“If he says his hand hurts, put it on his hand; if his head hurts, put it on his head. That's what your father does.”
I had just completed a year of internship and, with all the knowledge and wisdom of a new graduate, I had joined my father in family practice. It seemed strange, returning to the old familiar surroundings in a new garb. From the time I was a toddler I had visited my father in his office, looking in admiration at the huge oak desk behind which he sat. In one corner was a pile of copies of the BMJ and the Lancet, some obviously read, others unopened. There was a profusion of pens and pencils with a jar of royal blue Quink—ball point pens had not yet been invented. By his right hand was a heavy ledger which served as medical record, account book, and anything else worth writing about, all rolled into one tome. Just outside his office, and a little beyond what we would now call a treatment room, was the dispensary. This resembled a pharmacy of old, a large glass fronted cabinet with some bottles containing liquids of varying color and viscosity. Other widemouthed bottles contained crystals, large and small. I was intrigued by the curious names on the labels: Aq Menth Pip Conc, Tr Card Co, Sodii Sal, Extr Thyr Sic, to name some. A few large jars contained ointments such as Antiphlogistine, Whitfield's, and Icthyol c. Belladonna.
Private practice in Colombo was different from that in Great Britain and the United States. When patients came to see a doctor they did so for the medicine. The consultation and clinical evaluation were of little interest to them, a nuisance that had to be tolerated because it was the means to an end. After making his clinical diagnosis, my father would draw the ledger towards him and write out a prescription. This almost always consisted of a “mixture” and a “powder,” the former containing soluble medications and the latter insoluble ones. The wise physician avoided mixing aqueous solutions with oil based liquids, for this meant creating an emulsion—a process that was both time and effort consuming. Then, as now, time meant money. The patient then left the consultation room, presented his or her prescription to the dispenser, and watched with fascination as the medication was custom made from raw ingredients. The powders were divided into approximately eight equal portions and packed in individual wrappers. The liquid medication was poured into a bottle provided by the patient. As bottles varied widely in size a strip of paper extending to the upper level of the liquid was notched to indicate each of the eight doses provided, and this was then affixed to the side of the bottle. Of course, many patients turned up with no bottle, and one had to be provided (for a small additional charge) from those purchased from the bottle man. The patient then paid for the medicine, rather than for the physician's professional services, and departed with a three day supply of medication.
Then, as now, time meant money
The only other employee in my father's office, other than the dispenser, was Sankaran. He must have been a hundred years old; or so I thought, for I had known him for as long as I could remember. He swept the floors, washed supplies, tidied up everyone's mess, and generally kept the place in order. He had no family and no home, and he slept in a side room of the office, obtaining his meals from across the street. Sankaran's most important function was collecting bottles, and washing and drying them; for he knew the importance of cleanliness, if not of microbiological sterility. He treated me as he would any other child, and he saw no need to change his behaviour in any way, now that I was a “real” doctor. My parents had gone on a long overdue vacation, and my father had left me in charge of the practice. Of course, Sankaran was most concerned that I should do well and uphold my father's reputation. He would often give me little pieces of advice, clucking over me like a mother hen. I had made a serious error today, and it was Sankaran's duty to see that it was corrected. I had just seen a patient complaining of pain at some site—I cannot remember where. The discomfort was probably in a limb, back, or lower torso, a location where little could be learned by auscultation. I had not placed my stethoscope where the patient hurt, and this lapse on my part had caused the patient much distress. Just as many of today's patients speak more freely to nurses and office staff than they do to physicians, so too, areas of discontent were relayed to the bottlewasher. No doubt he triaged the complaints, made his own evaluation of their merits, and acted appropriately, which included drawing to my attention any deficiencies attributable to me.
And so I learned that day that a physician must use his stethoscope as a magician uses his wand, or a conductor his baton. I had grossly underestimated the power of the instrument and failed to perform a clinical evaluation satisfactory to the patient.
God had returned to his heaven
My father was the physician to two or three foreign embassy staff, and in his absence, I assumed these responsibilities. I received a call one morning from an ambassador's personal secretary asking if I would drop in for a “home visit” at my convenience. It was an era when most physicians (including specialists) visited patients in their homes at the beginning or end of the working day. The problem did not seem urgent, and so I decided to see the ambassador before I returned home that night. I was warmly welcomed and ushered to the patient's bedroom. On examination, it was clear that costochondritis was the source of the patient's chest wall discomfort. I had little doubt of my diagnosis and made my recommendations, writing out a prescription for an analgesic. All seemed to be well, and when I was just about to leave I thought that the ambassador felt uneasy. “Anything else I can do for you?” I asked. “Well,” he said hesitantly, “Ramanan, you are a good fellow, like your father, but if you don't mind, would you please put that ... that thing on my chest and see if everything is all right?” Too late, I realised the faux pas I had made. Confident of my diagnosis of chest wall pain, I had not taken the trouble to auscultate the chest. Trying to hide my embarrassment I carefully examined the heart: inspection, palpation, percussion (even though I knew it to be of little value in the evaluation of heart size), and a detailed and time consuming auscultation. I then made my pronouncement that all was, indeed, well. God had returned to his heaven, and all was right with the world.
It was many years later that I attended a talk on headache by an eminent neurologist. He was a good speaker, using humour to emphasise what he considered important. “The next time you have a patient with a chronic headache,” he said, “place your hands on his head and feel it. Chances are you won't feel anything to help you with a diagnosis but, boy! won't your patient be impressed. No one, ever, would have felt his head before. And, to impress your patient even more, place a stethoscope on his head. Why, one fine day, you may even hear a murmur.”