“The 2 most prestigious journals of medicine in the world are The Lancet and The New England Journal of Medicine. Richard Horton, editor in chief of The Lancet said this in 2015
“The case against science is straightforward: much of the scientific literature, perhaps half, may simply be untrue”
Dr. Marcia Angell, former editor in chief of NEJM wrote in 2009 that,
“It is simply no longer possible to believe much of the clinical research that is published, or to rely on the judgment of trusted physicians or authoritative medical guidelines. I take no pleasure in this conclusion, which I reached slowly and reluctantly over my two decades as an editor”
This has huge implications. Evidence based medicine is completely worthless if the evidence base is false or corrupted. It’s like building a wooden house knowing the wood is termite infested. “
Do read the rest of this eye-opening article and be aware of the various ways in which most research today has been compromised in order to benefit various vested interests. Comment below with some suggestions on how we can navigate these murky waters and practice high quality medicine in this century…..
As the nation celebrates Gandhiji’s 150th birth anniversary, this brilliant article talks about the similarities between Gandhi’s time and our own, and looks forward to the arrival of a saviour….
“There are rumours, once again, that a Chamatkaari Baba will arrive and put an end to this oppression of majoritarianism. We do not yet know the name of the hero, or when s/he will come. The heavens will send one, that much is certain. There’s no better time than the 150th birth anniversary of Mahatma Gandhi to believe in heroes, and to hope. The greater the repression, the bigger the Mahatma that will be born. Every action has an equal and opposite reaction, as someone famously said.”
Read the rest here.
Please view this video in the full-screen mode and answer the following question: (Edit: 5th Oct: The answer has been posted below)
What is the JVP feature seen in this video? What does it signify?
(Please send your answers to email@example.com and collect points for the correct answer.
Students: Please mention clearly your name and college. Students who receive the highest points over the next 6 months will receive attractive prizes!
The correct answer will be posted tomorrow!)
Answer: 5th October, 2019: These are Cannon A waves. Cannon A wave occurs with atrioventricular dissociation and right atrial contraction against a closed tricuspid valve. Large A waves are associated with reduced right ventricular compliance or elevated right ventricular end-diastolic pressure. The differential diagnoses of cannon A wave were atrial, ventricular, or junctional premature beats, ventricular tachycardia, severe tricuspid stenosis, first-degree atrioventricular block with a markedly prolonged PR interval, high-grade atrioventricular block, atrioventricular dissociation and Right Atrial Myxoma
As President Obama recently tweeted:
Just 16, @GretaThunberg is already one of our planet’s greatest advocates.
WANTED: Young, thoughtful, passionate, Indian, Christian medical, nursing and paramedical students and professionals who care enough about the state of healthcare in this country that they are willing to stand up and be counted for what is right.
As Greta Thunberg recently said, “My message to young people who want to have an impact on the world is to be creative. There’s so incredibly much you can do, and do not underestimate yourself.”
The headline from this news article screams out about how drug companies give gifts and incentives to ‘quacks’ in order to get them to prescribe antibiotics. These unnecessary antibiotics contribute to the development of ‘superbugs’….bugs that do not respond, any longer, to ANY antibiotics.
In the body of the article, reps talk about how they give doctors (not just quacks!) gifts, including fridges, TVs, and paid trips to ‘conferences’, in order to get them to prescribe their product.
Why is this practice unethical?
- Many doctors are therefore prescribing unnecessary medications to patients just to get incentives
- Poor patients in India are already struggling to buy medicines. Many families are pushed below the poverty line every year, directly because of their medical expenses. Many of these expenses are totally unnecessary but patients are paying for the incentives of the doctors
- This is very poor stewardship of the resources we have been given.
(This article originally appeared on this blog)
Those of us familiar with the story of Aunt Ida (Ida Scudder, the founder of Christian Medical College, Vellore, my alma mater) know of how her life was changed by three knocks on her door one night. Confronted with the problem of three young women dying in childbirth because of the lack of trained women doctors, the young and reluctant Ida was convinced of the need to train in medicine, and return to India as a medical missionary with a desire to train Indian women doctors.
(If you are not familiar with this story, you could listen to a recording of Aunt Ida speaking of the Three Knocks here)
A few years ago, I also had my own Three Knocks experience, when the stories of three patients changed the way I practise medicine. At the time, in 2007, I was working in a 120-bed mission hospital in rural Uttarkhand.
Patient A was an elderly gentleman brought in with a perforated duodenal ulcer. He was very sick. His lungs were permanently damaged due to smoking, and he was now in shock because of the peritonitis. After we resuscitated him and operated, he was shifted to the ICU, where he was ventilated for 4 days. After a stormy post-operative period, he recovered well and was ready for discharge.
Before he left the hospital, his relatives came to talk to me in the OPD. After giving them the usual pep talk (about making sure he ate well and stopped smoking, and so on) I asked them whether they had paid the bill. They had. I was pleasantly surprised, because they looked quite poor, and I had been expecting them to ask for some concessions.
How much was the bill, I asked. About ₹ 10, 000, they said. They had paid ₹ 4000 as an advance, and had now paid the remaining amount. Again, I was quite pleased. ₹ 10,000 was quite reasonable for such a major operation and hospitalisation, and especially for somebody who had been ventilated for 4 days. I felt quite proud of my hospital.
More out of a desire to make some light conversation before they left, I asked them how they had managed to pay the bill. They had taken a loan. (Fair enough, I thought to myself, ruefully. Even I might need to take a loan if I require major surgery in the future! It’s good to hear that even the poor are able to get loans when they need…)
So, what type of loan is this, I asked. They replied that they were going to be paying a 10% interest. For every ₹ 1000, they would have to pay ₹ 100. (Sounds quite reasonable, I thought)
Since we were making pleasant conversation, and they had already received some advice from me with good humour, I thought I would give them some more. “Make sure you pay the loan regularly and quickly”, I advised. “After a year, the amount would have increased to ₹ 11,000. And unless you plan well, you will be stuck with a large debt.”
No, they corrected me. The loan would be ₹ 11,000 by the following month. And it would increase by a further 10 percent the following month.
My jaw dropped, as I realised that the family was, in fact, paying 10% per month as compound interest. I quickly did the math. The repayable amount, after 1 year, for the initial loan of ₹ 10,000 would be ₹ 31,386. A whopping 214 percent interest per year!
Horrified, I tried frantically to prove that my calculations were wrong. But no, the family assured me. Those were, in fact, the conditions of the loan.
However were they ever going to repay this, I asked, aghast. The family, now perhaps seeing how upset I was, tried to reassure me. “No problem, sir”, they said. “The money lender has said that we can work for him on his fields. He will not pay us any money, but give us food every day. We can work for him until the loan is repaid. Nothing to worry!”
Slowly, the realisation of what had happened sunk in. My Du perforation surgery had pushed a family into bonded labour. My colleagues and I scrambled to arrange money to give to this family as a gift, so that they could go and settle this loan quickly.
A few days later, the story was repeated. Patient B. Also admitted for Du perforation surgery and ventilated post-operatively. This time, we asked the questions before the bill was paid, but found the family had already taken the loan. Another ₹ 10,000 loan, being repaid at 214 percent interest. Another generous offer from the money lender that the family could work on his land as bonded labourers. But this story had another twist. The money lender had promised them that if they did not report for work anytime, he would send his goondas to tear down the small tin-shack in which they lived. They were going to be living under the perpetual threat of violence. Again, we tried to put together funds to help this family out of their debt.
A few weeks later, I had the third knock on my door. This time, it was the wife of Patient C, a middle-aged gentleman admitted with acute pancreatitis secondary to chronic alcohol abuse. He was now ready for discharge, and the family was asking for a reduction on the discharge bill. The bill was ₹ 1200, and they wanted ₹ 400 to be reduced.
At that time, I had a clear and firm policy on alcoholic pancreatitis. No reduction in bills allowed. My reasoning was simple: If they had enough money to buy alcohol and drink every day, it was safe to assume they had enough money for the hospital bill! I explained this policy to the wife.
A couple of hours later, a nurse came to my OPD. The patient’s wife had been asking the relatives of other patients for a loan of ₹ 400. She was offering that they could have her 6-year-old daughter until she arranged enough money to redeem her back. I felt like crying. My treatment of alcoholic pancreatitis was pushing this family into human trafficking, possibly even sexual trafficking. We promptly wrote-off the Rs 400, and allowed the family to leave.
I was very shaken by these three knocks on my door. As I read more about the problem of emergency out-of-pocket spending for hospital expenses, I came across this disturbing statistic:
39 million Indians every year are pushed below the poverty line directly as a consequence of emergency health-care related expenses. (See this Lancet article)
Over the years, I have often remembered these three patients who changed my life. They have taught me some valuable lessons:
1. Even the poorest patients sometimes pay their bills without asking for concessions. They do so, however, at horrific personal costs. In our hospitals, we need to look out for these patients, and actively ask the questions about how finances are being arranged, and sometimes write off costs even when patients do not ask for reductions.
2. Even the highly subsidised treatment available at our charitable, not-for-profit hospitals can push poor patients below the poverty line, and even into human trafficking and bonded labour.
3. While health insurance does seem like the obvious answer to this problem (of out-of-pocket emergency healthcare spending, with its devastating effects on poor families), the insurance schemes available at present, (even those offered by the government to BPL families) somehow often seem to benefit the rich and middle class families, who are aware of their rights, and of available options and schemes. The poorest are often left out of the very schemes designed to benefit them.
4. The public health system is India has been designed to provide free and high quality healthcare to India’s poorest citizens. Unfortunately, due to a number of factors, (poor governance, corruption, apathy, and poorly trained staff, to name a few) our public health system is in shambles. I am convinced that it is our duty, as responsible healthcare providers, to do whatever we can to ensure that the public health system in India is strengthened and equipped to fulfil its role.
Finally, a word to my professional colleagues.
The World Health Organisation, in 1948, defined “Health” as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”. When 39 million Indians are pushed below the poverty line every year as a result of healthcare expenses, it is well past the time for us to ask ourselves some disturbing questions. Are we truly promoting health? Or is this itself a symptom that the healthcare ‘industry’ is desperately sick, and in need of healing?
(This post was written on Women’s day, 2017, and originally appeared on this blog)
On International Women’s Day 2017, I would like to remember the sad story of a woman patient we saw a few months ago.
For those who cannot understand the ‘medicalese’ let me annotate the antenatal card in the picture above.
This 50 year old patient came to us for an antenatal checkup. This was her 6th pregnancy.Pregnancy no 1 had resulted in a normal delivery at home. Girl child. Now 31 years old.
And so on. All normal deliveries at home. Resulting in daughters who were now 29, 27 and 25 years old respectively. She kept conceiving and delivering at home.
Until 22 years ago, when she had finally managed to give birth to a male child. Relieved and overjoyed, she had undergone a tubal ligation.
Sadly, the story did not end there. The son passed away in a road traffic accident 3 years ago.
And so this elderly braveheart underwent hormonal treatment and fertility procedures to try and conceive again. She finally conceived after IVF.
We watched as she came for every checkup on time, faithfully taking her pills and vaccinations, looking forward to welcome a new son, 31 years after her firstborn.
Things did not go as planned. Baby no 6, also delivered by a vaginal delivery, was A GIRL.
I shudder to think of the life ahead of this beautiful little baby, born as the fifth unwanted girl child in this family…..
It was yet another regular Monday morning in Duncan. I, walking about with the young and excellent consultants in Medicine, Anesthesia/Critical care and Pead’s, me, not doing much but just being around.
As we walked into casualty, there was this 50-year, obese male, in encephalopathy and taking very shallow breaths. A classic and clear patient with Obstructive airways disease and possibly an additional Obesity hypoventilation syndrome in respiratory failure. Some surgeon in a nearby nursing home had taken the risk of doing a cholecystectomy on such a high-risk patient and now he had come in with respiratory failure. His complex blood gases started of a series of conversations. Should we intubate and ventilate, if we ventilate, would he ever come out, or should we wait on NIV alone? If he does not come out of ventilation what would the next step be? Finally, after much consideration, the Anesthetist turned critical care specialist, decided for NIV only.
We walked into the ICU and my colleague the anesthetist, showed me another patient. 80-year-old lady with obstructive airways disease, with type 2 respiratory failure on NIV with blood gases not showing much change despite NIV. Question of what to do next? With no home oxygen support, no C Pap systems affordable, what would you do to this patient who is from a nearby leprosy colony? Send her off for palliative care or give more time?
The next bed was a young lady who had presented in severe pulmonary edema and full-term pregnancy 2 weeks prior. Our team had managed to immediately ventilate her and do a LSCS and save the mother and child. An echo had showed a Peripartum Cardiomyopathy. She had gone home well, and some where in the local hospital they had pushed in fluids and she was back in cardiogenic shock and severe pulmonary edema, recovering on ventilation.
Before I moved out of ICU, I joined the Pediatrician. She was struggling to sort out the complex endocrinological challenge of managing a 12-year-old child who had undergone a cranio-pharyngioma surgery at CMC Ludhiana 40 days prior to this. Child has been presenting with hypokalemic paralysis, acidosis, a Central Diabetes Insipidus, (CDI) has a TSH of 34 (? Primary hypothyroidism) and very low Cortisol. She was struggling with the question – what were we dealing with? A single diagnosis of Pan hypopituitarism or multiple diagnoses of Pan hypopituitarism with Primary hypothyroidism, RTA, and CDI?
As I moved to the medical ward, we started talking about another lady, whom we were struggling with. Severe deforming Rheumatoid arthritis, Thyrotoxicosis and an intractable vomiting that was not getting controlled with any anti emetics and preventing her from taking any tablets for the underlying diseases. She was refusing an endoscopy, husband was not willing to accept the diagnosis of Thyrotoxicosis, because the thyroid swelling was from birth as per him, and not significant, did not have money nor the willingness to take her for further evaluation.
We continued to talk about a patient whom we had just referred off, one unusual presentation amid the many hyponatremias we see, due to steroid abuse. This elderly man with severe hyponatremia, patient thought to be due to steroid abuse, like the many others but having a carcinoma head of pancreas, and hypo natremia being a para neoplastic syndrome.
Before I moved out into OPD, there were couple of more patients that caught my attention. A young girl being treated for the last 2 years as TB with multiple courses of ATT, admitted for evaluation. Quick clinical evaluation by the consultant has clinched the diagnosis – a Progressive systemic sclerosis, with Bronchiectasis, Cardiac and Esophageal involvement, missed in the multiple centers she had visited. At the same time the family unwilling to continue treatment, the moment they knew she had a chronic illness, unwilling to spend any more money on a girl!
Then there was this 40-year-old man who had presented with seizures, now recovering in the ward, with no family around – left alone. Turning out to be Stage IV HIV infection with pulmonary TB and possibly Toxoplasmosis (no CT possible because of lack of support systems) with a CD4 less than 15. Medical team trying to sort the medical, the social and other complexities of managing such a patient with no support systems.
As I was walking to the OPD my WhatsApp bleeped. An X-ray for opinion. A girl child who had a chest wall injury one month back brought in with an effusion on one side and encysted pneumothorax on the other side, question of how many ICDs to put and where. The fluid turned out to be “old blood” one side! Neglected for more than a month because being a girl child?
Reaching OPD, a young man was waiting with a recent onset “hyperpigmentation of face and sclera” and a family history of a brother having same problem. Was it just a congenital problem or something like Alkaptonuria? By then a staff was waiting – with history of recurrent parotitis and dry mouth, asking what tests she should do to rule out a Sjogren’s…
All these in a single day….
Why am I writing this? I hope some where some Internal Medicine or Pead’s resident or consultant would read this and decide to take a detour from their planned career directions. To come over and experience the thrill of clinical medicine and pediatrics management in a resource limited setting like this. And may be through that exposure, decide to spend some time learning, teaching and caring in a context that needs clinicians to care for a community that cannot go elsewhere, for such complex problems!
Written by: A senior consultant at Duncan Hospital, Raxaul, Bihar
Visit this page to read the news article.
Poverty, the horribly low status of women, commercial interests, and a corrupt healthcare system have combined to create a terrible situation….