Decisions are always difficult :)

As a trainee doctor working in government hospital, working with poorest in the country, I believed that education can solve most problems.

How wrong I was!

As a trainee doctor I saw suffering of people that I attributed to lack of education. They were superstitious, had bizarre ideas about illness and recovery, hardly ever followed medical advice especially about follow up of treatment. I firmly believed that as more and more people get school education, this will go away. People will have access to good information and they will make better decisions resulting in better life.

Then I completed my training and started my own private work.

Now my patients came from educated, mostly urban background and had some disposable income (hence they could afford private psychiatrist)

At the same time internet revolution was sweeping India (circa 1999-2000).
Information was freely available to anyone who could read English and afford internet.
Then internet became cheaper and arrived on phone.

And finally social media and WhatsApp happened.

How does it affect my work?

Take simple example of early childhood education.

Huge amount of information is available on internet.
But education doesn’t help us differentiate information, advertising, propaganda, knowledge and wisdom. Education dosn’t include ” नीर क्षीर विवेक” (mythological ability of swan to drink only milk and leave water behind).

Ability to read English and access to huge amount of information actually overwhelms thinking ability. This is compounded by lack of time as well. So we have information overload, poor training, time pressure and emotional situation.

Bingo! You have a decision making hell!

So mind accepts simplest possible explanation that conforms to previous biases. Add modern insecurity and belief in a world of dog eat dog. You become a perfect fodder for crooks’ designs.

Common sense (heuristics)is used by the illiterate but it is likely to be absent in the educated. Daniel Kahneman+Amos Tversky and Abhijit Bannerjee+Esther Duflo earned their Nobel Prize in economics due to their work on financial decision making.

I don’t know if medical decision making will get attention of good people of Swedish academy.

Back to our problem of early childhood education.

Now you will realize why people are willing to pay six figure sums (in ₹) to “coding for toddlers” companies. People running these companies KNOW and possibly accept in private conversations that it is all about making money.

But anxious parents with huge amount of information and lack of decision making skills get carried away. If it is so complicated for harmless education, just imagine how harmful it can get for healthcare related decisions.

Forget degrees, we need real life decision making skills.

A real life story to end this post –

As a trainee doctor, I once treated a patient with bipolar disorder. Like clockwork, he would get an episode of mania every 12-14 months for years.
He lived 300km away in a village. Arrived with his father at first sign of mania. (This sign was him sitting in village temple and singing devotional songs without break.)

His father insisted on starting electro-convulsive therapy on day one (they reached hospital on empty stomach as preparation for ECT) . He would be okay in about 10-12 days. My pleas to take lithium regularly to avoid these episodes would fall on deaf ears. His father would give back stock of lithium given to them at discharge. And they would leave only to arrive after 14 months.

I cursed their illiteracy, short shortsightedness and demands for Electro-convulsive therapy. I never tried to understand their decision making.

Now I am much older and I appreciate their wisdom in the path they chose. Taking tablets of lithium while working in field as manual laborer, keeping an eye on lithium level in blood, etc was too much problem for them. Going to free government hospital once year and taking ECT as treatment was a much more convenient option.

If I had made effort then, may be i would be on my way to Sweden to get the coveted prize 🙂

This is how Nobel prizes are lost 🙂

April 24, 2021

Big problem with modern doctors!

When you approach a doctor with some problem, you are vulnerable. You will readily accept most of their suggestions for “intervention/treatments”.

Sometimes your doctor will send you away without offering intervention/treatments. Because –
1. It is normal occurrence. No disease.

2. Your misconceptions need correction not your body.

3. It is a self limiting condition.

4. Intervention will make it worse. Better to wait and let it disappear.

5. Too early to identify precise problem. Not enough data. Better to wait for more data to emerge.

6. You get hassled by small issues, need to learn to live with some as long term health strategy.

And some more.

Such doctors are pure gold. Cherish them.

They are turning away a patient who is willing to investigate and get treatment because they are ethical.

Many patients feel that such doctors are rude, incompetent or don’t care therefore they are turning patients away.

I would pay more for a doctor who rightly tells me to ignore/wait/come back later/tolerate my issues than the one who jumps the gun readily

“emotional healing” is at the top of list of needs of many patients.

It is a legitimate human need. I agree.

Is it fair to expect it as top priority from a modern medical practitioner every time you meet them?

Are we getting more infantile as a society ?

Why do we constantly need hand holding and soothing ?

Is anxiety THE top problem in every healthcare interaction ?

Please don’t quote William Osler. He didn’t have medical negligence laws, internet, automobiles and insurance.

April 24, 2021

Are we all turning “mad”?

Here is a real life story about fighting delusions and living with them as it applies to today.

I worked in a municipal hospital during my urban internship stint. There was once a week Psychiatry OPD started by resident medical officer Dr Shirole and visiting consultant Dr Thombare (unfortunately, both have now passed away). I had already expressed my interest in Psychiatry So I was allowed attend this OPD.
Dr Thombare wanted me to learn about symptoms of mind so he asked me to talk a patient in detail. He allocated a middle aged man as my patient.

This gentleman was on treatment for many years and was considered a “stable” patient.

One afternoon, I sat down to hear his life story. As it was common those days (1994), he had suffered a few years of symptoms before receiving treatment. He had an extensive belief system supported by his hallucinations.

He firmly believed that his wife, children, other family members, neighbors and colleagues all were part of a group that kept an eye on him, stole his money, prostituted his wife and did terrible things to his children. He experienced that his thoughts were broadcasted on a special channel on cable TV accessible to only few selected people from that group.

I listened to him all afternoon with fascination. Struggling to tell myself that it was all only in his head. Later when I started my psychiatry residency in govt hospital in same city, I met same gentleman again as my patient.

Once, I don’t know what I was thinking, I decided to spend one more evening talking to him. I tried to “talk him out of his delusions” as intellectual exercise and failed spectacularly as it was bound to happen.

He had is own way of interpreting everything happening around him in a way that fit into his delusion. Even things that I considered as clear evidence that should have shattered his beliefs, were neatly misinterpreted by his mind as evidence towards his beliefs. After struggling with it all for an entire evening, I finally convinced myself about unchangeable nature of delusions.

Over next few years, he had 2 more episodes of his illness (Paranoid Schizophrenia) and I saw his delusional system evolve to include whatever was happening around I witnessed firsthand how his mind continued to invent past that was supportive of his beliefs.

Between episodes, he was a regular family man with a job. Just like me. For long time I believed that such experiences were common only with those brains that were occupied by psychosis.

And then internet happened, social media happened and post-truth happened. And I started finding regular chaps like myself getting consumed by stories and narratives. Including every new experience into their belief systems and they even have their own ideology’s TV channels catering to echo and magnification of their distorted beliefs. Now we call that belief political ideology and it is a freedom protected by law.

They all hold regular jobs but live a life of suspicion and anger and fear. Dividing the world between us and them.

No amount of convincing will do. They seem lost. No matter what they call their ideology, they seem to be more alike than different.

Ignoring reality and relations and real needs of present.

Only an asylum seems to be a sane place now.

April 24, 2021

Perspective affects decision-making

18 month old child is brought in by parents as they suspect autism.
Pediatrician saw the child 3 months ago and advised them to wait till second birthday.

Parents were worried so they self referred to me.

Should the parents consult me without knowledge of their regular pediatrician?
(Hearing test is already done. Normal.)

When I meet the family, child has definite delay in speech related milestones. All other milestones are fine. Signs of autism are absent.

Parents ask a pointed question – “Are you sure my child does NOT have autism?”

What are my choices ?-

Fact – child has no classical early signs of autism but there is no guarantee that over next one year they will not develop at all!

Yes, that’s how it works. There is teeny-tiny chance of going on to develop autism from here but small is never 0 in medicine.

Ideally – I should explain the complexity of “diagnosis” to parents, ask them to visit speech therapist for speech stimulation work and reassess after 3-4 months again.

This is what I did. They left. Clearly not pleased or sufficiently reassured.

I saw them again after a year after this consultation at a theater. Toddler was with them. Child still has no speech at all but is very sociable, smiley, reaches out to people like a normal child, plays nicely with other kids. No sign of autism at all.

Curiosity got better of me and I asked them about their journey after meeting me. They met several other specialists of child development, did various development tests over last year.

None showed autism. But still no specialist gave them “guarantee” of “no autism ever”.

Now, for someone working in this area, it is clear that parents are on a sad quest. They are asking wrong question. “Why does my child not speak? What should we do about it?” is a correct question. This question can help move things.
Their focus on autism is a problem. Unfortunately, they don’t want to start speech therapy till “clear diagnosis” is given.

So here is a child with significant speech delay who hasn’t received any help yet except a ton of tests. I feel bad for the child, parents, their first pediatrician (he was absolutely right in calling them back after second birthday).

This is a typical path of “pay as you go” medical system where people with money can purchase whatever healthcare they desire. Here I don’t think anyone is “wrong” but lack of trust combined with anxiety has ruined one year of their life. And will continue to do so.

They are already bitter about modern medicine now. It will take one charlatan alternative therapist to tell them “oh, now it is quite late. Allopathy has no real answers” and “try” XYZ therapy.

Anxiety and pay-as-you-go healthcare is a loss-loss combination for all except crooks.

April 24, 2021

Back to the roots for Psychiatry?

Psychiatry is presently not as ostracized as it once used to be, confined to asylums.

Now a days you may even find psychiatrists invited to public functions.

A welcome change but likely to be short lived.

Why?
Read on – #stigma has always been a huge problem for psychiatry.

We got mental health away from Shamans but managed to get stigma in the process.

Persons with mental illness were always feared and hated. Hence confined to asylum, away from sanitized life of people. Anything perceived as threatening (mentally ill, free thinking women, disenfranchised minorities, political opponents, sexual minorities) was labelled as “madness/character flaw/unsoundness” etc and sent to asylum to spend rest of their life. Psychiatrists worked in such places. Looking after those who were unwanted by the world. They made sense of this madness.

As medicine progressed, neurological basis were discovered and most importantly, prescriptions could be written to achieve “cure”. History of psychiatry shows that as soon as something is discovered to be –
1. Treatable by talk therapy (depression, anxiety, relationship issues, etc.)

2. “neurodevelopmental” to be treated with some medicines but largely support (autism, ADHD, intellectual retardation)

3. Effectively treatable with medicines (epilepsy, movement disorders)

It is moved to mainstream medicine and treated by psychologists, pediatricians and physicians/neurologists. Stigma continues to work strongly in society but MORE PROMINENTLY among medical doctors.
They are afraid of serious mental illnesses that involve losing “sanity”.

That means – Schizophrenia, Any psychosis, Bipolar disorder.

In India almost no non-psychiatrist doctor knows about “Phenomenology” and “mental status examination”. So they think psychiatrists just talk with people and give labels.

As we develop more effective medical and non-medical therapies for various ills of brain and mind,
psychiatry is headed back to asylum, its birthplace. A psychiatrist is trained in “bio-psycho-social” model to look after all aspects of mind-brain-body-self-others complex.

We are gradually handing over care of mentally ill to part-specialists because it is less stigmatizing (though not necessarily any cheaper or better). This leaves care of only seriously ill to psychiatrists and psychiatric nurses.

Sometimes in asylums, sometimes in community (not necessarily integrated with society).

“Mindless psychiatry” and “brainless psychology” is often rightly criticized. Now we have entered era of “narrative based mental health”

Where does it stand as science? How does it serve society? Is getting rid of multidimensional model specialists a really good idea?

Are we throwing away baby with bathwater?

I leave you to think and comment on this rapidly turning tide of twenty first century mental health.

April 24, 2021

Managing your anxiety about Covid

If you are worried about catching Covid while at home, you can try these simple steps to reduce your worry –

1. Use small chunks of time (15-30 min) by allocating to specific activity

2. Do not re-work plans – e.g. if you are buying groceries once a week stay with it.

3. Stop looking for more info – avoiding crowd + closed spaces and wearing mask all the time is enough.

4. Washing hands ONCE after returning home is good enough.

5. Watch your emotions – distract yourself from worry, anger, sadness by involving in physical activity, art, music, etc.

6. Step away from Covid conversations in person and online.

7. Spend time with children doing chores at home, study etc.

8. Get exercise as possible.

9. Simple slowed breathing with long exhalations is helpful. Start with just 10-15 breaths multiple times in a day. Don’t stretch concentration to breaking point.

10. Call up elderly relatives for light chat and help them remember “good old days” avoid Covid discussions with them.

11. Get good sleep by switching off screens hour or two before bedtime and take light dinner.

12. Start writing – whatever you want. May be just a written record of your free running thoughts. It helps to calm mind. Usual caveat – this does not apply as treatment of mental health issues.
If distress continues beyond 2 weeks and affects your sleep, appetite, mood on daily basis, get help.

Take care.

April 24, 2021

Coping with loss of parent or family member

Over last few months many mental health practitioners like me have received requests about grief counseling due to death in family (due to Covid 19)

A short article on helping kids deal with early days of grief.

First of all – all bereaved persons do not require grief counseling –
Culture and traditions help us deal with loss of loved ones in most situations and then there are time and life , the great healers.

So please don’t rush in with psychological help on day one. When death is untimely i.e. a person who dies earlier than old age, it can get complicated.

Many factors add to trauma of grief in pandemic –

1. Trauma of finding treatment for Covid19
2. possibility of immediate family being sick or in isolation complicates things. 3. Denial of usual rituals associated with dead.
4. Lack of extended family and friends’ physical presence to soothe the grieving persons
5. Loss of more than one member of family

List just adds up. My focus in this thread is in helping children in the family to deal with first few weeks of grief. Key issue is “primary attachment figure for the child”
The person who is emotionally closest from child’s point of view, who is approached by child to share all good and bad experiences, the person who is child’s support in all aspects is primary attachment figure (simplified) Usually this person is mother. But grandmother, father, elder sibling can also be in this or a similar role.

If primary attachment figure is intact, child are well buttressed to handle grief. What happens when this key person in child’s life disappears suddenly ?

Some simple steps can help the child cope better –
1. Let the child know about hospitalization. Don’t keep it secret.

2. Let the child know about deteriorating condition (if applicable) and passing away of the person.
3. Let another member of family take the role of mother (usually it is grandmother or father in urban families)

4. Let the child realize that they are supported and looked after by actions NOT by repetitive sermons.
5. Whatever belief about “after death” existence is accepted by the family should be offered to the child.

6. Let the child express their grief freely in a manner they find okay. Don’t try to suppress their crying and grief expression because it is too much for you to bear.
7. Offer help at bedtime. Many kids can’t sleep by themselves at such times.

8. Let the child settle down with family before exposing to visitors.
9. Don’t stop the child meeting friends and playing if child desires so.

10. Routine is healing. Let the child carry on with school, play, study activity as soon as possible. I have met kids who attended school next morning. This is perfectly okay.

11. Do not go overboard in caring for the child. Infantalizing them is not a good idea.
12. Let siblings help each other.
13. Children feel safe when they see confident adults around them. Sense of continuation is important for them.

14. Some young children ask “who is going to feed me? Who will take me to toilet? Who will tell me bedtime story?” These are legitimate needs of a young kid. They are not being selfish. They are scared. Give reasonable answers. Let them know that they are supported. It is never easy to talk to or look after a bereaved child. Have faith in nature and our in born ability to overcome loss.

Please do not shut the child away from last visit to the dead. Give the child a choice if they want to see the dead body and pay their respects. This is important for the child. Children as young as 3 or 4 years have participated in last rituals of their mother sitting in lap of father. This can help the child if they desire so.
Let the child move away if they are uncomfortable in the rituals.
Choice should be child’s. I hope none of us face this situation. But life and pandemics don’t follow our wishes.

When should you look for formal psychological help?
Few pointers –
1. Inconsolable state of child even when close family members are available. 2. Serious sleep and appetite disturbances lasting beyond few days
3. Regression – child going to psychological state of much younger age e.g. bed wetting in a grown child 4. Searching for the dead intensively or denial of death lasting beyond few weeks
5. Most importantly – inability to connect with another adult.

Don’t take the child with you for first professional consultation if possible. Many times it is possible to help the child via family members.

I hope you and friends don’t have to face this situation and all this information is completely wasted.

May the force be with us all.

September 11, 2019

Preventing Suicides : What can you do?

10th Sept is World Suicide Prevention Day.

We all know that 800,000 people die every year due to suicide. 250,000 of those are Indian. So every third suicide happens in India.

Though Suicide is biggest cause of death for young Indians (15-30 age group), we do little about it.

Can you help someone stay away from suicide?

In this blog, I try to give simple tips to help you prevent suicide without feeling overwhelmed. Everyone can help.

1. All of us feel suicidal at times. Nobody is immune. If you haven’t felt it so far, give life a chance. In spite of my years of training and work in Psychiatry, I have felt suicidal at times and at least twice i was quite close to ending my life but my therapist saved my life with regular support in therapy.

2. As of now, we don’t know precisely what causes final act of suicide. People reach that point through various pathways.

3. One thing is sure, loneliness and hopelessness contribute a lot to final stage. Anger may be a big push for some who die by impulsive acts of self destruction.

4. So, whenever you realize that your friend, acquaintance, lover, student, neighbor, relative, is avoiding people , you should ask if they are okay.

5. If you are wondering about their suicidal thoughts, ask them a direct question about it. Asking is the best way to help. Dont be afraid that you may INDUCE suicidal thoughts in their mind by asking such questions. You will NOT be inducing suicide by asking.

6. Offer to talk, brew a cup of tea/coffee/hot meal. Don’t advice. Just hear them out. At the end, thank them for trusting you with all the information, thoughts and feelings.

7. Ask what you can do to help them feel better. It is a simple question but a powerful one at the end of patient and helpful listening.

8. Keep in touch. Don’t disappear from their life after this conversation.

9. If you feel overwhelmed, don’t be afraid of saying that (“it is so much to experience. Listening to your experience is overwhelming for me. I don’t know how you brave it all. Tell me how do you cope with this?”)

10. When you feel worried about their safety, call a helpline. All cities have suicide prevention helplines.

11. Lastly, remember, company and patient listening are most powerful tools to prevent suicide.

A supportive hand in hand and a patient ear goes a long long way.
Get professional help whenever it crosses your desire to help.

If you want to read Marathi translation of this article, my friend Prasad Shirgaonkar has posted it on his Facebook Page, https://www.facebook.com/prasad.shir/posts/10157411734091411 .

September 11, 2019

Why are doctors reluctant to live and Serve in villages?

My tweet thread about reality of healthcare in rural and tribal area caused some storms in the teacup. so i am writing another thread about rural practice.

My exposure to rural practice is as assistant to urologist during my medical college days, rural internship and as visiting psychiatrist to rural areas around Pune (Maharashtra) in my initial days of practice. I do have many friends and classmates who continue work in rural and semi rural areas and their experiences are helpful too.
Enough has been written about lack of infrastructure and basic facilities in such areas that makes doctors or any person reluctant to live and work there. I will not get into it again.
Two issues that are avoided in public discourse are caste equations and harassment.
Caste – your surname is a dead giveaway of your caste in India. People do not hesitate to ask directly if they can’t place you in a box. Many doctors say that they don’t want to go back to villages of their origin just to escape living their entire life in this box.
For a sensitive person and a professional like doctor, caste is a hindrance no matter if you belong to a so called upper or lower caste. Caste equations will continue to haunt every action of yours and they can not be escaped at least for now. though things are getting better.
Harassment – by local politicians, government officials and anyone with any coercive power is a major reason to avoid villages. In cities this harassment can be reduced and other doctors are there to buffer the impact. In village you are exposed and alone.
In many places, as soon as you start work/practice, you need to visit all these powerful people at their homes and offices and offer your gratitude in words, actions, services and money too. Your “joining report” will not be filled till this round is completed.
Even a minor official and politician expects you to attend home calls at any hour if their wife’s third cousin has indigestion or their dog has cut his paw. There is no escaping this reality. Costs of ignoring these calls are swift and heavy.
Many doctors have written extensively about financial exploitation that doctors face even for minor services needed to set up and run medical practice.
These issues that drive rural population to cities, keep doctors in cities. Away from areas of need.
There is no romantic sunrise and beautiful rural life that poets talk about and politicians glorify from their bullet proof heavens. I am aware that this is a social issue and not medical issue. But this is reality of India and doctors can’t solve this with a pill box.
Unless there is social evolution and financial growth (reaching last of villages), this will continue to plague us.
Forcing young doctors to spend a year in villages as “bond” is a cosmetic step. Local officer happily accepts your salary as bribe and looks the other way.
Electoral politics of democracy prevents long term vision that comes with short term pain and delayed results. Healthcare is more of an emotional subject for politicians that gets applause and votes.
I am hopeful that economic growth (if and when it happens) will change things for all. It is long , painful process with its own heavy costs on social justice and environment.

Harassment politicians and govt officials are the reason doctors avoid
government jobs in cities as well. THIS is the real reason why specialist post remain empty even in metro cities and medical colleges. Politicians and govt officials ruin EVERYTHING.

JaiHind

September 11, 2019

Diversity of Humans

As a typical Indian doctor, I meet thousands of people in my clinic every year. My work with family court, Indian medical association, students of various disciplines, juvenile justice system, prison, NGOs, film & theater, etc. brings me in contact with people from literally ALL walks of life.

As a psychiatrist for children, I get to spend lot of time with all and get to dive deeper into their mind.

And I can assure you, I have never met identical people! Sheer diversity of human nature is mind boggling. Even in severe cases where similarity is supposed to be more than differences, what stands out is uniqueness of individuals.
When we say everyone is unique, this is something that I see thousands of times every year.

There are NO stereotypes!

A person believing in stereotypes of gender, caste, religion, language, social strata, nationality, occupation, has simply not looked beyond surface. Or has looked at the world through prejudice and past conditioning.
Never too late to truly open eyes and appreciate diversity of human mind.