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

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.

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

Is it enough to honor doctors serving in rural and tribal area?

2019
1. This year’s Republic day honor list includes many doctors who are not based in and around metro cities. This is a welcome change.

2. It includes Dr & Mrs Kolhe from Maharashtra. Their work to get affordable healthcare to tribal areas of Maharashtra is well documented. Their honor with Padmashree is well deserved and a joy to all who are interested in healthcare for all.

3. Every state of India has doctors who work selflessly in remote areas where no doctors are available. These doctors give away all comforts of civilized life and spend it in service of under served communities.

4. In Maharashtra, we have Amte Family (3 generations), Bang family (2 generations), Bawiskar family and Kolhe family devoted to this work.

5. All of them have also worked to improve access to drinking water, roads, schools and healthcare.

6. They have risen above and beyond call of duty to work in area of governance as it is a primary support of health and healthcare.

7. after 3 generations in same geographical area, things haven’t fundamentally changed.

8. Utter failure of governance in these areas is the real reason why individual families have to make ultimate sacrifice in service of poor.

9. Elected representatives who get homes in metros, lifelong free healthcare and pensions never feel the pain.

10. Elected representatives are happy to point fingers at doctors for not choosing these areas to “serve”. Almost all of them have homes in cities and children in urban, expensive schools.

11. It is inconceivable that a highly educated doctor will take her/his family to remote area where even drinking water is not available and everyone around is looking for a way to migrate to cities for better life.

12. While my head is raised high due to selfless achievements of Dr Kolhe couple. It hangs in shame because their work is needed 70 years post independence.

13. Every Padmashree, Padmabhushan, Padmavibhushan and Bharatratna bestowed upon a doctor for “selfless” service is a reminder that individuals are trying to fill the void where successive governments have failed again and again.

14. I honestly wish that rural development and economic development reaches a level where doctors will be honored for their innovative work in treatments and services and not for sacrificing their life due to failure of governance.
Each honor is a glory of individual but a mark of our collective failure.
#JaiHind