Posts Tagged ‘medical ethics’

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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 )


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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“Publish or perish “

This sound bite is regularly uttered by all academic leads in any university or medical school. I don’t know, why this bothers me. Looking back, many of our mentors & professors never had any great publications. Still, they were extraordinary teachers and wonderful clinicians with great wisdom. They created generations of high-quality doctors who are present all over the globe now. Is scientific publication that important in a doctor’s life? After pondering for quite some time, got a hazy answer to that query in one of my sleepless early morning academic dreams.

Hippocrates was one of the applicants for the post of professor of medicine at Harvard medical school.His application was rejected for a dismally low H index. The reluctant father of medicine tried to impress the authorities, by telling them that his experience was vast and used to teach medicine 2000 years ago, well before their country USA was discovered. The father of medicine almost begged to reconsider their decision.The miffed Harvard academic office ridiculed the old man and insisted nothing will work, except a minimum H index of  50 or atleast 10 papers as first author in a peer reviewed high Impact  factor journal. A dejected Hippocrates returned to Kos islands and asked his new generation fellows, what is this H index and Impact  factor stuff ? His students were worried about their guru’s ignorance. They some how convinced the greatest ever medical teacher to urgently subscribe for a platinum membership of a premium medical authourship services located in the Boston suburb and fixed a 30 day deadline for his first manuscript.

(What is this H index ?)  Why is it so popular?)    Ref : J. E. Hirsch  An index to quantify an individual’s scientific research output

Off to Kos Islands 

Now, let us travel back in time,2000 years ago to this picturesque nation, Kos islands in the Aegean sea,. This is where Hippocrates taught lessons under his favorite tree. No teaching apps, No 4k audiovisuals, The humble noise from within his lips became great wisdom thoughts. All that students had were set of ears to hear him. Hippocrates became the celebrated father of medicine for two reasons. He was the first to dispute the then-prevailing thoughts about human health and disease. He first proposed for every illness there is a hidden reason ie the beginning scientific basis. He insisted and negated the idea that diseases are bestowed upon by evil forces and spirits. The second one is more important. He realized knowledge, skill, and power are a deadly mix for the healing industry if they lack responsibility. He foresaw non-academic factors that will try to challenge the integrity of medical professionals and the health care delivery systems. It is astonishing to note how he could predict this 2000 years ago and wrote the behavior code for medical professionals which has become immortal.

How to grade the quality of medical professionals?

Scientific publication is just one of the indices of quality assessment for medical professionals. Grading them based on a few manufactured rating systems is beginning to look like an academic comical. There are many more visible and invisible, quantifiable and non-quantifiable quality assessment parameters that deserve attention.

Research  & Innovations are indeed the pivotal pillars that take us to newer frontiers of medicine. But, It is explicitly clear now, the prime purpose of research is definitely not aimed at the growth of science. It is more of a survival tool, intertwined with commerce, status symbol, pride, peer pressure, self-esteem, rivalry, or just a filler for CV. 

Final message 

Blanket statements like Publish or perish at any cost could be a dangerous doctrine to adopt in medical education which is essentially about healing and caring (& whenever possible, curing). In one sense, medical teaching is little to do with research. Many of the great professors in our country never published a single paper. Unfortunately, research and teaching have been made to look inseparable. Beware, history has repeatedly taught us medical professionals need not be hyper-intelligent. They need to be just wise, men /women of integrity, enriched with sincerity, righteousness. Proper consumption of knowledge is much more important than the creation of it. Let us hope the future will be at least as perfect as the past. 


My  H index stands at 15, I must confess I am confused a lot. Should I bother for more, or be just be happy to reach the H index of our mentor and father of medicine, which is numero Zero, and propagate his work. 


Grzegorz Kreiner The Slavery of the h-index—Measuring the Unmeasurable..Front. Hum. Neurosci., 02 November 2016

2.Academic excellence does not always require publication  Ernest L Boyer argued in his 1990 book, Scholarship Reconsidered: Priorities for the professoriate,(BoyerScholarshipReconsidered)

3.Too much academic research is being published https://www.universityworldnews.com/post.php?story=20180905095203579 



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Master health checks* , superficially look like a perfect modality to practice the greatest medical concept ie “Prevention is better then cure” .Let us detect all human diseases early , prevent its progression, regress it or completely cure it . Absolute bliss is it not?

Why then articles such as this one should ever get published, that too in one of the prestigious journal of medicine?

*Master health check .( Also referred to as annual General health checks.)

Master health check up geenral cochrane bmj editorial

While the title itself is provocative, it adds a tag line which is still more a shocker.

There are specific well-researched reasons for this preventive health check fiasco.The masters, who were originally the guardians of health soon became disease mongers.In the process, the primary aim of propagating the doctrine of “prevention is better than cure”, could not reach its desired goals. Instead of ignoring and reassuring the minor deviation of biological data and Imagery generated, they became a perfect feed for the hunters who are after the trivial and non-existing illness.

Final message

Good intentioned health checks are always welcome in selected high-risk population say pregnant women/children of developing a world (As in endemic countries of rheumatic fever) Also cancer , CAD , screening in people with a positive family history can be critical.

However, when these masters of health deviated and started making a living out of apparently healthy people. ( The side effects reached monstrous proportions hiking global health cost in a meaningless way).People, especially in counties with poor resources, are the ultimate sufferers, as the cost and efforts are diverted, to fix the health of healthy, while people with true illness continue to struggle.

Will the WHO* wake up and intervene against this skewed practice of routine master health checks in healthy, that are rampant in both rich and poor countries. Ideally, doctors should order preventive health assessment for those who may need it.

There are enough grounds for public Initiated periodic walk-in health checks to be banned (or at least restricted)

*WHO is world health organization

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*When I tried to condense three decades of my learning into the medical profession in three lines, I scribbled this. Sorry folks, if It doesn’t sound scientific for some of you! 

By the way, What is successful medical practice? Success for the Doctor, patient or both?  The answer to this question is never simple. 




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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.


 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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Hippocrates is bestowed with the Immortal  tag “Father of Medicine”, not because he invented  any miraculous gene therapy or a modern virtual imaging of human organs, nor did he found any magic drugs .He didn’t receive a single award  even from his local village, forget about any Nobel prize to him !


Mind you , he lived before Christ ,2ooo years ago , there was nothing in the hands of noble professionals, not even a piece of paper and pencil to note down patient’s symptom .They didn’t even know what organs human body contained no basic medical tests . They just had a pair of hand, working brain with six senses , strong will to work hard and most importantly a caring mind and a constant search for answers to lingering scientific queries .

good medical practice hippocrates medical oath ethics drsvenkatesan dr s venkatesan

Yes, Hippocrates is still holding the post of father of medicine because he was the first human  to propagate  thought that human diseases are not evil forces beyond our control, it may have scientific basis , every disease has a specific cause that arise from derangement of body function.

More important than this , he formulated a way to practice this profession in a dignified manner. He also predicted common sense may prevail over science  in innumerable instances. Going through his quotes , one could wonder , he probably predicted technology might hijack human Intellect as well !

hippocrates quotesQuotation-Hippocrates-disease-Meetville-Quotes-149262Now,we have every thing. Students read medicine  in animated 3D class rooms , physicians  get a deluge of body system data &  images beamed straight into their ipad . One can perform  complex interventions with ease in almost every  organ or  even replace it , if it doesn’t work .

Still , as on 2017  ,there is something huge , that is missing  in the Noble profession when compared to ancient days  (2 millenniums before!) when people thronged Hippocrates  clinic in the remote Koss Island of Greece, where he used to sit  with almost  nothing , but was able to offer definite cure for many .

What is that missing link  ? Without realizing  what it is, we enter the Noble profession and fervently  take the  customary Hipocratic oath . For many (or most ?)  of us it is amusing to read and practice that. Life has moved in  fast lane since then. It is a tragic truth , Hippocratic oath  have become  redundant , obsolete .or outright humiliating for few !

Final message 

Whatever you say, still Iam compelled to feel sorry for that “Good old man” who miscalculated the Integrity modern day Noble professional , (I would say, Mr H failed to  realise doctors are also made from ordinary human beings ! )

It’s ok . . . here is a “Doctor’s life maintenance” manual : Keep reading it periodically !

British General medial council , has done a wonderful job . It has published a practical life maintenance and behavioral guide for  doctors  which I feel is most important text to be read periodically and of course  followed  !

Link to Good medical practice

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