When I awakened, that April morning, in my attic bedroom, my head still cloudy from late hours of study, I felt constrained, reluctantly, to review my financial position. Thanks to the gratuity which I had received on my demobilization from the Navy three months before, the fees for my medical classes were paid up until the end of the year. The gold watch and chain I had inherited from my father, once again judiciously pawned, had provided me with the requisite instruments and secondhand textbooks. I had even managed to discharge in advance, my annual dues to the Students’ Union. In an academic sense I was strictly solvent.
But, alas, the other side of the ledger was less satisfactory. In my anxiety to ensure that nothing should interrupt this resumption of my studies, I had given slight heed to the minor consideration of keeping body and soul together. For the past month I had been subsisting on an occasional tearoom snack, supplemented by bizarre bargains from the local market brought into my lodging of an evening in a paper bag. I was, moreover, two weeks behind with my room rent, while my total assets—I counted the few coins again—were precisely three shillings and five pence. Viewed from the rosiest aspect, it seemed scarcely an adequate sum on which to feed and clothe myself for the next eight months. Something must be done. . . and quickly.
Suddenly I burst out laughing, wildly, hilariously, rolling about on the lumpy flock mattress like a colt in a meadow. What did it matter? I was young, healthy, filled with that irrepressible spirit only in a ruddy tow-headed Scot whose veins were infused with a dash of Irish red blood corpuscles.”
Gave the game away? That was A J Cronin, writing in Adventures in Two Worlds, his autobiography. There is not much wild and hilarious laughter in the books about doctors I have in my waiting room this time. Perhaps, this is because they don’t have, oddly enough, both Sandeep Jauhar and Atul Gawande talk about their fathers, about their illnesses and about mortality. Both doctors of Indian origin write from America, the land of plenty, where there is plenty of debate about medicine, the practice thereof, medical insurance, Obamacare, what-have-you. I only wish for your sake, for my sake as readers, we could have had a doctor from Canada — you do remember the contrast between the Canadian healthcare system and the American healthcare system as seen in Michael Moore’s Sicko? — and a doctor from England, where the Freakonomics and Super Freakonomics gents were asked to suggest ways to make the nation more cost-effective, and suggested that some items under the National Health should be paid for, because those who were simply taking what they could get because it was free were squeezing out those who really needed healthcare. Now, National Health is all that Britain has left, we have been told, as a religion and so there was no way Gordon Brown was going to touch it and so that was that. The PM did not get back to the blasphemers.
Atul Gawande first because his book Being Mortal: Medicine and What Matters in the End (Penguin India, Rs 359) arrived first. Like everything else he had written, this one reads beautifully. It begins with a portrait of his grandfather who dies at the ripe old age of 110, you read that right, when he falls off an ST bus somewhere in Maharashtra. How cool is that? A 110-year-old man wants to get on a bus and he is allowed to get on a bus. Would you let your hundred-and-anything-year-old anyone get on a bus? The problem with the very old is that they also lose agency. The problem with the very sick is that they also lose agency. Susan Sontag puts it well in that old classic, Illness as Metaphor: “Illness is the night side of life, a more onerous citizenship. Everyone who is born holds dual citizenship, in the kingdom of the well and in the kingdom of the sick. Although we all prefer to use the good passport, sooner or later each of us is obliged, at least for a spell, to identify ourselves as citizens of that other place.”
Being Mortal looks at what happens to the citizens of the other place. And, almost as I was reading this, my cousin S came over and told me of his mother’s death from cancer. It had turned up in her stomach and it was preventing anything from getting past the stomach into her small intestine. She ate and she threw up, she ate and threw up. When they took her to the oncologist, his compounder took a look at the old lady and said, “Take her home. Let her eat what she wants and vomit it all up. And, let her die.” But, it is difficult to do that and the doctor said she had a slim chance so he would operate. Again, the compounder said, “Tell him to do a stomach bypass. She might have a few months then.” The doctor didn’t and to cut a long story short, S’s mother died in a fog of pain.
Sandeep Jauhar’s book Doctored: The Disillusionment Of An American Physician (Farrar, Straus and Giroux, Rs 1299) takes a look at the other citizens of that other place: the attending doctors. It is a dismal book because disillusionment is a dismal business. And, it is here that the contrast between Cronin and the doctors of today becomes most acute. There’s Cronin, summoned to the bedside of a sick child in a croft whose fauces (what?) are covered with a greenish white membrane showing clearly that he has laryngeal diphtheria. He must act and so he swabs the child’s throat down with iodine and slashes its neck open and cuts down, down, until he had pulled the membrane free and then he sews up the child and inserts a silver tracheotomy tube and saves the child’s life. The mother’s eyes show “a gratitude—moving and inarticulate—like the attitude of some dumb creature to a god”.
No one would write like that today but my generation grew up on these images, of Frank G Slaughter’s surgeons and Cronin’s doctors (see also Adventures of a Black Bag) all the way up to a television series such as House. In Intern, Jauhar blew the lid on the training of a doctor. Now, he shows how difficult it is for a doctor to keep up with the plumbers and carpenters of his area and why he might appear on panels to recommend (or push) new medications or moonlight at other clinics. It is difficult to hold all these images together, to see doctors as mere mortals who know a bit more about your fauces than you do. Our civilisation now rests its faith on doctors when once we believed in priests. This is not a bad thing at all, especially since it is probably much easier to ask questions of a doctor. Answers? Well, those might not be as forthcoming. If time is money, the more patients you see, the better it is for you. As for the patient? Well, she can always sue for malpractice, can’t she? Better keep up your malpractice insurance, young man.
And, here’s a prediction. As more and more doctors are sued, as fewer and fewer doctors recommend that their children become doctors all across America simply because the money is falling behind the curve and the respect is going out of the courtroom window, one day, most of the doctors in America will come from this subcontinent.