From specialist to generalist, a doctor’s journey

Dr Kavery Nambisan describes how learning broad-based skills, rather than surgery alone, helped her make an unusual transition.

Patients line up outside her clinic. They mostly come in the morning hours, from distances of up to 20 km.

A Covid vaccine drive in Sittilingi, Dharmapuri, Tamil Nadu, organised by the Tribal Health Initiative Hospital, in 2021. Kavery worked here for six weeks when the doctor-couple who runs the hospital had to go on leave.

I wound up my surgical career of 36 years in 2015 and all I wished for was to hang up my white coat and stay in the dream home that me and my husband Vijay were building in a village near Ponnampet in Kodagu, Karnataka. A house with a freshwater well, enough space for a garden, a few beautiful old trees; and a high-tiled roof that has leaked faithfully during the rains.

But secretly, secretly, I knew it was not finished. I found myself dreaming of operations (visualising them step by step), of hospital wards, a nurse’s shout, of stretchers screeching between my ears, the irascible phone bullying me out of bed. Surgery is a bold and often risky venture. Risky because your work is a hair’s breadth away from life throbbing inside minute channels within flesh and bone; your fingers move in a disciplined trance and if you are a fraction of a millimetre off your target, you might nick life itself.

A month later there I was, with my rented room nestling between two barber shops. “Any professional doubts you might have, you can seek their advice,” teased Vijay as we drove back home. “Righto. When you come to me as a patient, I’ll borrow their instruments.”

Unobtrusively, I made the switch from the scalpel to the stethoscope. During my career, I have tried to learn broad-based skills rather than restrict myself to surgery alone. I worked in various departments of bigger hospitals and in teaching institutions. It helped me enormously. As a general practitioner too, I am asked to attend to a wide variety of cases. I try to keep abreast of my medical knowledge by reading, and interacting with colleagues.

In cities, the medical profession is compartmentalised into specialities but in a small rural town, most people do not have the means to hop between doctors. My clinic is open in the morning hours only, so patients started to come home. They were the daily wage-earners who live near us and neighbours on ‘friendly visits’ who inveigle you into checking blood pressure or treating migraine or a skin rash. We partitioned off a portion of the veranda and I stocked up essential medicines and, injections, bandages and splints. Rural cordiality ensures that patients are willing to wait while I finish bathing, boiling the milk, burning chapatis or finishing a call. The telephone, especially the ‘mobile’ pins down the user in more ways than one. We doctors have it hard. “Dactre, are you at the aaspathre? No? My son has earache. I’ll bring him to your house right away.”

Some of the privileged classes are put off by the equalizer effect of my scruffy clinic. “You should discourage these labourers. They spread all sorts of diseases. And how can you trust them? They will observe everything, then come back and rob,” says a neighbour. Never mind that there has been no such incident in the village. The fish-seller stops by late in the evening. He has had no time to go home for a bath before coming to the clinic and is apologetic about the odours that waft in with him. A woman I am treating for her arthritic pains regularly requests me to ‘hide’ a few hundred rupees for her, safe from her husband. I think the man knows, or do I imagine the scowl on his face when he meets me?

Excitement is always round the corner. Patients come in with the warning signals of a ‘heart attack’, with epileptic seizures, dog bites and injuries following drunken brawls.

Between patients, I have time to reflect. I can help patients by treating them when they fall sick but the real need is to prevent them from falling sick. The irony is that my surgical career is almost all about cure and not prevention. You have a lump? I’ll cut it out. A blockage? I can unblock it. Broken bone? I’ll fix it. The results are immediate and patients, grateful. The great bulk of medical thought, medical progress and medical expenditure goes into curing patients after they fall sick. In comparison, a negligible amount is spent on prevention of disease. In medical colleges, the learning of Preventive Medicine (and Community Health) gets low priority and is somehow made to seem dull and uninspiring. It is a huge mistake.

The average citizen is led to believe that the entire responsibility for his malady rests with the doctor. Not so. It is important to understand how the body functions and to learn about your illness by asking the doctor. I like explaining to patients and those that listen find it far easier to overcome their illness because it encourages them to take charge of their own bodies.

The first step is for the patient to understand the why of his or her ailment and then the how of treatment. The main causative factors of illness are heredity; environment; diet; stress; and lack of physical activity. If every citizen is provided with clean surroundings, uncontaminated water, simple nutritious food and the amenities for physical exercise, and if mental wellbeing is ensured, many of us can live beyond a hundred years, in good health.

We live because of it, (and at times for it) but we cannot live without it: Food. Nearly half the world’s population survives on less than the required amount; the rest of us eat way too much. We worry about the waistline but care little about wastage. Sixty percent of the patients who visit my clinic are well on their way to weakened hearts, afflicted livers and the degeneration of other organs all brought on by ill-considered eating. Diseases that were once the privilege of the upper class now punish all of society. Awareness about healthy food reaches the educated first. A person moving from poverty to relative wealth goes for fried snacks, bakery goods and fizzy drinks.

The director of a company that produces a popular brand of biscuits said in an interview that Indian mothers are ‘aware’ of the health benefits of biscuits. They use it as the first solid food given to babies. The power of advertising! A young woman who works as a domestic help told me that she never cooks breakfast. Her family of four starts the day with tea and glucose biscuits. India will definitely need more dentists to take care of a generation with early dental caries. The media supplies misinformation in the form of advertisements tangled with facts. Unhealthy high-end pap is shamelessly lauded by celebrities who will not touch them. The more expensive the goods being sold, the more treacherously untrue the superlative qualities extolled.

Mental wellbeing is an ill-understood term. The mind must be able to function in a smooth and happy manner for the individual to get the best out of life. Emotional grace provides us with the ability to understand and act towards the collective betterment of people everywhere, without the prejudice of narrow divisive factors. Even in our (seemingly) tranquil rural setting where I work, stress is a constant factor. Nothing is more worrisome than hunger, homelessness, unemployment and a lack of dignity.

Many ailments are triggered or aggravated by the occupation one pursues (see box). Almost always, patients are surprised when you tell them such facts. Some of them make the effort to address the problem.

Lessons from the pandemic

The Covid pandemic taught me many things. The one fact that came back to me strongly during these two years is that the pandemic itself would not have happened if the world was more tuned to prevention of infectious diseases.

An infection is when another living organism (bacteria, virus, or parasites) invades some part of the human body, multiplies and destroys the equilibrium. A simple example is when there is a cut injury to the skin which gets ‘infected’ and pours out pus; as also a common cold, where a virus enters the nose, throat and lungs, causing various respiratory symptoms like nasal congestion, throat pain, cough and fever. The defence mechanism of the body called the immune system tries to fight the invader by sending an army of white blood cells to the breached zone. If the body immunity manages to win, it stops the virus from multiplying. The cut injury heals fast, the cold is cured with ease. If immunity is weak, the virus gains easy entry through the skin and soft tissues or rampages through the throat and lungs causing serious problems.

The mechanism is no different in Covid patients. A person who has a strong immune system can fight the virus and thus avoid infection or get away with a mild attack. Those with weakened immunity, (diabetics, hypertensives and patients with kidney disease or malignancy) are more prone to serious disease.

With hindsight, it is easy enough to point out that the first ‘lockdown’ in March 2020 was botched because of the abrupt manner in which it was introduced. Our Prime Minister announced it a mere four hours earlier, giving no time whatsoever for those employed in various jobs and industries to make any plans for the fallow period that followed. (South Africa announced its lockdown four days early; Bangladesh gave a week’s notice before shutting down.) The plight of millions of our migrant workers suddenly rendered homeless and foodless, trudging back to their villages in inclement weather, their suffering and deaths cannot be forgotten. We had just one positive case of Covid infection in our district of nearly six lakh people. For several months afterwards, the lockdown was our problem. With no public transport, patients who suffered from chronic and acute ailments were unable to seek medical help.

Based on the experience of doctors in other parts of our country and abroad, I started using Ivermectin in early cases and referred only the more severe cases to the Madikeri hospital. I also used the drug as preventive medicine in a once-a-week dose for family members of infected persons and in all frontline workers in society, like the police, traffic inspectors, autorickshaw and taxi drivers, shopkeepers, vendors — all those who have to go out on work. It is best supplemented with immunity-enhancing vitamins and minerals — Vitamin C, Zinc and Vitamin D3, B complex and iron. I have been taking weekly Ivermectin through this entire period.

During the course of two years, the above method (along with simple antibiotics and cough medications) has been used in several European, Asian, African and South American countries. In Australia and the US, it is used by private practitioners but not advocated by the government. India has done a flip-flop, chiefly because of the confusing signals put out by the WHO. It is difficult to understand why the above simple measures to combat the virus have not been checked more vigorously; and why, when there are over sixty peer-reviewed trials that prove the efficacy of Ivermectin in humans, it is dismissed as “horse medicine”. WHO only needs to check its own statistical records which clearly states that over three billion doses of Ivermectin have been used worldwide since its discovery in 1976. If it were indeed ‘horse medicine’, how come we are not seeing serious side-effects or deaths due to its use?

In India, we have reputed doctors in cities and villages who have consistently used the drug to treat early Covid infections. Several state governments (UP, Odisha and Goa among them) have quietly added it to the medicine kits given to health care workers who treat quarantined Covid patients. The number of Indians treated so far would run into lakhs.

It is possible that with early and judicious use of Ivermectin, we could have avoided most of the hospital admissions, the use of antiviral drugs of doubtful efficacy, non-essential CT scans, oxygen dependence, ICU care and even death. It is puzzling and downright appalling that the WHO should continue to undermine its efficacy and safety, quoting a single hastily conducted clinical trial as the reason for its disbelief and ignoring all the other successful trials done the world over.

Effective vaccination for all, physical distancing and hygiene and early detection with treatment will curtail suffering and deaths. Our vaccination drive must pick up more speed and reach everyone. Many countries having vaccinated only a minuscule number of people, the danger of a prolonged Covid War which affects all countries might become a reality. We in India cannot afford to have another deadly surge. Malnutrition and undernutrition have increased by nearly 20% as compared to 2019.

The aftermath of the Covid years will shape the course of our nation and define the quality of life we leave for the younger generations. One can only hope that we will have learnt something from our failure. The most important lesson I have learnt is that the scales which are heavily tilted in favour of curative medicine must tilt in favour of preventive measures. And when a cure is necessary, we must try to opt for the most basic method or drug that will do the work.

I have used up a great deal of space to state a single, most obvious truth: Keep it simple.

(Kavery Nambisan is a surgeon and novelist. Her latest work ‘A Luxury Called Health’, published by Speaking Tiger, is now available online and on the stands. She can be reached at [e-mail])

Doctor’s notes

A few examples of high-risk occupations: Traffic police (pollution, high decibel noise, danger of physical accidents), truck drivers (back and neck strain from long hours at the wheel, sleep deprivation, unhealthy food from cheap eateries, loneliness), plantation workers (the risk of falls while climbing trees, snake bites, poisonous nettles, wild animal assault), sanitary workers (heavy physical contamination from contact with refuse, poisonous fumes, social stigma), meat-sellers and workers at the abattoir (risk of serious zoonotic disease, poor hygiene, inhalation of fine dust from chicken feathers), IT professionals (working at computers all day with elbows, neck and back and eyes taking a severe strain).

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