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.