Clinical Practice or Research

Last week's issue of the Lancet carries a profile of Dr Michel Kazatchkine, the president of the GFATM.It starts thus:

"In 1983, Michel Kazatchkine was a clinical immunologist at the Hôpital Broussais in Paris, France, when he was called to see a French couple with unexplained fever and severe immune deficiency who had been airlifted home from Africa. This man and woman were the first of many AIDS patients that Kazatchkine would take care of in the coming decades. There were no effective antiretroviral treatments available, and the couple lived only a few months on the ward before dying. “Those were difficult years with patients dying every day on the wards”, Kazatchkine recalls. Much of his time, he says, was spent providing end-of-life care, consoling patients, “and holding their hands when they were dying”."..............

And goes on about his early days. Dr Kazatchkine says he wanted to do something in hematology or nephrology while in medical school as "those were the fields you could really work on to study the pathogenesis of disease"

No comparisons really but thats quite the thought that occurred to me while I mulled between an interesting but not so lucrative endocrinology and ...what everyone told me to take- obscenely loaded cardiology.

It is sad I almost developed an abhorrence to surgery after I finished my postings at the department of surgery at BJ. Its the people who make an institute...and after getting a taste of the megalomaniacs at SGH, I told myself- "I dont want to be like these guys"
That premise was flawed, I realize in retrospect, as I was confusing my dislike to the people whom I saw practicing the subject with my feelings to the subject itself. I didn't want to make that mistake while choosing my subject of specialisation as I did love cardiology, but whatever practice of cardiology I have seen thus far makes me distraught and feel hopeless....and it was not very different this time last year when I was on the hot seat of my career.I am glad I have passed that crossroad unscathed, without regrets at being a fence sitter. I seemed to like most subspecialities of medicine. Not my fault really.But you can really practice a subject just the way you like to if you know what you want of it.You dont have to fit in moulds.Thats need based practice. Its sad that this can work to either good ( Paul Farmer) or bad( Ruby Hall Clinic) effect.

As long as I can do what I want to do, I think every subject has its utility/ charm. It is sad that some fields are not as monetarily rewarding as others.

My logic: If I can do what I want to do , and yet have the money for an occasional indulgence, and be able to pay for a comfortable life to someone who may choose to be dependent on me- I can do that only in what way I am choosing to follow now.

Coming to the original point: The Dr Kazatchkine thing.Bench work research or clinical work? ( I tend to drift off,na?...but then I think of it this way- Cardio= Clinical practice; Endo/hem onc = research )

Its disheartening to have this dichotomy. Why not both?

Bench work research( non existent in the place I might have ended up in) means knowing the guinea pig chordae tendinae and where to inject the ASOs to EF2 in its left main artery better than recognizing post wall MIs in a clinical case.The best chapters in Harrison are the ones in Endo, hem/onc. The Nobel prize in health related fields is awarded not in medicine but in physiology. Harrison 16th seems more and more like a book of pathophysiology than clinical practice. I used to think OTM was more clinical. But I guess, the Brits realized that if you cant beat the yanks, join em!Thats the way the world is going.We owe this to Drs Khurana and Fred Sanger and to the countless people who sit hunched over their elbows in labs, with the temerity to ask "Why", the ingenuity to frame a hypothesis, and the industry to put it to test in real time.Where will they find the time to see a patient. They have but one life , with just 24 hrs to the day.


Clinical work only is like the mayhem at KEM - overwhelmingly fantastic variety of cases but no audit! If only we showed the world what we manage!!It is also what one would refer to as , variously in other forms, private practice, GP giri,MOship. Not really bad.....but, .........

where's the music.

Some of the best clinicians in the world probably died/retired from practice from Govt medical colleges in Chennai, Solapur and Pune.They could pick a CP from a distance or a CTGV from history alone. They could manage complicated rheum cases with whatever little armamentarium they had to diagnose and treat, but they never kept note of how many they were treating, what were the parameters, what were the determinants of outcome.Even people in Mumbai( a certain Dr Medhekar) didn't know of their abilities( "lousy village docs...they prescribe, Sai baba treats")...how would the world ever know.

If I wanted to do both research work and good clinical practice....and risk not being a nut entirely.


" How do you know what you are going to do, until you actually do it"
---- Holden, in Catcher in the Rye