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Archive for the ‘bio ethics’ Category

Who is the guiding the guidelines, which have become omnipresent & omnipotent ?

I don’t know really. Some good people I guess. But, the doubt creeps in when they try to coerce it on us.

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This write up was triggered after encountering a patient who instructed his cardiologist to remove an incidentaly found block in Right coronary artery. 

Oftentimes, It is a funny & futile world out there in modern medicine. Revealing the complete truths or accepting ignorance in critical decisions to their patients, make the Doctors feel that, their academic modesty and reputation are at stake. 

Still, many patients expect (and think) the doctors to be 100 % transparent and want to understand the nuances of disease better than the doctors themselves. The current fad of online & offline health education for patients is not an accident of technology. Though some benefits exist, I feel, It is an intentionally promoted, maliciously motivated patient empowering movement, trying to disarm the true professionals.

Dear colleagues, always realize, never allow the default ignorance to become patients’ knowledge and ask them to take decisions on behalf of you. (I know, this is diagonally opposite to current principles of the practice of medicine) Fortunately, this issue doesn’t arise in most public hospitals in our country.

This paper was written 30 years ago with great foresight.

 

So, act with tact. You can’t hide behind the patient’s preferences in deciding the treatment choice. It can be “as unethical as” any activity that goes against the interest of the patients under which we are taking our oath. I don’t, recall anywhere in the Hippocratic oath, that we pledge to listen to the patient’s choice of treatment. (Rather, we assure to work in their interest always)

Final message 

Let us sharpen our own skills first. We shall think about how to distill and consume the muddy knowledge emanating from the current mess of premature research spilling all over academia. Don’t try to educate too much to your patients. There is nothing called academic empathy because leaving it to our patients will ultimately end up equivalent to medical negligence.

Forget about the patient-guided treatment menu card. Think about this, if ordering a trendy new medical investigation purely on a patient’s demand is declared as medical negligence, How many doctors on this planet will be left non-negligent.(Stop. then what is a master health check-up? Who is the master ?) 

(Hope this write-up is taken from a proper perspective. No intent to create a chasm between patients and doctors relationship )

Reference 

Drane JF, Coulehan JL. The concept of futility. Patients do not have a right to demand medically useless treatment. Counterpoint. Health Prog. 1993 Dec;74(10):28-32.

Postamble & Counterpoint

It all sounds good on paper. The consequence of not listening to our patients, especially if they land up with complications, will look awkward, is it not?  So, I always go by patients’ desires.

Patients tend to believe in fancy investigations and machines and not me, what to do?

No, it is wrong. You can’t justify it. Regarding your concern and impact on our reputation, nothing can be done. The medical judiciary desperately needs some reforms, understand the reality to protect us  I always tell my patients they have to accept me as a whole. (Do you enter the Aeroplane’s cabin and check the pilot’s mental and physical acumen every time you board a flight. It is trust,.. complete trust, that drives our life right !)

It is true, that medical professionals must be always under a continuous quality* control regimen.  The consequences of consulting less shrewd medical personnel, their errors in judgment, the stress of work, patients need to accept* just like a side effect of a drug or a natural history of a disease.

*, Unlike the engineering field, defining & controlling quality in medical therapeutics is a mystery exercise with multiple agendas!

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“It needs both. obviously”.

“Which is difficult? Innovation or regulation?

The answer is easy, am I right?

“If we are not able to regulate science …what is the purpose of magnificent Inventions & Innovations?”

“Who will take the responsibility for all motivated false research and resultant adversaries? 

Final message

Is shutting down (or grossly down-regulating ) research an option?

Foolish option…but

  • Who Initiated, funded, and masterminded the gain in function experiment with the innocent RNA viruses which were happily enjoying their nucleic acid life, along with the friendly bats in the wild forests, far away from human infestation?
  • Who ordered to hijack them to (in)human labs and hurt the sleeping viruses with sharp molecular knives to earn its violent wrath?

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What is the true success in a scientific career?

It is not the number of publications in journals or getting those big awards or memberships in prestigious scientific societies. True success is “something else,” says the Nobel Medical Laureate  Dr Willam Kaelin 

Great thoughts. Just wondering, what are those elements beyond our controls he was alluding to?

 

Video courtesy and thanks : http://www.nobel.org

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This piece of article by Mr. Arun Maira,(The Pakistan-born British Indian ex-planning commission member) is a real eye-opener in the manner we have understood science. All socially conscious scientists must-read. (If properly appreciated, the 15 minutes  you are going to spend on this is worth the time of one full semester in economics at a top-notch university )

Was the past perfect?  & Will the future be tense?

No is the answer to both questions. Noble prizes are increasingly given for some soul-searching simple researches. Complex research methodology is looked down on, especially in economics. Contributors of simple observational studies bordering on common sense shall be rewarded. Incidentally, this year’s physics prize was also different from other years (Given for finding faultlines in working models of climate change). It is heartening to note the shift in thinking and points to good times for true science. We have finally started to question the genuineness in the foundations of existing research models and epistemological purity of knowledge.Very soon, major global awards are waiting for the Innocuous looking amateurish research that is willing to expose trivia and the flawed understanding of science itself.

High stakes in the noble profession

Now, this has major Implications in the terrain of medical practice, a fragile scientific art that is dangling between facts and fakes, uncertainties of nature & certainty of greedy monetization, social inequalities, and finally the stupidity of half-baked knowledge.

I strongly believe the following two concepts if proven properly deserve the Nobel prize in medicine or economics with a huge Implication for humankind. 

1. In the global health care delivery, nurses and para-medical health workers have a multi-fold positive impact on universal health goals than the highly specialized doctors, who are at best have a minuscule role. There should be intensive restudy of their actual requirements and redefining  doctor vs nurse vs population ratio (What a big revelation,  even a novice can say this, but that is exactly  is the reason which makes it eligible for the Nobel award)

2. Specific treatment modalities are either lacking or trail behind the hyped-up diagnostic methods for a good number of illnesses. They are not only redundant but also malignantly consume the global economic resources without a real purpose. What is the big deal of accurately diagnosing and labeling a disease if there is no treatment? (Typical example in recent times,100s of millions of costly RTPCR tests are Indiscriminately used for an incurable self behaving pandemic).

Who is willing to do the above studies? I wish WHO can sponsor this. Research questions, methods, statistics, and even conclusions are ready with 100% accuracy, I am sure, they will withstand any rigorous scientific scrutiny. Though every Tom, Dick  & Harry can do this research from any academic garage, the chances of it getting noticed by Karolinska institute is low, unless It comes from an Ivy League or an elite European university. When someone receives this coveted award down the lane of time, hope this cranky post gets some credit.

Reference

https://www.thehindu.com/opinion/lead/over-simplified-models-complex-social-systems/article37061493.ece

Nobel Prize economics list

Noble prize in Medicine list 

 

 

 

 

 

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Is there a solution?

As I understand, we don’t have any. Maybe, we can try this.  No way, I can prevent it from appearing ridiculous for the mainstream scientists.

Truths often lie silently  buried deep (many times intentionally). They definitely deserve an intellectual resuscitation beyond the dirty world of data and evidence. Further, why should experience be considered as enemy of evidence ?

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Dr.Richard Asher,  a British physician from Sussex addressed a group of young passing out medical students way back in 1948 in London. The lecture was titled seven sins of medicine! We should thank the Lancet for having published this brief speech the subsequent year in its journal making it immortal medical teaching!

Seven sins of medicine lancet 1949

Seven sins of medicine

Though he was listing these sins among medical students, it is very relevant to every health professional.

1. Obscurity
Asher endorses the use of clear communication and plain language whether writing or speaking. Obscurity may be used to cloak one’s own ignorance, or due to an inability to communicate with those outside of the medical profession. “If you don’t know, don’t admit it. Instead, try to confuse your listeners.” is not uncommon. Regardless of the intention, whether to misdirect from incompetence or to foster a feeling of superiority, the patient and those surrounding them are often left confused and uncertainiy.
2. Cruelty
 This sin is perhaps one of the most commonly committed by doctors and medical students. Whether it be the physical thoughtlessness of a half-dozen students palpating a painful tumor mass, or loudly taking (or presenting) a patient’s history in a crowded room, one of the first things that is unlearnt by a medical professional is to treat the patient as they themselves would like to be treated.
3. Bad Manners
 Often overlooked, rudeness or poor taste in humour is condoned within the hospital setting. At the end of the day, many doctors and students are simply rude to patients that do not suit them. Whether it is a snapping at an uncooperative patient or making a cruel joke about them after leaving the room, the impact of these “coping mechanisms” (as they are considered to be by many) must be taken into account.
4. Over-Specialisation
 In a growing trend by the medical establishment, over-specialization and under-generalization is a growing problem in the wider medical community. Ignoring aspects of one’s education in favor of more interesting aspects is a behavior that is pathological and outright negligent in a student. Failure to diagnose or to treat a patient because “their signs and differential fall outside of my field, let’s turf them to another service” ought to be a seriously considered Supervisory & Training issue.
5. Love of the Rare
 (aka “If you hear hoof-beats, think horses. Not zebras”) The desire for rare and interesting diseases causes many medical students and young doctors to seek the bizarre rather than seeing a mundane diagnosis.
6. Common Stupidity
As well as the standard definition for this sin, the specific example of “using empirical procedures rather than tailoring for the patient” or the young doctor “flying on autopilot” must be mentioned. Ordering another test that is redundant, and for which the results may already be interpreted from the history, before starting treatment is such a situation. For example: requesting a hemoglobin count before beginning transfusion, despite the fact that the patient appears obviously anaemic.
7. Sloth
 Laziness. Also includes ordering excessive numbers of tests, rather than simply taking the time to take an adequate history

Final message

 It is astonishing, to note  Dr.Asher made this observation in the very early days in the evolution of modern medicine,(No critical care units, no HMOs, No industry nexus with research, & commodification of medicine  )  I wonder what Dr. Asher would have to write if he is alive in 2021.

Wish, every medical professional shall find their Asher score. Looking back on my career, I must confess my score would be 3 ( may be 3.5 !) out of 7.  Now, desperately trying to get rid of them. Mind you, the 4th (Overspecailisation)  and 6 th (common stupidity) is inherently built into the system. I think, very tough to avoid them.

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Few individual’s works mattered more than others in the field of cardiology. Here was a man born 1914 in Utah, studied at Rush university trained in Mayo, settled in Seattle as a pediatrician. But his passion drove him to become a specialist cardiac physiologist with an urge to find the answers to all those lingering queries that arise as a practicing clinical cardiologist.  He built an exclusive animal lab to study the mechanics and physics of circulation and cardiac pumps in the 1950s 

 

                          1914-2001

He can be called the new age, Harvey of the 20th century. He seemed to always bother, how is it that the 6 liters of blood traverse from heart to the periphery and comes back going through vast lengthy circulation with variable pressure and little energy loss.? He also made the very pertinent discovery in neural control, the effect of gravity on circulation. His interest in how venous return would have to match cardiac output was phenomenal. 

His grasp of cardiovascular physiologic concepts was so powerful and his book on cardiovascular dynamics was so popular. probably the first scientific textbook on circulation. I am sure he had shaped the thought process of so many physicians (I will vouch for myself) and helped create hundreds of cardiologists all over the globe. Dr.Rushmer also did pioneering work on diagnostic ultrasound and doppler. I can recall a video on cardiac embryology edited by him in the 1960s in pre-computer era that probably can not be beaten even today in terms of clarity of content and production value.

Through his thoughts like an engineer and mathematician still, he was able to blend the knowledge together and pass it on to the generation next clinician. No wonder, he was the founder and headed the department of biomedical engineering in the UW. The University of Washington holds an annual Rushmer lecture. 

If one person deserves an award for excellence in cardiovascular science for the 20th century, Dr.Rushmer’s name should definitely, come on top. Though he won several accolades, I feel scientific societies have missed an opportunity to felicitate him with the more worthy award. If the Noble prize in medicine is given for a lifetime contribution to cardiovascular physiology wonder why he can’t be considered for it posthumously.  

It is heartening to note, at the fag end of his career he moved from core science to philosophical and ethical truths of science and technology. He once said, “We’re confronted with the ethical, political, and technological consequences of our medical triumphs. We have to learn quickly how to deal with these profound problems by looking ahead to recognize and avoid complications of our technical breakthroughs’ How true his observation has turned out to be!

 

Reference

https://www.washington.edu/news/2001/07/16/dr-robert-rushmer-diagnostic-ultrasound-pioneer-dies-at-age-86/

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