COVID in Pakistan: a physician’s story [PODCAST]

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“The right choice of words, at the right time, can lift a person out of despair and literally save a person’s life, while an ill-chosen word, or worse, a purposely harsh one, can scar a person. The entire field of narrative medicine is formed around the principle of reviving empathy in doctors towards patients and their colleagues so that we keep the inner human alive in us as we treat the obstacles we are faced with daily.

If you are a physician seeing a multitude of patients daily, try spending time with the patient and offer them a word or two to heal.”

Natasha Khalid is a physician in Pakistan.

She shares her story and discusses her KevinMD article, “I’m a doctor who had COVID. Did I deserve this? Does anyone?”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Natasha Khalid. She is a physician in Pakistan, and she wrote the KevinMD article “I’m a doctor who had COVID. Did I deserve this? Does anyone?” Natasha, welcome to the show.

Natasha Khalid: Thank you so much. Thank you for having me here.

Kevin Pho: So we’ll get into your article in a little bit, but first off, can you share your story and journey to where you are today?

Natasha Khalid: So I have always been an avid reader and a writer. I did my medicine from a medical and dental college in Karachi, and then I did my internship at one of the best hospitals Pakistan has to offer. Later on, I pursued research while I was taking my USMLEs, and then I started my residency, and now I’m a year-three resident. As a resident physician, I’m practicing in internal medicine.

Kevin Pho: As a medicine trainee in Pakistan, what would you say are some of your biggest challenges?

Natasha Khalid: Having the modalities to investigate, like at the brink of your finger or at the back of your hand, that is one of my challenges. And then, you know, access to medicines, access to the latest medications that we can give for certain diseases. They’re not always available, and there’s a certain pool that we have to go through: cost-effectiveness when it comes to medication, because we’re not run on insurance.

And the biggest trouble that comes with patient compliance is the fact that they have to pay for the medication. So let’s say I find a certain group of medication really effective, but my patient cannot afford that, because he could hardly afford having his three meals a day. So the biggest challenge comes here: getting him to comply with medication. So cost-effectiveness, I feel, and the fact that there are certain preventable diseases that are still rampant because, A, there are myths; B, there are concepts that, you know, intervene in between.

A lot of people are not vaccinated. Like, it’s not a given that our patients will be vaccinated. It’s not a given that our patients would have access to clean health care, clean drinking water. So a lot of infectious diseases that you read about in the books, you see them live when you’re practicing medicine in Pakistan. So it’s not like a tunnel view you have, and also, being an internal medicine person, you have to think from all the boxes and from all the errands. And I feel like that’s the interesting part of our job as well, but also one of the troubles that we face.

Kevin Pho: Now, a lot of my listeners are certainly not familiar with what medicine is like in Pakistan. So I was wondering, can you take us through a typical day you have as an internal medicine trainee and tell us a little bit about the patients that you see and the hospital that you work at?

Natasha Khalid: OK, so I’m working at one of the hospitals which has come with a different concept. I will not take out the name, but we are the only hospital in Pakistan that is treating for free. And before that, I was working in one of the best hospitals in Pakistan, one of the, you know, recognized hospitals in the world as well, that gives you good-quality health for, let’s say, a certain amount that not everyone can afford. So a lot of underprivileged people can’t access that health care, right? So now I’m working in a hospital which deals with patients free of cost.

So my normal day these days: I’m on the floors, which means I’m one of the floor seniors, and we have a certain number of patients that are admitted under the internal medicine team that we look after. That would include the MICU and the ICU, certain ones in the special care, and then some in the wards that are stable.

So my normal patients would range from something as simple as dengue fever that would be complicated with malaria, or someone who has a B12 deficiency and would be working around normally with a hemoglobin of 4. So that’s one of the surprising things. Then, if I go further, I would have a patient who maybe had presented to me with a hemoglobin of 4.5, and I thought this was anemia, and I find out, oh, his digits are cyanosed. And then we progress, and we find that it’s a symmetrical bilateral gangrene, and maybe there is some underlying lupus. And surprisingly, that is what makes medicine interesting. We find out, OK, this was APLA, SLE, from someone we just encountered who had anemia. Or let’s say it was anemia, and then we find out through our workup and X-rays that it was a pericardial tamponade. Going further in the whole case, you find it was HIV, which makes my job interesting.

So what I do is I allot patients to my team, and then we look through the patients. We walk through them. We go through their plans. We go through their management and the labs we want. We study the cases, and then, you know, our consultant comes in, and we do rounds with him, and we discuss. And while we’re discussing and we see one patient, we counsel the family. So there are a lot of aspects involved. It sounds simple and easier. It’s not always that easy, because we always have one emergency, one case that needs a lot of attention. So that’s how the day goes. And then later on in the day, we have a session that we need to attend, and then, you know, give over to the other team about the patients, and maybe receive a case that’s coming in from the ER that’s been admitted.

Kevin Pho: In general, how big are the medical teams there? How many residents are there? Do you have medical students who also are part of the team? What does the team comprise of?

Natasha Khalid: In Pakistan, I’ll give you a general outlook of how floor teams are. So there’s always this hierarchy that follows. You’ll always have a senior-most resident, then a PGY-3, and then a PGY-2, and that could include like two PGY-2s, two second-year trainees, and the year-one residents, and then some interns, right? And then med students, the ones that are allotted in the groups that would join you, but they’re not really, really part of the main thing that’s going on. We would give them, like, histories to present and things to do. And that’s how the team works.

And a team normally comprises of, let’s say, five, six people, I mean, including the med students and internees and electives in this. And the work is divided according to the level of hierarchy. So let’s say if you’re an R1, you’d be expected to see ward patients. If you’re an R2, you’d be expected to see patients in special care and, you know, even ICU. If you’re an R3, let’s say, then you’re supposed to make sure you see everything and everyone does his work, right?

Kevin Pho: So let’s transition now into the KevinMD article that you wrote, and it’s about COVID and the effect on the physicians in Pakistan. Your article is titled “I’m a doctor who had COVID. Did I deserve this? Does anyone?” Now, for those who didn’t get a chance to read that article, can you just walk my audience through it and share the story of why you decided to write it?

Natasha Khalid: So I wrote it while I got COVID the second time, right? And I was sick to the core. I was in bed for days, and while all of that was going on, a lot of people who were around me at that point got COVID with me. And it all stemmed from the fact that we were working together, and the second wave in Pakistan had to come, and obviously all of us were not aware of it. Not that we ever took the mask off, but I feel like, you know, being caught through patients when you have so many is inevitable.

And while that had happened, a lot of other people at work had been overburdened, because now they had smaller teams, smaller call teams to work around. A lot of people had to come to work way more and maybe do more calls than they were expected to. And in all of that, we also have something like, a lot of people give presentations of mortalities that you have to make. So any patient that dies in the hospital, we have to come up with what happened, what was lacking in the care, and what could have been done differently. There’s this whole chart that’s made.

So on our WhatsApp group, this conversation was going on about how people have to do this work, and I was allotted, and I was given like a day to do it. So I was like, “OK, I am sick. I cannot. I can hardly move to the washroom. How can I write this?” And similarly, there were two more people. They were like, “You know, we’re in isolation. How can we, like, make and have a discussion with the consultant and forward it to you in that certain time period?” And with these questions, the chief resident was being bothered.

So, however, one of the senior instructors on us came up with this thing, which sounded very negative and very hurtful at that point: that people who at this point are in isolation or who are suffering from COVID are doing it because of their negligence. “So stop bothering the chief resident for it, OK? And do the work.” So that is what it stems out of.

And, you know, I have this writing thing. I’ve been writing since a very young age. So I remember it was my fifth or sixth day, and I started writing this out, because that’s one of the ways I connect. You know, this is one of the ways I let things out, and I find it very therapeutic for myself, and it helps me keep sane. So that’s when I wrote this article, and it just had me thinking of a lot of cases. And especially with COVID, you are prone to depression, and prone to thinking, and prone to going low. That’s also one of the things that I’ve experienced both the times I had it. So that’s how the article came up.

Kevin Pho: So when you were in isolation with COVID and you got that response from the chief resident, tell me what your reaction was and what was going through your mind.

Natasha Khalid: I was angry, and if I am being brutally honest, I wish this person had it instantly and went through the same thing to realize. But yeah, I was really, really angry, and a lot of people spoke on this while I was away, and they told me later. And, you know, I was really, really angry when I saw that, and that got me to, you know, a whole myriad of thoughts that go through your mind: OK, something of the sort happened.

Kevin Pho: Now, is there anyone that you could turn to, other than that chief resident, who can perhaps give you some support?

Natasha Khalid: Anyone I could, yes. I can, but I didn’t make a big issue out of it. I did process it further. Yeah, this is a very unempathetic statement that’s coming from somebody, but I didn’t. I was really too weak to come up with an argument and a fight about it. But yeah, among us residents, we’ve discussed it. We’ve had our conversations on this, on how dumb this is, to say something or blame people in a pandemic for having COVID, especially doctors.

Kevin Pho: Now that hopefully COVID is getting a little bit better, tell me some of the lessons that you’ve learned over the past one-plus years of the pandemic.

Natasha Khalid: So, OK, one of the biggest lessons that I learned is working together as a team, and that not just includes medicine residents as a team, but, let’s say, the other subspecialties that we have, it brings out a product that’s amazing. And, you know, that combined care for the patient comes out excellent. Having a multidisciplinary approach to something, that’s one.

Second, taking care, and that would include, while we had COVID strike the first time, how every person would help the other person tie their PPEs. It was a whole task to take it off properly and put it on properly before going to examine a patient. So, you know, that whole thing that came across, it was good. Like, it made everyone come closer. And, you know, the fact that even now, if I see somebody not wearing a mask, I would point it out to that person. So even though it comes out as rude, there’s another aspect to look at it: It comes out as a sign of care, because if you get it, you know, you don’t know what you’re getting into. So those are some of the good things that I learned.

Secondly, all the times that I’ve been in isolation, and all the times that, you know, you have to sit back and not work, especially for residents who are working crazy, and doctors especially, that also made me realize how important it is to be in touch with your creative side, or how important it is to have hobbies, or a life that is totally apart from what you’re living through day in and out. And patience, I believe, though. That’s all that came as a byproduct of this one year.

Kevin Pho: So we’re speaking now in the middle of June. Tell me what the situation is like at your hospital and what the vaccination rates are currently in Pakistan.

Natasha Khalid: So, OK, I don’t exactly know the numbers, to be honest, but people are getting vaccinated. They’re very well aware of the fact. Now, that would stem from two reasons. A, the government gave you an order to do it, or otherwise they would, you know, deprive you of certain things, so people are running to it. B, people really, really want to get it done. So I do get, like, a couple of calls every day from, you know, people to help them chalk out a plan and get vaccinated, connect them to somebody, or which one is better than the other. So vaccination rates are high, and people are conscious about it.

Second, as far as the patients are concerned, well, we do have them, but they’re not as much as they are in other parts of the country. Like, I am Karachi-based, and I know in Lahore it’s way too much, and in Karachi it’s not that much, especially in my hospital, despite the fact that the beds are full. But, you know, if there are, let’s say, three patients or four patients that are being admitted under medicine, and they have to run through a COVID test before they get admitted, we always have, like, one who tests positive and goes to the COVID ward rather than the internal medicine ward.

Kevin Pho: We’re talking to Natasha Khalid. She is a physician in Pakistan, and she wrote the KevinMD article “I’m a doctor who had COVID. Did I deserve this? Does anyone?” Natasha, you’ve been writing for years on KevinMD and sharing your stories. Now tell me where you got your start in writing, and why is writing so important to you as a physician?

Natasha Khalid: So, OK, I started writing from a very young age, right? That’s like 10 years back. And I loved reading, so, obviously, writing. And it was not just about my stories or my vulnerabilities, but it was mostly about topics assigned to me, you know, designed for newspapers. And it was a different life than what I had. It was always fun. And, you know, I like connecting with different kinds of people. So if I’m, let’s say, just in the medicine field, I would like to, once in a while, as, you know, an adventure, as an outlet, connect with people from art and find out what their thought process is. So this is how it came across.

And then we were working in Aga Khan, and we came up with this narrative medicine concept, and we started having these meetings in which we would discuss how can we inculcate this idea in the med students, and how to, you know, be empathetic towards the patients that they deal with, and how to develop empathy in patients, and how to make sure that the human part of them stays alive. Because all of us did feel the fact that we’re running so high on work that suddenly something happens, and then we realize, “Oh, this was something bad.” I mean, we go home, and we realize, “Oh, I had this too, and I recovered, and this guy died.” I mean, you know, sometimes you would have that fault, but nobody would talk about it.

The problem is nobody ever talks about the aspect of being affected by seeing a dying patient in the hospital, seeing a story right next to you, how it affects you. So there’s no conversation about it, because while you attend to one emergency, the other one awaits you. So that conversation never happens, and that is what really got me into writing for narrative medicine.

So we came up, we published an article that was about the art of healing and narrative medicine, and a lot of people came up in that. Somebody painted. I posted one of my blogs, how, when I saw a patient in the dialysis hall who was my age coming for dialysis, at that point in time I was only thinking, “Oh my God, I have to study for my exam. I don’t have so many publications, and when will I, you know, get done with all the exams and start my residency?” I look at this girl who’s my age, and all she is doing in a week is coming to the dialysis hall three times a week and getting dialysis done. And my lifestyle, if I would compare to that, was, “Oh, it’s the weekend. What am I doing? What am I watching every day? Am I studying this many hours? Am I working properly? Am I doing this and that?” You know, how your life has a given set of privileges which a lot of people don’t have, and we need to connect to that.

So narrative medicine and the writing thing came across through that whole process, and after that, I’ve been writing. And, you know, certain incidents, when they hit me, I do write them. Sometimes it’s funny, sometimes it’s good, because I feel like it bridges the gap between the people on the outside and the doc and the clinicians, right? So other people who would be seeing me right now would know the life that most of us live in the trenches. So, you know, the great divide that exists, I try to bridge that.

Kevin Pho: And my final question: What’s your take-home message that you want to leave with the KevinMD audience?

Natasha Khalid: Whenever you’re working, you know, make sure any word that comes out of your mouth is kind. If you’re discussing a case in front of your patient, which is his case, make sure, if you’re talking about the prognosis, which sometimes is bad, like most of the times, you’re not saying it there. Your words, even your communication among each other, is well-worded in a way that it doesn’t hurt the other person, because a lot of times that’s all that they would remember. And not every time, and, you know, you’re leaving somebody with the memories of you. So let them be good memories.

So I feel like one of the things most clinicians need worldwide is to be better worded, to be kinder, and to be understanding, and the same thing does not go applicable to patients. I feel like among the residents, among the doctors themselves, when you’re communicating about a disease and its prognosis, and, you know, try to make the mortality sound less ugly, if I could say it properly, like, let it sound less ugly, less hurtful, because you don’t know if the person standing next to you is suffering with a close member of the family going through the same thing. So these words, they have, you know, a huge impact, and if that stays unaddressed, it leads to problems later on.

Kevin Pho: Well, Natasha, thank you so much for sharing your time and insight, and thanks again for being on the show.

Natasha Khalid: Thank you for having me here.

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