My Doctor

 

My doctor !! 

What it really means.

It was 1983 when my career path first opened its doors. By the time I completed the first four and half years I had no idea about what field of medicine I’m best suited for. My brain just tried to sniff the trends of the times. My mother was less of a general practitioner than a gynecologist. Majority of the girls in my class and seniors before us strived to become gynecologists or pediatricians. I was a sheep within the herd. Or so I behaved. When I held the results of the final MBBS exam in my hand it was a mixed feeling. There was a huge relief that I had passed the exam. But that was tempered from turning into an elation when I realized that my grades would not suffice for a residency in gynecology. Pediatrics was possible but as a resident it would imply drawing blood from kids in the hospital. I wasn’t good at phlebotomy on kids during my student years. What my mark sheet was glaringly pointing out was something that I was totally unaware of before that moment. I had the top marks amongst my peers in the subject of general( internal )medicine. How did that happen? I was clueless. Yet it became obvious that if I intend to pursue post graduation this was the field it would be. 

I got the privilege of becoming the resident under perhaps the best professors in the department of Medicine, Dr Chikhalikar. He was a quiet and caring gentleman who was an astute clinician and a fine teacher. I was like a lost kitten trying to figure out myself suddenly with my newfound position as a resident in the department. My team mates were driven and had definitive goals in their lives. I lacked the drive and had no goals. The entire time seems to be like a blur when I look back. Mid way into the three year residency I met my future husband through a formal meeting arranged by our families. And before I realized what is happening, I was married to an American man. 

I quit my residency in Mumbai and my focus shifted to taking exams that would qualify me to start residency in the USA. While I cleared those exams I became mother to two kids, a daughter and a son, two years apart. Internal Medicine was taken for granted by then as what I was meant to study. By late 1993 I had all paperwork in hand and qualified to apply for a residency. Fortune sided with me and I landed a position in Internal Medicine residency at the LA County Medical Center-University of Southern California program in Los Angeles. 

Training was brutal in terms of the work load and hours. As interns we admitted an average of 25-30 patients per call night every 3rd day. Things still remained bad as junior and senior residents. But I was young and my two young kids had brought a new purpose to my life. There was a drive now to become financially independent like I was before my marriage. I was highly influenced by the remarkable professors at USC. Particular impressions on my mind came from Dr Rahimtullah in the department of cardiology, Dr Telfer Reynolds in the department of Hepatology, Dr Peter Singer in the department of Endocrinology, Dr Alexandra Levine in Hematology- Oncology and Dr Judith Currier in the department of Infectious Diseases. By my junior year my batchmates were mostly decided about post residency plans. What specialty to apply for or take up a job or take a break year before training further, they had it figured out. I was thoroughly enjoying learning and felt keen to specialize after the residency but again I didn’t know my true calling. Cardiology ? I loved it and had a knack for it but it was too intensive, too demanding of time. I couldn’t be a mother and a cardiologist at the same time. The same issue I saw with gastroenterology/ hepatology. These would keep me too busy. So I began to eye Infectious Diseases, Endocrinology and Oncology. Amongst these three, endocrinology seemed more intellectually stimulating to me. Dr Singer knew me well after the rotations I did in the department. A felllowship was well within my reach. 

But destiny had something else on the horizon. Abhay’s job in Los Angeles turned out to be a sham. His employer simply used him and after the first month basically stopped paying him the salary that was promised. Those were the days when speciality jobs were scarce in Los Angeles. The only reasonable option that came forth for Abhay was a position in Bakersfield. We had to survive with our two kids. He grabbed it.

For eight months we lived apart. Me with the kids in Los Angeles and he in Bakersfield, meeting only on weekends. This was the critical time when I had to decide if I want to pursue a fellowship. If I did, it implied another 2-3 years of staying apart because Bakersfield had no fellowship opportunities. I was at crossroads. But by this time I had a clear idea of my priorities. My first priority was my kids. My second priority was being financially independent. Having completed residency was enough to find a decent job and become financially independent. Fellowship was immaterial to achieving that goal. In the interest of the kids, moving to Bakersfield with Abhay and foregoing a fellowship was the best choice I could see. And that’s what I elected to do.

It was another stroke of destiny that I got a job with Kaiser Permanente and started work there in 1997. My connections at LAMC were fresh for the first 3-5 years since graduation. Mind still wandered and mused periodically about going back to specialize in some field. These urges came to surface especially when I was slighted in comparison with specialists in the group. 

There were many such incidents in the early part of my career that made me wonder if I had made a mistake by not pursuing the fellowship that was so much within my reach. One particular day the department administrator pulled out my regular medical assistant to work with the surgeon because his assistant was out. When I complained about it I was bluntly told that the surgeon gets the priority to work with an efficient assistant. In contrast, inconveniencing me was ok! This became a pattern and I had to simply tolerate it. My objections towards the discrimination fell on deaf ears. 

Primary care was also prone to being subjected to dumping. Specialists, though qualified to take care of small things like prescription refills, order labs, put in referrals or give work notes, tend to leave these tasks to the primary doctor.

My colleagues and me often get the run around from our specialist peers. The hierarchy is never subtle.

We are subject to unknown list of issues that have no boundaries. Patients often come with long laundry list of complaints and expect us to address all of them in one visit. It can range from mental issues, domestic problems, minor skin problems to significant issues like heart failure, acute problems like strokes to chronic problems like diabetes. Unlike specialists who most often know what to expect when they enter an examination room,we in primary care , more often than not, are in for surprises. 

The other factor that made me regret not doing the fellowship was the scant appreciation from patients compared to what Abhay would get as an oncologist. Patients will terminal illness like cancer were definitely more appreciative of the care received from the doctor than patients who did not have any major medical problems. Our patients were frequently more self centered, demanding and often rude and disrespectful. Despite trying hard to please them it was a big struggle to get good feedback surveys from them and it took a toll on me. Year after year I would sit with my chief for the annual review and had to promise to work harder so as to have fewer patient complaints and better survey scores. It appeared to be an unattainable goal. I struggled with the dilemma to stick to my principles of ethical medicine when it came to issues surrounding prescribing narcotics, giving time off from work, writing unsafe drugs, ordering unnecessary tests versus making patients happy by giving them whatever they asked for. I couldn’t compromise in all these years. 

Given all these disadvantages, I was coming to a conclusion that my kids should never choose to stay at the level of being a primary care doctor. If they become doctors, they must specialize if they have to feel valued. 

Despite a career spanning over two and a half decades I never once got a feeling that I am a good enough doctor. None of my colleagues voted me for recognition in the annual awards. While compliments from patients flowed in for my colleagues, nobody shared any compliments for my services from any patients. An occasional patient would write me a note or send a holiday card expressing gratitude. That was all. There were no laurels for me to boast about. I was average at best. My only satisfaction was that I remained true to my convictions about giving the best care to my patients even if that wasn’t always what they were asking for. I did not bend my principles to become more liked or appreciated. And I was grateful to those patients who remained under my panel for the long haul without changing to another physician even when they had the options available. There were indeed many of these who stayed with me for almost my entire career. I just never understood why they never left me. 

Until now. Until the time when my retirement date was finalized !! 

And as if a miracle and change of fortunes these patients suddenly began to express themselves.  A week or so back there was this patient who was gone for nine years and was coming back to town. She had heard that I was leaving and made the appointment just to see me even though she had no medical problem bothering her. “ Remember me? I used to give you a hard time. They sent me a letter that you are leaving and I said I want to see Dr Risbud before she leaves. I had to come see you “ she said . Then there were others who came. They came in to see me for that “one last time”. “ why are you retiring? You aren’t even that old”. “ I wish you could stay five more years “. “ You are the only one I trust “. “ You saved my life”. “ it will be hard to find another doctor like you”. “ I love you. God bless you “ “ Can I give you a hug?”. “ I feel happy for you but I am sad to lose you “. “ you are a good doctor “ “ I’m going to miss you “. “ I never thought of a day when you wouldn’t be here for me”. These are the words coming from patients who have been with me for some time. Strangely even patients new to me are asking “ will you take me as your patient? You are so good, I like you.”. And I have to tell them” it would be a privilege to take you in my panel, but I’m retiring at the end of the month “. 

This Friday afternoon was perhaps the climax of all this emotional exchange. I had a telephone appointment with a long time patient of mine. It had never been smooth between her and me in all these years. She would not take her medication as recommended, never keep her appointments, kept asking for more and more pain medication, would  not do her labs when asked. In every way she frustrated me and I kept banging my head for her to change her ways. She hasn’t seen me in the last two years and I needed to see her in person to continue her pain medication. I had started to give her fewer and fewer pills lately in a bid to make her come in to get the full quantity. A week back she had an office appointment and I was hopeful but she didn’t come. Friday she had a telephone appointment. She insisted she is in so much pain that she is in bed all day and cannot leave her home. I asked her if she would be willing to go into a nursing home. She flatly refused. How about palliative care? I had to explain to her what that was. She liked the idea. At the end of it I had to tell her about my upcoming retirement. She was unaware of it until then. She fell silent for a moment and then said “You are the best. I love you”. Now it was my turn to take a moment of silence. Tears were welling up in my eyes,(they are welling up even as I write this!) I told her it is difficult for anyone to make me cry but you are doing that to me right now. Her reply was “ it is good to let it out sometimes “. I was sobbing like a child and asking her “ why have you not taken care of yourself for all these years? Why are you in the position that you are right now? You could have done so much better!” My heart was breaking for her, the hopeless situation she was in and at my inability to make her recover from a downward trajectory. At the same time her love and generosity of spirit towards me was overwhelming me. All this time I was frustrated with her and she was showing so much love to me! 

In all of the above interactions with my patients in these last few weeks I got what I hadn’t been aware of in my entire career. Unconditional love, trust and gratitude!! I hadn’t the faintest idea of this. Suddenly I realized what “my doctor” means to patients. It took me this long to see the worth of my job. There is nothing, no other specialty I would exchange instead of being their primary doctor. There is nothing left for me to seek from my career. I got everything that I could have asked for. God chose what was best for me.

There is a Marathi word that expresses better what in English means “fulfilled”. क्रुतार्थ ! Krutarth!! That is the feeling I get as I close the chapter on a full time career and hand over “my patients” to the next generation of doctors. I have realized how karma can be invisible for long periods and why you still must keep doing what you do with the sincerest efforts. Even when you don’t expect it to knock on your doors, Karma may just surprise you one day and make you cry…….

I cried today. After a long long time. With a full heart. 

This experience too I must offer at the feet of my beloved Lord. That’s where it belongs and that’s where I want to rest. He took care of my patients and fooled them to think it was me. Now he will fool them into thinking someone else will be taking care of them. But how can he fool me? I know I wasn’t capable of anything by myself. 

Mukam karoti vachalam 

Pangum langhayate girim 

Yat krupa tamaham vande

Paramananda Madhavam 🙏🏼🙏🏼

With his blessings the mute can speak and the disabled can climb mountains. To Him I bow in obeisance. 🙏🏼🙏🏼

Amita recently asked me “ aai, what is your favorite fabric for saree? Favorite color? And favorite variety?

The first question is the easiest. Cotton is my favorite fabric without a doubt.

Color too is easy to pick. White.

It is a difficult choice to make about variety. After some thought I said Jamdani. The elegance and simplicity with simultaneous richness that Jamdani brings is hard to match. 

So here I was earlier this week when my staff had planned a small retirement celebration, wearing a cotton, pearl colored jamdani to work. It has elaborate floral motifs in self color on pallu and entire body.