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Archive for the ‘bio ethics’ Category

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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Today is one of the most auspicious days in Indian traditional festive time. Saraswathi pooja, a celebration of the Goddess of knowledge and education. I would like to share one of the all-time great quotes on learning from Thiruvalluvar a sage poet who lived in the southern Indian state of (mine), Tamil Nadu in 4th -5th century BC  2500 years ago.

 This Thirukural number 391 in the chapter of education goes on like this. (In the Tamil Language)

In English

Karka, Kasadara, Karpavai , Katrapin,

Nirka , Atharkku Thaga !

It says

Karka : Learn

Kasadara: Here comes the punch. Kasadara means pure.  He says simple learning is not at all-sufficient. One has to learn from good sources, learn deep that should be devoid of errors, contaminations, and falsehoods.

Karpavai  : Thus you learn all lessons in life meticulously.

Katrapin:  So, after this hard and enlightened learning, what we should do?  He answers next.

Nirka Atharkku Thaga: This means , don’t just stop with learning, follow it with action in a righteous way. Unless we do that he warns to conclude ( in another poem in the same chapter) there is no purpose of learning itself and we are again at risk of becoming illiterates.

So, what does this Thirukural teach the Nobel professionals who follow cutting edge medical research?

I think I need not elaborate . . . Acquiring knowledge and true learning has become two different processes.

It’s just a sample of one kural (Quote) among 1330 poetic quotes written in 133 chapters by this great philosopher of Tamil Nadu who shared the same timeline with Aristotle and Socrates of ancient Greece 5000 miles west of India. For those ,If you are interested in his monumental work on literature which can be referred to as the manual for effective living  (I wish to call it as “Standard operating protocol”  for human life)  please follow the link.

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This post was originally written in 2013.

A middle-aged man with STEMI  came to our CCU.  It is just another case of STEMI and asked my fellow to lyse.

Anterior STEM ecg

But it was not the case . He, told me, Sir, the patient had a syncope following chest pain and he has injured his face and Jaw. He was actively bleeding. When I saw this face, it was indeed  frightening.Strptokinase induced bleeding

What shall we do ? When a patient  with STEMI presents with bleeding facial Injury

  1. Rush for Immediate PCI (Which was  of course not possible in our place as it happened out of office hours! )
  2. Take that ultimate risk and thrombolysis
  3. Give only heparin ( Many times it is as good as  lysis )

We took a (bold ? ) decision to thrombolyse with streptokinase.(After  a CT scan which ruled out any Intracranial bleed like hematoma etc) Clopidogrel was also given.

absolute contrindication for thrombolysis facial trauma

Patient continued to bleed in the initial 3 hours and was oozing in the next 12 hours. Blood transfusion was contemplated, but it was not required. Dental surgeon opinion was sought, his teeth were pulled and a compressive bandage was applied.It arrested the bleeding.The ECG settled down.LV function was almost normal with minimal wall motion defect. He is posted for a coronary angiogram later.

Final message

 There may not be anything called “Absolute contraindication” everything appears relative

I presented this in the weekly clinical meet,  with a tag line of  How to save a patient, apparently by violating a standard guideline. Not surprisingly, It evoked laughter amusement from learned physicians. I wasn’t. Guidelines are meant to guide us agreed.They can not command us. They are not legally binding documents as well! Many lives can be saved if only we have the courage to overrule when it’s required.

Afterthought

Had this patient has bled to death during lysis what would have happened to the treating doctor? (or )If the patient has died due to MI, because of deferred thrombolysis, what would be the line of argument?

2020 update.

This case scenario is a non-issue as of today. With so much experience, we straight away do PCI . Just manage the oral bleeding if any.

 

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Poverty is a cruelest disease of mankind , the infective vector is not any deadly HINI or retro virus , but mostly the fellow humans themselves ! This is why WHO has included poverty in the ICD code (Z59.5 ) as a disease .

I used to wonder , as a member of Noble profession , should we fight against this disease or be happy to spend my entire life time cleaning the coronary arteries of affluent human-beings and earn few bucks !

Can growth of money eliminate poverty ? 

We may think so  . . .  but it doesn’t most times .Of course ,  affluence bring more jobs to the poor , logically it should alleviate poverty. But , we  know the reality. Its not that easy concept to understand . However we have robust evidence for the opposite ie affluence can aggregate poverty .

If poverty is a disease &  if  mindless  affluence is an Indirect cause for it  , then affluence also becomes a potential disease , Is in’t ? Will WHO include it in ICD listing ?

May I propose Z59.5A to be called  Uncontrolled &  manic desire for affluence ?  Since it is  made at the cost of  fellow humans , it should be clubbed along with poverty as a worrisome disease. Once its included in the ICD manual , I guess it will be unethical to ignore this disease. 

We all aim for growth in life .Nothing wrong in that .There are many facets of life that requires growth. Unfortunately , for most  homo-sapiens ,  growth is synonymous with multiplication of money . . . nothing else seems to matter ! Money when it grows unregulated ,  begins to control you and hijack your  body and mind .

One more issue to  comprehend is , rapid growth of money is possible only at the cost of something (or someone) else – Akin to cancer cachexia ,it depletes the body (Earth ) of it’s resources ( Nature abuse ,  extreme poverty , inequality ,  Third world exploitation , wars, etc ) For the  medical professionals  it is all the more important that growth shouldn’t mean money , as it has a direct and conflicting  impact on some one else’s life  !

mitosis of money 003

Just Imagine ,  if the all the car companies combine together , aim for a  dramatic growth from the current  4 %  to 25 % by 2030  and manage to  achieve it by any means ! . . . This planet will sink in the combined weight of automobile Junk !

It is obvious , uncontrolled growth in any form requires vigorous regulation and  Intervention and will eventually require a radical surgery if the growth goes unabated  !  

Counter point

It is foolish to link growing money and wealth  equivalent to cancer. Unlike cancer cells , money multiplied can be put into use for those in need .It is the principle of charity .But the reality is , human beings who are rabidly after money rarely have this mind set.In contrary the haven’ts have it in plenty. In my opinion, excess money has a dubious  capacity  to  contaminate  human values  ! (Why should some rich and elite opposes affordable health care  to poor ?)

Let us amass wealth and help others . Microsoft  is able to do it. Apple may do it later. What is the need for big companies social responsibility and philanthropy ? If the business worlds  motive and end product  promotes equality and goodness , sans exploitation , the question of charity at a later date never  arises.

Final message

If extreme poverty is a disease ,  forces that Initiates or sustains  poverty cycle can not be a bliss. In this context , the  manic affluence (& the urge for it)  should be included as a communicable disease since it seems to be most contagious as well.

In health care delivery “affluent and modern care” may also connote a sinister meaning. Poor people might think they are deprived of good care because they cant afford it. But ,truth hides deep. True sustainable caring is little to do with affordability+ , since most of the modern health care expenditure is jacked up with junk.

I know in my country people sell their life time assets for what they think as  crucial health care .(Of course universal health care insurance is just beginning to come in. Here again insurance based health care has inflated the actual costs and threatening to impose inappropriate therapies .

As a medical professional we should aim for the cheapest  and best form* of treatment to our patients . Artificially inflating the cost of therapy by worthless drugs, devices, procedures and disseminating them invariably leads to pathological  growth of science.

*If any one thinks “cheap and quality” doesn’t go together in medical care it is ignorance ! Most problems has simple and effective solution.

Post-amble 

 I object this statement -Modern health is nothing to do with affordability.

We need to go to the basics then .What is true health ? Forget about transplants, Organ Assists, Five star critical care .They seem to work in a minority , but drain the world economy. Its Impact on global health is at best minuscule. One Important analysis say 90% health care cost is wasted in prolonging the last 30 days of life of homo-sapiens.(Will get the reference for it )

Please note 

Diseases that occur to  affluent population  is entirely different topic . Can be found elsewhereDisease of affluence

 

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Bedside wisdom

We have been  using unfractioned Heparin for long , and its  is better than any other anticoagulants  in ACS . . . 

Our observation shows that Streptokinase has distinct advanatge over Tenektepelase as it works longer duration  . . .

My experience  says Diuretic and beta blockers  are still good as first line therapy for Hypertension  . . .

Mind you , there are infinite  number of such wisdom in every sub specialty of medical field.

However , the typical response from any  modern scientific intellect would be . . .

Stop it . . . Its old  stuff folk  , What does the current data say ?

medical-data-ethics-futility

Common uttering  in scientific forums,

Is there data backing up your  treatment modality ?

Is there sufficient data ?

Come’on , grow up , don’t talk about experience in a scientific forum . . . come out with data man !

No one seem to care the quality of the data . Every one bothers  about the quality of the Author and Journal instead  .  if its X Y Z its ok If its A B C no its not acceptable data.

Probably , Data is most misused word in medical science.

In scientific world,  “unpublished sense” goes straightway to  dustbin ,while we have so many avenues for the  published nonsense to  be celebrated (Still, bulk of guidelines in cardiology is backed up by Level C evidence which means experience  of experts !)

By the way what do we mean by data ?

Its organised collection of genuine scientific information , that’s post processed ,  follow it up with sound inference and faithful questioning and debate that should ultimately end up as  “clinical  application” in patient domain for consumption.(No prizes for guessing , whats happening in real world !)

OMG, give us back that elusive Common sense . . . which  I  think we  lost some time  at the turn of this millennium  !

Wrong or useless data : Who will recall ?

Once applied to patient , these data is  to be scrutinized and monitored . If we find a study conclusion  and reality does not match , we  need to stall the data from adversely  exploding .Every stake holder should have the power to do it. There have been instances a treatment modality got banished in one country is legally permitted in other country knowing fully well the futility.

Final message 

Modern scientific Data* is not God sent. Its  created , synthesised and disseminated in various mind factories. All you require is , backing up with some pioneering journal publication with huge impact factor.It’s not really blasphemy to question things which doesn’t make sense .Unfortunately , wrong data can be tackled only with further data .(There is no other means I guess !)

When does “good common sense”  become hard data and evidence ?

Its the act of publication , so  please guys whenever you  find some contamination  in so-called scientific data  please post here.  To begin with I am registering a new Journal  “Commonsense journal in cardiology”

*Please note, data is not a bad word as this write-up  seem to suggest.Naturally occurring , epidemiological and  observational data about diseases are the foundations for medical science .The issue become murky when few motivated humans play brutal  games at the sensitive  interface between science and truth.

It should be acknowledged , there is a distinct risk  of  this fight against falsehood end up in blocking  true progress  of science . Still , Homo sapiens  are (believed to be !)  intelligent enough to differentiate good from bad , that’s the reason God gave us the sixth sense !

Link to Lown Institute (Started by Cardiologist and Nobel peace prize  Laurate Dr Lown who strives hard to pursue this goal)

Further reading :  Scientific Reversals in cardiology 

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