Ships of Theseus

Back in the day when I was student, I used to fondly think of medical conferences as the modern day equivalent of Epidaurus in Ancient Greece.A grand annual meeting of enlightened minds discussing important things with a noble purpose. I suppose I was blue pilled and naive.

This idea persisted even as I got into MD and was involved in a conference (like other pgs of my batch). Ironically most people from my batch, never attended conferences outside Jipmer.It seemed odd, but then work kept us busy. Slowly, things started to look different. More and more conferences didn’t resemble the idyllic knowledge meets that I had believed them to be. Try as might, I couldn’t shake the feeling that something was amiss.

In the movie Matrix , Morpheus offers Neo two choices – the blue pill and the red pill. The blue pill allows him to forget everything, continue as usual as if nothing has happened. “Take the red pill and I shall show you how deep the rabbit hole goes”, says Morpheus. As Neo reaches for the red pill, Morpheus cautions – know that this will give you the truth, nothing else. In a sense, this fork in the path is hardly unique to Neo. All of us, at some point face this – we can to either continue to live in our cozy web of fantasy or face the reality. Sadly, unlike Neo we aren’t always offered the choice.

As I got older and joined DM, I started going to more and more conferences and CMEs. I didn’t choose the red pill. It was shoved down my throat.

Many people it seemed came to conferences just to collect bags and have a good dinner with booze. The grandeur of the conferences I attended couldn’t mask the poverty of meaningful research. To add insult to injury, number of conferences and events steadily increased . Of course, you can’t conduct events without money. Somebody has to pay the bills. The industry pitched in. This meant that the content of the talks have a binary choice – be purely utilitarian or commercial. The former is to satisfy the large number of general practitioners who are fishing for that nugget of wisdom which they can implement in their practice. The latter is more insidious and has been actively banned in some countries. Nevertheless, premium slots and premium speakers are often about some drug or the other. It was as if the entire enchilada is geared towards teaching doctors what to prescribe, without getting into any boring nuances. Of course educating the generalist working in the trenches is a worthy goal in itself – provided it doesn’t devolve into mere sound bites.

The kind of difficult talks and long discussions needed to clarify a concept usually don’t have many takers. It requires much more effort to both give and listen to such talks. Consequently it needs to be protected. Think of the governmental choice between constructing a shopping mall vs a park in vacant plot. If the choices are purely dictated by revenue, this would be a no-brainer. However a government, unlike a corporation, ought to have the mettle to rise above the bottom line, numbers and do what is good, but not profitable.

As I contemplate the meaning of conferences, talks, CMEs and other meetings I have attended,I am reminded of the Ship of Theseus. The legendary Greek king Theseus won many naval battles and the people kept his ship in the shore , as a reminnder of his bravery. As the years rolled by, the planks of the ship started to rot and get damaged. Old ones were replaced by new planks and over a few centuries, precious little of the original ship remained. If the entire ship were to be replaced by new parts, does the ship still retain its identity? This philosophical conundrum has baffled men far better than I can ever be. How much of the ship can be replaced while keeping the identity intact?What is the last plank that when replaced completely changes the identify of the ship? Does the ship have an identity of its own at all – or is it irrevocably tied to the brave king ? Is identity ever independent of time?

The original creed of the medical conference, (if it ever really existed) has somehow been hit by a terrible mutation. While most doctors would claim that the big Pharma and the money are responsible, I know deep down that our community owed a big mea culpa too. Like the Ship of Theseus, conferences are in danger of losing their identity. How much commercialisation can we allow before a medical conference ceases to be one?

It’s time we had a serious conversation about conferences.


Reproducible research with Stata

Anyone who has used R for statistical analysis would be familiar with the incredible power and ease of use of RMarkdown. Having the code, data and the narrative together in one document enables reproducible research. More than anything else, it makes life easy.

As a fan of Stata, I wasn’t as satisfied with the stock options in Stata. As usual, user contributed packages come to the rescue. It may not be as elegant or extensive as the RMarkdown – for instance you can’t make HTML5 presentations with Stata programmatically. However, with LaTeX you can create beautiful Beamer presentations directly from a single text file written in Markdown – an easy to use markup system. The opportunities are nearly infinite.

What you will need ?

  1. Stata 14 or above
  2. Markstat package ( install using ssc install markstat)
  3. Whereis package (install using ssc install whereis)
  4. Pandoc – install it from the official Pandoc site

Once you have installed Pandoc, install Markstat and Whereis packages in Stata. The next step is to tell Stata where Pandoc is located – so that it can convert the markdown file into a html document.

If you are on, windows and installed Pandoc in the default location, type this in Stata

If you are on a Mac, fire up the terminal and type

whereis pandoc

Copy the location of the pandoc executable, and use it to tell Stata where it is located , like so

whereis pandoc /usr/bin/pandoc

Now that you are done, get back to Stata. Open Stata do file editor and start typing your narrative. The code blocks are separated by a tab. This is ridiculously easy and is even easier than the official dyndoc option in Stata 15.

Once you are done, save the file as filename.stmd. Note the extension. If your operating system hides file extensions by default, make sure you display them. Otherwise you might save the file as which is not what we want. Now you can generate the final document which you can share with colleagues by typing

markstat using filename.stmd,bundle

The bundle option is to ensure that any image that is generated is knit into the html file. You can omit it if your stmd file doesn’t have any images, but it find it a good habit to use the option anyway.

Here’s my brief screencast of how it is done. (Sans audio)

The best part is, since the source document is essentially a text file, it can be easily shared with colleagues too.

Note: If you want pdfs to be generated you need to have LaTeX installed in your system. (MikTeX for windows, TeXLive for Linux and MacTeX for the Mac)

Bad Obstetric history : Role of Endocrinologist

This is a presentation I gave in Magna Code Endocrine Update 2018. As the name implies, this outlines the role of an endocrinologist in the management of women who have recurrent pregnancy loss.

A lot of endocrine conditions need to considered, some of which may not be immediately apparent. An endocrine opinion is often useful in these cases.

As usual, my presentation is open sourced and you can use it without attribution for any purpose. Here’s the link

Bad Obstetric History

Post transplant diabetes

Yesterday I saw a patient with post transplant diabetes. I guess this is a good time to share a presentation on this topic I did a while ago, when I was in final year DM. The purpose is to make it easier for those who make a presentation on this topic to get started and to give a brief 2 minute refresher for the time strapped DM/MD pg going for exam.

Here’s the link to download the presentation as a pptx file

Post transplant diabetes

Stranded : My accidental visit to the city of love

Sometimes things happen, that seem so incredible, that you wonder if you could have scripted it better had you written your own fate. Of course, this is in hind sight- and hindsight is 20/20.

I had been to Athens for 3 days. That trip itself was something to cherish , as it was my first visit abroad. Apart from a great academic experience, the visit turned out to have a lot of ‘meetings’ with interesting people. Everything was going according to the plan. Our team from Chennai had myself and a couple of ladies- a dietician and a study coordinator.On the last day, we bid adieu to the people from different countries (after winning an informal quiz) and were ready to come back home via Paris. I had no idea that day, that our best laid plans would be scuttled by the capricious hands of fate.

We had a little over an hour to catch a connect flight. The Paris airport is huge – bigger than any I have seen so far. (If you think it’s small, congrats!you certainly have traveled the world enough).Our flight from Athens landed a few minutes late – a little annoying , but nothing to worry. We proceeded to the connecting flight.

That’s when our luck went south. The sign boards weren’t really clear about where to go and the people weren’t quite helpful either. To our utter chagrin, we realised that we had to catch a bus and a train in the airport to reach the connecting terminal. A little something we hadn’t planned for, but still doable. Or so I convinced myself. I could see clouds of worry in the faces of my team mates. Being a perennial optimist, my pulse stayed a comfortable 70 bpm.

There was a pandemonium at the place where the bus stops. Some 100 people were standing and discussing loudly. It was truly a Babel of cacophony – I couldn’t understand a word. Luckily the couple behind me were Scottish. They told me that the bus was delayed because someone had left a bag inside it. I thought, what’s the big deal – we all forget our bags sometimes, or so I told myself. Unfortunately trouble was brewing.
An unclaimed bag can look ominous and naturally it triggered a security protocol. There were frantic calls by the airport authority. It was then that I knew they were actively considering the possibility of a bomb.

WTF! I cursed under my breath. Like any normal person, I don’t like terrorists, but at that moment I was so furious that I could have mauled one.The precious minutes were flying away and the airport guys just shrugged their shoulders saying it is a matter of security and that they can’t do anything unless the bag is cleared by the bomb squad.

With nothing much to do other than pray, we waited patiently. Some Americans were getting worked up and gave a piece of their mind. It was mildly amusing that regardless of your skin color the French authorities treat you like nuisance. It was mildly amusing, but I wasn’t in the mood.

As the seconds ticked away, I knew that our plan was collapsing. Stranded in a foreign airport on a first visit abroad because of a bloody bomb scare? Who could have thought of it?

To cut a long story short, we missed the flight. The dietician and study co-ordinator were restless, on the verge of tears. A couple of others from India were with us – an elderly Mallu lady who didn’t speak much English, traveling to Houston alone and a software engineer traveling home to Chennai from Zurich.

We proceeded to the airport authorities to try and salvage the situation. If you think Indian government hospitals send patients on a never ending loop of redirects, try missing a flight in the Paris airport. We had to move from 2C to 2E to 2M to 2K to 2F ! It seemed like the French were teaching us English alphabets. Damn, these guys didn’t know we were the second best Englishmen. To make matters worse, these terminals weren’t really close to each other.

The AirFrance guys took their own sweet time to confirm our version of events. There was only one flight per day to Chennai and we had missed it. Their contention: Since the delay wasn’t at their end, (they blamed the airport authority) they can’t provide us any accommodation. However they would give us tickets for the next day’s flight at no charge. That I was flying business class made no difference. Just when I thought things couldn’t go worse, our baggage wasn’t traceable in Paris ! I had boarded the flight at 6 AM ( and had to wake up by 2.30 AM). I was a little tired and had no clothes to change.I remembered the lines from my 10th standard English book (they occasionally come in handy) – an adventure is just an inconvenience rightly construed.

It appeared that the providence had conspired for us to visit the beautiful city. So I decided to make the most out of it. Luckily , the schengen visa allowed me to enter Paris. Luckily there is no such thing as Frexit.

I walked out of terminal 2F into city of love. The weather was a little colder than Athens. As a Pondicherrian, the sign boards seemed vaguely familiar – though I didn’t understand what was written. Took a bus from Aiport to Tour Eiffel (line 2).

The Eiffel is a good 26 km from Charles de Gaulle airport. The scenery on the way was breath-taking. I wondered why anyone who has ever visited this city would ever live elsewhere. On the way , I saw some big ticket hotels standing as a symbol of the French opulence. More than anything else, the design of the city was oozing history in all its infinite pores. Every stone has a story, if only we have the ears to listen. The city seemed so beautiful that it seems to be built for the Gods!

The man sitting next to me spoke little English. We exchanged glances and nothing more. The bus dropped us at Avenue de Suffren – a street by the same name exists in Pondy too. We strolled through the street to be greeted by the magnificent splendor of the Eiffel tower. The tower is , to say the least, huge.

WhatsApp Image 2018-04-28 at 9.57.05 AM
There are some names written on the sides of the imposing metal structure – perhaps belonging to the men who worked for this marvel to be possible. I noted wryly that few people remember them today. That’s not the point anyway – they gave their best and it showed.

As we stood in the queue for tickets, we met a German girl , exploring Paris. It was a relief to hear English.She had been working on and is passionate about cryptocurrency and bitcoin mining. When I was her age, the only thing I was good at was solving MCQs. We were soon joined by an American student who started extolling the virtues of the GoPro camera and how it helps to make great videos. I couldn’t help but wonder about the implausibility of the moment – here I was in one of the most iconic places in Paris, discussing AI, Bitcoins and professional video editing with a German and American. The world is really a small place. The thread of thoughts that unite us weave imperceptibly into  beautiful and complex fractals.

WhatsApp Image 2018-04-28 at 12.09.18 PM

We climbed upto level 2. The climb was steep and left me a little breathless. I had already clocked 14k steps that day. Every muscle in my body longed for rest. But the pull of the Eiffel was irresistible.
A gust of chill air struck my face as I reached the top of the tower. There was a mini bar – perhaps catering to people who want to get high in the sky. The Instagram generation was busy taking photos.

I stood there, gazing at the evening Paris in all its beauty wondering if I would ever be able to put in words and do justice. This post is a feeble attempt. The mighty river Seine flowed steadily in the background, oblivious to the waves of emotion I was experiencing.

WhatsApp Image 2018-04-28 at 9.57.04 AM

After some time, we climbed down. I took a detour to the famed Louvre museum. It was getting late and I couldn’t see the museum as fully as I would have loved to. I took a few pics.

The Paris night sky was getting darker. I went to the Champs de Elysees before returing to the bus stop.

WhatsApp Image 2018-04-28 at 9.57.05 AM-2

A Vietnamese couple had come for their honeymoon and I had dinner at the Cafe Ribe with them. I sat there painfully aware that , within my lifetime, my country would never look like Paris. Nevertheless I extended a warm invitation for the couple to come to India. Can a warm invitation to a hot country be called hot invitation? I don’t know.

The bus came back and I boarded it – fully exhausted, but with a stupid satisfied grin on my face. I have no idea what the driver thought. As I cam back to the airport, I saw this pic that aptly summarized how I felt.

Life is unpredictable. The surprises are sometimes sweet, sometimes not. Even if our best laid plans go awry, there’s always something better around the corner. To explore, enjoy and experience.

As I got ready to come back home, I saw this pic that aptly summarised what I felt.

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Vitamin D in pediatrics and dermatology

Vitamin D in pediatrics and dermatology

Since I have been giving a few presentations lately, I thought it would be a good idea to share each of them as blog posts. Now before anyone points out, this is the simplest and laziest way to make a blog post. However it is probably of some use to someone- that’s the point of this blog anyway.

This is a presentation I gave for the MagnaCode endocrine update 2018. As you might guess by going through the presentation, I am not a big fan of the use of vitamin D for any random symptom. 🙂

Vitamin D in pediatrics and dermatology

Of Green cards and blue skypes

Recently, I had been to a health camp for elderly,organized by a particular community. The organizers welcomed us with some authentic Udipi cuisine. The lip smacking food augured well for the day. After a few minutes, we started seeing patients. There were about 100 in all. Unlike the health camps I had been to before, the patients here didn’t seem poor by any stretch of imagination. Many men were clad in crisp pinstripes, perhaps reminding themselves of their bygone days. The womenfolk were colourful as usual – from silk sarees to fashionable chudithars; the place resembled a marriage hall more than a health camp.I wondered what brought them there on a Sunday.
Soon they were talking amongst themselves. The room had come alive. They talked as if there were no tomorrow. Noisy opds were my natural habitat. I felt perfectly at home. As the patients started coming one by one, I realized that their medical problems were, to put it mildly, minor. Yes, they had the usual wear and tear of age, but nothing that would require the knowledge in the huge books I had learnt over a decade. This would not be a day of Eureka moments. There would be no endorphin surges that we get when we crack complex cases by connecting disparate dots.
A wizened old man, lumbered towards me. I asked him what his problem was. He hesitated a moment, but told me he had diabetes. I looked at the lab reports he had brought. The numbers were fine, considering his age. He said something about vague aches and pains. This is a routine every doctor goes through, we even have a fancy name for it – myalgia. But as I grow older, I realize that myalgia is just an empty euphemism for things we don’t understand or can’t solve. Every myalgia has a story behind it, clamoring to be heard by those who are patient enough. Time was on my side that day. I decided to dig deeper.
The man came from a respectable upper middle class neighbourhood. Like many Indian parents, his life revolved around his children. He was well off, and since he expected a windfall from ancestral property anyway, he had no worries about retirement. His life’s arc was so predictable that it could be superimposed on those of  his friends or relatives and we would see perfect congruence. He educated his kids in the best of schools. He had been proud when he waved off his children to the foreign shores, much to the burning envy of his relatives.
After that, it was a predictable tale of green cards and blue skypes. He hardly ever saw his children in person. Being a man of means, he could afford to go to the land of many people’s dreams. He learnt first hand why foreign countries were called ‘foreign’. It wasn’t that his children were bad or unkind. The change had been too much and too swift. He simply didn’t feel at home, away from his beloved Madras. He wondered if it was all worth it.
As he recounted his story, I saw some of my own fears, biases and hopes in him. We were separated by 40 years of age, yet we shared a penchant for the same simple pleasures. An early morning coffee, a walk to the nearby temple and some light reading. A chat with friends, of ‘life matters’ and beyond. An evening spent with children – playing and teasing. Life’s greatest pleasures cost little. Yet we join the rat race, hoping that running will save us from the fear emanating from stillness. We believe that having a lot of money will make our dusk seem like dawn. If only life were that simple.
I remembered something I read somewhere. A widow is someone who has lost a husband. Widower, orphans and a lot of words exist for those who have lost their loved ones, but there is no word for someone who has lost his children. That’s how awful it is.
These are the new age orphans. Financially comfortable but lonely and sad. I guess, they visit doctors just to talk to someone who would listen. As I scribbled some medicine, he gave me a nod. No words were spoken, none were needed. We both knew we didn’t care about the numbers on the glucometer.
Hidden behind the ‘carnivalesque’ appearance of the health camp was a  soul crushing sadness. It was a health camp, just not only for diseases of the body. Ailments of the soul are harder to cure, but a listening ear goes a long way.