Periya Doctor

Periya Doctor

Vijay Gopichandran

Yesterday’s clinic was particularly stressful and hectic. I sorely missed my colleague who usually sees patients along with me on these clinic days. She had somewhere else to be and so couldn’t make it. I had just returned from a foreign trip, mildly jet-lagged and was not at the top of my game. But here I was, in the clinic, seeing patients. Each patient who came after 10 AM had to wait for at least 3-4 hours to see me. Some of them were frustrated, some of them angry, but most of them were calm and happy. I was asking myself, “What am I doing here?” I am a community physician masquerading here as a “periya doctor” (in rural Tamil Nadu senior doctors with a few grey hair and lot of experience are referred to by this name). Am I a ‘periya doctor’? Yes, in certain ways, I am. I am 41 years old and have about 20 years of clinical work experience in my bag. When some patients start narrating their history, the pattern is so typical that I am often able to plan the treatment even with the first few words. But in so many other ways I am not a ‘periya doctor’. We provide basic medical services, common cold, cough, fever, headache, body pains, and the works. For everything else, we refer to a higher center, to which often patients do not go because of the distance, or apprehensions about the huge hospital. We do not do much for those patients, who need specialty care, but cannot go to a tertiary center. We have worked out small solutions on a case to case basis for a few patients and have helped them get the tertiary care they need. But by and large, I am not a real ‘periya doctor’ for these patients. For example, I have a patient in the clinic with advanced non-Hodgkins lymphoma with recurrent massive lymphoedema of both lower limbs. There is very little I can do for her other than pain relief, that too with only mild non-steroidal anti-inflammatory drugs. But she continues to come for treatment to me. I have a patient with multidrug-resistant tuberculosis, who has a wife, three young daughters, and an elderly mother, but refuses to take treatment and is mostly immersed in an alcohol-induced stupor. Despite several attempts at counseling him, engaging with other NGOs who work with patients with tuberculosis, we have not been able to do anything about it so far. In these cases, I am no ‘periya doctor’ in any way. So I end up with the same set of questions and uncertainties, who is a ‘periya doctor’ after all?

The answer to this came during a discussion with my friend, who also happens to be a student in the college where I teach. On the way back from the clinic, we were discussing the patient with MDR TB who is refusing to get admitted for treatment. I was expressing my opinion that all our efforts are useless in some cases like this man. However, hard we try, we may never provide the correct and good quality treatment for some people. I was speaking out of dejection and frustration that emerges from years of failed attempts at improving the quality of life of the poor and being struck repeatedly by the reality that certain social and cultural factors are so strong and cannot be changed in one’s lifetime. The young medical student refused to take this for an answer. He argued, “how can we leave it like that? How can we sink into inaction? Yes, his poverty, his poor awareness, social situation, alcoholism, and family situation makes him default from treatment for TB. Yes, probably we may never be able to influence all of that in this lifetime. But, does that mean we just give up?” He refused to accept the fact that treatments are sometimes futile. I saw the young, raw, innocent enthusiasm. I remembered the time when I was 20 years old and in medical college. I was far more trusting and hopeful about treatment. I remembered the case of the patient who was admitted to my General Medicine ward with ulcers, injuries, maggots all over the body. He was a young man with mental disability and in a form of catatonia. He had poor physical hygiene and had ulcers and maggots all over his body. He was severely malnourished. When I first saw him, he was almost in a terminal condition, about to die. But my young enthusiasm and naiveté did not let it go. I attended to him carefully, cleaned him up thoroughly against the advice of all staff and faculty of my department, and started an intravenous fluid for him. When nobody else in the entire ward was even remotely interested to get anywhere near that young man, I was going all the way trying to salvage his life. He died the very next day due to overwhelming sepsis. But I still remember how I went all the way to help him. My senior faculty, staff nurses and colleagues, everybody gave me the “I told you so” look and talk when he died. But that was what I was made of, enthusiasm, innocent hope, and faith that medicine works. It took 20 years of repeated failures and frustrations to make me what I am today, far less heroic in my attempts, and far more balanced in my approach to treatment outcomes. I ask myself whether I have become a worse doctor compared to when I was younger? Has realism trumped idealism? Must I have remained idealistic? I came back to the present and realized that this young student, my friend, is like me when I was his age. He trusts in medicine. He believes that he can make a difference. Who am I to temper him down?

I realized that when I was young, each time I treated a “hopeless” patient with hope and trust in the treatment, I was reinforcing the habit of action in the face of adversity. I was training myself to act in the best interest of the patient despite very adverse conditions that prevented a good outcome for the patient. I was building a habit of action and avoiding slipping into the lazy trap of inaction. My friend, the young student, helped me realize that today, even though I do not have high hopes for the patient with MDR TB or the lady with advanced non-Hodgkin’s lymphoma, I am still doing everything I can to help them because it has become my habit. I have made ‘action’ my habit, that independent of hope, trust, and faith, the action continues. Though I have absolutely no trust in the fact that the patient with MDR will give up his alcoholism, become more serious and take his anti TB medications regularly, I still do everything I can to help him because it has become my habit.

Maybe this is what being a ‘periya doctor’ is all about. Being a ‘periya doctor’ is a complex combination of the following

1.      A strong level of competence to know who is healthy and who is not

2.      A sound technical skill to identify the limit to which I can treat and when I should refer

3.      A sense of naïve enthusiasm and trust in medicine, treatment and positive outcomes

4.      A sense of balance gained through repeated failures, frustrations, helplessness and a tempering of the over-enthusiasm in treatments

5.      A consistent habit of detached action – where therapeutic action is detached from emotions, hope, faith, heroism – but driven by a single motive of doing whatever is the best for the patient.

As I finish writing this blog, I must thank my friend for constantly nudging me to write this. I was totally disinclined to write this because it sounded too raw and personal for a blog. But here it is for your eyes. Thanks for reading this!