| DoctorNDTV: Could you describe your typical working day? | | Dr MK Mani: I wake up at 5 am and reluctantly go for a walk mandated by my cardiologist. I attend to some personal correspondence in the morning before going to the hospital. My ward rounds are from 9 am to 10.45 am, and from 11 am to 1 pm I see new outpatients in my office every day except Friday, when the entire unit (6 nephrologists and 6 registrars) goes on a teaching round discussing interesting patients of all the doctors from 9 am to 1 pm.
My lunch break is from 1 pm to 2 pm, during which I eat for 10 minutes in my office, and then attend to my correspondence. Follow up patients are seen from 2 pm to 6 pm every day (including Friday) with an hour’s teaching session in between.
I make a quick evening round of critically ill patients only and then go home. The evening is spent in reading and writing (professional matters only on a working day) and I go to bed at 11 pm. | | |
| DoctorNDTV: What, according to you, are the attributes of a good doctor? | | Dr MK Mani: It would be wonderful if all of us were motivated by a burning desire to relieve human suffering. Unfortunately, that attribute belongs to only a minuscule minority. Almost all of us entered the profession because we or our parents considered it a good career with a comfortable or even luxurious living, and a high standing in society. A few might have been interested in the science of medicine. Many were driven unthinking into the medical college by medical parents who wanted their progeny to inherit a practice or a nursing home, or just to emulate them.
Whatever led us into the profession, we are here, and we should reach a modus vivendi. We are fortunate in that our routine work enables us to help everyone who comes in contact with us, so we will do good as long as we, as the law requires, exert a reasonable degree of skill and care. Once we come in touch with so much of human suffering, anyone with even a minimum of humanity would endeavour to relieve his patients to the maximum extent possible, and will not charge so much as to add to their woes. I wonder where we are going wrong. To begin with, medical colleges are the scene of the most horrendous ragging of new students. Seniors forget what they went through in years past and do physical and psychological injury to their successors. Surely anyone who can inflict torture on anyone else has no place in a healing profession. These students should be expelled from the college immediately.
The next thing that worries me is the fees that we gouge from our patients. I see no reason why the very wealthy should not pay for their treatment, but we should not impose the same scale of fees on the poor. One problem of corporate hospitals is that they concentrate on the profit motive. The charges are certainly twenty times cheaper than what it would cost in hospitals overseas, but they are far too expensive for the average Indian. The advantage of working in such a hospital is that the facilities provided and the standards maintained make it possible to practice medicine at the most efficient level. It is possible for a caring doctor to reach an agreement with the management of his hospital to provide some relief for those who cannot afford the costs. I work for one of the most expensive of these hospitals, the Apollo Hospital, but I have been able to ease matters for the poor and the middle class because we have a number of concessional packages of investigations. For end stage renal disease, we subsidise dialysis for a limited period of three months, so that a patient can have the time to have a donor investigated and go through with a renal transplant. I have made the sacrifice of working as a full time salaried employee rather than practising, which means some restriction of my income, but considerable easing of the burden on my patients since we only charge a consulting fee once in three months, no matter how often we see the patient in that period.
I am horrified when I see the fees charged by many in the profession, the acceptance of cut backs from hospitals and institutions for expensive investigations, the prescription of medicines that cost the earth when a cheaper drug would work equally well, the influence we allow the pharmaceutical industry to have on the profession by accepting freebies, which automatically call for a quid pro quo in the form of our prescriptions. I am as fond of physical comfort as anyone else, but just how much can a person eat, however rich he is? My good doctor would care for his (or her) patients, and that would make him spend the time and the effort on making himself good at his work by spending some time on reading. He would keep his fee structure reasonable, and would not prescribe expensive medicine when a cheaper one would do just as well. He would not accept demeaning handouts from the pharmaceutical industry, or accept cutbacks from the proprietors of CT scans and lithotripters. He could certainly make sure that these sums are given to the patients as a discount on their charges. | | |
| DoctorNDTV: What has been the professional achievement that has made you most proud? | | Dr MK Mani: I would list two pieces of work. One is a protocol I have developed for the prevention of chronic renal failure at the community level. This is run by the Kidney Help Trust of Chennai. It involves the screening of the entire population of 43,000 people in 56 villages and hamlets, once every year or two, for diabetes and hypertension, using the simplest of methods, a simple questionnaire, a urine test for sugar and albumin, and recording the blood pressure. This is done by girls from the area who have completed their schooling and are not being sent by their families for higher education. We can easily train them to do the tests and maintain the records we need. The patients thus picked up are seen by our doctor (the Trust pays a doctor for each visit to the area).
Those with complications are advised to go to a hospital, but most will not go. Diabetes and hypertension are treated with the cheapest available drugs, reserpine and hydrochlorothiazide, metformin and glibenclamide, given to the patients in their villages. We have been able to achieve perfect control of hypertension in 96% of the hypertensives, and perfect control of diabetes, glycated haemoglobin consistently below 7%, in 52% of the diabetics. A further 25% of the diabetics had significant improvement in the diabetes though we did not achieve the target level. We were able to reduce the prevalence of chronic renal failure from 28 per 1000 population to 11 per thousand, at a total cost of Rs. 22/- per capita of the population per year. Since none of these people could afford dialysis or transplantation, and the Government hospitals can only give transplants to a small fraction of those who need them, this is the gift of life to 17 people per thousand of our countrymen. It has not been so easy to quantitate the reduction of coronary or cerebral vascular disease, but we are confident that we would have done some good on that score too. This project was recognised by the International Society of Nephrology to be the best prevention programme anywhere in the world, and I continue to hope that I will some day be able to persuade the Governments of India and the states of India to incorporate this in their health programmes.
The second method I have worked out is for patients attending the hospital for established chronic renal failure, and is aimed at slowing down further deterioration and thereby delaying the need for dialysis. It consists in pushing up the dose of angiotensin converting enzyme inhibitors and angiotensin receptor blockers to the maximum tolerated by the patient. Since many of these patients come from areas where there are no nephrologists or even specialist physicians, and they cannot travel frequently to major cities, we ask them to have their blood pressure recorded and blood urea and serum potassium estimated at laboratories near their residence. They send these reports to us by fax. Thanks to Rajiv Gandhi and Sam Pitroda, almost every village in the country now has a fax office. I do not accept telephonic communications. It is better to have a written record as there is less scope for misunderstanding of the dose to be taken. We can then adjust the dose of the drugs used, again the cheapest in each category, enalapril and losartan, to the maximum, and achieve the maximum benefit. It has been possible to slow down the decline in renal function from a glomerular filtration rate of 50 ml/min to the end stage from 9 years to 26 years on the average. Since only a minuscule fraction of these patients can afford dialysis or renal transplantation, this protocol gives them 17 years of extra life. The expenses of the tests at their local laboratories and of the fax communications are small, and affordable to many. I am now endeavouring to spread the message to more and more Indian physicians and nephrologists, so that these benefits can be made available to the entire population of the country, and not just to the few thousands of my patients. | | |
| DoctorNDTV: Why did you choose your present job? | | Dr MK Mani: I would have preferred to be a nephrologist in Government service, and to have been able to serve a larger number of disadvantaged people. However, when I returned to India after specialising in nephrology overseas, having taken study leave for this purpose from my post as an Assistant Professor of Medicine, I was not given the only post of nephrologist then available in the Tamil Nadu Government Service, which was kept vacant till a privileged candidate of the Government returned from his training. I had to continue as Assistant Professor of Medicine. Since I wished to work in the speciality in a hospital setting, I accepted an invitation from Dr. Shantilal Mehta to work as Chief Nephrologist in Jaslok Hospital in Bombay.
My desire was always to work in Tamil Nadu, since I had received my education practically free from the Government of the state, actually from the people of the state. It pained me to have patients referred to me in Bombay for transplantation from nephrologists in Madras. I therefore accepted the offer of Dr. PC Reddy to work in his Apollo Hospital in Chennai. Work in Jaslok had conditioned me to work in the private sector, and I was sufficiently experienced in the problems of working in a hospital where the patient had to meet all the expenses to know the drawbacks. I was also sufficiently well known by then to successfully negotiate the terms, to be a full time doctor in a system that was geared to fee for service, and to extract the concessions from the management of Apollo Hospital that I mentioned earlier for less affluent patients. I must pay my tribute to Dr. PC Reddy and the Apollo Hospital that, while I perhaps made some contribution to the growth of the hospital in the early days, the organisation does not need me now, but continues to maintain the concessions that had been given to me in the initial days. I am therefore able to continue work here though in general I do not approve of the corporate sector and its approach to medicine. There is no doubt that the facilities available for work in hospitals such as this are unrivalled in India, and I have been able to do clinical research of significance here. | | |
| DoctorNDTV: What would you have been if not a doctor? | | Dr MK Mani: That is a difficult question to answer. I had decided to be a doctor from the time I was four years old. I do not have the time to detail the reasons here, but the interested reader could read about it in my autobiography, Yamaraja’s Brother, published and sold by the Bharatiya Vidya Bhavan. Therefore I never seriously considered any other profession. If not a doctor, perhaps I would have been a teacher of history, since that is the subject I most like to read outside medicine. | | |
| DoctorNDTV: Who is the person you admire the most or are most influenced by? | | Dr MK Mani: Two people would qualify for this. The first is my father, Mr. TMS Mani, an ICS officer who rose through the ranks to be Chairman and Managing Director of the Neyveli Lignite Corporation, and died prematurely at the age of 54. He was scrupulously honest and totally dedicated to his work, and did his duty as he saw it without in any way bowing to the dictates of politicians. He was indeed a civil servant nonpareil.
The second was my guru Dr. KS Sanjivi, who was to the medical profession what my father was to the administrative service, a perfect role model. Ethical and humane to the core, he too never yielded to pressures from administrators or politicians that called for any deviation from duty. I strive to be a worthy son and a worthy disciple. | | |
| DoctorNDTV: What is your opinion about medical training in India? | | Dr MK Mani: We are completely off the track here. Our system of education is what the British left for us. In the years since independence, we continue to slavishly follow that model, while they themselves have experimented and innovated, and gone on to different ways of teaching their students. My contention is that the basic MBBS should be a competent general practitioner. Yet our system of education gives us a smattering of different specialities, but no training whatsoever in handling the majority of sick people. Why have examinations in diagnosing and investigating valvular diseases of the heart, when all we will do in practice is to send the patient to a cardiologist? Why should a candidate fail in his examination for not identifying the exact valvular lesion, when even cardiologists today ask for an echocardiogram or more before they commit themselves to a diagnosis?
All we need is that the general practitioner should identify that there is something wrong with the heart, or the brain or the lung, and then send the patient to the competent person. On the other hand, we need to know far more about how to handle fevers and diarrhoeas, aches and pains, most infections, and of course the long term non-communicable diseases like hypertension and diabetes. The outpatient department of most teaching hospitals, and the general medical wards, would provide the ideal teaching material, if only we would make use of them. We should take our students to the outpatient department and take the first six patients off the bench, irrespective of their disease, ask the students to see them briefly in just ten minutes, and then discuss them fully. In the wards, we should start with the first bed and then go round the ward, discussing the patients who are actually there, not hunt for “teaching material”. If this means discussing patients with fevers frequently, that is what the average GP will see most of, and so it is well worthwhile. Obviously the examination system will have to change. Candidates should not be given heart and lung and nerve “cases”, but should get a similar handful of patients from the outpatient department and from the wards. Ultimately, they will have to pass their examinations, and we will have to teach them what is needed to succeed. If we continue to examine students the way we do now, we will have to teach them in the same way too, and the products of the system will be incompetent both as general practitioners and as specialists.
We need to look at the time we spend on the basic sciences. How much of the anatomy and physiology, the pathology and pharmacology, and especially the microbiology we study in our undergraduate courses is of any use to us in our practice? We could scrap the vast majority of all that teaching, save the time and spend it more usefully. Anatomy should be taught by surgeons and should deal with only the very basics, and physiology should be taught by physicians, as should pathology and pharmacology. Microbiology is largely unnecessary, and the interesting and relevant facts about bacteria and protozoa that make them dangerous to humans are what should be stressed by physicians and surgeons. The undergraduate should spend more time with dermatologists, ENT surgeons ophthalmologists and dental surgeons, who should also demonstrate and teach only that which is within the purview of a general practitioner. The paediatrician should have far more of the undergraduates’ time, but his teaching too should be on how to handle the common problems of children in the community, and the ability to recognise what is too much for a GP to handle.
If a person has the interest and the ability to specialise further, he could apply for and undergo the necessary training, and there too my accent would be on what the Indian specialist is likely to see, and on what can be done in the majority of our hospitals. From that level, a good candidate would know how to get the further knowledge he needs for going into the depths of the subject, with the availability of so much material on the Internet. | | |
| DoctorNDTV: Does the Indian health care system have any problems? If yes, how would you tackle these? | | Dr MK Mani: Our biggest problem is of course the lack of funds. I am surprised that, given that limitation, our governments seem incapable of doing what the average householder in India, also struggling continually with a similar lack of wherewithal, does. The answer is to prioritise, and use existing funds for what is deemed essential. It has clearly been demonstrated that prevention is more cost effective than treatment of many different conditions. Why do our planners not strengthen the prevention programmes? While medical colleges clearly need to keep up with the latest trends in medical care, it is meaningless to scatter CT scans through the hospital system.
I would concentrate on providing basic medical care to the common man. We have some 150 or more Corporation dispensaries scattered through the city. They should be improved and better staffed, and should take over most of the patients now attending the General Medical and Surgical out patient sessions at the teaching hospitals. Patients would get more personalised care with shorter waiting times, and be more able to go to work before or after their consultation near their homes. | | |
| DoctorNDTV: Do you think Indian health websites are useful? Your views about DoctorNDTV? | | Dr MK Mani: I am afraid I have no opinions on health websites. My use of the internet is restricted to tracing and reading articles through PubMed, and on reading some of the journals to which I subscribe. I do not spend time on other web based activities. I was not aware of Doctor NDTV till you asked me to write this, and I am unlikely to spend much time on the Internet even with that knowledge. | | |
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