The NMJI

NURSES AND ETHICS
You will recall the earlier account in this column of a senior staff member at the S.N.D.T. College of Nursing in Mumbai who is carrying out a research project on ethics in nursing. To the best of my knowledge, this remains the only example in India of such a study being carried out by any medical person towards obtaining the PhD degree.
Nurses in Mumbai have now added another feather in their caps. On 15 February 2004, they organized a day-long seminar on ethical values in healthcare. Matrons at the Jaslok Hospital and Bombay Hospital joined hands in this effort. In addition to local experts, they invited senior nursing and intensive care consultants from Sweden and Poland, who added considerably to the importance of the proceedings.

Equally praiseworthy was their decision to invite a young plastic surgeon practising on his own in one of Mumbai’s suburbs to deliver the keynote address. Dr Arun Sheth fully lived up to the expectations of the organizers and provided a clear, ‘no-holds barred’ overview of the present state of healthcare in the state, our deficiencies and what steps could be taken to improve matters. As he put it, loss of morality is our national malaise. This can only be tackled by instilling moral values in our children so that they will grow up to be honest adults. In his ‘adolescent practice of five years’ he has not seen any improvement in the thinking or practice of his colleagues. Money matters first and money matters last! The welfare of patients gets a low priority. He also feels that herd mentality ensures that the average doctor will not antagonize the medical establishment or colleagues by independent, principled thinking and ethical behaviour. Dr Sheth’s frankness and constructive attitude earned him well-deserved applause.

I have space here for just one more of the several other interesting presentations.
When Dr Laura Wolowicka, Professor Emeritus in a Polish university, was called to the lectern, she endeared herself to the audience with her opening sentence. ‘I am in the unenviable position of having to deliver my talk when it is already past the time when I should end it!’ This gentle dig at previous speakers who had continued their presentations well past their allotted time was followed by a succinct account of her experiences with patients dying in intensive care units. Her wisdom and experience were reflected in her observations and suggestions. The need to respect the dignity of the patient and of relatives at all times was emphasized. The greatest care is called for when death approaches. Unfortunately, many healthcare workers tend to flee the scene precisely then ‘as there is nothing more we can do for the patient’. In fact, this is the time when the patient and family need all the support that can be offered. Dr Wolowicka finds the patient greatly comforted when she invites the relatives to the patient’s bedside at this time so that they can spend the last few minutes together. Her intensive care unit has set aside an area where this can be done without hindrance to the care of other seriously ill persons.

At the end of her talk, a young nurse, now working in a semi-rural setting in Maharashtra, asked about the care of the corpse. She told of her own experiences while training in a large hospital in Mumbai. The body was wrapped up like a sack of potatoes, heaved onto a dirty, uncovered, rattling trolley and trundled down the corridor in full view of other patients and relatives. Dr Wolowicka and Dr Elsy Athlin (Associate Professor, Karlstad University, Sweden) explained the practice in their hospitals. The body was treated with the same care and respect as the living patient. Relatives were asked if they would like to participate in the preparation of the body. Many welcome this chance to do something even at the very end for their loved one. After withdrawal of tubes, catheters and cleansing of the body, it is covered in fresh clothes provided by the relatives. The body is placed on a trolley similar to that for live patients, a pillow inserted under the head and a clean cover used as a drape. The trolley is brought to the morgue by a special elevator, which bypasses the hospital corridors.

I recall learning of a further refinement in Japan. From the intensive care unit, the body is taken to a small shrine in the basement of the hospital. The senior resident doctor and nurse accompany the relatives. Having placed the body in the shrine, the doctor and nurse take leave of the relatives in the traditional manner, bowing to each of them. The relatives complete their ritual or religious practices before taking the body away.

THE CHOICE OF POOR PATIENTS
In a recent paper entitled ‘Health care under neo-colonization’, Dr C. Sathyamala (of Swasthya Panchayat Lokayan and the Medico-Friends Circle) points out that the ‘minimum essential clinical package’ proposed by the World Bank and under consideration by our government bears little relationship to the illnesses suffered by the poor. It will prove inadequate to meet the healthcare needs of this segment of our population. When the package is coupled with the introduction and progressive increase in fee for services rendered by public sector hospitals, the poor will be left with no means of dealing with their illnesses. This is especially tragic as public hospitals—particularly those in Mumbai—were founded for the express purpose of catering to poor patients.

It is of interest that many poor families prefer medical care from the private sector. I see several poor patients at the private hospital where I now work. They have followed me from my earlier public sector hospital. Those needing admission and surgery are directed to that hospital. I offer to speak to my erstwhile colleagues there and ensure prompt admission. I reassure my patients that the equipment and expertise there are of high order. And, of course, I emphasize that the costs in that hospital will be a fraction of the cost in the private hospital. Despite 15 minutes or more of discussion, most opt for treatment at my current hospital. They do the rounds of charitable trusts and other such funding agencies to meet costs.

When queried, several explanations are offered by the relatives. Attendance at a hospital such as the King Edward Memorial Hospital or Sir Jamsetjee Jejeebhoy Hospital in Mumbai necessitates spending the entire day or days before a diagnosis is offered and treatment prescribed. This means loss of daily wages in addition to the expenses of travelling to and fro and payment of hospital charges. The patient is made to run from department to department with long queues at each stop. Arrogance, indifference and a total lack of concern are encountered everywhere, especially from the clerical and other non-medical staff. Senior doctors are often not approachable. The younger, inexperienced doctors offer little by way of explanations or choices, issuing orders and ultimatums instead.

If we wish to make our public hospitals a refuge for poor patients—as they are intended to serve—it is essential that they stay true to the traditions set by their founding fathers. Poverty necessitates greater concern for these patients. Illiteracy cannot be the excuse for not offering explanations or choices. Many of these patients are more intelligent than their literate fellow-citizens. They have to be to survive despite their many handicaps.

ON AWARDS
A few days ago, the Times of India, Mumbai, featured a large advertisement. Students and admirers of a senior consultant cardiologist in the city announced a meeting to felicitate him on the Padma Shri title conferred by the government. The advertisement referred to him as being the father of coronary angioplasty in India. On reading the advertisement, a wag in the hospital exclaimed: ‘Where’s Mummy?’

I am sure the consultant must have been deeply embarrassed by this advertisement.
On 28 February 2004, BBC telecast a programme on Dr Richard Feynman in its series entitled ‘Genius’. In it, Dr Feynman responded to a query on what it felt to be awarded the Nobel Prize in Physics. He replied that he did not understand the fuss made over such awards. ‘I had already received my prize in the pleasure I got in discovering what I did and from the fact that others used my work…’

Chuck Doswell of the American Meteorological Society, elaborating on Feynman’s comment, expressed similar sentiments. ‘Being a scientist, being allowed to do the work that we love so much ... in my view, this is the primary reward that we scientists get. Obviously, it’s very nice that our employers pay us as well! I can remember my first check that I received as a meteorologist ... it felt like stealing, this being paid to do something that was so much fun! …The idea that I should expect more from this profession than the very generous things I’ve received strikes me as the height of greed. It misses the point of what science is all about… Money has never been a motivator for me ... the opportunity to do the work is what motivates me. I have difficulty understanding those for whom money has such allure…

‘ As for recognition ... the most sincere and meaningful recognition that a scientist gets is that the work one does is used by one’s peers. When your scientific results are cited by your peers, when that work stimulates your peers to do other, related work (even if that work is motivated by the desire to show that your work was wrong!) ... this form of recognition from the scientific community is not just flattery or some sort of accident. There can be no more meaningful recognition than when your peers have understood what you have been trying to share and have found it useful or stimulating in what they are trying to do. Anything else—any other form of recognition—is, at most, frosting on the cake.’

I wonder what the students and admirers of our senior consultant cardiologist would make of this!
A TIP FROM A VETERAN TEACHER
In closing, I offer you one of the many tips that Dr O. P. Kapoor provided the audience at a meeting of the Bombay Medical Congress on 29 February 2004. Dr Kapoor is famed for his marathon classes at the Birla Matushri Sabhagar each year where he expounds over several weekends on various aspects of medicine to an audience of over 1500 persons.

He talked of the 70 and odd hathiyars (weapons) that each doctor must use for successful private practice. First among these is the fly swatter. As Dr Kapoor pointed out, history taking is often the most important part of the examination of a patient. The history provides the diagnosis in 90% of cases. A fly buzzing around the patient and you impedes proper history taking. The successful doctor must be an expert in fly swatting and must, without missing a beat, swat the pest as it makes its first appearance on the scene.
But how does one develop such expertise?
Simple, says Dr Kapoor. When you start practice, you will have no patients. All you will do as you wait for them is swat flies!