Do debates actually harm medicine?

It was during the second year of DM , I was exposed to an interesting kind of academic activity in a conference -the medical debate. The issue in question was a thorny one – with conflicting data. The speakers were excellent and put forth brilliant points for and against the motion. As it so happened, they were both comparable not just in their credentials as doctors but also in their public speaking and debating skills.
As I attended more conferences, it soon became clear the debates were a fixture in many medical conferences and were eagerly awaited by the audience. The speakers in turn tried to do as much justice to the topic as possible. Unfortunately there were some problems

  • Some speakers were better than others – and their point of view was more likely to resonate with the audience
  • Even if the speakers were convinced of the other person’s argument to some extent, it soon became a contest in hyperbole

Most importantly it became a contest between individuals and not ideas. This is of course, entirely predictable to anyone who knows how the human mind works. We back people with ideas, not just ideas. Arjuna vs Karna, Tesla vs Edison, Steve Jobs vs Bill Gates – we revel in the great individual rivalries. You might scoff at this rather ridiculous over simplification. After all, the attendees of conferences are highly educated people, not given to emotional support of one speaker or the other.
Unfortunately, education doesn’t make us immune to biases and blind spots. The nature of the debate means that, the speakers have little incentive to expound on the gray areas and are forced to make emphatic statements in front of an audience baying for certainty. Medical science is rife with uncertainty and it is this uncertainty that make it interesting. To dissect the gray zone in which the debate occurs, the speakers and the audience need to know a lot of details. Some of these details like statistics are boring to the average listener ,but is at least available in public domain. Others are effectively hidden from the prying eyes of the public and are probably sleeping safe in the digital vaults of the companies that conduct the studies.
The need for certainty of the average audience member and the near universal reluctance to dig deeper into difficult topics makes it much harder to convey the nuances involved. At the end of the day, the audience are at risk of taking home the message they understand / like the best – setting the stage for eloquence based medicine. So I wondered, if the non-specialist audience could be influenced by the better speaker in the debate, would it make sense for the companies to ask for a particular speaker to speak for their product? Perhaps I’m being too cynical – I will leave it to your judgment. The moderator of the debate should be a person with impeccable credentials and should be able to rise above the need to simply give the audience some satisfying soundbites. Luckily in most debates this is the case – but not always.
More than posters, oral paper presentations and invited orations, debates spark enormous interest. With great popularity,comes great responsibility. Sometimes, I wonder if the moderator should make slide – instead of , or after the rebuttal. People remember what they see – so this should probably tilt the balance towards the truth (if one is known).

After every debate, I’m reminded of the final scene in the Kamal movie Nayagan, where the don’s grandson asks him a very simple question “Neenga nallavara,kettavara? (Are you a good man or bad man?)” – to which Kamal replies ‘I don’t now”. Some audience are like Kamal’s grandson – hoping for a simple answer to a very complex and nuanced question. I wish we had Kamals to tell them the truth.


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

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.

Medicalruminations turns one

It’s been a year – of great fun and learning.Medical ruminations turns one today! I have benefited immensely from your words of wisdom.

Just wanted to take the time out to say a Big Thank you 🙂

Thank you card



An antidote to apathy

Sometimes your moment of epiphany comes in the most unlikely of places. And things are never the same again.

It was November 2012. I had just gotten married and booked tickets to Andamans. On day 2 , we had gone to the Cellular Jail. Little did I know that the night would mark a tectonic shift in my world view. They had arranged a light and sound show to show the tourists about the struggles of countless men incarcerated there during India’s darkest years. The sheer impossibility of escape and the brutal conditions of the jail would break even the strongest men.

I was transfixed and with great respect visited Savarkar’s cell. Veer Savarkar was kept in a cell (strategically) just opposite the gallows – so that he can see the prisoners getting hanged. The man had written  – in Hindi – a poem to the birds,

“I don’t know your language, but If I did, I would teach you the Indian National anthem”

Even now, it’s hard for me to say in any language,including my own, what I felt at that moment. Perhaps a gush or respect , a wave of pride,love for the nation all mixed in intoxicating proportions, that I almost lost balance. It was then that the unthinkable happened.

Several people behind me had been making noises, smoking and making fools of themselves generally. In spite of admonition from the guide, they paid little heed to the sanctity of the ground they were treading. It was a generation that didn’t have to deal with British atrocities. The irony of the situation wasn’t lost on me – that they were able to do that in Cellular jail only because of the sacrifice of thousands of freedom fighters. Sometimes when you get something, without toiling for it, you hardly understand its value. These ungrateful brats had the temerity to go to gallows and make some stupid jokes!

Life had come a full circle. From the time when we were united and used every means to wrest freedom from a cold empire, we had become a nation with no pride or self respect. I,Me and Myself had become the dominant personal ideology. The government had embraced a politics of anything goes and by natural progression, scams rocked the country. The regularity of these scams would put any Swiss watch maker to shame.

I had little idea of Modi or BJP then. Nor was I particularly aware that nationalism was an antidote to the plague I was witnessing. I was one of those happy go lucky guys whose life revolves around a book, a laptop and a cup of coffee. I was decidedly apolitical. Of course, just because we don’t take interest in politics doesn’t mean politics won’t take interest in us.

The questions kept haunting me through out my honeymoon – just like the rhythmic waves that hit the beautiful beaches of Andamans. Why did these people feel no respect or love for the freedom fighters? Why were they not proud of their heritage? Where did we lose the plot? More importantly, what is the solution?

Of course, it was apparent that in a vast and diverse country like India, it is juvenile to expect a knight in shining armor to come and change things. It was also clear that we were at cross roads in history – a decisive moment – when things can only change for the better, if there is a thorough overhaul of the dominant narrative. The political discourse needed some shaking up. We needed to find some way to unite the country – the sleeping giant – and gear up to take a larger role in the world stage.

It was then that Modi happened. The social media powered campaign was a blitzkrieg. Like so many of my country men, I came under his spell. We see only what we want to see, and believe someone who says what we want to hear. He was a master orator and I cursed myself for not knowing enough Hindi to understand his speeches.

Three years on – when I look around – I am happy that things have finally started to change.But sometimes it’s hard to shake off the feeling that we might have gone overboard. The duality has become quite stark – not that is always bad – after all , if you looking at good and bad, you can’t complain of them being totally different. The media has become more polarised – so much so that it’s hard to tell what is true these days. The quality of public discourse is laughably poor – incessant fights on language, religion and caste continue to plague us.

As India has become a global power to reckon with, our vulnerability to external threat has diminished substantially. To put it in our PM’s words, India of 2017 is not the same as India of 1962. The standoff in Doklam and China’s cautious approach is ample testimony to this fact. Our growing clout is undeniable.

Unfortunately we are quite vulnerable to ourselves and our folly. We may have become more divided nation – or so it seems. The very drug of nationalism which was intended to treat the apathy has now reached militant heights. The shrill cry of hypernationalism is threatening to tear the fabric of our cherished diversity. After all, our flag is a tricolor, not some monochrome.

I was and still remain a subclinical sanghi. I do wonder if my political pendulum is beginning to swing towards the centre. On this glorious Independence day, we must realize that our differences don’t matter as much as our shared history and bonds. We need to tell our kids that we take great pride in our Indian identity- the primary identity of all of us.Just like our forefathers who toiled hoping that their children and grandchildren would one day live in a free India, we need to work hard to ensure that we don’t drop the baton. We owe it to those brave souls who shed their blood and sweat in cellular jail.

Happy Independence day!

Jai Hind!


Marriage and the nocebo effect


Today morning, I opened The Lancet, to see an interesting Statin trial that looked at SAMS (Statin associated muscle symptoms). You can read the trial here

Adverse events associated with unblinded, but not with blinded, statin therapy in the Anglo-Scandinavian Cardiac Outcomes Trial—Lipid-Lowering Arm (ASCOT-LLA): a randomised double-blind placebo-controlled trial and its non-randomised non-blind extension phase


Statins are cholesterol lowering drugs that are sometimes associated with muscle pains. Unlike myopathy or myonecrosis, muscle pains have no objective  biochemical or histological component. The authors had analyzed the statin related adverse effects during the blinded(patient doesn’t know he’s taking statin) and the unblinded(patient knows he’s taking statin) phase of ASCOT trial. When the patients knew they were taking statins, they complained of muscle pains. When they didn’t know what they were taking, they had no symptoms !

In other words, their expectation of what statin might cause (after learning about it from net/other sources) influenced their symptoms. This fascinating phenomenon is called the nocebo effect.It’s the negative cousin of the well known placebo effect. It reflects changes in human psychobiology involving the brain, body, and behaviour rather than drug toxicity.Muscle related adverse effects are often low in randomized trials  compared with observational studies. The strength of this study is that these were the same patients, no run-in period existed to exclude patients intolerant to therapy, and few patients had previously taken any statins.

This reminded me of some of the unfortunate posts on marriage I ve been seeing in Facebook and Quora of late. The liberal rants have an unmistakable pattern – they claim that marriage is the worst thing that can happen to a person. There are some sites (such as this one) whose only job appears to “educate” people on the evils of marriage and praise any and every form of decadence. You can see this in present day movies as well – the premise is that if you get married you are screwed. All these sources happen to think the plural of anecdote is data – it’s not.

It’s possible this can have a “nocebo effect” on our youth – for example,some of the fine boys I know appear to have become unusually nervous at the thought of getting married. Such negativity  may even become a self fulfilling doomsday prophecy. At the expense of committing the same sin as the liberals(the plural of anecdotes!), I must say there is nothing to be afraid of about marriage. Sure,occasional mishaps happen – but they are ,thankfully, still not the norm. Of course, our world view is colored by our own atomized experinces. I am also aware that just because,my experience is overwhelmingly positive doesn’t mean everyone’s will be the same. In any case, it’s important to keep an open mind. Negative thoughts are clearly useless.

PS: Here’s a pro tip: Stay away from the leftist/liberal websites that spew constant trash, if you can. You won’t regret it.

The One Eyed Surgeon

Yesterday I attended an annual internal oration on the cancer scenario in India and the challenges that lay ahead. With abject poverty, woefully inadequate infrastructure and acute shortage of oncologists in several parts of our country, the stats predicted a bleak future.It appeared as if we were going to a nuclear war armed with sticks and stones.In this hopeless scenario, I was reminded of one of my heroes, a man who fought against impossible odds and scripted one of medicine’s most glorious victories.

The year was 1957. A middle aged surgeon was working  in Uganda, in the Mulago hospital in Kampala.He was a devout Christian and considered himself a missionary. By his own admission, he wasn’t a great surgeon.What he lacked in surgical genius, he made up for in tenacity. One day a boy named Africa who walked into his clinic. The malnourished boy had a large swelling in his jaw-making him look grotesque. In a few days, the boy died of his tumor. A couple of weeks later another boy walked into his clinic, with the same kind of swelling and met the same end eventually. The surgeon was intrigued – by the striking similarity of the cases and the ferocity of the tumor. He decided to investigate.

He had a handicap though – a stray bouncer had damaged one of his eyes permanently during an adoloscent cricket match. He was aging and was working in Sub Saharan Africa -far from where the limelight usually shone in medicine. He had no funds or even great expertise to draw upon. The people he treated were poor and wanted some solace for their pain, not fancy research.

Nevertheless with characteristic zeal, he asked around if doctors had seen similar cases. They said yes – so he pored over the records and to his astonishment found several similar cases, all of them ending in death. No one had connected the dots till then. He then looked at the literature – sure enough, there was an article about a similar tumor in 1901 in an obscure tropical medicine journal. The tumor he had seen wasn’t new. The pathologists had reported each of these tumors as sarcoma.

He quickly wrote a manuscript titled “A sarcoma involving the jaws in African Children” and posted it to the British Journal of Surgery. The reply never came.

By sheer accident, he met a physician called Oettle in South Africa. Oettle was younger and his star was on the ascent. By now the surgeon had collected grim photos of his patients. He showed Oettle and asked about similar cases in South Africa. Oettle waved his hand and said these cases didn’t exist in South Africa.

With no formal training in epidemiology, the surgeon decided to send out questionnaires with the photos to doctors across the country. The pace was excruciatingly slow – it took around 4 years for 400 responses. Armed with the information, he represented each case with a pin on a map. Since he couldn’t afford colored pins, he painted the pins with his daughter’s paint himself. A pattern was emerging. The tumor seemed to have a geographical distribution.

He presented his finding in Middlesex. Little did he know that his presentation would trigger a multinational effort against a common enemy.Among the audience was a man named Tony Epstein, a British pathologist. The idea of an infectious agent causing the tumor began to emerge. There were skeptics – unlike other infections, there are no cancer epidemics. Nor did the brothers and sisters of these unfortunate children get the disease. What kind of infectious agent behaved like this?

The surgeon decided to do a ‘geographical biopsy’. He applied for funds and got a 15 pound grant from the British government. With that and the help of his friend, he took an old four wheeler, repaired it and started on a long Safari. In sweltering heat, he would travel to Johannesburg and then back to Kampala, covering a total of 12 countries! In each place, he collected data (even before that term became entrenched in medical literature). On a hunch,he got external review of the old  slides. The results surprised him. The tumors were neither sarcomas nor carcinomas. The originated from lymphoid tissue- a lymphoma. Under the magnification of a microscope, these small round cells resembled a starry sky.

Tony quickly enlisted the help of his friend Yvonne Barr. Since they coudn’t isolate the infectious agent – it was too small – they decided to try a different approach. They looked for antibodies to the small infectious agent – presumably a virus. Sure enough almost all the cases had antibodies directed against this agent and it even stained the tumor cells. At long last, they had discovered the first human cancer caused by virus, one that bears their name – the Epstein Barr Virus.

Meanwhile the surgeon’s name became popular in medical circles and he received an offer to try methotrexate in these children from Sloan Kettering. To his amazement the tumor melted in these children. It returned in some. So he begged for another cyclophosphamide from an American manufacturer, which managed to hold the emperor of all maladies at bay even if for a short while.

This is the story of how within a decade a cancer was discovered, its morphological fingerprint identified, its geography dilineated, its causative agent discovered and its  treatment started.It is  the story of how an one eyed Irish surgeon, saw what all others had missed. It is a story of discovery that spans several continents in the face of impossible odds. It is a story that shows than even the ordinary can achieve great things with perseverance.

So when you feel  overwhelmed that you are in some remote no man’s land fighting a lone battle, remember this surgeon.


The name is Burkitt. Denis Parsons Burkitt.