Facultative sexuality

Disclaimer: If you are a kid reading this, close this and watch Shin Chan. If you are an adult prude reading this, close this and watch Shin Chan 🙂

A lot of young people come to endocrinologists with hormonal issues. Some of them turn out to be interesting cases. Very few change your world view.
Today I had an interesting discussion with a fellow Endocrinologist. Apparently the number of homosexuals he saw has increased. That seemed unusual and disturbing. What might account for this? Is this a kind of referral bias? Initially I thought this must be because of the decriminalization of homosexuality – the infamous article 377 A. So it is conceivable that a lot of closet homos were revealing their orientation to the world. This is similar to the early detection hypothesis for many common chronic diseases. As in the chronic diseases , there is more to the story.
The endocrinologist told me about the story of some immigrants to Chennai. These men earned around 15000 rupees or less per month. After their monthly expenses, they had hardly any money left to splurge on entertainment. Perhaps they could afford a cigarette or two. These sexually frustrated young men couldn’t afford a girl friend. Nor could they get married, as even the peers in their own companies state categorically that they would never marry these low ballers. It is a known fact that money plays a major role in marriages. Being an underpaid male immigrant to a city is perhaps the least enviable position one can be in.
These men found themselves in a world of Tinder, but could not partake in it.Left with no other option, they found intimacy with their equally frustrated room mates. A form of situational homosexuality. While situational homosexuality is well known in prisons, barracks and other places where access to the preferred gender is absent, it is virtually unknown among free dwelling people. This form of acquired homosexuality doesn’t always stem from a lack of options.
Were these men bisexuals and were identifying as heterosexuals forced into homosexuality ? This is possible because of the heteronormative environment we live in. I wondered whether they tell the doctor this story to earn a victim tag. However, the story was consistent among men who had never met. May be they were telling the truth. They find themselves trapped in a urban prison of their own making and indulge in high risk behaviour. I can no longer see the lodges and the mansions that dot the city landscape in the same way ever again.
I turned to PubMed as usual to see if this has been reported before. I could find a study of homosexual behaviour among Indian men and was shocked to see that only 26% had homosexual tendencies ! This means that vast majority of homosexuals were opportunistic homosexuals /’acquired’ homos. This is exactly the opposite of what is found in the west. The westerners don’t turn to homosexuality because of poverty/lack of heterosexual options.
What does all this have to do with medicine? Because many homosexuals in India aren’t the ‘natural’ ones – at least according to published literature and anecdotal reports, there is perhaps a window of opportunity. Reorientation may well be a reality in some of these cases. (This is a politically thorny issue in the west, but no so much in India). It also means that the traditional conservative fears in the US and other countries aren’t too far fetched – exposure to media/movies/literature that tend to normalize homosexuality can potentially have a tremendous impact on impressionable minds.
How many of these men continue to remain homosexual throughout their lives? Unfortunately we don’t have Indian data on this. Klein sexual orientation grid can be filled up for each of these people and they need to be followed up over a long period of time. In the mean time, these men need to told about the perils they are putting themselves in and should be counseled appropriately.
Sexuality is not set in stone as many of us like to believe. It is more malleable than we care to admit. It is time to realize that there is a rich poor divide even in sexuality – the rich identify in their social media profiles as sapiosexuals, some poor are -well for want of a better word – facultative sexuals.

Further Reading

  1. A study on male homosexual behavior

Medicines that kill

I received a frantic call from my agitated cousin a couple of days back. His close relative had been admitted to the ICU with dangerously high blood pressure. The manometer showed 220/120. He had thrown seizures and an MRI was promptly taken. Thankfully it was normal.The man was in his sixties and apart from a stable kidney problem, had been chugging along just fine. Like most people with chronic conditions, he was taking a lot of tablets, including drugs to reduce blood pressure.
I thought he had stopped medicines, but I was assured that wasn’t the case. Something else had gone wrong. So I decided to dig deeper. One week back, the man had a bad headache. Like most of us in that situation, he took a paracetamol and went to sleep. To his chagrin, the damn headache returned with a vengeance next day. Having run out of ideas, he went to a nearby “medical shop” and asked for a tablet. The “shopkeeper” thought that it was his duty to give the strongest headache medicine he had – and he gave a tablet that is commonly used for migraine.
Unfortunately this migraine tablet contains ergot alkaloids – substances that can constrict blood vessels and cause a steep rise in blood pressure, especially in those with hypertension and impaired kidney function. It is akin to throwing petrol on the embers. Predictably, the tablet did its job and the man landed in the ICU with a hypertensive emergency. Sure,the ICU folks controlled his BP and made him alright, but this was a close shave. And it happened too close to me for comfort.
It made me realize, for the zillionth time, that trouble is always around the corner and even the most insignificant things matter when your organs aren’t at their best. It laid threadbare a problem most of us don’t realize – that we don’t have any over the counter drug in India! (technically we do – but you can pretty much get any medicine(except narcotics) over the counter, no questions asked). For the most part, we don’t have pharmacies either. We instead have ‘medical shops’ which will sell medicines, no matter how dangerous they are, without a prescription.
All poor countries are plagued by poor regulation. The problem is compounded in our country by the health seeking behaviour of our patients. They would rather ask a friend or neighbour for a quick fix instead of going to a doctor. Since all medicines are available over the counter, they assume that the drugs are innocuous. Nothing could be farther from truth.

One might think that learning about the drug would solve these problems. However that is wishful thinking. The package insert is generally written in such a small font that if you can read it, you can easily become a fighter pilot. And it is so inscrutable that if you can make sense of it, you should seriously consider becoming a doctor yourself.
Googling isn’t much better either. For factual queries, google is great. However choosing a medicine is a much more involved process. That’s why we spend a decade or more learning about it. It takes a special kind of ignorance to think that this can be learnt by googling for two minutes.
Let me convince you..
Many elderly people are on multiple medications which interact in myriad ways. For example, if you want to know the effect of three drugs on some biological parameter, it is naive to think that the
Total effect = Effect of A+ B +C

In reality, it is more like a function
Total Effect = f(A,B,C…)
Where the dots represents a mix of unknown factors and issues specific to a patient(such as kidney failure). More importantly the nature of this function is unique to each patient.
As doctors,we don’t know the exact effect either.But experience allows us to make a close approximation. As you can see, this process is too complex and too important to be left to some ‘shopkeeper’.
At the end of the day, we are responsible for our health. Self medicating is the easiest way to screw up that health. From drugs for common cold to muscle pain, many common drugs can cause deadly side effects in selected people. Smart people do the right thing – they meet their doctor when their health is at stake. Self medicating is dangerous and stupid.

Moral : Don’t self medicate
Conditions DON’T apply. No exceptions.


The Accident Within

During my MBBS convocation, our chief guest mentioned something that stuck with me. One of the core qualities of a doctor is tranquility – keeping calm in the face of an emotional storm. It is vital to strike a balance between empathy for the suffering of a fellow human being and the cold rationality of diagnosis, to save the patient. The newbie doctors often wrestle with this duality and as time passes, we get used to it. Soon the patients come to occupy an otherworldly dimension,needing only a careful scrutiny for diagnosis and treatment. This drift comes more easily to some people. I’m one of them. I never considered myself the ‘emotional’ type. As I coasted through medical school, I saw many cases of blood and gore. Perhaps, not as much as a surgeon would – but I had my fair share. As a physician, I had frequent encounters with stories that span the entire spectrum of human existence – from sob stories to tales of triumph. I have felt inspired, happy,sad, annoyed, bored, thrilled – and several shades of grey in between these. Yet I was always unperturbed. About the only thing I never felt often was vulnerability. I wonder if the learned professor who came for my first convocation would be proud of me.
That changed on this fateful Friday.
I had gone to the ICU to see a patient with hypocalcemia ( a condition where the blood calcium level is low). This lowering of calcium can be dangerous and can cause the heart to lose its rhythm. So I ( along with a senior colleague) went to do what was required. The ICU colleagues took us to the patient.
The patient was a thirtyish young man. His life until admission had been pretty ordinary.He had had a child a couple of weeks back (just like me).As a contented young man, he went to sleep. When he woke up, he couldn’t lift his legs. They were painful and swollen. The family quickly realized that his ordinary life had taken an extraordinary turn. They rushed him to the hospital.
Upon arrival, the doctors set out to examine him. They couldn’t find a pulse in both legs. They first thought they were unable to perceive the pulse, because the legs (from hip down) were swollen. Not wanting to take a risk, they escalated to the next step of investigations.
The doctors and the patient were in for a rude shock – the man’s blood vessels supplying the kidney and all vessels below the bifurcation of the largest artery in the body(called aorta) had simply clotted. The clot could also be found in the heart. It was as if someone had foamed his vascular tree below his belly button.
Such a catastrophic event always has a domino effect. And it did. Deprived of their blood supply, the muscles had died ( a process known as necrosis). The dying muscles released their protein contents which had clogged the kidneys, already struggling with precarious blood supply. The body desperately tried to contain the damage and initiated an inflammatory cascade : only to worsen the condition. The dying muscles and the surrounding inflammation in the finite space of his legs were throttling the blood supply further , causing what is called a compartment syndrome. (where the pressure in the compartments of leg is unbearably high). It reminded me of the freak accidents in the Hollywood movie franchise called the “Final Destination”. This time, the freak accident happened within.
It soon became clear to the managing team that they had to make a tough choice – between limb and life. Choosing the lesser evil, they decided to amputate both his lower limbs. The patient was informed of this development and had agreed. Remarkably all of this happened within 3 days!
It was at this stage that I met him. He seemed to be faring reasonably well under disastrous circumstances. Perhaps his brain couldn’t process the gravity of the situation and had gone into hibernation. Mine unfortunately hadn’t and I was, for the first time in a long time, visibly perturbed. Curiously when I saw him, there was no blood in the scene. I still don’t know what triggered that feeling in me. True to my training, I convinced myself it is multifactorial. I couldn’t shake the feeling that this could happen to anyone.
In circumstances such as these, it is generally best to focus on the problem at hand. Well, it is comforting to be in familiar territory of analysis and differential diagnosis. The case could be a fulminant form of a rare connective tissue disease, one that causes arterial clots. Then I realized perhaps the diagnosis didn’t matter at this moment. We name a disease, in the vain hope that it will give us some measure of control over it. Sometimes fate has a different idea.A young man’s life has been irrevocably changed. The entire army of doctors and all the combined man hours of training were no match for the ferocity of the disease. We stood helpless against the furious onslaught on his blood vessels. Of course, the man would live. I wasn’t sure whether to call it living or existence. May be there will be light at the end of the tunnel. May be I was too blind to see it then.
What struck me was that through all this commotion, the man had seemed more calm than me. While I had seen cases which struck a chord, I have never been in a situation where the patient was more calm than me. I must admit I was a little spooked.
Moments like make us ponder about the meaning of life – and realize the meaninglessness of the petty fights, parochial politics and proud oneupmanship. They remind us that nothing is permanent and no one is immune to misery. They urge us to make the most of the moment and in our short life, do something worthwhile.
Life is full of turns. Some we choose. Some are chosen for us. We can wallow in self pity or take charge – after all most of us aren’t this unfortunate.
That day, the fragility of the human life stood in stark contrast with the calm human resilience. An immovable object and an unstoppable force.I chose to focus on the latter.

The prisoner’s dilemma of karnataka healthcare

The starkest change I noticed after moving to Chennai was the unusual flux of Bengali patients. Even for relatively minor ailments, one can see the Bengalis coming all the way to Chennai. I assumed they had come to visit some relative and had a health checkup as an aside. Quickly I was disabused of my notions – these people had come to Chennai to  have regular health care. It seemed implausible, yet true. Having limited Hindi knowledge and zero fluency in Bengali, I never got around to unraveling the cause of this medical exodus. In the medical landscape of our vast country, Bengal is an outlier – where people seek healthcare disproportionately (and sometimes inexplicably) from another state, far off from their own. To be honest, West Bengal has some of the best doctors. For reasons best known to them, these people choose to come to Chennai (or Vellore). The key word here is “choice”.

As many other novelties in life, it wore off after a while and it had become a routine affair, until I heard about the KPME bill. Some erroneously call it an act – it isn’t, unless it is passed. For the first time, I wondered if Karnataka would join Bengal, in a situation where people seek healthcare outside Karnataka. The crucial difference is that they will not “choose’’ it, but perhaps be forced to do it. The proposed KPME bill has such far reaching consequences.

Predictably the social media became abuzz with activity. The vigilante public was baying for the private doctor’s blood. The doctors put up a valiant fight. Having been pushed to the wall, they have called for a state wide strike. The politicians have let the issue fester and are trying to fish in the muddled waters – as is usual for their tribe.

I am not going to describe the bill or list out its pros and cons. People far more qualified than me have already done that. I would instead try to show why the public would be better off supporting the doctors than the politicians.

I realized was that this is a type of Prisoner’s dilemma in game theory- a mathematical construct where two completely ‘rational’ entities don’t cooperate even if it appears in their best interests to.

Here’s an example from Wikipedia

Two members of a criminal gang are arrested and imprisoned. Each prisoner is in solitary confinement with no means of communicating with the other. The prosecutors lack sufficient evidence to convict the pair on the principal charge. They hope to get both sentenced to a year in prison on a lesser charge. Simultaneously, the prosecutors offer each prisoner a bargain. Each prisoner is given the opportunity either to: betray the other by testifying that the other committed the crime, or to cooperate with the other by remaining silent. The offer is:

  • If A and B each betray the other, each of them serves 2 years in prison
  • If A betrays B but B remains silent, A will be set free and B will serve 3 years in prison (and vice versa)

  • If A and B both remain silent, both of them will only serve 1 year in prison (on the lesser charge)

It is illustrated by the image below ( in game theory, this is called a payoff table)


Since each prisoner aims to maximize the payoffs, the dominant strategy is to betray – which results in a strong Nash equilibrium in the game. As you can see, the mutual cooperation is a better strategy, however neither entity can be sure that the other party will cooperate. So in the absence of information, there is a tendency to betray.

Now imagine the game played multiple times – an iterative version of the same dilemma and both players remember their previous encounters. It can be shown mathematically that for purely selfish reasons, mutual cooperation yields better outcomes.(The math behind this is quite complex though)

What does this have to do with the KPME bill?

The two entities in question are the public and the doctors. Although this is not a public vs doctor’s issue, just like the policeman in the scenario, the government has successfully made it so – to hide its own inefficiency and failures. As in the Prisoner’s dilemma, with imperfect information, the natural tendency is to betray the opposite party. This tendency can be short circuited to some extent by improving the information flow. After all, if both entities can trust each other, they are likely to realize that mutual cooperation is the better strategy (that maximizes the payoffs for both) in the long run.

While the public can almost certainly derive some term benefit by supporting the bill, they will be left to the lurch in the long run. In the same way, the doctors would pay a price in the long run if they were to adopt a strategy that maximizes their returns without regard for the public.

This is a type of iterative Prisoner’s dilemma where each entity has an opportunity to communicate freely, thereby identifying the strategy that will result in a win win situation. We must realize that healthcare is not a zero sum game – both doctors and public can benefit, if only we can reduce the distrust and communicate freely.

So the two things that the doctors must do urgently are

  • Disseminate authentic information to enable an honest debate
  • Work towards reducing the trust deficit

Let’s say the public/government still goes ahead and the KPME bill becomes a law. What would happen?

Doctors would have no reason to work in small nursing homes. They would be shut down. The hospitals with deeper pockets might continue for a while – but they would allocate the funds elsewhere and would shut shop.(it’s not as difficult as it sounds). The doctors would find better opportunities elsewhere and move. The brightest young boys and girls , after seeing the war waged on doctors, would decide that it isn’t worth their while to do medicine, causing the inexorable brain drain. Since the government hospitals don’t come under the ambit of this law, they would most likely remain the same. The rich and powerful would go to nearby states to seek healthcare. The poor though would be caught between the devil and the deep sea – an inefficient government hospital and a non existent private option.

Soon they would have no other option than  to start looking for options – and perhaps they might land up in Chennai ! (who knows I might be saying “Kannada gothilla” very soon to someone!)

KPME bill is a disastrous spiral into to the abyss. The people must realize that while on the surface it looks like a doctor vs patient issue it is not.


Failure to realize this might make the public act on imperfect information, just like the prisoners. And the outcome won’t be good for doctors or the public.



Solving the attribution problem in research

Imagine you have a name like me -Karthik. This is quite common in Tamilnadu and perhaps even in South India. Luckily since we don’t use surnames and rather father’s name as the last name in our state, each name is more likely to be unique. (Unless you have a family history of common names 😀). If I had been in the North and have a surname like Aggarwal or Gupta, it becomes signinficantly more difficulty to identify me as a unique individual even after knowing both first name and last name. In normal circumstances,this wouldn’t be a problem. However when you start publishing, this causes unwanted issues. In database terms, one way to uniquely identify an observation is to use composite fields -the combination of two fields,such as first name and last name. The strength of the composite field depends on the uniqueness of the combination. As I said before, this first name last name combo doesn’t work well in places where the surname is very common. There is perhaps a north south difference even in this.

Why is this a problem?

For individual faculty/researcher

You may have to use your name with title of publication or affiliation to retrieve your publications. This is cumbersome and can lead to under or over counting.

For the institute/ university

It is very hard to improve something we can’t measure. So an institute might want to track the research productivity of its faculty and researchers. One way is to have an aggregate of publications at the level of institute,department and individual. This would be automatically updated and a report can be produced quarterly. This helps us visualise the trends in publication and see when and where we need to buckle up and improve.
All of this requires identifying the publications and correctly attributing them to the respective authors. If there is a problem or error in indetification or attribution, then the whole exercise will be a waste of time.
A software called Researgence uses an approach of searching for all possible combinations of the relevant fields. This isn’t free, but can be used by universities and institutes to track their research output. As you can imagine this is computationally intensive and needs manual verification.
So we need some way to uniquely identify individuals and their contributions.
How can we simplify this process?
By following the same method that is used to uniquely identify inviduals – by assigning a unique id( for example a number or alphanumeric code) to every researcher. That will solve the problem of attribution.
Two services are available which help in this regard. If you are an academic, go over to both of these and sign up. Both are free to use.

  1. ResearcherID
  2. ORCID

From your next publication, you can let the journal known your ResearcherID or ORCID during submission itself. And it won’t matter how common your name is.

Insanely simple data collection

Problem: You want to collect data quickly using your mobile phone, but you have neither the resources nor the expertise to design a solution from scratch
Solution: EpiCollect

EpiCollect is a free data collection app developed at the Imperial College of London. In my opinion, it is the simplest way to collect data on a mobile, without writing a single line of code. It is so simple that you can make a fully functional data collection form in under 3 minutes! It even allows you to take the patient’s photo or read a bar code.


How to make a simple data collection form?

The steps are

  1. Go to EpiCollect website
  2. Login with your Google account
  3. Create a project
  4. Make a web form using the drag and drop form builder
  5. Set the access to your project to be private and visibility to be “visible”
  6. Download EpiCollect app to your phone
  7. Login and search for your project
  8. Start entering data
  9. Export to CSV(or JSON if you want) [ you can also view it on the web]

What is so exciting about EpiCollect?

  1. It is free for everyone – unlike REDCap you don’t need an institutional email id
  2. It allows flawless data collection using a mobile app – even offline
  3. It allows some special fields for data collection – like photos,audio,video, barcode – useful for qualitative research as well
  4. It allows geotagging – useful for field research
  5. It allows advanced data collection – data validation(even allowing regex – regular expressions),branching and jumps
  6. You can add multiple users to your project – for example, a multi-department registry

I want to know more. What can I do?

Go to the EpiCollect website and you will have all the information you need. I can guarantee that you will find the process very easy – even if you are a luddite. Just give it a spin.(Be sure to use the latest version-EpiCollect 5).

Note: You can do some other advanced stuff with this. For example, MicroReact (which uses EpiCollect allows researchers to track epidemics in real time)

Oath of Penury

A recent Vijay starrer has come under a lot of criticism for ‘negative’ portrayal of doctors. In fact, some senior doctors have called for boycotting the movie(well within their rights) and advocated piracy (something that is clearly illegal). Perhaps this looks like retributive justice to them. This selective doctor bashing is nothing new though – after all the doctors are soft targets. 

Each one of these movies has a stale pattern of ideas –

  • The doctors are thieves.
  • They make way too much money
  • They need to be punished
  • The patient is always right

If you happen to  think  doctors are thieves,I am pretty confident that you haven’t seen one in close quarters. Most doctors are rather benign chaps who would gladly skip their lunch or a weekend outing if the situation demands. This can hardly be said about any other profession. Any bad trait is invariably present in every group of people on earth – no matter how differently you slice and dice the groups. So it is a statistical reality that some doctors will be bad – as will be some engineers, pilots, auto drivers and so on. It is stupid to use outliers alone to make judgments about a profession.

Do the doctors make a lot of money? It depends. The ‘doctor’ is not a homogeneous entity – there are the average joes and the super rich amongst us. The question therefore is – do the doctors make money by fleecing the public? The answer is a qualified no. Once again, by focusing on the outliers, it is easy to come to a dubious conclusion.

So why does this idea have such visceral appeal to the masses?This idea  stems from the  erroneous thinking that doctors run the show in major corporate hospitals. It is vital to understand that while there has been a gradual deterioration in the social mores, it is hardly limited to the medical profession. Before you dismiss this as a thinly veiled whataboutery, imagine your childhood – the media, the education, the local business -indeed everything that you can imagine has become increasingly commercial. No single person/sector can be held responsible for such a massive change. Thus the commercialization is a direct result of our shifting priorities and our values.

When a tectonic shift occurs, there will be some winners and some losers. It is inevitable. So the question is – are doctors actually the winners in this large scale commercialization? To answer that we need to rephrase the question – is the average doctor a winner in such large scale commercialization? The answer of course is no. Corporate hospitals employ only a few doctors and often don’t pay that well. The mad rush for postgraduate courses and the cut throat competition in medicine has made it increasingly difficult for the average doctor to start a practice. So much so that the doctors of the previous generation, could realistically expect to start a practice, go through the mandatory lean patch, and come out successful in a reasonable time frame. It is increasingly difficult for doctors of the current generation to do so. The pressure to get another degree (something that will never cease to exist) and the economic realities force most doctors to work for a pittance in hospitals.

On top of this, the changing expectations of the public has put a huge amount of pressure on medicine. The casual and stupid belief that doctors (for that matter anyone) can exist without money is ludicrous. Nobility has been pushed down the throats of doctors so much so that the idea of a poor doctor laboring in a rural area without facilities and taking five rupees as fees titillates the people. These very same people however have very clear financial goals for themselves. The prevailing quasi socialist political atmosphere normalizes this fantasy and in most cases gives some kind of external validation to the dumbos who think this way.

I always wonder, if these guys think becoming a doctor is such a great way to make money, why didn’t they slog their asses off to get into medicine in the first place? It is politically expedient to avoid asking such uncomfortable questions to which we all know the answer for. Let’s get real – inequality is as old as the sky and the oceans. It was there before we lived and it will exist for eons after our demise. Does that mean inequality is pretty or inevitable? Perhaps not,but frankly I am not sure. Some people will work harder and earn more than the others. As long as they do so within the boundaries of law and pay their taxes, it should be no one’s business how much  they earn.I

It is high time, we accepted that no profession is there to do just ‘service’. When we became doctors, we took the Hippocratic oath – not an oath of penury.