal of time. One has to find that time and have the patience to answer the same questions over and over again.

One of my patients, an adolescent, came to hospital moribund with septicaemia and succumbed without responding to treatment. His father was not around when he died and turned up half an hour later and demanded to see me. I was involved with resuscitating another patient and sent word through a registrar requesting him to wait in my office. I had already discussed the situation with him and told him that the chances of survival were poor. He did not wait but went away and sued me. However, when the case came up in court, he did not turn up to pursue the suit, so I think it was just the anger that I did not speak to him immediately that made him go to the lawyer.

I mention this to stress the importance of conversation. It is often irritating to go over all details with all the members of the family and then have them request another interview because an important uncle has just arrived and wants to talk to me. I try my best to comply. It is better to spend the extra half hour now than to go through a lengthy law suit later.

Documentation is vital. A busy doctor will never be able to remember all details of every sick patient. If every visit to the patient is recorded on the case sheet, it will serve to convince anyone that the patient has been properly seen and all possible was done. The registrar would have entered all that on the case sheet, but the consultant should certainly look over those notes and sign them. I made a habit of making a detailed round once a week, reading through all the notes on every case sheet and adding my comments. It is also an excellent teaching device.

Hospital patients have case sheets, but what about a private practitioner who sees patients only in his clinic? He is also at risk of being sued, though obviously the risk is smaller than with a hospital patient. Most practitioners ask each patient to maintain a notebook in which the doctor makes an entry on every visit. The patient has to bring the notebook each time. This is helpful for the doctor to have a record available to refresh his memory every time the patient comes to him.

I believe this is a very bad system. Every doctor should review his patients now and then, calculate his own results and compare them with the published literature. Is he doing as well as the literature predicts, or worse or perhaps even better. If worse, where should he improve? If better, what is the reason? What leads to the improved result? If it is significant, it is the duty of the doctor to publish it so that others can try his methods and prove or disprove his findings. Such a review can never be done if the doctor has access to only one patient’s record at a time. In days gone by, it might have been difficult for a doctor to store so many records in the limited space of his consulting room, but today with computers ubiquitous, that is not a problem.

TAMIL NADU GOVERNMENT SUPPORT FOR STUDENTS

Among the admirable schemes of the Government is the provision of financial assistance to a large number of students to enable them to pursue studies. The website https://naanmudhalvan.tnschools.gov.in/schemes provides information about a large number of schemes with instructions on the requirements and procedure for application. I remember, in days gone by, a large number of very bright students who could not pursue higher studies because the family lacked the wherewithal to finance their education, and perforce had to take some employment which could not fulfil their potential. There can be no greater gift than the gift of knowledge, which opens the doors to limitless advancement of careers and status in life.

The Central Government also has a variety of schemes available, and I presume other states may also offer such assistance. It becomes all the more important for school teachers to inculcate the desire for knowledge among their students. It is sad that the teaching profession does not receive the respect it deserves and therefore does not always attract the best people. I remember my own high school class teacher with reverence, gratitude and affection. My debt to him is enormous.

Not every bright youngster is keen on pursuing higher studies, even when the financial aspects are taken care of. Some are intellectually lazy and do not wish to put in the effort. They would rather accept whatever job they can obtain, take the salary and enjoy themselves in their spare time with whatever relaxation they can afford. Who is to say they are wrong? Long hours spent burning the midnight oil may not be to everyone’s liking. To each his own.