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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.

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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.

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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.

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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.

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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.

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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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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.

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).

nayagan
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

Love,

Karthik