While our brain perceives whatever option we choose is the best for the patient , in reality it is rarely true !
The only comment I wish to make, there is nothing called standard guidelines for complex and unusual problems .We need not be obsessed with protocols !
Please remember , If you apply standard guidelines in non-standard situations 9/10 times we are going to err !
So my choice would be, to go with your gut feeling , of course your gut should be alive , up to date and periodically maintained !
If you don’t have the guts . . . don’t worry you have plenty of other options !
Unfortunately, there is a strong bias towards raw basic science when it is given in the filed of medicine.Do you know ,there is no Nobel prize exclusive for medical science ? It shares with human physiology the only field included for Nobel prize in medicine.
Evolution of human history reveals it is not the stunning scientific discoveries that impact the mankind . It is largely dependent on how we use them . It is true and natural ,invention of sub atomic particles , decoding quantum mechanics and trans-cellular signals always generate great interest than others.
In medical science, time and again we have seen problems arise in applying fruits of scientific research into practical usage in the patient domain in the bedside.
What is use of rewarding inventor of nitric oxide with a Nobel prize , when billion-dollar nitrate industry is thriving on a non existing life long indication of stable angina .
It is surprising to note , Nobel committee does give credit to wisdom & intellect while awarding prize in peace, literary or economic sciences. For some reason it lacks such a vision when it comes to medical sciences !
We have seen Nobel prize being awarded to organization that strive for peace and welfare of society and community like UN ,EU etc.The world health organization is the premier power supposed to provide and regulate the health in this planet.I do not recall any time WHO was close to considered for the Noble prize in medicine !
Nobel Ironies
Nobel committee rewards economists who point out lacunae in vital world macro and micro economics theories.
Dubious men(Heads of state ) are decorated with Noble peace prizes for preventing a war in one geographical area while doing exactly the opposite elsewhere !
In this modern millennium where scientific pursuits are contaminated and many of the research questions are misdirected or irrelevant , Nobel committee needs a through rejig in the manner in which medical Nobel prize is being awarded. We know ,Noble’s death wish was to award the brightest mind with highest scientific breakthroughs in those world . . . but
I guess Alfred Nobel if alive would have changed his rules .He wouldn’t have imagined modern science would systematically devalue common sense and reinventing it would also deserve an award equivalent to Nobel !
Some of the medical discoveries that deserve noble medical prize
States which excel in school health nutrition and other basic health programs for the downtrodden
Doctors who promote bed side clinical skills
Tobacco eradication networks
Organisations like medicine san-frontiers which strives for basic life saving medication for all
Journal houses that specialise on Medical ethics and clinical sciences
Medical professionals and institutions provide value education
Medical economists who expose the wasted financial resources that widen the gap between sick and rich
How about Nobel prize in cardiology for preventive cardiologist who successfully terminates a million statin prescription and restoring natural exercise directed lipid regulation in them ?
How about Noble prize for a noble physician sitting in corporate hospital infested with all commercial ingredients who could resist and argue successfully against inappropriate tonsillectomies and appendectomies ?
I am sure , such a man will be a laughing stock for most of us !
An appeal to Nobel committee
It is a wish , Noble prize in medicine is to be included for people who do yeomen services in preventive and clinical care and professional who carry forward the legacy of caring for the sick with clinical application of available scientific wisdom !
In this scientifically obsessed world , It will be a new beginning in the way future medical research will be directed and nurtured ! Only then the true power of Noble prize in medicine will be realised !
Tree of life : When professional morality suffers a mortality . . . human health becomes a causality !
Greatest threat to the future of human health is . . .
Not from exotic infectious agents , bird flu or mosquito fevers
Not from epidemic of cardio vascular disease
Not from thousands of published diseases in ICD code
Not from aging population and failing vital organs
Not from lack of availability of life saving drugs and devices
Not from lack of hospital beds.
Not from good sanitation
Not from hunger and poverty
Not from lack of para medical workers
Not from lack of health awareness and education
But from . . .
The way health care is administered in this planet .
The way noble professionals are created .
The way trivial health issues prevail over major health crises that wallop the health budgets.
The way by which medical morality is systematically destroyed
The way “concept of health” is sold as a buyable commodity by insurance companies.
The way medical journals churns out junk articles in the name of research.
The way corporates indulge in delirious pursuit to increase bed occupancy rate of their patient ware houses (Also called Hospitals)
The way greedy drug companies aim to increase the per capita drug consumption of ill informed homo-sapiens by discovering pseudo drugs for pseudo illness
The way health insurance policies are misused
The way rich spend billions for reconstructive cosmetic surgery while the poor die for want of basic medicines !
Medical facts exist in a dynamic fluid state . Finding the truth is often a herculean task .Disagreeing is easy . ( Proving a point may require a hundred experiments . . . but for disproving needs only one !)
Still , the essence of medical knowledge is about distillation of medical facts and myths and extracting the truth.
Do you know the levels of scientific argument ?
There are seven levels of arguing .
Argument , agreement and disagreement are central to the growth of science especially so in medical science. It can vary between polite refusal to blunt antagonism . Graham’s levels of disagreement throws light on this aspect of human intellect .
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By default , most human brains live in the bottom of this triangle. Where does the medical professionals stand in academic forums ? I am afraid they show little difference from that of lay public . Ad Hominem is extremely common in medical journalism . I have personally experienced this from elite peers ! A paper sent from a third world country like India is straightaway rejected or regretted without even looking at core content .
By the way . . . where do you like to stand on Graham’s scale ?
The irony of modern medical care is 9/10 times medical negligence is defined in terms of acts of omission in required level of care . In reality most medical negligence acts are related to knowingly overdoing a futile diagnostic or therapeutic modality.
This irony was never understood by the public, the professionals or even the judiciary .This remains the most dangerous issue facing modern medicine !
Finally some light is appearing in the horizon . A Missouri Cardiologist is suspended for overdoing things he knows best . . . namely coronary stenting !
This may bring chills over many cardiologist’s spine .
If you are a doctor and whatever be your specialty . . . if you do not read this article and understand the nuances probably you will not become a complete medical professional !
While BMJ struggles to propagate a vital truth , this banner on a Indian high way tempted the public to go for 64 slice CT scan . . .just like that !
Final message
Accruing medical knowledge and skills is only one aspect of medical profession. Applying it properly in our patient population is entirely different ball game . Let us be disease curers and not disease hunters . This is important because disease hunting is a dangerous game , where victims can be innocent bystanders. This is exactly same thing Hippocrates refered to as Primum non nocere 1000 years ago. It has required a huge statistical study to RE-INVENT this universal fact !
Here is the two versions of a discussion by a cardiologist to his patient , on the day of his discharge from a state of the art trans national heart health service in southern India.
An alluring cardiologist .
I have implanted the world’s best drug eluting stent to your block .
The block has vanished without a trace .
You will be free from pain here after .
You can enjoy a new lease of life .
You can go for holidays , you can cherish , you can do whatever you want .
Forget about complications it is negligible.
But please take all the drugs regularly .
A Bitter cardiologist
This stent is a temporary solution to your problem .
Do not think you are cured of your illness .
Atherosclerosis can never been cured completely.
You have to be careful .
Avoid very strenuous activity .
It can re occlude at any time even if you skip the tablets for few days .
After all, it takes only 6 minutes to form a blood clot .
You may require CABG in future as most stents get blocked by 5 -10 years .
Further , the drug you are taking may develop resistance and you may recur the same old problem .
Final message
So , the art of medicine is to hide some of the unpleasant outcomes from the patient and project only positive aspects to our patients *
* This is often a controversial issue . Scientifically advanced health care system do not agree with this . But I would believe , that is one of the major reasons they are suffering from huge health care crisis !
I do not agree with the concept of empowering patients with bitter truths . This need not be vigorously practiced. Disclosure of all potential complication to our patients , by itself a trigger such events by meager anxiety .
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Please Note
The author acknowledges all the queries posted by the readers and wishes to answer them .Due to logistic reasons only few could be responded. Inconvenience caused is regretted.
Dr.S.Venkatesan MD 