Social Indication

Yesterday morning, on my out patient day, I was prescribing a medication to a gastritis patient.The patient was a 40 something thin built man who had quit alcohol some time ago, but still continued having severe burning pain in the upper part of his abdomen. Just after I finished instructing him on the usage of the medication, a young medical representative lady came to me and requested me to prescribe the drugs her company manufactured.The drug was a commonly used medication sold in liquid form for wound cleansing.I told her that the drug was a very useful product which we had found comparitively cheap and very effective during our daily surgical practice,I would prescribe the medication as and when feasible. I also requested her to leave a sample with one of my postgraduates so that we can use the sample on some poor patient. The lady smiled as she said 'Sir, our product is very cheap and affordable, it only costs Rs 54 for a 50ml bottle'. Well, it was my turn to smile back at her as I said 'Look lady, your brand may be the cheapest and the best in the market but sometimes even that is not affordable for some of my patients!'. She left a sample, rather reluctantly, with my junior and left.

The same afternoon the gastritis patient came back to me and requested me to prescribe a drug which was available in the hospital. I told him frankly that he had a severe variety of the condition and as our hospital had no such 'strong' drugs in stock, I would still advice him to buy it from outside. He was embarassed a bit when he told me that he could not afford the medication (about Rs 19 for 10 tabs) as he had just enough money to get back to his home in Doddaballapur taluk.I told him to buy the medicine as soon as he gets some money and gave few samples of the drug my postgraduates had.Reluctantly, I wrote him some 'weaker' medications (not very effective and which would take more time to act too) which he could use and (more importantly) which were available with the hospital pharmacy.

There was no other way. Even though the drugs which I prescribed produced less than the desired effect I had to give those drugs.Apparently, getting the patient back home was more important than the correct treatment in the present situation.I had followed the Social Indication (rather than the Medical Indication) rule to give a less effective drug for a disease condition.

Indication,in medicine, is defined as the basis for initiation of a treatment for a disease or of a diagnostic test;may be furnished by a knowledge of the cause(causal i.),by the symptoms present (symptomatic i.)or by the nature of the disease (specific i.).(Stedman's Medical Dictionary, 28th Ed).In simpler terms,an indication is a term describing a valid reason to use a certain test, medication , procedure or surgery.

All throughout my undergraduation and postgraduation days (MMC, Mysore and KIMS, Hubli respectively,both Govt hospitals) I have been lucky enough to work under professors and teachers who had a penchant for social indications.I have seen them use their authority and intelligence to employ it at various situations.I have seen patients not being discharged from the hospital just because they did'nt have the money to go home, old people being admitted to the hospital just because there was nobody in the house to care for them, prolonging the placebo tablet treatment just to keep the lady from being beaten by her husband,admitting dying patients because the immediate relatives were not bold enough to give a satisfactory end of the patient and so on.I believe I have learnt from them as well as from my own mistakes and interest to fit social indications wherever they might feel right.

In the same way as we doctors and surgeons respect the ethics of our sacred practice(to be correct and accurate always) we should also respect the situations people are in, or are going through, which is most of the times, quite a big challenge.

To err is ...Surgeon!

My post graduate students frequently squabble with me regarding the 'chances' they get to operate.Ours is a teaching hospital and I perpetually encourage discussions and learning.Though teaching is a part of my profession I have always considered myself an eternal student.Surgical skills are largely obtained by constant practice at surgery, but we have to understand that it is not the only way of learning to cut.I like to teach my students the required surgical skills and also the lessons surgery teaches us with respect to life.

Surgery, as far as I'm concerned has two important things(which are not covered in textbooks), the skills concerned with it and the confidence one develops to do such surgeries, but before doing that a surgeon has to be sure of what he is trying to do and how and why he is doing it(which will be given in various textbooks).

As you can expect,the part which is learnt from textbooks is the easier part(mind you, its not the easiest part!), and the part which cannot be be learnt from books is the more challenging part.But as a surgeon becomes more experienced and as he matures, I believe a third aspect of his life emerges which is the toughest part to learn.This part, quite surprisingly, is the part where the surgeon learns to value the life of the patient being operated.Very often, it is said that the concrete step in becoming a surgeon is when the person appreciates 'when NOT to operate on a patient'!. Absolutely true.

Only when a surgeon develops the third component is he considered an efficient surgeon. Fortunately and unfortunately this skill comes into the individual only with experience.Fortunately because it gives great benefits (more than anything else, monumental satisfaction and peace of mind and not to neglect the increase in patient numbers and monetary gains) as one learns this and unfortunately because it might be ages when one acquires this and the person may not be in a position to reap the benefits at that age!

The question which arises immediately is 'how do we acquire this ability more quickly?' or 'how do we acquire experience swiftly?', for the time gained is what makes the huge difference.

The answer lies in learning from others mistakes!,it may sound quite simple or ordinary, which it is, but unfortunately I have found out that this is the most neglected issue among we surgeons.We dont quite appreciate the wrongs done by our colleagues! Be wary that it could take much longer time to achieve success than what you think.

To err is human ...and as surgeons are humans too(breaking news!) all surgeons commit mistakes by default.Well, thats the good news. The better news is that we can always learn from somebody else's bad surgery and the best news is that there is nothing to come off worse and everything to gain from it.

Happy learning!