He must be kidding!!

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

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

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

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

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

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

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

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

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

Research? Extension?

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

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

Finally the coup de grace:

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

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

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

" Venu, vidi, where is he?"

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

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

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

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

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

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

FECAL TRANSPLANTATION

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

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

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

Feliz Navidad !!!

Gold, frankincense and myrrh

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

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

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

But they say it's a small world.

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

Job to do

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

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

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

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

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

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

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

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

Just do it....

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

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

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

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

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

"Just do it dude"

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

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

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

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

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

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

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

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

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

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

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

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

Everybody's at home

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

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

My readings

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

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

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

Happy reading.

Rabbit run. Rabbit stop.

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

Activity beckons.

Floydian philosophy: (with my distortion.):

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

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