The stethoscope is an instrument that is used for listening to sounds produced within the body. It is particularly useful in ascertaining the condition of the heart and lungs by listening to their action. In fact, it is an instrument that a doctor can hardly do without. However, in lighter vein, I wish to describe how junior medical students at least during our time, used their gleaming new stethoscopes for "extra-clinical" purposes. The most junior male freshmen used long bones in a human skeleton to impress teenaged schoolgirls at bus stops, and for that matter, anywhere outside the four walls of the Medical College. But they later graduated to a stage when the femur (or humerus) they carried with them, was replaced with the newly acquired stethoscope. Little did they realise then, that they were only displaying publicly, their lowly rank in the medical hierarchy. The French physician René Théophile Hyacinthe who invented the stethoscope in 1816 would be turning in his grave if he knew all this!

When the total ban on private practice by government doctors came into effect in the late sixties, the majority of specialist consultants serving in major government hospitals opted for early retirement and went into full-time private practice. One of the worst affected by the exodus was the Colombo Group of Hospitals where the most senior clinicians were then serving. It was a serious setback not only to those institutions, but also to the Colombo Medical Faculty. Medical students who were junior to us thus lost the opportunity of being taught by some of the best clinical teachers that we as medical students were fortunate to have.

Among the clinical consultants whose services were lost to the poorer patients and medical students were Drs. P. R. Anthonis, Noel Bartholomeusz, D. F.de S. Gunawardene (surgeons), Ernie Peiris, D.J. Attygalle, W. Wijenaike (Physicians), Stella de Silva, E. H. Mirando (Paediatricians), A. G. Muthuthamby, A. M. Mendis (Obs/Gyn) to name a few in the major clinical specialties. This is not a complete list by any means, but they were all household names in that era.

Government Doctors and Private Practic

A few years later, following continued agitation by the two major doctors’ trade unions – the Government Medical Officers Association (GMOA) and the Association of Medical Specialists (AMS), private practice for consultants was restored under certain conditions. To cut a long story short, strict enforcement of rules under channeled consultation practice ran into problems resulting in a "free for all" situation where almost every government doctor, specialist or not, were engaging in some form of private practice. In the absence of any strict guidelines as to who was entitled to private practice and who was not, even doctors in the preventive sector who didn’t have the advantages of those who served in curative institutions started doing what is commonly referred to as "locum practice".

Under that system, general practitioners who wanted to take a weekend or an evening off, called in public health physicians who had jobs with a five-day week and regular office hours to "hold the fort" in their absence. Apart from the small but useful supplementary income, this category of doctors had other incentives to be lured into "locum" work. That government doctors engaged in private practice when off duty is public knowledge now, not an open secret any more!

It was at a time when I was attached to the Health Education Bureau that I too decided to get back to clinical work in a very limited manner, making sure that such part-time work did not interfere in any way with work in my regular full-time job. After such a long lapse, it was a major shift back to the clinical scene and direct contact with patients. Apart from helping myself, with this action, I was also able to help out a few of my friends who were well established in Family Practice (also called General Practice). Thus, some time in the early eighties, I first became the regular "locum" to my batch mate Dr. H. N. Wickramasinghe, who had his Dispensary and Surgery at Hanwella. Mainly due to the difficulty in traveling, I later worked regularly for Dr. T. T. Kasturiratne who is a specialist in dermatology, but had a family practice at Maharagama. On a less regular basis, I also worked for Dr. Gamini Walgampaya at Wellawatte and for Dr. Nalin Jayatunga at Kohuwala.

While Dr Wickramasinghe’s patients came mainly from the rural villages in and around Hanwella, Pahathgama, Kosgama and Kaluaggala, Dr. Kasturiratne’s patients were from the more urban areas in Maharagama, Nugegoda, Kottawa and Pannipitiya. As Dr. Kasturiratne had to see patients in his own speciality at some leading private hospitals in the city, he needed my services on a very regular basis during evenings and on weekends. As to be expected, a large proportion of Dr. Kasturiratne’s patients came with skin ailments. Quite naturally, I tended to follow his regimes of treatment for common skin disorders and in the process, I too learned a lot and gained practical experience in treating patients with dermatological problems.

Dr. Kasturiratne also had a small laboratory where a qualified Medical Laboratory Technologist (MLT) did simple blood and urine tests. As it is the doctor who has to order such investigations and draw samples of blood, I too soon got back the needed skills not only in inserting a needle into a vein to draw blood, but also to administer both intra muscular (IM) and intra venous (IV) injections. On auspicious days, it was common to see many parents bringing in their little daughters to get their ears pierced so that they could wear their first earrings. It was amazing to see how skills learned during five long years of rigorous training but had become rusty through disuse, could come back almost naturally, with just a few days’ practice.

Clinical Skills and Continuing Education

I always believed that even a public health physician should have the ability and confidence to treat a common medical disorder, clinically diagnose a more serious condition and make a referral when necessary, or even to give First Aid in an emergency. Such situations (where the "doctor in the house" is called to action) arise in day-to-day life when a family member, neighbour, friend or relative falls ill. It can even happen in a flight during air travel, if the "non-clinician" happens to be the only doctor in the cabin in the airplane. It would require more "guts" to watch a fellow passenger dying without any medical attention at all, than to fumble your way through (if that be the case) in volunteering to provide whatever assistance is possible.

I was able to keep up with knowledge on new drugs and those in common usage mainly by reading journals and attending continuing education programs conducted by professional associations. Quite frankly, l was also able to gather valuable information from the many Medical Representatives who dropped in regularly at the GP’s clinics/offices to promote their own brands of drugs. In the process, I even struck up lasting friendships with some of them!

Part-time Patients – Full-time friends

It is not ethically correct to divulge names of patients that I came to know in my part-time family practice. Some of them have become famous having excelled in their respective fields of work. I can count among them, quite a few architects, engineers, administrators, journalists and even popular singers and film stars who are well-known figures in Colombo society today. What is most gratifying is that through personal contact over the years with their parents and relatives, I have come to know that some of my youngest patients are today doing extremely well in life as grown adults both in Sri Lanka and in other parts of the world.

Follow-up of Patients

To me, my part-time work was not merely a job that brought in remuneration. I often went out of my way to follow up patients that I had referred to the major hospital in the area. Unlike the regular GP, due to the part-time nature of my work, I had much fewer patients to deal with. Thus patient follow-up was conveniently done, particularly as my own place of residence at that time was very close to the Colombo South Hospital to which the more serious patients were often referred.

Executive in Distress

There is a little story that I will not forget easily and well worth recalling when writing about my work as a part-time family practitioner. A middle-

Part-Time

aged male patient was brought in very late one evening when we were about to put up shutters for the day.

He had laboured breathing and a noisy wheeze. But despite his apparent distress, he looked smart and was well dressed. At first sight, even a qualified doctor would be inclined to think of the typical asthmatic that is regularly brought in to a doctor’s room with the same symptoms. However, a little bit of the history ascertained from the accompanying family members, often make the doctor think twice before coming to any conclusion regarding a probable diagnosis.

In this case, the patient’s wife kept telling me in fluent English that her husband had never had such a problem before. That proved to be a crucial point. A quick physical examination and use of the stethoscope virtually confirmed my worst fears. The blood pressure being elevated, I was already thinking of a more serious condition than an ordinary attack of bronchial asthma. Having suspected acute left ventricular failure (LVF) commonly referred to as "cardiac asthma", I lost no time in rushing off the patient immediately to hospital. I was well aware of the limited facilities and resources available in a GP’s clinic to tackle such emergencies, and that time was of essence.

Without washing my hands off the case, I followed the patient in my own car as I was heading home in that same direction in any case. The doctor in the OPD at Kalubowila Hospital confirmed my tentative diagnosis, and after administering the urgently needed treatment in the OPD itself, admitted the patient to a medical ward immediately. Being a former employee of the hospital, I was able to facilitate the entire process. The Consultant Physician who happened to be a friend of mine told me later that the patient would have definitely died had treatment been delayed any longer. The heart condition that manifested itself as a full-blown illness at such a relatively early age was due to undetected, untreated and hence uncontrolled hypertension (high blood pressure), which he had been living with for several years. The patient (who made a full recovery) and his wife were later virtually falling over each other in expressing to me their genuine appreciation and gratitude. Some years later, I heard that my patient, who was a top executive in a reputed mercantile establishment at the time of his illness, had later been elevated to the level of a Director in the same company.

Ulterior Motives

Under normal circumstances, such unusual dedication to the welfare of patients would have obviously aroused suspicion in the mind of the established doctor under whom the "locum" doctor worked. More often than not, "locums" did that with ulterior motives, "cultivating" patients for a practice that they themselves were planning to set up in the same area undercutting the erstwhile employer. But in my case, the employers being my personal friends who were well aware of my life’s goals, ambitions and future plans, they were convinced that I had no such plans or tricks up the sleeve. My "follow up" of patients only helped my friends with their own practice.

Power of the Stethoscope

The stethoscope is an instrument that is used for listening to sounds produced within the body. It is particularly useful in ascertaining the condition of the heart and lungs by listening to their action. In fact, it is an instrument that a doctor can hardly do without. However, in lighter vein, I wish to describe how junior medical students at least during our time, used their gleaming new stethoscopes for "extra-clinical" purposes. The most junior male freshmen used long bones in a human skeleton to impress teenaged schoolgirls at bus stops, and for that matter, anywhere outside the four walls of the Medical College. But they later graduated to a stage when the femur (or humerus) they carried with them, was replaced with the newly acquired stethoscope. Little did they realise then, that they were only displaying publicly, their lowly rank in the medical hierarchy. The French physician René Théophile Hyacinthe who invented the stethoscope in 1816 would be turning in his grave if he knew all this!

It would be an interesting digression if I were to explain here how a "medico" comes to own the first stethoscope. Anyone who is fortunate enough to have been a student at the 138 year-old Colombo Medical Faculty no doubt would be familiar with the important "milestones" in a five year career of sheer hard work made tolerable only by the occasional outbursts of "high spirited" mischief, fun and frolic. "Crossing Francis Road" to get across to more respectable surroundings leaving behind the aroma of dissected cadavers (dead bodies) and "body fluid" in the Anatomy Block was one. The second milestone was when we "Crossed Kynsey Road" to go across to the General Hospital (near the Khan Clock Tower) where we actually came into contact with living patients for the very first time. It was only then that the stethoscope became a part of the medical student’s paraphernalia.

In my own case, after that initial period of three years or so when I worked in a hospital setting, by virtue of the non-clinical nature of my work in the public health field, I have had to discard the stethoscope at least temporarily. But as I approach retirement from a full-time job after nearly 42 years of continuous service, and with plans to live my retirement in my country of birth, a question that comes up is " Will I ever use it again on a more regular basis"? Chances are that I will. But one thing I can say with certainty is that it will never ever be for a fee! Apart from kith and kin, friends and neighbours, the poorest of the poor in the most remote villages in Sri Lanka would be the beneficiaries.

E-mail: luckyabey@gmail.com