It was my first day at work as a house officer in a remote village in rural India. My supervising doctor had finished for the day and had gone home. I was about to leave when I was told that a “regular jaw dropper” had arrived. Curious to see who it was, I was greeted by an 80 year old man and his wife. The old man's mouth had refused to shut and was held wide open with some discomfort. Weird and wonderful differential diagnoses flashed through my mind, but, try as I might, I could not recall any major illness that had this sole symptom. In order to gain some time, I tried to discover more about the problem. The patient himself being unable to speak, his wife provided the history.
Since he had lost all his teeth and his jaw bone had receded, the patient had found yawning satisfactorily to be dangerous. Every time he let out a fully fledged yawn, he could not shut his jaw again afterwards. My supervisor had, according to the wife, put his fingers in the patient's mouth, pulled the jaw outwards and forwards, and then let go. This had always solved the problem. “So that's it then,” I thought with relief. It seemed to be a simple case of temporomandibular dislocation.
Informing the old man and his wife that this was my first day as a doctor, I attempted to repeat the manoeuvre and was surprised when, with a click, the head of the mandible returned to its natural home, and my first “independent” patient was “cured.” I thanked the couple for consenting to be treated by me and letting me gain valuable experience in the process. They in turn were pleased that I had been adventurous in treating them.
Many months later, near the completion of my house officer training, I was working in a district general hospital in a medium sized town a few hundred miles from my rural posting in the remote village. It was a bright sunny morning with a long queue of patients already formed at the entrance of the outpatients department. There was no luxury of booked appointments, and all those attending had lost a day's wages. I was met by a very distressed elderly woman accompanying an elderly man, who, although having tears streaming down his cheeks, had not managed to say much about his problem.
The woman composed herself and told their story. The couple had spent the past two days trying to find a doctor in the town to cure the elderly man's problem. This had started when he had been very tired and had let out a full fledged yawn, when he discovered that he could not shut his mouth. No doctor had been able to advise them on what was wrong. I offered to set him right and, with a flourish, put my fingers in his mouth and relocated the dislocated mandible. Without any warning, the old man and another 10 people accompanying him rushed to touch my feet. In Indian tradition, this respect is accorded only to the elders in the family or community. The old man, now clearly able to speak, thanked me a million times for treating him, something that quite a few doctors in the town had been unable to do.
I was left thinking that what we learn as medical students and doctors owes so much to the type of patient we see. Had I not seen that first, knowledgeable patient, I too would have been left wondering what the latter patient's problem was. Certainly, no such case had presented during my years at medical school. The other irony was that in India, where the best health care is confined to cities, my first patient had received prompt care in a remote village, whereas the second patient had had to endure two days of misery in a medium sized town.