Dr Farokh E Udwadia, arguably the country’s best diagnostician, speaks on his book – “The Art of Healing versus Technology and Playing God”
– Interview by Bachi Karkaria
He is a fervent, and eloquent, evangelist for the art of healing as distinct from the science of cure, a continuous student of the humanities. This arguably accounts for his reputation as India’s best diagnostician. He is the colossus of Breach Candy Hospital. When he walks through the corridors of Parsi General, people reverentially stand up. He has mentored thousands as professor of Medicine at JJ. He is perhaps the last of the legendary physicians. And he is as passionate about Mozart as about the symphony of the human body. Interviewing Dr F E Udwadia is equally elevating. Excerpts from a long conversation.
KARKARIA: You are quite the Renaissance man. The importance of the humanities recurs in all three of your ‘lay’ books, including the imminent ‘Tabiyat’ – Medicine and Healing in India And Other Essays (Oxford University Press).
Dr Udwadia: The humanities generally give you a wider perspective. And if you want to know exactly how a human being works, you will be much better off by studying them. Read poetry, literature, and you get a good idea of what suffering is. If you can appreciate your patient’s suffering, your response to his disease is much better.
It’s the most important of the arts. Music unquestionably helps the healing process. Soldiers in the World Wars convalesced better. Now it is being scientifically understood how it acts on certain parts of the brain, which perhaps control the immune response of the body to disease. Personally, it gives me a feeling of relief, of satisfaction, ennobles the spirit. Great music is a great blessing. I’m passionately fond of it.
So let’s talk of your passion for the ‘art of healing’ as distinct from the science of cure.
Medicine is an equal measure of art and science. Curing is science intervening to get rid of a disease or infection. But healing involves the whole mind-body complex. Important distinction. There are conditions which you cannot cure, but you may be able to heal a fair amount of anxiety and discomfort. Not uncommonly, the problem is more in the mind, And that is where the art of medicine comes in. Sometimes you cure and you heal. Sometimes you cannot cure, but you can heal to some extent. Sometimes you can heal when there is no real physical illness to cure.
What’s the missing link in medicine today?
Medicine has lost its path because it’s so enamoured of machines and technology. The doctor relates more often to these than to the patient. He’s making his diagnosis in the laboratory rather than at the bedside.
So, is the famed ‘bedside manner’ now on life support ?
Not yet, but it’s really neglected. Lack of empathy is the one reason for the decline in medicine. Only when a patient is listened to at length, and examined carefully, can there be the doctor-patient bond which lies at the core of medicine. This is particularly so in a very sick patient, who almost has an antenna which senses genuine empathy. When that happens, there is faith, and it’s amazing how much faith can heal. Empathy can make the difference between life and death. He feels ‘My doctor says I’m going to get well, I believe in him, and I will get well’, and that influences the body. No one knows exactly how, but it does.
We can’t wish away technology.
No, but we have to keeping stressing that there’s another, older side to medicine. After all, can science and technology ever be able to take a good history from a patient? Or take the place of a good physical examination? No! It’s important to realise that your eyes, ears and hands can sometimes detect what no technology can.
Tell us more about deploying all five senses. You wrote about listening to ‘recognise the blowing diastolic murmur of aortic incompetence’.
You’d miss the diagnosis of very early Parkinson’s, if you didn’t look at a patient’s face, or notice the way he walked into the room. Or a child with high fever may have just a few purpuric spots, blood spots, which could point to a serious illness.
In complicated cases, we need a GP to point to the right specialisation. But the species is almost extinct. Today’s GP writes out a prescription even before you’ve finished describing your symptoms.
Sadly, true. The old-school GP asked probing questions, looked at you, listened, stood by you. When specialisation started, those great individuals were great general physicians too, well-versed in the whole gamut of diseases. Medicine has become compartmentalised, that’s the sadness of it. The heart specialist looks only at the heart. He doesn’t factor in the body in which it resides. It’s important for a specialist to be aware that beside the brain, heart, kidneys and lungs, there’s a human being. You can’t treat merely the organ.
What are the lacunae in today’s teaching?
Inevitably, there’s more to learn, so much more time must be spent in classrooms. Genetics is an important allied science now. Biochemistry and biophysics. So there’s little time left to spend with patients. As students, we learnt most in the wards.
How does the ward teach more than the classroom?
Medicine is learnt at the bedside, never from books. You could study a huge medical tome on medicine, and be able to answer everything from it. But would that make you a good doctor? No. Because you have had no contact with the patient. Every patient is different. That’s the most important thing. His response to the disease will depend on his genes, constitution, mental state, sense of well-being and strength. Even his geography. Moreover, you need to take a good history astutely because people of different temperaments present their symptoms quite differently. So, many variables have to be taken into consideration. So, that’s why your best teacher is the patient; the more information, the greater your knowledge. Of course, you keep improving as you realise, ‘this is where I went wrong, why I went wrong, what should have been done’.
In your 2004 convocation address at BHU, why did you include charity among the hallmarks of a great physician?
There’s a quote: ‘Don’t enter the temple of science with the heart of a moneylender.’
Tell us more about medical ethics.
Beneficence is the most important, doing good to the patient. That’s not limited to your medical intervention. It extends to his inner being. That is where humanism comes in. Second is patient autonomy — which often conflicts with beneficence. So good medicine is a balance. A young man comes in with severe pneumonia, blue and breathless. But, because of his fear of hospitals or doctors, he refuses to have the breathing machine he requires urgently. Without it, he’ll die in a short while. I try and explain, but he is adamant. Patient autonomy says he doesn’t want it, but beneficence tells me if I want to do good to this patient, to the point where I might save him, he needs the machine.
How did you convince him?
I didn’t. I just asked the doctor to sedate him immediately, intubate and ventilate. He recovered after a fair amount of struggle because we had wasted those precious minutes, by which time he was almost pulseless and pressure-less. He survived. In a critical situation, beneficence prevails.
But when it comes to a chronic patient, say with cancer, and he’s absolutely against chemotherapy, I tell him, I cannot promise that it will cure you, but it will certainly extend your period of quality living. I ask him to think it over, discuss it with others. If he returns as adamant, I will respect that.
In ethics, you’ve included justice.
It’s doing the right thing. Sometimes it is not possible to do exactly the right thing. Then you do what is the least wrong. At the JJ we had a tetanus ward with nine beds and two breathing machines. Sometimes five or six people required one simultaneously. Do I give it to those who are most ill? But, how do I know that those less ill today won’t become more ill tomorrow, because this is an acute disease?
Isn’t tetanus always fatal?
Even, with very severe tetanus, people can live. We started this ward and we (that is all my boys and girls working round the clock) brought down the mortality from 100 per cent to almost 18-19 per cent.
In your decades of practice was there a ‘Eureka moment’, an epiphany?
All I can say is that you are often taken by surprise. You’re thinking along a certain line, and you find you were wrong. But the important thing is that you must admit it. I’d tell my students at JJ, ‘After you’ve written the patient’s history and the findings from your examination, add what you think is wrong with him: One. Two. Three. So, when all the tests have been done, and it turns out different, you can’t fool yourself’. If you don’t admit it, you’ll never learn.
Is death the ultimate mocker of medicine’s hubris?
No. Is there any other certainty in life? Death is the only certainty. So you have to take it axiomatically. Unfortunately, modern medicine, very often, wants to fight death to the very last. Ivan Illich, a professor of sociology in Mexico, wrote a fantastic book, Medical Nemesis I made it compulsory reading for my registrars at JJ.
But isn’t it tempting to play God?
Oh no. If you do, you never know where to draw the line. You must do whatever you can within the realms of reason; that comes with experience. You do not want to prolong the act of dying, but neither can you can you write off the very ill patient. The more you live as a doctor, the more you realise that people you thought were going to die sometimes get up and walk out of the hospital, and the one you thought was almost certainly going to live, doesn’t. That’s the uncertainty of life, and the uncertainty of medicine too.
Your views on euthanasia are conservative.
Active euthanasia — giving something to a sick patient with the express purpose of killing him — is to me morally wrong. Respect for life is our basic tenet. A great man was trying to sum up the essence of a doctor’s ethics. Then one day he chanced upon a beautiful sunset. He wrote, ‘Suddenly the words I was struggling for struck me. They were ‘reverence for life’. That was Albert Schweitzer, a great, great doctor who spent his life in an African village looking after really ill people, with very little equipment. He said, if you have reverence for life, then you’re good, kind, truthful; you have empathy.
Is your most difficult moment telling a patient that there’s no hope?
You don’t ever say that, not in India. Even if he’s dying, he will not want to talk of it. And, I personally don’t see the point of it. A patient feels, ‘I know my illness has reached a stage where I’m going to die but I just might live a little longer than everyone thinks.’ Why should I extinguish that faint glimmer of hope? Of course, I’ll tell the whole truth to the relatives.
But, a very few patients have discussed this at length with me once they know the end is at hand, and it is a fascinating what they feel, and say. They ask questions, to many of which you have no answers. But whatever you reply must be something that uplifts them, never disturbing.To ‘What is there after death’, I’d rather say ‘It will be better than what is here in life’. And that’s what I honestly feel.
You believe in a life after death?
I do. No one has come back from the dead and told us about it, unfortunately. But for me it’s a deep belief. That there’s some other power who’s perhaps directing us. And that power will continue after death.