Rajesh Nallapati, MD, MBBS: You Must Know Yourself Before You Can Know Your Patient

  

Rajesh Nallapati

Rajesh was born in Guntur in Andhra Pradesh, forty miles west of the Bay of Bengal. The hot humid agricultural area in South India is an important site in the history of Buddhism.  It is felt to be where, nearly 2,500 years ago, the Buddha taught the never-ending cycles of existence. Buddhism flourished in India until about the 12th century when it was “absorbed” by the various strains of the folk religion that would later be called Hinduism.  

 His family moved 50 miles from Guntur when Raj was about four. His father was a primary care physician who would sometimes, for example, ride his bike from their small village to the tiny nearby hospital to deliver a baby using forceps. The two doctors in the town “did everything” said Raj, and his father became very “popular.” 

At the local school, Raj and his two younger siblings sat on the dirt floor under a thatched roof carefully holding their simple black slates; there were no books. They walked home for lunch and during monsoon season, their feet would be covered in thick mud. 

Indian children sitting outside at a school
during the COVID-19 pandemic
(Credit: Reuters/Prashant Waydande)

The Family Moves to Hyderabad

After six or seven years there, his father (then in his late 30s) decided to become a general surgeon so he moved the family to the ancient teeming city of Hyderabad for a residency. Young Raj got into “a horrible fight” on the first day of third grade at his new school, but he quickly adjusted. And as his father trained, his “amazing” mother took care of the household chores, including collecting scarce clean water between three and five in the morning, the only time it was made available.

The future Dr. Nallapati was a good student who was “always in the top two or three” in his classes. The textbooks were in Telugu, the local classical language.  English was introduced in the fifth grade, but only as a studied subject; Telugu remained the standard until the students were in the tenth grade.  Teeming India has 22 “official” languages and 121 major languages. (According to the BBC, Telugu is the fastest-growing language in the US.)

Official Indian Languages (Credit: Wikipedia)

When Raj was in the eighth grade the family needed more money than his dad was earning working for the government.  So his father took a more lucrative surgical post in Iran. By the time he returned, two years later, his son was thinking about a career. 

Medical School

In India, the 11th and 12th grades were comparable to junior college in the US. Raj had always looked up to his father, and after briefly considering a career in agriculture (he was “fascinated by plants”), he decided, instead, on medicine. 

There was intense competition for spots in medical school. Raj did well in the required testing and was accepted to the Siddhartha Medical College, about 30 miles from  Gunter. He said he loved the basic science and pathophysiology of “the disease process” and studied diligently. To advance his knowledge after medical school he hoped to go to the States to study internal medicine. 

Govt. Siddhartha Medical College, Vijaywada (Credit: MOKSH)

For some reason, Raj tarried and waited until his fourth year in medical school to complete the USMLE exam to be eligible to apply for a U.S. residency position. When he came home on weekends to study for the critical tests he holed up in the library at the Guntur Medical College. It was a fateful choice. You see, that’s where he first spotted the medical student who would (several years later) become his wife, Dr. Vatsala Parchuri (Guntur ‘96).  

Dr. Nallapati had to go to Singapore and Bangkok for the USMLE, and after passing the exams he was ready for America.  But since Raj did not enroll in the “match” system that pairs prospective residents with specific programs based on mutual interest, he had to “scramble” to find a spot.

New York and then York for Internal Medicine

Rajesh came here on a visa and stayed with his cousin in New York as he applied for a residency. He landed an interview with a hospital in New York but they didn’t take him.  Time passed. Looking slightly further afar, he saw that the York Hospital (in neighboring PA) needed someone to fill an open slot. 

When he met with York’s director of the internal medicine residency, Dr. Wolfe Blotzer, the meeting went well. (“I was so nerdy. Maybe he thought I was intelligent,” quipped Raj with a laugh). It went so well, in fact, that when Dr. Nallapati returned to his room at the Yorktowne Hotel the small red light on the telephone was flashing. The message:  He was offered a position.  (He told me he was only the second foreign medical graduate in the medicine residency at York; many more would follow.)

The Yorktowne Hotel
(Credit: York County Economic Alliance)

A generous cousin lent him $2,000 for the first two months rent in York and he bought a ten-year-old car (a 1986) for about $1000, and he was on his way.

Dr. Nallapati started his three-year internal medicine studies with the idea of doing primary care. He had a few simple goals: How do you learn more? How do you get things done? How do you get things right? 

The training was mostly directed toward diagnosing and taking care of sick hospitalized patients.  Raj found that the science and application of medical knowledge in the hospital setting was relatively easy to master. But he and his fellow residents viewed their weekly four hours of dreary outpatient clinic (tending to people who weren’t acutely ill) as “painful, burdensome, and unnecessary.” 

(Incidentally, Dr. Nallapati and Dr. Parchuri were married in the second year of Raj’s residency and Vatsala joined him in York the following year for her own training.) 

Outpatient Practice

After he finished the three years, Raj found that the intense hospital-based work had not prepared him for the altogether different practice of outpatient primary care, the medical care that, in his words, “should be freely available, like water.”   

Fictional Walk-In Clinic/Hospital set in coastal southern India
(Credit: Fandom)

Everything (not really everything, but many things) he had learned “went out the window,” he said. Dr. Nallapati was faced with the daunting challenge of figuring out how to deal with human personalities, not just, for instance, falling blood pressure or poor cardiac output or sepsis. 

And that he had to learn this on his own as he encountered one suffering patient after another. It wasn’t long before he concluded that communication, the mysterious and remarkable coupling of brains, was the most important and most challenging part of his daily work. 

Communication and Kindness

The first step in communicating is listening. Dr. Nallapati gradually learned that by calming his anxieties and clearing his prejudices or preconceived notions, and by being more balanced, he could hear better. By listening closely (with true attention) without judgment, but with empathy and patience, the answers to problems would eventually come to him. 

And by being kind to the patient, yes, kind, he could know what they wanted, what they expected, what they needed.  He would intuitively know what to say to make them comfortable, how to counsel them, and how to engage them in self-care.  Trying to help people in this way he could focus on “basic human values.” 

We want to be listened to; we need to be heard. Developing effective listening skills was “an evolutionary process,” he said. The agenda during a visit, dictated partly by the health systems that require physicians to tick off a list of boxes, and partly by the doctor’s own biases, is not the patient’s. 

The truly effective clinician is mindful. According to Dr. Ronald Epstein (1999): 

The goals of mindful practice are to become more aware of one’s own mental processes, listen more attentively, become flexible, and recognize bias and judgments, and thereby act with principles and compassion.  Mindful practice involves a sense of unfinishedness, curiosity about the unknown and humility in having an imperfect understanding of another’s suffering. Mindfulness is the opposite of multitasking. Mindfulness is a quality of the physician as person, without boundaries between technical, cognitive, emotional, and spiritual aspects of practice.(p. 835)

And:

Self-knowledge is essential to the expression of core values in medicine, such as empathy, compassion, and altruism. To be empathic, I must witness and understand the patient’s suffering and my reactions to the patient’s suffering to distinguish the patient’s experience from my own. Then I can communicate my understanding and be compassionate, to use my presence to relieve suffering and to put the patient’s interests first. (p. 836)

To emphasize the importance of listening, Dr. Nallapati believes (and there is much evidence to show) that 80% of making a correct diagnosis comes from the history obtained from the patient. The physical exam may provide another 15% and only 5% is the result of testing. Get the story wrong and the correct diagnosis will be missed. 

Meditation and Self-Knowledge

Jayram

Raj said that meditating has helped him tremendously in this endeavor to get things right. Though he was “always” interested in meditation and read books on it, only in the last ten years has he practiced it regularly. He has been greatly helped by his friend and colleague, Dr. Jayram Thimmapuram, an accomplished meditator and calming instructor. Dr. Nallapati said that meditation is “the most important thing in life.” (Let that thought sink in for a minute.)

His daily practice of about thirty minutes of mindful meditating has given him invaluable insights into himself as he tries to see things more clearly, to become aware, he said, of “the smell of your own rotten tooth.” By understanding yourself, who you are, you can avoid the dangerous traps of preconceived ideas and biases that lead us astray. 

As a follower of Hinduism, Dr. Nallapati believes in reincarnation; that our soul, our true self, survives the death of the body. He feels that the reason you are born is to “clean up yourself and prejudices” to be a better human being, to live a virtuous ethical life, and to accumulate good karma. And that you will be reborn again and again until you become enlightened and realize that you are one with God, the all-encompassing reality. 

Raj mentioned a book by Brian Weiss, “Many Lives, Many Masters” where people under deep hypnosis recalled previous incarnations. What happened in one life affected future lives.  (Evolutionarily, we are the product of the distant past and the source of what will happen next.)   

Some Random Thoughts

Speaking of books, when he was younger, Raj (are you ready for this?) used to read a 300- or 400-page novel every day. Now, even with the meditator’s steady focus, he doesn’t have the patience to make it through a whole book. Instead, he watches movies. His daily dose of cinema leans heavily towards dramas, especially the classics.

Dr. Nallapati is also a thinker. Looking forward, what does he see? He said that while the “standard of care”  of American medicine is “great” the access is poor and the cost in our “for profit” system is “outrageous.”  Both problems need urgent solutions. 

He worries that the push for a brain-computer interface, as currently championed by Elon Musk, will be “the end of mankind” as it will (have the potential to) “completely control humanity.” Raj feels, instead, that the true promise of modern medical technology lies in tapping the regenerative capabilities of the stem cell. 

But what about now? Dr. Nallapati told me that the most important indicator of “health” is our fitness, not the presence or absence of disease. He is concerned about the worldwide obesity epidemic and he is a proponent of home cooking and of eating “real food.” He believes that intermittent fasting, with long periods of ketosis, has major health benefits (especially as nearly all cancer cells depend on a continuous supply of glucose and can’t use ketones).

As we travel along the cycle of life striving to live ethically according to our true nature as revealed by meditation, and by engaging with others through mindful listening and sharing, we can discover, among other insights, the importance of kindness.

"Kindness" (excerpted)

by Naomi Shihab Nye  

Before you know what kindness really is/ you must lose things,/ feel the future dissolve in a moment/ like salt in a weakened broth…

Before you know kindness as the deepest thing inside,/ you must know sorrow as the other deepest thing…
Then it is only kindness that makes sense anymore,/ only kindness that ties your shoes/ and sends you out into the day to gaze at bread,/ only kindness that raises its head/ from the crowd of the world to say

It is I you have been looking for,/ and then goes with you everywhere/ like a shadow or a friend.

Reference and Recommended Reading:

1. Epstein, Ronald. "Mindful Practice." JAMA 1999, 282(9): 833-839. 

2. Hahn, Tich Nat. The Art of Communication. HarperCollins, New York, 2014.  (A photo of my worn and marked-up copy is above.)

Reservoir Park in the fall (Photo by SC)

By Anita Cherry 11/22/24