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Posts Tagged ‘hippocrates’

Common sense would  indicate  medical care is  meant for the sick and ill  . Relieving  the mankind  from all those  suffering  with a healing hand has made the  medical profession noble and sacred .Medical science   grew with this sole aim  many centuries ago  .Some  times  we succeeded   and many times we failed  and the journey is  continuing .

In those days ,scientists were dedicated , inventions were genuine and were driven by a need to conquer a diseases .Some where along the line, (May be in the last 2-3 decades?)   our quest for money power exceeded commonsense  . Commerce entered   every  walk of life and  medical science became the biggest causality.

The purpose of noble   profession was forgotten . Simultaneously   public awareness and quality if life vastly improved in many of the developed countries . So the traditional illnesses  either disappeared  or reduced   to a great extent . Then came the life style diseases.The cost of treating  an illness spiraled too much especially   in the scientifically advanced countries . What was perceived  as great health care system  became  the  most ridiculed  health system in the planet  ?

Why ?  The simplest answer to this q  is

In the name of science  and  modernity , medical treatment  was glorified beyond the level it deserves ,  and hence  the  cost of treatment is  kept at artificially  & foolishly high  (This often involves  diagnostic   exploration of human body with modern gadgets without any meaningful   purpose )  .

ie , In  a  nutshell  of modern medicine is   often a medical mirage than a miracle . We know ,  the chances of success  as we  try  to chase it. If we think the  world is   waking  on this issue .

We are in for a surprise ! Even as  every one  is asking for outcome analysis in modern health care

more and more countries just imitate the failed ( Scientific and moral failure ) western models of health care .

When major illness are reducing in a society what will the health care providers do ?

Feel happy ?  Yes that’s what   a  sane   mind  would   do .  In a capital  rich ,   health conscious ,   knowledge  driven  society the opposite happens .

When  the patient  input  into a top hospital  reduces , the MBAs   in  them plan strategies  to bring  increase the bed occupancy rate and  maintain  patient  parity.

If sufficient  patients  are not there in a community what shall we do ?

Create  more  patients

Creating  new patients is a too dangerous game ,  what shall we do ?

In the  name  of preventive screening   let  us  label   normal  persons as patients .

How to do it ?

The following examples  are personal observation made in  huge city of educated elite  in a developing country . Excuse me if it offends a few  . . .

Define, redefine all criteria that define the disease (There are

  • Make, 130/85mmhg of blood pressure as pre hypertension and make them visit our HT clinic every month.
  • In the  name of risk stratification do CRP, Micro HDL , Apo a   etc and  catch them  for primary risk reduction for a non existing illness
  • Let us  label  all the   age related  bone loss as  deadly osteoporosis and do bone graft.
  • Let us  call  the occasional post dinner stiff stomach as non ulcer dyspepsia   and  insert a  endoscope  into the patient tummy .
  • Do a 64slice CT  in a master health check and convert many  of the healthy  normals into carriers   soft  coronary plaques.
  • Do a ultra sound scan  in every one who takes alcohol and  give our brains a temptation to label  the normal  fatty streaks  as infiltrative  fat disorder .
  • Do routine pelvic scan and detect  sub clinical fibroid uterus as potentially  malignant and  post them for hysterectomy on the next operation day.
  • Convert all healthy women as a  potential cervical cancer  and administer  herpes vaccine and help  the vaccine company share  move up in wall street !
  • Finally , screen  all  our  playful   kids for   learning disability and   label them as slow attention deficit disorder  and  make their  life permanently   miserable .

The list is endless  . . .

Final message

We  are in a  era ,  where  even   a  simple  illness  ( common cold ? )  can be converted into a billion dollar industry . ( Are you aware of H1N1 fiasco ,  The role of   WHO  and  mystery labeling of pandemic !)

While the above  misadventure  with scientific excesses   goes  on merrily  , lest we forget , millions of children  and adults  suffer in misery for want of  live saving  investigations and drugs  in any country .

When a person with a head injury dies due a  missed   subdural  hematoma for want of CT scan in one hospital  ,  ” in the adjacent hospital”  a wealthy and healthy man  ( who got admitted for master health check up ) undergoes  a series of scans  all over the body   even as he is  watching   the  satellite TV in  the comfort of a  five star suite   !

God will never  forgive  the  noble professionals   if they are part of this  negative health care  forces

Finally  ending with a very positive note !

The new   initiative by  Obama   , ” Health care  for  the uninsured ” is to be welcomed as great move  and will do a world of good .

But , our  only  request  to WHO ( or related   bodies )  is to create a forum or authority  to  impeach all fancy diseases from the medical   literature  !

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Pessimism, from the Latin pessimus (worst), is a state of mind which negatively colors the perception of life, especially with regard to future events.

Understanding pessimism is not that simple  . Some people argue  optimism   represents a strong mind while  a pessimism  is the domain of the weak . But it is not necessarily true.  Both pessimist and optimist are unreal , and playing the dangerous game of predicting the future. So realism is the answer .

In this era of information highways , commercial exploitation of science ,  our thought process is grossly determined by our perception of events.We hardly have an intention or time to analyse our thought process.

  • An optimist  ( Rather , unregulated optimist ! ) is a person who welcomes  any growth good or bad.*
  • A pessimist  is  a  person who welcomes only good growth.*

So how to identify good growth ? That is the million dollar question!

  • Many of the  optimists may not  bother about the final outcome of a treatment *
  • A pessimist bothers only about that .
  • An optimist  rarely asks questions, blindly accepts every thing !
  • A pessimist never believes any thing !

Actually the fundamental principle of scientific medicine lies in proving the null hypothesis null and void.Any treatment is useless until proved other wise .  So pessimist can be argued to follow true science , while  many of  the hardcore  optimists are blind believers ..

*It may be  a harsh   way of  interpreting an optimist  but  uncontrolled optimism  has played havoc in our  patients like many of the failed treatments (Some of them released prematurely into patient domain   has  killed many lives  . Power of positive thinking should be within the  realms of scientific feasibility !

So in  our  journey   to  conquer human health ,   we   may  proceed with  an optimistic mind and  a pessimistic eyes !

This understanding is all the more important in this era of contaminated science .It is a well known fact ,  now last 50 years of  planet earth has inflicted the maximum damage  to ourselves  than our ancestors did in 5000 years. That’s why we are compelled to meet at Copenhagen .(We never learn from our mistakes, that’s a different story !) .

There is definite and urgent  need for world summit  on  cleansing the medical science from  the clutches  of commerce  and ignorance . A medical green house effect, with dangerous holes in health care  is imposing on us (Another pessimistic thought . . . of course in the interest of human kind !)

World health organization ,  a sleeping giant has to be awakened on this issue


Final message:

Mankind has evolved over many millenniums ,  probably with a sole  purpose of living ,  that is reproduction and propagation of our genre without harming the environment and other species.

Unrestricted  and unregulated growth of any kind is dangerous we call it as malignancy in pathology .In science , we tend to call it a” great future ”

Our  sixth sense*  has  outgrown  miserably  out of  reality  , as have we decided to take on the nature and GOD .Now , many developing country men do not believe in death .They are fighting a losing battle against the God. And they suffer with escalating health costs of keeping the elderly ,  alive who are  knocking at the doors of heaven or hell . The same countries,  which deny funds for curable illnesses of the poor is a different story altogether !

The principle of modern medicine  would ideally  be

  • Reduce human suffering irrespective of economic status
  • Curing a illness if there is a cure
  • Prolonging life if there is useful purpose
  • Allow a good quality death if there is no cure.
  • Most importantly  , prey to god give us strength and capacity to identify which is good and which is bad for our patients  .

Read and learn for a  complete guide on optimism and pessimism

* It  is  important to recognise , the same sixth sense  has   made it possible to share our views through a great tool of  Internet  . So we should not be against the growth of science but against the misuses and wrong interpretations of it .

Pessimism

Optimism

The traditional characters  of  a pessimist

//

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Modern era of cardiology aims to treat ACS  as and when it develops .That is , as soon as the vulnerable plaque ruptures or a thrombus  blocks the victim’s coronary artery.

But this can be achieved only if the patient reacts to this event.We know 20% of ACS can be totally silent. Some produce very vague symptoms especially in elderly and diabetics. ECG and enzyme changes may help us in patients who do not have clear symptoms.There are variety of markers available for STEMI & UNSTEMI.(CPK-MB, Troponin T , myoglobin etc) Now we are working at finding a marker for ischemia without necrosis. Ischemia modified albumin is one such molecule that is showing promise.

The ER department world over have vigorous screening protocols to diagnose ACS  for  the patients with chest pain. There are thousands of triaging protocol in the  emergency management of chest pain.In spite of  the highest awareness and availability of  scientific expertise , knowledge base the error rate of diagnosing  ACS  stands at an astonishing 58%.  This may seem odd , but this is what  this land mark article in NEJM tell us  (Data from Boston , Milwaukee etc).

Out of 10500 patients with suspected ACS. Only 17 % had real ACS.  55% were admitted initially as ACS  later turned out to be non cardiac .This may seem  acceptable for many  even if it is  an act of unnecessary admission and investigation. It gives us , a sense of satisfaction for not missing a diagnosis of ACS. But it has it’s own risk of complication arising out of unnecessary investigations.It is a chain reaction of  suspicion that  may end up in a coronary angiogram in many ! .It is also a well recognised fact these patients    spend  atleast an average of  2 days  to get rid of the ACS tag over their  necks .

Experience has taught us  simple presence of a human being as a patient within an  ICU ( however short the stay  may be ) can be a health hazard and risk .  This  55 % error ,  which does exactly  this to  our  patients with chest pain  who reach the ER  never bothers us  This is because  we feel credited both academically as well as financially .

In the same study 2.3 %  (About 25 patients) with true ACS  were sent home  after a missed  diagnosis . Paradoxically  this 2.3%  has worried the medical professionals too much . . . This happens  ,  even as we  do not have proper data on  how many of them had a real adverse event after a missed  ACS.

So the message here is even in best centres both missed and wrong diagnosis are  rampant. while wrong diagnosis (25 fold more here  )  is easily accepted by the medical community .We can justify  this as a screening camp for ACS  ,  akin to arresting  a group of suspected  criminals in a  preventive raid ,  later releasing for want of evidence.

In the morals of  criminal judiciary  , it is often said one can afford to  lose  a real offender from the clutches of law  , but a  innocent should  never be punished in any circumstance .

In medical parlance this  goes something like this  . . . Thousand patients shall die because of his or her illness but not even a single healthy person should die due to unnecessary treatment.

The above thoughts  were in response to  the excellent original article on missed diagnosis  of ACS from NEJM.  http://content.nejm.org/cgi/content/full/342/16/1163?ijkey=652d8337709a8bf84c813f4c9d685863ee053162

Final message : (Sorry for the  lengthy message !)

Can we afford to miss an  ACS in emergency room ?

“Definitely not” . . .but do we succeed in that ?  The answer is same “definitely not “

When we are able to accept with pride every time  we make  a  wrong diagnosis of  ACS  in perfectly normal people , It may to provocative to say  we can  also  afford  to do  the same  when we occasionally   miss a  diagnosis of ACS  as well .  Law of statistics dictates for every correct diagnosis made there is many fold number of wrong or missed diagnosis takes place. May be , reducing that is the only aim of medicine.

We need to realise  with even with a 55% of false positive initial  diagnosis  2%  real ACS  escape net !The only  fool proof method  for  not missing  ,  even a single case of ACS   is to label every patient with chest pain as ACS .

In this vexing  issue , we should realise  , in field of  medical decision  making ,  errors  due to acts of commission  ( Making an  inappropriate drug/procedure /surgery  is easily accepted by medical professionals as well as   the court of law !) . But acts of omission ,   like missing a diagnosis or failure to prescribe  a  drug or perform a procedure  is rarely accepted   and  is  considered   a great negligence and  bring intense guilty feeling among the physicians .

This  perception is definitely  not warranted in this  greatest profession  of glorious uncertainties ! Both acts of commission and omission  cause significant damage to  patients . In this modern era  ,  we have clear  statistics  that   reveal ,  acts of commission  leads far ahead over it’ s counterpart in injuring our people .

Hippocrates got it right over 2000 years  ago .  First let us do no harm  . . .

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For  all those youngsters , who are into the mystery world of medical research  , please begin your journey with this great book.  The greatness lies in it’s  simplicity in expression & search of truth !

Download this 1 MB  marvel  ,  free from  http://www.jameslindlibrary.com  in less than a minute

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  1. Do 64slice MDCT  in all patients who has  a coronary event and follow it up with catheter based CAG.
  2. Use liberally the new biochemical marker ,  serum  B-naturetic peptide (BNP) to diagnose cardiac failure in lieu of basal auscultation.
  3. Advice  cardiac resynchronisation therapy in all patients  who are in class 4 cardiac failure with a wide qrs complex .
  4. As it is may be considered a  crime to administer empirical  heparin, do ventilation perfusion scan in all cases with suspected pulmonary embolism.
  5. Do serial CPK MB and troponin levels in all patients with well  established  STEMI .
  6. Open up all occluded coronary arteries irrespective  of symptoms and muscle viability.
  7. Consider  ablation of pulmonary veins as an  initial strategy in  patients with recurrent idiopathic AF. If it is not feasible  atleast occlude their left atrial appendage with watch man  device.
  8. Never tell  your patients   the  truths  about the  diet , exercise &  lifestyle modification (That can  cure most of the early hypertension) . Instead encourage the  use of  newest ARBs  or even  try direct renin antoagonists   to treat all those patients in  stage 1 hypertension.
  9. Avoid regular heparin in acute coronary syndromes   as  it  is a disgrace to use it  in today’s world. Replace all prescription of heparin with  enoxaparine  or  still better ,  fondaparinux  whenever  possible.
  10. Finally never discharge  a  heftily  insured patient   until  he completes all the  cardiology investigations  that are available in your hospital  .

Coming soon :  10 more ways to  increase cost of cardiology care . . .beyond common man’s reach

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                                            The science of medicine has evolved over 2000 years since the stone age days.It has  currently reached  a glorious era with  cutting edge  scientifc  technology .Today  one can map the entire human genetic blue print and intervene in the  disease  even before they manifest .One can   keep dying people alive for years with multi organ transplantation. Modern medicine has taught us  how human sufferings can be prevented and life can be prolonged (with or without purpose !)

The term conservative management  conveys two different

meanings for medical professionals.

conservativ-3

For other group of physicians

 

conservative-4

                         

                             Ever since the days of  application of leech over the  head for treating migraine and a crude knife abdominotomy for emergency exit of babies from  pregnant mothers in distress  , healer’s   mind has always  perceived “something  has to be done  urgently when some body suffers”  this sort of  reaction is probably  inherited  and is related to  the primitive flight or fight response .

This may be true in  some of the emergencies but it is untrue in many of the non emergencies.

                                          Unfortunately ,  our mind  finds it difficult   to differentiate  between these  situations . With constant exposure to dramatic medical breakthroughs , modern day physician is made to believe   “Some thing  is always  better than nothing  when illness strikes. Human body is a wonderful machine which has it’s own service station ! in the form autoregulation  and the meticulous  homeostatic mechanisms. Only if the disease process overwhelms,  it needs intervention.( Typical example:In the routine viral fever , you don’t adminster Acyclovir or other antiviral  for all of them !

                                        The problem with early aggressive approach is,  it fails to give an oppurtunity  for the body’s natural defence forces  to respond. Further , we will  never ever know how the administered treatment is going to fare vis a viz the natural response.( With due respects to RCTs).   While the field of medicine   has  so much  evolved , our thought process,  especially  the  aspect of clinical  reasoning  has always been lagging behind .It is now considered  as inferior or even unscientific  treatment  if  some one follows a conservative approach to a problem even if  it  provides   same outcome of that of an invasive or aggressive approach ( The classical example is PCI for chronic stable angina The COURAGE study).

The other major issue is the hazards of unwarrnted  invesitigations , drugs and procedures

Classical example:No one knows how much morbidity or mortality the routine Swan ganz catheter  caused when it was rampantly used for over two decades to monitor central venous pressure .It is estimated  that in modern medicine  there are at least  few  drugs or devices  in each speciality waiting  for the same fate  as that of  the swan ganz catheter.

No body knows when it will be exposed .Our EBM will take it’s own time . . .Till that time humanity need to suffer.

This thinking is not new  The concept  “First do no harm is over 2000 years old”

hippocrates-primum-non-nocere

Questions in search of answers

 Does law of conservation of energy applicable to human body and medicine  ? 

 Can we defy death with modern medicine ?

Final message

  • Conservative management is still  a great medical concept  in many situations  and one should not allow it to die  by the whims and fancies of the modern scientific forces.
  • Whatever you do on the patent’s body  do it ,  only if it is going to helpful for him /her. If you are unsure  Whether a given  treatment  is going to help or not ask this question to an expert .
  • The widely prevailing  dogma  of aggression is always better than  non aggression  has absolutely no evidence.
  • So approach a clinical issue disease by disease ,  individual by individual.
  • Now , in this era  high tech  medicine  ,  It is lot more tougher to choose a conservative path as the pressure to do more and more  looms  larger ! It is easier to follow the crowd  than a path of your own .
  • Always remember it needs a  stronger  mind to  act according to our conscience !

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                Human civilisation has met so many challenges.Man kind has enjoyed the benefits of modern medicine for over a century.Now comes the new threat.Threat from within.The onslaught of marketing force has contaminated the medical science .

              It is widely  recognised  commerce is masquereading as science , from stem cell research to futile and costly  drugs, and  questionable  devices and procedures . 

How is the medical  community responding to this  issue ? 

Silence  is the response !  Why silent ? Are we the part of the problem ?  Occasional articles in the  Annals of medicine, Lancet, BMJ, or JAMA talk about these issues and nothing happens next .

Click below  to read one such article from the recent issue of Annals !

 

 

Let us hope the world financial crisis currently we are witnessing , would be good for human health as all futile market driven  , enforced medical expenditure goes bust !

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