|Year : 2019 | Volume
| Issue : 2 | Page : 209-211
Posting in Varanasi: A blessing in disguise
Mounika Boppana1, Chakor Sunil Vora2
1 Department of Medical Oncology, Krishna Institute of Medical Sciences, Secunderabad, Telangana, India
2 Department of Medical Oncology, Sassoon General Hospital, Pune, Maharashtra, India
|Date of Web Publication||20-Dec-2019|
102, Sirisha Apartments, Engineers Colony, Yellareddyguda, Hyderabad . 500 073, Telangana
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Boppana M, Vora CS. Posting in Varanasi: A blessing in disguise. Cancer Res Stat Treat 2019;2:209-11
From a structured and an extremely well-organized parent institute, we landed in one of the peripheral centers of Tata Memorial Hospital (TMH in Mumbai, India) in the holy city of Varanasi – the Homi Bhabha Cancer Hospital (HBCH). We were sent like the lifeboats from a mother ship to give life to and boost the growth of the upcoming branch. Our first impression of the city was that of a dusty, dirty place with bad roads, crude people, illiteracy, and early-onset tobacco addiction. However, there was something strangely attractive about this place that we could not quite fathom in the beginning. My grandmother used to say that staying in Kashi for three nights in a row would set us on the path of moksha, but we had come here to stay for 120 days in the service of humankind. We looked upon it as a great opportunity career wise, philosophically, and spiritually.
With these mixed feelings, we set out on our task. Initially, we thought that it would not be quite different from our job at TMH – a sheer clinical job profile of seeing patients in the outpatient department (OPD) and wards. However, soon, it dawned upon us that apart from being responsible clinicians, we would have to play the role of good administrators, a role that we had never played before. It involved training many people, right from the housekeeping staff in the OPD and wards to nurses, junior residents, clerks, junior social workers, pharmacy staff, etc. It put our administrative, counseling, organizational, and communication skills to test. The ultimate goal was clear in front of us – to make this center a mirror reflection of TMH in every respect in order to deliver optimal patient care.
It was a mammoth task, but we set out accomplishing multiple small tasks one by one, gradually clearing hurdles – small and big. Most of the staff consisted of people hailing from nearby towns and villages. Their attitude toward work was quite different from ours, and we found them a bit resistant to change. Initially, we took an authoritarian approach. However, this did not work and rather backfired in the form of hostile responses from some of them. We soon realized that we should instead have an approach of being friends who care for their colleagues, teachers who guide their students, employers who understand their employees, and leaders who lead by example. This change in our attitude took care of multiple problems. The staff at HBCH started considering us friends, teachers, guides, and, on many occasions, their 'family doctors.' We were in a position to bring about an attitude change in them and improve the work culture. This in turn improved the functioning of our department and helped in delivering better patient care.
In the initial days, patients used to crowd like a mob around the doctors in the OPD. We attended to patients on the basis of their token numbers, with exceptions being made only for sick or elderly patients. A strict implementation of the token system instilled discipline not only in the OPD staff but also in the patients and caregivers. This allowed for smooth uninterrupted patient care in the OPD. The housekeeping staff in the OPD were critical to the proper maintenance of this system. In order to maintain a good continuum of patient care and build a good doctor–patient relationship, we ensured that each patient was seen by the same doctor at every visit. This helped us develop a good rapport with the patients with a thorough understanding of their social and financial situations that aided us in proper treatment planning. This immensely increased the patients' trust in us. As we saw the patients over a span of 8 months, we knew their individual case histories in and out and that helped us in faster and more efficient OPD management.
The nursing staff in TMH are so efficient and experienced that we never even realized how much troubleshooting they do at their level. On the contrary, most of the nurses at HBCH were young with minimal experience even in general nursing, let alone oncology nursing. For chemotherapy administration, they used to very crudely set the rate of infusion without even calculating the drip rate. For example, rapid infusion drugs such as gemcitabine were given over several hours, whereas prolonged infusion drugs such as 5-fluorouracil were given rapidly over one to two hours. This was because they were unaware of the importance of strict adherence to protocols and the consequences of such deviations to patient outcomes. We used to complain daily to the nursing superintendent in the beginning, but, we eventually realized that this just made them afraid of us but did not quite improve the situation. By conducting teaching sessions for the nursing staff at HBCH on topics such as handling chemotherapy drugs and antisepsis, we partially solved this problem. Apart from that, in our daily rounds, we used to share small bits of knowledge with the nursing staff on duty. We gently suggested that they think logically, reason out everything that they did in the wards, and read about every new drug that they had not heard of before and encouraged them to keep learning something new every day and get better. After a few weeks, we saw the change and the impact of this change in the nursing care. Most of the nurses were religiously following the handwashing technique, chemotherapy drugs were being administered over the exact duration that they were supposed to be, and too many more to mention. When we left HBCH at the end of 8 months, many nurses complimented us saying that they had learned a lot from us and we had inspired them and had brought about a change in the way they work and their overall attitude toward work. These compliments gave us a satisfaction that could not be defined in words.
There were multiple deficiencies in this recently started hospital. For example, immunohistochemistry (IHC) was not being done at HBCH, and we had to send pathology samples to TMH for the confirmation of diagnosis. In this process, the diagnosis used to be delayed by 2 weeks. We had to start the patients on empirical chemotherapy in the meanwhile in order to alleviate their symptoms. The hospital laboratory was functioning till 3 pm on working days. For any sick patient in the night or after 3 pm, the samples had to be sent to outside laboratories which would again take a toll on the finances of the patients. The poverty of the patients hit us hard. We were shocked at how disadvantaged these patients were with respect to literacy, finances, and resources. Some of them came from hundreds of kilometers away, sometimes from the very interior villages of Uttar Pradesh and Bihar and were without access to even basic primary health care or at least a decent mode of public transport to reach Varanasi. We had seen very poor patients coming from far-off places to TMH, but here in Varanasi, the poverty and ignorance was at an entirely different level. Prior to the establishment of HBCH, these people had to travel much greater distances to Delhi or Mumbai for cancer treatment. This institute came as a boon to the patients of this region – it would cater to the needs of a large part of the Ganges belt, thus obviating the need for traveling long distances for cancer treatment.
Initially, HBCH did not have a blood bank. We were sending patients to blood banks at other centers in Varanasi, which was a difficult and costly affair for them. From January 2019, the blood bank at HBCH became functional. A replacement blood donation from patients' relatives was mandatory at our blood bank, as the number of blood units was very scanty in the beginning. Patients' relatives would eye us critically when counseled for blood donations due to various misconceptions at the community level about blood donation. This was understandable considering the illiteracy. We managed to make at least some of them realize that blood donation is a very noble and lifesaving act. For word to spread from these few people, for a change to happen at the community level, and for the eradication of misconceptions regarding blood donation, it would take time, but, we witnessed a beginning. We also got in touch with some voluntary organizations formed by the students of Banaras Hindu University so that they could provide blood donors in times of emergencies.
Finally, IHC was started. Testing pathology samples for estrogen receptor/progesterone progesterone receptor and Her2neu was followed by other basic IHCs so that most of the pathological diagnoses could be made at HBCH, and there were very few samples that we had to send to TMH if we were unable to arrive at a conclusive diagnosis with the available IHCs. Our interactions and relations with the department of pathology also improved over time.
The multidisciplinary Joint Clinic, also referred to as Tumor Board at some institutes, was one point of contact for faculty members of all the specialties. Discussions with the surgical, radiation oncology, radiodiagnosis, nuclear medicine, and pathology colleagues added greatly to our knowledge and understanding of the varied aspects of patient management. We were fortunate to have competent and open-minded colleagues in these departments at HBCH.
No oncology unit is complete without the supporting departments of diet and physiotherapy. Moreover, we had the same in the form of a young and dynamic team in both of these departments. We made it a point that every patient with head-and-neck cancer receiving concurrent chemoradiation visited the dietician on a weekly basis. This ensured that the patient was counseled not only by the treating doctors but also by a dietician for the need of a feeding Ryle's tube at an appropriate time during the treatment. Thus, good coordination played a role in better patient management.
There were multiple visits by the Director, TMC, from Mumbai. Representatives of all the departments used to be invited for discussions about various problems whether they were related to patient care or facilities being provided to the doctors. We were fortunate to have frequent visits from the Director who would not only give a patient ear to the issues at HBCH but also take quick action to solve the same. After putting forth in many such meetings that a 24 hour laboratory was mandatory, we finally had a laboratory functioning round the clock. This was a step forward toward starting treatment for acute leukemia patients.
The central venous catheter clinic plays an important role in cancer patient management. We insisted on starting the same at HBCH. This helped us in treating patients with infusional chemotherapy regimens. Two nurses trained at the TMH catheter clinic were pivotal in starting this clinic at HBCH and they in turn trained a lot of nurses in catheter care. We were also among the long list of beneficiaries who learned catheter insertion and catheter care.
There were a few issues related to the food and accommodation of the doctors working at HBCH. In the initial days, we complained about this and made attempts to bring about improvements in those fronts as well. However, we slowly learned to overlook some of them and overcome the rest. As months passed, we stopped bringing up issues related to our food and accommodation and focused on issues related to further improvement of the system in the hospital.
Our 4-month experience of working in HBCH, Varanasi, was so satisfying that we decided to stay back for another 4 months. Those 4 months were hot summer months with scorching heat. The daytime was comfortable as we used to be in the air-conditioned hospital from 8 am to 8 pm. However, in the evenings when we got back to our hostel, we used to suffer the brunt of the summer. We were provided with coolers that were of no effect at temperatures above 45°C, making it difficult to sleep. But, there was some satisfaction at the bottom of our hearts that we were easing the pain of many patients, we relieved the mental agony of so many patients' relatives by being compassionate to them, and that we have done all this good in a holy place like Kashi. It felt like serving God Himself. This sense of satisfaction made us smile at the end of the day forgetting the physical discomfort.
As we mentioned in the introduction, the city streets were dusty and crowded with indisciplined traffic. However, the markets were full of garments made with the famous Banarasi silk. There were shops selling the traditional art works made out of silk, wood, stone, Sphatik, and a variety of metals. To our surprise, there were multiple restaurants not only serving tasty food but also having an ambience at par with the international standards.
The Vishwanath temple of Varanasi is one of the 12 Jyotirlingas and has lakhs of devotees visiting Lord Shiva here daily. Another place of solace was the Great Ganges. The serenity one experiences on the banks of the river, commonly known as the 'Ganga Ghat,' helps settle all the turmoil in mind and recharges you to take on the challenges on the way ahead. The boat rides in the river Ganga and witnessing the Ganga Aarti were unforgettable. The Jain temples and Buddhist monasteries at Sarnath are just half an hour drive from the city of Varanasi. The holy city of Prayagraj famous for Triveni Sangam can be reached in 3 hours. We used to take refuge in all these places at the end of long working hours and had our share of fun.
Our hearts were heavy when it was time for us to leave Varanasi. Many patients had got emotionally attached to us and vice versa. They used to treat us like their family members with lots of love, bringing us goodies from their villages such as homemade jaggery, sweets, and 'Prasad' from their local temples. Many patients were sad that we were leaving. It was not only the patients but even the housekeeping staff in the OPD, the nursing staff, the social workers, the security personnel, the hospital bus and car drivers, and colleagues from other departments and the Director wanted us to stay back. Even now, many of our patients from Varanasi call us to update us on their health status and tell us that they miss us a lot.
To conclude, TMH, Mumbai, has taught us the science of oncology, but this 8-month posting in Varanasi has given us deep insight into life as a whole. It has given us perspectives into the various aspects of human existence including emotions and spirituality. This was a rare opportunity that we had never expected. It changed our view toward patients and made us look at them not just as numbers or cases but as true embodiments of divinity. This made us serve them wholeheartedly and respect their will, emotions, and opinions. It has given us the kind of professional satisfaction that we had not experienced before. It has sculpted us into better doctors and more importantly better human beings. When we look back at these 8 months, what we were then and what we are now, we beam with pride. Fueled by this new energy, we have set out to accomplish our goals and serve the society better and also enjoy the profession at the same time.
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Conflicts of interest
There are no conflicts of interest.