Wednesday, 7 May 2025

REMEMBERING PROF. M.K. MITRA BY HIS WARD TEACHING

 



Prof. Manoj Kumar Mitra was a Reader in the Department of Medicine when we were doing our MBBS. He was a very methodical teacher with a unique analytical power. His lectures were always very well crafted, to the point and crystal clear. Though nephrology was his passion but he treated a wide variety of patients and his ward teachings were a joy to behold. All the ward beds were allotted to us, the medical students, and we were expected in the evening ward session, to meet the patients, greet them, seek their permission for a conversation and subsequent examination and then proceed to take a detailed history. This would be followed by a clinical examination and we would write down our findings. Then we would ask the resident team a bunch of questions, which, if it was a quiet day, would be patiently answered. If however, the ward was overcrowded and the schedule too busy, we would be brushed aside as unnecessary irritants.


I still remember a tall Sardar ji by the name of Dr. P.P.S. Sethi would be one of Dr. Mitra’s residents and he was a kind hearted senior, who, if available, would answer all our stupid questions. And, if we were bold enough to approach the Senior Residents or the Chief Residents like Dr. Alok Banerjee, Dr. Sumanta Chakraborty, Dr. Pramod Dhawan or Dr. Sunil Sennon then it would be a huge bonus. They were all walking – talking encyclopedia and they could elicit some amazing physical signs and pick up some astonishing heart murmurs. To juniors like us, they were like magicians eliciting shifting dullness, Adson’s Test, Bronchial breathing and Machinery murmurs!

 

All these efforts were made because next morning in the Ward Teaching the physician in charge of our teaching Prof. M.K. Mitra, Prof. A.R. Sarkar, Prof. Mahesh Chandra, Prof. Mam Chandra, Prof. Ashok Chandra, Prof. R.C. Ahuja would go from bed to bed and ask the student, who was allotted the patient, to present the case. This is the description of one such ward teaching, conducted by Prof. Manoj Mitra.

 

The Case Presentation

This middle aged man had a long history of coughing, which he insisted was seasonal and would exacerbate in the cold. He had been to many doctors and had a bunch of prescriptions of different antibiotics, anti allergic drugs and cough syrups. This time his sputum was pinkish in colour, which scared him and so he agreed to get hospitalized. He was finding it difficult to climb stairs of his first floor home and got easily fatigued. Prof. Mitra patiently listened to the history, asked a few questions in Bengali to the patient, and then did a thorough examination. Then he reassured him that they have arrived at a diagnosis and he will be absolutely cured and will be discharged very soon. He also told him in Bengali that now he was going to teach the students about all the medical problems similar to his but it will not be about him. So, he need not unnecessarily worry. Then he turned around to address us, who were all around his bed:  


Most people assume that coughing is associated with a lung or an airway problem. But, an unusual suspect may actually be the heart. It isn't unusual for people who have heart failure to experience significant coughing. In fact, a cough may indicate an important sign that heart failure treatment is inadequate, or, possibly, treatment itself may be causing problems.   

 

1. Heart Failure

Unlike what you may think heart failure does not mean that the heart just stops, that is cardiac arrest. Rather, it means that the heart's pumping ability has been impaired to the extent that the heart is not always able to keep up with the demands of the body. Heart failure can cause a number of cardiac disorders, including

·        coronary artery disease

·        hypertension

·        hypertrophic cardiomyopathy

·        diastolic dysfunction

·        heart valve disease

and several others.

Heart failure is a common disorder. Due to the heart's inefficient pumping ability, blood returning to the heart from the lungs tends to back up, producing pulmonary congestion, which is why people with heart failure are often said to have 'congestive heart failure.' Consequently, with pulmonary congestion, fluid, and a little blood, can leak into the alveoli (air sacs) of the lungs. This lung fluid is what's largely responsible for the dyspnea (a feeling one cannot breathe properly) commonly experienced by people with heart failure because coughing is the body's way of clearing the airway and bronchial passages. Thus, it makes sense that a cough can also result from pulmonary congestion. 


Types of Heart Failure

1.      Left-sided heart failure. There are two types of left-sided heart failure:

o    Systolic failure. This is when your left ventricle isn’t able to contract normally and your heart can’t push an adequate amount of blood into circulation.

o    Diastolic failure. This means your left ventricle doesn’t relax properly due to stiffness and your heart doesn’t fill with enough blood between beats, or the pressure for the heart to function is very high.

2.      Right-sided failure. In right-sided heart failure, your right ventricle loses pumping power and blood backs up in your veins.

3.      Congestive heart failure. The term heart failure is sometimes used interchangeably with congestive heart failure.

Left-sided heart failure causes blood to build up in your pulmonary veins that carry blood from your lungs to your left atrium. This buildup of blood can cause breathing symptoms, such as:

  • trouble breathing - dyspnea
  • shortness of breath
  • coughing, especially during exertion
  • shortness of breath when lying down - orthopnea 
  • sleeping on extra pillows at night

Right-sided heart failure leads to blood buildup in your veins, which in turn may lead to fluid retention and swelling. The legs are the most common area to develop swelling, but it’s also possible to develop it in your genitals and abdomen.

Common symptoms of right-sided heart failure include:

  • palpitations
  • chest discomfort
  • shortness of breath 
  • fluid retention, especially in your lower body - oedema
  • weight gain

 

2. Cardiac Cough

Coughing caused solely by heart failure can take several forms. A wet cough produces frothy sputum that may be tinged pink with blood, tends to be quite common with heart failure. Heavy wheezing and labored breathing may also accompany spells of coughing, along with a bubbling feeling in the chest, or even a whistling sound from the lungs. Coughing symptoms like this usually are a sign that heart failure has become substantially worse, and such a cough is usually accompanied by a general flare-up of heart failure symptoms. These symptoms are likely to include

·        Dyspnea

·        orthopnea  or shortness of breath when lying down

·        oedema swelling in dependant parts of the body

·        paroxysmal nocturnal dyspnea or waking up from sleep in the middle of the night, gasping and coughing.

However, people who have this severe form of cardiac cough are generally sick enough to seek medical help without much prompting. 

A cardiac cough can take a much less severe form. Some people with heart failure will develop an annoying, more chronic, drier cough that may produce a small amount of white or pink frothy mucus. People who have this less severe form may assume it to be due to some other cause, attribute to their smoking habit, and thus may fail to seek medical assistance. In doing so, however, the symptoms of heart failure are likely to become substantially worse. So patients should not ignore the onset of a cough even if they consider it to be mild. 

 

3. Medication-Related Cough

Beta blockers are prescribed to lower the heart rate and blood pressure in hypertensive patients. These also target beta receptors throughout our entire body, including the lungs. This may trigger an asthma attack with symptoms such as coughing and wheezing. 

Calcium channel blockers treat heart conditions such as hypertension and coronary artery disease. While uncommon, they too may indirectly cause a drug-induced cough in some people. 

Coughing is also a side effect of a new class of medication that is being tried in patients with heart failure: angiotensin-converting enzyme (ACE) inhibitors. ACE inhibitors. These are helpful for heart failure because they dilate the arteries, thus making it easier for the heart to pump blood. These drugs, in trial have shown to produce a cough in about 4% of the test subjects. The cough they experience is generally a dry hacking cough which does not produce sputum.


This is how in 45 minutes this bedside teaching session ended. He encouraged the student presenting the case and urged him to keep up the good work. He then turned to the patient to profusely thank him for his cooperation in the teaching programme and the group moved on to the next bed.

 

These bed side teachings were the heart and soul of our teaching programme in King George’s Medical College. These sessions would improve our’ history taking, examination skills, and knowledge of clinical ethics. It taught us professionalism, and fostered good communication and role modelling skills. These educational sessions would integrate theory, practical skills, and patient contact to make the educational process as realistic as possible, and allow us, the students to develop empathy with the patients. Teaching small groups in the presence of the patient allows trainees to be closely observed and taught clinical practice and medical examinations.

 

Rather than only listening to a presentation or reading from a blackboard, learners have the opportunity to use most of their senses—hearing, vision, smell, and touch—to learn more about the patient and his or her problems. I experienced this during the early years of my training with the first patient I admitted as a resident of surgery with pancreatitis—the smell of alcohol on the breath, the dry tongue, and the decreased skin turgor. By the bedside, I also learnt about the pigmented spots around the umbilicus in severe haemorrhagic pancreatitis and Rovsing’s sign in acute appendicitis. These experiences create hooks upon which a great deal of clinical learning can be hung. 


Although it is known to enhance a student’s learning experience and improve patient care, the use of this type of teaching is unfortunately in steady decline. Absence of quality teachers and the litigations that teachers fear to get entangled in after such teaching sessions are doing immense harm to medical education. Prof. Mitra is still in active practice and stays in New Hyderabad in Lucknow. He chairs several ethics committees and is always ready to help all his students and patients.

Thursday, 1 May 2025

FINANCIAL PLANNING FOR ALL AGES


 

Financial success doesn't happen by accident—it requires purposeful planning that evolves as you move through life. Just as your priorities shift with age, your money management strategy should adapt to each new decade. What makes sense in your twenties might not work in your fifties, and retirement brings entirely new considerations. My father worked in Life Insurance Corporation of India and was extremely meticulous in budgeting for meeting the diverse needs of my mother and their three children. Very early in my life, I was told the value of financial planning by judicious and purposeful investments. I am trying to recollect the lessons learned three and a half decades back and share them with you.

This decade-by-decade financial roadmap offers tailored guidance for every life stage, helping you build wealth gradually while avoiding common pitfalls. Whether you're just starting out or nearing retirement, these age-appropriate financial strategies create a framework for making informed decisions that support your changing goals and circumstances.

 

Your 20s: Building the Foundation

Your twenties mark the beginning of financial independence - you're finishing your education, starting careers, and standing on your own two feet. This decade sets the tone for your financial future. Five essential money moves in your 20s:

1.      Start banking properly. If you haven't already, open a checking and savings account. Beyond the practical benefits of managing your money and paying bills, established bank accounts signal responsibility to potential landlords, employers, and lenders.

2.      Begin saving consistently. Develop the habit of setting aside money from each paycheck. Aim for enough savings to cover 3-6 months of expenses for emergencies. Setting up automatic transfers into a recurring deposit (RD)account or a Systemic Investment Plan (SIP) in a mutual fund makes this process painless and effective. This fund may turn out to be your best Health Insurance Plan in days to come!

3.      Think about retirement now. It may seem distant, but people who start retirement contributions in their twenties can retire earlier with much more money. Take advantage of any employer-sponsored provident fund scheme, especially if matching contributions are offered. Opt for the New Pension Plan(NPS) now.

4.      Create a realistic budget. Understand exactly what comes in and what goes out each month. Add up necessities like rent, food, loan payments and savings, then subtract from your income. Whatever remains covers discretionary spending. If nothing's left over (or worse, you're in the negative), it's time to cut expenses.

5.      Start building credit wisely. Your credit history affects many future opportunities. Begin with a low-limit credit card that you use responsibly and pay off monthly. If you already have debt, make a plan to pay it down systematically, prioritizing high-interest balances first. Make on-time student loan payments to establish good credit habits.

 

Your 30s: Growing Your Wealth

In your thirties, you've moved beyond basics and face new financial challenges. You might be thinking about home ownership, starting a family, or moving up in your career. Five key financial priorities for your 30s are:

1.      Expand your investment strategy. While your PPF, NPS and Mutual Fund investments should be growing steadily, now's the time to review their performance and possibly adjust your approach. Your age allows for somewhat aggressive investments. Talk to your retirement plan provider about aligning investments with your personal risk tolerance. It the market is favourable switch a part of your debt investments into equity. Make it a habit to make a regular annual investment in gold or gold bonds.

2.      Consider homeownership. Buying property can be a smart long-term move, but only if the timing is right for your finances. Financial experts recommend keeping your monthly mortgage payment below 25% of your income to maintain healthy finances. Real estate values hardly ever fall and the earlier you purchase your house, the cheaper it will be.

3.      Review your insurance needs. If you've married or had children, life insurance becomes important. It provides for your loved ones if something happens to you. Generally, younger people pay lower premiums, making early enrollment a money-saver.

4.      Put basic estate planning in place. Creating a will is essential, particularly if you have a spouse or children. This document addresses both family and financial matters that would arise after your death. Depending on your situation, you might use online resources or consult an estate planning attorney.

5.      Refine your budget regularly. Review your spending plan at least quarterly and adjust as needed. If expenses exceed income, tighten up your spending habits. Continue paying down non-mortgage debt while saving for future goals.

 

Your 40s: Assessing Your Progress

Your forties are the time to evaluate your financial plan and make sure you're on track. You've established many financial habits, and now you need to check if they're working as intended. Five financial tasks for your 40s should be:

1.      Attack remaining debt. With mounting responsibilities and expenses, many people in their forties carry credit cards and other debts. Make debt reduction a priority now. Determine a monthly payment you can manage, then tackle high-interest debts first.

2.      Evaluate retirement readiness. By now, you should have a clear picture of your retirement savings. Meet with a financial advisor to review your investment strategy, set specific targets, and confirm you're on pace to meet them. If not, adjust your approach. Make sure you're taking full advantage of employer matching in retirement plans and the prevailing market forces. Your investment in gold should continue, you are doing this for your spouse and children.

3.      Check life insurance coverage. Ensure your policy still matches your family's needs. Major life changes like having children or buying a home might mean you need to update your coverage amount or type.

4.      Update your beneficiaries. To protect your family, verify that the right people are named as beneficiaries on your will, life insurance, retirement accounts, and other financial assets.

5.      Consider additional protection. Beyond life insurance, look into whether disability coverage or long-term care insurance makes sense for your situation. During this decade, many people find themselves caring for both children and aging parents. Don't let these responsibilities cause you to neglect your own financial health.

 

Your 50s: Preparing for the Next Chapter

In your fifties, you're likely established in your career. Your children may be independent, and retirement is becoming a more concrete reality rather than a distant concept. Five financial goals for your 50s should be:

1.       Work toward zero debt. With careful money management, you should aim to eliminate debt during this period. As retirement approaches, focus not only on reducing existing debt but also on avoiding new financial obligations. Simply put: live within your means.

2.      Strengthen your emergency fund. Having fully funded emergency savings becomes even more critical now. Unexpected events can still happen, and you want to avoid tapping into retirement funds to handle them. The RD which you started in your twenties is now grown to become your health insurance fund, an insurance plan which will never disappoint you.

3.      Reassess retirement plans. If you're behind on savings goals, take advantage of catch-up provisions that allow higher contribution limits for PPF or Pension funds. If you're on track, maintain your current strategy.

4.      Adjust investment risk. With adequate retirement savings and a target retirement date in mind, consider reducing your investment risk. Use online planning tools or consult a financial advisor to determine the right level of risk for your portfolio. Depending upon your assets and liabilities adjust your investments, more towards debt rather than equities

5.      Update estate plans. Review your estate documents, will, and insurance policies. Make adjustments based on life changes and current laws. Confirm that executors, beneficiaries, and guardians still reflect your wishes.

 

Your 60s: Transitioning to Retirement

Your sixties mark the shift from earning to spending your retirement savings. This decade requires careful planning to make your money last. Five financial priorities for your 60s then are:

1.      Develop a retirement withdrawal plan. As you move into retirement, create a strategy for drawing from your various accounts. Experts recommend managing withdrawals carefully to extend the life of your savings.

2.      Maintain a realistic budget. With regular employment income ending, tracking spending becomes even more important. Adjust your budget to reflect your new financial reality where your money is now working to make money and you are not working so much.

3.      Identify your income sources. Know exactly where your retirement money is coming from. First ensure your essential needs are covered, then plan how to fund discretionary expenses like travel, home renovations, and special events.

4.      Review your estate plan. This is an excellent time to update or establish comprehensive estate planning documents to ensure your wishes and that of your spouse’s are carried out.

5.      Consider healthcare costs. If you have a regular medical insurance it will cover some, if not all expenses, but if you have that RD still running you are assured for supplemental coverage and potential long-term care expenses that Medicai Insurance doesn't cover.

Your 70s: Enjoying Your Golden Years

Your seventies offer a chance to enjoy retirement while still maintaining financial security. This decade balances prudent money management with quality of life. Five financial considerations for your 70s should be:

1.      Monitor spending carefully. Continue managing your expenses to ensure your retirement savings last. Regular budget reviews help prevent overspending as living costs change.

2.      Finalize estate planning. Ensure your will and other estate documents are current and reflect your wishes. Consider discussing these plans with spouse and trusted family members.

3.      Prioritize health management. Healthcare often becomes a larger expense now. Budget for medical costs alongside preventive care that keeps you active and engaged.

4.      Create "spending guardrails." Financial experts recommend establishing flexible spending boundaries that allow you to enjoy retirement while ensuring long-term security. These guidelines help forecast sustainable spending levels.

5.      Make the most of your "go-go years." If your health allows, this might be the perfect time to cross items off your bucket list. Balance adventure with financial responsibility.

 

Your 80s: Securing Your Legacy

In your eighties, financial planning shifts toward protection and legacy. This decade focuses on preserving assets and defining your lasting impact. Five financial goals for your 80s should be:

1.      Guard against financial fraud. Stay vigilant about potential scams, as seniors are frequent targets. Consider simplifying financial arrangements and involving trusted family members in monitoring accounts.

2.      Reassess your living situation. Evaluate whether your current home still meets your needs or if downsizing would improve your quality of life and financial and social security.

3.      Update your legacy plan. Review beneficiary designations, charitable intentions, and other elements of your estate plan to ensure they reflect your current wishes.

4.      Consider philanthropic goals. This is an ideal time to finalize plans for charitable giving that expresses your values and supports causes meaningful to you.

5.      Document your financial information. Make sure loved ones know where to find important documents and accounts. Consider creating a comprehensive guide to your finances for those who may need to assist you.


The idea is that you have to remain in charge of your life at all times. For this to happen, you have to take charge of both your health and your wealth. Wealth management, which involves accumulating, conserving and distributing wealth, should always be under your control. Estate Planning involves a comprehensive approach to manage this estate during a person's lifetime and determining how it should be distributed after their death to optimize tax benefits as well as smooth transfers. It goes beyond simply creating a Will and encompasses various legal and financial strategies to protect and transfer wealth according to the individual's wishes. I wrote a blog on wealth management some months ago. You can read it by clicking this hyperlink: https://surajitbrainwaves.blogspot.com/2024/11/wealth-management-and-inheritance.html