Pages from a family doctor’s diary

It was the summer of 1968 when I set up my practice in a village called Binnamangala in east Bengaluru. The name of the village was eventually lost amid the rapid development around it, and the area came to be known as Indiranagar. I chose Binnamangala because established areas like Jayanagar, Malleswaram, and Basavanagudi already had family doctors, while this emerging locality had only one and I would be the second.

. Family medicine now is a bit of a dying practice, and I do not blame younger readers for wondering what it is. It looks after different aspects of health — from preventive and palliative care to treating acute and chronic conditions across ages and sexes, performing minor procedures, supporting mental health, and promoting healthy lifestyles. Think of us as gatekeepers of health. I encourage patients to keep home-testing kits for blood pressure and glucose, remind women about breast and ovarian cancer screenings, and advise smokers to get chest X-ray examination and and stay up to date with colon checks in those who have a family history of colon cancer.

. Family physicians are also known as primary care doctors or general practitioners. Unlike specialists who treat specific organ-based illnesses, we provide long-term care — often for entire families — either directly or through referrals. While superspecialists focus on one part of the body, we take a broader view, treating patients in the context of their family history, culture, and lifestyle.

. However, my first consultation in Binnamangala was hardly urgent. A young woman walked in with a packet. She was not sick; she wanted to sell the leftover medicines she was carrying. When she saw I was not interested, she swept them off the table in a huff, and went her way. I sat there wondering: Is this the kind of patient I am going to see?

. Most of my patients came from villages like Appareddypalya, Doopanahalli, Tippasandra, Domlur, and Ulsoor, all within 1 to 3 kilometres. I remember one house call to see a boy with a high fever. In the drawing room, his grandfather sat cross-legged on the floor, rhythmically clapping his hands, with a towel on his lap. I asked the lady of the house what he was doing. She said, “Doctor, that’s how he swats mosquitoes.” The towel was dark with dead mosquitoes. Back then, Indiranagar was poorly connected, dotted with swamps, and overrun by mosquitoes that drove everyone indoors by evening. Few were “brave” enough to move into the new extension, then infamous as ‘Mosquito Nagar’.

.Bengaluru’s Metro mess: Deadlines and delays. A majority of my early patients were poor or from the lower middle class, and a few were wealthy landed gentry. Even the well-off rarely showed it. I am reminded of a middle-aged man who always wore a faded white shirt, a grey coat that had seen better days, and worn-out chappals. I charged him much less than usual, often nothing. He would smile warmly and leave without fuss. One day, as he was leaving, he bumped into a friend in the waiting area. I overheard their conversation — they were sending baskets of grapes to Coimbatore. My ‘poor’ patient was a vineyard owner! From then on, he paid the usual fee; the parting smile stayed the same.

. Human connection

. I’m 83 now, semi-retired, and see fewer patients. If not for my habit of keeping a diary of funny yet insightful moments with my patients, many of these memories would have faded with time. I have turned some of these notes — written in Kannada and English — into two books: ‘A Family Physician’s Life’ (2024) and the just-released ‘Untold Tales From a Family Physician’s Bag’. Family doctors lead interesting lives, and my hope was to share the everyday stories of people’s lives through our lens. We stand at the crossroads of healthcare and human connection. Our roles reach beyond the clinic into homes, where we share in both births and losses within patients’ families. Our rewards come in many forms — from hugs to tears of joy, bouquets, paintings, and, just this week, a generous batch of Alphonso mangoes.

. An example of how far a family tree can stretch in patient care: Long back, a 25-year-old man from Cox Town came in with pain and swelling in his foot. Gout, I diagnosed. Later, he brought his wife, struggling with high blood pressure (BP) — I detected a murmur and my cardiologist friend diagnosed a heart condition. Their son, dealing with BP and obesity issues, became my patient, as did their grandson, who showed early signs of obesity. The consultations branched out when his wife referred one of her sisters from the US with chronic asthma, and another from Indiranagar with anxiety, high BP, and anaemia. Tragically, the latter’s husband, who battled depression, took his own life. Their son, a swimmer, came to me with chronic anxiety. Their daughter was brought in with a Covid-19 infection but sadly didn’t survive. I now treat her husband for borderline high BP. Because of my close bond with them, I was invited to the wedding of a third-generation family member, a bright woman whom I’ve known since birth. To my surprise, I was escorted from the back of the wedding hall to the stage to bless the couple — ahead of their families or other guests.

. Likewise, former Indian test cricketer Roger Binny and his family — wife Cynthia, son Stuart, and now daughter-in-law Mayanti Langer — have been visiting me for years. I met Roger unexpectedly, at a VHS rental shop on CMH Road. I was browsing for cassettes when Binny came in looking for a referral. I introduced him, and now we bond over cricket, golf, and our love of nature.

. Sometimes I feel that our family doctor, Dr Shanbhag, may have influenced me to become one myself. I spent most of my early years in Sagara, Karnataka. It was a town of about 10,000 people. Those were the days of relentless rains and illness — childhood asthma, whooping cough, diphtheria, and recurring fevers, including malaria and typhoid, of which I suffered. I was a frequent visitor to Dr Shanbhag’s clinic and recall him sitting with me through bouts of racking cough. But frankly, I chose medicine not out of any lofty ideal to serve humanity, but because I was good at biology and poor at mathematics.

. When I graduated in 1965, India was at war with Pakistan, and the armed forces faced a severe shortage of doctors. Prime Minister Lal Bahadur Shastri appealed to young medical graduates to serve, even briefly. I served as an army doctor for three years before setting up practice in Binnamangala, and another one in Cox Town.

. Throwback years

. Before the age of ‘Dr Google’, patients often came to us uninformed — which was both a boon and a bane. Still, educating them has always been central to our practice, especially for those of us who started half a century ago.

. There was a widely held belief in the healing power of injections. However, I only administered them in true emergencies — such as a severe asthma attack. I also avoided prescribing tonics, another patient favourite. As a result, many did not return. I often joke that I lost two patients to gain one who appreciated what I was trying to do.

. People also did not believe in paying for medical advice alone. Most assumed doctors earned through dispensing medicines or giving injections. So, a doctor who did neither and still charged a consultation fee — three rupees — was not well received. Had I given an injection, the same patient would have gladly paid double and walked out rubbing his shoulder with a satisfied grin.

. As the middle class grew and people became more educated, their willingness to seek out and pay for professional advice also grew. The 1970s to 1990s were the peak years for family medicine in India. With few hospitals or specialty clinics around, people relied on us. House calls were common. I would visit 3-4 patients within a 10 km radius on my motorbike, with traffic never a concern. However, labs were limited, and diagnostics rarely went beyond X-ray examinations. Technologies like ultrasound, CT, MRI, echocardiograms, and treadmill testing were still a decade or two away. If young doctors today wonder how we managed, we just did.

. Today, a heart attack is treated with an angiogram and angioplasty, and the patient is home in three days. In our time, we diagnosed heart attacks with bulky ECG machines and managed care through a handful of nursing homes or public hospitals. The treatment was often harsher than the illness — patients were put on punishing diets, confined to bed for four weeks, and not allowed to use the bathroom for the first 48 hours.

. Ulcer treatment was no better. Patients underwent gastrojejunostomy surgery because we did not yet know a bacterium — Helicobacter pylori — was the culprit. It took a bold Australian doctor, Barry Marshall, who swallowed the germ himself, got sick, and then cured it with antibiotics, to prove the link. Today, ulcers are treated medically and surgery is rare. Still, some of those patients who underwent such surgery then, return for vitamin B12 shots, which they need because the surgery disrupted absorption.

. In later years, I would miss caring for children. We once did a fair share of practice of paediatrics, obstetrics, and gynaecology, but the advent of specialists has gradually eroded the broad scope of our work.

. Misplaced priorities

. Are we redundant? Far from it. Back then, we saw daily cases of asthma — due to widespread parthenium — along with fevers, diarrhoea, hepatitis, and typhoid. Today, chronic conditions like diabetes and high BP, infections like tuberculosis, mental health issues, ageing-related problems, and adult immunisations keep us busy.

. The problem? Fresh talent in family medicine is hard to come by. Back then, MBBS training was of superior quality, and further study was not essential. Today, an MBBS graduate needs an additional 2 to 3 years of training to become a qualified family doctor. The current education system prioritises specialists, focusing on curative over preventive care. With fewer family doctors, students have fewer opportunities to observe and learn from — and the field also pays less than most subspecialties. Rarely do hospitals have family medicine as a standalone department. The public is forced to turn to crowded, costly corporate hospitals for even basic care.

. Staying updated across specialties requires constant study, and I found myself outdated after just three years. To bridge this gap, doctors like me started the Family Physicians’ Association in 1979 and the Doctors Club in 1983 in Bengaluru. Today, I serve as a mentor to the Karnataka branch of the Academy of Family Physicians of India, advocating for primary care’s rightful place in India’s healthcare system.

. A case study on the critical role of family medicine: One afternoon, a 25-year-old businessman called me from Chennai. He was vomiting, and the local doctor’s treatment wasn’t helping. I asked what he had eaten. “Upma,” came the reply. I told him to get on the next flight to Bengaluru. Back then, HAL airport was active. He came straight to my clinic. I ran an ECG — he was having an inferior wall heart attack. He was rushed to the hospital and went on to live another 45 years, passing away just a few months ago. I suspected a heart attack because his father had one too. I had been by his father’s bedside at home until his final moments. At that time, we had no defibrillators or modern resuscitation tools. That family history helped me sense the urgency behind what seemed like a routine call.

. Lasting memories

. One of my later entries in the diary was about the online world. My colleagues and I were on the wrong side of 70 when the pandemic pushed us into webinars. Not much came of them — only half-cut heads, blurry faces, and indistinct voices. While I have gotten better at it, I still do not find teleconsultations as effective for patient management. Also, it is those little offhand chats during a physical interaction that help carry patients through a bad cold or a rough day.

. Two years ago, a patient from Mangaluru came for a check-up after a long time. After the consultation, he asked, “Doctor, you haven’t asked about my sons!” and went ahead to rant: “They’re useless”. Sometimes, patients also rope us in like family mediators. A businessman asked me to talk to his daughter, who was not keen on marrying. After our chat, she met the next guy privately and said ‘yes’. The father? Still upset. “You met him during rahukalam — bad time!” he reasoned. Fast forward — they married, moved to Australia, and now the father blames the Aussie heat on their rahukalam meeting. Then on a house call many years ago, I was puzzled to find the home facing away from the street. “Vaastu,” the man of the house explained. Thanks to the orientation, he said his business boomed, his family’s health improved, and he even got the ‘wonder’ Maruti car.

. Another insight my practice has given me is how differently people respond to loss. A woman, devastated by her husband’s passing despite my care, shoved me in anguish. Another time, I arrived too late for a house call. But the patient’s wife comforted me: “Doctor, it’s not your fault. It was meant to be.”

. And once, an old man ‘rose from the dead’ to chastise his son for making a scene. My late friend was handling the case. The man, a diabetic, had missed lunch, taken his insulin late, and slipped into a coma from low blood sugar. Believing him to be dead, the family and friend poured milk into his mouth as was their custom, which revived him!

Pages from a family doctor’s diary

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