 This is a Manipal Hospital's podcast. I feel this medium is for those people who love the audio medium, so that you can do all your other work, you can be driving to work, you can be packing your children's lunchboxes and tackling other things and at the same time be listening. So that is the plus that people will get from this show and the podcast. No, I'm a great fan of podcasts. In fact, I listen to them when I'm in the car, use me about half an hour or 45 minutes of whatever I want to do in peace and I can listen to what I have to listen and want to listen. So there are no distractions really. How would you like listening to yourself? Well, I would rather listen to you rather than myself. As always, as always, a pleasure to talk to you, Dr. Sudarshan Balal. Let us jointly welcome people to the first ever episode of this podcast by Manipal Hospitals called the White Court World. I want to begin by asking you, must have been first of all a very busy day already, but I'm going to take you on a little flashback to 2021. Tell us what that year was like. Some of us to stay safe were inside our homes, but it was not like for you, like for lakhs of doctors across the world. No, absolutely. I think the last two years have been like no other events I have ever witnessed in my life. The Corona pandemic was truly a black swan event that has never been seen in many decades of my medical practice. It was truly a bolt from the blue when it hit us in 2020. And very interestingly, once the first wave was over, as we were entering 2021, I usually give my new year prediction and someone had called me and said, what is your prediction for 2021? And I had said 2021 can only be better than 2020 because nothing can be worse than 2020. And then I realized how wrong I was when the Delta wave struck us quite brutally actually in 2021 and almost destroyed our healthcare and economy. So I think what we need to introspect is that each year can be either better or worse. I had never predicted that 2021 would be worse than 2020. So I didn't make any predictions for this new year. And alone before we had the third wave, but fortunately much less lethal. And I think we are coming out of it too. I'm really glad to hear you say that because every day you just open the newspapers or you're scrolling up your devices for latest updates. And then they say doctors across the world, some of them are seeing a stealth variant of the COVID after Omicron. So as laypersons, it's difficult to sift what's right and what's not to be worried about, what could just fade away. So one of the duties of this podcast will also be to clear a lot of information across many fields. Before we actually go further in this conversation, I want to tell those people who are listening to us a few things about you, which means I formally introduce Dr. Balal. Dr. Sudesh Balal is the chairman of Manipal hospitals. But for those who have been under his care or heard of him or heard him while he was speaking, we also know that he was the best outgoing student, the blue ribbon awardee right back in his alma mater of the Kasturba Medical College Manipal. You've been a recipient of many gold medals, Dr. Balal. Now what also strikes me is this rare distinction of being one of the few to be triple board certified. What does that mean? Someone like me understands that it's internal medicine, it's nephrology and critical care. Doesn't mean Dr. Balal that you're not just one, but you're a double and three in one doctor, are you? I think most doctors are many in one, but I'm glad that I was able to pursue all the things that I really like both within the country and outside of the country. And I'm also proud to have received or conferred fellowship by the Royal College of Physicians, even though I had never trained in the UK. Yes, yes. Some of the other things that Dr. Balal has been involved in, first of all, is also the chairman of Stemputics Research Private Limited and currently also the president of Nat Health, which is the healthcare federation of India, New Delhi. Many had sworn like Dr. Balal modestly said that many doctors are many in one, but being a clinician, being an excellent teacher and a compassionate physician is something that he's been known for. And I can speak for it given we have had many conversations with fellow members of the, on the jury of a certain social awards. So it's really a good place to be and to ask you of many things, Dr. Balal, which you know, coming from you will give us a lot of clarity. Meanwhile, I also want to tell our listeners that Dr. Balal has been actively involved in many social aspects and responsibilities through their family trust, which is called the Belanje Sanjeeva Hegde Trust. So from what I read from the site and have heard is that it supports 1000 dialysis operations per year for the poor. There are free ambulance services, kidney transplant patients, poor patients with kidney diseases, they get subsidized care. And in Hebron, which is in Urupi, Karnataka, there is health insurance for the poor villagers. There's also scholarships for medical students and many such activities. So for me, writer, what I find very inspiring and will be for particularly doctors entering the profession who are going to be listening to this show is this marrying of expertise in the medical field, but plus also being a socially responsible citizen, someone who's in a give back mode. So one of the questions for you Dr. Balal is this pandemic season about which you have described made doctors, medical professionals do many things differently, you know, the healthcare model. Now, can you just tell us what that difference was? So what's the pivot also been in the Indian healthcare? Thanks for the generous words, Vasanthi. Minor clarification, I was the past president of NatL, it's a one year tenure, but I got 15 months because of COVID. They didn't want to change the presidency. So I got an extension of three months during my term. So I think you cannot be a good doctor without being a good human being. So I cannot think of anything where you can separate your medical profession from your social activities. I think the two have to go hand in hand, because our profession is such is where we try to give soccer to patients and their families. And we also need to give them a non-medical kind of assurance that we are there to help them at the time of need. It doesn't necessarily have to be only health issues. Believe it or not, a lot of time we will come and talk to me about many different family matters, including alliances in the family. So the medical man becomes a matchmaker at times? I must share this with you. The funniest thing that happened is once I was on rounds and there was this elderly lady, very sweet lady that was getting ready to go home. So I did visit her and said, we are glad that you're doing well, take care and we'll see you as an outpatient a month from now. And she seemed very embarrassed and then said, Doctor, if you don't mind, Nimatran, Prasne kella, can I ask you something? I said, okay, we always encourage them to ask questions. Nimige oba magaidhaan alla doctoru, you have a son who's a doctor. So I said yes. I said yes. Then the next thing she says is, I have a eligible grand doctor, you'll see we can have an alliance. So those are the kinds of things that people indulge in. So what I'm saying is it cannot be hardcore medicine alone. I think we should practice medicine with compassion. And of course, it was probably inappropriate, but I took it in my stripe and said he's still young, he has more degrees to achieve. So he's not going to get married now. So that kind of a thing. But these things do happen. But what has happened in before we move on to anything else in Corona is that we have had both the clouds of Corona with many silver linings. Of course, everyone is aware of the clouds of Corona, the lockdowns, the effects on the economic front, on the healthcare front, loss of footfalls in the hospital, significant damage to non COVID care, which is a serious, which was a serious, serious event. People couldn't go to the hospital, even when they needed it. And especially in my field, dialysis, which is three times a week, people going for dialysis was a huge problem. There was a huge physical financial mental stress for the healthcare workers. And of course, because the internal migration crisis, many of our projects were postponed because there are no workers available at that time. Many of the projects were postponed by six months to a year. So these were all sort of well-known clouds of Corona. But there were many, many silver linings, which people don't talk about. First and foremost to me was the acceptance of digital health, which we'll talk about a little later, I'm sure. Second is there was a significant decrease in the non COVID respiratory illnesses, whether it's flu, cold cough. During the peak COVID, we never saw any cold or cough, even at home, because everyone was maintaining distance, not coughing, following cough etiquette, and hardly any non COVID respiratory illnesses. And very interesting statistics, Vasanthi, during the first few months of COVID, there was a significant decrease in the death rate because the accidents in the country had come down drastically because people were not traveling. And of course, there was a lockdown. So the number of motor vehicle accidents had significantly come down. The other important things that happened was that healthcare sort of was recognized as the prime mover in the country and was given the importance that richly deserved. And more importantly, I think the medical profession regained its nobility. We were getting tarnished for various reasons. And this brought back the nobility, which was very close to my heart. And of course, in the field of science, vaccines, which would take about eight to 10 years to develop, were developed in a matter of eight to 10 months, which is a stupendous success for our scientific community. And these are the good things that happened with Corona. I'm not saying that Corona was all bad or all good. Certainly, it was a balance probably more worse than good happening out of it. But at least, there's a lot of good which we should carry on for the future. Yes, Dr. It's important to look at it as a whole. I want to draw your attention, in fact, to the rural side of healthcare, somebody who's also looking at... What was very unfortunate was, I think, the cities by and large were well equipped, whether it's medical facilities, experts, infrastructure, so on and so forth. But unfortunately, the worst affected areas was rural healthcare. And this actually made the government invest a large amount of money allocation in the previous budget, where significant importance was given to rural health. There was a need for strengthening of the PhDs or the primary health centers, Thaloka hospitals, Zistik hospitals. And most importantly, we had to bridge the rural urban divide, both manpower issues, infrastructural issues, and to a large extent, our digital health moves helped us to divide. And that's played a great, great role. And these are some of the lessons we have to carry on for the future too. So I think there have been many lessons learned. Hopefully, we won't forget them and we'll do that for better planning for the future. Just a right segue from what you mentioned, because in 2020, India has announced a national digital health mission. So to actually look at so many aspects, to bridge this gap that you were just referring to, between the urban and the rural and also to digitize the health records, because there's so much disparity, Dr. Balal, in the kind of services that is available in cities versus tier two towns versus villages where some of the places, it's absolutely non-existent. And telemedicine can play such a greater role. There needs to be investment, just so that even the unreachable areas of India have that access to healthcare via technology. So I think that is a growth we will see in the next few years. I do hope so, because I think for decades, digital health was sort of in a quagmire because of legal and regulatory issues. Everything changed in the last week of March 2020. I call that the red letter week in the history of digital medicine. Over a matter of few days, the government made it possible for us to use teleconsels and use digital health for healthcare in not only within the cities, but more importantly, the rural areas. And something that will always stay etched in my mind is one incident that happened soon after we started teleconsels. I had this elderly gentleman who used to come from one of the remotest parts of West Bengal. It would take him about 24 to 48 hours to reach Bangalore, maybe spend half an hour with me at most, and then another 48 hours to go back to Bengal. And because there was a lockdown, we told him we could use telemedicine or make it as a virtual consult. And fortunately for him, I think he had a granddaughter who was familiar with her computers. And she used a laptop. I do not know how they managed to get the connectivity, but they did. So I saw this gentleman as a teleconsel. And what was interesting is it was a very, very rural setup. He was on the typical chart points that you see in movies. And suddenly when I was talking to him, I saw something move behind him. I sort of didn't get to know what it was. Then I realized he was in the... Was it the cattle at his place? And there were cows moving behind him. And we were able to carry on with our conversation. And here we have a teleconsult across India, miles away, probably 48 hours of traveling time with a specialist in Bangalore from one of the remotest parts of the country, from a cow shed with the help of a laptop and the granddaughter assisting the grandfather. And we achieved what we wanted to achieve and that is the power of digital health. And I think we should harness that power for the future. There are many wrinkles to be ironed out, but those are issues that can be handled as we go by. But I think this is a great beginning for us and we should capitalize on that. Of course, there are challenges. There are these wrinkles that you refer to. I'm going to draw attention to one such, which really bothers me as, particularly as a woman, which is the gender inequality in the world of medicine. The fact that why is it that there are so few female doctors in say, neurology or even your own field, doctor nephrology, cardiology, gynecology, it's almost like, okay, if you're a woman, you probably must love birth. So there are these stereotyping, there is all this. So I see that as a huge challenge, isn't it? Absolutely. You struck the nail on the head. That's something that I've been noticing for decades. Unfortunately, there seems to be not only a gender inequality, but I would call it as a gender discrimination, not only in women entering medicine, but also in the delivery of healthcare. I think in general, women get poor healthcare as compared to men, and there are enough statistics to show that, I mean, less number of women come for dialysis or transplants, whereas distribution of the disease is the same among both genders. So in general, women are not able to get the healthcare they deserve as much as men, because we are a patriarchal society, and that has to change and should change. And women are more giving rather than taking, if you see the number of people coming forward to donate the kidney, it's always about 70 or 80% women donating versus 10 to 20% to their wives, mothers, sisters, whatever. There are very few good men left. What is the thought usually behind this, Doctor? I remember, and it was a very disturbing aspect, but it's true what you said that somehow it's also taken for granted that the woman in the family can spare the kidney, whereas the man has to go out and work. So how do you even address these gaps in the system? I think it's mostly a patriarchal society that we live in. Secondly, I do believe that women are more giving than men, whether it's at home or wherever, I think they're more giving, they're more compassionate in general. So I think they come forward more easily. Of course, there's also issues of coercion in some cases, and we try very hard to make sure that when someone comes forward to donate, there's no coercion. And if there is a coercion, we actually make it as a white lie. We tell them she's not fit to donate. That's a life for a good cause, isn't it? Yes, absolutely. We have had instances where they'll say, my sister will donate or my wife will donate, they'll bring them, and then we find out that the person was really not very keen, then we tell them that she's not medically fit to donate, because we certainly cannot do something that is not right, it's unethical. And we don't want to put the lady into any kind of a problem at home. So we tell them they're not fit. But you raised a very important issue about women in medicine. I've seen this for decades because I've been part of medical education, and I get invited for a lot of convocations to be the chief case on and so forth. And I've seen a significant trend which has changed in the last couple of decades or more. Initially, when I used to go for these convocations, almost 70 to 80% of the people getting the degree were all boys and 20 to 30% were women. But that has changed now. I think now there are about 70% women and 30% men, or maybe at least 60% women and 40% men. But what has changed dramatically is in the olden days, about 90% of the ranks went to men. Whereas now I think 90% of the ranks go to women. So I keep asking the boys, what's happened to you guys? You have stopped studying, because almost always now we have to hand over the blue ribbon or the gold medals to the women, because they've done exceedingly well in medical college. However, there are certain fields that people still have some reservations, I guess, about going to a lady doctor, mostly in the super speciality surgical fields like cardiac surgery, neurosurgery or any kind of surgical fields. That's what I wanted to know about. Yeah. Yeah, I think that again is a mindset we need to realize that women have better hands than men in addition to being very proficient in what they do. If you see basically women have much finer skills than men in general, so surgery is no different. It's a mindset that we need to change. Believe it or not, when I first went to training in the US, that was probably about 30 or maybe closer to 40 years ago. One of my postings was in surgery. And my colleagues, I had just gone to the US, was fairly new to the system. This guy said, I believe we're going to be posted in surgery. So I said, yes, and then he had a smirk on his face. So I said, I really don't know why you have that smirk on the face, because I didn't know. He said, you'll see your boss tomorrow, then you know. What happened to be a lady? And those days, it was extremely uncommon even in the US to have lady surgeons as the boss. So most people sort of didn't take it as a compliment being posted in surgery where the lady was a boss, but she was an extremely proficient surgeon, very good teacher, and I had a great time. But what I'm saying is this gender kind of inequality, discrimination has existed, but fortunately, it's getting better. And now I think certainly there are a lot more women in the field, not usual traditional orthopedics and gynaecology or pediatrics, but also in fields that demand a lot of their valuable time. However, I think they have to make their own choices because balancing their life and work is an individual choice. So I have equal respect for women who decide to stay at home. In fact, I tell many people that being a homemaker is far difficult than being a neurosurgeon at times. But that's the choice that they have to make. But certainly, I think we should treat everyone equally. And I'm glad that more women are in the field. And if you walk into my department, you'll probably see more women than men. And some of the best minds we have had in our department are women. Yes, one has seen that. And one important point that you made about women having academic excellence, more girls stopping and even in their medical education. But that somehow also needs to transition and translate into not discriminating when they enter into higher fields of medicine. The other point, Dr, being even the faith of the patients in certain fields where they expect to see a male physician, like I think the opposite holds true when it's a gynaecologist, somehow people are more comforted when it's a woman. But in so many other fields, I also hear from specialists or women doctors saying that patients do not trust a certain gender in certain fields. So I mean, these are also, I think, very, very nuanced, this thing of how biases work, how our mindsets are as a society. So all in all, it should become more fair and equitable, I guess. I would think so. But these are things that have been happening for generations. So it won't happen overnight. I think even today, there is some hesitation on part of male patients to go to women doctors, especially in the surgical field. But that is changing. It's not the same as what used to be 30, 40 years ago. I think more and more of them accept women doctors in fields other than obstetrics, gynecology, pediatrics. So I think I know of a lot of patients who don't have any qualms about going to a woman surgeon or a woman cardiologist or a neurologist. So I think things are changing. And I think as we move further, it will change further and soon will not only be equals, but I'm sure women will be respected far more than men. Yes, like one can see that you're rooting always for women. You're one of those feminist, you know, strong ideal doctors. I also want to draw your attention to another aspect. And I'm glad we are spending time on this podcast on matters which otherwise don't get talked about. You know, there are so many taboos around topics, but in this episode on white coat world, we are addressing something which is at the very fundamental level of medicine. There are so many young people, young women, maybe even transgenders who would make great strides in medicine. And I think that level playing field is important. One of the last questions that I want to ask you on this is on the question of ethics itself, which is again, foundations of good healthcare and the trust between the Vaidya and the Rogi or the doctor and the patient has always been very sacred, particularly in the Indian system, whether it's family doctors and people tend to trust doctors more. But that component, Dr. Balal, over the past few years, I have seen a lot of erosion. It's quite possible that distrust also comes in with, let's say a corporate healthcare setup. The doctors may or may not have anything to do with that system. But what I want to ask you very candidly as a layperson on the show is that how do we ensure that medical ethics are in place? How do we use that ethics to build better healthcare for India? Thank you very much for asking me this, Vasanthi. This is a question that's asked of me many times. I'm very glad that you asked me this question because it's very close to my heart. I keep asking myself and also whenever I'm addressing a young audience, I ask them, what is it that differentiates a usual doctor from a great doctor? And is it just knowledge and skills or is it something else? Knowledge and skills are certainly essential. But my take on this has always been, it is compassion, empathy, hard work, and most importantly, ethical practice of medicine and a humane approach is the core of being a great doctor. One has to be a good human being to be a good doctor. Unfortunately, there are many in the medical field or at least some in the medical field who may, what we call be the black sheep of the society. But fortunately for us, there are very few and these are the people that we need to police and regulate because if we don't police ourselves, someone else will. And I also believe that ethics in medicine is something that we start very early. It should be part of the curriculum in all medical schools. And also we should have a selection bias when we appoint people at various levels that we place a lot of emphasis and give a lot of weightage to their ethical practice of medicine, how humane they are, their interpersonal skills rather than medical or surgical skills alone. And my advice to the senior leaders in the fraternities, please lead by example, because young minds are very vulnerable. They would go by what they see and if they see their teachers, mentors, professors behaving in an ethical, compassionate humane way, they would follow that. And I've seen that over and over again. I've seen some students come from backgrounds where their bosses have been not very compassionate and you can see them see that rubbing on them. And I've seen some people who have come from training programs where they are extremely compassionate ethical training and you can see that change in them. So they are very moldable at this age. And I think we should catch them young, put this up in the medical school curriculum. And certainly we should lead by example so that all doctors not only learn the medical skills, but also have an ethical bent of mind and practice humane medicine. I think as we speak, Dr. Desbel always been this raging debate around us about the cost of medical education and whether that also plays a part in some of them thinking that money invested in getting that education the first place is so huge and sometimes out of reach of people who want to see their children as doctors and see themselves. That later on, it's also prime sense and how do I repay all those loans and debt. So it's really a larger issue that needs to be looked at, I think more holistically. Absolutely. I think, see if you have to invest heavily, then it's human nature that you expect returns. So if your education is so expensive, obviously someone has to pay for it. And there is no clear cut answers. There's no black and white situation. What my suggestion is, of course, there is merit seeds, but there are few and far in between. So not everyone can get in by merit. We should have a reasonable cost for medical education. And what should happen is there should be scholarships available, subsidies available, student loans available, so that even an average middle class or a lower middle class family should be able to go to medical college if they have a student or a son or a daughter who's willing to get into medicine. So money should not be the only barrier to get into education. Of course, you need to have the aptitude. You should only get in if you want to be a doctor. And if you want to be a doctor, we should have means of sustaining them through that financial hardship, which happens even in the US. I mean, most students, parents don't support them or would not want to support them. They come on scholarships and student loans. So I think something similar should happen. And we are glad that at Mahe, there is an element of scholarship for the brightest of students. And that's something we should emulate in other institutions too. And I'm sure the government will work on subsidies and loans for students, merit students who want to get into medicine. That's right, doctor. As we wind up the show, tell us one secret of being this, of wearing this smile, despite all the things that you have to do and so much of pain and suffering that you have to deal with. And you look like you are probably 10 years into the profession as a doctor or even less. For changing the 50 years to 10 years. So which means you have to tell us a secret of, you don't look like you have 50 years, half a century spent in the medical profession and retain that same Josh. How do you do that? I think it's a predominantly family influence. I had very strong women in my family, my mother, my wife and of course the other women in the family, including my sisters in law. I mean, I don't have any sisters. So the sisters in law were like my sisters. And all of them have been strong influences. And I must admit that I have never seen my mother be grim, always smiling and always encouraged us to be happy. I think that's ingrained somewhere in my subconscious. And I try not to let the situation get old of me or get the better of me. If I am very angry, I just don't say anything for a few minutes. I try not to show it and I don't react in anger. That's what I keep telling my children and my students that if you are angry with something, don't burst out as a reaction. Let it go for about 10 minutes. Nothing is going to change the world in 5 to 10 minutes. After that, whatever you have to say, you say that and try to be happy because if you are a grim morose doctor, which patient would come to you and which patient would be happy taking advice from you? I think as doctors, we have to spread cheer, be happy, be smiling, listen to them and be compassionate. So I don't think you should have a grim appearance, be angry, throw things around. I think that's just not the right behavior. So I try to be happy as much as I can and even if I am not happy sometimes, I still present myself as a happy man. Great secrets shared in some of the times when you walk into the doctor's clinic or room with some ailment, you just see the doctor and you are cured. You see sometimes a doctor, she or he doesn't even have to give the medicines. Sometimes you just see them and you are like, so I think there is a lot of reassurance, that kind of comfort that you feel with the person who's healing you, who's treating you and it's been great to draw some of your own life experiences to issues that India is dealing with as a whole. So likewise, White Court World will have many, many conversations in the weeks and months to come with doctors such as you. I'd like to thank you for being my guest on this show, Dr. Balal. It was my pleasure, Vasanthi. Thank you very much. Yes, and that with that, it is a wrap on this episode. Until we meet you next time. Namaskar and Adha.