That Thin Line/ Achilles heel

There is something excruciating about a fallen hero. The object of admiration and envy, now the focus of ridicule. From the pinnacle of success to the deepest doldrums of depression.

There is a thin line between white and black. Between having courage of conviction to being stuck up. Between being practical and being dishonest. Between being authoritative and being a dictator. Between being ambitious and being cut throat competitive. Between having empathy and being a sissy. Between being focused and being telescopic. Between being a realist and being a cynic. Between sharp intellect and sarcasm.

We cross these lines imperceptibly. And then our best qualities turn into our Achilles heel. If we can still see ourselves, we can sometimes turn back. Most times, our insight is transformed into short sight.

Most times, we, the victims of our own qualities, are doomed to fall from heights. The very qualities that propelled us to those heights pull us down. The fall is way faster than the painstaking climb.

If some way, we could see ourselves as we cross the Lakshman Rekha , more of us would remain on the way up rather than slide into ignominy.

Mountain top

It was a week full of work. Spiced with disappointments, tempered with undeserved malice and just a little hint of a conspiracy. With a mind abuzz with multitude of thoughts, plans and unfinished agendas, I set out on a mid week break to Pachmarhi.
Pachmarhi is where I spent the first year of my life. My mother pointed out the little hut in the church premises where she lived when she was carrying. And the vicarage bungalow where they lived after I was born. As we went about the usual tourist's round up, from the cave temple of Lord Shiva, we saw the enticing peak of Chauragarh, about 1308 feet tall, proud amongst plateaus.
It took us less than a minute to collectively take a call to scale this peak. And early morning, before sunrise, we set off.
The road is long winded, some 1365 steps. Starts from the temple of the Gupt Mahadeo: a shrine in a crevice of a cave in a valley. And leads up to another hill, and then around another hill. Every time, out of breath, when we would glance up, the peak would still appear one more hill away. The fitter ones among us, my eleven year old for one, pranced up with abandon. I languished, took breaks and gathered myself up again to take to the climb.Slowly, all thoughts were spaced out by just one: somehow making it to the top. Every cell of the body just focused around making one more step.
The long circuitous climb seemingly unending climb ended with a breathtaking view of the plateau and the valleys. Worth every painful step.
I noticed something strange on the way down. I was 'in the moment'. It was strange lightness that started from a near empty mind and for most way we floated down effortlessly. The mountain had taken away all troublesome thoughts and filled it with an amazing lightness.
I think that is precisely why temples were built on hilltops. While the devotees inch up to meet their deity, they shed all their petty thoughts and get into communion with the infinite and timeless. And concentrate on what is important: the next step and then the step after that. Because that is the only way to make it to the top.

Listen

Its a usual scene. Patient starts a long winded story about the vague pain in her tummy and ill defined weakness and then the tingling she feels in her fingertips and then the swelling in her hands and feet. We listen, carefully filtering out the bits we need to put together a passable and plausible diagnosis and forget the rest. In the beginning, we listen: carefully, silently and a little anxiously. Not wanting to miss a single clue hidden in that long history. Then, eventually, one look and the opening line of the story tells us all that is worth knowing. We attack the prescription and fill it with pills of various shapes and sizes, and summon the next in line.
Slowly, we forget what it is like to listen. We stop listening, first to our patients, then to others around us. Our world shrinks so much that it contains only us. We cannot talk or think of anything or anyone beyond our grand selves. How we put in long hours and toiled to become the great doctors that we are. How no one understands how difficult our lives are compared to those of lesser mortals.
Eventually, we stop listening to ourselves. We go about life, like automatons. Hearing just enough to keep us going through the rut of diagnosis and treatment. Never stopping to listen. Never waiting to listen.
The word SILENT, contains the same letters as LISTEN. It would do us a lot of good  if we sometimes listen, not with the intent of diagnosing or replying, but only with the intent of understanding. Because, as the saying goes, knowledge speaks;but wisdom listens.

Do you know your doctor?

Being a patient is scary. You tell your secrets, your story to a stranger. You submit your body to be probed, prodded and cut open. You trust them with your life.
There are a thousand things that you must want to know about them. Are they qualified to take your case or have they just 'bought' a degree? Are they competent enough? What is their complication rate? How many cases like yours have they operated? Are they receiving 'favors' from drug companies? Will they keep your information/malady confidential? Are they receiving kick backs to prescribe certain tests?What are their values? What motivates their treatment: only financial gain or a need to see you get better; irrespective of what they 'make' out of it?
But, in reality, patients know none of this. All they know is your name, hospital association and maybe some feedback from some old patients.
In India, doctors traditionally were put on a pedestal. The treatments they doled out were partaken unquestioningly.Doctors are Gods on earth, believed the previous generation. So, they never felt the need to 'know' their 'Gods' better. Because, back then, 'God' could not be chosen.
But now I would want to choose my doctor. For me, it is relatively easy. If I have to choose a doctor from surgical specialty, I will ask my anesthetist friend. If medical, I will ask my pathologist or radiologist friends. Of course its not fool proof, but I have it better than the lay person.
It must be just a game of dice of the rest of us. Choosing who you entrust your life and limb only on basis of someones opinion of them or their proximity to where you live sounds quite risky.
Its also quite unfair to the competent young ethical doctor who was not born into big money, because you may never reach him.
But internet is the big game changer here. Now you have access to your physicians degree, their experience, their linkedin profile, their website, their reviews. Also their blogs, their surgical videos. So now, you can actually know what they are, largely, before you decide to visit them.
Before you decide on treatment, you can search the alternatives on internet and discuss with them.
Sadly, there remains much more to be disclosed. Vested interests in drugs and therapies, funded research, kickbacks for referral, medical errors, hospital acquired infections and many more things need to be uncovered and out in the open.Look at this interesting concept from the USA about knowing doctors better.
Doctors , actually stand to benefit out of disclosing everything to the patients. We hide behind charts, medical jargon and our white coats. We build a wall around us, because, deep down, our patients scare us. We know that we are only human. We cannot ensure that everybody gets well, or everyone lives or that no 'bed' breaks. But we can ensure that we put ourselves out there in the open, tell everyone what we are, what we do best and what we do not. And in the process, accept our limitations, showcase our achievements and accept that 'we the doctors' and 'them the patients' are on the same side.
To quote Leana Wen, who inspired this blogpost " I leave you today with a final thought. Being totally transparent is scary. You feel naked, exposed and vulnerable, but that vulnerability, that humility, it can be an extraordinary benefit to the practice of medicine. When doctors are willing to step off our pedestals, take off our white coats, and show our patients who we are and what medicine is all about, that's when we begin to overcome the sickness of fear. That's when we establish trust. That's when we change the paradigm of medicine from one of secrecy and hiding to one that is fully open and engaged for our patients." Do you know your doctor?

People unlike us

There are two kinds of people I meet through my day. Doctors and patients. Rather, healthcare workers like us who administer care and those who receive this care. Being married to a doctor, this universe extends even at home. This would happen in all professions when you work long enough, one would think. But doctors have it different.
In a reunion of schoolmates, I became painfully aware of the fact that I was sticking out like a sore thumb.Unlike my loquacious self, I was tongue tied and looking around desperately to join a conversation.I realized that my sense of humor was full of medical terminologies which the layperson could not 'get' and most of our funny anecdotes about idiosyncrasies around our jobs fell flat in a mixed gathering. Meanwhile a patient called me to inform that she had started her periods and as I was talking to her in one corner of the party about how many pads she was soaking today, I turned around to find a classmate aghast and shocked. So, I stood, nursing my Coke, till I was saved. Three of my classmates purposefully strode to my corner and started asking me about their 'gynec problems'. They appeared God send to me. I recovered my lost confidence and launched into a detailed treatise of how they should prevent and treat these problems. Rest of the party went smoothly as I advised anyone and everyone about their medical ills, real and imagined.
Another such opportunity presented itself soon. I was invited to a dinner by a neighbor. The other invitees were not doctors. I felt that knot in my tummy as the D day approached. I thought of declining ( doctors have the luxury of emergencies which can come up last minute). Then I prayed that someone would have some medical query which I could address and bid my time.
Strangely, the three hours passed quickly and effortlessly. There was hardly any discussion on medicine, but I found myself drawn into conversations. It was a refreshing change to talk to intelligent achievers, administrators and homemakers. We made small talk, but conversation flowed effortlessly and easily. And, at the end of it, I wished I knew each of them a little more, a little better.
It is easy to get caught in our web of diseases and maladies. Easy to restrict ourselves socially to our own kind. But it is refreshing to see the world sometimes from undiseased eyes.
People unlike us, sometimes are eminently likeable.

Assembly line

Medicine. Its exciting at first. After our preclinical classes, when we are ushered into the wards, to see real patients, all of us have felt thrilled. Then, as we climb up the ladder, pass exams, acquire skills and degrees, the excitement wears off.
We choose one specialty: specialize into one branch. And then , some of us, choose an even narrower sub speciality, a smaller cubbyhole. And spend rest of our lives in that small space of one organ or system or problem. We learn all there is about that subspeciality, painstakingly acquire all skills required, and ultimately after a long journey of fifteen years or so, start our practice.
In a few years, medicine becomes a rut.
Day in and day out: same old cases, same old surgeries.
And slowly, the sense of 'wonder' wears off. It is replaced by an assembly line approach.
The patient is no more a 43 year old banker who is finding it tough to control her weight, but ' that hypothyroid lady'. In the wards, we find ourselves looking not for Mrs Aparna, the schoolteacher who was operated yesterday, but 'that day 2 postop hysterectomy'. Slowly, the person/patient is seen as the disease and called by not their names, but their conditions.
Slowly, our increasing expertise means that we arrive at the diagnosis within seconds and spend less and less time with the patient in OPD consultation. Any queries , and they are shunted to the assistant for explanation.
The queues grow. The practice expands.
Slowly, we feel less like a healer. More like an assembly line worker.
I read Atul Gawande's book 'Better' last week. In his last chapter, he writes about asking unscripted questions to our patients..
' On the surface, this seems easy enough. The , your new patient arrives. You still have three others to see and two pages to return, and the hour is getting late. In that instant, all you want to proceed with the matter at hand. Where's the pain, the lump, whatever the trouble is? How long has it been there? Does anything make it better or worse? What are person's past medical problems? Everyone knows the drill.
But consider, at an appropriate point, taking a moment with your patient. Make yourself ask an unscripted question: " Where did you grow up?" or: 'What made you move to Boston".....
..... You don't have to come up with a deep or important question,just one that lets you make a human connection.'
Some of us might argue that patients come to us for our technical skills, for our diagnosis and treatment. Not for connecting with us as human beings.
But I still sorely remember my consultation with a Dermatologist some time ago. The gentleman did not look me in the eye throughout the ten minute consult. I came out feeling cheated and angry. I felt like a disease and not a person.
Wiser after that encounter, I have always been enriched by my patients and the lives they lead. The anxious 40 year old tubal factor infertility is a Principle of three schools and runs a charity for homeless street kids. The mother of two kids who is repenting her abortion and wants one more kid to get over the guilt of terminating that pregnancy. The couple who failed cycles of IVF with us, and call me every year for their adopted child's birthday.
Asking unscripted questions, delving into lives and not just diseases, makes our lives much more fulfilling. Diseases and their treatments are finite. But human life, with its vagaries and varieties, is infinite.
Connecting with our patients, not as diseases they happen to harbor but as people: mortal, sometimes flawed, eminently human and infinitely interesting, is the most satisfying part of medicine. Everybody can treat, but few can heal. And so, we need to connect.Not only to heal the patient, but to heal ourselves.

Egg donation in IVF

A common scene in IVF clinics is when we fertility doctors have to break the news to the couple that the lady has exhausted her own eggs and egg donation would be the best/only way to have a child. Unfortunately the threshold for using donated/shared eggs is reducing very rapidly.In some clinics the doctor has to only see the lady's age at 40 to solemnly nod her head and say a “NO” to IVF with her own gametes. While most women at or just above 40 do have a poor ovarian reserve, there are some who still have a few good ones left. Especially the women with a shorter duration of infertility like a 40 year old who is married only for a couple of years versus someone her age who has been trying for say 15 years.
Recently a lady41 year old who had been refused IVF with her own eggs at two clinics came to us for IVF. While the ovarian reserve was borderline, we took her up for IVF. Some tweaks in our usual protocol and we got 4 follicles which gave us 4 good quality oocytes. All four fertilized after Intracytoplasmic sperm injection and resulting four embryos were transferred to her uterus on day 2. The reason for transferring four embryos was her age (usually we transfer about two or three embryos). And on day 18 post egg pickup it was what patients call a “BFP”: a Big Fat Positive with beta HCG value of about 480 IU/ml.
A transvaginal scan done today showed a single gestational sac with a good embryo and steady embryonic heartbeat.
It is days like these which make the toil and tears worthwhile.
And reaffirms our belief that third party reproduction with donated gametes or surrogacy is always the LAST option.
So, if your doctor suggests that your best chance is with donated eggs, wait before you take the plunge. Take a second opinion, do your research and hunt for a clinic that respects your right to genetic procreation. Who knows, your own baby may be waiting for you at the end of that long dark tunnel.

Right to records

It baffles me to no end when patients who have done IVF cycles come without any records of the treatment.
All of us know that IVF is not successful 100% of the times. So any patient who has one cycle, is likely to need another one in future. Whenever we plan the first IVF cycle, the protocol chosen is an educated guess from the details like the cause of infertility, age, condition of the ovaries and the hormonal profile. What we always cannot predict accurately is how the patient will respond to the drugs, the quality of resulting eggs, number of fertilized embryos and their quality. In the second cycle, we know all these details from the previous cycle ( provided they are recorded and given to the patient by the clinic!).
I always compare the first cycle of IVF to choosing a dress of your size in a shop: you choose the closest fit: Small, medium or large and buy it. It might fit you very well, or might sag in some places. The second cycle can be tailor made exactly to your response: the dose, protocol, culture protocol all can be modified learning from the first cycle  to optimize the cycle so that it fits you like a glove.
As a doctor, it is our duty to give the details of the dose of medications, protocol, number and quality of eggs, hormonal levels during treatment, fertilization rate and embryo number and pictures to our patients. This information is priceless. God forbid if the treatment doesn't result in a pregnancy, this information can help us ( or another clinic, should they decide to switch doctors!) tailor anther ivf cycle much better.
As a patient, it is your right to receive all this information. Always ask before you start the treatment if the clinic parts with this information.
If not, maybe you are not seeing the right doctor. Know your rights to get it treatment right!