It has been over two decades now, back in 1989 to be precise when I came back from the U.S after a stint of a research fellowship at the House ear institute in the U.S. I got back to my Alma mater and rejoined in the position of Assistant Professor at ENT department, Kasturba Hospital, Manipal. I was bubbling with a lot of enthusiasm at the prospect of putting into practise what I had learnt in the U.S. Somehow things didn't work out like the way that I wanted to. I have nobody to blame but myself. Looking back I realise that I lacked the patience that goes with introducing ones ideas into an established department. The operation theatre at that time was rather primitive and scarce, with so little operating time for us juniors. The new theatre complex was taking forever with no clear cut completion date in sight. The free weekend rural medical camps for the local Lions and Rotary clubs were getting monotonous and exhausting. The race to sign the attendance register each morning by 8 am. and teaching the uninterested undergraduate students was even more taxing. I was rather disillusioned with the state of affairs, as is common among those who come back from the U.S. I soon realised that I was not cut out for a teaching job, and I couldn't think of myself retiring as a senior professor some day in the distant future. I called it quits within six months after getting back and rejoining the department. I decided to get back to my home town and start my own private practise without any attachment to a medical college.
Mangalore is a place with the distinction of having the first private medical college in the state and with a lot of renowned doctors teaching in medical colleges. Mangalore was the hub for medical treatment, with lots of patients coming in from the surrounding regions. The unwritten law at that time was that only those teaching in medical colleges had a good practise, so people were very sceptical about me starting a practise without a post in any medical college. I was determined to prove them wrong. At that time nobody bothered about the interiors of a private clinic. I wanted to start a new concept for private clinics. I found a rather large space of 600 sq.ft for an unbelievable rent of Rs. 400. I invested some money on the interiors and a split air conditioner which was new at that time and set up an ultramodern posh clinic in the heart of the city. The interiors were matched with an imported Japanese operating microscope, an audiological set up with audiometry and tympanometry which was also imported. My clinic in 1990 was the first to install a personal computer, which was unthinkable at that time. Within a few months all the patient data were being fed into the computer through a custom built software program. My sister who was here in Mangalore at that time greatly assisted me in this endeavour. I made my entry into the world of private medical practise with a big bang.
Looking back, I felt that entering private practise was the easiest part. The difficult part was to follow. Initially patients flowed in more out of curiosity than with an intent to get a cure. A lot of them want to test your knowledge. The initial patients that you see are the ones without any diseases, but hypochondriacs. They have seen all the doctors in the town and they walk in with prescriptions dating back to the time before you were born, and claim that no doctor so far have been able to diagnose their illness. Those few patients who are suffering from actual illnesses and who need a surgical cure run to a senior surgeon the minute you inform them.
Building values : Practise is something which you have to do everyday, in whichever field you choose. Now I realised as to why it is called 'Medical practice'. Whether anybody comes or not you have to be in your clinic at the appointed time. You have to develop a discipline in order to be there everyday. So many distractions come your way, but you have to overcome all other temptations to be in your clinic. All types of people walk in with all type of questions. You have to answer them patiently. So developing patience is a key to a successful practise. You have to exercise a lot of restraint in some dimwitted persons who never seem to understand your instructions. So anger management is also a great must have quality. Initially, you find that with all the hard work that you have put in you have not made much money at the end of the day. Your friends in other fields manage to make more with a lot less effort. Here, you have put in years of work in order to acquire the expertise to diagnose and operate , and your good friend who has not even stepped into college is running a business and making much more money than you can dream of. Then you ask yourself whether all this effort was really worth it. Slowly over a period of time you realise that you have not chosen this profession in order to make a lot of money but in order to derive that professional satisfaction that you get when you have cured somebody of their misery. This satisfaction is something only a ardent practitioner is entitled to. This satisfaction is reserved to only those who practise honestly. That satisfaction is like opium. The more you get it the more you want. No amount of money can buy this satisfaction. Empathy is a major quality that any medical practitioner should develop. This comes over time. It cannot be put on. It should be genuine, since the patient can feel it when you fake it. When you genuinely feel for a patients misery, half the treatment is already done. This I believe is the major part of treatment. This feeling comes when one feels that the patient has implicit trust in the doctor. You don't develop this feeling of empathy when you sense that the patient is doubting your judgement, when he is arguing with you over something trivial or is trying to test your knowledge, or if he lying to you. It is a mental connection that comes only when both the doctor and patient are calm and trusting. Initially it takes much longer to connect, but with experience this connection can be made much more quickly. It is a key to building a rapport with your patient. A smile on your face goes a long way in establishing this connection.
Learning while your practise is also an important part of private practise. Most of us think that once you have got your degree to practise, you can put your medical college books away. Post medical college learning is a lot different. It involves learning practical skills, unlike a lot of theory that you learn in college. It should either enhance your existing skills and also try to acquire totally new skills, as happens when new technology is introduced in your field. This can happen only when you are watching or hearing somebody better than you lecturing or operating. Hence attending conferences or live surgical workshops are very important for acquiring such skills. Most of the practitioners don't want to be away from their clinics because they don't earn when they are away and also feel that patients might go away if the doctor is not in most of the time. It is only a myth. They might go away temporarily, but eventually they come back because you are constantly acquiring new skills for the patients benefit. In 1992, two years after starting practise, I came to vaguely hear that nasal endoscopy, which was in its rudimentary stage at that time was being used to diagnose and treat nasal and sinus diseases. The news came in that Prof. Stammberger from Graz, Austria was coming down to Mumbai and sharing his experiences at J.J hospital. I immediately rushed and attended the conference. None of the my medical college colleagues attended the conference. I saw the potential of nasal endoscopy and went on to buy one at a substantial cost of Rs. 30000, which was a significant amount for a budding practitioner at that time. A lot of my colleagues asked me as to how I could buy one without knowing how to use it. I said no, but you have to have access to a nasal endoscope if you have to learn to perform nasal endoscopy's. Some senior colleagues commented that I will never recover the cost of the scope in private practise. They all missed the bus. They didn't see the potential of the endoscope. Eventually, I went on to buy other endoscopy accessories worth about 15 lakhs over a period of time. It also took me a long time to improve my skills and get over the learning curve without causing any harm to the patient. I even attended a workshop conducted by Dr. Stammberger in Graz, Austria to improve my skills. Eventually over the years, nasal endoscopy caught on and my other colleagues acquired the necessary skills to use the scope. The point that I want to make is that you have to identify a future technology sufficiently early, make a beginning and be at it till you are good at it. It will give you a good head start. It might take a long time, but eventually you will get there.
A funny instance occurred after I acquired the scope. I had a case of a child who had put in a 5 paise coin into his nose. It was located right at the back of the nose and could not be accessed with a naked eye. I used the scope to successfully remove the coin. I was really thrilled and I charged Rs.100 for this achievement. The patient's parent came up to me and asked me as to how I could charge Rs.100 for removing a measly 5 paise!
Extending your reach: It was my father's idea that I should do something for my native village. Hence I started visiting the nearest town Belthangady, taluk headquarters, once every fortnight. I was the only ENT consultant visiting there and soon I had a roaring practise. I used to take my friend Dattatreya, an audiologist and speech therapist along with me and we used to offer the full range of services in a rural setting. The psychological profile of a rural patient can be quite challenging. Most of the times they do not fall into 'text book type of diseases'. A doctor has to be adept at treating these patients in a psychological sense. It can be quite frustrating at times. Superstitions are the main obstacles. Getting around it is quite challenging. I also started visiting Dr.Ravi Pai's Ashirvad hospital. I used to land up in Chickmagalur from Belthangady in the evening, run through some out-patients and perform ear surgery on sunday mornings. I used to carry my portable Takagi microscope to Chickmagalur. The patient profile in chickmagalur is entirely different compared to Belthangady. The strategy to convince a patient for surgery is entirely different. You have to adopt a more aggresive strategy. The soft approach will not get you anywhere. My friend Dr.Noorudheen T, who was practicing at Kasargod left for Saudi Arabia and I started seeing his patients in his clinic in Kasargod once a week. I then extended this visit to Deepa hospital at Kanhangad. I never ventured to operate in Kerala. I thought it too risky to operate in Kerala, since the patients can turn viral if anything should go wrong. However I learnt a great deal of Malayalam and the working of the Malayali brain in those years that I visited these places. The erratic train schedules and the frequent lightning hartals and bandhs forced to put a stop to my kerala visits. After 10 years of these rural visits, I stopped it entirely. After a period of time I came to realise that whenever I asked a patient from kerala to come to Mangalore for surgery, they used to get operated by a Mangalore surgeon who never visits Kerala. They felt that I used to visit these places in Kerala because I didn't have a good practise in Mangalore. Once I was stuck in Kanhangad railway station and when I called up my clinic, I was told that I had a few patients from Kanhangad waiting for me at my clinic in Mangalore. I then thought that it was time for me to stop this door-to-door treatment. "Rolling stones gather no moss" applies to private practice too after a certain point. But overall I gained a lot of experience from these visits.
Mangalore is famous for its erratic power supply. Once a week we have no power at all for a whole day. I used to manage with a small portable generator. I couldn't run most of my equipment during these power cuts. My air conditioner wouldn't run and I had to examine patients under sweaty conditions. I knew that in order to rise above this level in practise I had to get to better place with good uninterrupted power supply. An opportunity presented itself one day when Dr.Noorudheen decided that he wanted to shift to Mangalore and establish a private practise. We decided set up a joint practice. I bought a small portion of the office where Dr. Mohan Suvarna, a practising Urologist had already bought the major portion. We three bought the entire 2nd floor of the building and set up practise there. Eventually Dr.Noorudheen never made the move to Mangalore and I had to buy his portion of the office too, and now only two of us share the entire floor. We have large generator with enough spare capacity to run all our equipment and more. I then went on to install Stroboscopy, Fibre Laryngoscopy for diagnosing voice disorders. Vertigo is an area every ENT surgeon avoids, because it can be challenging and time consuming. I went deep into the subject, attended workshops and dug deep into my books and installed Electronystagmography equipment. I happened to meet the famous vertigo specialist Dr.Anirban Biswas at one of the conferences and during our discussion he informed me that a Danish company was offering Video Oculography equipment at a huge discount. I immediately grabbed the offer and now I have a developed a good patient load of vertigo patients too.
The path of private practise is difficult but can be overcome gradually with perseverance and patience. You can take the easy path or the difficult path. The easy path is made up of dishonesty and cheating. You can make a lot of money quickly. It is very tempting to go along this path, but it will only bring tears but not true happiness. On the other hand, the difficult path is slow, with a lot of obstacles in your way. It tests you in every way. It throws challenges at you, it tempts you to go astray. It frustrates you at times. But if you can overcome these challenges, it brings a lot of happiness and satisfaction which is everlasting. I have still not reached the end of the road. It will be interesting to see what this path has to offer me in my latter half of my practise. I only pray I do only good to my patients and they should come to no harm in my hands.
