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Before we swallow the AI pill

Posted on by Anand Philip

Real stupidity beats artificial intelligence every time.

Terry Pratchett, Hogfather (1996)

Thesis: We're employing AI1 to fix problems in medicine we already know how to fix without it but can’t be arsed to.

For an ungainly amount of time now, regulators, scientists, clinical quality people, policymakers and others have been trying and failing at getting doctors to use antibiotic prescription guides to decide what first-line drug to give and what to use as second-line. no.one.cares.

every hospital and every department has their own way. I’ve seen places where different consultants in the same department had their own preference for the same diagnosis. And somehow it was the resident’s job to remember that Dr. Mehta wants ampi+genta for his appendicitis patients and Dr.Thomas would scream at you if you didn’t write cirpo+ceftriaxone+sulbactam for his appendices.

this is not limited to antibiotics; the first line anti-hypertensives used, choice of drugs for diabetes, basic investigations for low back pain and many many more things have very poor adherence to standards and evidence. reading a prescription audit paper from India is depressing. brothers and sisters, we are terrible at doing medicine according to standards or evidence.

this is because in India as in many other countries, many, perhaps most, doctors stand to make money from using specific drugs and from writing investigations2 and this, among other things, makes doctors poor governors of other doctors.

even when this direct economic benefit is not present, the science of medicine is influenced by the superstitions of medicine and the egos of the hotshots making life and death decisions. there is neither any accountability, nor any punishment3.

No amount of tech will fix this, for as long as the incentives remain broken.4

for a lot of people pushing the AI pill on to doctors, convincing us that this supposed superintelligence is to be trusted is a trick to get us to do the basics things right5. Don’t write antibiotics for someone with a viral cold FFS.

for others, it is because there is money to be made here. How many hospitals can really afford to build train and deploy their own models or even have a data-science team? In most of the world, and not just in hospitals, the datascientist is someone with an excel formula addiction and the database is the company google drive filled with weekly reports.

for a few it is about research. And, I think, that is the stage at which AI works best. that is the level of maturity of the tech itself. it is far too early to do AI (read: LLM) interventions in medicine that reach the bedside. for one, the stack keeps changing. for another, the entire tech industry is now all about how to make LLMs useful, which has nothing to do with how to make useful things.

the exception to this (no bedside rule) is probably computer vision, but still, the long road ahead there is about figuring out how it can be useful to the GP and the intern and the resident who hasn’t slept in two days and has 9 more patients to see before she gets to sleep.

Most of the work in computer vision in medicine seems to be in how to make it work for the radiologist. Which seems foolish to me, they already know how to read CT scans and MRIs, it’s the rest of us who need help. But the complexity of the operational aspects of this prevent the interventions from reaching the people who need it the most.

It’s like we’re installing more lights in well-lit areas because that’s the only place that has electricity connections.

sure, if tele-radiology can churn out more reports every day thanks to AI, this will help a lot of people everywhere, and there is a legit business opportunity and it should be taken. But it should not be confused with “democratizing healthcare”6.

The industry calls this the last mile problem; someone ought to tell them that in India as in life, the last mile is 90% of the distance7.

What I am saying is that before we swallow the AI pill, we must with brutal honesty answer the following questions.

  1. Will this help the care provider or the patient in a way that improves outcomes?
  2. Does this solve a problem the provider and the patient actually wants solved?8
  3. Is AI the right way to solve this?

And if the answer isn’t a resounding yes to the first two of those questions, maybe don’t do it.

Footnotes

  1. I know AI isn’t just language models, but well, that’s what the industry is claiming, so why should we not treat chatgpt as the alpha and omega of AI? ↩︎
  2. because many if not most doctors get kickbacks or baksheesh or “referral fees” as it is called in India. And this can account for up-to a fourth of the doctor’s income ↩︎
  3. we’ve all seen the HOD’s favorite SR get away with more sins than politicians in India do. ↩︎
  4. Medicine isn’t unique in having ethical challenges, the world of AI has its own ethical issues, I recommend my slightly dated guide as a starting point: Ethical AI, Basic Readings ↩︎
  5. I am sympathetic to this camp. in fact, i think we should stop letting doctors decide first line medicines and dosages for most problems. doctors should only be allowed to tweak the prescription to the patient’s preferences or needs. ↩︎
  6. that term gives me reflux ↩︎
  7. also, we measure things in kilometers here because we are a civilized people ↩︎
  8. there are, of course any number of important questions to ask; will this intervention marginalize people who are already have a raw deal? what harms will this cause? is this sustainable? will this benefit the last woman standing in the line? ↩︎

Book review: The Truth Pill by Thakur & Thikkavarapu

Posted on by Anand Philip
Table Of Contents
show

An Important book written in ALL CAPS

Topics covered in this book:

  • How approval for new drugs, new fixed drug combinations and new generics are supposed to work and how they actually work
  • What are the quality standards and monitoring mechanisms in place for scientific medicine, as well as AYUSH.
  • Laws governing AYUSH, scientific medicine and the production of drugs in India.

What I liked about the book:

  • Thorough research into how things are supposed to work in the area of drug regulations in India and an even more detailed research and experience into the million ways in which it is failing to work. Seriously, these two know their drug regulation problems.
  • Thorough understanding of the main players, organizations, lobbies etc. involved in this messy situation
  • Stupendous amounts of cred as far as I am concerned due to being a whistleblower as well as a RTI crusader/activist and all the litigation they have tried.
  • Focus on transparency, access to information, rights to quality
  • Documentation of various types of issues and the corruption in different bodies
  • Clear-sighted tracking of the bureaucratic games and political shenanigans around drug laws in the country.

What I learned from the book

  • We have a lot of outdated laws regulating drugs and other allied health products. These are exploited and used by both the governance people and the drug companies to push a lot of outright shitty medicines to the public
  • There is a LOT of corruption, incompetence and lack of transparency in the organizations that are supposed to be watchdogs and regulators
  • Successive governments and bureaucracies have generally found ways to pass the buck, do ass-saving paper pushing and pandering to sentiments rather than make any substantial and scientific changes.
  • We have a lot of under-equipped and underfunded drug regulators and inspectors
  • The quality of drugs produced in India is for all practical purposes at the mercy of the individual pharma company that does the production and there’s very little if any, real oversight or really punishment for even serious lapses.
  • Every month somewhere in this country, at least one pharma company is shown to have produced sub standard drugs and even then the judiciary seems to think harsh punishments are not needed. I mean, people have died and the dudes who made those meds never saw jail time.

Problems with the book

The whole book is narrated by someone who is shouting at YOU AND ALL THE IDIOTS WHO RUN THIS COUNTRY AND ALL THE CORRUPT DRUG MANUFACTURERS, THE INCOMPETENT JUDICIARY, THE CLUELESS LAW MAKERS OF NEWLY-INDEPENDENT INDIA WHO DID NOT HAVE 21ST CENTURY VALUE SYSTEMS OR KNOWLEDGE AND DRUG RIGHTS ACTIVISTS WHO ARE ALL CORRUPT TOO.

My blood pressure was measurably higher when I was reading this book. Seriously. There’s like four people the authors have anything nice to say about from 1923 -2023 (and two of them are dead). Oh, and the USFDA. They LOVE the FDA and the way things are done in the United States. 

<sarcasm> I mean, I don’t blame them, they’ve been fighting the good fight all their lives when literally everyone else in India is asleep, incompetent and corrupt. </sarcasm>

I get it, though, one of the authors has been constantly targeted and harassed by various government agencies and big pharma. So I get where the tone is coming from, I know righteous indignation, I used to have a lot of it. Now I just have reflux and indigestion.

But the roid-rage-hulk-smash tone of the book made me want to put it down and stop reading about fifteen times. I stayed the course only because they did thorough research, and what is an activist without some righteous rage, really. 

The other issues are that the policy and legal recommendations made in the book without fail made me wince, flinch and facepalm. The authors forget just how poor this country is, and just how many people there are.  The authors also don’t know a damn thing about the practice of medicine in the real India. They are operating from an america-centric and america-learned model of how health should be dealt with.

The most important implied recommendation of this book seems to be BURN IT ALL DOWN. 

Throughout the book they mention the dozens of parliamentary and other committees that have looked into these problems, and how so few of these reports see the light of day and fewer still get anything changed. Because the suggestions are not useful, or due to the unwillingness of the governance system to make any real changes.

This book has the same problem.

For eg.

  • They repeatedly suggest stronger laws, after describing just how poorly existing laws are implemented.
  • They suggest that online pharmacies will solve the supply chain problem (omg i cannot even)
  • They suggest that small pharmacists who are found to have bad drugs should be punished heavily.
  • They repeatedly recommend increasing the legal pressure on smaller players in the supply chain.

You cant improve state capacity by making tougher laws.

You can’t fix corruption in high places by punishing the small guy.

Some medication is most definitely in many many cases better than no medication, talk to a doctor, any doctor.

You cannot copy-paste quality standards designed in USA and Europe to solve for India.

That’s not how anything works. 

Would I prefer my patients got 40mg of  Telmisartan every time they buy a drug, YES.

Do we need to improve the capacity of drug inspectors and dis-entangle the regulatory nightmare, HELL YES.

But do we do it by shutting down everyone who only has 20 mg of telmisartan in their 40mg tablets, heavens no. The 20 mg the patient gets at 0.05 Paise a tablet is worlds better than the 0 mg he will get at 2 rupees a tablet.

In the words of the y00ths I interact with, the authors desperately need to touch grass.

Petition to ban archaic/unscientific procedures during medical examination for sexual assault

Posted on by Anand Philip

Posting an email sent  by Sana [CEHAT]

Greetings from CEHAT!

As you must be certainly aware, the ‘Delhi Gang Rape Case’ has drawn some attention to the role of health systems in responding to sexual assault and rape. In this light, some of us – CEHAT, Human Rights Watch, and academics from JNU – have drafted a statement on behalf of medical professionals, highlighting some of these problems, and calling for reform in the manner in which sexual assault survivors are responded to by the health system. We hope that it will put pressure on the government to change the way in which they are approaching health responses to sexual violence in the country.

For more information on why the practices mentioned in the petition are
problematic, please refer to:

  1. FAQs on the role of health systems in responding to sexual assault
  2. WHO technical opinion

Please do have a look and endorse if you agree, and also circulate it to any other doctors, medical students or other health professionals you might be in touch with.

Please send in your endorsement in the following format:

Name:
Profession:
Designation:
Institution:
Contact:

to   cehatmumbai@gmail.com with the subject ‘PETITION’. The last date is 19th January.

Medical professionals demand the ban of archaic/unscientific procedures during medical examination for sexual assault

Move from evidence to care!

We, the undersigned medical professionals  , would like to voice our  strong protest at the continued use of the unscientific and inhuman “finger test”, the undue focus on hymenal status, and the overemphasis on genital injuries in cases of rape of women and girls in India. These procedures are still part of the current proformas being used in public hospitals in India and are contrary to the guidelines for medico-legal care of for victims of sexual violence issued by the WHO 2003.

When caring for victims of sexual violence, the overriding priority must always be the health and welfare of the patient.  The provision of medico-legal services thus assumes secondary importance to that of general health care services (i.e. the treatment of injuries, assessment and management of pregnancy and sexually transmitted infections).  Performing a forensic examination without addressing the primary health care needs of patients is negligent . As the WHO recommends, concern for the welfare of  the patient extends to ensuring that patients are able to maintain their dignity after an assault that will have caused them to feel humiliated and degraded.

Although the finger test and related procedures are outdated and have been officially removed, this has not translated into changes in the medico-legal practice . The evidence act also has been amended and clearly states that survivor’s character/past sexual history is not be commented upon.[1] Many doctors, police officials, defense lawyers, and judges use findings about the “laxity” of the vagina, the “elasticity” of the hymen, or “old tears” in the hymen to wrongly conclude that a girl or woman is “habituated to sex This practice should be banned with immediate effect, and all questions that allow such findings to be recorded should be removed from all medical protocols for the examination of victims of rape and sexual assault.

The finger test is legally irrelevant , as the Supreme Court  ruling in 2003 has ruled that finger test results cannot be used against a rape survivor, and that a survivor’s past sexual history is immaterial to the issue of consent at trial .

The finger test and comments on old tear of the hymen have no forensic value , as it predicated on the assumption that an unbroken hymen is evidence that no rape took place. Actually, the hymen is a flexible membrane that only partly covers the vaginal opening. Conversely, a hymen  may have an “old tear” for many reasons unrelated to sex, so examining it provides no evidence for drawing conclusions about “habituation to sexual intercourse”. In fact, only one-third survivors may report any injury. In  any case, whether or not a woman has had any previous sexual experience has no relevance to the issue of content.

The finger test is inhuman and degrading, itself amounts to  sexual assault.  Most doctors and hospitals tend to seek blanket consent for the medical examination. Therefore rape survivors have little information about the actual medical procedure involved.

In addition to the banning of the finger test, there is also an urgent need for a collective proscription on comments on the hymenal status and position as well as on the degree of tears and the overemphasis on evidence collection at the cost of provision of care.  Many countries have operationalised the WHO guidelines of 2003 and made changes in their practice. In India, the results of these methods are routinely used by defense counsel and relied upon by judges in rape trials to unscientifically determine a rape survivor as “habituated to sexual intercourse”.

We also reiterate the dual role that medical professionals should play in their response to sexual assault as health care providers and those who assist in medical evidence collection.  As the WHO guidelines on medico-legal care of victims of sexual assault says, the therapeutic care for rape survivors should be the “overriding” priority when doctors respond. We are concerned that many hospitals and doctors in India do not provide adequate therapeutic care, including access to emergency contraceptives, prophylactic medications, counselling, and information about HIV and other sexually transmittable diseases lack of such care can lead to aggravated health consequences for the survivor
This practice cannot be eradicated until the central government intervenes  and issues a uniform gender sensitive protocol that is made applicable across India, with adequate resources to train and monitor the use of this protocol.

We demand that the Indian Ministry of Home Affairs together with the  Indian Ministry of Health and Family Welfare should:

  1. Ban the finger test and all its variants from all forensic examinations of female survivors, as this are unscientific, inhuman, and degrading practice
    1. Develop and institute in consultation with Indian women’s, children’s, and health rights advocates, doctors, and lawyers, a protocol for the therapeutic treatment and gender-sensitive examination of survivors of sexual violence  , such as those has already used in Mumbai public hospitals and endorsed by several health professionals.
    2. The protocol must comply with the standards and ethics issued by the World Health Organization, including the right to provide or refuse informed consent for medical treatment and examination.
    3. The protocol should emphasis on the need to seek the history of the incident in order to collect only relevant medical evidence  ,  correlate findings with the nature of sexual assault reported, record delay in reporting, and note other activities such as bathing, douching, urinating after the sexual assault that result in loss of body evidence.
    4. The protocol should exclude the following information: size of the vaginal introitus/hymenal opening/number of fingers admitted by the opening; comments on old tears of the hymen; comment on habituation to sexual intercourse; irrelevant obstetric history (such as history of past abortions); findings on women’s built, nutrition, weight and height
    5. The protocol should include clear directions for provision of Emergency Contraception, HIV/STI prophylaxis, treatment for immediate injuries, psycho social support to the survivors and her family, and follow up care  .
  2. Devise special guidelines for the examination of child survivors  of sexual abuse to minimize invasive procedures.  Ensure that any test is only carried out with the fully informed consent of the child, to the extent that is possible, and the informed consent of the child’s parent or guardian, where appropriate.
  3. Instruct doctors not to comment on whether they believe any girl or woman is “habituated to sexual intercourse”.
  4. Instruct all senior police officials to ensure that police requisition letters for forensic examinations do not ask doctors to comment  on whether a rape survivor is “habituated to sexual intercourse .” and/or whether rape has taken place or not
  5. Communicate to trial and appellate court judges that finger test  results and medical opinions about whether a survivor is “habituated to sexual intercourse” are unscientific, degrading, and legally irrelevant, and should not be presented in court proceedings related to sexual offences.
  6. Update all medical jurisprudence textbooks to specifically  exclude the finger test and its variants. Ban the use of medical textbooks that rely on the “finger test” and its variants by defense counsel to badger and humiliate the survivors of rape, sexual assault and child sexual  abuse.  Currently, forensic textbooks prescribe the finger tests and provide details on types of hymen. In their advice on how doctors should make observations in cases of alleged rape, there is a regrettable continuing overemphasis on injuries. Some textbooks teach students that “a health woman cannot be raped’, ‘working class women are muscular and so can offer resistance”, ‘if sexual intercourse is forced, then injuries must be present’, etc.
  7. Introduce a mandatory special curriculum on the dignified  treatment and examination of sexual assault survivors as part of medical education.

Fixing the healthcare mess; Satyameva Jayate or showmanship?

Posted on by Anand Philip

Dear fellow Doctor; from your Facebook posts, emails to me and tweets, it is obvious to me that the Satyamev Jayate episode on corruption in healthcare worried you deeply. some of you were happy that such an exposé happened, but most of you were worried that there was over-dramatization and untruth in the presentation, and that this would lead to doctors loosing respect in the sights of their patients. As it is, India is known for its violence towards healthcare personnel, it is only fair that you feel that people would use this show as an excuse to attack more doctors.

I too, felt that many of the things Mr. Amir Khan said were unbelievable, some of them were clearly exaggerations and one-sided and I wondered about the truth behind the cases he presented.

But before we jump into another analysis of how Amir Khan got his medicine wrong, let’s look at a few other things.

Here is a list of some of the recent healthcare related scams and exposes that happened independent of Mr. Khan
  1. Senior Professors of prestigious institutions caught following orders from Pharma companies about drug safety reports to the DCGCI.
  2. AMRI, Kolkata hospital fire – revealed bad infrastructure, collusion of top doctors in hushing up things, lack of training and preparation in dealing with emergencies.
  3. Female infanticide – Millions of female babies are being aborted. A phenomenon Involving parents, Radiologists, Gynecologists.
  4. IMA protesting against nurses strike even as they support doctor’s strikes. This, in-spite of the horrendous working conditions and pay of nurses.
  5. MCI’s dissolution – It was so corrupt, that even a corrupt government had to agree.
  6. Surrogate mother industry – poor women being exploited, paid, but not as much as promised, not following international norms in number of pregnancies.
  7. Harvesting of ova- recent report shows how this is probably harming young girls without their knowledge.
  8. NRHM scam for which 22 doctors were suspended – INR6000 Crores is thought to have been stolen.
  9. Hysterectomy epidemic. – Need I explain?
  10. Illegal clinical trials and deaths from them.
  11. Reports of patients being affected from drug trials and not being compensated.
  12. The AYUSH report – No standardization, AYUSH doctors prescribing non AYUSH medication.

There are more, of course.

Let’s now look at the main points raised by Amir Khan in his program; not specific cases, because he is not a doctor and is not qualified to make judgment calls on treatments given to patients. Let us just look at the basic complaints patients had.

  • There is lack of communication between doctors and patients. They don’t feel like they are part of the decision-making process about their own disease.
  • There is a lot of bad handling of deaths, accidental deaths etc. News not being shared, defensiveness, etc.
  • Actions of many or some doctors is leading to a wide-spread distrust or doctors, more so because if you go to 2-3 doctors for the same problem, they often suggest different treatments
  • Issues with improper consent taking and explaining of need for surgeries and other procedures.
  • Lack of information about what a hospital is licensed to do, what training doctors have, and the fear that people without sufficient training are treating them.
  • Referral fees, cuts and other forms of bribes paid to doctors affecting medical judgment.
  • Money being a major deciding factor in issuing medical college licenses and other kinds of licensees.
  • Bad policing by medical bodies leading to un-checked unethical and bad medical practices.
  • Too much power held by private players who don’t care about medicine, just profit.
  • For the government, healthcare spending seems to be low priority.
  • Poor get differential treatment.

Is any of this fabricated or unreal?

They are real; you and I know this.

We are poor communicators, busy as hell, running between wards and OPD or from one clinic to other, often we just cannot find the time to sit down and explain things to each patient. There is also the problem that what we think is communication might not be what the patient wants, and our training does not really help or prepare us to communicate better.

All of you have heard stories, of patients being admitted into the ICU for what turned out to be gastritis, and probably seen patients who have had two cholecystectomies and appendixes removed from both sides of the body. This happens, a lot, and it is a frustration we all share.

How can we reconcile with the fact that an unknown, but very large part of healthcare practice in India has a less than ideal or even acceptable level of quality and that the system is designed not for the patient, but for the professional?

While we mull on that, here are some things he got wrong, in brief.

  1. Using branded expensive drugs and not cheap generics – Not all drugs have generics, not all generics are tested, and in many instances there is significant difference in quality. There is also the patient’s expectation to use standard medicines. Much as I hate them, I can trust the quality of medicine made by a large pharma company, how do I trust a generic?
  2. Healthcare as a business is not necessarily evil, and the solutions that were put forward, including making everything government run is simply out of touch with reality. Your neighborhood green grocer is a businessman; this does not mean he will sell you poisoned vegetables if it gives him better profits. Businesses can be run ethically, and markets have great power of self-regulation.
  3. Doctors have a right to livelihood. Just because we are doctors, to expect sacrificial living is ridiculous. If indeed, as Amir Khan suggests, we are the smartest of the lot, then we deserve proportionate incomes.
  4. Doctors control only a part of the healthcare system; costs of drugs are for most parts out of our control, as are institutional costs. Blaming doctors for high cost of drugs comes from not understanding the basics.
  5. Doctors have an exalted position, but this kind of a mess could not have been created without collusion and involvement of regulators, businesses, government, other members of the medical team, and the market. Blaming just us is myopic.
  6. “Most doctors in India need to get their licenses revoked” is an unforgivably careless and unsubstantiated claim. While I don’t want an apology from him, Mr. Khan should know that it only displays his ignorance.
  7. “Will not see a doctor in India” What about Devi Shetty? Again, a very careless thing to say, but hey, it’s his choice. There are people who don’t want to vaccinate their kids, some people even say this on TV, but that is their choice, their life.

Back to the show.

Most of the reactions against the show hinged on one of the cases discussed in which there was ambiguity about the process. In this clamor to prove that Amir Khan got his medicine wrong, we forgot and ignored the other stuff, the stuff that I listed above.

Dr. R Srivatsan, Senior Fellow at Anveshi Research Centre for Women’s Studies wrote this in an email when this episode came out:

I think when a critique is mounted against you, it is important to look close and hard at yourself and the community you belong to. Where there is smoke, there is bound to be a fire you don’t want!  Most often people don’t have the time to bother to criticize you — except when you cause a great deal of pain.  Criticism is an opportunity, a possible door to transform a process — it has to be nurtured, not snuffed out with hurt defensiveness.

Could we benefit from such a show? Can we use this time to weed out or at least distance ourselves from those whose practices all of us find distasteful?

Doctors are at a particular advantage here; it doesn’t matter how famous Amir khan is, it doesn’t matter how widely his message reaches, people still need doctors. Maybe we can use this as an opportunity to make things better.

Let’s agree to this:

  1. People who were on the show are real people; I think it is safe to assume that they were speaking their truth. Even if one of them was not, there were others who were. They don’t need to speak untruth because there is no lack of bad diagnoses being handed out. We need to live with the fact that there are unscrupulous doctors, and we all know people who fit the bill.  Protesting this fact is only helping them.
  2. Amir Khan is an actor.  He runs a reality TV show. He is not a scientist, has no background in public administration, and the show is not a journal nor a scientific exposition. There will be things wrong with the show. He will get facts wrong. Have you met people who spend their Sunday morning reading out the Journal of Industrial Biochemistry to their families? Didn’t think so. Facts are often boring, Mr. Khan will try to make them attractive and sometimes, the real face will get buried under the make-up.
  3. No silly excuses. Some of you made what is possibly the silliest of excuses, ever. “Everybody is doing it, why target Doctors?” SILLY. I’m going to let you figure out why.

We work long hours, the pay isn’t amazing, the system is corrupt, without cutbacks and the pharma parties, life would be tough. We want that to change, we want to practice great medicine and have a life.  We want pays that are proportionate to our effort and attainment, we would like to be respected and acknowledged for the good work we do.

How is cursing Amir Khan helping us achieve any of that? What will help? I think we know some of the answers, not all of them. What are they? Lets talk.

Introducing What’s Up Doc? A column at eSocialSciences.org

Posted on by Anand Philip

I am giddy with glee to announce that I will be writing a monthly column about the practice of medicine and related issues at eSocialSciences, a “region-focused repository and a new and yet evolving publication space for easy and quick dissemination of scholarly work that can be a space for discourse among researchers, policy makers and the civil society.”

This month’s column is about communication and medicine. Medicine is all about good communication, they say, yet, very little is said or taught in most medical schools about how to be good at it. Do read and comment.

“Be nice to patients”: Communication and Practice of Medicine.

Medical school began with a series of “introduction to medicine” lectures. One of them was on communication, taught by the same professor who introduced us to medical ethics.

 

In the medical ethics class, through a case-discussion, she impressed upon us the need for being non-judgmental when dealing with patients. She did a fantastic job, considering she had just one 45 minute lecture. Her lecture on communications, though, is a blur. In my defense it was 11 years ago and I remember her parting words very well. When we told her after the lecture that there was just one session on communication and this clearly needed more sessions she said “I’ve been telling them, but who listens to psychiatrists?”

 

Doctors and other healthcare professionals, I would love to hear more from you about this, and related topics. Do comment.

What we dont talk about- Steroid Abuse among Teenagers in Brothels in Bangladesh

Posted on by Anand Philip

According to a photo essay by Andrew Biraj on Bangladesh’s legal brothels, madams dose (often underage) sex-workers with Dexamethasone, a steroid, to make them look older and fatter. The photographs are sexually suggestive and made me uncomfortable, but the issues are worth examining.

These kids, as young as 12, are bought from parents or lured into sex-trade as an escape from penury and then literally fattened before they are pimped to costumers.

Dexamethasone is a powerful corticosteroid. It suppresses inflammation in the body and is used in the treatment of various disease like Rheumatoid arthritis and other AutoImmune diseases.

One of the most visible and early side effects of corticosteroid use is deposition of fat on the upper body. Typically, short term use will result in chubby cheeks, rounder shoulders and some deposition of fat on the chest. This might give the appearance of being chubby or healthy but is a side effect, and not a pleasant one.

Corticosteroids have a darker side, CDC lists some of the side effects

Possible side effects of short-term corticosteroid use:

  • Increased fat on the face (rounded face), upper back, and belly
  • Upset stomach
  • Increased blood sugar
  • Increased hunger
  • Behavior changes, trouble sleeping, irritability, depression
  • Increased risk of pneumonia, thrush (white coating in the mouth), and other infections
  • Weight gain, salt and water retention
  • High blood pressure
  • Stretch marks on the skin, acne, poor wound healing, increased and unusual hair growth

Possible side effects of long-term use (3 months or longer):

  • All short-term side effects
  • Poor growth in children (can be severe)
  • Brittle bones (bones break easily, problems with hips and shoulder joints)
  • Muscle weakness
  • Diabetes
  • Eye problems

As you can see, not only are these kids subject to being sex-slaves, but also face a lifetime of illness for a decade of two of sex-work.

There is very little medical data from Bangladesh about steroid abuse, The only people who seem interested are news outlets. UNICEF in its “Background Paper on Good Practices and Priorities to Combat Sexual Abuse and Exploitation of Children in Bangladesh” mentions it in passing and refers to an 2010 BBC story about the same.

Most public health and medical research into sex-work looks almost exclusively at Sexually transmitted infections and HIV/AIDS, a few look at violence, but the longer term health and non-psychoactive drug abuse often gets sidelined.

One could dismiss this problem and say “if you are not going to live to be 40, STI’s are more a priority than Diabetes”.

Read more at

Let us make things better: the “Indian medical doctors on the web” survey

Posted on by Anand Philip

I am doing a survey.

Do you know how many Indian medical doctors who use the Internet blog? well, no one does. Neither do we know how many of us are students, how many are on twitter and how many talk about work online. We most definitely do not know if any of us follow professional guides to using social media written specifically for doctors. I want to find out, and I think irrespective of your profession, you would want to know more about your friendly neighbourhood doctor on the net. Without being creepy, of course.

This is a survey of Indian Medical folk on the web. By Indian I mean practising in India, and by Medical folk I mean allopathic doctors(medical students too). The reason for this “Discrimination” is convenience and because I can.

If you are a medical doctor, please take the survey, if you know one, mail her a link. Thank you very much.

If you are not a doctor, don’t take it, there are trick medical questions and I will know.

Here you go. Click here for the great Indian medical doctors on the web survey.

Feel free to re post this link on your site, or embed it. For convenience and tracking you can use this URL to email people: http://bit.ly/indsurvey

The survey will run for 14 days starting Monday September 12th. Email me with suggestions and feedback at Uberschizo at gmail

Indian Doctors and Medical Students on the Web Survey by Dr. Anand Philip

Indian medical Doctors and Medical Students on the Web Survey by Dr. Anand Philip

PS: There are no trick medical questions.

Top Criminals in Indian Hospitals

Posted on by Anand Philip

Criminals in hospitals Image by murplejane

Ten years inside hospitals gives you a great instinct to pick out criminals. Oh yes, there are a lot of them in the hospitals. Here are the greatest offenders and how to deal with them.

The Poor:

They can’t afford the services, yet they come. They never do what we ask them to, want multivitamins and “saline” and never come when we ask them to. They are dirty, and don’t pay even if they can afford it. Definitely deserve the long waiting times and getting sidelined for “paying” patients.

The old:

Slow, stubborn and forgetful, they can never come to the point. If they have bellyache, they start with the time they stubbed their toe back in 67 and the time they met a white doctor who gave them a red liquid for the belly ache. Definitely deserve the patronizing behaviour that we have perfected; don’t pay attention, just nod, agree and give them something for symptomatic relief. Talk loudly, most of them are deaf.

The very rich:

Scum of the earth, just the worst people in India. They walk around like they own the hospital and treat us like we are beggars. Clearly they deserve to be robbed. Such sense of entitlement, such low respect for the profession. Keep changing doctors, want results yesterday, stingy. Definitely deserve the over charging and the excessive tests, they ask for it.

Women:

90% of their problems are psycho somatic and they create such a fuss about the rest 10%. If you are a guy, they wont let you touch them, if you don’t, and get the diagnosis wrong, they curse you. In the labor room they wont push when they need to and scream like a banshee, as if it’s an elephant coming out. Never open their mouths if their husbands hit them, so we can’t do anything. Definitely deserve being given antidepressants for the vague symptoms and the slaps on the labor table.

Villager:

You can smell them from a mile away. Sure they work in the fields and have animals, but can’t they buy soap? or at least some chap perfume? many of them are rich but pretend to be poor, they don’t change their clothes and treat the women so bad. if you are a girl then you’ve had it, your old man wont spend a penny on you. Depending on the case, definitely educate them about taking bath and sending their girls to school.

Prostitutes and homosexuals:

Why can’t they just say it? how many times will I have to “guess” their tendencies and do the right test?  I mean I am a professional, trained to deal with them in a professional way, then why can’t they just open up? They hem and haw and beat around the bush and never tell you what’s really going on. As if they can fool anyone. Anyway, poor women, forced to live like this, sometimes I feel sad, but I have to do my job and I can’t care for emotions. For them always do STD panel, even if they complain of head ache, they actually mean something else, so no point in asking if you should do it, they will just say no.

Criminals in hospital Woody allen being chased by a gorilla

Image by JohnMcNab

 

Surely, I am joking. Right? How can an educated, cultured professional hold such beliefs. These show the beliefs of a micro minority, right? No lessons to be learned here, just how some people can’t be cured by education. Correct?

Dear Doctor, Why Do You Care How Many People I Sleep With?

Posted on by Anand Philip

I am a doctor, sometimes, that is my shame.

Dear fellow professional:

Did someone ever teach you how to ask someone their sexual history?

Did you get any systematic training  in handling sensitive issues?

Do you know if you sound judgemental while posing a question to a patient?

Do you know there are professional and standard methods in approaching sensitive issues?

Can you put a patient at ease when talking about their substance abuse issues?

Do you ask more than is relevant to the medical situation?

Do you explain to your patient why you need to ask such personal questions?

Do you say “you should not smoke”, after asking if she smokes?

 

I am a doctor, sometimes, that is my shame.

I studied at one of the best centres for medical education in India.

Yet

For every 100 lecture on what to ask, there was maybe, one lecture on how to ask.

“Get the patient’s sexual history”, I was instructed

The patient was a 20 something woman. I was a 20 something guy. Her mother was with her. There were 15 patients waiting. It was a disaster.

10 years in the medical system, multiple postings in gynaecology, yet not one workshop on “how to ask the awkward questions?”

It was assumed that I would know, or learn. That the patient would understand that I had to ask these questions. That it was the patient’s “duty” to answer.

“Do you smoke?” Can mean many things, do you know that?

Tell me, I am eager to know.

Inspired by a recent conversation on twitter

 

Featured Image by  jakebouma

Let’s talk about shit

Posted on by Anand Philip

By the time you finish reading this sentence at least one child would have died in india of diarrhea. The most important cause of diarrhea is  contaminated drinking water and poor sanitation.

Rose George is a British journalist [wikipedia] and author whose book “The big nessecity [amazon]” addressed the issue of lack of sanitation as one of the greatest killers of the modern world.

This is her on Shit and India.

How/when did you get interested in sanitation?
It was a long story. I used to work at a magazine called COLORS, owned by but left alone by Benetton. The editor was Oliviero Toscani, famed for the scandalous Benetton ads. One day he decided to do a coffee-table picture book about shit called CACAS. I researched some of the very short texts that accompanied the pics and thought them fascinating. I was astonished that I could consider myself well-educated and not know, for example, that a quarter of the world’s population has no toilet. But I also learned that the topic of sanitation could be entertaining, and that urine can change the colour of your wallpaper, and that sewage in the streets probably led to the invention of high heels, and that kings used to defecate in public and eat in private. It is a rich, wide, deep and endlessly fascinating topic.

After the book, how do you keep being involved in the sanitation world-if you do
Yes, I do. I keep a blog about mostly sanitation matters at www.rosegeorge.com and still write op-eds here and there about sanitation.

I also do a lot of lectures about sanitation. In the last month, I gave a keynote speech to 2500 freshmen at the University of Pennsylvania, who had been assigned my book as part of the Penn Reading Project; then flew to Stockholm to hand out awards to journalists writing about sanitation and water; then to Hong Kong to talk at a conference of 1500 investors, to persuade them that shit is a scandalously underexploited resource, both as fertilizer and as energy.

What are, if there are, your most memorable experiences in India?

You don’t forget three days in a slum in a hurry. I originally intended to stay overnight in a slum but chickened out. I wouldn’t have been worried about the accommodation; all the houses I visited were pristine. But as soon as you step foot outside you are overwhelmed by filth. And of course, there are hardly any toilets. On the other hand, I met some fabulous people in India who I think of as sanitation footsoldiers. Milon Nag, who runs a plastics factory outside Pune and who has developed a low-cost plastic sanitation slab that is now regularly used in emergencies; Dr. Mapuskar, a doctor near Pune who arrived in his village – now a town – to find no toilets and became a sanitation evangelist, persuading 100% of people to install toilets and even human shit biogas digesters (a miracle in India); or the wonderful staff of Gram Vikas in Orissa, who are attempting to get villages to install 100% Total Sanitation. In one village they went to, it took 162 meetings for people to agree but they did and now disease has been dramatically diminished and the village school teacher told me 80% more girl children go to school. People think a toilet is a symptom of development but actually it can trigger it.
What are 3 easy-to-solve problems that governments and other agencies should tackle immediately?
1. Stop focusing on clean water at the expense of sanitation. There is no point installing one without the other.
2. Switch mindsets: Expensive wastewater utility systems are not always the solution. There is innovation in sanitation: use it.
3. Stop thinking that development has to cost a fortune. Invest in software like human behaviour change-makers. Persuasion doesn’t cost much but it can reap so much.

What are 2 of the knottier issues?
There is only one knotty issue: Diarrhoea. It is astonishing in 2010 that children die of something that is easily curable, and that they die at the rate of one every fifteen seconds. Astonishing and disgraceful.

How can the behavioural change be brought about rapidly- it happened within a generation in most of the world- why are some parts lagging behind so much?
Because often the investment goes to hardware and not to the software. Humans are complicated creatures. They can be persuaded but it takes marketing psychology. People have to want to use a toilet, and that is not always a straightforward thing to bring about, to someone who has been shitting in the bush quite happily for generations. There has to be investment in persuasion.

Some practical technological solutions?
Far too many to list. Practical Action does good fact-sheets on sanitation solutions. Akvopedia has a great database of technology.

We dont like talking about shit, its considered boorish and uncouth. But of all times now, we need to start talking about shit seriously. The sanitation challenge india faces is not going away anytime now, and is getting worse in some places like big cities.

I will be talking about shit in 1 or 2 more follow-up posts at the end of which I hope to have converted you into a fellow foot soldier for shit. In the mean time, do look through the Akovopedia portal on sanitaion for some great technologies that can radically reduce cost and improve outcome in implementing sanitation. Viva la revolution!