Guilt and the doctor

This is from Edwin Leap's blog....he asks a tough ask. Live without guilt.It takes a lot of insight and predetermined reactiveness to go through I think.There is a little justification in the 100% mortality argument and death epidemic terminology of his....comes of sounding as the typical American reaction to things..try to escape a bad feeling by justifying a good angle to it.Finally he does not take extreme sides...thankfully.If we were to live our entire lives without guilt we would all be uniformly intelligent Buddhas.Read on...

Physicians, collectively, feel a lot of guilt. We feel guilty that we don’t know more. We feel guilty that we don’t do more. We feel guilt about our need to be on committees and be educators. We often feel guilt about the money we make, even as we feel frustration when insurers deny payment. We feel guilt when we speak angrily to another doctor, a nurse or staff member, and extra guilty when we talk down to our patients. We feel guilty when we don’t stand up to someone who berates us. We feel guilty about our delinquent charts. We sometimes feel guilty about the economics of medicine, and a fair amount of physicians feel guilty enough to advocate a national health-care system
We feel guilty that we eat junk food, drink too much coffee, and exercise too little. We feel guilty that we haven’t spent enough time with our spouses and children, then feel guilty that the retirement and college tuition accounts aren’t bulging with money.
And worst of all, we feel guilty about suffering and death. Because, especially in emergency rooms around America, what we see is a lot of both. We learned, as medical students, that death was the thing we were supposed to stop. And our constant inability to stem the tide of the death epidemic (now in it’s gazillionth year) fills us with untold milligrams of pure, autoclaved, concentrated guilt.
I realized this recently. I had some remarkable deaths in my department, and they left me feeling sad. They left me feeling guilty. And as always, they left me going back over the entire situation in my head.
Even as I write this, I’m considering the patient I saw last night (who may have died by now) after her toxic carbon monoxide inhalation. What could I have done differently? How could I have saved the other woman last week who died? Or the man the week before that? If only they could just open their eyes and talk to me again, and say ‘Thanks! I feel better! I think I’ll go home to my loved ones now.’ I wonder, as I often do, if I failed. Guilt quite literally rises from the dead.
Our culture doesn’t help the guilt problem. Every tragedy, every inconvenience, must be blamed on someone. We have review boards and commissions, congressional inquiries and consulting bodies, plaintiff’s attorneys and medical boards, and it seems at times that all they do is sit around trying to assign guilt (never guilty themselves, of course, for the problems and even tragedies caused by layers of administrative refuse). And we, in culture at large and in medicine in particular, respond with new policies, new procedures, new classes and algorithms, and with newer, deeper levels of guilt than ever before.
But here I want us to stop and ask this question. What does our guilt do for us? And I’ll give the answer, because I don’t want you to feel guilty while trying to find the answer. Guilt serves a function as a moral guide. Without guilt, we become sociopaths, incapable of feeling remorse, and incapable of making proper judgments in our interpersonal interactions. Guilt helps to hone our relationships with God and man.
However, it does little else. And when we feel guilt over things that have nothing to do with choices over right and wrong, then we misuse guilt. Like performing an appendectomy with a baseball bat, it’s simply the wrong tool for helping us make day to day decisions. And it is a horrible implement to use for our own self-assessment, for we are always our own worst critics who can never see how brightly we shine.
Guilt is an especially terrible thing to use on ourselves when we work in a place where pain and death are regular visitors. It wears us down. And usually, it is false. Because even if we make a mistake, it isn’t a moral failure. It isn’t that we intended to give a wrong dose, or miss a diagnosis. If we harm intentionally, we should feel guilt. But if we only make a mistake (and that’s what they are, mistakes) we should try to make amends, to undo the damage and to learn so that we do not repeat our error. But we don’t need guilt.
The thing is, we practice an imperfect science on human beings, who are uniformly doomed from day one. The will all have illnesses and accidents. And 100% will die. It’s our job to stave that off as long as possible. It’s our place to make humans healthy and comfortable, so that they can lead productive, happy lives. But it isn’t our place to make them immortal. And it isn’t realistic to think that we won’t do the wrong thing from time to time.
I know there are consequences to errors, and there are emotional weights to bear when we see death and tragedy. But guilt is one weight we have to learn to set down. It keeps us from moving forward. It drowns us in emotion and memories of what might have been. And it doesn’t help anyone, whether laid upon us by patients, families, administrators or attorneys. But more to the point, when we lay it upon ourselves, we are trying to make a sacrifice to atone for our humanity. And we can never scar ourselves enough to change who we are; mortal, fallible, imperfect, wicked, self-hating, amazing, near-angelic, loving, wonderful, awe-filled and God created. We will be those things no matter how much guilt we think we need to heap upon the altar of our hearts.
So lay it down. And try for once to live a day without guilt. It’s an amazing experience when you can do it.

Aus der Deutschland

Some of the demerits of socialised medicine: There cannot be one fixed standard for all.This is from the lancet.


Physicians' groups in Berlin have slammed an aspect of the government's health reform which has left around 20% of doctors having to pay for their patients' medicine out of their own pocket, with some also facing fines for their prescribing practices.
The new Bonus-Penalty Ruling (Bonus-Malus-Regelung) placed even more pressure on doctors to spend less on medicine.

The Bonus-Penalty Ruling drew on the daily defined dosage (DDD) notion pioneered by WHO. Though WHO originally introduced DDD solely as a means to compare prescription demands in different countries, the Bonus-Penalty Ruling takes the notion of a DDD and attaches a fixed daily budget to it.
As a result doctors in Germany are now allowed to prescribe only a set daily dosage at a set daily rate.Under terms of the Bonus Penalty Ruling, set daily rates apply for drugs used to treat high blood pressure, depression, migraines, prostate illnesses, and osteoporosis. Drugs, for example, used to treat depression, migraines, and blood pressure are only allowed to cost 37 cents (around 25 pence) per day.
The potential benefit of the legislation for doctors is that if they spend less than their budget, their regional KV will award them with a form of “credit” allowing them to spend more on prescribing drugs thereafter. For this to happen all doctors within one regional KV must together spend less than a collective budget. If, however, this collective budget is exceeded, the individual doctors who spent less than their individual budget, go unrewarded.

Interestingly the WHO says that DDD system by itself is not suitable for guiding decisions about reimbursement, pricing and therapeutic substitution.

And I thought.........!

People who are others have had harder, more painful tales to narrate,
Been wretched with angst and pestilence;hunger and insatiation
Lost a parent or two, eyes, limb, insight, faith and hope ;
Honor, love, ambition and home for no fault of theirs, maybe.

They have taken hope in mere nothingness, and themselves
Cried to Lord, Eli Eli Llama ...... . there was no one else to cry to,
Perhaps not even the Lord, why would they have felt thus if He were?
And built themselves, as much as for themselves , still weeping.
What do I weep for: I haven't half the pain; eyes moisten, but heart's never wailed

The weary Chariots trundled into sunset; dust, blood, grime and disillusionment
Heavy on the forehead of the armored warriors whose flagging,creaky bodies followed
With no protest, among scythes that had sliced clanking on helmets that shielded.
They shall eat and sleep. to awake to go kill or get killed, chanting on their lips
'Dulce et decorum est, pro patria mori'...it is glory to die for your fatherland.
They never cried,how ever could they - someone wailed their hearts out for them.

BJMC Hostel E Block

Who says we don't have fall colors in India.

Dull Makhani to mull on

Am reading Haroun and the sea of stories. The early Rushdie. Lots of magic realism, lots of beautifully OTT spontaneity.Full of Iffs( the water genie with colored whiskers) and Butts ( the hoopee with an attitude and the bus driver chasing the sunset)and Gup and Chup- the two sides of Kahani the second moon of the earth , a place where stories flow as water currents to be piped to the emotionally barren regions of the earth whose people have forgotten to smile;Prince Bolo, Princess Batcheat and P2C2Es( processes too complicated to explain) and all that other chlorophyllosophy of the Pasha of Phantasmgoria.
Get the drift.....ok, good.

There is a story about Dull, the lake( not 'the Dull Lake', each inanimate thing seems to come alive here)- whose emotions mirror those of the people who stay in the valley of K( cant get Kashmir out of him!)So you know why it is mistakenly called Dull now.
But when someone gets angry the wind blows huffingly to rock the boat, and when someone is depressed the air reeks of a stench and the sullen mist envelops. Then Haroun tells them to think of the happier moments of their lives, even if they were like an interval siesta mode..and you know what happens- the mist and the stench clear, the silver peaks( snow) and the golden fields( saffron) reappear from the hue.

" Its just a story"...Haroun says.

Thats a two tailed statement...
"its a story, thats all"
OR
" its all just a story"
....whichever way you view it.


I hope you get the drift- I am not an iota of a gifted storyteller as Rushdie is. Deepa certainly did not get the idea I was hinting to when I extrapolated this to " attitude determines altitude"Remember the Champu, Gokul and Banshi story from Std VIII reader- pratikriya hi jeevan hai aur jeevan pratikriya.

From the Lotos Eaters

How we change....How perception and clear thought is clouded...by the overwhelming righteousness of emotion.....how eternally we want to be in this Rubaiyat like "ah my beloved fill me the cup "world, this myrrhic SakiNaka of sorts.

.......from the Lotos Eaters by ALT.

They sat them down upon the yellow sand,
Between the sun and moon upon the shore;
And sweet it was to dream of Fatherland,
Of child, and wife, and slave; but evermore
Most weary seem'd the sea, weary the oar,
Weary the wandering fields of barren foam.
Then some one said, "We will return no more";
And all at once they sang, "Our island home
Is far beyond the wave; we will no longer roam."

Messhealth

Polls are not the time for discussing legislation- motives are often appeasement, treading the safe line, keeping most of the people happy most of the time. Thats why Hillary Clinton went two steps back on a more aggressive socialist health plan to go slow. Who would want to pay out of their pockets really for someone else's health...and if this becomes negotiable in return for a vote.........are you nuts...!?!


http://content.nejm.org/cgi/content/full/357/12/1173?query=TOC

My momma always said, "Life is like a box of chocolates"

" You never know what you will get"

Tie fuss

British hospitals are banning neckties, long sleeves and jewelry in an effort to stop the spread of deadly hospital-borne infections, according to new rules published Monday.Hospital dress codes typically urge doctors to look professional, which, for male practitioners, has usually meant wearing a tie. But as concern over hospital-borne infections has intensified, doctors are taking a closer look at their clothing.

"Ties are rarely laundered but worn daily," the Department of Health said in a statement. "They perform no beneficial function in patient care and have been shown to be colonized by pathogens."

The new regulations would mean an end to doctors' traditional white coats, Health Secretary Alan Johnson said. Fake nails, jewelry and watches, which the department warned could harbor germs, are also out.

Johnson said the "bare below the elbows" dress code would help prevent the spread of Methicillin-resistant Staphylococcus aureus, or MRSA, the deadly bacteria resistant to nearly every available antibiotic.

The New York Hospital Queens team found nearly half of the ties worn by medical workers harboured disease-causing bacteria.Almost half (47.6%) of the ties worn by clinicians were found to harbour bacteria that can cause disease.This was eight times the odds of ties worn by security staff from the same hospital being infected.

I hate the piece of clothing. It has no purpose.I have never been able to knot one right.Neither do I wear a washed one daily.Its health risks are imaginable of course: carotid sinus syncope, glaucoma,means for strangulation. One of my professors at KEM who has a fetish for oddly colored ties( we know who, don't we?) nearly strangulated himself while choking off the airway of a person whom he was trying to intubate when the tie got into the ET tube!!!
But i hate it for being a colonial handout from the prissy sahebs of old- whose purpose we have never questioned, insulting our originality in our inability to come out with something better.A bow( so gay!) or Chinese collars ( not for the syringomyelic or double chinned) just pass muster.

They gave the fool education of note
To call him doc, a stupid white coat,
And if he blundered, was ain't upstaid, too TIEght
To strangle him, this kanthalangot.

From US to them

This really is an outsourcing heist of sorts!!

When I bought my traveler's health insurance I was arguing about how I might never need even a dollar of the $50,000 amount that the insurance company provided as a limit and that they give me some plan which had a smaller cap limit for lesser charge.But then when I realized that an investigation in the US costs the same amount as back home with only the rupee prefix replaced by dollars I think no amount is small here.


I used to think that traveling and staying in a foreign country was always going to be something of a Achilles heel for 'Health tourism'. But it is apparently not.....

"Foreign health insurance firms, especially from the US, are making a beeline to the country. Global players like Blue Cross, Blue Shield, Cigna Insurance and Aetna insurance are hot-footing it to India not only to set shop but also to explore options to send patients from US and Europe to India for life-saving procedures like coronary bypass surgery and heart valve replacement.
This is no medical tourism, but an organised, off-shoring of good healthcare insurance. The New England Journal of Medicine refers to them as “medical refugees” — patients keen to go to foreign countries for life-saving and life-enhancing procedures like hip and knee replacements and save on insurance premiums.
Germany-based DKV Group, which has teamed up with the Apollo group of hospitals, is also eager to set up a standalone health insurance company in India to cater to this huge and growing overseas demand. The firm has applied for a licence to the regulatory authorities.
Dismayed by the high surgical costs in US, American patients are packing their bags to have necessary surgery performed in India. Health insurance firms are holding their arms leading them to international destinations to be treated by paying a fraction of the premium they pay in US.
American health insurer Cigna Insurance, which was present in the country a couple of years ago, is looking to make a comeback. The earlier arrangement enabled Cigna’s covered members to access treatment at reputed hospitals in the country.
“People are getting desperate for good, cheap and realiable medical care,” says Vishal Bali, CEO, Wockhardt Hospitals, who had an earlier tie-up with Cigna.
“Cost is a major factor. Hospitals in India usually charge around $6,000-8,000 for coronary bypass surgery, $6,500 for a joint replacement and $6,500 for a hip resurfacing, which represent a small fraction of the typical costs at US hospitals.
‘‘India is not just known for its outsourced back-office skills any more, such as reading of X-rays, medical transcription or billing. It’s the actual clinical care that is now being outsourced,’’ says Bali.


What is interesting is that if lesser wait time is an incentive and cost of treatment is not( as I think would be with patients from UK)then potentially the hospitals in India would be 'legitimate'( I believe this is morally illegitimate) in charging at a rate much higher than prevalent Indian fees( are there any??!!?) and equivalent to rates charged in their home country.


Where all...this outsourcing in health might lead to is a speculative topic...will there be layoffs like in the tech sector? Will American doctors cry hoarse and election campaigns and cartoon strips find fodder in ridiculing the accents and work culture of the brown doctors? What is the continuing incentive for the Insurance companies, how do they measure Quality Control,commodify nonoperative care?Will it result in new hospitals in India?Will medical professionals who migrated for the lucre make that green-back-pack trip home? Could we have Nomad doctors?
I don't know answers to these Qs. I would be a freakonomist Freed-Man or own a couple of these companies if I did, wouldn't I?

Thanks!

Thanks to Denish, Gaurav and Charusheila for their prompt generosity in forwarding me full text articles from the JAMA. Have had a busy week away from home with some handicap in time management and internet access.

I think I should make a mention about Gaurav's forwarded article.
I have always wondered where Google makes all its money from if its services are all free.Its ads are not so obscenely in your face as indiatimes or MSN, nor do they offer premium services or cornball upgrades.Some of my more 'connected'friends might be able to enlighten me on that I am sure.If Reed Elsevier wants to make access free in return for some Viagrotesque ads that we have to loop across then frankly I don't mind that.

http://www.nytimes.com/2007/09/10/business/media/10journal.html?_r=1&oref=slogin


A flip side would be that common folk ( they don't come common in the USA really!) who otherwise might have no incentive to pay and purchase access to a journal might end up reading about adverse effects of drug trials or how so much of medical diagnosis is often serependitious or even misdirected and put one and one together to get five in their own math of it. (Its funny, I came to know of nephrogenic systemic fibrosis through a TV ad of a medical negligence claims attorney before I read about it in medical literature!!God knows what his math is or what he is educating his clients about!!!)We know how statistics can present a totally distorted picture when provocatively disguised- Vioxx, WHI...usw.Ratios and differences don't mean the same thing right!?!
But I guess this is a welcome move anyways...lets wait and see what OncoSTAT's experience is.Until that hope and pray that BMJ doesn't follow the NEJM way.

One more point: in developed countries, access to an aticle might mean reproducing it in references to another later article. In developed countries many a times it is knowledge acquisition- thats my BJ experience. You are not being fair charging for that -educational institutions or students, make it free/ heavily subsidised.Making access free after 6 months clearly defeats the purpose of information dissemination.Its selfishness at its obscene best.

And regarding HINARI....

http://www.who.int/hinari/eligibility/en/index.html



I guess NEJM got their inspiration from them. They use per capita GNP to decide who to give free access to. There are flaws to this approach in that it assumes this figure extrapolates to health care, it ignores inflation and local currency appreciation.
In India's case -per capita income gets skewed as much by the 1 billion denominator figure as it does by the ridiculous amounts that MBA graduates from SP Jain or IIMs make.And the fact that people making this money are largely professionals employed in private companies and of a younger generation. Health insurance is largely non existent outside organised sector employment,hospitals are considering scrapping CGHS care provider status due to onstant bickering on the amount that they get paid for it; tertiary health care institutes are largely government run, underfunded behemoths grovelling under their own weight of responsibilities and the people they cater to are from the other extreme of the spectrum, and sadly the majority.

Statistics are like a bikini....so said the Surd.
Beneath them is the truth thats never heard.

Losing my religion

Marquez said somewhere- "its not important what you do in life but what you remember of what you did"
Those might not be exact words- I do not remember exactly. But my interpretation is something like that. I do not know whether this was prior to his senescent oral fixation phase or when he was more sane- which to say he actually never was. But then his insanity was so beautiful- who else can imagine a town losing its memory collectively or a war so surreal- like Asterix and the gauls whipping the Romans in Hemingway imagery of Civil War( what an oxymoron that!!), you almost forget its people killing each other and brothers in arms and dulce et decorum est seem all so weepy and whiny.
Anyways ..thats a perspective of a retired peripatetic who chooses to reflect I thought.How could things you do not be important in your life? They define the parameters that are you.
But......... try and remember things you did three years before this one. Try and imagine one week in your life then.What can you remember? Can you remember what your motivation was that week, which book you were reading?Did you have a fight? How did the hated monday merge into momentum of tuesday? Did you make a promise, can you remember one thing that was memorable so that you might remember it maybe five years hence?Was there any?How many such weeks pass away without anything to remember,in a listless ennui...an inertia to not make an effort to excel, to make it memorable.The days you got up, brushed your teeth, had a bath and went to work, chatted at work,read Doonesbury, did whatever work you had, came back, watched TV,thought the government sucks, sat at the PC checking mail, ate your dinner and and slept.How many can you count?

Perhaps that is what Marquez meant?! That we need to remember..to make a conscious effort to remember. But to also create experiences that we may remember. Childhood easily was adventurous enough. It had the growing pains, the closely spaced phases of transition from hyperaction to peer relations to rapid learning to introspection. There seems to be too long a phase somewhere later where nothing happens, or happens infrequently.

Part 2 of the Q:
How much of an effort do we make to remember?
Some cling to the past- it is to escape the insecurity of the present maybe.
Some maybe not.They act, act in the living present, heart within and Groucho Marx overhead.There is no Either/Or for them...its And And accumulations.This is the American way.Indians in the US are either more religious than folks back home, or they melt into the hoi polloi that is this country.Everyone is trying their best to survive, make money, give their kids a good future, working their asses out 5 days a week at Dunkin Donuts or Microsoft or Accenture, keying their systems to charcoal gray and business black-berry dreary 5am mornings, evening showers and breakfast bars, irritable bowels and lives run by PDAs ,weekend holiday traffic and 9 pm phone traffic, voicemail impersonalness and a call before you visit etiquette. Everyone- Iraqi Kurds to grasshopper tambrahms to greenback hungry Gults to frustrated Peruvians to the Filipino medical student is living this pan-neo-omni life( new all encompassing- thats the idea...pardon my inadequacies in English). They bring their culture pans and pots, their genes and diseases, their accents and intonations, their frustrations and aspirations to this supposed land of opportunity.And they become one of this culture of the developed world.
They wont remember.Life is too hectic to. They are reliving their childhood in a way. Each day is as much an adventure as it is mundane and cyclical- for they cannot drop out of it.There is no retirement. Vacations are scheduled, then you re enter.You are a runner, a kite runner chasing a thousand splendid things that exist till you consume them. You pretty much should have the stamina of the uberamerican Forrest Gump by now. Your legs are stronger than your glutamate circuits and hippocampi.
What do you have to remember anyways?

To conclude with another inexact quote( perhaps Rushdie... I don't remember exactly except that Dharav brought this up in a mail of his)
'life is what happens to you when you are looking elsewhere.'

Mull on this!

In theory there is a possibility of perfect happiness: To believe in the indestructible element within one, and not to strive towards it.

Franz Kafka

Debug the humbug..

Dr Patwardhan forwarded this story some time back:
I have taken the liberty to edit and put in my own inputs( in italics)


An OLD FABLE:
TRADITIONAL VERSION

The diligent Indian ant works hard all summer in the sweltering heat building his house and saving up supplies for the winter. On the other hand, the grasshopper thinks the ant is a fool and laughs & dances & plays the summer away. Come winter, the ant is warm and well fed.
The grasshopper has no food or shelter and he dies out in the cold.

MODERN VERSION

BBC, CNN and NDTV show up taking pictures of the shivering grasshopper next to a video of the ant in his comfortable home with a table filled with food. The World is stunned by the sharp contrast. How can this be that this poor grasshopper is allowed to suffer so?

Arundhati Roy stages a demonstration in front of the ant's house. Medha Patkar goes on a fast along with other grasshoppers demanding that grasshoppers be relocated to warmer climates during winter.

Amnesty International and Koffi Annan criticize the Indian Government for not upholding the fundamental rights of the grasshopper. The Internet is flooded with online petitions seeking support to the grasshopper. Opposition MPs stage a walkout. Left wing parties call for "Bharat Bandh".

Uttar Pradesh demands a Judicial Enquiry and immediately passes a law preventing ants from working hard in the heat so as to bring about equality of poverty among ants and grasshoppers. Lallu Prasad also allocates one free coach to Grasshoppers on all Indian Railway Trains, aptly named as the 'Grasshopper Rath'.

Arjun Singh announces a Special Reservation for Grass Hoppers in educational institutions and all public Services and finally, the Judicial Committee drafts and implements the Prevention of Terrorism Against Grasshoppers Act (POTAGA).

Failing to comply with POTAGA and not having enough to pay retroactive taxes, the ants home is confiscated by the Government and handed over to the grasshopper in a ceremony covered by CNN, BBC, and NDTV.

Arundhati Roy calls it "A triumph of justice". Laloo calls it 'Socialistic Equalization'. The BJP calls it the 'revolutionary resurgence of the downtrodden' and Kofi Annan invites the grasshopper to address the UN General Assembly.

IN THE MEANTIME
In the meantime the Indian Ants at the behest of their cousins the American Carpenter Ants have long since migrated to the US and built up multi million dollar companies in the silicon valley.
Mean while, millions of grasshoppers continue to die of starvation in India despite the reservation and special conditions provided by the government.

THE FINAL OUTCOME:
A lot of hard working ants are lost from the mother land , grasshoppers have divided themselves into the the genuine grasshoppers, the ones who want to hop on to the bandwagon,and the ones on Grass who wanted revolution against the ants.They all end up fighting against one another, called the ants the traitors, there was a community of leeches ( including the likes of Jejune Singh,RamUdaas Passthewine and a too sexy guy who wears dark glasses all the time)who came, saw the chaos and cashed in on the sentiment and won the election, the communist frogs protested that it was not fair at all- they were not sure what was not fair when asked, but it was nice to protest they thought- and so the story goes on.....


MORAL OF THE STORY:

In the words of Dr ShaanBUG,(grasshopper representative in chief, chief patriot,expert stonethrower and fencesitter, aspirational leader)

"We bugs are a beautiful monstrosity. Our beauty lies in our diversity, though we keep bickering with each other we come together beautifully in national spirit during events such as hockey movies and protest rallies . Karan Johar has made a moving montage on this - we would love to show after the censors edit the communally disturbing parts - its about our all encompassing spit...oops typo..spirit- its called HUM-BUG."
"And lets kill all the butterflies for their non involvement in this."

JAMAmia!

Its hazardous to form conclusions from articles reading merely abstracts. Thats something the physician who is just an MD loves to do.Its the way we are fed information- sometimes embarrassingly from medical reps than textbooks.Its because we do not find it interesting to go through the statistical analysis and would rather brush through the basic materials and methods and discussion - or worse just the conclusion.Or maybe we do not understand the statistical analysis sometimes. Sometimes we just don't have the time.

There's a sad angle of residents in countries like India not having access to full text because even teaching hospitals do not have subscription to paid journals!! Here I think the New England Journal of Medicine did us a great disservice by making access to full text articles pay to view.It was immensely disappointing to residents and hospitals like BJ where sometimes case discussions at the MGH substitute for M&M ( I seriously don't understand the logic of doing that because you do not have 'interesting cases'for M&M anyways!!)I had to do a collection drive from the residents to buy a subscription for the Dept of Medicine at BJMC.(The professors as usual did not pay up!!)But seriously aren't the editors of NEJM reading too much into the economic gains made by India ...seriously how much of that techie centered, oversexed economic growth has percolated in primary health care or health insurance reform or even health statistics?!This is really a rhetorical question because none has really...thats a unqualified statement I know...but the majority of the Mumbai populace still go to KEMH and not PD Hinduja Hospital.Thats where the people who later on practice at places like PDH train.And if they are not getting EBM access then its a serious educational access anarchy we have here.

It is predicted that India's economy will overtake the US economy in terms of size by 2024, but still the per capita income will be 1/4th that of the US. The health expenditure for India has been 6% of GDP...approx 60% this goes into national health programs and primary health care. What proportion goes to Medical Education I do not know. The health minister of Maharashtra claims they spend around 4-5 lac per MBBS student( a basis on which he enforces a bond amount of 5-35 lac on people pursuing post graduate courses)...thats a huge fib!! They end up showing expenditure incurred on running hospitals as that required for training students. The sufferers are the students/residents who do not get access to what a medical student form the US can get at a tap on his PDA.

Anyways..coming to the point- JAMA carries two interesting articles this week( remember I have access only to abstracts) One about the impact of the ACGME working hours regulation imposing a cap on the number of hours residents spend on call on the mortality rates at teaching and non teaching hospitals and VA. It concludes that there is no significant or marginal difference in either way( inc or dec mortality)at 2 years post the regulation.There are two points I do not quite understand on this- I am sure I would have got a clarification if I had read the discussion- what impact does the hospital status have on resident working hours if there is a guideline which is followed universally? And the conditions listed are all acute care conditions, the highest mortality would occur in the initial period- either in the ER or immediate care setting. Again, the group of conditions clubbed together are non homogeneous.In the VA hospitals the regulation resulted in an significant decrease in mortality i the medical group and not i the surgical group. I am not sure what conclusion to draw from the second part - again I have no access to discussion or the related editorial.

Yet another study makes a case for the most expensive exam I have ever given...the USMLE Step 2 CS. I do not think there is a more expensive exam administered for even management courses.But the study correlates scores on a Clinical Skills exam, which I believe should be similar to the CS- washing hands, greeting the patient,not forgetting the hi and goodbyes- to physician malpractice claims and complaints. And wonder of wonders, it does find a significant correlation. Statistical true lies? Post hoc ergo propter hoc? Again...no full text access.

The last article reiterates the first passage of this post :most residents do not feel comfortable with biostatistics.

The overall mean percentage correct on statistical knowledge and interpretation of results was 41.4% Higher scores in residents were associated with additional advanced degrees, prior biostatistics training, enrollment in a university-based training program and you will not believe this---male sex!!Estrogen be damned!!What the hell- I seriously do not understand.Despite being male;-)Someone get me the issue please!

Black diamond pearl

Sometimes the beauty of the vernacular- the abuses of rustic Bhojpuri,the raw poetry of a Nivdung, the dhakki chiki nuances of Madras bashai, the sweetness of fastly spoken Bengali monotones are lost in the homogenised unifying Hindi and fraternal English that we all speak to be functional in a market centric world.

One is a foreign tongue which we speak at schools, colleges and work, but not to our mothers when they teach us to speak, not to ourselves when we are thinking within( Einstein would slip into German while deep into a conversation);

The other a national integration concept initiated by the romantically noble intentioned, but naive Nehrus and Rajajis, bolstered by cinema, TV and other media, furthered by a migrant population that travels state to state transfered by Govt services or aspiring for greener pastures, mingling in Tamil sangams or marwari sanghas or Maharashtra Mandals, speaking an impoverished mother tongue and a functional Hindi, a Kulturlos ( trust the Germans to come up with a word for the indescribable!)group.

A pan Hindi world cannot capture the beauty of a Shyamchi aai- a well in the aangan where Shyam learns swimming, or the Mastar concept of teacher- can you do that in Hindi? Nayakan had to be a tamil speaking don-Dayavan who spoke Hindi in the film( whew!)And how different is Pongal from Onam and Basant and Baisakhi?!So many of AR Rehman's songs sound so absurd when lyrics are translated into Hindi for phonemic matching than meaning. Roja meaning rose becomes Roza- whatever that means!!?!So many of his songs, many penned by Vairamuthu are actually poems. In Hindi they become Jiya jale jaan jale nainon tale, raat bhar dhuaan chale......what the boonsocks does that mean!!!

Vairamuthu (meaning diamond pearl)
is the lyricist for the song that follows, set to music by ARR. Some of his songs are real beauties: the film Rhythm where each song is set to an element of nature is one of my favorites.Sample from Rhythm:

'Oh River aren't you a lady- ask me a reason why-I shall tell a hundred'

' Oh Wind, You came to my doorsteps
And slowly opened the door
Oh Wind, I asked your name
“I am Love”, you said

“where were you yesterday
oh wind, tell me” I asked
“I was in your breath“,
you said and went '

And the one from Pudhiya mugam, music ARR, singer UnniMenon:


Kannukku Mai azhagu
"Kaajal" makes the eye beautiful

Kavidhaikku poi azhagu
"Lies" make a poem beautiful.

Kannaththil kuzhi azhagu
A dimple on the cheek is beautiful

Kaar koondhal pennazhagu
Dark tresses of hair make a girl beautiful

Ilamaikku Nadai azhagu
An energetic gait adds beauty to youth

Mudhumaikku Narai azhagu
Grey hair adds beauty to old age.

Kalvarkku iravazhagu
Robbers perceive the night to be beautiful

Kadalarkku Nilavazhagu
Lovers perceive the moon to be beautiful

Nilavukku karai azhagu
The stains on the moon make it beautiful

Paravaikku siragazhagu
Feathers make a bird beautiful

Avvaikku koonazhagu
Even a hunch adds beauty to Avvai(a wise old lady in Tamil
mythology)

Annaikku Saeiazhagu
A child adds beauty to its mother

Vidikaalai vinnazhagu
The sky at the break of dawn is beautiful

Vidiyum varain pennazhagu
Till the break of dawn, a woman is beautiful

Nelluku Naatrazhagu
The saplings make the unchaffed grains beautiful

Thennaikku keetrazhagu
The branches make the coconut tree beautiful

Oorukku aarazhagu
A river adds beauty to a town

Oorvalaththil therazhagu
A chariot adds beauty to a procession

Thamizhukku "zha" azhagu
The alphabet "zha" adds beauty to the Tamil language.

Thalaivikku Naan azhagu
I add beauty to my mistress