Letter from Mumbai

PHYSICALLY HANDICAPPED PHYSICIANS

The topic came up for discussion at a recent medical meeting. It appears that the consensus opinion of administrative heads of hospitals and clinics is in favour of able-bodied staff members.

Those with a handicap are either summarily dismissed or viewed with suspicion. An extra level of supervision is imposed on them and their probation is already weighted against them. What is surprising is that this attitude prevails even when the handicap has no relevance to the specialty practised by the clinician and that patients appear to be more tolerant of handicaps than administrators.

We must remain in admiration for the parents of these physicians. When the handicap is present from birth or makes its appearance in infancy or childhood, ‘well-wishers’ and even near relatives favour relegating the child to occupations that will be ‘less strenuous’. For every child with a handicap who succeeds in striving towards the achievement of her dream, there must be many where the parents give way and mould the child’s mind towards run-of-the-mill and lacklustre careers.

Even after the hurdle of entrance into medical college has been crossed, the handicapped individual is often treated with pity instead of empathy. Some teachers are openly dismissive of her efforts. Some are diverted from their chosen fields into ‘safe’ specialties such as public health, biochemistry, pathology or dermatology.

Many successful physicians learn to isolate themselves mentally during these troubled years of training. Unwelcome and derogatory comments are filtered out. The resolve to be able to help the ill by becoming good and competent physicians is strengthened.

As was the fate of women when they first entered the medical profession, handicapped physicians often need to prove themselves to be better than their able-bodied colleagues in all academic arenas.

To those of us who have seen the rise to glory of such individuals as Dr George Coelho in Bombay, Dr Mary Verghese in Vellore and Dr Suresh Advani in Mumbai, the attitude that prevails in 2023 towards handicapped physicians is inexplicable.

Dr Coelho spent much of his life in a wheelchair, a victim of poliomyelitis. This did not stop him from founding the first department of paediatrics in India in the Byramjee Jejeebhoy Hospital for Children—part of the Sir J.J. Group of Hospitals— in 1928. He also helped develop paediatrics at Bai Jerbai Wadia Hospital for Children in Parel and, later, at the Bombay Hospital in Marine Lines and has often been called the father of the specialty of paediatrics in India.

Dr Mary Verghese met and studied under the tutelage of Dr Ida Scudder at the Christian Medical College in Vellore. Although her initial inclination was towards practising obstetrics and gynaecology, she followed the advice of her surgeon, Dr Paul Brand, who treated her for paraplegia after a mid-thoracic cord injury in a motor car accident. Dr Brand needed a surgeon who could operate on patients with hand deformity after leprosy. She underwent specialized training on such operations while confined to a wheelchair and went on to help many such patients. Eventually she headed the Department of Physical Medicine and Rehabilitation in her alma mater. This department has grown into an institute named after her.

Dr Suresh Advani, like Dr Coelho, was ill with poliomyelitis as a child. He, too, has been confined to a wheelchair. Overcoming his handicap and an earlier rejection by a medical college, he obtained his MBBS and MD from the Grant Medical College and went on to head the chemotherapy department at Tata Memorial Hospital in Mumbai. He started the use of haematopoetic stem cell transplantation in India. He has since achieved a national and international reputation with several honours heaped on him.

Is it not time we shed our prejudices against handicapped persons in the medical arena?

DOCTORS AND NURSES

We need to instil into our medical students the need for considering nurses as our partners in treating patients. Of course, as in every other arena of education, this can only prove effective if we, professors and consultants, teach by example.

I bring this up as I continue to encounter instances of appalling behaviour on the part of doctors towards nurses. Fortunately, in the best of our teaching hospitals, this is uncommon but variations on the theme are seen periodically, especially when the nurse is junior or under training.

During the 60 years and more I have spent in hospitals, I have seen brash, young doctors disregard information provided by nurses that indicate worsening in the condition of the patient. On one occasion, the diligent nurse had noted worsening nausea and vomiting and, while sponging the patient, rigidity of the abdominal wall. The young resident laughed at her when she approached him. ‘I’ve seen the patient. There is nothing wrong with him. In any case who is the doctor—you or I?’ He was about to walk away. Her plea for action would have been disregarded had a senior consultant not happen to be passing by. Seeing the distress on the face of the nurse, he halted, listened to her, confirmed her finding and set the ball rolling for treatment of peritonitis from a ruptured appendix.

A medical degree makes some of us feel that we are superior to nurses, endowed with greater wisdom and in no need to listen to their suggestions even when they are senior and experienced nurses.¹

As a young resident I have often been guided by ward sisters, alerted when they sensed impending disaster and helped by them to save the lives of several patients. They have instructed me on appropriate tests and urgent consultation with my seniors. They have also pointed out the use of inappropriate drugs or dosages (as when a dose for an adult is prescribed for an infant), the need for better measures to reduce pain and when a puzzling persistent rise in blood pressure was due to a severely distended urinary bladder in a paraplegic patient.

I cannot emphasize strongly enough the cardinal lesson that I have taken to heart to the benefit of many patients. When a senior and experienced nurse tells me, ‘I don’t like the look of that patient,’ I go immediately to that patient’s bedside and spend time in finding out what is going wrong and correcting it. Many senior and respected consultants do not start their clinical rounds at the patients’ bedside. They do so at the nursing officer’s table. They ask the nursing officer and the resident doctors about each patient to be seen and listen carefully to their observations and comments. The consultants then study the patient,’ charts. Thus prepared, they proceed to examine each patient and draw their own conclusions about improvement or worsening in their clinical status and prescribe further treatment.

Physicians and nurses form two arms of modern healthcare in hospitals, each complementing and supplementing the effort of the other group for the betterment of patients under their care.

Although the duration and content of their training differs, this cannot render one group superior to the other. Collaboration between members of the two groups is mandatory for the welfare of the ill and wounded. They must share this common goal and do so with mutual respect. It ill behoves the medical profession to treat nurses with condescension and, at times, even with ridicule.

That such prejudiced behaviour is noted in other countries as well² is no consolation.

In his address Doctor and nurse,² Osler reminded nurses that although medical men absorb a larger share of attention and regard, nursing was the older and more honourable calling. ‘In one of the lost books of Solomon, a touching picture is given of Eve, then an early grandmother, bending over the little Enoch, and showing Mahala how to soothe his sufferings and to allay his pains. Woman—the link among the days—and so trained in a bitter school, has, in successive generations, played the part of Mahala to the little Enoch, of Elaine to the wounded Lancelot.’

He concluded his talk thus: ‘And, finally, remember what we are—useful super-numeraries in the battle, simply stage accessories in the drama, playing minor, but essential, parts at the exits and entrances, or picking up, here and there, a strutter, who may have tripped upon the stage. You have been much by the dark river—so near to us all—and have seen so many embark, that the dread of the old boatman has almost disappeared, and

When the Angel of the darker Drink

At last shall find you by the river brink,

And offering his cup, invite your soul

Forth to your lips to quaff—you shall not shrink:

your passport shall be the blessing of Him in whose footsteps you have trodden, unto whose sick you have cared.’

In doing so, he reminded his audience of nurses that often, up to the moment of death, it is the nurse who tends to the patient, moistens his parched lips, soothes and comforts. And she does so without shrinking, full of empathy up to the very end.

WHY IS THE SEARCH THROUGH THE LITERATURE SO SHALLOW?

I belong to a generation that learnt medicine when there were no computers and the internet was not even a dream. As we took our baby steps into research and publication of papers, we were taught to spend hours in libraries and consult the Index Medicus, Current Contents and the annually published cumulative indices to journals. (As an aside, since there were no photocopying machines, many of us developed callosities along the lateral aspects of the terminal phalanges of our thumbs, index and middle fingers as we copied relevant text from books, journals and other publications into notebooks.)

Our teachers rightly taught that our paper was valueless if it did not add to existing knowledge on the subject. To ensure that it did, we needed to learn about existing knowledge and this meant extensive searches of the ‘literature’ of medicine. Several supposed breakthroughs, ‘first reports’ of a variety of clinical and laboratory findings were eventually tossed into the garbage can as we encountered earlier publications on them. Dr Macdonald Critchley’s cautionary note kept ringing in our ears: ‘Anyone who thinks he has stumbled upon something new or obscure should not neglect to search the Manual (A manual of diseases of the nervous system published by Sir William Gowers in 1886) before claiming originality.’ Dr Gowers, himself, was well aware of the value of his textbook as a treasure-trove. In a letter dated 2 March 1903, he wrote: ‘…the only thing that makes me sigh is when men, especially old pupils, write on a subject I have gone into in the Manual and never refer to what I said.’ Critchley emphasized ‘even now we have not quite caught up with and identified all the clinical gems which Gowers collected’.³

Alas! The lessons taught by Dr Gowers and Dr Critchley appear to have been totally forgotten. Gone too is the felt need to consult those old reservoirs of published knowledge—the indices. Present authors feel that it is sufficient to make a Google search on any given topic and study just the first 25 or 30 of the cited publications.

Is it any wonder that in neurological publications today, references to the work of such pioneers as Drs Jacob Chandy, Baldev Singh, Menino D’Souza, B.K. Bacchawat, C.G.S. Iyer, Homi M. Dastur, Gajendra Sinh, D.S. Dadhich, J.N. Sidhva, K.V. Mathai, Jacob Abraham, Praful M. Dalal, M. Sambasivan, D.H. Deshpande are scarcely seen. Even such well-known authors as Drs B. Ramamurthi, Noshir Wadia, Darab K. Dastur, Subimal Roy and S.K. Shankar are fast disappearing from bibliographies appended to published papers. I am pleasantly surprised that Dr Prakash N. Tandon’s name still continues to feature in several papers.

There are several unwelcome consequences of the current trend. The wheel is reinvented again and again and credit handed out to the more recent ‘inventors’ and ‘discoverers’ at the expense of the classic clinicians whose descriptions were published decades earlier. The older papers were much more comprehensive, with detailed and, at times, classic descriptions and with references to important earlier work now no longer studied. Where the papers deal with pathological and radiological findings, the earlier papers carried invaluable clinical details that can, even today, guide the pathologist and radiologist.

While books such as those by Dr Robert Wilkins^4,5 were once treasured, I am not sure how many copies they would sell now!

Is it not sad that the wonderful inventions of the computer, world-wide-web, powerful search engines such as Google have as an unwelcome consequence slipshod and cursory reviews indicative of a loss of scholarly discipline?