Being Mortal by Atul Gawande

Sri.Nagaraja Shastri was a musician and dramatist, well-known and respected in his youth. Because of intermarriages between cousins, which is quite common in south India, he was uncle to three generations - my husband's grandmother's, my father-in-law’s and ours. When he and our aunt became too old, they moved to our village so they could be cared for by his daughter. While the village did not have top-notch medical facilities, the old couple didn't seem to need them either, as they were still quite independent and healthy in spite of their age.

The first (and only) sign of problem we saw was many months later, when Nagaraja mama felt easily out of breath. He was taken to a doctor in the next village, who said that he couldn't do anything as he had bradycardia, and he had to go to Bangalore if he wanted treatment. Nagaraja Mama was eighty-six years old and had never been admitted in a hospital. After much deliberation, we brought him to Bangalore and admitted him to a hospital to see what the doctors could do.

It was very clear that he was diminishing by the hour. That didn't prevent the ICU doctors and nurses from putting him on intravenous medication right away, for bringing the heart rate up. He was trying to pull the IV needles out, so they bandaged his fingers together so he wouldn't have an opposing thumb to pull the needles with. He was angry and with his slurring and incomprehensible speech he was scolding the nurses for taking away his freedom. After multiple tests the doctors came to the conclusion that the only way to keep him alive would be to put him on a pacemaker.

Our aunt, on consulting about this, was clear that she didn't want her husband to go through any more pain, and wanted to let him be. Without a pacemaker, he died on the hospital bed a day later, with only the ICU nurses around him. A question that was gnawing at my heart for a long time, was whether we made a mistake in not opting for a pacemaker. Secondly and more importantly, I was thinking whether we made a mistake in bringing him to the hospital at all.

We are confronted with choices all the time. We seem to perpetually hit the forks that diverge on yellow woods, and the path we take makes all the difference. In medicine, they are choices that decide life and death, or Scylla and Charybdis. With the modern medical technologies available, life could be Scylla. It is these hard choices that Dr Atul Gawande talks about in his book “Being Mortal”. Through many case studies and personal experiences, he tries to educate patients and their loved ones about the questions they would need to ask and get answers to, before consenting to treatments that can wreak havoc on the quality of their lives.

Reading this book required courage from me. I have been brought up in a culture where death can but be the next step to liberation; however, talking about my own death is inauspicious. To read this book, I had to confront my own probable sickness and eventual mortality. Through the course of the book, I had to ask myself tough questions - what would I do, what would I have to do if I were in the patient's shoes, or God forbid, in the caregivers’ shoes?

I have been a fan of Dr Gawande’s writing for years. Even if it is not a subject I am not frightfully interested in, (Obamacare vs Trumpcare, for instance), his writing is capable of grabbing and sustaining attention. Being Mortal is about medical facilities of today that let terminal patients live out the remainder of their lives in peace without subjecting their bodies to more pain, especially if the pain is not going to bring about any improvement in the quality of their lives later.

Consider another case. My granddad had had a paralytic stroke at a very young age, probably due to an infection. He had regained the use of his arms and legs later and was active for a long time. However, he had a second stroke which was debilitating. He survived that too with treatment. When he had a third stroke a few years later, the doctor gave up. He asked my parents to take care of him as well as they could for the rest of his life. A few months later, my taata passed away in his own house, with his family around him.

Dr. Gawande cites statistical studies to prove that providing hospice care to terminally ill patients significantly improved their quality of life. For instance, hospice patients who stopped chemotherapy treatment lived 25% longer and had far more fulfilling lives than the ones who underwent chemo. He analyses the fact that 25% of insurance spending goes for 5% of people who are already on their deathbed. Why not divert it to hospice care which will probably be more helpful for patients than more needles and scalpels and isolation?

Of course, everything is a challenge, especially in our country.  The first problem is that of greedy hospitals. There have been instances of hospitals performing surgeries on dead bodies to milk insurance money. How do we even get these hospitals on board for something like hospice care?

The second and equally difficult challenge would be to confront the concept of mortality. We have not learnt that, in spite of studying scriptures day in and day out. But if we don't take the first step, who will?
 

Thoughts Before a Medical Examination

I have my origin in the big town of Bellary, now a city. Life used to be simple back then. We went to a nearby school. We used to be vaccinated regularly too. When we were sick, mostly my grandfather used to give medicines and we would be alright. Taata was a medical practitioner and treated people with Homeopathic and Ayurvedic medicines.

I have professed my interest in the Medical field elsewhere on this blog. This interest probably came from seeing my grandfather treating his patients day in and day out. The medicines were usually kept secret from the patients, the reason being that many of the ingredients that went to form the medicines were used almost daily in the kitchen. (I knew them, since I was the privileged helper.) The aura of mystery, and more importantly, total belief in the doctor and the medicines probably helped recovery. From simple diseases like gastritis and menstrual cramps to scorpion bites and jaundice - I have seen him restore the health of many people. And when he was baffled or was unwell himself, he went to another doctor, Ananth, who visited weekly. This was my earliest experience with healthcare - simple, fairly dependable and very affordable. Taata and Dr.Ananth did not prescribe any fees for their services. They accepted whatever the patient gave. My grandmother recounts instances where my taata himself gave some money to the patient, because he/she was so poor. His technique was also simple. He used to feel the pulse of the patient. That information along with the symptoms were, almost always, enough to give him an idea of what ailed the person. Dr.V.S.Ramachandran, in his ‘Phantoms in the Brain’,  recounts of an instance when his professor told him to observe the nails of the patient. A change in the angle between the nail bed and the finger would always mean the onset of malignant lung cancer. This simple, noninvasive diagnosis could be made far before more serious symptoms appeared. Diseases like typhoid and Rubella can, apparently, be diagnosed by their characteristic smells, and Parkinson’s by the gait of the patient.

Things ceased to be this simple in the medical field, long ago. Gone are the days when doctors used to feel the pulse of the patient routinely. A doctor is always seen with a stethoscope, one of the first and most useful medical instruments. What with the heart monitors and EKGs and oxygen monitors and a zillion other instruments available today, reading pulses and diagnosing illnesses by smelling or hearing a person walk, is an art that might well be preserved by doctors stranded in remote  islands.

Heart monitors and oxygen monitors are just the beginning. We now have electronic instruments for measuring almost any bodily function. Good old steam inhalation now has electronic measurement of temperature, and pressure and what not. (A humorous aside - my son then about four years old, a gadget-freak, looked at the nebulizing unit at a hospital and said with a wide smile "Amma, I want to be a doctor who can uset that machine"). We have ventilators and pacemakers that were unheard of in older times. While it is indeed heartening that we have now reined in technology to be on our side in our fight against disease, it is really disturbing that in this fight, we subject our bodies to great torture and never learn to let go.

In the olden days, certain illnesses were just accepted. When my granddad had a stroke, he took some strength-giving medicines but did not get his blood pressure checked or take beta blockers. My grandmother says proudly that she has never undergone any tests - just took an injection (she forgets which) while pregnant with my Father, that's all. Now, at 86, she is fairly healthy and fairly strong for her age.

Things have changed for our generation. We are more aware, healthier but also very scared. I suppose that scare can actually be justified. Take iodine, for example. The deficiency of iodine causes some irreversible problems. When iodine is lacking in a child's / pregnant lady's diet, there are high chances that that child will develop mental retardation. Goitre is a well-known illness, also caused by iodine deficiency. To prevent these diseases, salt companies started adding iodine to salt. This has gone on for a while now, resulting in another side-effect, that of a non-functioning thyroid. Unfortunately, this can also be rather dangerous if undetected, as thyroxin is required for each and every function in the body. An under-working thyroid might be the cause of an enlarged heart or obesity or just any condition we can think of. Now, if the solution is as simple as getting a blood test done and taking thyroxin everyday, why not do it? Why rely on your intuition only, when you have a foolproof, if only more invasive and expensive method to diagnose a problematic thyroid? Removing iodine from salt is definitely not an answer, so the mandatory checking of thyroxin levels is.

That was just one example. Many doctors now recommend taking the HbA1C test, instead of / in addition to the traditional fasting + post-prandial blood sugar test. For people over thirty five, annual treadmill tests are mandatory. Multivitamins and multiminerals are prescribed regularly. After a certain age, Aspirin in your prescription is considered normal. But wait, this is for well-adult check-ups; taking those tests do not demand much of our time and energy, and one should not have any complaints. However, suppose one goes to the hospital with high blood pressure and is unfortunate enough to get admitted (it is a damned-if-you-do-damned-if-you-don’t-do situation, really), he/she is started immediately on medicines like Atorvastatin and Sorbitrate, even when they are quite unnecessary (and are likely to cause complications).

But the most unwanted involvement of medicine has to be in the childbirth area. Three of my cousins were born at home, two delivered by my grandmother. They are hale and healthy and doing very well. A fourth cousin was delivered (at the insistence of my uncle's family) at a hospital. He is doing fine, too. The point is that being born at home was not bad for my cousins. These days, as soon as one gets pregnant, they start thinking about c-sections and epidurals. (I am ashamed to say that I did, too). Heck, even for 'normal' deliveries, episiotomy is routine here in India. As are oxytocin shots. While these are established as safe, they take away the feeling that birth is a natural process.  

I am certainly not denying the advantages of high-tech medicine. In olden days, giving birth used to be called 'punarjanma' for women. And it has to be accepted that the reason for the high life expectancy that we see now is solely because of the advances in medicine. But my grouse is that these days the tendency is to pop a pill rather than go for daily walks and eat healthy.

Gawande, in one of his articles titled ‘...Insurance Imbroglio...”, talks about a hospital where the nurses regularly went on house-visits to check on the child asthma patients admitted to their hospital, and thus reduced the readmission percentage considerably. This left many of the hospital beds empty and reduced the hospital profits! As Gawande says, it is not easy to work out a mutually beneficial (beneficial to both doctors and patients) solution.

So what is the solution? According to a recent poll, the top issue for Americans is healthcare. What they mean by healthcare is obviously high quality diagnosis and treatment that's also affordable. Unfortunately with medicine becoming another corporate industry, this looks difficult to accomplish.

'Complications' by Atul Gawande

Writing about books has two positive results and one negative. The positive results first. One -I never run out of subjects provided I keep on reading new books, and two - suppose I want to remind myself of this book, say a few years later, I can just read this review of mine. I have often felt the need for the latter. The negative result - I will be writing about things I have not experienced personally. Many of the ideas will not be my own. But I am willing to take that risk. Henceforth I plan to write about all the interesting books I read. I hope to intersperse the "book-review posts" with other subjects, but let that be for now.

The latest book I read, 'Complications' written by Atul Gawande, was very, very interesting, and it is an understatement. I have been interested in the medical field for as long as I remember. When I go to the doctor either as a patient or as the patient's relative, I am informed. I usually have a fair idea of the side effects of the medicines prescribed. However, after reading 'Complications', I realized how inadequate all that was. It was an epiphany. I trust a couple of doctors implicitly, and the fact that they too can be fallible, is scary, but true. The book talks about mistakes that even good doctors might make, and that wee bit of extra cautiousness that has often saved patients' lives.

Gawande writes with the clinical precision and detachment capable only of a surgeon. And yet there is humanity, there are the intense emotions that even doctors experience. There is not a dull chapter, or even a dull sentence in the book. It could be called delightful, if the subject were not so morbid and serious.

I remember freaking out when I went to the hospital at an unearthly hour and saw the young, inexperienced duty doctor instead of my usual gynecologist. One cannot deny that more experience makes better doctors. And age does matter. Most people I have met are more comfortable with old, experienced doctors than younger doctors with sophisticated degrees. Gawande states an instance where experience came in real handy. A patient came in with a reddened and swollen leg. All the indications were pointing toward cellulitis, a common but treatable infection. But just weeks ago, Gawande had lost one of his patients to necrotizing fasciitis, a rare and fatal bacterial infection that can be treated surgically, only in the very initial stage. (These bacteria, usually strains of streptococcus A, can enter the body through a "wound" as small as a pinprick.) His experience made him order a biopsy and his fears were indeed true. The patient had most of the tissue removed from her leg, but she survived. What would have happened to her if the doctor did not have this kind of an experience earlier? Would the warning bells have sounded even then? It is really hard to say!

There is also this matter of statistics. Cellulitis is a common infection. And about 5% of the cases, thought to be cellulitis at first, turn out to be necrotizing faciitis. Does this help the doctor make a decision on whether the patient in front of him right then has one or the other? Can a good doctor assume that exactly 5 out of a hundred cellulitis-patients that see him have the flesh-eating bacteria? No! Statistics are there to just comfort and/or caution, but they can never be used as a guideline.

From the days of Hippocrates and our own Sushruta, Medical Science has been improving. But newer technology has its own costs. I remember feeling elated when I read about "laparoscopic cholesystectomy" in my high school days. I thought of all the lives that would be saved because of the new technology. The thought that never came to me till I read "Complications" was the learning curve of the doctors. Gawande describes a laparoscopic cholesystectomy (the removal of the gall bladder) that he performed. Only after reading that did I realize how complicated it was, how difficult it was to learn new techniques. Doctors, like all others, take time to learn. But unlike us engineers, their experiments are with life; the stakes are high. One mistake, just half a second of haziness while wielding the scalpel can kill. Okay, I may be exaggerating, but the point is that doctors are responsible for the most precious things in this world.

And they deserve that responsibility. Risks have to be taken if lives are to be saved. Gawande talks about an unusual surgery, the gastric bypass surgery. (There was a report about this surgery in this week's 'Health' supplement of the Indian Express). In this surgery, the stomach is stapled, thereby reducing its size, and about a metre of the small intestine is bypassed, so that less food is absorbed. This is the best cure now available for morbid obesity. I mean, just think of the capability of one four-hour surgery! Many people are leading healthy and happy lives because of the surgery. So, at some point, a decision has to be made. For doctors, however, difficult decisions have to be made all the time.

In the Indian tradition, we say that one should trust the doctor completely. Indeed, it is said that the result is proportional to our trust. From a psychological perspective, this makes complete sense. Though *all* our illnesses are not rooted in the mind, many of them are. Therefore, trusting the doctor is important. But how far do we go? Ultimately it is our own body we are talking about. In Kannada they say 'ಹೊಸ ವೈದ್ಯರಿಗಿಂತ ಹಳೆ ರೋಗಿಯೇ ಮೇಲು', which is true to some extent (My grandma used to do this. She had diabetes, and whenever she ate an extra sweet, she would take a little more of her diabetes medication, without consulting the doctor!). There should be a sort of a compromise between the doctor and the patient as to who listens to whom, to what extent.

'Complications' got me started on thinking about a related thing. There are happy endings and sad endings. But, isn't 'Life' mysterious? A person who has four heart attacks may survive and thrive, whereas another may die of a pinprick. A pacemaker can help an ailing heart, a ventilator can substitute the lungs and a dialysis machine, the kidneys. What is the nature of that "one thing" that keeps all these and more working together in so much harmony that if one organ fails, all the others gradually fail, too. I am delving into Philosophy here, but isn't that a question worth considering?

What a man!

There are few people who deserve the above exclamation, and Sir C.V. Raman is one among them. I just finished reading "Raman and his Effect" by Dr. G. Venkataraman, and it has left me dazzled by one of the most brilliant gems India has produced. I knew next to nothing about Sir C.V before I read this book. I knew that he was a great scientist, knew about his work on acoustics and a little about the Raman effect. What I did not know about the man was his ego, his passion for Science, his love for India, his admiration for roses and minerals and diamonds, and his ego...

Raman is most celebrated for the discovery of the Raman effect . The story of its discovery is interesting. On his way back from his first ever trip abroad, Raman saw the blueness of the Mediterranean sea and wondered why it was. At that time, it was thought that the sea reflected the sky, and the particles in the sea-water absorbed light themselves. The accepted theory was that together, they gave large water bodies their characteristic blue color. But now, Raman had his own doubts. He always carried useful instruments with him, and he made some experiments right there, on the steamer. He then concluded that the water molecules were scattering the light incident upon them. During scattering, the frequency of the light altered, giving rise to the blue colour of the ocean. Raman Effect was thus discovered, and now has its applications in optical communication and analysis of materials, among others.

Perhaps lesser known is the work Raman did on Acoustics. He discovered how the mridangam and the tabla could generate actual musical notes, unlike other drums. He poured fine sand on the instruments immediately after striking them, and by observing the patterns formed by the grains, made fascinating discoveries about the harmonic nature of sounds produced by these instruments.

As a scientist, Raman had to be content with the less-than-adequate amenities he was provided. He was a true engineer. When there were no electric lights in the institute, he used sunlight for his optical experiments. That was Raman, never daunted by mundane, practically un-solvable problems such as poor infrastructure. His solution was simple - supplement the lack of infrastructure with the brilliance of the mind!

Raman's ego was proportional to his brilliance as a scientist. This mammoth-sized-ego was probably justified, probably, because he really was one of the best physicists of the time... After successfully completing the interview for the Assistant Account General's position at Calcutta, Raman said -"I took one look at all the candidates there and knew that I was going to stand first", and indeed he did. And what can you say about the confidence, nay, ego of the man who reserved steamer tickets to Europe in July for the Nobel awarding ceremony, even though they were only going to be announced in November!

There are a few other interesting anecdotes in the book, a couple of which I would like to share. A small boy once asked Raman if he was not ashamed of his turban, while travelling abroad. Raman then related this experience of his. When in London, he attended a lecture of Ernest Rutherford's. He happened to reach the place a little late, and was looking for a seat in the benches at the back. Rutherford then addressed him by his name, and invited him to come and sit in the front. He had recognized Raman because of the Madrasi turban! How could he be ashamed of his turban when it had served as a mark of identification? Another anecdote goes thus. While at IISc, Raman gave a problem in Spectroscopy to his student. The next day, he found the student sitting dejected. When asked why, the student replied "Another person is working on the same problem at UK. He has a 100 kW light, whereas I have only a 10 kW light". To this, Raman retorted "It does not matter, put a 100 kW brain on it!". Simple, ain't it?

In addition to being a great scientist, Sir C.V was also appreciative of Nature's beauty and bounty. He loved to collect diamonds and other crystals (in keeping with his passion for
optics). He grew a variety of flowers both at home and at Raman Research Institute. He states "I regard as the greatest feature of the world Nature herself. She is the supreme artist; she creates forms of beauty, loveliness and color, unsurpassable..."

I hope I have given at least a snippet (however small it may be), of the man who was perhaps as wonderful a person as he was a scientist, inspiring respect and awe in millions of seekers of knowledge. As I am writing this, my head bows in reverence to his great intellect. Little wonder that we celebrate February 28th as the National Science day. That was the day when Raman announced his Raman Effect to the world.

A note about the book itself. This book is one of a series, 'Vignettes in Physics', written by Dr.G. Venkataraman. The author received the Padmashri for the popularization of Science. 'Vignettes in Physics' satiates the curiosity of the ordinary reader and arouses interest in those serious about Physics. The author fondly calls it the "Junior Feynman series". Though this is the first book in this series that I have read seriously, I feel that it is excellent for people like me - who really want to delve deeper into Physics but do not have the time to study the Feynman lectures. Other books in this series are about the Chandrasekhar limit (Note: Raman was Chandrasekhar's uncle), QED, Bhabha, Saha, Quantum theory, etc. I am quite sure that each and every one of them will be an interesting read.

Time Travel

Okay, this happens to me whenever I am reading about/working with non-causal systems. I start thinking a lot about time-travel. Wouldn't it be great if we could travel back in time and set right many of our wrongs? Or if we could travel to the future and see how our great-grand children would look? Practicalities aside, it is an amazing concept.

Time-travel has been a pet subject for sci-fi movie makers, for a long time, and it does not seem to get old at all! There used to be this series telecast on the Sci-fi channel. A man is tossed from one body to another body and another, all in different times, so that he can set right the wrongs done by other people, and finally return to his own body to the present. He has only one friend throughout this exercise - Al (I think), who appears to him as a hologram. It was an enjoyable series. Fi, yes, but Sci? I should think very little Science was involved :)

And there are those gadgets that have invited a lot of speculation but have always eluded serious research for practical reasons - the time machines. H.G. Well's book 'Time Machine' was even made into a movie starring Guy Pearce. I still have to read the book. A more famous movie and a personal favorite involving time machines, is the 'Back to the Future' trilogy. Who can not love the bungling 'Doc' and the spirited young Michael? And there is another good movie called 'Frequency', where a man communicates with his father from the past and saves his parents from fatal accidents. Even the famous 'Star Trek' has a few episodes on time travel. Coming to Indian cinema, we have 'Aditya 369' which is a pretty good movie too.

There is this theory about how time-machines may work. I had read it someplace, years ago. The events happening on the earth can be seen from the Sun eight minutes later, because the light from the earth takes eight minutes to reach the Sun. So, if you can travel faster than the speed of light (Ah, there is that limit again!), you can 'view' the events that happened eight minutes ago, first hand. There is no way of checking it because we still have not found a way to travel faster than light. And interfering with the past still cannot be explained.

Traveling to the future only gets trickier. There is absolutely no explanation that even remotely makes sense, of how one can travel into the future. Some argue that there are millions of futures etched out for you, and you just pick one each nanosecond of your life. Keep choosing futures one after another and - well, you can travel to the future! However, this argument is not even worth considering. There are just too many unknowns in the equation.

Theoretical physicist Kip Thorne suggests that wormholes, which are allowed by the laws of Theoretical Physics, can be used for traveling in time. Something that comes from an eminent physicist like him cannot be disregarded. But we have to continue being in the present, and see what direction research takes.

As far as I know, the concept of time-machines and time-travel is quite recent. I have not come across that in Indian or Western mythologies that I have read. From all practical observations, our conclusion is that Time flows only in one direction. That is what our ancients also seem to have thought.

That is the sensible thing to think, too. As a subhAShita goes -
गतशोकं न कुर्वीत भविष्यं नैव चिन्तयेत्
वर्तमानेषु कार्येषु प्रवर्तन्ति विचक्षणाः ।