He must be kidding!!

I am reproducing an article from The Tribune dated Dec 13. It is a report of a summit held earlier this month where members of the American Association of Physicians of Indian Origin( AAPI), IMA and MCI were in attendance. As much as the reporting is Shahmbolic- "Ministry of Overseas of Indian Affairs?!!"- I am also left wondering why a VC of Datta Meghe Inst of Medical Sciences has to be a spokesperson for an MCI sponsored event. Sharad Power?

I shall highlight some of the startling Rimes that this Cub Mariner has to tell us. I almost decapitated myself laughing my head off.Here's how you, me and even Dupree can get their articles published in a newspaper, and why we shouldn't.( Comments in Italics mine)

New Delhi, December 13
The United States has said India’s recognition system for undergraduate medical courses is at par with theirs, an achievement that could facilitate mobility of doctors from here to the US.

( Makes that sound so official....made to sound as if Dr VM, VC is spokesperson of the US Gov dept of education , na)

The National Committee on Accreditation in the US, highest statutory body in the US responsible for foreign accreditation, has granted parity to the recognition system in India for undergraduate medical courses, Dr Vedprakash Mishra, vice-chancellor of the Datta Meghe Institute of Medical Sciences University, said at a news conference convened to brief on the Indo-US health summit starting tomorrow.

This is the link to the NCFMEA, the agency that reviews accreditation systems. Mind you, this does not mean it accredits by itself.
"The role of the NCFMEA is to review the standards used by foreign countries to accredit medical schools and determine whether those standards are comparable to the standards used to accredit medical schools in the United States"
Neither does it mean that you can bypass the USMLE exams that even the US graduates have to go through, and avoid getting the ECFMG certification( did anyone have that thought btw?). The purpose of the review of accreditation is for US students who want to pursue medical education abroad and want to avail educational assistance in form of Federal Family Education loans. So Dr VM, VC's statement is probably more so to attract children of Indian immigrants to come and pursue their medical education at institutes like the Datta Meghe Inst and not the reverse as Cubbie boy would like us to believe.The MCI's evaluation system has been reviewed already in 1997 and 2003. Quid novi Dr VM?

The parity has been granted for two years. The parity does not give automatic passage to the US or any other country. But the standards of education will be treated at par with the US which will enable students’ mobility to the US, said Dr Hemant Patel, president, American Association of Physicians of Indian Origin (AAPI).

Finally someone who makes sense!!But Dr Patel, have I misread? 1997 is ten years past!

The parity status was given on six parameters-curriculum, teaching, method of evaluation, extension, research and impact of education processes.

Research? Extension?

The first-ever Indo-US healthcare summit is being held here on December 14-15, Robinder Sachdev, a spokesman of Indian American doctors announced today.
Over 125 Indian-origin doctors from the US will be attending the summit, marking the largest ever gathering of NRIs from the US in New Delhi. This summit is being organised in partnership with the Indian Medical Association, the Medical Council of India and the Ministry of Overseas Indian Affairs.
The objective of the summit is to hold a dialogue and discuss specific steps about healthcare in specific states in India and strategies to mitigate the incidences of such diseases.

Which states? Which diseases? Is the AAPI a new GFATM or PEPFAR? If you have the money,please donate to improve the medical colleges in India. Folks like Dilip Walse Patil are least inclined to do so. They would rather fill their coffers recovering bond monies.And please, Wren and Martin is not an expensive buy.

Finally the coup de grace:

The Association of American Physicians of Indian Origin (AAPI), the moving spirit behind the summit, has signed an MoU with the Ministry of Overseas of Indian Affairs to provide rural healthcare in targeted states in India. Doctors from the US will be coming and delivering voluntary services in rural areas as per the MoU.

Show this to Dr Ramadoss please. While us medicos are unwilling to go to rural areas and serve the poor people- besides serving the MOs chicken and khamba every week of course, the genteel APIes have shown us the way with their PIOusness ...we deserve a rap on our Patel-las for fleecing for the poor cash strapped government which pays millions for our education and then choosing not to serve.Bad servers we are. Maybe the AAPI can help him in his hour of need.

My PJ: What did Ramadoss say to the AIIMSonians after Venugopal was evicted?

" Venu, vidi, where is he?"

Creativity.......again, and some shit

I had a discussion with Gotya recently about creativity and how it might manifest in his profession, as well as mine. He has an argument that I wasted whatever creativity I had in going into medicine which...probably..... is a killer of creative thought in all the protocol based management, memory intensive curricula with no scope for laterality, and all the legal ramifications of possible 'therapeutic misadventures' that creativity needs allowance for.

I was leafing through some of the paintings which his father had made and was amazed that so much creativity flowed through the hands of someone you might not even notice as anyone beyond what he appears..simple/prototype middle class mensch. Conversation drifted to a statement that creative people with poor hastakala skills ( I am making this word up for paucity of any suitable) make it as abstract artists. And that creativity is in thought, it is an idea..which manifests in a abstract painting or a photograph or a innovative program or entrepreneurial breakthrough idea.Where could you possibly fit in medicine in this?Did I really kill whatever iota of creativity I had- I can't draw like Gotya's dad, nor click a great photo nor sculpt, and my bestest poetry was at best freshlimesoda.com stuff, (which is lost with that website going off webspace)- coming into medicine?

Which brings us to a question which I have answered many people while interviewing , but never asked myself when I entered medicine.
" What attracted you to medicine?"
Good marks?!!
People say, or are told to say that they recognized a trait in themselves which they nurtured through their career.Thats kosher interview stuff. Many of us are never so far sighted unfortunately.We never understand the ramifications of what a career in medicine might mean when we take it up after Std XII, when angst, puberty, peer influence and Erikson's stages are wreaking havoc on thought process . Which is not to say that no one should take medicine. But which is to reinforce that you need to recognize and follow what is innate in yourself.For which you need time to inflect.Which is why the American system is not all bad....premed for 2-3 years, then med school. Gives you time to ripen your thought.

Taunts like Gotya's do make me ponder.When we are at crossroads again....after MBBS, after MD, after DM...do we use our faculties well and choose? Or get down to mugging MCQs , then shall choose depending on our rank.Then issues like a DGO in a big hospital versus a MD in rural hospital factor in....how sadder can it get. My friend who did Ob/Gy from BJ , and was a very popular lecturer till recently, rebelled against his wishes for a lost cause of group based practice and took up the subject when he could have well gone in for Medicine,which he liked.
Another friend won't come to the US for a course longer than two years because he has commitments to 'settling into life'.Living for your ideas is selfish, so they tell me.

Now that we have made a jump and are well into 'the system', lets also look at how Gotya is wrong. His argument would mean that doctors are uncreative people. Which is as atrocious an assumption as mine in even believing him for a minute, and coming up with the above. A creative medicine person will diagnosticate without tests,s/he will recognize patterns, s/he will ask himself questions and research for answers.I had written earlier on this blog about creativity and the physician...I had also mentioned about low cost innovative technology that people used in an appropriate setting and tasted remarkably successful results. People remain what they are. Creativity doesn't die.It manifests differently.Each circumstance offers an opportunity to use your creativity in a setting appropriate manner.You can always stretch the limits on this, you just have to have to want to do it( and not feel guilty about it).
Nothing sums it up better than the formula that Harvard cognitive neuroscientist Joshua Greene proposes (in the image above)

FECAL TRANSPLANTATION

You could have better terminology for this. Is it just getting some yucky stuff to sound fashionable?Anyways...Aas, Gessert et al have done it for C difficile infusing stool through a NG tube, others have done it through enemas, the logic being resurrecting the gut flora balance.They could not prove whether it was the Vanco pretreatment or the stool feeds( !!!) which cured relapses. But imagine...calling yourself a transplant donor when all you have to do is poop...and having a stool harvester team - what do you call them- FillThee PassTurds.
Hope it catches on in a more appealing tablet form or so.

Anyways..among other stuff, do read Medvalley High's rants about what he calls the 0.7% challenge

Might go on an outing this week....posts might dry up a bit.
Adios.

Feliz Navidad !!!

Gold, frankincense and myrrh

It is a small world...an Airtel ad will exhort.It indeed is. You do get an occasional stare of exclamation from the guy sitting ahead of you in the bus when you are talking to your friend in the lines of " abbe woh HongKong se call aaya kal, and Philadelphia call karna hai yeh week"
But it is a small world. When a filthy rich Dr Patwardhan can travel to Pune just to attend Sawai!!Small world when news comes first from the USA about events in Indore or Bangalore.And you have Gtalk at hand always.

I reiterated to myself that I am a good diagnostician when the MRI proved what I had suspected for long. And seeing kids who once huddled over PJ Mehta in the wards while twas residency days, now as uppity residents who mete and dole with self anointed righteousness gave me a nostalgic been there- done that kick. And twas reiterated to myself again why private practice exists....you can never get the attention you seek from a busy physician who has an OPD to finish, students to teach and zebras to pick and fetish upon.

It is snowing in Boston....Ananya looks like an adorable Magi doting over babies Priya and Nikhil, .... I wish I could have been for the Reading get together. Christmas is in Pune as Diwali was in Boston. You can't dash through the snow on a one horse open sleigh through Lakshmi road possibly.

But they say it's a small world.

Oh the weather outside is so 20ish
And I am so bored mugging my Spanish
And since we have no place to go
Let it snow! Let it snow! Let it snow!

Job to do

Steve Jobs said in his speech at Stanford in 2005, where he talks about three stories of his life,( I searched out this transcript specifically for Ramu...he might have read it already though) that,

"If today were the last day of my life, would I want to do what I am about to do today?"

And that he had read somewhere that if you live each day like it were the last of your life, someday you will most certainly be right.

I remember Dr Deshpande, our teacher in Physiology, a cute looking lady ( I detest the word, but she was ...cute) - who used to tell us, while we grappled with the weight of Guyton and Gray's anatomy on our 'guide' mo(u)lded brains, to "keep an attitude to 'studying' in medicine which is unlike what your colleagues in engineering or in any other course might have. Imagine you have an exam the next day...... everyday. For every patient is an exam, and you cannot be caught unawares or afford to fail."

In hindsight I feel thats one of the lessons that medicine teaches you which you can extrapolate( I love the word!!) beyond the corridors of the hospital.To want to do each thing so well that you want to justify the title you prefix your name with, something your engineering friends cannot do .And there are no measuring scales, no standards here....but a desire to live upto.....what- Schweitzer? Capecchi?Kotnis? Farmer? Bang? Sudarshan? Hegde? Arole?Patch Adams? yourself?

So often we fall hopelessly short of this standard!!!

Jobs' idea seems difficult to imagine. My friend told me once that " kranticha vichaar kshanabharacha asto"- a revolutionary thought stays for some time.You have to cherish it and grow on it. Those who work on it as a way of life end up as the names mentioned above( except the last) When faced with a situation where you do not know blue pill or red pill , do you play it safe, or do you aim for something more?

There is another take to it( Krishnamurti / Bertie ?...don't remember) ...many years down the line, when you sit back on your easy chair and think about how you did, beyond earning and spending, beyond loving and being loved, beyond being 'successful in life' - often in other people's opinion more than yours, think if you gave your best shot even if you did not end up the best. And a smile lights up your face when you realize you did. This is a fictitious moment.It might never come, it might never be. But can you live up to the expectation of that moment?

Just do it....

I was leafing through Tagore's Gitanjali. I have a really old copy published in the 30's that I picked form a raddhi bookshop sometime. I had made some really funny notes the first time I had read the book.Like a Nike logo next to this verse...one of my favorites.Since the book is already losing leaves, I thought I shall keep a e-note of this.

I must launch out my boat. The languid hours pass by on the shore
The spring has done its flowering and taken leave. And now with the burden of faded futile flowers I wait and linger.
The waves have become clamorous, and upon the bank in the shady lane the yellow leaves flutter and fall.
What emptiness do you gaze upon! Do you not feel a thrill passing through the air with the notes of the far-away song floating from the other shore?

I used to make mental pictures to understand poetry- figure out scenarios that would fit the words.( I had an equally funny one for Ozymandias)To remember this scenario I had created a story- in drawings - of an oarsman who had traveled across an endless Gulf to a surreal island with exotic flowers to get his ailing kid an orchid which he dreamed would cure his child of his illness. This at the cost of his daily wages he earned ferrying goods . He must locate it before winter causes the plant to lose its exuberant bloom, and its heavenly fragrance.He searches all over the island ,as fall/winter chases his footsteps, hunger gnaws at his determination.He searches out a lonely spot at the other end of the island where he finally spots the elusive flower.But winter has begun to tickle his bones..he smells the flower...it is barely what he was told it would be. He trundles hopelessly back to his boat, sobbing his heart out. He sits on the banks, watching across to the horizon as the sea stretches along endlessly, hoping that his child would not see him in his misery. In his sobs he does not hear the flautist play and the courtesans sing , as music fills the atmosphere and the chill and mist seem to vanish in the healing notes that waft through.

He cries out, " Lord, I have failed. Carry me, for I have no will to go and see my child die."

And his Lord whispers, from across the ocean into his ear....."despair not....your love has carried you thus far, and further shall you go. Launch your boat, so what if the flower has lost it's fragrance, you carry the fragrance in your heart.Love gave you your motivation till you came here, now faith will."

"Just do it dude"

The rest... of being ......or not being....

Quite as much as I sometimes regret not learning Shakespeare and English poetry from tatha while he was alive- I was weak in maths and needed my dose of Hall and Knight to kindle my left brain too , I also am thankful to some of my teachers who chose to rush through the State board books so that they could teach us some' real stuff'.

I have never met Ms Ramaswamy later, but the pains she took to etch Othello's soliloquy " It is the cause, It is the cause, my soul......" into my memory, or the para by para pauses she took while we painfully trundled through Wilkie Collins' Chandraphattar, or when she let me do my stuff when I differed from what she advised- and ended up hopelessly wrong, all, quite make her the best teacher I have had.

Was reading the rest of the lines after the most quoted lines of Hamlet. We were taught just the first four lines....and I thought that was it. I figured out that the rest was too heavy on existentialist stuff...too much for 8th graders. But then for blogPOST- erity, here goes:

To be, or not to be, that is the question:
Whether 'tis nobler in the mind to suffer
The slings and arrows of outrageous fortune,
Or to take arms against a sea of troubles
And by opposing end them. To die—to sleep,
No more; and by a sleep to say we end
The heart-ache and the thousand natural shocks
That flesh is heir to: 'tis a consummation
Devoutly to be wish'd. To die, to sleep;
To sleep, perchance to dream—ay, there's the rub:
For in that sleep of death what dreams may come,
When we have shuffled off this mortal coil,
Must give us pause—there's the respect
That makes calamity of so long life.
For who would bear the whips and scorns of time,
Th'oppressor's wrong, the proud man's contumely,
The pangs of dispriz'd love, the law's delay,
The insolence of office, and the spurns
That patient merit of th'unworthy takes,
When he himself might his quietus make
With a bare bodkin? Who would fardels bear,
To grunt and sweat under a weary life,
But that the dread of something after death,
The undiscovere'd country, from whose bourn
No traveller returns, puzzles the will,
And makes us rather bear those ills we have
Than fly to others that we know not of?
Thus conscience does make cowards of us all,
And thus the native hue of resolution
Is sicklied o'er with the pale cast of thought,
And enterprises of great pitch and moment
With this regard their currents turn awry
And lose the name of action.

When you hear hooves...hmm....ask Google

Well, the googleblog categorically mentions that Larry and Sergey would rather not prefer that you use the word Google as a verb. I tried to mull on a PC title for this posting ....obviously the verb 'googling' was out. Putting the word in capitals as 'Google it' was softer, but all the same fiendish as a Modi.So, disclaimer: I am not cocking a snook when I write"ask Google." It is for shortage of ideas. Ask.com has a much more friendly interface, but not a 'Google scholar' or 'pages from India.' I use Scirus and Healia, but Google has not disappointed me for medical queries. They even ante dated Stumbleupon with 'I am feeling lucky' button.

There was an article in the BMJ about Google getting the answers to problems posted in Case records at the MGH from the NEJM 58% of the time. We all know BMJ publishes junk research from time to time - the romance in the ER one was a ludicrous example.But come to think of it logically, how frequently would you hit something like Muckle Wells syndrome depends on how the person who asks the query enters the search item. He has to look at the rash and fever and look for cognitive shortcuts. He has to know whats important to add to the search list and what to discard.He has to know that the scenario fits sarcoid more than amyloid. We know of this as an anchoring heuristic- a familiar point which he/she knows and builds the case diagnosis from there. It is impossible to know every bit of information that exists about every condition in medicine.Google does all that for you...it keeps your Harrison handy on your laptop, it has the mind map like circuitry, and it can put your a+b+c together like Greg House would.Some of us like to do such syndrome hunting- e+g+h is Whipple's or Prader Willi or other such Gestalt stuff. But guys, to carry French's index of differential diagnoses and Wallach for interpretation of diagnostic tests and do it manually you would waste a hell of a lot of time reaching anywhere.

I do not see using Google for this as being wrong, or as an insult to anyone's intellect.For reasons: a) The possibility that you will arrive at a wrong diagnosis seems faint given that you are entering true factual data of positive findings that you have elicited.The issue is of sensitivity not specificity. b) Since you cannot present this as Evidence based hypothesis testing, you would obviously investigate further to test the biological plausibility of the idea before choosing to intervene on a 'hit' given by Google. c) In all cases you would follow the traditional iterative process of forming hypotheses while asking history and conducting exam, use the other two cognitive short cuts- representativeness heuristic (Spot Diagnosis method) and availability heuristic (past experience), and ask Google only when you are clueless at the end of your interrogation.

There are cases of the obsessive compulsive, patients who Google too much- the recent TIME article on one such patient is a good example.I have had an encounter with an acquaintance who waxed eloquent about her not being a vaccine person what with all the "autism going around", and defended her argument saying that "the evidence is there, you cannot deny it". I hadn't seen the evidence she alluded to, and had to take a step back there.But having seen what she was referring to, I wish I could have told her then that the most viewed videos on Youtube aren't exactly what you would call Evidence. I do share Jay Parkinson's frustration when my half read misinformed relatives choose to harp on a antediluvian dichotomy of allopathy Vs homeopathy/ ayurveda, and the latter being 'holistic', 'attacking the root cause of illness' , and choose to base their ideas on word of mouth or vague search results. But do you get confrontational with such people? I would disagree. It is better to be a facilitator in care of such patients, but to care to correct them when their enthusiasm veers them into wrong directions.

Moral: Let's accept Google as a useful tool.
But then, a fool with an idea is still a fool.

Came across this assortment of postings on the use of Google in medicine on the Clinical Cases blog.

Everybody's at home

Strange stuff.....appa does not work anymore, amma is recuperating at home, my gran is too old to work, she anyways hasn't ever worked in her long life . I am not working right now. Everybody is at home. And no one is bored!!

Have you ever fed someone with your hands? It is a deeply satisfying act. I mean hmm...beyond just the act of delivering a morsel of food to someone who can't him/herself.....Beyond the neuroticism of feeling short on time all the while....and thrusting a granola bar and coffee hurriedly into your own mouths, as you feed your own ego with low cal fattening stuff, do your own job, love yourself, even love others coz you love them loving you back..quite unlike all that ersatz ......just a bit of languorous timelessness to it.
There's also a feeling of giving to it...at an individual level.Of appeasing the hunger of someone else.I guess cooking for someone is also somewhere there in terms of satisfying your Giver instincts.I never wondered when my mother would go through all the trouble of cleaning, cutting, cooking to make us a huge bowl of Sunday evening 'tiffin' while she herself ate little or none of it.Lakshmi...your khane ka khazana is no less appeasing to you than it is to us I guess?

My readings

For suckers like me: Quail and manna. List of free articles on Pubmed.

And Dale Carnegie's mantra for MRs: How they win over and influence doctors. This is from the PLoS. Particularly interesting are the tables.

And finally....a directory of medical bloggers from India. Maintained by Indian Medic.

Happy reading.

Rabbit run. Rabbit stop.

Taking a step back and observing things as they happen. Jumpy cousin, woozy aunt, crazy Dani, helpless mother, restless rabbits, pati peripatetic, wishy washy sistahs, loads of money, Kaka's antipathy, some Spanish. Go fish.

Activity beckons.

Floydian philosophy: (with my distortion.):

Run, rabbit, run
Dig that hole, forget the sun,
And when at last the work is done
Don't sit down, its time to dig another one.

For long you live and high you fly
And smiles you'll give and tears you'll cry
And all you touch and all you see
Is all your life will ever be.

Clutter of sorts

There's a shock bubu in my sensory cortex. There's too much happening with a deafferenting of sorts.There was way too much travel. My Nashville trip merged into Boston, Reading, Mumbai. I interviewed with Mickey and Farhat for the MSF job.It was a fun thing- given real life situations to work on and stuff to manage. Felt more like an MBA assignment- to deliver food sorties to a camp in Nigeria and manage a depressed health worker, a theiving local mechanic, a broken down truck, an impending strike,ambitious plans to establish another feeding center,a disgruntled warlord who feels ignored. Made me want to start stat. But the fact that my limited period of availability would mean that only a miracle would ensure that I get to go on a mission was a bit of a dampener.Maybe I get to work with them in Mumbai.I should know from them folks soon. But then, the shock bubu - I did not feel so bad to brood on it. In other circumstance I would have. But amma has a surgery tomorrow.

Mhatre ajji died. If anyone had to know what loneliness means...man, it cannot get lonelier than it was for her.She sort of made it into oneliness with Krishna.The ISKCON people came with their drums and cymbals and sang sad bhajans. It seems unreal for me sometimes that someone can crave death so much, and not commit any hara kiri but wait patiently knowing that age or ill health will smite you on the head with the fatal blow one day...and each passing day is not the glory of sunshine and the newness of opportunity, but a long parched longing wait.

Again shock bubu ensured that my ADHD assailed senses did not want to make me mull on this, but to ponder a moment and move on.

Have things piled to do. But they can wait for now.

May the surgery go well.

Life goes around in circles

DC, Hartford, Nashville, a probable Albany, Mumbai.

If you are on a large circle, you never know when you are making a turn.

The earth is spinning while you've been running
You're gonna get back where you've been
While I've been dreaming about the real thing
My reality chases a dream.

Transformer

This was lying in the posts to edit for a long time.
Disclaimer: If you have better things to do( I did not when I started out writing this.) don't read this.If The Matrix is your Gospel truth and you look upon Bladerunning as a possible future career, read on.

Happened to read some stuff about transhumanism some time back, when time ran drearily, and disuse atrophy threatened. Seemed oddballs and kooky initially- a movement that proclaims to help people do 'better than well.'

I had a sticker stuck on the cover page of my school diary- it read, in Comic Sans MS font, "Good is not good where better is expected."I remembered.I read on.

Wikipedia ( funnily Citizendium, for all its refinement has no entry) puts it as "international intellectual and cultural movement supporting the use of science and technology to enhance human mental and physical abilities, and to ameliorate what it regards as undesirable and unnecessary aspects of the human condition such as stupidity, suffering, disease, aging and involuntary death."

I am piqued.Who are these guys? Surely they aren't aiming at sculpting a philosopher's stone?! I mean it is good to aim to improve. But how do you itemize it into a protocol or menu?That seems Riddikulus...get some parallax for gossakes.

The World Transhumanist Association defines it as "the intellectual and cultural movement that affirms the possibility and desirability of fundamentally improving the human condition through applied reason, especially by developing and making widely available technologies to eliminate aging and to greatly enhance human intellectual, physical, and psychological capacities."

Wow. So PC!!
Abstruse. As PC stuff usually is.

They aim for convergence of Nano, Bio, Info and Cognitive technologies. I was looking for hard examples. Came up with fancy shmancy names: Extropianism ( proactive evolution), Immortalism( technological immortality), Abolitionism ityaadi. Nice to read. But does not form links beyond sounding sexily vague.There are no examples to see. There is no bamboo microscope or AI based prosthetics for cripples, no Deep Thought on brain mapping for Psy illnesses, rather Bootstrapping on boozed up bombast.

My take is that as a transhumanist you could write a great bestseller, or script a hit TV series/movie.Tarsem Singh ...Cell. Remember? Feed the public on such neuromancing with the quaint, put in the CIA, a Jason Bourne and a rumpunctious hotbod like JLo, plenty of intellectual masturbation ( 'IM', as the surgical twats acronymize) with some of the above words, and you have a pseudoPhodu cheez.

Go through the WTA website, you realize it is really an idea of bringing together all progressive thought into one scaffold of improvement.It is as vague as it is ambitious. Because people never set out to eat and drink to build a beauteous fat cell 2.0, and prefer simple non intellectual fornication to IM. How can you call it a movement?Its rather a way of thought, life maybe.

There are ethical angles ad infinitum. It creates a world akin to the alpha beta Omega craziness of Huxley's Brave New World. A caste system of sorts, of those who want to stretch the limit versus those who want to make two meals a day.

All in all: Keep the font Comic Sans MS on that.Not serious are you?

If I had time to waste, I would have written more. I don't, and hence I end here.I want to use the time to evolve pro actively.

Dance to the music in eternal sunshine of the spotless mind

I used to laugh out uproariously every time I saw his photograph.
Until I came to this Ubuntuised country. Now I respect the philosophy that everyone has a right to be an asshole.I am the wise one( ass hole to somebody else) because there is an asshole like this.Respect everyone, however BORATic he might be.He is the one is responsible for who you are.

I clicked this while we were in Melghat, some 6-7 years ago.Came across this snap( have I posted this already before?) while I was going through old files I had saved on my iPod. It goes like this: Melghat has never had electricity. The last time electricity poles were erected was in the 1980s when Indira Gandhi came visiting.But when she went back, the two warring State Electricity Boards of Maharashtra and MP went back to their pehle tum bickering as to who should be responsible for providing electricity for these suckers.


With all the malnutrition deaths taking up news, the NGOs came to Melghat. They provided solar panels to the villagers.

But you can't, well, give a bushman a fork and knife and expect him to use it the way you do. So what do they do with the solar panels: Watch:

Btw the song they played was Bagh aga bagh sakhe kasa bugu bugu laag tay ..........

Brain waste, funny taste

An article I came across in the JAMA on health worker migration alludes to what they call " Brain waste"- skilled migrant workers are unable to find work in their area of expertise and end up working in unrelated low-paying jobs.

Exotic sounding word.No neurons being tossed into the bin.But compelling on the idea of why people mix up career and life.People have very quaint ideas when they make the switch.

While I must admit at forth that I am no sage on this, I have heard mixed views.
For people like DRK, working in resource poor areas was a brain waste.That its no use working for excellence when you are fighting with red tape and cost cutting all the time. It is funny, none of my teachers have given me negative feedback on that.Not Dilip Mathai, not DRK, not Kaka.
Hardik was honest to admit that its all about money.
One friend of mine, now an intern in MI told me that he came here with romantic notions that what he saw in western movies about a open country and 'promiscuous' lifestyle was true.
"Tab life mein aish karne ka aise lagta tha"

There's a whole bunch in KEM and BJ who think the Mah government is going crazy on bond issues, trying to bulldoze its way through on its supposedly moral high ground, and count it as wise investment to rather spend time and money in making it to elsewhere.

Abhijit said he wants to learn interventional pulmono skills.Charudutt said the same thing when he first came.Learning skills.Lot of things have changed since.

Lifestyle is a major draw.But I presume that means cleaner roads, more taxes, being distanced from near and dear ones,loneliness, nice big cars,safety, subtle racism. It is a mixed bag, really.It is about making choices based on priorities.As Dhiraj says," i would rather be a first class citizen in a second class country than be a second class citizen in a first class country."
No one person is right or wrong here.Just that 'results might vary based on experience.'

Many medical students seem to do so because it is a fashionable thing to do.All the batch toppers are doing it.It catches on as a trend in places like MAMC or AIIMS, where Ramadoss has to address the convocation thus:" don't go away. And if you do, please come back."In my MD batch I am the only one who chose to give my USMLE. In the batch after mine, half the batch is already interviewing.

Renita gave me a totally new perspective: of parents of unmarried girls equating getting married to someone in the US and going there as being an indicator of success in life. I got registered on shaadi.com, just to test the waters and am already put off and shall be deleting my profile.


These are individual anecdotal experiences, a bit colorful,but unsupported by sexy stats.For a more detailed discussion read the WHO fact sheet on this. But I gather, at least from the Pinoy experience, everything starts with an individual experience, an anecdote, a word of mouth, which people tend to trust.Then when things get big, people become numbers, more reliable.

If anyone does read my blog, your experiences are welcome.

Yeah...Mukesh Ambani is the richest man on the earth......so?

Territory size shows the proportion of all people living on US$10 purchasing power parity or less a day worldwide, that live there.

And the Sensex touched a sexy 20,000.So?
More such maps and great stuff at worldmapper.

To give you a sized perspective of things>>>>

Watch the video here....amazing stuff!!!

http://www.micro.magnet.fsu.edu/primer/java/scienceopticsu/powersof10/

LoveER

Believe me or not. If you plan to work in Emergency Medicine, there is a high chance that romance will strike you sometime or the other, more so if you are tall, muscular, with chiseled features and had suffered personal tragedy in the past.

Brendan Kelly from Department of Adult Psychiatry, University College Dublin does a study where she studied 20 randomly selected medical romance novels. And published her results in................... the Lancet !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!( Lim-> 1/0)

Lance my conservative heart, you blokes. Holy whatchamacallit!!

And the conclusion:
These novels draw attention to the romantic possibilities of primary care settings and the apparent inevitability of uncontrolled passions in the context of emergency medicine, especially as practised on aeroplanes. These novels suggest that there is an urgent need to include instruction in the arts of romance in training programmes for doctors and nurses who intend working in these settings.

Get me some beer please.

The new Harry....expectations

We all have grown up on this book figuratively, and literally speaking- ventured through the 14th while looking up to seniors who read the 12th and 13th, snacked on titbits from the 15th( the most extensive edition to date) ravaged the 16th with pencil underlinings and dogs ears and sticky notes, sweaty forearms and contemptuous doodles...and finally here comes the 17th. Waited a long time for this!!

The 16th was probably the one with the most mistakes- 'non caseating granulomas in TB', holy mackerel!!- as also the most monoclonal antibodies. It was a colorful cousin come visiting, but we hoped for short time.The editing left a lot to be desired - GI and immunology had a lot of unnecessary chapters, the cover was unimaginative and the colors looked as if they were splashed all over with childish glee, the mistakes were atrocious, and I still like to have an atlas- it is what makes OTM a pleasure to read when line after line of text get to your rods' nerves.

The 17th will be out March 2008. Priced $199 on Amazon. From what I can see it seems it is packaged as one book.I hope I am wrong, carrying it along will be a pain. And the middle chapters will be a pain to read with print going down into the central gutter.We want to hypertrophy the gyri, not the brachii.

Dr Loscalzo joins the editorial board. That had to be, given that so many of Harrison's authors are from BWH :-)
The promotional video says there's a 40% increase in content. This valuable new collection includes even more great depictions of pathophysiological processes, decision-speeding algorithms,( we never needed an overdose of that guys, least of all for something like osteoarthritis, probably the worst flow chart in the 16th. And the emergency medicine section had hardly any!!There's always Fred Ferri for flowcharts guys. Butt I have to hand it to you on this, endo flowcharts rock!!) clinical photographs, essential radiology images, an atlas of EKG tracings ( thats a great addition), and full color depictions of key pathological specimens( again, I hope this doesn't get too extensive)

There's 40 new chapters- including Health Disparities," "Quality and Safety in Patient Care," "Hospital Neurology," "Electrophysiology in Neurological Diagnosis," "Clinical Management of Obesity," and "Approach to Heart Murmurs" . All good additions I would agree.

There's a new section called regenerative medicine ( fancy name!!) which includes Stem Cell therapy, tissue engineering and the works. This had to come I guess. So they take some tonnage out of the outlandishly heavy on content Genetics chapters.

There are three great additions I feel:
1)Paul Farmer makes his debut in a chapter called Global considerations in medicine. All chapters will have a Global Considerations icon, which identifies important epidemiological, diagnostic, and therapeutic distinctions between global regions to aid in the diagnosis and management of specific diseases. This will help Harry shed the America specific image it is perceived to have, and enter the league of OTM. A big round of applause for this one.

2) The classic Introduction to Clinical Medicine section features new e-chapters addressing Patient Safety and Quality, Ethics in Medicine, and The Economics of Medicine; Health Disparities, and more.

3) Bonus content in a DVD, as eChapters. This includes 37 chapters spanning some 300 pages , 90 videos and include content such as an atlas of CTs and a chapter on radiography of the chest,atlases of renal pathology and urianalysis, neurology, vasculitides among others.

Harry also has taken a leaning to putting factual information into procedural approach with the 'approach to the patient' boxes since the 16th.They push the pedal on this one with extra additions in form of symptom management. I do not know the details, but this is again a welcome addition form an internist's POV.

Fact is Harrison is the most popular medical textbook all over.It is a humongous task for the editors to even attempt to cater to all their reader base. But this edition seems to be a great first step.I look forward to March 2008.

Gandhi the UnNoble

I found this engrossing piece on Gandhi on the nobelprize.org website. Ovyvind Tonneson, the editor of the official site from 1998 to 2000 writes, quoting from personal diaries of the members of the Norwegian Nobel Peace Prize Committee. Nominated 5 times in 1937,38,39 and 1947 and 1948, each time the Nobel Peace Prize Committee shot down for reasons as varied as Chauri Chaura, partition, the rioting that followed, and also the fact- in 1948, when he strongest candidate -that the Nobel Prize had never been awarded to anyone posthumously till then.In fact in 1948 the Nobel prize for peace was not awarded to anyone, the official statement from the Committee being that there was 'no suitable living candidate'

The earlier committee( 1936) had harsh words about Gandhi, Jakob Worm Muller, an advisory to the Committee had these words to say:
"He is a freedom fighter and a dictator, an idealist and a nationalist. He is frequently a Christ, but then, suddenly, an ordinary politician." There are many hate sites which say Gandhi's fight in South Africa was restricted in that he took up cause for the Indians but not the blacks.

Muller probably misinterred on Gandhi's philosophy including his message of shunning cowardice for violence as being inconsistent on his principle of non violence.It is important to remember that Gandhi was a soul keeper who chose to be truthful to himself more than a politician. When confronted with making a choice between being truthful and being practical, he would choose the former, thus infuriating many of his colleagues, who chose to play the politics game upfront.He was the writer, thinker, Nehru was the orator. Many of the things good or bad that are ascribed to him are actually the INC's decisions.Besides Gandhi himself accepts that he made mistakes. He accepted to be a part of the British Empire initially.

The exact reasons, deliberations of the Committee are not cited. These are Tonneson's conclusions. Statute 8 of the Nobel Foundation states, "the deliberations, opinions and proposals of the Nobel Committee with the award of prizes may NOT be made public or otherwise revealed."

The irony is that eminent personalities, who based their own actions on the pattern of Gandhi's teachings, were themselves awarded the Nobel Prize in later years — Albert Luthuli in 1960, Martin Luther King, Jr. in 1964, Mother Teresa in 1979, the Dalai Lama in 1989 and Nelson Mandela in 1993.The irony is that Yasser Arafat and Henry Kissinger can be awarded the Nobel prize for peace by the same people who prefered to be holier than thou with Gandhi!!!

Visual acuity six by sex

This is an uproariously funny Snellen's chart for testing your acuity of vision!!LOL.No one will be 6/6 on this I guess!!

E-gad-o !!

Came across this website in the WSJ health blog. Kevin MD does a great job really Digging up stuff from every known place on the www. Well here's the news: Siemens is offering a 1.5 T MRI scanner to the hospital which comes up with the best video detailing its reasons why it deserves to get one free of charge. Some of the videos are outright hilarious- watch the granny one.I don't know if it's intended.

I wonder.......,WTF....., I bite my orbicularis oris....

When we got an MR machine at KEM, it was the first MR machine in a municipal hospital in Mumbai, and one of the best in the city. It stood packed in huge boxes for some time because they could not carry it to the first floor where the MR console is now located. So they had to demolish a part of the wall, use a crane loader to lift it to first level, and then rebuild the wall.Of course, the KEM building being of some heritage value, the paperwork took some time coming through.
And there used to be such a long wait period for MRs in the initial months, this being the place all other hospitals would refer their patients to, people would have average wait periods of 2-3 months!! And getting an appointment for an indoor patient was an equally painful experience. Of course as we started reading MRs with the MR team, we came to be acquainted with each other more. I always had it easy referring a patient for an MR, coz them guys knew my referrals to be genuinely indicated, unlike some other colleagues of mine who had a tough time getting the job done- hehe!

My HP nearly cooked the goose on that one:
I had a patient with a double valve replacement who developed an ADEM like condition after an exanthematous fever. My houseman scheduled an MR, and sure enough Darshana/Yogesh obliged promptly. While rounding in the evening I asked my HP where the patient was. He said, " woh to MR ke liye gaya."
"What??!!!" , I stared back as if the great God had smote me down with a huge scimitar, too bewildered to shoot an abuse even. Primum non nocere( first,do no harm) is a cardinal rule we learn on the first day of medical school.

"You"....I fumbled..."bloody murderer". That was all I could manage for all the venomous upsurge.
" The valve will rip through his chest in that magnetic field"

( Some of you medically educated guys might have got the plot already. Others, come over to edge of your seats and read on as to how the motivated medicine resident saved the day.)


I shat my pants running down to the MR room trying to see if he had got in the gantry already, hoping that a flying Medtronic Hall valve hadn't damaged the machine besides of course ripping his chest apart.That I presumed was a foregone conclusion. 'I hope his sutures held strong.God, my license....weird thoughts buzzed through my brain randomly.

I was done. He was inside, with the queer humming sounds emanating from the room.

" Chalu hai?" I asked with bated breath.
" Fir kya?!" Yogesh said.
" Nothing happened I hope", I asked, biting my lips. "Valve hai uske mitral and aortic position mein"
" Abbe c#%@ye !!! Bataya kyon nahi " he howled at me open eyed, perspiring fast.Something similar had hit him too probably. Suddenly I felt in my HPs unenviable position, expecting the murderer word to come any moment.
" Idiot, isn't it your job?" I asked, knowing that it was a weak hit back, but I had an ass to save.

Then it struck both us pathetic retards simultaneously- if it hadn't happened till now, it wouldn't happen from now.Man, is it not a great feeling when the heart, that has sunk to your bollocks rises up relieved, beating like a wretched hummingbird!!! We researched and found out that the valves are MR compatible. The patient was discharged a week from then, with around 70% recovery, his valves safe and clicking away merrily. Subkuch TickTock hai.

Another MR story....... to get some dil ki bhadaas out...I mean WTF...a free machine...: a free machine!!:
Anyways:

There are people who work in the BMC who wear the BMC badge all so proudly!! These are the folks who are actually never found at work. They hang out in groups at the canteen sipping chai, gossip, go to 'aunty's' and get drunk in daytime, abuse nursing staff, look out for opportunities to strike work at smallest provocation to their mojo, ally with notorious corporators, act as recommendation guys-" saab, isko dekh ke lo haan, apna dost hai!!"- at OPDs, and make a buck out of it.They would prefer this mode of work to what the BMC pays them for: sweep or mop corridors, ferry patients, help in the wards.
And they will break lines in the OPD and thrust their paper in your face saying, " Shtaff hai!!"To which I have suppressed many a frustrated "so what motherf@#$er" under gritted teeth and murderous expression.One similar aayabai association chief from Nair Hospital comes to our OPD one busy Monday.
" Saab, MRI karne ka"
" Kyon?"
" Magaj mein dard hota hai"
After I get through a history, I conclude that this lady with a tension headache needs no imaging.So I go, " karne ka garaj nahi hai."
" Pan mereko karne ka hai na. Maine NAir mein Shitti scan kiya, Usmein kucch nahi dika. Roj magaj thanthanaata hai. Kaam ko bhi nahi gayi ek mahine se. "( Gasp)
"Kuch to fault hai"( yeah, u have your ass and brain in the wrong places, lets do a bilateral hemispherectomy!!) "Aur mein shtaff hai na, mufat mein ho jayega, aap chinta mat karo kharche ka."( Gasp, gasp!!)

I refused to write an MR for her. To which she said she knew the Asst Dean. I said I didn't know him...I said that sacchi.Pronto, the bitch goes to the Asst Dean, a glorified idiot who decided to quit academic pursuits after MBBS was too much for him, and I get a call.
" Karun taak ki. Kaay problem aahe?"
" Sir mala vaatat nahi tila laagnaar."
" Tujhya seniors la vichaarlas ka?"
" Yes sir" ( you filthy bastard!!)
" Kaay ahe, hi loka nantar khoop problems detaat. Press valyankade gela tar problem hoil re.Asha conditions madhe apan karun takaycha." ( Yeah yeah, teri bhains ko anda maru...)
" Theek aahe, sir pathvun dya tila"

And then I cocked the ultimate snoop.Dawg!!Vaibhav, my friend was registrar at the 'headache OPD'- a recent flight of fancy method by Dr Mehta to waste a resident's afternoon of good reading. I told her," udhar magaj ke special doctor baith te hain. Unka final hota hai. Woh bole to haan, nahi bole to naa. Chalega tumko?"

'Bade doctor' Vaibhav gave her TCAs and a fit to resume duty certificate. no MRI. I did the MR guys a favor. I never got an MR request refused. Thats why!!

Gautama smiled....

CABGs from India

I had briefly referred to medical tourism in an earlier post, speculating about how the nitty- gritties would work out.
I recently read a fabulous article by David E. Williams. from healthleadersmedia.com on the future of medical tourism from an American perspective.He makes five important predictions he feels will be relevant to the future of medical tourism. I shall reproduce some of his comments.

( Words in Italics from the original article. Rest, my inputs)

1) Medical tourism will cross over to the insured population in 2008: Insurers are beginning to get requests to cover medical tourism from multiple sources: employers and their benefits consultants, foreign hospitals and governments, medical tourism facilitators, and individual members who want to receive coverage overseas. There are important initial steps in this direction. For example, Blue Cross Blue Shield of South Carolina has added Bumrungrad Hospital in Thailand to its hospital network. Jaslok Hospital has tied up with Cigna.If you thought safety and standard of care were issues, the Joint Commission International has accredited over 100 foreign hospitals.

2) Mini-med plans and small employers--not big health plans and blue chip companies--will be the early adopters: Williams argues that though the big spenders will initialize the process, close to half of Americans work for organizations with under 200 workers. Only 60 percent of employers with fewer than 200 workers offered health insurance in 2006.Smaller employers look at insurance differently. Many are shifting to so-called "mini-med" or "limited benefit" plans that cover day-to-day expenses such as doctors' appointments, but not surgery. I wonder how they can commodify a medical service offered?Surgery, or a procedure is easier to. A $50,000 angioplasty in the United States costs less than $6,000 in Mohali, India, according to GlobalChoice Healthcare. Yes thats gains of around 42,000 counting airfare and stay.But with mundane spiels like the annual physical,or a pap test, will it be financially prudent to make a 10,000 km trip to Hyderabad?These would form the major bulk of doctor visits by employees and I don't think thats going to come to foreign shores.Unless you are driving from California to Mexico.I would reason that pathology or radiology would be major gainers here for obvious reasons.

3) Opposition to medical tourism by U.S. physicians will be modest: At the community level, over 25 percent of physicians in the United States are foreign-born. They are familiar with the level of professionalism and training in other countries. U.S. patients are also accustomed to getting their care from foreign physicians. He also draws attention to the fact that a shortage of physicians means the US physicians will be willing to share their work burden with their colleagues abroad.Well said, but the outsourcing juggernaut does whip jingoistic passions among the misinformedly sentimental. There might be patients who will refuse, this has to be factored in.

4) State governments will begin to embrace medical tourism by 2010: Rising healthcare expenses require states to shift funding from other programs or raise taxes, both of which are unpalatable. He gives the example of NY having half a million Dominicans. Santo Domingo, which has some excellent cardiac surgeons and low prices, is a 4-hour nonstop flight away. Why wouldn't New York at least explore the possibility?Possible. But you never know how politicians think.

5) The emergence of medical tourism won't have a major, direct impact on U.S. healthcare costs, but the secondary impact will be substantial: If every U.S. resident who could go abroad for treatment actually went, the savings on total medical costs would be about five percent. That's still a big number, especially compared to other initiatives that are available. But to look at it another way, if healthcare costs are increasing by 10 percent per year, taking full advantage of medical tourism only buys us about half a year.For a country like the US, with the most expensive health care system in the world( around $210billion!!) this might not translate into a very big gain, true.Considering that a major part of this expense is not a public spending, but out of the common man's pocket, the gains will accrue to demand supply equation that the provider and customer share. Queer are the dynamics of health care in this country, where fair market capitalism dictates that need supersedes want. Of course, no one is aiming for great shifts in any hard indicators of health care. (The US health care system does not figure in the first ten or twentys of the WHO list despite being the most expensive.) It would be ridiculously naive to expect anything more than a drop in the ocean. But for the person who feels the pinch most, a dollar saved is a dollar gained.

Subspecialities, not superspecialities

I have grimaced with utmost condescension at the many times people who go into specialties tend to act as if they have forgotten the medicine they learned before they stepped into the specialty. Like Sagar looking at an EKG of LBBB and saying it looked scary because he did not know what it was, or getting consults for fever from cardio, or the GI resident folding hands saying he didn't do intubations anymore since he was a specialist .

Let me be clear( to myself as well) I love Cardio- I did not quit Cardio because I did not like it. As a subject it is fabulous to learn and practice.In terms of outcomes- satisfaction of cure- it is Hearteningly leagues above say, Nephro or Neuro. The next generation in India is going to be one of the bards of lard, the centrally obese affluent who will come to ERs clutching at their chests while at the peak of their productive lives.Call it thrift gene theory, diesel exhaust related or whatever you choose to- we will be the Type II Diabetes capital of the world.And that translates into serious business of the heart. Whatever one has to say about the number of cardiologists passing out, and it being a market of sorts, them guys are never going to be found without work.Its what more and more people should be doing.

But what pisses me off is that the whole practice of Cardio seems to shift focus onto getting stents into improbable and really unnecessary areas.Into milking the Interventional cow to obscene levels. And it is not an isolated event - its ground situation everywhere. And you would be questioned if you wanted to practice preventive cardiology, if you elicited a plantar response, if you put someone on medical therapy for CVD or chose draw a blood culture.At a certain level, the scopist or Interventional Card guy provides a service- hence can be called a technician doing a 9-5 Cath Lab job- and is paid for the level of skill he can show. To be away from the "human touch" has its advantages too in a overtly litiginous society.

One cannot completely blame this state of things- one cannot be an expert in every given condition which the human body suffers from, and yet be fashionable in the way he/she slides a Cypher into the LAD.If you will be seeing ARVDs and Fazio Londe day in and day out, how would you possibly be wrong if you did not know the treatment of malaria off hand??!!

I am including an extract from Jerome Groopman's book How Doctors Think:

The narrowest subspecialist, the reasoning goes, should also be able to provide this [broad] range of medical services. This naive idea arises, as do so many other wrong beliefs about primary care, because of the concept that doctors take care of diseases. Diseases, the idea goes on, form a hierarchy from simple to difficult. Specialists take care of difficult diseases, so, of course, they will naturally do a good job on simple diseases. Wrong. Doctors take care of people, some of whom have diseases and all of whom have some problem. People used to doing complicated things usually do complicated things in simple situations--for example, ordering tests or x-rays when waiting a few days might suffice--thus overtreating people with simple illnesses and overlooking the clues about other problems that might have brought the patient to the doctor.

Which probably is a reason I am trying to pick on Pulmo/Crit Care or ID as subjects to specialise in. Of course this is not the only motivation...there are many more. But these retain the 'common touch'( why am I quoting Kipling so often, so outofcontext?!) with the broad motherlanguage of medicine while still providing you with the qualification to "earn more than the chaiwallah" as Dr Anand puts it.

There is an algorithm that I saw on someone's Orkut profile about making a choice of which subject to choose after medical school based on your traits. I think in choosing a subspeciality one has to look beyond traits into what your expectations are, what you want to acheive, or what will keep you going when down the line you can manage things at purely a spinal level.This is an algorithm I have come up with. Sorry for the patchy work. But inputs, if any, welcome.

CABG - heartily enjoyed

Do you want to practice doing CABGs in virtual space?

http://www.abc.net.au/science/lcs/heart.htm

Nice timepass. Wonder why Zapak.com dosen't add it to its list!!And when you botch up, see the message you get!!

Power of a theory!!!

TPM,Ethical practice, Lamarckism and other things

"Say what you will about the sweet miracle of unquestioning faith, I consider a capacity for it terrifying and absolutely vile!"
-----Kurt Vonnegut.

Read the story in the link for some more questioning of faith:
http://www.tpmcafe.com/blog/drmatt/2007/oct/18/us_health_care_system_lessons_learned


There is how everyone wants to be in the beginning - never going against what they believe to be basically Good.We are all born with no morals, logic.Where the lesson of adaptive synthesis happens varies.Call it epigenetic, in the way it moulds your perceptive ego, it is scary.We learn our lessons from experiences that made an impact on us.

How true it is: If you ask the wrong questions you will get wrong answers.If you ask what do I gain from cut practice instead of what you stand to lose, you will never know when you changed directions. People carry this right/wrong lesson with them for life. They hesitate to ask ourselves the question why as much as how and what.They don't ask these questions because the uncertainty of not knowing the answers is not comfortable.

Then a desensitization process sets in. It doesn't hurt that much later because everyone is doing it. And if it continues to prick your conscience then you are an aberration.Someone like the protagonist in the movie Dombivili Fast.Not that all the other people are bad/evil. But if they left living on a day to day basis, I do not know how they would survive with all the guilt they carry.

Btw, I loved the name TPM cafe. Was flashback to TPM's rounds at KEM. Accepted, he was unapologetically brash, but his lessons stick around like Boomer chingam on your limbic cortex.

" RaviKiran,you can make mistakes because you are in KEM, which is like being in Fort Knox. If this patient were to sue you, then you, your grandfather and your grandfather's grandfather can spend the rest of your lives mopping the floors of the hospital paying the damages!!!!"

" You are the treating doctor, not Sai Baba!!!" (Thats such a TPM special....)

" Would you do the same if your father was the patient?!!"

Making notes....

Read this in the Med Economics blog. Making my notes...

Over the years, an increasing number of jurisdictions have taken the position that a resident, even one just starting out, will be held to the standard of a fully trained physician.

A recent New Jersey case, for example, found that residents—regardless of their specialty or years of training—should be held to the level of expertise required of established physicians

It did so, in part, based upon a number of federal court decisions that said that residents—and other medical caregivers with even less training—must meet the same standard as fully licensed physicians. The defendants presented themselves as doctors, the court said, and should be held to the standard of care they claimed to possess. Anything less wouldn't comport with the care patients expected and were entitled to receive.

" I don't want to make the wrong mistakes"

Whoager !!

Shall be traveling mid week to Baltimore.

One of the many disadvantages of not having a laptop:being disconnected- you sit twiddling thumbs or staring at Cipherspace or write unfashionably in scraps OF PAPER at airport waiting areas and friends' places while all around you are typing ferociously onto screens you can't peep into, wondering sometimes if people are really half as intelligent( or even fertile with those hottie hot toppings on their laps) as their embellishments make them seem to be.
Ah...two/three years back I would count my hours being connected rather then being disconnected!!
Someone have a laptop to donate/sell cheap?

Travel is fun.
But preparing for travel and waiting in transit are a PITA.As is carrying important documents with you during travel,especially when you have to go to the loo and the file is tucked under armpit or the bag staring at you while you are in the evacuation mode.As is the TSA. As is traveling to and from the airport.
Pretty stupid moral of the story: travel is fun, sometimes funny.But not if you are the involved party.

Things that are pending: the statin post is due for editing, one on transhumanism for completion.Need to sort out the links issue.

I hope to sign the contract and get done with things. Inactivity is killing, so are near null bank balances.
Wish me luck.

Knock me baby...one more time!!!

I happened to read a couple of articles about Mario Capecchi, this year's winner of the Nobel prize for Medicine/Physiology. Beyond all the insanely juvenile discussion on USMLE forums( of all places really!!) about whether it should be 'Al Gore and the UN organization headed by the guy with the funny name' who won the Nobel prize for peace, or 'Rajendra Pachauri led IGPC and Al Gore, you myopic Americans' , and each group calling the other racist( God I have started to hate how every TD&H is twisting this word to personal gain ), this is really a story that inspires. It is like a whiff of hard earned fresh air amidst the stench of the mediocre.

Mario Capecchi struggled in his childhood as a kid bound to hospital fed coffee and bread, stripped of clothes -so that they could not run away, in German held Italy. Hunger was another thing that kept them from running away.They were kids, mouldable to the situation. No one attempted a great escape.His mother found him after the American soldiers liberated them from the Nazis. Capecchi had his first bath after 6 years!!

As many of the wise scientists did then, he left for America.He came to the banks of the Charles river.But he found Harvard crowded by the rivalry of people who I mentioned earlier, place such a premium on their name. So he set off for the University of Utah.This is where he did most of his research work.

Capecchi looks at science as a series of circles: the smallest circle is the one in which everyone is doing the same thing. As you move farther out, "fewer people are willing to go there, but you're charting new areas. Go too far, step out of bounds, and you're in science fiction. So you have to be careful. But you want to be as close to the edge as possible."

Thats really a fabulous concept of innovative thought.Hindsight gives you that wisdom I guess.But when he proposed his theory of gene modification to the scientific community then, he was laughed off. he found himself in a situation he had expected.Like Barry Marshall who had to drink a petri dish of bacteria which he extracted from a patient with peptic ulcer, and get horribly sick to prove that his theory conformed to Koch's postulates. Guess Capecchi had the last laugh, with his army of knockouts beside him keeping heart, nerve and sinew and allowance for the doubting too of the bourgeois scientific junta.

Mangesh keeps putting up interesting status messages on his Gtalk messenger. One of them a quote by Einstein: " It is as if in punishment of my contempt for authority, fate made me an authority myself"

Am I romanticizing the karma cola here- asking for adversity in a masochistic hoping for the pleasure of the success to follow?Post hoc ergo propter hoc? There's the American way of rationalizing this that maybe he did not succeed because of the adversity. Maybe he succeeded despite the adversity.
Capecchi has his take on this: There is no control group,here, that lets you measure what you missed.

Great read...heartening !!!

http://www.jayparkinsonmd.com/blog/?p=24#comments

Ecstatin.....then all fall down.....

Last week I was doing this post on Statins,.. the wonder drug of the new world. I am combining that with a recent post I wrote after the Exubera debacle this week.

Akira Endo synthesized the first statin way back in the 70s.But since the 4S and WOSCOPS studies of 1990s they have become domineering superstars- Lipitor outsells any other drug in this country still.At some time doing a thesis on statins was the most fashionable thing to do because there was a high chance you could get it published. Med Reps fought tooth and nail to outsell each other's brands to GPs.

A recent article from the AJRCCM mentions about the effect of statins on pulmonary function decline in a VA population. They tested FEV1 and FVC decline in smokers and non smokers over a ten year period. For those not using statins, the estimated decline in FEV₁ was 23.9 ml/year, whereas those taking statins had an estimated 10.9-ml/year decline in FEV_1.Within each smoking category, longtime quitters (quit 10 yr ago), recent quitters (quit < 10 yr ago), and current smokers the effect of statins was always estimated to be beneficial.


The cardiologists have raved about the statins for more than a decade.The neurologists, endocrinologists and nephrologists joined the bandwagon. Now the pulmonary guys too. They thought it was juts the lipid lowering. But when trial after successive trial showed mortality benefit the metabolism guys knew they were missing something.Then finally they came up with the prenylation of second messenger molecule theory which explained the pleiotropic effects.
Wonder why Dr Akira Endo has not been awarded the Nobel prize till now.




There is of course the other side of things:

There are many critics who say far too many people are on Statins than there should be- listen to Mark Porter's lecture on the BBC podcast series here: http://www.bbc.co.uk/radio/podcasts/medmatters/

Of course, the fact that Lipitor became a cash cow for Pfizer has also partly to do with the way it was marketed.The target was not just to the naive consumer- Dr Jarvik advising on DTC ads to take your statins to ensure you don't have to use his artificial heart ever- but also the practitioner.I have seen people get statins with no real indication, just because their doctor thought it was good for their heart.And of course the patient was hooked for life to the drug by naive doctor, disjointed thinking and the profit motive of the pharma companies.So then you have nonsense products like Caduet just for Pfizer to milk the Statin cow a little more.

Profits grew as midriffs did.Syndrome X was the pan affliction of a noveau riche affluent humankind and more and more research money was pumped into drugs that hit every angle of the kilo peccadilloes. Pfizer pumped in the millions into Torcetrapib, theoretically a fantastic concept of a drug.But it turned out to be a major failure and Pfizer was left wounded by a good billion.

At one point Pfizer had three of the world's ten top sellers: Lipitor for cholesterol, Norvasc for blood pressure and Zoloft for depression. But the latter two have lost patent protection, and their sales are vanishing. Lipitor will go off-patent by 2011.Since 1998 Pfizer as spent $55 billion on research and development and another $180 billion on acquisitions. Yet in that time only nine medicines from its labs have hit the market.Viagra, touted as a megahit, is now only a fairly good success, with annual sales of $1.7 billion. And the Exubera failure just rubbed things in.
The Pfizer share has seen a 40% price decline since 1998.Guess for once the Viagra magic did not hold things up.

Improbable research

Morparia's fertile imagination!!!

Love him/hate him

The Bill & Melinda Gates Foundation announced today that it is committing $100 million over five years to create a new fast-track grants initiative to support innovative global health research. The initiative’s goal is to encourage scientists worldwide to explore creative, unorthodox ideas that could lead to major breakthroughs against some of the greatest health challenges facing poor countries.

The new initiative, called Grand Challenges Explorations will focus on rapidly evaluating a large number of innovative ideas that could lead to new vaccines, diagnostics, drugs, and other technologies targeting diseases that claim millions of lives every year.Grant applicants will be asked to submit relatively short funding proposals, which will be reviewed on a fast-track schedule. Explorations grants will be approximately $100,000 each, and successful projects will be eligible for additional funding.

Bambeau

Was reading the Nature blog about appropriate technology in resource limited settings. There was a post about the Rs 150 a piece microscope made entirely from bamboo by a Delhi based NGO.

I felt an overpowering sense of Deja Vu reading these lessons in thrift and innovativeness scripted people all over the world, who shared a common denominator of scarcity of resources.

My mind went back to the bear huggers we fashioned out of hair dryers for hypothermic patients, the bustle we used to create when we disconnected the plasmapheresis machine with everyone rushing to the basin to wash the filter and tubings for reuse, the extracorporeal Le veen shunts that we used to fashion out of IV sets for refractory ascites, the three bottle pleural drain of yore, the magnesium conundrum, times when Psy registrars would stare gaping openmouthedly when we gave their DTs Phosphorus enema through RT.

Many more that I have seen if not been participant in- Abhay Bang's abacus, the clean set for the dais that Dr Arole had fashioned out of things we use at home,the safety pin external fixator of Dr Mookhey.
I am sure many people will have other innovative things that they did to add to this list. Its unfortunate that we sometimes have to work with awfully inadequate resources. But as Gawande wondered: " And what I wondered was: How do they do it?How do they possibly take care of all the hernias and stab wounds, the appendicitis cases and tubercular abscesses — and sleep, live, survive themselves?"

And he received a reply: "Practicing medicine in India represents an experience of extremes: exhilaration from saving lives but frustration from often being a helpless spectator — both in the same day, many times over."

Do post in your experiences guys.Might not necessarily be medicine related.

Tooth scary!!

Holy crap!!

Dentists’ incomes have grown faster than that of the typical American and the incomes of medical doctors. Formerly poor relations to physicians, American dentists in general practice made an average salary of $185,000 in 2004, the most recent data available. That figure is similar to what non-specialist doctors make, but dentists work far fewer hours. Dental surgeons and orthodontists average more than $300,000 annually.

Thats obscene.

And they want to keep it that way- little work, more money.

Despite the rise in dental problems, state boards of dentists and the American Dental Association, the main lobbying group for dentists, have fought efforts to use dental hygienists and other non-dentists to provide basic care to people who do not have access to dentists.

Why are they suicide prone then?Confused souls!!

Brain stem cell therapy!!

I used to think that MBBS was about learning medical common sense. That you don't give beta blockers for diarrhea, or that chest pain is an emergency and ASV is for snake bites and adrenaline for anaphylaxis.

But then I thought, even at the end of MBBS, that blood is life saving....and I did not know in how many ways I was wrong:


A doctor couple has been arrested in Rohtak, Haryana for causing the bizarre death of their son by attempting to transfuse into him the blood of his more intelligent sibling.In the process, the younger and intelligent Piyush died while Abhishek is battling for his life in a hospital.

All this happened because the mother wanted Abhishek to clear the medical entrance test and study to become a doctor.

The wife recently had a dream in which their "guruji (godman)" told her that if she transfused Piyush's blood to Abhishek, he would clear the medical entrance test.The couple brought instruments to their home and attempted the transfusion by making an incision near the neck of both boys. While doing so, the younger one died of excessive bleeding.

Seeing the whole thing going horribly wrong, the mother slit her wrists. She is now being treated at a hospital here.

Ayyo kadavale!!!!!!

Vent it out

He is the guy who wants to know all the secrets of life.First he struck fame with TIGR, where along with Fleischman and team they decoded the entire H influenzae genome( favorite AIPGMEE MCQ!!)He attempted to outgun the Human Genome Project guys with shotgun sequencing at Celera.(This really fired them into fifth gear to complete the project well before time.)

He published his own complete genotype on the Internet, an effort that cost more that $60 million.He created with his scientists, Synthia", a synthetic chromosome that they are calling (and patenting as) a "minimal bacterial genome" and using this they claim to have created the first man-made organism: Mycoplasma laboratorium.

It cost the HGP $3 billion to do the blueprint completely. Now Venter wants to get it to less than $ 10,000.Venter is a major contributor to the $ 10 million bounty offered by the X prize foundation to any company which manages this.

Fred Sanger ,the only person to win the Nobel prize twice, did all the spadework with painstaking effort perfecting the Sanger technique for sequencing the genome.But Venter wants to mechanize it like a conveyer belt of sorts churning out genomes after genomes.We thought DNA chips were nouveau chic- he's giving you the full monty.

Craig Venter wants answers to everything,be the in-control guy.

I may be a conservative on all of this,but I have mixed feelings about all of this.Although I should acknowledge all this as extremely exciting, all these efforts seem to me to be in dedication to the deterministic dogma of genotype being the purpose/God/creator/Oracle and phenotype being the expression/action/karma/creation/life.It aims to commodify our current knowledge into a branded, personalized medicine which throws functional genomics and proteomics out of the window.It is an idea which companies like 23andme and AT and T have tried to market to the geekily aroused common American.It has no connection with medicine as it is practiced.

By the way,Venter's genotype had shown genes for Alzheimer's disease, antisocial behaviour and cardiovascular disease!!Go figure.