I.
I am not entirely sure how common it is to get so bored on vacation that you voluntarily return to your old workplace and accidentally start practicing medicine. Probably not very. But recently, thanks to certain flight disruptions in Dubai which I do not need to elaborate on, I found myself stranded at home in India far longer than anticipated.
I was going stir crazy. My parents, who maintain a baseline level of mild disappointment that I ever emigrated, suggested I go informally shadow the psychiatry department at my old hospital. "See what psychiatry is like at home," they said. "Maybe you will learn something."
I was already experiencing a profound disillusionment with psychiatric training in the UK, and my previous exposure to the Indian equivalent was highly idiosyncratic. During my internship at this same teaching hospital, my psych rotation had collided perfectly with the initial Covid lockdowns. Outpatient services were entirely shuttered. Any ward patient capable of bipedal locomotion was immediately discharged.
I spent those two weeks checking vitals in the female suicide ward and conversing with a very pleasant schizophrenic gentleman who had a hyper-specific obsession with light fixtures. He had been living on the ward for a decade (no next of kin and nowhere to send him after discharge except to the streets, and then the cops would drop him right back on our doorstep) and had somehow become a genuinely competent amateur electrician. I personally witnessed him replace multiple malfunctioning bulbs. He did very solid work.
So when my parents broached the idea of visiting, I agreed. It was mostly curiosity mixed with a bit of nostalgia. That intern year was almost certainly the worst year of my life, but people assure me this builds character. I thought it would be nice to show up as a glorified medical tourist and see what my Indian counterparts were up to.
II.
After pulling a few strings, I arrived at the outpatient department. It was exactly as crowded and poorly ventilated as I remembered, though stopping just short of actual asphyxiation. I located my point of contact, a second year postgraduate trainee, and optimized my posture to fit onto a partially vacant seat without crushing a colleague's purse.
The initial wave of patients presented with the classic poorly differentiated psychosomatic complaints that are the norm in developing countries. When your native language lacks a dedicated lexeme for "depression", psychological distress predictably routes itself through somatic channels. It manifests as a vague stomach ache or random peripheral tingling. We prescribed pregabalin, gabapentin, or amitriptyline, depending on mood, handwriting and the current phase of the moon. The patients were generally just thrilled to have seen a doctor at all.
Eventually, more interesting cases arrived. Because I was actively peering over my colleagues' shoulders, they generously suggested I take a crack at handling some of them myself. Sure, I thought. Why not?
I quickly came to regret this decision. I have a laundry list of complaints about British psychiatry, but I was not quite prepared for the reality of the Indian clinic.
First, the documentation varied from poor to completely nonexistent. My once finely honed ability to decrypt physician scribbles into valid pharmacological interventions had totally atrophied. Furthermore, the patients were terrible historians. I do not mean this as a moral failing; it is just a downstream consequence of local selection pressures. Government hospital care in India is free. This strongly selects for patients who are overwhelmingly poor, undereducated, and often separated from the physician by a formidable language barrier. Add the baseline communication difficulties of psychiatric patients, and taking a history feels like trying to reconstruct Herodotus from a copy that fell into a blender.
But it was a good challenge. I wanted to prove I could still read between the lines.
Almost immediately, I encountered a truly spectacular case of polypharmacy. We had a lady on lithium, valproate, and approximately a dozen overlapping medications. When were her lithium levels last checked? My best guess is shortly after the universe discovered helium-helium fusion. Thyroid function? The only confirmed fact was that she theoretically possessed a thyroid gland. She had coarse tremors, which could have been caused by literally any combination of the chemicals in her bloodstream. I consulted a senior resident, and we agreed to slash the regimen down to the bare minimum and demand some actual blood work before she returned.
III.
The cases only got weirder. Consider the medical tourist from Bangladesh. He had early onset schizophrenia, but he was relatively stable on his current regimen. Why had his parents brought him across an international border? They claimed they could not source brand name amisulpride in Bangladesh. A quick Google search suggested this was highly improbable, but here they were.
To make matters worse, the family was incredibly vague about his actual medication list. Besides his known antipsychotics and thyroxine, he apparently took a mysterious pill every morning. What was it for? They had no idea. What was it called? A mystery. What did it look like? It was a small tablet.
It is a miracle I did not tear my hair out. After another consult with the attending, we switched him to a more easily sourced variant of amisulpride and advised the family to stockpile six months of it before going home. As for the mystery pill, we essentially applied Chesterton's Fence to psychopharmacology. Chesterton's Pill was deemed structurally load bearing for this mixed metaphor. It clearly had not killed him yet, so we left it exactly as we found it.
My final patient was a six year old boy. His mother presented a constellation of complaints: he was hyperactive, liked staying up late, and lacked focus in class. It looked like a textbook case of ADHD. But given his age, I thought it was worth digging deeper. I learned he was functionally illiterate, possibly dyslexic, and his teacher had explicitly told the mother to get him evaluated.
Then the mother casually mentioned his "fright."
During normal daily activities, the boy would suddenly freeze. He would look incredibly distressed, and then he would get the human equivalent of the zoomies. He would sprint around the room. After the running stopped, he would approach his mother or older sister and bite them. Sometimes he bit hard enough to draw blood. He could not explain why he did this or what he experienced during the episodes.
I looked at him again. He was a perfectly normal, fidgety kid missing a few baby teeth. There were no obvious signs of hydrophobia, though I mentally filed rabies under "highly unlikely but technically possible."
I had absolutely no idea what I was looking at. I debated the case with a colleague. I suggested ADHD comorbid with Oppositional Defiant Disorder. My colleague argued against ODD because the kid was perfectly well behaved in the clinic. I countered that ODD typically manifests at home first, and is usually restricted to familiar adults. Then I floated the idea that his bizarre running and biting episodes might be complex partial seizures.
My colleague theorized it was an intellectual disability or learning disorder, perhaps part of a broader genetic syndrome. I shrugged. He was probably right. There might be a perfectly neat clinical label for this waiting in a dusty textbook somewhere. Or perhaps this is just another reminder that our diagnostic categories do not actually carve reality at its joints.
We eventually compromised. We prescribed clonidine to manage the behavioral symptoms and cover ADHD to a limited extent, then referred them to a clinical psychologist and an ENT specialist for good measure. I had spent more time on this one child than on my previous three patients combined, and the clinic was simply not built for that level of investigation.
I still have no idea what was actually wrong with him.
To avoid ending on a downer, I was happy to hear that the amateur electrician had, in fact, been discharged sometime in the past five years. None of the current trainees had heard of him. Right after I'd "treated" him? I'll take the credit, if no one's looking.
My parents, for what it's worth, were pleased I'd made myself useful. They remain cautiously optimistic about my eventual return.
I remain unconvinced, but I did find the pace to be California Rocket Fuel compared to my usual fare. Who knows? Maybe I'll get bored of making ten times the money, one day.
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Notes -
Very entertaining. I will ask, however, where you may stand ethically, writing publicly about such patients? I'm not sure of the standards.
It's a very good question, and one that has generated a lot of discussion over the years. Self_made's milieu (sorry I'm too boomer-core to actually tag you but I imagine you'll see this) is likely less intellectually masturbatory than mine, part of that is training locations, part of that is also just how things are with the way healthcare and the world has changed.
As physicianing becomes just a job, and the role is more maligned than deified, the idea of those special obligations (and privileges) we used to have goes away. This may be a bad thing, but it is.
Some thoughts.
Hypocratic Oath - It's dead. Many schools have gotten rid of it in general or replaced it with woke screeds. While ethics is taught, it's often head cudgeling "professionalism" ethics. Thinking abstractly about moral pulchritude is gone. I usually blame everything on wokeness, and will do so here.
Official ethical guidelines are often shockingly self constructed or not actually enforceable. The Goldwater rule is pretty famous on this front. This is further complicated by the fact that much of practical ethical behavior is locked into a complex web of federal and state laws that are generally not actually explored by the legal system and can be mutually incompatible (ex: mandatory report this is one jurisdiction but CAN NOT in another jurisdiction, but what happens if care crosses state lines?).
A classic question like "do I report the alcoholic school bus driver" is fraught as hell and younger generations have basically been taught not to engage with the question and to report to risk management.
Basically ethics has been beaten out of the curriculum.
Engaging with your specific question -
Oliver Sacks famous wrote about specific patients. Ish. He also famously made a bunch of stuff up. Conveying the meaning without the details (and with a mild to moderate to sometimes excessive level of alteration and fabrication) is one way to tell the story. Hat was written in 1985 - it's an old argument.
I am unsure how much Theodore Dalrumple fuzzed his patient stories, but he is considered politically unpopular because he illustrated reality as it is. Life at the Bottom is important because it's real, regardless of the reality of the specific patients, but if they are real specific people the value still makes it worth sharing.
For me - when I've written my patients stories here and on our predecessors with my old handle, I generally tried to write about patients whose stories are common or obscured enough detail that many docs would say "did this happen to me?"
This isn't to say I'm judging self_made. Writing to process training is a time honored and important way to not fucking go crazy and become a bad physician, especially for someone whose story has taken them to a place where the other ways of processing are less available.
India is a big country, with many Indians (citation available on request). I genuinely don't think that you can uniquely identify anyone I've ever written about, barring myself. A schizophrenic man from Bangladesh? A young kid with behavioral issues? Victims of polypharmacy? Good luck narrowing that down to less than a thousand people.
Interestingly enough, this scenario is pretty explicitly addressed when it comes to the ethics curriculum and guidance for British doctors. I would be expected to warn the patient to desist from dangerous drinking, and if they disclosed drunkenness on duty or continued to drive, I would be legally obligated to report them to the DVLA so that their license gets yanked. This applies doubly so for bus and truck drivers (I refuse to call them lorries).
https://www.bevanbrittan.com/insights/articles/2017/patients-fitness-to-drive-and-reporting-concerns-to-the-dvla-dva/
There is a lot of bloviating about ethics here. UK medicine is obsessed with the topic. It was half the grade on the exam that gatekeeps most postgraduate training.
There exists a massive top-down push to reinforce the image of doctors as a noble, duty-bound cadre of esteemed professionals. That self-conception is gradually fraying in the younger generation, because we sure as hell aren't paid or treated like we're special.
I figured the UK had a culture of ethical handwringing but that you might be spared it due to location.
Like I said not criticizing you for your post however we see one of the Common Points which is that even without identifiable information patients can read it that way, and it does generate consternation and distrust at times. Not necessarily a reason to not do it.
With respect to the bus problem - don't report so that the guy feels comfortable opening up and can get treatment and harm mitigation is often selected as the answer.
I think, on a empirical basis, that this effect is insignificant. Med influencers make significant amounts of money and acquire fame by attracting patients using case reviews, and I don't think Scott has ever suffered for it.
Would be ranked very low here in the UK. The best answer would be to try and warn him to cut down on drinking (if he just happens to be an alcoholic but doesn't disclose driving while drunk) first, and then if he persists or outright admits to drunk driving, the doctor is to inform him that he's duty bound to report to the DVLA.
I don't know about elsewhere but Med influencers are widely mocked and attacked, one guy at Mayo just had his career tanked. Some of this is probably jealously but with the exception of saint Glaucomflecken most medfluencers are trash.
Also I believe Scott lost his job and had to start his own business because of his writing.
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