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Why Nobel prize in medicine is not given for clinical science ?

Posted in bio ethics, Cardiology - Clinical, Clinical cardiology, medical quotes, Two line sermons in cardiology, tagged , , , , , on May 23, 2014| Leave a Comment »

nobel prize in medicine 2

Why not Nobel prize for clinical  science ?

 

nobel prize for medicine

Nobel prize was constituted  to reward people or organisation  who make a  huge impact on the welfare of man kind. It is given in various categories  for  outstanding contributions in Physics, Chemistry, Literature, Peace, Physiology or Medicine, and Economic Sciences

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 !

Reference

Link to Wikipedia Nobel prize in Medicine

 

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Evidence based chaos in critical care units !

Posted in Cardiology -guidelines, cardiology -Therapeutics, cardiology-ethics, tagged , , , , , , , on February 8, 2013| 1 Comment »

Critical  and intensive medical care is meant for supporting  an  individual organ (or multiple organs )  at times of extreme distress ,  till the  healing process  prevails over .Later , the patient  shall be shifted safely out of the unit .

Whatever be the modern technology , the single most important factor that  determines the success of ICU outcome  lies within the  patient body ( One estimate says  patient factor constitutes almost  85-90% -Dukes medical center )

Ironically , the modern gadgets, drugs , devices  threatens  . . .  rather  fights . . . with this  inherent  patient fighting  mechanism . We will  never-ever know how many cellular switches are turned on by our biological high  command ,  that compensates  and tries to restore  body  homeostasis.

critical care unit icu ccu.jpg evidecne based medicine modern medicine

Here is a  personal experience with a patient management scenario in an ICU  . The  patient is none other than my father !

He  is a 82 year old man who has  developed a acute febrile illness which rapidly degenerated into  acute respiratory failure  and  X ray  showing  infective bilateral pneumonia  and  probable ARDS  .He was on ventilator for 4 days  and subsequently weaned  off but still  heavily dependent on oxygen . His lung is wet with crackles and wheeze intermittently . His cardiac function was excellent . In one of the episodes of hypoxia he  developed  , mild shooting of blood pressure and minimal ST changes .  Alarmed  by this he was started on  beta blocker , for the first time  . It  was titrated up to maximum doses for a suspected ischemic  episode .

It is  well-known , ECG changes are extremely common in hypoxia , tachycardiac  stressed individuals .

Sympathetic  blockade  is important , only  if ,  it is an inappropriate surge  . When the body fights a disease it is the only major biological weapon available to him .How is it justified to block it ?

When this was discussed with the  team they said they have no power to deviate from  protocol and there is one article , that says  BBs are  beneficial even in COPD !

The patient  continues to be in ICU dependent on oxygen with extreme  ICU fatigue  definitely worsened by the heavy dose of adrenergic blockers which is in my opinion delaying recovery !

Different   organ specialist are prescribing  drugs  according to their level of understanding  (evidence is always available for them  . . . some where )  and radiology fellows  keep taking  snaps of  distressed  organs  in various angles  in HD quality images . Meanwhile , CT scan  seems to have revealed a chronic  interstitial  process   . . . how to diagnose a chronic lung condition  in a man who is  yet to recover from major acute inflammatory lung Injury ! I do not know ? And the current development is they are considering disseminated tuberculosis !

You may a big physician , the patient  may be a very close family member  , modern health care  system makes you watch  helplessly once you hand over  patient to a   complex care  unit .

We hope for the  best .

Final message

               Medical practice  . . . however intensive the care may be  . . .   the bottom line is  . . . it  should be based on  common sense . Modern medicine  tends  to make  this faculty of our brain  blunted .

The  specialty of Intensivist   is largely  misunderstood  . It goes more with  satisfying scientific egos  and public  perceptions  rather than true patient needs .

We need not react to every changing parameter that emanates  from the modern machines  that  keep sending out live  data from a seriously ill patient ,  on a moment  to moment  basis ! (We simply do  not need that ! If only a pilot  reacts with  jitters to every air pocket turbulence ,  he will  not reach the destination safely  ! )

From a cardiologist perspective ,  the humble  request  to all Intensivists   and critical  care physicians   is ,   avoid being  in  “fire fighting mode”   for all  those subtle ECG changes  that occur  in ICUs ,  especially with multi- system disorder (Caution : Acute coronary syndrome in CCU / post PCI  set up   is different story altogether where even a minor ST shift can be significant ! )

Heaven’s  sake  let us  rely more  in  our  brain rather than  the machines and devices !

Above story is not even a tip of an Iceberg . I come across it  every day  in  many ICUs  I visit  . The  most saddening aspect  is ,  we can not point out these mistakes  to our fellow professionals ,  as it  amounts to   hurting academic egos .They are more important  than patient care at any given point of time !

Counter point

For any system to work  , it  needs  a  strict set of guidelines ,  other wise the system of care will fail. This is a  fundamental basis on which modem medical  care works . The only issue is ,  we  should keep checking for any inadequacies in the evidence base and try to correct it. So do not blame the  EBM . It has come to stay .That is the future ! You are very pessimistic towards  modern science !

Rapid response to counter point

But the real issue is  . . . by the time next evidence base finds a major flaw  in the existing system of care ,  damages are already done . So with your clinical acumen  every learned physician is free to create  his own real world  experience .(That is also called Level 3 evidence now ) ** Protocols are not  sacred sermons . It  may  be (rather must be !)   violated if there is a need for the benefit of patient .

Disclaimer

* This is not an  attempt to disgrace the concept  of intensive  medical care . Please remember ,  finding fault  could be same as finding facts .(At least in   medical care )

 

Update ( February 24th, 2013  Sunday , 12.05  AM )

After 25 days of  intensive and aggressive  medical care   we lost one of the great lives

of modern times  which will be celebrated by his  sons and daughters forever !

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Mysteries in Medical Philosophy !

Posted in bio ethics, Quotes, Venkat quotes, tagged , , , on May 18, 2012| Leave a Comment »

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And the “sickness” award goes to . . . that frail man in check shirts with an extensive diabetic foot !

Posted in Uncategorized, tagged , , , , , , , on December 14, 2011| 1 Comment »

There were times medical  profession’s  only purpose was to take care of the sick . Modern  principle of living  has contaminated  every walk of life .Medical profession  leads  by example in this race .

How can one justify celebrating a disease in a grand manner in public domain  in the name of increased awareness  ?

I am shocked to find an ad in a recent  The  Hindu Ad  (25-11-2011)

Some of the words  used are terrible and highly objectionable . It amounts to an  insult to all diabetic patients.

  • Diabetes award !
  • Diabetic  Carnival !
  • Join us in the fun of diabetes !
  • Glitz and glamor of diabetes!
  • Festival of diabetes !

How can a patient celebrate his illness ?

I think  the news paper  which  publish such ads  should also show some sensitivity .

I agree there are lakhs of diabetic patients who do require  intensive treatment  but the fair held in the air conditioned corridors of  a trade center is  never  going to address  this issue.

( Can I ask these organizers to  help and  serve the real diabetic burden in ill equipped public hospitals  across  our state ? )

It  is simply a commercial extravaganza   creating a fear complex among the healthy , rich men and women and make a living

out of   human anxiety . 

Who sponsors these medical  award nights ?

For those who are unaware  of the games doctors and pharma companies play,  here is a shocker – large amounts  of money is pumped into  such public events.

This is part of  a  larger board  room  strategies ( Can it be a conspiracy  !) to increase the per capital consumption of drugs of our population . And no doubt   doctors are integral part of this scheme with or without intention .

While MCI can penalize  a individual doctor  even for accepting a pen as gift from pharma company ,

they can do nothing but simply watch  as millions are  exchanged  in the name research , health education ,  and awareness .

The height  of  the  irony is  , these events are sponsored by WHO and the world  forums as well  !

Ironically   the  doctrine of  modern medicine  seems to suggest   . . .“Ethics is   primarily for individual physicians and do not  apply   for institution ”  This is the single   most dangerous  concept that is  playing havoc with human health”

It closely mimics the principle  of   war justice  . An  individual shooting another individual  is a definite  crime ,  while  multiple  individuals  killing  multiple   individuals   is not a crime , it is a war !

Disclaimer

The author has no  personal grudge  against any hospital or organization instigation. It ‘s   an expression  against so many commercial activities that occur  in the medical filed on day-to-day basis !

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Sufferrings due to a Healthy heart !

Posted in Uncategorized, tagged , , , on February 5, 2011| Leave a Comment »

Healthy heart syndrome (HHS) . This is  essentially a state of mind  , being in constant worry  that something  will happen to their  heart , in spite of  having  normal parameters.

HHS is a new age medical entity  of   the mankind   .  Here  the heart suffers   because  of excessive  knowledge  , affluence and entry of market forces into health care .

  • It is often a media driven frenzy . Having an insurance policy is the biggest risk factor
  • May be cured after taking few scans and some times end up in invasive Angiograms or even a PCI
  • In a  few it takes a course of  malignant anxiety disorder . Those afflicted indulge in daily BP check weekly cholesterol check , monthly cardiologist visit and yearly  64 slice CT scan.
  • Curiously ,   the definite cure  occurs only    after they suffer a heart attack .This makes them less anxious as the inevitable  has  been experienced .
  • There are occasions when too much anxiety  (for not developing a heart problem !)  will trigger a real event .
  • Some of the   medical institutions and health care providers   are also part of the problem as  many  of them perpetuate the condition as  they  keep these vulnerable  people (with healthy heart) guessing  and  do not fully disclose the reality .
  • The incidence of HHS seems to be rampant  as  there are  recurring instances of multiple stents deployed  in  apparently healthy hearts  .

Final message : Let us suffer from disease not from health !

While , many  patients with  multiple blocks ,  bye -pass surgeries   and  half- functioning  hearts  ,  lead  a   near normal life  ,  it is  ironical ,  a substantial number suffer    with  HHS and inappropriate  interventions .

Let us hope ,  modern medicine  which  goes deep into Nano medicines  and bio Robotics look  into this issue also !


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Why many doctors* , consider patients as their property ?

Posted in bio ethics, cardiology-ethics, medical quotes, tagged , , , , , , , , on December 11, 2010| Leave a Comment »

Medical profession is the noblest of all !  . Doctors are akin to God in  many ways  ! They  have the potential  to remove the  sufferings of  mankind  . These are the often made  quotes about doctors   for  many centuries. Today’s medical professionals are ,  a  strained   lot  to fulfil their role expected of them .They have to maintain the social identity and earn enough to sustain their image in society. The onslaught of commercial and pseudo-scientific concepts have ruined the profession considerably.

Those were the days when the family physician  concept was flourishing , where in  a doctor was taking care of entire family. This  concept has  taken a different avatar now .

Now a doctor feels , once the patient is seen by him becomes his/her  patient rather a property! This perception has grown in a malignant manner , many doctors do not refer to a specialist even in deserving cases  fearing patient poaching .

This  possessiveness  of doctors about their patients leads to many  of the  unethical behavior .

My case . . .my patient . . .   my fees , . . .this sort of approach though appeared  good in the past ,  is rapidly becoming a liability for the patients  .Lack of organised health  care   by private and Government sector also amplifies the issue .It is pathetic to note         ,  at least Govt hospitals have some accountability ,  majority of private health systems  do not have  mortality or morbidity auditing . 

The my patient, my property  doctrine is playing havoc in medical health delivery system  .The following are the situations where a patient genuinely suffer due to this abnormal thinking pattern of many of the medical professionals today.

  • When general practitioners want to have control of their patients even after referring them to big tertiary care centres.
  • This is being encouraged  by the corporate desk of big hospitals as they probably send financial benefits to the referring doctors. Hence doctors are worried their property may get lost during  transit or inside the  big hospital. There are instances , I  have witnessed , where severe mitral stenosis are manged medically by some established physicians fearing that their property will be lost .
  • Patients with severe angina are not offered angiogram and remain on medical treatment fearing loss of monthly consultation fees.
  • When the care takers energy and thought process are consumed in many non academic activates one can expect how the illness can be taken care off.
  • When investigations are ordered the primary referring doctor feels he is being denied of  kick backs from costly investigations which is enjoyed bu the specialists .so these general practices what to finish of all required investigations in their desired lab and sent to the specialist.
  • This has led to  curious  situations  where a  ENT surgeon calls for  a  64  slice CT scan and obstetrician asking  for MRI brain (  because the patient is theirs  ! )  

The sequale is two fold . 

The specialist often gets annoyed  and  feel insulted  to read an investigation  ordered by a  different physician(  rather irrelevant  physician !) done  in a non friendly lab  without incentives.

  1. Either he looks at it reluctantly
  2.  Or orders  fresh investigations

 (Some physicians show   extreme  arrogance ,   as  they call for fresh investigation even if the patient is having    good quality ,    investigations  with  images done recently  !)

Finally , the most dangerous thing

A  patient once admitted  under a  doctor, the  prescriptions and procedures are  often  controlled by the admitting doctor .We  have seen a pathetic situation of plastic surgeon admitting a rheumatic heart disease and trying to manage  with the help of  telephoning consultations with a cardiologist .

There is a  chaotic  discipline  in ordering Investigations and treatment modalities  in our country .Any one can order any thing they want .In this scenerio,  abberrant patient  behavir leads to further  complications as patients  themself  decide what investigations they want.

What is the solution* ?

The concept of family physician is still a best option . It has to be continued. There need to be a proper referral services into well equipped, staffed ,  audited institution in every district and counties either controlled by Government or well-regulated. private bodies . The financial remuneration for the doctors should be constant and fixed irrespective of the form   treatment they provide.

In other words the entire health care delivery  should  be centralised and institutionalised .The need for specialist to be assessed properly and care should be rationed .

                                                           Consider this  anarchic situation –  An   asymptomatic, incidentally  detected  30 %  PDA  lesion in a rich,  bed ridden ,  old man   is  stented by a  3rd generation drug electing stent in a corporate hospital,  while   many  young  Indians with a productive life  with  critical  left main .proximal LAD   is allowed die in peace .

                                            Where are our medical economists and  health care planners hiding ?  ! And we are talking about billion dollar medical  tourism industry .

A general practitioner  should receive same amount as consultation as a neurosurgeon or cardiologist .If we  divide  the doctor into different grades according to the knowledge  and place of work ,  the lesser doctors  will find someway to equalize their earning with their superior colleagues.

After all , all doctors take the same oath . . .   A  doctor who treats a febrile convulsion in a remote village by administering  a timely diazepam  injection can not be considered unequal    to  a Cleveland neurosurgeon   who clips a AV malformation in the circle  of  Willis to terminate  recurrent convulsion in a similar child .

* One would  tend to  think , these solutions are highly theoretical  not implementable in today’s world.  But trying to bring order to a dysfunctional  medical  care delivery system is not a crime any way !

Final message

Most doctors continue to be noble and dedicated.  But the faith in them is rapidly eroding .This is becoming  a dangerous trend . They can not to be  blamed  in isolation.   It is the dynamics of  social and economic scenario  that  are  driving  the medical profession in a journey towards a  commercial extravaganza , where humane care is  as obsolete as a Mediterranean dinosaur !

Now young doctors are  readily manufactured  in the countryside   (Not my merit  , but  bought as commodities akin to real  estate) . A three bed room flat and a MBBS  seat roughly  costs equal in India !

There is  no wonder then  , doctors will treat their degrees  and patients  as  precious   property . Nothing wrong to consider  them as their property ,  but let them handle the property with at most concern , faith and trust !

Disclaimer *This  article does not intend to  defame any doctor or medical profession . It aims to  encourage a wider debate on the issue  . This is  about  many physicians which we come across everyday   in  our  towns and cities  .This article may be irrelevant in  many  other  countries and  to those physicians working in a completely institutionalised  health care delivery system  including  Govt .hospitals where the collective care (or is it collective no care ?)  is the norm .

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Why doctors are referred to as “Practicing” Medicine

Posted in bio ethics, cardiology-ethics, general medicine, Uncategorized, tagged , , , , , , , , , , , on August 1, 2010| Leave a Comment »

It is  often  quoted  “Practice makes  every one  perfect”  . . .  Doctors continue to practice for ever  . . .If practice is only  a rehearsal  , when do they perform  for real ?

And , we know  a doctor spends his entire life time practicing  . . . In other words  doctors are only experimenting .

So , do not get fooled by his errors . Errors are bound to  happen  during their  practicing sessions !

The problem  with general public  is , they never understand this basic fact – medical  science  is nothing but  a , on going research on human body .If only  we understand this  we can accept  the millions of medical  mistakes*  that occur  every day in  the global  medical  profession . The major  aim of modern medical science  is to reduce that .

* Of course, negligence is a punishable offense . But,  we should also realise , non- negligent medical  mistakes are many fold higher than negligent ones .

While  a careful doctor will avoid negligent mistakes a thinking doctor will avoid   non -negligent mistakes also.

This puts onus back on doctors. We need to critically analyse , every

treatment modality we follow .

If you are a strong believer of   “Medicine is indeed  a  science and doctors are scientists ” , please read this article from British medical  journal and conclude  yourself.

http://www.bmj.com/cgi/content/full/328/7454/0-h

Further reading

The bestseller  How doctors think

Picture courtesy : Jupeter stock Images

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Guideline violations in cardiology practice : Every body does it , so do I !

Posted in Cardiology -Interventional -PCI, cardiology- coronary care, cardiology-ethics, tagged , , , , , , , , , on August 24, 2008| Leave a Comment »

All is not well,  that ends well !

                                       Treatment guidelines in cardiology  practice  are periodically published by ACC/AHA/ESC.These guidelines  represent the current scientific practice. They are called some times as recommendations. Medical professionals tend to adhere to this guidelines whenever possible.They are not legally binding in most of the countries.In USA some states believe it, to be legally binding.

 

The problem with these guidelines  are , they are classified as class 1 ,class 2 , class 3 recommendations.

 

Class 1, A  drug , device  or a procedure  Is definitely useful and must be prescribed.

Class 3,   A  drug , device  or a procedure  Is not useful and should not be used .

Class 2*, A  drug , device  or a procedure  may be useful  or may be harmful , and hence may be used or may not be used . (Vaguest possible guideline!)

 *Altered to convey the meaning

What are the  guideline violations that can be sued in court of law  ?

A person with established  CAD who is not been prescribed a  statin (Cholesterol lowering drug)  can be sued straight away,  even if the patient has no adverse outcome due to the nonprescription of that drug. The issue here is , the doctor  has not prescribed  a drug which has  proven benefit .The law is clear on that .Most will  agree that,  the  doctor is at fault ,  and he  is never protected  even by their  colleagues .He  can’t defend his action.

What are the medical errors that can never* be sued in court of law !

But the same doctor who opens up a totally occluding coronary artery in an asymptomatic patient(CTO -chronic total occlusion) and lands up  in a complication and the  patient dies. This could be  major guideline violation as opening a CTO in an incidentally detected , asymptomatic patient is a class 3 recommendation. Neither the physician, patient , institution  nor  the regulatory authorities bother about this even though there is strong case for censure , in reality it never happens. Number  of  experts from leading hospitals do this procedure in live work shop all over the world with full media glare, It is an irony the same  experts are only  writing  in their  guidelines  that  these procedures should not be done inappropriately.

And this medical  error ( Should we call it a  crime if it is knowingly done ! )   keeps growing as the physician never feels guilty about it .

The message here is

 A physician of a state of the art hospital,  in a scientifically advanced  country  goes scott free and guilt free  even if he openly violate the scientific guidelines and do a inappropriate procedure that result in a patient death. Mean while a small time physician in a remote place in the same country can be taken to task  for not prescribing a officially  recommended drug (By standard guidelines) .He will be labelled unscientific and unethical even if his non prescription , had not caused any untoward health outcome .

In short , in today’s modern medical practice 

 Even a  ” Minor error of  ommision”   attracts guilt and perceived fear among the physicians. Meanwhile  many  of the ” Major errors of commission”  done by professionals are rarely frowned upon and thus these  mistakes continue to perpetuate !

*There should be a strong provision in medical law to address the issue of inappropriate procedures even if the procedure has not resulted any untoward effect to the patient.

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