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My husband and I went to a new doctor. He was a GP in a cardiology practice (no idea why). He looked the the snowman character from Rudolph the Rednosed Reindeer (voiced by Burl Ives) with legs - I mean a *perfectly* round torso - in all directions, with a head on top. We’d had blood work done and he started with my husband. Some liver enzyme issues (my husband is British, and the culture of drinking was pretty strong - so it wasn’t unrealistic) and all, but nothing really big. And he was treated with respect. Then he gets to me. I’m an overweight woman of about 40 years at that point - and my blood work is . . . perfect. He treats me like I *cheated* on the lab tests. That I cannot POSSIBLY be a healthy, overweight woman of 40 some-odd years. And to be honest, I’m quite used to that treatment by medical professionals. They are at the same time dismissive of any actual complaints I might have (to the point I stopped complaining eons ago), and insistent that something must be wrong all based on my weight. But the . . . irony . . . of someone who was actually MORE overweight than *I* was - telling me that (absent any and ALL evidence) I was “unhealthy” simply because I was fat was . . . condescending . . . patronizing . . . offensive . . . all of those things and so much more.

I was sitting in my car in Holyhead, Wales when I realised that my heart was doing about 180. I walked slowly into the terminal building and asked to see a 1st aider. She checked y heart rate and immediately called a paramedic. Paramedic arrives about 10 mins later, wired me up to an ECG and called an ambulance. Ambulance came from 20 miles away and brought me to hospital. In hospital, i was seen immediately and had blood taken for immediate analysis which came back in about 40 mins suggesting that I had had a heart attack. I sat in a chair for about another 30 mins then got a bed in their cardiac unit,and was connected to another ECG. Because I was in another country, I didn’t have any pyjamas available, so the hospital staff gave me some scrubs, toothbrush and toothpaste. The ferry management had had my car moved into a secure location, my wallet, passport and keys were kept in the office until I returned Over the next week, I started to feel like a pincushion, with blood-thinning agents. No further signs of problems, but they did an angiogram anyway. No problems there either. Shortly after getting home to Ireland, I got a request for my welfare number. I sent them that, and never heard any more about it. They sent a written report to my GP, and he arranged follow up checks. None of it cost me as much as one penny.

Three questions are rolled into one.Medical schools are hard because the human body is a complex organism. It takes time and hard work to gain a foothold on the details of its structure and function. Once that is over one must learn about the nature of diseases and their causation, and finally get to know the methods of investigations, treatment and prevention of diseases. End of medical school is not the end point of study for a doctor—it is the starting point. When a doctor qualifies and gets his license, he is on the first rung of a very long, constantly lengthening ladder. Medical science is advancing at such a rate that a doctor’s learning process continues during the entirety of his or her lifetime. One must keep in touch with recent advances even after one has well and truly retired. When recently at a party an acquaintance approached a classmate of mine and wanted to know something about the TIPSS procedure that a relative of his was to undergo he was able to give a reasoned answer. TIPSS is Trans jugular Intrahepatic Porto Systemic Shunt. This procedure was not only unknown in our time but technologically so advanced that it was undreamed of. This types of queries from friends and relatives happens to all retired doctors and they better be prepared for it lest they are marked down for museum specimens.*Medical practice till the 1970s was structured as follows: The General Practitioner was the primary physician. He (it was always a he) was the figure that has given the good reputation that medical profession (though severely eroded) still enjoys. Except for occasional references to specialists he attended to all the medical needs of his patients. Fever, colds and cough, digestive disturbances, headaches and other aches, childhood ailments and minor injuries were his bread and butter. Other than minor surgical complaints like abscesses the GP referred surgical cases to the general surgeon. Heart and lung complaints that were beyond him the GP referred to specialist physicians. There were no cardiologists and neurologists in those days.Women doctors attended to obstetrics and gynaecology. For the surgical needs of their patients lady doctors either attended to these themselves or referred their cases to surgeons.The whole arrangement was carried out under unwritten rules. This code of conduct goes by the name medical ethics. The specialists never saw cases that came directly to them. The case must be referred. The specialist will not see cases once referred to him if they come directly to him for a second bout of the same illness. He will request the patient to come with a reference from his GP, or if it urgent he will see him but refer it to his GP for follow up care. This is not a business arrangement to prevent undercutting. The interest of the patient lies at the heart of this as illustrated in this incidence.After qualifying to be a surgeon I was working as assistant to a surgeon in a government medical college hospital in Madras. This is not dissimilar to the residency training that specialists must undergo before being licensed as a specialist. To supplement my income, I started a general practice not far from the hospital where I worked. This was not an uncommon practice in those days (1965) in India. I was doing well. One day a man aged about 40 came for loss of appetite of a month’s duration. He was anaemic. When a surgeon sees a man aged about 40 with loss of appetite and anaemia the first thing that passes through his mind is cancer of the stomach. Clinical examination of the abdomen was normal. In early cases of cancer stomach it would be so. This was before the days of flexible gastroscopes. I ordered for barium meal x-rays of his stomach and gastrointestinal tract. I knew the patient from earlier visits. I have treated his two children for various minor complaints. This is one of the great things about general practice. You know the patient and his family in a personal way. You also know a lot of his family history especially how much they can afford for medical care. You do not bill them beyond their means. Even the barium meal examination I arranged for him at my hospital. It was free for he was a government servant. I was concerned for him. Cancer of the stomach in those days had the reputation of being ‘the captain of the men of death’. His young family will be in dire straits without him. The next day in hospital I asked a physician colleague about this case. ‘What diagnosis will first come to your mind if a 40-year-old patient whom you have seen in good health a month ago comes with intense loss of appetite and anaemia?’ I asked. His training as a physician made him think differently. ’Chronic renal failure,’ he said promptly. Rethinking about the case I thought my surgical training had misled me into diagnosing cancer of the stomach. I got my patient’s blood urea done. It was well above normal. I took him to a physician colleague and requested him to take over the case. The patient needed dialysis and when last heard of he was registered for a renal transplant.I learnt an important lesson from this case. Specialists cannot see a case with an open mind. Their mindset is always towards their specialty. If they see cases direct, they will often mess it up. They must only see cases referred by general practitioners. The GP does the preliminary examination and investigations and refers the case to the appropriate specialist. A specialist who refuses to see a case that does not belong to his specialty is doing the right thing.Getting treated by a specialist without reference to a GP also has serious drawbacks. If the patient suffers from a condition that was confined to one specialty like say heart attack or stroke, then it does not matter. When multiple systems are involved, as they not uncommonly do, it can cause problems to the patient. Recently a very important person in India had the misfortune to suffer from such a multi-specialty ailment and it was widely rumoured that this VIP, despite top specialists being involved, did not get the best coordinated care possible resulting in tragedy.The General Practitioner disappeared in the 1970s. Medical science had advanced so much that it was more than what one person could handle. The GP who was a family adviser on health matters is gone and has not been replaced. The Primary Care physician has proved to be an inadequate substitute. He does not enjoy the stature of the GP because he is more into referring his patients to various specialists rather than treating them himself. Many of the problems of modern medicine can be traced to patient’s lacking a guide through the medical labyrinth.*There has always been a shortage of doctors and this is not going away in the foreseeable future. Medicine is a difficult profession. Those Quorans who want to know as to who makes more money, the cardiologist or the neurologist should stay away from the medical profession for their good as well as the good of the profession. Among professions that make good money medicine is a hardest, takes the longest to train, and the most arduous to practise. If a person is smart enough and willing to do the hard work necessary to become cardiologists and neurologists then he/she has the capacity to earn much more with much less strain in other professions like business, finance, manufacturing etc. Medicine is for those who have an aptitude for it. Among other things good doctors must have a desire for service. That is what sustains them.In 1950 when I joined medical college in India the country was free from British rule for just 3 years. The country was underdeveloped for in the 200 years of British rule India exported raw materials to Britain and imported British manufactured goods. Industries were very poorly developed. Job opportunities were few and medicine was a hotly favoured profession. In developed countries like the U.S. job choices available are many. Only those with an inclination enter medical schools. That is one reason for the shortage. But the shortage in developed countries to some extent is met by importing doctors from developing countries like India. This is harmful for the countries from which these doctors emigrate. It is a tragedy that in a country like India, where scarcity of doctors is acute, many medical graduates trained at government expense for a pittance desert their home countries for the purported physical comforts of the developed world.