Lessons One Should Learn From Shehla Sherin's Death

If you do not avoid news like me, you would have heard about the tragic death of a 10 year old in Wayanad a couple of days ago. You can search the name and find the story on your own, but a few facts are established already.

1. Shehla Sherin had her foot go into a hole on the floor of her classroom and was afraid a snake bit her in that incident
2. There was delay in taking her to the hospital
3. Anti-Snake venom was not administered at the local hospital, and the child was referred to a tertiary care center at least an hour away.
4. Child died on the way.

I won't unnecessarily go into speculations on what other things happened on that fateful day, but having managed emergency department in a rural hospital for over an year, I will use this sad death to illustrate two very important lessons for every doctor.

Lesson 1: Never take any complaint lightly, even if the circumstances lead you to think otherwise

There are two ways patients can come in. There are people who exaggerate, and people who downplay. Take all symptoms seriously.

There are no insignificant complaints. There are no insignificant findings. Whatever the patient tells you has to be taken seriously. Even if the patient asks you to not take it seriously. At the height of experience and confidence you might be able to predict that something isn't as serious as it sounds, but be really really careful before making that decision.

I had once a patient come to the casualty with a swollen foot. The patient had intellectual and speech disabilities and therefore there was no proper history. The bystander (who apparently takes care of the patient) told that "someone must have hit him". My colleague suspected a snake-bite because of the way the swelling looked, but nevertheless ordered a whole blood clotting time test and a foot x-ray to rule out a fracture. My shift was about to start and while I was taking charge from my colleague I inspected the foot of this patient closely (in the x-ray room). I could see two small points of bleeding close to each other - fang marks!

We immediately told the bystander that this is not "someone must have hit him", it is a snake bite, and that the patient will die unless something is done immediately. This bystander did not look like they liked the patient very much because they asked me "please do whatever you can here itself, don't refer us to higher center". We knew that the best we could do was given anti-snake venom (which we immediately started doing) but the patient might require blood products which weren't available and required referral. So, we took a stand and sent the patient as soon as the ASV went in.

There was this other patient who came at noon on a different day with severe chest pain, as if he was going to die the next moment. He was a smoker and alcoholic with a very good chance of having a heart attack. He wouldn't even lay still for us to get a proper ECG, and whatever leads we could obtain looked like there were ST elevations all over. The MI protocol kicked in, we gave all the painkillers, anti-coagulants, and sent the patient to the nearest cardiology center. News later was that he was just having severe gastritis due to alcoholism. But, we did what we should have done.

We've had a patient with vague headache/chest pain admitted for observation die on us under strict observation. I've had a patient with diarrhea go into dehydration and shock. I've had a lady who could perceive fetal movements but have no fetal heart activity on ultrasound. We've had a person with cellulitis of lower limb go into septic shock and die while we were on rounds. We've had a bystander who missed anti-epileptic medication die after getting seizures and aspirating. I've examined a kid with high fever who had febrile seizure on the way out. We've had a kid admitted for being dull after vaccination die in front of us, despite our best efforts. We've had a child in waiting area who wasn't breathing well arrest by the time they were identified by a patient care worker to be requiring urgent attention. I've had a patient with vague thigh pain turn out to be deep vein thrombosis and die next day.

Always have the worst outcomes in mind when making decisions. Be mindful about patients who you haven't even seen yet. Communicate a lot. Err on the side of cautiousness.

Never be afraid to wake seniors up from sleep. When in doubt, ask for help. If you are not sure about something, check it again. If something happens while you could have done something which you didn't, you'll regret that your entire life. And that is a pain.

Lesson 2: It is a privilege to have access to the miracles of modern medicine. When you have the power to use things, please also have the courage to.

There is always going to be a risk. It is risk that makes the work of a doctor exciting. If you've chosen to be a doctor, there is no way you can avoid risk. Even if you become a dermatologist, you can land up in soup. As a doctor, the only way to avoid risk is by quitting professional life and meditating inside a cave.

Risks shouldn't hold you back from attempting something that's required for your patient. I got this lesson the first time when I was still an intern, and was in KR Hospital's Medical ICU. I was trying to insert a catheter into someone's jugular but I was going too superficial. My senior then told me "Always remember, what you're doing is for the benefit of the patient. You're only going to harm them by not doing it confidently. The patient will die if they don't get this line. So you may as well put it in boldly."

There is a definite role for experience and knowledge in being able to build the confidence to do things. But neither of that will come unless you want to do those things for your patient. If you are shy of cutting, you can never be a surgeon. If you are scared of side effects, all the pharmacology you know is absolutely of no use.

Too many doctors think that by not committing something they're keeping themselves safe. But their fake sense of safety comes at the cost of the patient's suffering. Laws of medical negligence apply to acts of omission as well as they apply to acts of commission. With all your training you may as well do something and fail, than be a mean coward. That's what your license is for.

Use anesthesia (ketamine + midazolam, if you will) when draining breast abscess. Give powerful analgesics when people are in pain (don't give diclofenac for MI/fracture. Give something like pentazocine). Use second line and third line drugs when the first line fails. Give aminophylline or magnesium sulphate for COPD/Asthma. Steroids and immuno-suppressants are in various guidelines for a reason - use them when indicated. Even newborns may need anti-epileptics. Benzathine Penicillin is the best available cure for Syphilis. "Higher antibiotics" are not reserved for higher centers. Use vasopressors (and for heart's sake not fluids) in hypotension where failure needs to be considered. Use nitroglycerine to control high blood pressure. Use heparin. Use atropine. Use adrenaline. Use BiPAP. Resuscitate. Use oxygen. Use fluids. Give vaccines. Conduct deliveries. Splint fractures. Suture large wounds. Intubate and bag till the ventilator in referral center. Use all the things you've learnt to deliver care. That's why you're a doctor.

And if you feel you're under-prepared for any of those things even after MBBS, work with sincere people in rural hospitals (like VMH or THI or BHS). Learn the skills. Learn the craft. Understand pain and suffering. Care for other humans. Become a good doctor. Then do whatever you want to.

Epilogue

I had a rule when I was working in ED - "Nobody dies when I'm on duty". The only exception was patients admitted for palliative care. Imagine if every doctor in our country made rules like that for themselves.

Understanding Adrenaline Dosage

Have you ever administered adrenaline for anaphylactic shock? I've never had the unfortunate need to. I'm sure anyone who ever does will forever remember the correct dosage. But for me, it is always a confusion. Every time I vaccinate someone at my clinic, I look up the dose of adrenaline just to be sure.

The first problem is the dilutions. Dosages of adrenaline are (or were) mentioned in dilution. 1:1000 & 1:10000. There begins the confusion.

Firstly, let us understand where the 1000 comes from in 1:1000. Have you seen a small vial of adrenaline? That is 1mL. It has effectively 1mg of epinephrine/adrenaline. But why is it called 1:1000? Because 1mL of water = 1g of water = 1000mg. So, the 1:1000 actually refers to 1mg of adrenaline : 1000 mg of water. Unnecessarily complex!

All you had to say was 1mg in 1mL. And that is why this labeling is now being followed in some countries.

So, there you have a small vial - a 1mL vial - with 1mg of adrenaline in it.

Now, let us look at the other form epinephrine comes in. Epinephrine also comes in a big syringe of 10mL. But even this 10mL contains only 1 mg of adrenaline. The total amount of adrenaline in this 10mL form is the same as a small vial.

What is different then? Well, when the volume increases without increase in amount, the concentration drops. The 10mL form is more dilute than the small vial. Can you guess the dilution? It is 1:10000 or more easily expressed as 1mg in 10mL.

So, the first thing to internalize is that the small 1mL vial we see has 1mg of adrenaline (it may say 1.8mg of an adrenaline salt, but the effective amount of adrenaline is 1mg). And this is a concentrated form of adrenaline.

What that also means is that the 1mg/1mL adrenaline is never used directly IV! The reason is that this can cause an arrhythmia or other damages to the heart muscles.

If you're bored reading text, watch this youtube video telling these same things.

Now, the dilute form and the concentrated form are for slightly different uses. The concentrated form is given IM in anaphylactic shock. The dilute form is given IV in cardiac arrest.

When giving IM adrenaline for anaphylactic shock, the dosage in adults is almost always 0.5mg (0.5mL of the concentrated vial). If you can remember this fact it is easy to calculate the pediatric dose as well. The adult dose can be thought of as if it applies to a 50kg person. So 0.5mg for 50kg = 0.01mg/kg and that is the pediatric dose. (This 50kg adult approximation applies for many other drugs in calculation of pediatric dose. Let me know in comments below about other drugs that can be calculated this way).

When giving in cardiac arrest, in which case the dilute form (1mg in 10mL) is used, the adult dose is the entire 1mg (or 10mL) given intravenous and repeated based on the protocol you follow.

That is all there is to know. Just a 0.5mg and a 1mg.

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 huge lawyer fees that we hear about usually are in big courts for defending big crimes. Perhaps the stakes are really high in those situations. To add to that, a court case is usually once in a lifetime situation for most people and one they probably have never encountered before. Therefore the clients are in a much more vulnerable situation and would be willing to pay a lot.

This "high stakes" reason appears correct because there is similarity in healthcare. When you go to a hospital with a heart attack, you don't care how much the hospital charges are going to be, you just want your (chest) pain free life back. But when you have a cold (which is probably the 14th time you are having it in your lifetime), you know it is going to be better in a few days and there is no real reason to spend lots of money.

That probably explains why the market rates in general practice is very small. People usually present with simple illnesses and a sense that their illness is a simple one. Therefore there is not much value they are seeking from the doctor - most clients are in for quick relief from symptoms, if possible.

Therein lies the complexity of general practice too. I'll explain that in a bit, but first let us look at one more difference between lawyers and doctors. Lawyers take money from clients and work for clients by being sharp witted and coming up with strong legal arguments. But their "appearance" is in front of a judge. The favorable outcome is defined by the client but realizing that outcome requires very little of the client's participation. Usually, the judgement made by the judge also unequivocally settles the judgement on the lawyer's performance.

Now let us talk about general practice. In general practice, your client does not just pay you, but also has to work with you for their own success. There is no third person involved. The client has to believe in the doctor, has to believe in the advice given by the doctor (that the advice is for their own good), has to follow the advice strictly, and also has to make a judgement about how good the entire process have been. This is where the previous point comes in.

The reason why clients come to a general practitioner is often for quick relief from their symptom. Most of the time in medicine there is no quick relief which is also good. For example, painkillers are quick relief from pain due to strain. But the good thing to do maybe in many cases to take rest and allow body to recover. Common cold may slightly improve with nasal decongestants, but overuse maybe harmful. Sometimes sticking to medicines which cause nausea, vomiting, diarrhea or many other tolerable side effects are required in the face of greater dangers like multi-drug resistant tuberculosis.

Sometimes the right thing to do in the view of a doctor maybe different from what the client thought would be the right thing to do. This would not be a problem for a lawyer as the client does not have a role in deciding the success of the lawyer's approach to the "case". But when doctors are in this situation they have to use all the skills they have in convincing the client about why there needs to be a change of expectations. And the success of the treatment itself relies on this "winning over" of the client.

And after all that exercise, the client has to pay. ICUs, OTs, and emergency departments have it easy. There is a lot of money to be paid, but most of the work is done by nurses or doctors and the sick person usually just has to lie down on a bed (conscious or not). General practice? Totally different ball game.

With that context, how much is a reasonable consultation fee in general practice? 50? 500? 1000?


Before locking our answer, let us look this from another side. The general practitioner is a small entrepreneur. The GP has a home and has a life. The GP needs to make money to survive. But the GP is also a doctor. No conscientious doctor can do injustice to their profession or their clients. They cannot simply symptomatically treat diseases without thinking about root causes. Diseases have to be managed correctly. Counseling is an important aspect of treatment. And all of that requires time - time to be spent in consultation. And time is money.

The question on consultation fee thus has to be somehow linked to the consultation duration. What is the minimum time a doctor should spend with their client to fulfill their obligation/duty? There can of course not be a single answer to this as every consultation is different. But practically, from my experience, in a single person clinic the doctor (who is the single person) has to spend at least 20 if not 30 minutes in a consultation for there to be some quality.

How much of that can be delegated? Whom to delegate to? Of course in a single doctor clinic the only person to delegate to is the client themselves. Can clients prefill questionnaires about their health condition? Can clients read informational pamphlets instead of having to listen it directly from the doctor? Does trust suffer in attempting such time saving measures? These are all questions with no definite answers.

Does building a healthcare team help? It can definitely help. At Restore Health we have a multi-disciplinary team where a lot of tasks are shared. But still there is considerable amount of time spent by each person of the team in providing care to a client. And we charge 500 in general practice consultations. Are there people who think that is too much? Definitely, yes. Including sometimes our own doctors. But there are times when we have saved the client a lot of money and good health and spent considerably more time in the process. We do not have "dynamic pricing".

Perhaps there needs to be more thought put into showcasing all the value that is created by a GP and monetizing some of that at least. All this while treading on the right side of ethics and not breaking the delicate thread of trust that connects a client to a doctor. Who says general practice is not challenging?

My train of thought was derailed when the train I was sitting in reached my destination. As I stood up to deboard, the lawyer next to me took my seat. Perhaps she was thinking about how much to charge her next client. Perhaps not.

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.

That judgement was specifically about settling the question of whether healthcare is a service that falls under the definition of service as defined in the consumer protection act (the act of 1986). For ease of reference I will quote the definition from the old act:

" "service" means service of any description which is made avail­able to potential users and includes, but not limited to, the provision of  facilities in connection with banking, financing insurance, transport, processing, supply of electrical or other energy, board or lodging or both, housing construction, entertainment, amusement or the purveying of news or other information, but does not include the rendering of any service free of charge or under a contract of personal service;"

Notice that healthcare is not specifically mentioned. Supreme Court read this definition and confirmed that healthcare is included in the broad definition of "service of any description" and spelled out conditions where it would be excluded.

Now, here is the definition from the new act:

""service" means service of any description which is made available to potential users and includes, but not limited to, the provision of facilities in connection with banking, financing, insurance, transport, processing, supply of electrical or other energy, telecom, boarding or lodging or both, housing construction, entertainment,amusement or the purveying of news or other information, but does not include the rendering of any service free of charge or under a contract of personal service;" (emphasis for words that have been added)

Where is the "healthcare" word dropped from then? Well, it is from the draft bill that was introduced.

Now you can read the full judgement on how the new definition also includes healthcare in it.

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 forced to choose between these combinations, the one with dicyclomine makes more sense to be used in primary dysmenorrhea. But self-medication is mostly not the right thing to do because a lot of dysmenorrhea maybe secondary to things like endometriosis and maybe better treated by other drugs under the guidance of a family doctor or a gynecologist, and sometimes just mefenamic acid (in the right dosage) might be enough to control primary dysmenorrhea.

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 need for clarity, specifically that "The Indian Penal Code is silent about the legal validity of consent given by persons between 12 and 18 years of age"

In a "special article" in Indian Journal of Anaesthesia co-authored by a couple of anaesthetists and a lawyer, they say "A child >12 years can give a valid consent for physical/medical examination (Indian Penal Code, section 89)." (sic). And then they give reference to "Rao NG. Ethics of medical practice. In: Textbook of Forensic Medicine and Toxicology. 2 nd ed. New Delhi: Jaypee Brothers Medical Publishers (P) Ltd.; 2010. p. 23-44. " Sure enough, Rao NG's book does mention this on page 35.

But, unfortunately, Section 89 of IPC doesn't really say so. Section 89 talks about "Act done in good faith for benefit of child or insane person, by or by consent of guardian." (emphasis supplied). In my reading of section 89, it only applies to acts by guardian or by the consent of guardian. A doctor doesn't become the guardian or "other person having lawful charge of that person" at no time in their usual work. So this is just propagation of errors.

There is a "Scientific Letter" in Indian Journal of Pediatrics, which reads only sections 87 to 90 of IPC and boldly claim that a child above 12 years age can give consent for routine elective surgery. The authors have affiliation to departments of forensic medicine or pathology. I agree with their interpretation of the sections, but I have to warn others that this does not ensure that a judge will agree with this interpretation. I could not find from sources I have whether this interpretation has been tested in any court.

The other side of the story is that according to Indian Contract Act, only someone who has attained age of majority is competent to contract. Age of majority is 18 in India. The doctor patient relationship is a contract - implied or explicit. Therefore, a minor cannot really enter into a doctor patient relationship. But in my opinion, this should only matter when there is a question about the legality or the validity of the doctor patient relationship. To just talk to a minor, there needn't be a doctor-patient relationship.

Here is a link to the Indian Penal Code. Read sections 87 to 90 and form an opinion on your own.

If you ask me what I would do when a 13 year old comes to me for a consult, I would say "I would go ahead and talk to them to see what they are here for, but I would not do any procedures or anything that could (even theoretically) cause harm".

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-based discrimination (I guess).

Reservation is seen as giving unfair advantage to people. People who get their seats through reservation are seen as people who do not deserve the seats. When they get low marks this is brought up again as the reason (and not that most people end up with low marks in medical colleges, no matter which kind of seat they got while entering).

Is their excess workload in medical colleges?
Undoubtedly, yes. This is a complete failure of the public health system of our country. Have you seen the medical OPD of a government tertiary care hospital at 10am? The doctor there has no time to even breathe. Patients with any kind of condition - simple/complicated are referred/self-referred to tertiary care centers necessarily/unnecessarily. This kills the efficiency of government tertiary care centers. And on the other hand, primary and secondary level centers go underutilized. Not many hospitals have the system to reject patients. I have heard NIMHANS does this. They screen, they accept/reject patients. They refer back to lower hospitals as soon as possible. This perhaps prevents NIMHANS from going crazy (pun intended). But what about other big government hospitals?

Is this workload issue exacerbated by seniority based hierarchy?
Yes again. Medical colleges work on the principle of infinite delegation. The Head of Unit delegates to Professor. Professor to Assistant Professor. AP to Senior Resident. Senior resident to final year PG. Final year PG to second year PG. Second year PG to First year PG. First year PG to Intern. Intern to the patient, sometimes, even.

When the delegation culture is accepted, there is no way adding more staff helps, either. If you are a new staff and you don't delegate, you are an idiot.

Is ragging accepted?
Yes. The entire system is a form of ragging. The hierarchy I just described, that is the foundation of it. That a junior is the slave to the senior is the concept that underlies the hierarchy. The sort of visible ragging that is prohibited through law is just tip of the iceberg. This visible ragging is the initiation step into the hierarchy. The catch-them-young process of making people subservient. The training phase for silent acceptance.

If it is so bad, why does nobody speak about it?
Can't you see the irony of the situation? The system is designed to prevent people from asking questions. From the first day of medical college people are taught to stop thinking for themselves, to mend in like sheep, to stay low and not attract attention. (This happened to me. I was overjoyed on the first day of medical college about the fact that I am finally in a medical college and I was wearing a small smile on my face in the histology lab when attendance was being taken. One of the faculties was offended by my smile. A "helpful" old faculty suggested to me that I change my ways. Literally on day one.)

Who do you think, trained "well" in such a system, will come out and criticize the system? Only those who could keep their spirit alive throughout, or those who could rekindle their spirit afterwards. How many of us are capable?

Plug: Is this herd mentality also the reason why people are stuck in the race for specialization?
You answer.

The Power and Limits of Classification

Link to journal article:

https://www.nejm.org/doi/full/10.1056/NEJMp1811491?query=TOC

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 providers to use when it comes to gender, such that there is neither negligence nor over-cautiousness.

This article does leave a few hints on how that framework might look like. Thanks for that. 

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 patterns that humans have easily learned, but for the sake of figuring out patterns, perhaps within an individual, that a human cannot easily learn by going through information)

AI can be a very good physician assistant. I have previously written about an intelligent EMR. The only barrier to using digital EMRs is the user interface. There are ways to optimize that interface. An intelligent combination of predictive suggestions, tapping rather than typing, reading data from text, etc will help.

Once physicians can start using EMRs the possibilities are endless. Here is a list of things that come to the top of my mind:

1. Intelligent to-and-fro symptom/sign/examination suggestion (that physicians can use to not miss important symptoms)
2. Standard treatment guidelines based suggestions on medications and investigations
3. Drug interaction checker
4. Locally relevant and contextual antibiotic resistance patterns
5. Patient's past reports based insights, trends, analytics, etc
6. Medical records exporting, highlighting important information, etc.

If you are interested in building something like this with me, let me know.

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 during school) was to go to the library, pick up a book, and read. The competition with other students who used to read more books (by numbers noted in the library register) only helped propel the habit. When it was time to leave and the library teacher would come tapping on the shoulder asking me to leave, I would take the book home if it appeared interesting.

I still remember one Sunday when I read The Diary of Anne Franke (C edition, I think) from cover to cover at home. Now, this book has an interesting side story that makes libraries not just a collection of books and something much different from digital book reading devices. There are a few sections of the diary in which Anne Frank touches upon sexuality. One particular such page which has some graphic description (which I do not remember now) was so often read by the library users that the page had become dog-eared. In fact, you could open the book randomly and there was a very high chance that page would open up. And I promise I read that page only a few times. That worn out page perhaps was a silent broadcast to all the readers of the book about the curiosity in everyone's mind. There are mechanisms in digital world which allows people to "scribble on margins" which can be read by other readers on their digital devices. But I do not think any digital mechanism can have dog-eared pages.

When I was in ninth and tenth standard, I had become bored of my school's library. Also, I would play football right after school and by the time I was done the school library would have been closed. That is when I discovered the public library in Mattanur bus stand. More than the books there, it was the librarian there who I spent time with. He was preparing for IAS examination and would talk to me about Sweden and Malayalam literature and so many other things that was happening in the world. I took War & Peace from this library once and it was so boring that I never read past the first chapter. Finally when I stopped going to the library, the book remained in my home's bookshelf for more than an year. I later got a postcard from a new librarian who wanted the book back and also made me membership charge for that entire year.

The school I did 11th and 12th in also had the ritual of birthday book donation. And the library there was huge too. But somehow I never used this library. And of course, there was "entrance coaching" to attend after school leaving very little time for actually going to the school library.

Joining Mysore Medical College changed a lot of my expectations from "education system". A library without general books was one such new experience for me. Yet, I would frequent the college UG library. In fact, Swathi and I have spent a lot of evenings in that library sitting across each other and holding hands while reading. Sunil's mention of the pleasure in finding a hidden gem is amazingly accurate. Though MMC library's "gems" were mostly old editions of Gray's anatomy, I particularly remember one physiology textbook by Vander which explained some of the concepts in ways nobody had ever taught me till then. It was one of those treasures you value so much that you would show it to nobody else and try to hide it in some corner of the shelf. But fortunately I didn't have to do any of that because not many of my friends were interested in the library, let alone a textbook that no teacher had recommended to them.

My favorite book is "The Emperor of All Maladies - a Biography of Cancer". If you ask me, it is a textbook of medicine (especially public health) that every medical student should read. But I can make a fairly reasonable bet that the college library wouldn't have that book, even today. But, I also know for a fact that it has multiple copies of all the editions of a book titled "Companion for 1st MBBS" (and also 2nd MBBS, 3rd MBBS, and 4th MBBS). This is a question bank which contains past questions asked in the university exam. It is perhaps the most widely read book by the undergraduate student in Rajiv Gandhi University. And that speaks volumes about what our education system prioritizes. Libraries are only victims to the same.

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 otherwise, has a huge set of problems of its own). Private healthcare is becoming increasingly commercialized with doctors themselves becoming silent or vocal salespersons of treatment that costs more and earns more profit rather than treatment that the patient actually needs and prefers.

Where is the problem? If you can find out a single problem as the "root cause" you perhaps are being too optimistic. There are problems everywhere, many cross cutting factors are responsible. Many factors are outside anyone's control. Many factors require complex solutions that span economics, politics, education, and other dimensions of the nation.

Sure, we need to start somewhere. Can we look at regulation of the profession as one possible starting point out of many? Let's take a deeper dive into that.

When someone says "we need more regulations", what do they actually mean?

Regulation is always a top down thing. There needs to be a regulatory body or a regulator. And then this regulator has to control or rule over the regulated. Who constitutes a regulatory body? People with various backings, various moral stances, and various external forces acting on them. Who appoints these people? What is the process of selection? Who keeps them accountable? Who are they answerable to? What lobbying power do large establishments have on them? What lobbying power do patients have on them?

Let's say we found a perfect, ethical, practical, reasonable, diverse, sensitive, enthusiastic, energetic regulatory body. Such a regulatory body often "regulates" through policies or guidelines. Now when it comes to policy, there are two more fundamental issues.

First is formulation of policy. For the sake of simplicity of understanding, let us call it "law". What are the considerations one has to have when a law is framed? It has to protect the vulnerable from the extremely powerful. It should not prevent progress. It should not be in contradiction with the Constitution. It should be sensitive to the needs and demands of the society, while at the same time being considerate of the needs and demands of the professionals. Imagine creating a one-size-fits-all law in a large country like India. What is practical in urban India may not be practical in rural India. What is practical among literate people may not be practical among illiterate. Sometimes things that make a lot of sense to the policy maker in their office room may make no sense in real world practice.

Despite all that even if a policy gets formulated, there is the question of implementation. In a country ruined by corruption and with single states that have population larger than most other countries, how should policies get implemented? Who will enforce implementation? Technology is usually thrown around as a solution. But technology has deep limitations, especially in solving problems that are fundamentally because of what is inside the devious human mind.

"Regulations" don't come easy.

But, when ill-devised regulations come in, they can become really harmful to the entire ecosystem. There are countless examples and discussing the demerits of each is out of scope of this article.

What then is a better solution? The answer is that there is no simple or single solution to most of world problems. It takes patient and broad thinking, years (or generations) of effort, and commitment from all the stakeholders to work towards solving the problems to arrive at solutions. Sure, regulations may also be part of that solution. But even those regulations need to be the product of deep engagement from everyone. Pushing things onto others' plate is not going to help. What is helpful is if those who complain are also making an attempt at the solution.

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 medicine. That way, the time required by the specialist is minimized. If a patient can afford and requires a longer, customized consultation, they can request that for a higher cost. Then it can work economically as well.

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?

 Positions: 

1. WHO-CARE Global Surgery fellowship - *Specialist Obstetrician*:

2. WHO-CARE Lancet Global Surgery fellowship - *Specialist Surgeon*: 

3. WFSA-RCoA-CARE* fellowship - *Specialist Anaesthesiologist*:

4. WHO-CARE Paediatric fellowship - *Specialist Paediatrician* First referral SNCU services

*WFSA: World Federation Societies of Anaesthesiology RCoA: Royal College of Anaesthesiology

In a concerted effort to improve the health indicators, CARE-India, has been working with the Govt. of Bihar, has been working since 2010 towards a healthy Bihar. you may have seen TEDx talk of Dr Taru Jindal was working within this model at the Motihari district hospital.

You will be a member of a high-performance team of specialists (Anaesthesiologist, Obstetrician, Paediatrician and a General surgeon) working within the District Hospital - which WHO has recommended as the key facility for the delivery of Emergency care. The mode will be continuous and intense engagement with clinical work and clinical mentoring for 4-6 months at a single facility to impact the Emergency care metrics as outlined by the Lancet Commissions.

 The Govt of Bihar has agreed for an initial pilot of 5 district hospitals, with a rapid scale-up to all 35 district hospitals and the First Referral Unit (FRU) hospitals.

Salaries and working conditions will be in keeping with International health NGO standards. 

 Safety and accommodation are a priority for our personnel at CARE-India. While there are many Government, University and Non-Government agencies supporting this program, you will be on the employee payroll of CARE-India (and not of the Govt of Bihar nor the WHO).

For clarifications and to apply write with your CV: Dr. Nobhojit Roy, Team Lead, Systems Strengthening, CARE-India (nroy@careindia.org) with a CC to Dr Monali Mohan (monalimohangupta@gmail.com). Or text/WhatsApp on 98212-91225.

This TEDx talk is about a young doctor's experiences while she tried to bring about change in a district hospital in Bihar.

Do listen when u have time. It's a cool story 😊

https://youtu.be/RRRFK2rgAgQ

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

Link to original article: http://ijmedph.org/article/217

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: http://ijmedph.org/article/217

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 there a list of all Penicillins? Who maintains this list?

After figuring out what Penicillin A and B was, I remembered Alexander Fleming. If Fleming discovered Pencillin, then we should start with him.

So, here's Fleming's 1929 paper where he describes the discovery of "mould broth filtrate" which for convenience he decided to call "penicillin" : On the Antibacterial Action of Cultures of a Penicillium, with Special Reference to their Use in the Isolation of B. influenzæ.

He wrote the fungus closely resembles P. rubrum. Some people "corrected" him later. Some then corrected the corrections.

Okay, so in 1929, there was only one Penicillin and it was Fleming's Penicillin.

Then, for almost 10 years nothing happened. That's when Ernest Chain and Howard Florey came into the picture. They figured out a way to get good Penicillin. As early as 1940, they discovered Pencillin resistance. An Enzyme from Bacteria able to Destroy Penicillin. If you want to read more about the interesting history of the discovery of penicillin, read this review.

What Chain and Florey synthesised apparently was different from what Fleming discovered and therefore they initially named it Penicillin A and filed a patent. Later, they renamed it to "notatin" to avoid confusion. They also wrote this brilliant article on how they used it on some patients.

Van Bruggen and others in 1943 described another compound from Penicillium which had bactericidal activity and was different from any of the Penicillins till then and named it Penicillin B.

It was soon clear that Penicillin A and Penicillin B were identical. This compound is now called Glucose Oxidase.

From then on, it was mostly about improving on the techniques and therefore most literature is on patent articles. Here is one where Penicillin F and Penicillin G is described. I have no clue why they skipped over C, D, and E.

Around this time, people started producing all kinds of Pencillins.

As I could not find the list anywhere, I decided I will make that list. Here it goes.

Penicillin A - Glucose Oxidase
Penicillin B - Glucose Oxidase
Penicillin C -
Penicillin D -
Penicillin E -
Penicillin F - C14H20N2O4S
Penicillin G - Benzylpenicillin
Penicillin H -
Penicillin I -
Penicillin J -
Penicillin K - Natural penicillin
Penicillin L -
Penicillin M -
Penicillin N - Natural penicillin
Penicillin O - Almecillin
Penicillin P -
Penicillin Q -
Penicillin R -
Penicillin S -
Penicillin T -
Penicillin U -
Penicillin V - Natural penicillin
Penicillin W -
Penicillin X - Natural penicillin
Penicillin Y -
Penicillin Z -

Please let me know if you find the missing items.

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.

The happy picture of the candidates from day 1

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 are doing this then? Well, turns out they have been doing this for years and nobody dared to ask. The DNB exams have been happening the same way from the beginning. Candidates take DNB exam with no knowledge of what they will be assessed on. Professor Suptendra has written about this in this IJME article titled "A farce called the National Board of Examinations".

I have filed an RTI yesterday with the following content:

I, as a citizen of India, hereby exercise my right to information granted under sec (6) of RTI Act, 2015 by requesting the following.

1) Please provide me with the questions asked (including answer options) in the NEET PG Entrance exam held on Jan 6, 2019.

2) Please provide me the answer key of the above questions.

3) Please provide me with the questions asked (including answer options) in the NEET PG Entrance exam held on Jan 7, 2018.

4) Please provide me the answer key of the above questions.

5) Please provide me with the reason why there was a non-disclosure clause at the beginning of the NEET PG entrance test held on Jan 6, 2019.

The information may be emailed to my address: asdofindia@gmail.com

Thank you

This was addressed to National Board of Examinations. I'm sure the response will be "proprietary test". Also remember that NBE makes 30 crores profit on NEET PG registration alone with no sanction from MoHFW.

What are students supposed to do to prepare for NBE's proprietary examinations? Go to entrance coaching institutes? Read textbooks and continue working? The atmosphere around entrance tests is so tense that students are scared to prepare on their own. They are forced into joining medical entrance coaching centers.

But why? How can a test that decides who gets access to the very few postgraduate seats in India's medical education system be made proprietary? Are you saying that only students who have the time and resources to go to entrance coaching centers should be able to prepare and score well? Should only people with time and money be becoming pediatricians and gynecologists?

What will that mean to India's health system?