Indian Journal of Medical Ethics

The inspiration to become a doctor came from Dr A. V. Baliga who performed an appendicectomy on my elder brother when I was 10 years old. The glowing reports I heard about this ethical, brilliant, patriotic and philanthropic surgeon led me to decide to become a doctor. I put in enough effort and became one - not a surgeon but a pathologist.

I started my practice in 1966 in Ghatkopar, a northeastern suburb of Mumbai. I was born and brought up in Mahim, a predominantly middle-class Maharashtrian locality. In those days, Ghatkopar had a predominantly well-to-do Gujarati population. We Indians are not all that broad-minded and the regional spirit is very strong. Maharashtrian patients would prefer to go to a Maharashtrian doctor and a Gujarati doctor would have a predominantly Gujarati clientele. Exceptions to this rule are rare. As a result, I was worried when I started practice. There was one point in my favour: I knew Gujarati well. Also, one of my friends, a consulting physician, Dr. R. C. Khokhani, was my neighbour. This physician friend believed in ethical practice and was broad-minded.

My practice started on a good note. However, I also received feelers that if I gave a cut, my laboratory would be flooded with patients. The offer was tempting but fortunately better sense prevailed and I declined these offers. As a result my practice did not touch the summit straight away. It went up gradually - as a matter of fact very gradually.

Some incidents early in my practice helped me build it on a strong base. A patient with a fever of unknown origin (FUO) was referred to me for urine routine exam, complete blood count, malarial parasite, Widal test, urine culture, etc. I detected malarial parasite in the peripheral blood smear, and told the referring family physician that I would drop the other investigations, thereby saving the patient considerable expense. The patient recovered with anti-malarial drugs. As it turned out, the patient's uncle was a wealthy shrewd and intelligent businessman who, impressed by my sincerity, became a well-wisher of mine.

On another occasion, I was called for a visit to do Prothrombin time of a woman. I found that the patient was a widow who lived alone, in a small room under a building's staircase. She did not say a word but I decided to skip my visit charges. The lady mentioned this to her doctor, Dr. Bhogibhai Shah, who became a great friend of mine and started referring all his cases to me. Because he was a leading practitioner in his area, my own work soon increased.

Honesty and integrity pay in the long run. If you get a urine sample for culture and antibiotic sensitivity (ABS) and there is no significant growth, you can report this and lose the charges for ABS. Or you can do the sensitivity and earn a little more. However, people have native intelligence and judge you correctly before long. Those convinced of your uprightness never leave you, and also bring more patients. This more than offsets your temporary losses.

If in a case of FUO, the urine showed the presence of many pus cells, I would suggest to the referring physician the possibility of it being a urinary tract infection and ask him to reconsider the necessity of investigations like Widal.

In a country where some patients are worried about earning enough to buy rations next week, cost is a very important issue and we should try to cut down on expenses as much as possible. If you explain your actions to the patients most of the time they appreciate it and become your life-long fans.

At times some hypochondriac patients come to you directly and ask for many investigations. If you talk to them, make your diagnosis and perform only the relevant investigations, you are doing good both to the patient and to yourself. There are a hundred ways that you can help the patient - all you need is to be empathetic. At times, I have been called for a visit for a blood test, I have found the patient normal - either he was not ill to begin with or he had recovered. Under these circumstances, I have come away without doing any tests and not even collecting my visit fees. Many readers are likely to say I was overdoing the act of a good samaritan and was not practical. They have a right to their opinion but the trust and respect I have earned out of such actions has to be experienced. It cannot be described on paper.

In February 1968 - about two years after starting practice - I attended a discourse by Sri Sathya Saibaba at Chembur. He exhorted the audience to render service to fellowmen. "If you can't see God in your neighbour how can you see him high up in heaven?" he asked. Taking his advice seriously, from April of that year, I reduced my charges by 25 per cent to 33 per cent and it has stayed that way for many years. True, I could not modernise the laboratory and introduce newer investigations but we were able to perform the basic investigations at very modest charges. This action again is a personal one and not everyone will agree with me. But I did what was best suited to my temperament and made me happy. After all, as the sage Yadnyavalkya told his wife, the sage Maitreyi, "A person does everything to please himself. Even if he loves his wife, it is because that makes him happy, and not for the sake of his wife."

Lest this sound like I am an angel, let me confess that I have made enough mistakes in my life - mistakes of both commission and omission. I must have paid a price for them. Over the years, I have tried not to repeat the same mistake - but perhaps made new ones! I remember one incident during the very early part of my practice. When an electricity failure prevented me from doing a particular test properly, I foolishly decided to give the report all the same. I thought I could get away but was caught red handed. I apologised profusely and learnt my lesson. Since then (to my knowledge and as far as my memory goes) I have not committed any such errors - I am aware that my memory may not be strong enough.

By and large, patients have been forgiving towards me whenever there was a mistake on my part. Whether you call it luck or goodwill which made patients take a lenient view, I leave it to your judgment. On my part, I have always tried to overlook my patients' faults for a simple reason - I see myself capable of committing all of them and some more.

About regional or language bias, I must admit that it took me some time to look upon every patient with an equal eye, irrespective of language, caste or creed. It's tough but becomes easier as you continue to practice, and finally it becomes your second nature. The results are heartwarming to be experienced not to be talked about.

At the end of 36 years, I have a decent, but not a very large practice. Financially, I am just an upper middle-class person. No luxuries for me. I am a stranger to the five-star culture for the simple reason that I can't afford lt. Am I a failure in life? The answer will depend upon your point of view. I am painfully aware that life is too complex and there are no definite answers to such questions. There are many grey zones. I myself am not clear about the mystery of life, and have decided not to get involved in scholarly discussions and clever arguments.

I decided to take the simple path of being good to people and to help them in little ways, within my limits. The results have been gratifying though not sensational. I have taken an interest in promoting blood donation and eye donation, and in helping the disadvantaged. Such activities have been possible because of my patients' generosity; I devote my energy for such work when there are few patients. It keeps me busy and happy and there is no time to worry about less practice. Moreover, this has given me innumerable friends all over the country. At least my mind does not have an opportunity to become a devil's workshop. I also do not have to make efforts to keep referring physicians happy. They are my friends whether or not they refer patients to me. This detached attitude gives peace of mind.

I can hear it coming: "It's all right for Dr Pai to talk philosophy since he has not taken a big loan to start a lab and does not have to repay interest and loan installments." I did take a loan when I started my practice. It was small by today's standards and I was able to repay it comfortably.

Or you might say: "The conditions are worse now; one cannot survive unless one falls in line with others." All the good and not-so-good practices were prevalent in earlier years too. I too was told that I wouldn't survive with a clean practice. I have survived. That part of the day when I am trying to help others - either professionally or socially - I feel very alive.

Finally I would like to practice my favourite shloka from the Bhagavad Gita: "Those who partake of the remnants of a sacrifice (those who help themselves after helping others) are absolved of all their sins. While those who cook for themselves (selfish people who think of themselves) verily eat their own sins."

What is ethical practice? The answer is easy. Do not do unto others what you would not have others do unto you. Follow this golden rule not only in your medical practice but in every sphere of life and you won't go wrong. Going one step higher, do good even to those who wrong you, and you will emerge happier and more evolved. This is a fact of life. If you treat medical practice as a profession - as a noble one at that (vaidya narayanhari) - what you do, how you practise and how you live are more important than what your competitors do. As a matter of fact they are your colleagues. Treat them as such and you will see a sense of peace and serenity descend on you. In the final analysis, what all of us want is peace of mind.