HMS

Been to HMS and Dana Farber today. These are the hallowed meccas of medicine supposedly...most of Harrison being written by people who roam the area between Longwood Avenue and Binney St; Eugene Braunwald is sitting some few square feet away, Douglas Zipes and Peter Libby are teaching some residents/fellows some place near, path breaking research is going on someplace else- I mean BWH, Dana Farber, BIDMC, Joslin, Children's hospital all in one expanse of area not more than JJH: this place rocks.I mean ROCKS!!!!!

But then the fact that there is so much snootiness, inaccessibility to the whole place is a one major put off. For all the appeal of the place,its hopelessly overpriced- they put a premium on getting in ....which is too high for me to get through as an IMG.Its a huge fat slippery American ass we have here.

A roll muster of interns gaining admission into PGY1 positions at BWH is available at the Brigham's website. Going through that makes me realize that we follow such a linear path from MBBS, to MD to DM- life is so much more easy in the training phase.These guys take pitstops at Oxford, Colombia and Africa, establish an NGO or two, patent a drug or technique before they enter residency. That they are compensated in that they do not need to have a 'set up' once they finish residency/fellowship and mint the moolah rightaway equals off the input output equation between us and them.But this is probably the most productive phase of your life man- wouldn't one want this to be a once in lifetime experience.

One of those days

We had a metaphor for uselessness at BJ...valloochi pishvi( bag of sand) ....it is a feeling of uselessness packaged and given manifest form, identity and character.Given a power to wield over you.That was II/Ist....a time in your life when you were allowed by seniors to spend entire days in the canteen, driven by registrars out of wards had you dared to venture in, written doses of Haltax in milligrams, barely made the 75% attendance by proxy,and had the temerity to attend term end viva voce unprepared and smile at the examiner saying,"its II/I sir, what do you expect?"

That time has gone. But today was one of those days. When you stare at boredom and boredom just returns the vacuous stare.Even daydreaming seems to evade me, I am staring at the same page of Infinite Jest for hours, like a petit mal status.

Tomorrow shall rise, and we shall shine.

In India...

Nodding in agreement to everything the senior says(' haan mein haan milana'),using the word 'wow' so frequently with good or bad events that he/she mentions,sending thank you notes and gifts with lofty poems and dedications...is called 'chaatna'

Here it is just 'being polite'

Transvaginal cholecystectomy!!

My last post was about creativity and doctors.Well,I have to take a step back here.
White coats are benign, but give a monkey nuts and bolts / scalpels and forceps and he can wreak havoc.
Is there is a limit to where you can insert scopes? Its the surgeon at his sado-masochistic best!! Called Natural Orifice Transluminal Endoscopic Surgery ( NOTES) its a logic of U have holes and you have pipes, and you have your imagination, do what you can.
Well, in a consumer driven market it might well become a next hot thing in surgery. It spares you the scars...However small the laparoscopic incisions might be, it looks ugly when you are working your hours in the gym for that washboard surfacing.
Plus the approach ports are easily accessible-the vagina is the best supposedly.Others proposed are gastroscopic, transcolonic and transvesical.Dr Puntambekar could do a Wertheim hysterectomy through the transvaginal approach. If an entire fetus can pass through- why not a gall bladder?Man if you have seen a Jayle's retractor stretch the vagina you would believe you could turn the person inside out through the vagina!! Males are at a disadvantage here I guess. But they aren't cosmetically inclined too is commiseration enough.

First there was the endoscopes in the 50s and 60s.Then the laparoscopes in the 80s.In 1987,when Philippe Mouret performed the first laparoscopic cholecystectomy. The Anglo-Saxon world called it the "second French revolution" .

The PEG tube is a delectable combination of the transabdominal and the transgastric.It was just time before someone had to think of why not...say.. combine the two....The first was called operation Anubis was presented at the Japanese Congress of Surgery in Osaka on April 6th, 2007.Anubis was the ancient god in Egyptian mythology who restored Osiris to life through mummification using long, flexible instruments. The project was named after this reference.In fact the procedure was formally proposed as early as 2004.And a guy from India, Dr Reddy, has being doing gastroscopic appendectomies since some time it seems.The procedure has come a distance and seems prepared to go a distance. But one has to argue, especially with the appendectomy thing- is this a case of convenience to the patient or subservience to the surgeon's egotistic indulgences? Ok I accept the case of maybe those who can't go through TIVA, but a resounding NO for all others. Why eat an orange with your feeding arm encircling your head? Having mastered the routine spinal stuff,is this a case of wanting to play ball at one higher level.

Other potential advantages proposed include the need for reduced anesthesia requirements and hence shorter hospital stays. Avoiding potential complications of transabdominal wound infections (i.e. "hernias")- I don't buy.And a laparoscopic incision is so small!! Yes post op pulmonary function will be good. But this is a procedure for elective bread and butter procedures on the well fed higher socioeconomic patient group- choles,appendices.This is a procedure that needs to prove its utility beyond the transvaginal approach.

Borrowed stuff again..

I seem to be overdosing on borrowed stuff....but its quite an interesting read


http://healthcare-economist.com/2007/10/02/health-care-system-grudge-match-canada-vs-us/

The brain remains our sexiest organ- only if turned on.

'Inspired' by an article from the BMJ:Table is Bru'd and Colgated( kaapied and pasted).Rest my inputs with occasional sprinklings of the writer's thoughts.

Common medical mental failings

Attitude:


Resistance to change

Cynicism

Lack of empathy

Intellectual tiredness

Emotional froideur

Cognitive function:

Failing memory

Irrationality

Erratic performance

Humour:

Outright failure

Relentless levity

Illiteracy:

Numbers and statistics

Emotion

Culture and literature

Language

Creativity:

Lack of ideas

Lack of opportunity

Workaday triviality

Put monkeys in white coats and they lose their bananas.

Traditional medical thinking follows the chimps. Despite centuries of medical science and epidemiology, we itch to name things, to define discrete categories, and to treat syndromes as entities. We automatically regard association as causation- maths was our least loved subject and we took biology in Std XII to escape the differentials and parabolic equations- and overvalue repetition in chance events.Occam's razor is an over taught rule and TB can cause everything except pregnancy is a joke we all hear from medicine residents' clinics. Even clever doctors make the usual errors in probability calculations.Thats all geeky stuff. We docs are hardworking guys who pride on learning hands on , rather than minds on.Flesh and bones and blood is easier to appeal to imagination and more romantic ( gee those TV channels where God plays the doctor's role- and not vice versa) than some Schroedinger's cat and Sine theta upon Cos theta equals Tan theta.

Its a tradition thing.
Its like the all appealing American sport concept..sunday evening is football where 200 pound hulks will wrestle for a oval football( oxymoron of sorts- balls aren't ever oval are they, ball never touches foot)while pretty girls dance in colorful skirts while people watch over chips and soda.Sunday evening cannot be any different. Its the ultimate dumbed down all conforming concept that can be.Tennis and soccer are for girls, who plays cricket anyways. Ball game equals you know what.If you mean something else, you are such a jerk.Similarly medicine is a tradition thing- as hallowed( love the way it rhymes with 'Hollow')as hallow can be. Medicine has to be the way it has been taught for centuries- anatomy and physiology doesn't change. Why should doctors?

Should a medicine man be creative then? Thats something of an antithesis.To be creative one has to have nothing to lose mentality for things.A human life can't be possible at stake- you can't have designer surgical scars or creative drug therapy.Its not what we are taught.We are taught to get by on pattern recognition, regular routines, and lists of things to do - techniques that do at least work but are rather less than our sporting best.Where is the scope for creativity?
Creative people are not necessarily reliable, and predictable chaps are not creative. But doctors are supposed to be both safe and adaptable.

So then, you would argue,is there a dumbing down of sorts, a waxy flexibility not allowing for laterality in thought.Maybe not. I have had the liberty of learning by trial and error during residency at KEM- litigiousness is the last thing to exist amongst the killjoy plethora of miserable circumstance and emotion. Have given bromocriptine to my hepatic encephalopathy patients, done exchange transfusion for borderline indications in sickle quasi crisis situations, done a hash of a Le Veen shunt for refractory ascites patients, liberally used magnesium without serum levels, lavaged ET tubes with Ciplox solution, used a hair dryer to warm a hypothermic patient, half dosed people with Artesunate...many more innovative spontaneous need based interventions . I would not hazard to do that in this country. But these were still within certain limits of biological plausibility and ethical viability.They are not radically alarming or avant garde. There is not a relativity theory or a abstract thought process yet in medical management protocols.

Protocols, protocols!!...well-since I uttered- In making protocols for management we are risking not making use of our brains to the complete extent possible. Think of the most cerebral event in managing a patient- is it writing the right side orders, interpreting test results? Or is it deciding when to change to plan B, racking your brain running out of differential diagnoses, figuring the mechanics of multivalvular disease or the etiology of that stroke from the semiology of events tracing the path of that embolus, explaining asymmetry in the hypothesis testing of the iterative process.People who have worked in wards will know what to pick.Prof Louis Aledort had mentioned at a conference in Mumbai- " the most enduring thing that keeps me from getting tired of getting up everyday and going to work is seeing, almost unexpectedly, an interesting patient or an engaging case discussion that will make all this worthwhile."

Dr Aledort's words reinforce the theory of Use it or lose it.
There are encouraging initial steps
- evidence based medicine, gives method to mayhem( remember the third adjective used in the definition of EBM is 'judicious'!!)
- medical wikis and blogging - a Medicine 2.0 of sorts
- the recognition of the concept of need based medicine is a first victory in some ways
-'appropriate technology'
-inquisitive trialists and liberal FDAs- will have their problems, but also gains to accrue.

One should appreciate the fact that successful doctors of the future will have to extend their development beyond their short spell of formal specialist or general practitioner training. Clinical and technical proficiency has to be achieved in the time available; but a full medical life will require more in the future and over its full span.

That cartoon has a reference btw:
Hangwi Tang and Jennifer Hwee Kwoon Ng
Googling for a diagnosis—use of Google as a diagnostic aid: internet based study
BMJ, Dec 2006; 333: 1143 - 1145

To my connected friends

Could you forward me the full text if you have access please:

Who are the doctor bloggers and what do they want?
Coombes BMJ.2007; 335: 644-645