Information Deluge

Since the advent of Covid19 into our country there has been a flood of information. What started as a trickle has now become a flood. Electronic and paper media are full of the news related to this virus. As I sit and analyse the various reports, I get this impression. Bad news gets more publicity that good news. More gory the details more newsworthy is the story and there is and will be many such stories in future.
Let us look at some facts.

At the time of my writing this piece, there were 75000 positive cases with 1600 deaths. Which means less than 1.5% of the infected cases, which is better than what is seen in most countries.  Even if one considers the possibility of inadequate data collection, the figures are still low. Is this encouraging figure because of the success of social distancing and mask wearing? To some extent it may be, especially because of imposition of travel restrictions. But social isolation of keeping 6 ft away from one another,is an impossibility given the socioeconomic conditions prevailing in our country. So one can take it that it has not been implemented except may be in the 10% upper economic strata. So is mask wearing, though I see many wearing masks, most may not know how long the mask lasts. Cloth masks need to be washed in detergent solution daily. Surgical masks last for 4 to 6 hours and needs to be discarded. N95 masks can also be reused, but again needs to be sanitised before use. I asked a few persons and most of them didn't know these facts. So I presume, this mask wearing too is more or less been not very effective.

Then why is the mortality, is so low? I see the following reasons

1 Travel restrictions
2 Demography. Only 15% of the population are elderly who are more susceptible. As these do not normally socially interact and their numbers are small this could be one major factor.
3 Efficient public health and primary care. In states like Kerala where these are strong the spread is also very slow. In some states who have the machinery in place for disaster management like in Orissa too this is true. States like Karnataka too have shown good results
4 Virus mutation and environment. It is possible that hot weather and a less virulent strain mabe other factors.

What is the likely scenario when the lockdown is lifted

There will be a spike in positive cases and the mortality figures may show a slight increase, when once the travel restrictions are lifted and economic activity restarts. But the doomsday predictions of people dying on our streets etc etc is most unlikely to happen.

Some advice from an old person

We humans are social animals. Social isolation is detrimental to mental and physical health. We should meet and interact. Of course, we need to sanitise our hands, wear proper effective masks and if possible keep a safe distance. In case of flu like symptoms not going in a couple of days get tested with out panic. Remember, it you are young you belong to 93% who will recover and if you are old there is 85% chance of full recovery

And for the next three moths watch less of news TV, read less of newspapers and don't read and what's app forwards!

Much ado 

Diabetes is one of the eminently preventable disorders. This disorder has now become a money spinner for pharma companies, diet counsellors, endocrinologists and a special breed of doctors who call themselves as diabetologists. There’s so much hype built up, that this is considered as a deadly disease and news, social and electronic media are replete with reports, one way or the other related to this illness to the extent that India now has the dubious distinction of being known as the diabetic capital of the world. And our super doctor endocrinologists taking the cue, repeat this sentence ad nauseam in every CME that is held on this subject.

One of my patients, let me give him a name Banwari Lal.

Banwari came to see me some time back.

I could see him very anxious and tense.

He said,' doctor Saab, I am going to die' 

Banwari is a second-generation patient of mine and I have known him almost since he was born. Now this strapping 40 plus man who has been pretty healthy so far is now here announcing his imminent death.

I asked him,' how are you going to die?'

He said with all seriousness, ' Sugar disease'

How do you know you have one? I asked

Another story emerged. Banwari got a phone call couple of weeks back, the caller identified himself as an executive from Estocare, a nationally known diagnostic company and they have a great offer especially suited for successful business leaders'

Our Banwari was suitably impressed with him being amongst this chosen elite, asked what these tests and the cost.

The executive proceeded to explain that the offer was for 40 tests and cost was only Rs 2000  which normally would cost Rs 3500 and what is more, their technician will come to Banwari's residence to take the blood sample.

Greatly impressed, Banwari placed the order and next day a sample of blood was taken. 

The results came by mail and amongst the mostly unnecessary tests there were some marked in bold font suggesting abnormality. Going by his knowledge of sugar disease (his father too has it) Banwari knew that sugar levels were high and he like his father has this dreaded disorder 

Things would have been different had he come to me in the first place soon after he got the report.

An avid TV watcher, he had heard a discussion on diabetes by a panel of doctors and he thought it best to consult a clinic solely devoted to this disease.

He fixed a date with this super specialty diabetes clinic and went there as suggested in an empty stomach.

There his blood was drawn once again and he was given a breakfast of the clinic's choice.

This done he was asked to get an ECG and ultrasound of the abdomen done. When asked why these additional tests, he was told by the nurse who had a permanently fixed smile that it is to find out if has any additional disease. Thus, held captive in that clinic, he was kept busy till noon when his turn came to see the diabetes specialist doctor.

The conversation went along the following lines.

Doctor gravely looking at the opened file in front of him asked, ' You are Banwari Lal'

Banwari confirmed indeed he is.

You have a problem, said the specialist. 

As he already knew this because of the bold fonted figures, Banwari chose to be quiet.

‘You heard what I said'

This time Banwari was forced to say yes.

Your blood sugar and lipids are high and unless these are brought to normal you run the risk of complications involving your heart, brain and kidneys which may result in serious complications including death.

Banwari did know about diabetes but this disconcerting information about causing death was new to him as his father who is 75 years old, a diabetic and still alive

You need to change your life style, exercise regularly and take medication which I will prescribe now said the specialist. 

He proceeded to give a prescription for three types of medications.

Banwari was now asked to go to another room where sat a lady who specializes in giving advice on diet to diabetics.

The lady took his weight and found him overweight by 5 Kgs.

Banwari is a Guajarati and a devout Jain.The dietary discussion with this lady from Banwari's point of view was very painful. 

When she learnt that being a Jain his last meal was before sunset, she told him in no uncertain terms that he will have to eat according to her chart and not starve. Banwari telling her that he is not starving fell on deaf ears.

Banwari's wife too had gone with him and both were given an hours talk on what each ingredient of the food that they eat [ displayed on a large tray] and the calorie value of each of these.

By then it was nearing 2 pm and past their lunch time and in addition to hunger Banwari also had a headache with all this detailed information stuffed into his head. Except information needed for his business, Banwari’s brain finds it difficult to understand others and this calorie gilorie stuff that the diet expert was telling him was beyond his comprehension and therefore the head ache.

His wife Sunitha too is my patient and it was she who advised him to see me before he does anything like staring the medication and try the diet.

Before I saw his reports, I checked his BP and heart. Both were normal and he had good circulation in the limbs. There was no evidence of any skin fungus. Weight was borderline high. I felt he was in good health.

Now I opened his now fairly bulky file.

His fasting sugar was 140 and after food it was 210 and his LDL was 140 and Triglyceride was 240.

I felt like laughing  

He must have seen the expression 

He asked, ‘doctor Saab, why are you laughing’ in Hindi

I said, it's a smile of pleasure to see these reports, you can get back to normal within next two months if you follow my advice

Then what about heart attack kidney attack? he asked

‘Nothing will happen and you are not going to die and may even outlive your father’ I said half in jest

But what about my evening meal? He asked with some anxiety 

You can have your night meal before sunset’ I said.

I gave him a diet and exercise schedule which would not greatly disturb his life style.

He came back the other day.

His fasting sugar was 130 and after food it was 160 and both the LDL and triglyceride levels had dropped and he was on no drugs.

I told him to continue the slightly altered lifestyle [ bit more of exercise and controlled eating] and assured him at the next visit, in 3 months’ time, all the values will be normal

A very happy and relieved Banwari took a grateful leave, leaving behind a box of sweets

Hopefully his gift will not make me a diabetic.

Back bencher

I am comfortable sitting at the back in any function, be it a continuing education meeting, a wedding reception or a civic get together. This habit I acquired some 50 years back in medical school. Then it gave me an opportunity to unobtrusively leave the hall through the large french windows placed strategically on the sides of the lecture hall. Those days the lecturers if they noticed one’s absence, took no offence.

This habit has stood me in good stead and gives me ample opportunity to leave midway without offending the speaker or the organizers. On rare occasions, when I had to don the mantle of a speaker I keep a subtle watch on the back rows to see if any one leaving midway, a sure sign of boredom/ inattention. I am rather fortunate that it has not happened often.

In those bygone days, the continuing education programs were simple affairs with a lunch or high tea thrown in at the beginning or at the end. The speakers mostly depended on memory and experience and spoke extempore. Naturally some of them bored us to death. Then too being a back-chair occupier came in handy to take unobtrusive leave.

Has the advent of advanced audiovisual aids motivated me to occupy front seats? Sadly no. I find it has made matters worse. The modern-day speakers, with rare exceptions, have taken to reading these projected slides and not really addressing the audience. Droning voice combined with dimmed lighting is conducive to sleep and it's with difficulty that I keep my head up and eyes open. This goes unnoticed if you are a back seater. When I compare the speakers of yesteryears to the present ones the ones of the past get a higher score. May be, being old myself, I may be biased. I remember vividly my Neurology teacher professor late M.K Mani miming grand mal and petite mal (now the modern neurologists have named these differently) while speaking on epilepsy. Similarly, I remember another M.K Mani ( great teacher, alive and kicking) speaking on hypertension, though with the help of slides but hardly  looking at them.

Lately I am facing a piquant situation. Thanks to my seniority and mop of grey hair, I am easily spotted and given our penchant for recognizing (respecting?) old age, I am forcefully escorted to the front row of chairs to my discomfort. Here again there's is some hierarchical distinction. The front most row is generally is a row of cushioned sofas or well-padded chairs meant for VIPs and thankfully the organizers have not recognized me as one and they usually make me sit behind these.

The front row occupants generally come late and the importance is based on the position they hold rather than to any achievement academic or otherwise. Needless to say, by arriving late, they also hold up the proceedings. In one such meeting a serving police official of ill repute was the chief guest in a professional function. I felt happy that I was not in that front row sitting with this worthy.

It's a different matter in social functions like weddings and receptions. Being the family doctor for generations of families, I often get invited to many of these which even includes ceremonies associated with death. Often, I have the dubious distinction of having presided over these deaths. Readers should not get the impression that I am another Dr Harold Shipman [who killed many an elderly]. In my case these patients who died under my care at home were terminally ill and I saw to it that unnecessary hospitalization and the resulting expense were avoided. Weddings however are joyous occasions. Normally I try and avoid these ostentatious and wasteful ceremonies. But sometimes I have to attend as the families concerned are too close for me to not to.

Recently I went to a wedding. The girl, a third-generation patient, I have known since her birth. She is now placed in the US and the young man; her groom is a German. The girl’s father and mother and the grandparents from both sides also are/ were my patients. Both the grandfathers are dead (under my care at home), but the ailing grandmothers pushing 80 are very much alive. So this intimate relationship made it impossible to avoid this wedding.

The simple wedding ceremony was over and the time arrived to bless the couple. Normally the elders of both sides take the first honor followed by other relatives and friends. In this wedding, this tradition was broken and I was ceremoniously escorted to the platform where the bride and groom sat and was requested to initiate the process. It must be a spectacle to the well-dressed gathering to see this chappal clad, shirt and trouser wearing, nondescript old person belonging to another caste and community, being escorted to initiate the holy process.

This kind of affection, respect and love makes us family physicians feel that we made the right choice in choosing this branch of medicine

Medicine, no longer a career choice?

I have known Dr S since her school days. She passed her MBBS and internship four years back. I remember the time when she came to see me with her intention to become a doctor,having secured good marks in her PUC. I had tried then to counsel her against her choice by giving the true picture of what awaits a young doctor in this country, especially a woman doctor. She was adamant and duly proceeded to get a seat in the government quota in one of the medical colleges that have mushroomed in and around Bangalore. She proudly said after she got a seat that it was in government quota and not in management quota which meant bought seats and generally of inferior quality. I knew of this college's unsavoury reputation, but prudently kept quiet.

Now she has come to see me, nearly seven years later. Instead of a sprightly and healthy 18 year old young woman, I was seeing an obese woman with features of hypothyroidism. I asked her where is she working and what has brought her to me.

She said.' uncle, I am not working full time, I am preparing for yet another NEET! This will be my last attempt. If I don't make it, then that will be the end for me' She was on the verge of breaking down. Long experience has taught me, that in such situations, the best way to show empathy is to remain silent. After a while, she continued, 'I should have followed your advice, this profession is not for me. I am earning 20,000 Rs  working night shift and my sister who is younger to me is earning 1,50,000 working as a software engineer. She is also getting married in six months.' another pause and she continued, 'as you can see, I am also unwell, I went to Dr.... and she has put me on hormone pills and it has made me put on more weight' her torrent of misery stopped at last.

Here, with this young woman I was facing two problems. One is physical and the other is emotional.

Handling the physical part was lesser of the two problems,Though both were likely to be interlinked.
It took me more than an hour to counsel her that passing NEET is not the end all of one's life and the importance of regular exercise and managing her diet and taking care of her body and also her mind. And how earning money and comparing her with her younger sister will lead to mental illness and how improper such comparisons are.

She went with advice to get her thyroid profile, blood sugar and an ultrasound scan to exclude PCOS [Polycystic ovarian syndrome]

When she went she appeared to be in a better frame of mind than when she came in to see me.

She is an example of the fate and uncertain future many young doctors in our country are facing now.

Alcohol habit and

Helping the cheat

I am not sure if I have written this before, if so, my apologies for repetition. As a story told at different times, takes different colors, it may be still worth reading!

This incident occurred some twenty years back. Recollection came about because of a recent finding of clandestine drinking by a habitué.

The old Brigadier must have been in his 70s when this episode occurred. The main players Brig and his wife are no more. Brig Menon enjoyed his two large whiskies every evening and has been doing so for many years and was none the worse for this. His wife was not a party to this habit and was very critical of this and was trying her best to get him off. She was not very pleased when after seeing his lab reports and finding his liver function tests normal, when I told the Brig that he can have his two large pegs without worrying about liver damage. She admonished me for being frivolous for giving such advice!

They would visit me once or twice a year and during their next visit,’ I asked the Brig, ‘How are you doing’ Before he could answer, ‘the major general [wife ] took over,’ she said, ‘ doctor, he is very much better, that he is not drinking now’. I was a bit surprised at this and asked him how come he managed to get rid of the habit’ Again Major General replied,’ he was forced to stop as his cardiologist advised him that too much drinking is bad for his heart and liver. This threat of twin danger obviously has had the effect and the old Brig had stopped drinking. I did not like the advice given by the cardiologist, if true that is, that has deprived the old man of the one simple pleasure in his in his old age. Brigadier was sitting silently and I felt he did not like his wife that much at that moment.

Few months later, they met up with me again. This time it is because of Brigadier’s frequent urination at night. Doctor, ‘he goes too often, sometimes every fifteen minutes and it is worse in the night time’ said his wife. Brigadier as usual was quiet. I asked him and blood test done to exclude diabetes? The answer was yes done recently and there is no diabetes. Now I was fairly sure, Brig was having trouble with his prostate gland. After some discussion, it was agreed that he gets the tests done and then see me.

Next day Brigadier managed to come alone to see me.

‘Doc, I need to tell you something in confidence, he began, I still have my two drinks in the evening. I keep the whisky in an empty dettol bottle at the top shelf in the bathroom where my wife cannot see it and even if she sees it she will think its dettol and at that height she cannot reach it’ My frequent visits to the cloak room has made her bring me to you and you thought it is due to my prostate enlargement’ Now you have advised her to get me the test done, I have no option but to do so''.

I thought for a moment and sat thinking for a while, then I said, ''Sir, you get the tests done, at your age the report most likely will say there is enlarged prostate, you bring the report and I will tell your wife that such frequent urination only at some hours in the night does not need treatment and if it becomes worse, then we can give medication and no surgery is needed’’

Major general, when she visited me next, complimented me for diagnosing he husband’s condition and giving correct advice!

That is what happened and all of us, brigadier, major general and I remained happy ever after, till their demise that is!

Happiness and other such matters of mind

This morning the button which that anchored my pants up snapped. Fortunately it happened at home and no embarrassment ensued. I needed to sew the button back on the appropriate slot.Though this was no emergency, I felt I should try my hand at it.

My wife keeps a kit with sewing thread rolls and assorted needles. It's some years since I have done this and wasn't sure if my 75 plus years old eyes are up to this job. It was with some tremulous hands I took hold of the needle and thread and it took me just three attempts and I succeeded in threading the needle. Sewing the button on was pretty easy That I was able to thread the needle made me very happy at that moment.

 Happiness is difficult to describe. In a way we can say it's the opposite of sorrow. Sadness is easy to define but happiness is not that easy. One can say that It's a state of mind where at that moment there's a sense of euphoric contentment. I have experienced this often. There is a pair of bulbuls who are resident around my home and they regularly patrol and part of it is the shrubs that line my driveway. Bulbuls have a very fruity call and when I hear the call I go out and watch them.For almost a week I didn't hear or see them and I was becoming a bit anxious about their safety and two days back I heard their call. This was happiness. The other morning while playing golf I witnessed a glorious sunrise and that was happiness.

 But all these sensations/feelings are ephemeral. Can we make this feeling permanent even when we are faced with problems, pain and suffering? I heard a Buddhist Monk speak on this subject. According to him it's possible by meditation which will rid the mind of negativity and will elevate and educate the mind to experience happiness all the time. Such a mind will be rid of desire,jealousy, anger,anxiety,which are the basic causes of most suffering. I honestly don't know if meditation helps or not but I know this much. Material possessions don't bring happiness. On the contrary they can be the cause of unhappiness

 What about pain? Does meditation help to overcome or lessen the pain sensation? Sage Ramana Maharshi was seriously ill with disseminated cancer and he was in severe pain during his last days. When asked, he told his disciple, yes body is suffering and the mind is not or some such.Those who are interested can get more details on his last days by googling. I have written in the past about Robert Trent Jones,the all time great golfer and the stoic way he suffered the disability caused by Syringomyelia. There appears to be a lot more to learn about how mind controls matter. It may make good reading to access Norman Cousins’s books, Anatomy of an illness and the healing heart.

Research
What is research? The literal meaning is that one searches for something that is already been searched by some one else. But the real meaning is that you do something which is original or contributes to or enhances the existing knowledge. There is continuing effort in this direction allover the world in all fields of human activity and there is thus an explosion of knowledge happening almost daily.
Most of this kind of work is from western world predominantly from europe and USA and lately from China.
Despite having a surfeit of technically qualified men and women in our country our research output is abysmally low in comparison. Often we blame the inadequacy of resources,equipment, money and discordance between industry,universities and the government. While all this being true to some extent, there are some, more valid causes for the lack of research. The most significant one is I feel is the hierarchical structure of our institutions. Let us take for example a university professor who has 50 undergrads and ten post grads under him and five other teachers working with him.From where the research ideas arise? From the 60 students or from the 6 faculty?Ideally the ideas should be from the students and may be some extent from the faculty. The role of the faculty should be to to guide the student in the research methodology and to take the idea forward to wards the logical end. That is publication.
For any idea to come up one must have an inquisitive mind. This is natural when one is young and education is to encourage the growth of this. Unfortunately in our institutions lot of importance is given to accumulation of already known facts which is tested at the end of the year by an examination. As the numbers are large the interaction between the teacher and the taught is also not intense. This is the main reason why indian students do so well when they go to USA or Europe where the student teacher interaction is better and the student becomes a quality researcher as he is encouraged to develop an inquisitive mind which has laid dormant when he was here in India.
As we have seen, what ever quality research papers that have an Indian origin have come from few institutions who do not have this hierarchical structure and where there is more student guide interaction.
When a young man/woman is given the freedom to think and allowed to freely interact with others, be it faculty or seniors in an informal group many ideas will emerge. So there should be an inquisitive mind, an atmosphere and suitable environment for any research ideas to emerge/sprout.

Let me illustrate with a real life example.

There are a group of young doctors headed by another not so young doctor. I closely interact with them on a day to day and on need based occasions. No harm in naming them, The young ones are Dr Swathy and Dr Akshay, the not so young is Dr Ramakrishna Prasad and the oldie in the group is yours truly.

Couple of days ago four of us met. We were discussing B12 deficiency in diabetics who are on Metformin. The question that the inquisitive minds wanted an answer was whether it is due to combination of diabetes and metformin or only metformin? Do those diabetics who are not on metformin also prone to B12 deficiency? If so when combined with metformin the deficiency becomes worse? All these were research questions which needed to be found out and we are at it.
Another question that was posed was why so many people develop B12 deficiency? Even amongst non vegetarians. The only answer I could give is that these are people who eat meat occasionally and are there fore de facto vegetarians. Is there any other reason? Are they absorbing the vitamin poorly?
Then came the best route of administration. Oral or in the injection form. I said the injection form. She asked why? I said in my experience there is quicker absorption and better results. Is there a proof that B12 given orally is less effective? I didn't have a proven answer. Another research idea

By the above example one can realise how effective this method of interaction between interested groups that will result in emergence of research ideas.

Following is the comment from Akshay

Akshay S Dinesh	10:58 AM (8 hours ago)

The hierarchical nature of research in institutes has a lot to do with the hierarchical nature of funding and more importantly passion. If we want to increase India's research throughput it is not just guidance on research that we'll have to give students, but also guidance on life in general. Our education systems may truly have to fulfill Vivekananda's words:

Education is not the amount of information that we put into your brain and runs riot there, undigested, all your life. We must have life building, man making, character making assimilation of ideas. If you have assimilated five ideas and made them your life and character, you have more education than any man who has got by heart a whole library...

I suppose when people think about "purpose" of life and "meaning" of life, that is when they will have enough passion to do the hard work that research takes. When people are worried about "settling" in life, that's when the problems start creeping in.

Akshay