Letter from Mumbai

Respect Shown To Organ Donors

The staff at St Luke’s Hospital in Meridian, Idaho, USA were highlighted in a Facebook feature (www.facebook.com/ 758549766/posts/10157117618069767/) and with good reason.

They have set up a Walk of respect for every organ donor. As the donor is being prepared for the move to the operation theatre, staff members from all departments in the hospital silently make their way to the corridor leading from the intensive care unit to the operating theatre. By the time the donor’s trolley is about to roll, every inch on each side of the corridor is occupied by individuals standing in complete silence, paying their respect for the invaluable gifts being conferred by the individual passing between them. If one or more of those on the sides have interacted with the donor or the family members following the trolley, they step into the corridor, personally indicate their gratitude and step back. At times, there are tears rolling down their cheeks.

Once the trolley disappears past the doors leading to the theatre, the wall of respect breaks up as silently as it was formed as workers return to their wards and laboratories.

As a spokesperson of the hospital pointed out: ‘This is our way of paying tribute to the patients, their incredible gift of life and show solidarity with the family during a deeply emotional occasion.'

I strongly recommend to you a video-recording of such an occasion. You will find it at https://www.youtube.com/ watch?v=hF5uPzkxsAM.

It goes without saying that we need to follow the example set by St Luke’s Hospital (and other hospitals following this or similar practices) in our own transplant centres.

Death Certificates

The death of a dear relative focused my attention on these documents.

As a medical student, I was taught that a death certificate is a very important document. In addition to attesting the cause of death, it enables the authorities to decide on the disposal of the body. If the cause of death be unnatural, an autopsy becomes mandatory.

When such certificates are studied en masse invaluable data can be harvested on the incidence of diseases in a community, the need for strengthening preventive measures and assist in the formulation of long-term measures on public health. We were cautioned by our Professor of Forensic Medicine and Medical Jurisprudence, Dr Homi Shapurji Mehta, to exercise great care in filling each column on the certificate.

Currently the certificate requires details on the cause of death under the following heads:

• Immediate cause. An explanatory note informs us that ‘the disease, injury or complication which caused the death’ is to be noted here.
• Antecedent cause. ‘Morbid conditions, if any, giving rise to the immediate cause, must be listed here.
• Other significant conditions contributing to the death but not related to the disease or conditions causing it are to be mentioned here.

We are also required to state whether the cause of death was natural, from an accident, suicidal, homicidal or unknown (requiring investigation). It is obvious that such a certificate can only be provided by the patient’s registered medical attendant, well-acquainted with the patient’s history, physical findings and details on the final illness.

I am therefore surprised to find no column on which information can be provided on the duration over which the physician was treating the patient, the length of the final illness and the basis for the diagnosis.

Despite exhortations to avoid the practice, it is not uncommon to see cardiopulmonary failure listed as the immediate cause of death. All deaths follow cessation of cardiac and pulmonary functions so such an entry insults the intelligence and is of no help to anyone evaluating deaths to formulate public health measures.

Most physicians fail to provide a reasoned and logical entry such as ‘Myocardial infarct following obstruction of the anterior descending branch of the left coronary artery’ or ‘Hepatic encephalopathy, portal hypertension, gastric haemorrhage’ or ‘Severe and extensive laceration of the cerebrum and haemorrhages into the brainstem following an accidental large depressed fracture of the skull’.

Similarly, under ‘antecedent causes’, a short description of the disease(s) leading to the immediate cause of death is conspicuous by its absence. ‘Diabetes mellitus, systemic arterial hypertension and atherosclerosis’; ‘Cirrhosis following hepatitis C’ and ‘Fall from the 13 th floor of a building under construction’ may form suitable entries in the 3 examples provided in the preceding paragraph.

On a brief search, I was able to garner 2 papers on the accuracy of death certificates abroad.^[1],[2] Here is one conclusion from the first paper from the Maine Medical Center, USA: ‘In analyzing the data, it became evident that the same issues with accurate completion existed at our institution as were evident at the national and international levels. Most notably, some type of error (major or minor) was present in 46 of 50 (92%) of cases.' The second paper, from the University of Vermont, USA featured this conclusion: ‘Of 601 original death certificates, 319 (53%) had errors; 305 (51%) had major errors; and 59 (10%) had minor errors.'

Our readers and I will welcome information on systemic analyses of death certificates provided both in the metropolitan cities and in smaller towns and villages in India.

I am sure there will be much to learn from such studies and, perhaps, we shall gain an indication of how much needs to be done to improve matters in India.

Commencement Addresses to Graduating Physicians

In western universities, graduating students are also provided an opportunity of listening to a reputed and respected speaker who shares experiences and values. Notable speakers on such occasions have included Winston Churchill. John F. Kennedy, Alexander Solzhenitsyn, Mother Teresa, Salman Rushdie, Susan Sontag, Steve Jobs and J.K. Rowling. Among medical luminaries, we must list William Osler first and foremost (see Aequanimitas and other addresses). Among others, of interest to many of our readers is Elizabeth Kubler-Ross.

Here I draw your attention to the address by Dr Harold Stevens at the George Washington University School of Medicine, Washington DC in 1964.

Dr Stevens retired as Professor of Neurology from that medical school in 1978. He was acclaimed not only in his chosen field but also as a teacher, medical historian and a musician. He founded the first clinic for handicapped children in Washington DC in 1946.

His talk in 1964 was entitled ‘Humor plus humility equals humaneness’.^[3] Characteristically, he started his talk with a quotation from Osler: ‘The greatness of a school lies in brains, not in bricks.' Stevens reminded his young listeners that 4 years of medical instruction is only a brief pulse of time, with much left uncovered and too many things left unsaid.

While many speakers wax philosophical on such occasions, Stevens reminded his audience that a sense of humour is indispensable to the practice of medicine. He reminded the students that since they were to interact with patients and their families, the humour he referred to incorporated the ability to perceive and laugh at one’s own frailties.

‘To humor must be added humility, for without it humor would be harsh and devoid of meaning. This synergism of humor and humility releases us from the bondage of self-importance and permits us to accept ourselves… with amused affection. He was reminded of Thackeray, who called humor a mixture of love and wit.'

Humour benefited the physician as well. ‘A sense of humor will.. .ease the pain of the bruised ego. It will help you view the antics, idiosyncrasies and power plays of your colleagues with bemused tolerance rather than chagrin.'

In the course of his talk he invoked James Thurber’s unforgettable Walter Mitty, especially as he rescues the patient whom the surgeon had given up as ‘coreopsis has set in’. He reminded his audience of the question he had set them a while ago in a multiple-choice examination. In it, he had listed among possible diagnoses in an 8-month-old infant worsening despite treatment for meningitis ‘coreopsis has set in’. ‘I did not expect any loud guffaws but I did expect a few smiles and some recall of the heroics of Walter Mitty. To my dismay, no one in the class recognized the phrase. No one recognized that coreopsis is not a disease but a flower (that is also known as calliopsis or tickseed). What’s more, seven students marked this as the correct answer. ' Stevens told his audience that his dismay and disappointment was not that the students got the question wrong but that they did not recognize Thurber’s humour!

Stevens recommended the reading of works by Thurber, George Bernard Shaw, Mark Twain, Drs Oliver Wendell Holmes, Oliver Goldsmith, Anton Chekov and Rabelias, whose humour, he pointed out, ' stems from their ability to perceive with compassion, to caricature without destroying and to laugh and forgive’.

There is much more to learn from this address.^[3] I have two reasons for featuring this account of Dr Steven’s address.

I wonder how many of our younger readers are familiar with Walter Mitty or the works of the authors Stevens recommended.

Do our medical colleges have such commencement addresses? If so, do our readers have their own favourite commencement addresses that they wish to share with the rest of us?