My Rural training for Family Medicine, sometime around Feb-2010

I’m posted in a rural health centre as a part of my post graduate training, where I’m undergoing training in the nuances of primary health care and communication skills, guided by a senior lady physician.

About 3 months ago, Aziz (name changed), a 20-year-old frail young man, was brought to us by his elder sister. He had been having fever, cough and breathlessness since 2-3 days. He had now started coughing out streaks of blood, which finally drove them to seek medical help.

His sister, playing the informant’s role dutifully, added that he was mentally subnormal. With his widely placed eyes and eccentric facial expressions, he seemed to fit the bill. He seemed hard of hearing, and had difficulty in comprehending what was spoken to him. He sometimes followed simple instructions.

We asked whether he’d coughed out blood before. The sister said that he had similar symptoms from his chest some ten years back. He had been treated in some nearby hospitals, without much change. Finally he had been referred to the Medical College, where he was found to have TB and was managed accordingly. He recovered fully. An ECHO test done around the same time had showed some defect with the valves in his heart. He later used to have only the occasional minor illness, for which they resorted to modern as well as traditional medicines, as per their convenience.

The patient being from an extremely poor family, our options in advising investigations were minimal. This mentally sub-normal boy had 2 elder sisters; one of them was married and had her family to look after. They were not comfortable with the idea of us referring him to a higher centre. He was thus started on a course of antibiotics and simple treatment measures. He was advised follow-up on alternate days.

During the follow-up visits, his symptoms were found to be improving steadily.

But it was his personal and socio-economic circumstances that raised our interest and concern for him. His family members were worried about his long-term care and survival in society.

His sisters’ anxieties were thus: how would he be able to fend for himself in future? His peers made fun of him for his handicaps. And who would take care of him once the remaining sister was also married and gone? Would he be able to care or earn for himself? Would he ever marry? Who would willingly give his daughter in marriage to such a person?

Apparently, He was almost like any other child till he was in 4th standard. Over the next two years or so, he had a remarkable deterioration in his studies and social activities, and dropped himself out of school. One of his schoolteachers co-incidentally happened to be in the clinic during one of the visits, and reminisced that the boy had been mentally sub-normal and a poor performer.

We found it difficult to communicate with him; he was in a shell of his own. He revealed, quite hesitantly, that he had tried to work as a cleaner in a truck. But since people at work only seemed to shout at him for his laziness and uselessness, he felt bad and stopped work after a few days.

He looked depressed. His body language made no attempt to hide his extinct self esteem. He once told us that he’d himself realized long back that he was mentally subnormal and incapable of understanding anything. He talked in sudden, loud, impulsive but short bursts, and seemed to go back to his shell immediately. It all fit some criteria for known medical conditions- some syndrome, autism, personality disorders, etc.

But something, somewhere seemed to be out of place. Oddly, he seemed to understand questions and instructions when he was extra-attentive to what we were saying, especially when he looked at peoples’ faces when they talked to him. When there was pin-drop silence all around while conversing, he seemed to do better.

We had been wondering all while that maybe he could be trained in some simple occupation. By now, another doubt crept in: Is he really retarded, or is it more of a hearing impairment?

In the next weekly charitable ENT clinic at our clinic, simple tests to assess his hearing were done. Later, audiometry testing was done, free of cost, in our main hospital. He was found to have profound sensori-neural hearing loss in one ear, and moderate impairment in the other. Considering his financial status, the ENT doctor arranged a hearing aid for him, which they’d got as a sample from a pharma company.

Over the next week, there was no news of him. It was as if he’d disappeared.

He suddenly turned up two weeks later, a remarkably changed, cheerful man. He said that he went back to work, as a cleaner in a truck, and did reasonably enough this time. He had been on a longish haul and saved two hundred and fifty rupees over the week!

His self-esteem had skyrocketed; the change had made him look far healthier than he possibly ever might have been!

He paid us a couple more visits later, possibly to convince us that the change had been real and sustained.

It had simply been hearing impairment. The how’s and the why’s, we could not be really sure. But this explained the innocuous mention by him that “people got angry and shouted at me when I’d tried to work”. Why he’d gone bad at studies and dropped out. Why he’d become a loner.

And it had resulted in him being branded as a ‘retard’ for some 7-8 years.

This treatable problem was assumed to be due to him being mentally subnormal, rather than it being the other way round. His family members, in all their innocence, assumed so. His teachers never realized it.

Ruling out such simple causes for “developmental” problems is something that is suggested amongst the first things for such people. Yet, members of the healing profession, including us, had missed out in differentiating between cause and effect during all previous interactions, over so many years. A simple suggestion for a hearing assessment could have made a real big difference to this guy!

Apparently, once the opening line of the sister’s presenting complaint went “he’s mentally subnormal…”, we’d rather not waste time talking to him.

He was too insignificant for that, maybe?

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