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The Curious Case of Consultation Fees in General Practice

Today as I was returning home in metro two lawyers occupied the seats next to mine. I was reading A Reader on Reading by Alberto Manguel. But I distinctly heard one of them tell the other "I have two cases tomorrow evening". That set me thinking.

Advocates have "cases" and so do doctors. Advocates have "clients" and so do doctors. (Some doctors call their clients patients because some clients are indeed patients. But some doctors call even their patients clients, appreciating the fact that ultimately the people who come to them are dignified individuals seeking a service and with autonomy in choosing service providers.)

Advocates are also notorious for charging sometimes lakhs for an "appearance". But here doctors have itt slightly different. Doctors also get called money-minded and unscrupulous, but they get called so for charging much less than what advocates usually charge. Why is this so?

I came up with various possible reasons. One, the hu…

Healthcare in Consumer Protection Act 2019, VP Shantha and why you should read the source

There are good journalists and bad journalists. It is the reader's duty to discern between what is right and what is wrong. The problem in the 21st century is that that duty is completely thrown into water under the guise of "forwarded as received".

There are a lot of articles in newspapers talking about dropping the world "healthcare" from the list of services under the consumer protection act of 2019. Many of them have fancy headlines suggesting that healthcare will not be a service that falls under the ambit of the new consumer protection act. At least some of them have written objectively stating where the word is dropped from without going into judgement on what this means.

But many doctors are reading headlines and thinking that the consumer protection act will not apply to healthcare henceforth. What they need to read to know they are wrong is just one judgement by the Supreme Court in the "Indian Medical Association vs VP Shantha, 1995" case.

Meftal-Spas vs Meftal-Forte for Menstrual Pain

I was recently asked by someone whether Meftal-Forte is a better drug than Meftal-Spas for menstrual pain.

I hadn't heard about Meftal-Forte till then. So I looked up. 1mg told me both the drugs are manufactured by Blue Cross.

The page about Meftal-Spas gives us what I knew already - it is a combination of Mefenamic Acid 250mg and Dicyclomine 10mg.

The page about Meftal-Forte told me that it is a combination of Mefenamic Acid 500mg and Paracetamol 325 mg.

Based on this, the quick answer is "No. Meftal-Spas seems to be better suited for menstrual pain in people who find relief by using it. But self-medication may not be the best way to manage menstrual pain."

The longer answer is that dicyclomine is an anti-spasmodic that is widely used with anecdotal evidence supporting its use in primary dysmenorrhea. Mefenamic acid is an anti-inflammatory drug that is indicated for use in primary dysmenorrhea. Paracetamol is not really indicated for primary dysmenorrhea. Therefore if f…

Consent of the Pediatric Patient

Last week, an interesting question was raised in our primary care fellowship ECHO session. "Can you give consultation to a minor without the guardian's consent?" A simple scenario could be when a 15 year old girl comes to your clinic alone, anxious, and asks for a consult. Would you proceed normally? Would you ask her to call her parents and come back? What would you do?

During the session I quickly searched and found an article in Indian Pediatrics, which said that "A child between 12-18 years can give consent only for medical examination but not for any procedure". But then, I went back to see on what legal basis this was said. They seem to have referred Legal Aspects of Medical Care, a book by RK Sharma. I unfortunately do not have this book to figure out which source in law RK Sharma has used.

So I started searching more. In National Medical Journal of India, Karunakaran Mathiharan goes through various clauses of multiple statutes and state that there is a …

The Case of Dr Payal Tadvi or the Case of India's Healthcare System?

Dr Payal Tadvi committed suicide exactly a week ago. She was a postgraduate student in Obstetrics & Gynecology. Investigation is going on about the death. There are quotes from family members that she was being harassed on the basis of caste by seniors. Those seniors have written their side blaming workload. (Please go through the links if you do not know the details)

Let us leave them aside and ask ourselves a few questions now.

Is their discrimination in medical colleges?
There is. All kinds of it. Economic capacity. Skin tone. Age. Seniority. Language. Region. Residence in the state where the medical college is in. Category of seat. Every damn kind of discrimination. There is discrimination in medical colleges.

Is their caste-based discrimination in medical colleges?
I think the answer is yes. I haven't seen much first hand. But, there is definitely discrimination based on reservation. And since reservation is based on caste, it can indirectly be told that this is caste-base…

The Power and Limits of Classification

Link to journal article:

My comment: 
In our work with transgender men and women and other gender minorities, this was the common opinion among all "categories" of people - to stop categorizing them.

Here is another illustration. HIV prevention and control efforts in India has a certain stress on prevention among high risk groups. For many people in the field, "LGBTQ" is a high risk group. If you look at it, the only thing common among the members of this "category" is that they are all gender minorities. By using the term "LGBTQ" many lesbians and transgender men who are actually "low risk groups" get mischaracterized as people with risk of HIV and gets repeatedly asked to do HIV testing.

The people we talk to have all been affected by the medical system's lack of ability to deal with the full spectrum of gender. They strongly ask for developing a framework for healthcare pro…

The Ideal Physician AI Assistant

When I hear "Artificial Intelligence" and "Healthcare" together in a sentence, it is usually never a pleasant thing I'm listening to. There almost always is some kind of reinvention of wheel where Google's hardware cycles are spent in trying to solve something meaningless.

For example, it is futile to differentiate between tuberculosis and cancer from an image of the chest where the answer may never lie in the image, but rather in the symptoms of the patient. Even if AI tells the physician that the ECG it is reading is normal (which the physician probably noticed on their own), the physician still has many reasons to refer the patient to a higher center.

These are isolated examples. But it is the isolation that makes these good examples. AI's role is not in isolation. AI's role is in integration. AI (or computers) should come in and fill in where humans struggle - processing large amounts of data. (Processing data, not for the sake of figuring out p…

On Libraries

Sunil K Pandya asked on NMJI "Are Libraries in Our Medical Institutes Dead?"
Badakere Rao responded to it with his memories of physical books.
I had this response:
The article on libraries and your response to it was a sweet read to me. The school in Mattanur that I studied from 1st standard till 10th standard had a large library (when I went back last month, it felt small. Maybe everything was much bigger when we were smaller). If my memory serves me right it had 4000+ books. The most beautiful thing was that when any student has a birthday they would celebrate it by donating a book (or more books) to the library and their names would be announced in the school assembly. This kept the number of books keep increasing. Perhaps it became a prestige issue for parents to send only quality books with their kids for their birthday, because all the books so donated were usually good and new books. From as far as I remember my favorite pastime after school (and free hours…

Why "Regulations" Are Often Not Helpful Solutions

The other day I saw an impassioned plea from a doctor asking associations to "regulate the profession". The reason they cited was that healthcare is turning commercial and often this goes against the best interest of the patient.

One of the many things I learned in National Law School listening to Prof Nandimath and others is that "regulations" come with their own set of problems.

Let us look at it more closely.

First, what is the problem we are trying to solve? The healthcare system in our country (many other countries too, perhaps) have huge flaws in it that lead to suffering and poor quality of care for the end user (the patient). Medical training is focused on the wrong parameters (recent change of UG curriculum to a competency based curriculum is proof of this). Distribution of healthcare providers is disproportionately concentrated in urban areas. Healthcare is episodic. Government policies are weakening public health system. (Public health system, even o…

Product Idea: "Explain My Prescription To Me" Service

Many doctors have very little time to spend with the patient. So little time that sometimes they start writing prescription before even arriving at a provisional diagnosis. Imagine how then, would they explain to their patient why they have written a particular tablet for them?

Is there a product/service idea in this vacuum of counseling that should have been provided by the doctor? Are there people who are not able to ask the right questions to the internet to find the answers?

Perhaps there should be an app that is front-end for a prescription description service. The user uploads their prescription and also attaches a short voice note with their symptoms. This goes to a doctor/nurse/pharmacologist/pharmacist at the back-end who responds by reading out the prescription and counseling the patient about what the medication is, what it does, what side effects can be expected, etc.

The counseling of each medicine can be recorded and reused for the next patient who is prescribed the same…

What Can an Individual Do?

Forwarding a message I received from Dr Dharav Shah who is creating a wave of change in youngsters across India making them abstaining from the first puff and the first drink so they lead a healthy and happy life without the poisons we love.
Do watch the video. I had tears only once, but your mileage may vary.
Dear friends,
Last week i had forwarded TEDx talk of Dr Taru, who had worked in a district hospital of Bihar. The NGO with which she was working, needs doctors for similar work in district hospitals in Bihar.
If you know any surgeon, Gynecologist, pediatrician or Anaesthetist who would probably like to take up this challenge for 6 months or more, please inform them about this opportunity to contribute. Please forward this ad in your medico groups
Are you upto the challenge of being an agent of change, working towards improving Emergency services in a progressive Bihar?
1. WHO-CARE Global Surgery fellowship - *Specialist Obstetrician*:

Reviving community medicine in India: The need to perform our primary role | International Journal of Medicine and Public Health

Link to original article:
This is a very thought provoking article I came across yesterday. It says that the actual role of a community medicine specialist is as a family doctor in primary health centres.
My college had a "preventive and social medicine" department. Now it all makes sense.
If you look at community medicine departments in the present situation you see that they restrict themselves to TB, HIV, Leprosy, or whatever diseases have a national program on them. No national program? Out of scope of community medicine. And even within these, the role that community medicine department likes to play is that of a CME organizer. I do not remember a case discussion in community medicine in my college days where the patient was actually in front.
What community medicine needs is a practice base. 
Read the article here:

Interactive textbook with adaptive level of complexity

This is an idea I've been having since a long time. I think it is relatively easy to implement as well.
We need textbooks like we have online maps. Textbooks that give you an overview first and then let you zoom in to any part and get more and more details. The deeper we go and the more details we have the harder will the level of complexity be. So, a beginner can probably zoom out and get a large overview of all the topics they need. Someone who already has the overview can zoom in at a part and get some more details. Then, they can zoom in again and get more details, and again, and again till they reach the maximum available information.
Writing such a textbook may seem complicated but all it takes is some amount of reorganization of thoughts and marking sentences by their level of complexity.

Why is Benzylpenicillin called Penicillin G and Phenoxymethylpenicillin Penicillin V?

This one took a lot of searching. My initial hunch was that the G and the V stood for amino acids. G for Glycine and V for Valine. I thought, maybe, if these amino acids were not substituents, at least they would be the precursors involved in synthesis of Penicillins. I had also heard the word "Penicillin Gold" somewhere suggesting that they could be acronyms as well.

After some searching around, there was a chance discovery of this page on some encyclopedia that said "The different forms of penicillin are distinguished from each other by adding a single capital letter to their names. Thus: penicillin F, penicillin G, penicillin K, penicillin N, penicillin O, penicillin S, penicillin V, and penicillin X"

Now I knew there are more letters and these are chosen just because they are in the alphabet and not because of anything special. So the question became, why these letters? Did they start with Penicillin A and go down all the way till Penicillin V and even X? Is…

JLS: SJG Ayurvedic College, Koppal

On 6th March, Wednesday JeevaRaksha team did the first JLS (JeevaRaksha Life Support) course in an Ayurvedic college in Karnataka at SJG Ayurvedic College, Koppal.

I took Hampi express on the night of fifth and reached by about 9 in the morning and the workshop had already started by the time I reached the venue. The participants were enthusiastically interacting with the facilitators.

Choking was my topic and for the first time I had a "choking charlie" for demonstration. After a small lunch we had the scenario trainings and tests. A lot of candidates became eligible for being trainers.

That evening Ramya, Sahana, and I went on top of Gavisiddeshwara Temple and watched a beautiful sunset.

On Thursday, the training of trainers took place with the candidates who were selected on the previous day. All of them showed real potential to be great facilitators.

Why are the question papers of NEET PG not available anywhere?

If you are a medical student, you know what I am talking about. The PG medical entrance test, called NEET PG, is a proprietary test conducted by National Board of Examinations. You have to sign a non-disclosure agreement to attempt this test. You cannot, according to the agreement, disclose the questions asked to anyone. Neither does NBE publish the question papers anywhere.

How is this fair at all?

For comparison, all the JEE advanced question papers from 2007 are put on the official website of JEE advanced. The USMLE website has content description booklet, plenty of sample questions, and practice tests. While the NBE's website proudly writes everywhere that their exams (not just NEET, all of them) are "proprietary".

This would not have been a problem if NBE was some private body which conducts test for the sake of individuals. But NBE is not that. NBE is an autonomous body under the Ministry of Health & Family Welfare. NBE is not a private entity.

How come they ar…

De Quervain's like Pain After CPR

Yesterday I was demonstrating CPR in a life support workshop. Today, I have pain in the left radial styloid process area.What could it be? Searching took me to two pages of interest. One is AAFP's page on diagnosis wrist pain. This page talks about many things including Finkelstein's test which is grasping the thumb with other fingers and then ulnar deviation of wrist. It was negative for me, and I definitely did not have De Quervain's tendonitis.But it could be the same tendons. What are the tendons involved in de Quervain's? The extensor policis brevis and the abductor policis longus which both go through the groove lateral to the radial styloid process. Maybe there was some microtrauma?The other article was about wrist injuries in emergency service providers. It does not look like I have a scapholunate ligament injury. So I decided to read more about de Quervain's.I found an article - Walsh and Miller: Pain about the Styloid Process - which beautifully captures …

A Letter to the Disillusioned Intern (or Medical Student)

Disillusionment. It happens to the best among us. It has happened to you? Welcome to the club.

After all, who wouldn't be disappointed? You could have become anyone - an architect, an engineer, a teacher, a scientist, a mathematician. Yet you chose to become a doctor. Of course it was your calculated choice. What a fantastic profession is it, after all? When a doctor talks to a patient, she is a teacher, an artist; when a doctor is diagnosing an illness, she is a detective, a scientist; when a doctor is communicating, she is a writer; when managing an emergency, she is a leader; in her career, she becomes an administrator, a guide, a policy analyst, a visionary. A doctor's profession is an incredible melting point of careers. Unique, interesting. And above all, serves humankind like nobody else.

And what did it all come to? Running around like a dog completing errands passed down to you in the strictest hierarchy ever. (It is called dog work, did you know?) Maybe learning a bi…

Why Jacob Vadakkanchery's Arrest is the Best Thing for Naturopathy, AYUSH, and the State

There is a lot of context needed here.

To begin with, Jacob Vadakkanchery is a self-proclaimed healer naturopathist from Kerala who goes around asking people to believe that modern medicine is harmful for health. His arguments are so basic and trying to respond to an argument he raised had me writing a 1200 word blog post in Malayalam explaining what science is and whether medicine is a science. He was arrested in the second week of September by Kerala police for asking people not to take Doxycycline prophylaxis (in the aftermath of the floods) under at least section 505 of IPC. Section 505 is one of those sections which exist owing to the "reasonable restrictions" over freedom of speech and expression in the interest of public order as per Article 19 of the Indian Constitution. It punishes people who spread rumors that are likely to disrupt the society unless they are based on reasonable grounds.

I, am an HIV physician and general practitioner of modern medicine. I have pre…

Healthcare With Smartphones?

Imagine this. You are a 36 year old lady working as maid in two houses, not supported by an alcoholic husband, and mother of two school going children. Your husband had a wart on his genitals and now you have it too. It is not particularly bothersome, but you are not sure what you should do about it either.You think it would be a good idea to go to a hospital, but which hospital? Which doctor should you meet? Would they judge you? Do they charge too much money? Is it going to hurt? Whom do you even ask these questions?Enter our app.You will be asked a series of questions in your own language. The questions get more and more specific as you answer them. They will also be read out to you in case you can't read. By the time you have answered about 10 questions, the app knows what your problem is.The app has been fed with a well designed set of protocols/algorithms that need to be followed in each situation. It has a curated collection of resources (hospitals, clinics, labs, lawyers, …

Reimagining Kinnars (Hijras) as Health Workers for Reproductive & Sexual Health

Supreme court struck down section 377 a couple of days back. India is moving forward in the right direction. There is still a lot of work left to do.

We see kinnars (hijras) working on roads asking people for money. They are "strange" humans in other people's mind and when people look at them all that comes to their mind is their gender issues and sexual connotations of those.

This strangeness might be the reason why people are unwilling to give them jobs. Could we turn this around?

Reproductive and sexual health is a topic that is absolutely neglected in our education system. There is plenty of embarrassment in discussing topics related to sex as well.

What if, then, we put them both together? What if we empower kinnars by giving them training and other resources required, to go into the community and work for reproductive and sexual health? Like ASHA workers they would promote health. They can even distribute interventions like condoms.

This is a positive change in man…

Way Forward

On 30th of June, SVYM organized a one day session on careers after MBBS at Vivekananda Memorial Hospital.

Interns and/or final year students from Mysore Medical College, Bangalore Medical College, Hassan Institute of Medical Sciences, JSS Medical College Mysore were among the ones who were in the audience.

After the SVYM video, it began with introductory remarks by Dr Chaithanya Prasad, the director of VMH.

Then Dr MA Balasubramanya talked about administrative careers after MBBS. The gist of it was that as doctors, we are already administrating. There is no running away from it. We should embrace that reality and go forward with it.

Dr Kumaran K took the audience through the story of his life in research and thereby had them thinking about how to pursue a career in research.

Dr Ravindranath motivated the audience to take up surgery as a career and showed various alternatives to the MS degree to become a surgeon - majorly about options in various other countries.

Dr RK Nair talked abou…

First PEP - Days 7, 8, 9, 10, and so on...

Well, I lost count.

I didn't miss a single tab. But I have, as usual, missed on writing the experience.

There are indeed some highlights.

First, a house surgeon and his friend from my college came all the way to Nugu and our hospital after reading my posts. I guess I put enough philosophy in his head that he comes back and joins here later.

Then, I'm making good progress in my thesis work, interviewing patients about their perspectives on how they became sick. I have interviewed three patients till today. Each interview gave me a completely different story. I have even moved to Asha Kirana hospital asking permission to interview patients there.

Also, Amazon made three deliveries. My favourite book - The Emperor of All Maladies, my favourite stethoscope Dr Morepen ST 01, and Tripti Sharan's Chronicles of a Gynaecologist. (all affiliate links) 
Finally got a hard copy. Horror stories one after the other. Chronicles of — Akshay S D…

First PEP - Days 4, 5, 6

Days fly by as usual. It's already day 6 and I'm wondering what I did on day 5. (I slept all day).

Day 4 - Monday, 30th April

I had general OPD duty. In essence I was jobless almost the entire day. I sat in the injection room and saw some 10 patients.

This morning I had tried to swallow the LPV/r without any water. It wasn't a very good idea as one of it got stuck to the throat and I almost had to do Heimlich on myself.

It's the day we went to Nugu and savoured garlic bread and churmuri prepared by all the ladies.

On the way back Kishan & Suchitra ran out of petrol. So I had to empty a 1 litre bottle of water into my throat and fill petrol in it. Swathi and I went on a scooter ride after about an year today.

Day 5: May day

All I remember of this day is sleeping all day. I tried to get some useful work done after waking up in the evening. But having finished dinner, I slept again.

Ah, ah. I also sent an email to the canteen manager regarding the legality of "c…

First PEP - Days 1, 2, 3

After having done the "Perfectly Messy Prefect" series and "Jog Journal" series, I have now gotten the opportunity to start a new series - on Post Exposure Prophylaxis.

Let's start with the good news. I put a central line in a patient (that's my first time after MBBS and the first time I was confidently doing it on my own).

This patient who's been admitted with Cryptococcal antigen showing 3+ in their CSF needed lots of amphotericin for two weeks. Putting amphotericin in a peripheral venous line is okay, but it can soon lead to thrombophlebitis and both patient and doctor will have a hard time managing it. So we decided that it must go through a central line.

And it was imperative that this happened in the new emergency department that was inaugurated the same day. Dr Ram was around and his guidance is better than the ultrasound guidance he gives.

First thing we settled was whether the artery went lateral or medial to the vein. Of course it goes lateral…