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Changing The "System"

People of all kinds routinely blame the "system" for many things. They're absolutely right. It is the system that shapes human behavior. In a system where certain behaviors are rewarded, those behaviors are repeated. And vice versa. We are all Pavlov's dogs in that sense. That's why awards and honors are instituted. To reward the right kind of behavior even if that's not the expected norm. Awards motivate extraordinary people. What motivates ordinary people? The system. The "system" is the system that encourages and supports ordinary people to do things that they do in their ordinary life. The system includes written laws, unwritten laws, stereotypes, hierarchies, economic condition, political condition, geographic and physical condition, infrastructure, feelings, mythology, myths, news, fake news, communication, ... literally everything you can think of forms the system. Who builds the system? The naivest answer to this and the most convenient answe

Don't Let Them Dehumanize You, Doctors!

The society will try to dehumanize you in various ways. And you will feel pressurized to play along too. Don't let them do that to you, as much as possible. --- Every patient comes to you with the expectation of a complete cure. They do not care that you are human. Reset their expectations. Let them know that there are limits to what you can do. Stay human. Once, I was second call in VMH when a patient was brought dead to the hospital. The doctor on duty wanted to send them home in the same ambulance they came in so that they don't have to be bothered about arranging transport. But the relatives were getting angry that the doctor is not trying to save the life of the patient. I was called in. The patient was "obviously" dead. But it wasn't that obvious to the people who loved the patient. They were expecting an omnipotent doctor to be able to bring the patient back from dead. People will always come to you with unreasonable expectations - whether they express it o

History Taking Through Heart

I was trying out the Daily Rounds app on Android and came across a case description "Unilateral limb swelling in a 51 year old lady. No comorbidities. KFT normal. How to proceed to diagnosis?" This reminded me about how clueless I was about history taking during medical school. I think if I've learnt anything well by now, it is on how to take a detailed history. And looking at this question made me realize how much that helps me in coming to diagnoses. So here are some super simple tips to take detailed history while building a personal connection - which doesn't require any knowledge of pathology or medicine. Start with the person You might have learnt that asking for name is the way to build rapport. But that's a lie. Asking for name is so you can write it in your notes. If you want to build rapport, talk to the person in front of you (and not the patient). I've found that the question "have you had breakfast?" in their language (adjusted for the t

What Patients Don't Know About Medical Schools

There are people who assume that doctors who get into medical school through reservation end up as bad doctors. They have no clue how medical school works. I won't go into the reasons why reservation (or affirmative action) exists. That is one of the easiest ways for governments to "do something" towards inequity in the society. This post is about the relationship between medical school and bad doctors. Defining bad doctor Let's first define a "bad" doctor. An objective way of measuring that would be - a bad doctor is someone who kills the most number of patients. There's a problem with that though. A doctor with no patients would then not be a bad doctor. And a surgeon who takes on the most difficult cases (with proportionately higher chances of deaths) would also be considered a bad doctor. So, the absolute number of patient deaths is not a very good measure of the badness of a doctor. Maybe we can then take the subjective measure of "patient sati

Want to Predict COVID? Ask the medical officers or lab managers

From the beginning of this pandemic I've had very accurate predictions of COVID surge, lull, and fall from two kinds of people - PHC medical officers and lab managers. The PHC medical officers see anywhere upwards of 200 sick people per day and they get to see how many people are coming in with COVID like symptoms and notice patterns before they are even tested. The lab managers keep a track of test positivity rate (and test rate) and can sense that it is getting overwhelming vs underwhelming. The only kind of people who haven't particularly been helpful are the people who draw graphs based on numbers from government sources.

Three Stories On Connecting Health Data

  Story 1 There was a small research institute with 20 people. Someone among the staff did an online survey to ask everyone their demographic details (name, age, gender, email address) and their diet. After four months, another person ran another survey. By then there were 23 people in this institute. This surveyor asked everyone their name, email address, haemoglobin.   Now the director of the institute wanted to connect diet to haemoglobin levels. So they took up the older survey and assumed that since email addresses will probably remain the same, they could use that field to "connect" these databases together. But, alas, there was one person who changed her email from to   But never mind. They knew who it was. So they just fixed this by copy pasting rows in a spreadsheet. Story 2 A survey was done in 20 villages. There were two teams of 5 data collectors who divided the villages equally. They went to households and collected from the people dem

Whose Responsibility is Health?

How do you trigger a never-ending debate on Twitter about health? You have two options. Either talk about a bridge course from Ayurveda into modern medicine. Or talk about compulsory rural service. Why, though? The superficial reason is that Twitter is a stupid medium where there is not enough space to make a nuanced argument. The deeper reason is that it is not clear whose responsibility "health" is. And that's because there are two ways of defining what "health" is. There are folks who take health to mean absence of diseases. Even when the community medicine department in medical schools keeps talking about WHO definition of health , many medical graduates focus on "diseases" because the rest of the medical school talks only about diseases. This percolates to the rest of the society and in the overall society there is a clear notion that health is the absence of diseases and that healthcare is access to curative services. The impact of this definitio

Questions to Ask About Vaccine Data Tracking

In vaccine data tracking debate, please question the assumption that the government needs to track who is taking vaccine. What are the implications of not tracking who is taking vaccine? What are the risks and benefits? Who gets excluded when IDs are required for vaccine? What is the government trying to prevent by making IDs mandatory? What are the costs of tracking vaccine beneficiaries? What will the tracking be used for? Only if tracking people is required does discussing the mechanism of such tracking make sense.

Wonder Regimen to End Tuberculosis in India

Have you ever looked at Tuberculosis and thought, "Hmm. I wish there is a way to end this disease"? Well, wonder no more. Anurag Bhargava, Madhavi Bhargava & Anika Juneja have come up with a regimen that can achieve your dream. Another good news is that treatment with this regimen can also be helpful in many other diseases. Even better, it is a non-invasive regimen. Want to learn the regimen and start using it in your practice? Click here [PDF, 1.9MB] to know more. (You might want to skip to the end for the actual prescription, but read the full paper for context). Dr Anika Juneja, one of the authors of this paper, has won the India HPSR Fellowship this year.

The Art of Setting Up Success

What makes a great surgeon? Do they have long fingers? Or steady hands? Or the heart of a lion? I think it is the preparation they do right before they make the incision. In VMH, I would be assisting various surgeons, especially Dr MR Seetharam in orthopedic surgeries. MRS is very methodical in preparation for a surgery. Every surgery is different. One might require an expensive equipment, or a team of skilled surgeons. The patient might have severe comorbidities that make post-surgical management difficult. The economics might not work out. Functional recovery maybe more important. There are many factors that go into choosing the right kind of surgery for the right kind of patient. MRS will be thinking of all these as soon as becoming aware of someone who has an issue. But that's not the preparation I'm talking about. Inside the operation theater, with the patient and others eagerly waiting, there's a final and crucial step of preparation that MRS does. The X-rays are put

Science is Broken Because Scientists Can't Think Rationally

Scihub is being sued in Indian courts by the journal industry. There are some people worried about it. But it is funny how our knowledge system works. Take this tweet for example: Scientific publishing sure is rigged & broken. But hoping that the very bandicoots that are getting fat from the status quo will take hints and improve the system is beyond naive. The telling lack of collective resistance from scientists too enables this perverse model to thrive. — M D Madhusudan (@mdmadhusudan) December 24, 2020 The reason why journals charge exorbitantly and still get away with it is because almost all academicians publish only in those journals. And why do academicians publish in those journals? Here comes the greatest hypocrisy/logical fallacy of academicians. They think that publishing in "prestigious" journals bring "prestige". They even have a way of measuring prestige without making it sound like it's an emotional thing - impact fa

Lumbar Puncture and HIV

Lumbar puncture is a fascinating procedure. It is cheap, it can be done in relatively remote places, and it can be learnt easily given access to enough people who need it. LP has an incredible role in the management of many complications related to HIV. I've heard stories about how there used to be 5 LPs done every day in VMH during the time when HIV was causing rampant destruction in Karnataka and India. When I was there, we would do about 5 in two weeks. Nevertheless, when a colleague asked on Twitter about CSF analysis, I thought I should write down some of the things I believe to know about Lumbar Puncture itself, especially in relation to its use in management of complications of HIV. The first many LPs I saw were all done for spinal anesthesia in KR Hospital. Till then all I knew about spinal anaesthesia was a friend's description of the back ache he had post a "cool" hernia surgery because they had "poked many times for anaesthesia". I think I hadn&#

Public Lives of Doctors?

Social media has made our private life public. Facebook, Instagram, even WhatsApp (through stories) thrive on users generating engaging content. Often this content is snaps from daily life. A picture is worth a thousand words, yet can be generated in a second. Image centered social media platforms rely on this to keep themselves going. What about doctors (and other professionals) on social media? Is it any different for them? Should it be any different? This post has been triggered by the #MedBikini hashtag. Here's one tweet that reveals what happened: This journal article considers social media posts where MDs hold alcohol, wear inappropriate attire, and give opinion on controversial social topics as “potentially unprofessional.” How would any of these adversely affect the care we give to patients? 😳 #MedBikini — Ronnie Baticulon (@ronibats) July 24, 2020 I will not spend a lot of time discussing this particular paper or the twitter response to it.

What to Make of Itolizumab?

It is the worst of times . Science is suffering an identity crisis. The world is in dire need of science. Science isn't used to being rushed. "It is a giant and slow churn", said a friend once, "and spews a breakthrough once in a while". Is it possible to make the process faster? That's what everyone is wondering. And praying. And waiting, eagerly. Science isn't used to getting this attention. "Coronil is 100% effective", said Patanjali folks. "Favipiravir is 88% effective", said Glenmark folks. How to know the truth? Seeking truth has never been easy. Never has it been easy for journalists, scientists, or the common person. In some sciences there are multiple truths . Is medicine one of those sciences? Can there be a single truth in medicine? I won't use words like epistemology and ontology in this post. (Because I still can't remember which is which). But the question is essentially two: 1. Is there a single truth? 2. Is th