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.

Academic inflation

I had an interesting discussion with a senior endocrinologist on the relative ease with which heroes are made these days. We live in a fast world where anyone is just a viral post away from the pedestal. Of course, staying there is a different issue altogether. At least, everyone gets a chance to try – for that we must be grateful to the internet for being the great leveller.

The internet has had a profound effect on academia too. The doctors of the previous generation had to put in a lot of struggle to get a paper published. Today we have such marvellous tools at our disposal that the process has become quite simple.The number of journals has increased significantly. The publication process can be completed from the comfort of our living room with a laptop and an internet connection. All of this has predictably resulted in increase in the number of articles published.

Consequently the relative value of each individual publication has probably gone down. For example, if we consider the value of a  This is similar to inflation in economy. A ten rupee note was more valuable ten years back than today. These days, it isn’t uncommon to see a mid career academic with more than a hundred publications. (at least in my domain). To keep things in order, we have invented quite a few metrics.

In this era of hyperpublication, it is upto the reader to tell the diamonds from the dross. Still, the journals cling onto their role as the gate keepers of scientific knowledge. However, that role has been significantly weakened and the power has undeniably shifted to the reader.

What does all this mean for us?

It means it is no longer enough to get published. The question is not whether we get published. The question is who is reading our work? It is vitally important that students remember this distinction, lest they think publication is some form of digital brain dump. It takes a lot to raise the bar, when the publication houses would much rather lower them. As is true of many difficult things, the results are worth it.

Painless pricks

Problem: Your diabetic patient is not checking blood glucose frequently. She is sick of pain in the prick sites and would rather not check blood sugar

Solution: Make the pricks painless and hope the patient will check blood glucose regularly

Some people might scoff at the solution. How can you make drawing the blood from your patient’s finger painless? It doesn’t make sense? You might perhaps think that making the needle thinner should help. Unfortunately that wouldn’t be enough. Because even thinner needles also have to prick deep enough to draw blood. Besides one might need a thinner needle that goes in just the right amount to draw blood. Often the patient squeezes the finger – which leads to more pain.

One option is to use Lancing pens – they are significantly better than just pricking with any old needle. However they still continue to be painful. This is a problem especially for children with diabetes – there is ample data to show that frequent glucose monitoring and corrective steps are necessary to achieve optimal glycemic control.

It is in this backdrop that a device has been introduced. It’s called Genteel – and it promises pain free blood glucose testing. How does it make a prick  pain free?

  1. It uses vacuum to draw the blood vessels
  2. It plunges only deep enough to hit the blood vessel ( for most people), and avoids the nerve endings*
  3. It has a vibration mechanism that distracts the patient from feeling the minimal pain. The end result is an almost painless prick. The device isn’t available in India at the moment, but it can be ordered online for a price of $ 119(after 10$ discount). (shipping costs extra).

I couldn’t find evidence that this device reduces pain/ improves the frequency of glucose testing /improves glycemic control. There are various testimonials by children who have used it and found it to significantly reduce the pain. Since they probably don’t have any commercial bias, I decided to take their testimonial at face value. However that doesn’t negate the need for some solid scientific evidence.

Realistically we have three choices
1. Wait for the evidence to accrue and avoid experimenting
2. Have a demo pen in the clinic and have the kids try it out. If they like it they can buy it.
3. Do a trial of the device in Indian setting – preferably including the soft end points such as pain and frequency of glucose testing and harder ones like HbA1c.

I favour option 2&3. The reason is simple – it isn’t too costly, there’s a 4 month trial period during which the device can be returned if found useless, and unlike non invasive glucose monitoring systems this one isn’t some black box approach to diabetes.

There are other approaches to relatively painless blood glucose testing. One option is Abbot Freestyle LibrePro. Unlike Abbot Freestyle LibrePro, Genteel is an one time investment. And it can be easily shared among family members*.(the lancets have to be changed)The advantages are obvious. In case you know some type 1 diabetic child who could benefit, please share it with your patient.

Disclosure: I have no conflicts of interest to declare.


The Plain Language Movement & Law

The plain language movement started in both sides of the Atlantic in the 1970s to make law easy to understand. The legal documents were plagued by legalese and were thus inaccessible to the commoner. This problem can be traced back to almost a 1000 years when William, the Duke of Normandy defeated the Anglo-Saxon King Harold in the Battle of Hastings in 1066. As William and his followers spoke a dialect of French, English became the language of the common and lowly folk.
The courts and lawyers soon followed suit. Within a few decades the Legal system had became inscrutable to the common man. With the ascendancy of English came the urge to rid the system of the French and Latin terms and replace them with crisp Anglo Saxon words. The push to make common sense in common language fashionable had a reasonable amount of success.
The legal system and the people benefited a lot from making things simple. Unfortunately, the Plain Language movement only focused on the law, not medicine.

Saving Medicine From Medicalese

Flip(or click) through the pages of any medical journal and you will see how hard our language has become for anyone outside our profession to make sense of. Even among doctors, each discipline has its own jargon and stylistic idiosyncrasies making it harder for others to understand. We live in a time when obfuscation is celebrated as a skill and straight talk is scoffed at.
To give an example, I was reading a top endocrinology journal yesterday and was dismayed to find that the pages have been hijacked by genes, genes and more genes or molecules,molecules and more molecules. It felt like the journal had written in 100 size font in invisible ink – look, this is for the experts. No one else is welcome.
I am not arguing that the top journals should dumb down their content or ask authors to keep click baity titles. However I’m certain that the scientific community will be better served by a Cochrane style plain language summary for every scientific article. In fact developing a written version of the elevator pitch is likely to narrow our focus on what matters. However, most journals don’t have the space/ inclination for such summaries. We need a plain language movement for medicine.

What can we do in the meantime?

Kudos. It is a free online service to explain about your research in plain English. Each paper gets these four pieces of information – Title, What is about, Why is it important and the Perspectives of the author. Kudos also provides shareable links and can automatically post to Facebook, Twitter and LinkedIn. It can even track the response your article is generating! (It’s like having your own Altmetric dashboard)
Here’s a plain language summary of one of our papers – Tumor(s) Induced Osteomalacia- A curious case of double Trouble
If you are an academic, check out Kudos. It’s free and the experience can help you focus on what matters.