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.

TMC VS KEM

TMC

-The largest medical center in the world spread over 675 acres with 100 buildings.
-Funding approx $ 5 billion- more than many countries' health care budgets.
46 – TMC institutions - Includes 23 agencies of government and 23 private not-for-profit health institutions. List includes Baylor College of Medicine,The University of Texas Health Science, The University of Texas M.D. Anderson Cancer Center, University of Houston System,Texas heart Inst at St Luke's Hospital, Ben Taub etc.
-5.5 Million – Approximate patient visits,10,000+ – International patients
-6,500 – Beds
-10,000+ – M.D.s, Ph.D.s and other doctorates
- 33,000 full time students.
-73,600 – Employees
-26,000+ – Registered nurses, LVN's, clinical caregivers, technicians, and medical support staff

KEM-

- Campus over not more than acres in single digits. 7 buildings.
- Funding I don't know. But I remember LSB saying that PGI,Chandigarh had funding 20 times what KEM got!!
-3 million total annual outpatient visits,83,000 annual admissions.
-1800 beds,( official) unofficial- any body's guess.
- 940 total residents and attending physicians.
- Provides training to 2000 undergraduate, postgraduate and specialty students.

First hospital to perform heart, renal and liver transplant surgeries in India.

Make your comparisons!!

From the Archives

At long last-this week's Arch Int Med contains articles of good clinical relevance.About hyponatremia being predictive of mortality in CHF, effect of pneumovax on severity of CAP, a meta-analysis of trials on dual blockade of the RAAS system on CHF.
My interpretations : Hyponatremia in CHF is hypoosmolal with increased TBW- this in turn reflects the severity of heart failure. So the result is expected...you are just calling a spade a spade. Whats new about that?
Why should pneumovax affect severity of CAP? Well assuming they are referring to typical CAP, the three most commonest organisms are pneumococcus, Hemophilus and Moraxella in that order. So if you have protected against pneumococcus you have the relatively less virulent two to deal with. Big deal then!!But if it were atypical pneumonia I think I do not have an explanation entirely. Again the polysaccharide vaccine is not a very good immunogen, memory T cell response in the aged would not be that good with the current policy of one shot at >65 years( which I have never understood)Also most folks receiving pneumovax before that age have specific conditions that predispose to pneumonia occurrence.And pathogens in them might not be the same as in healthy people.So....what gives?I don't know.

I used to think- give a CHF patient Alsikiren plus beta blocker plus ACEI plus ARBs plus Aldactone...khallas. Absolut paralysis.Mother of block nanas. But I think there are problems we have to deal with here. I do not know the prognosis of medical nephrectomy...have seen it just once in a nephrotic we put on ACEIs. But the KDOQI recommends close follow up in a diabetic CRF put on ACEIs, as beyond a few weeks things level of, and the prognosis is actually good.I wonder why someone does not take this up as a thesis topic- multiple RAAS blockade in CHF and prognosis of renal disease if any.

Jhakaas !!! Mast vaatla.Tumhala kaay vatla?

Nobel

The Nobel prize for physiology for the year 2007 was announced today.
Mario R. Capecchi, age 70, at the University of Utah in Salt Lake City, Sir Martin J. Evans, age 66, at Cardiff University in Wales and Oliver Smithies, age 82, at the University of North Carolina in Chapel Hill, will share the $ 1.54 million prize for the technique of mouse models for genetic disease- creating knockouts and gene targeting.

Wei used to tell me she was the knock out queen at Astra Zeneca - had quite perfected creating knock outs for various enzymes and thats what she used to do all the time.Of date there are 2500 gene knock out models that people like Wei have helped create.Hmm...

It is really such a simple technique in theory.But innovative. Like the hybridoma technique for MAbs. DRK used to say...you don't need to be all high tech and recondite to be innovative. It might be a simple corruption of pathophysiology.Thats how great ideas take fruition.Listening to Mammen Chandy explain RT-PCR was one of the most enlightening experiences for me.He likened it to a story from the Genesis, almost child like in his narration. And in his exuberance in going from step to next step like episodes in a story taught me that great minds keep things beautifully simple.They don't know all the things all the time. But they know what to do all the time.

We complicate things by oversexing them.We think that if it is difficult to understand, it must be something great. Like Despo's quaint logic- the special theory of relativity is great because so few people understand it in concept.Thats exclusivist.I wonder if Despo ever did. If people do not understand it, what utility is it going to have except being fodder for intellectual masturbation at shibboleth conventions for those who do?

Einstein had this to say: "The only thing that interferes with my learning is my education."

Motivation....

This is all true...I have changed names of course.

Existentialist Pedagogy: Every act we perform has a motivation/ incentive. Many a times it is basic id stuff..survival skills, gratification......the Sex and Violence thing. Other times it is more.More than is readily apparent.It might seem impulse/ spur of moment brainlessness at important moments decide the crucial decisions we make- the so called Gut feeling. But even these mirror an unconscious motivation of the psyche moulded by its aspirations and ideals.

When there is a hand to mouth fight to Just Exist, there are no aims and objectives or even methods. Its a plain oral-anal infratentorial stratum of life.
It is the story of a Bhimadevi, CSW , sometime abducted girl from Nepal, admitted with multiple hyperintense lesions scattered in the cerebral hemispheres which neither radiologist nor clinician nor neurologist could figure out the etiology of. And her paramour Ismail, laborer at Masjid Bunder, who has rescued her from some Grant Road brothel,and would agree to anygoddamnedthing I thought would work and wanted to try on her .All he would say is " Shaam ko laya to chalega na saab?" And by evening he would have money that he would thrust in my hand and say, "ye lo saab, jo dene ka hai usko de do, bas theek ho jayegi aisa karo." She died undiagnosed- speculative differentials included fungal vasculitis, nocardiosis, HSV encephalitis among others.I was unpreparedly naive to this situation - Dickens is dead, so what kept him going? Godammit she was a closed case I had told him- CD4 was 36,no diagnosis, septic, but he would still work his ass out to get the money by evening. That pestilence, a crudely simple, rustic affection could keep one going on vada paav and chai all day, pushing handcarts and carrying loads to pay for her medicines, carry her urine, stool and blood samples ungloved,pet her deliriousness into a calm like no calmpose could - I could not believe this.And all of this for someone who he knew had a DC already written for her when she entered, uncondomized Kamikaze, with puberty being her only qualification required for the job she chose to make a life of - GOD...deliver me.

I have known four people closely who chose to commit suicide at a time when Life had its curtains of opportunity still drawn. Only one succeeded thankfully. These were highly intelligent people, with families which were supportive and 'normal', in medical school and engineering college and youth pumpin the anabolism. I wonder why?I wonder why?What it takes to inject yourself with Propofol, Pavulon and potassium chloride while people outside are queuing at the bathroom to get ready for ward work, your spouse of 6 months is struggling with internship, your parents are making plans of when they could make that surprise visit- and you pull the biggest of surprises on life and its bustling regularity itself.

What goes on in your mind when you ask yourself to b intubated while being exsanguinated despite resuscitative efforts in the ER?

What is your motivation when you have 7 years of post doctoral research, have 7-8 publications in peer reviewed journals, work in one of the world's best cancer institutes, and are applying for residency for PGY1 positions competing with people 6-7 years your junior, attending stupid interviews suited and booted presenting a dumbed down version 'minus 2.0' of yourself? Why I ask....service, money, connection with people are the words I hear....but my inerudition causes me to stumble to make one complete phrase of it.

Your best friend of years suddenly goes out of radar for months. You ask people who know whats going on? "He's gonna do pure research, no practice for him" is what you hear.You wonder, a life out of 'N glycosylation?!' are you kidding? Is he feeling that he has fallen back because of the choices he made? Is he aiming to be a Susumu Tonegawa or Hargobind Khurana? Has he lost his nuts? Is he a true blue research junkie evangelist?

What led him into it?

What keeps you going when you are in hot and humid Kutch, have lost your baggage, passport, thousands of miles away from home; when you know the ground situation better than some random politician who chooses to make a helicopter visit, despite not knowing a word of the local language, have a bowel which reacts most violently to what food you have to bear with daily,don't know when you will be going back, don't care,are equally adept in lifting corpses and doing audit of supplies and writing reports- hell don't mind it really because you started as a jack of all of that? Thats a long and disparate summary of the guy...and I still don't know what kept Paul going.

Reading the wikipedia biographies is an extremely enriching experience. I do not have the energy or the resources to go through whole biographies. But it just gets you interested enough to wonder what the hell did this guy do on a day to day basis? Was he a MDP? Did he love, screw, watch movies, read newspapers with the same ennui as you or I do or was he in constant flux? What were the messages he took from random events of life like apples falling usw.Was he just an aggressive Machiavellian Robert Gallo or an underachiever Ramanujan? Ich kenne nicht.

These are random thoughts. I probably do not understand what their motivation is because I cannot possibly be intelligent a priori. ... have not had a refinement or evolution of thought enough to comprehend everything that life throws at one unexpectedly.Sometimes I do....sometimes I am clueless. Some time I shall sit on a wise rocking chair and know it all. But.. To be certain of everything is a frightening prospect.

HMS

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

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

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

One of those days

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

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

Tomorrow shall rise, and we shall shine.

In India...

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

Here it is just 'being polite'

Transvaginal cholecystectomy!!

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

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

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

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

Borrowed stuff again..

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


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

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

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

Common medical mental failings

Attitude:


Resistance to change

Cynicism

Lack of empathy

Intellectual tiredness

Emotional froideur

Cognitive function:

Failing memory

Irrationality

Erratic performance

Humour:

Outright failure

Relentless levity

Illiteracy:

Numbers and statistics

Emotion

Culture and literature

Language

Creativity:

Lack of ideas

Lack of opportunity

Workaday triviality

Put monkeys in white coats and they lose their bananas.

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

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

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

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

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

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

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

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

To my connected friends

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

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