Social Indication

Yesterday morning, on my out patient day, I was prescribing a medication to a gastritis patient.The patient was a 40 something thin built man who had quit alcohol some time ago, but still continued having severe burning pain in the upper part of his abdomen. Just after I finished instructing him on the usage of the medication, a young medical representative lady came to me and requested me to prescribe the drugs her company manufactured.The drug was a commonly used medication sold in liquid form for wound cleansing.I told her that the drug was a very useful product which we had found comparitively cheap and very effective during our daily surgical practice,I would prescribe the medication as and when feasible. I also requested her to leave a sample with one of my postgraduates so that we can use the sample on some poor patient. The lady smiled as she said 'Sir, our product is very cheap and affordable, it only costs Rs 54 for a 50ml bottle'. Well, it was my turn to smile back at her as I said 'Look lady, your brand may be the cheapest and the best in the market but sometimes even that is not affordable for some of my patients!'. She left a sample, rather reluctantly, with my junior and left.

The same afternoon the gastritis patient came back to me and requested me to prescribe a drug which was available in the hospital. I told him frankly that he had a severe variety of the condition and as our hospital had no such 'strong' drugs in stock, I would still advice him to buy it from outside. He was embarassed a bit when he told me that he could not afford the medication (about Rs 19 for 10 tabs) as he had just enough money to get back to his home in Doddaballapur taluk.I told him to buy the medicine as soon as he gets some money and gave few samples of the drug my postgraduates had.Reluctantly, I wrote him some 'weaker' medications (not very effective and which would take more time to act too) which he could use and (more importantly) which were available with the hospital pharmacy.

There was no other way. Even though the drugs which I prescribed produced less than the desired effect I had to give those drugs.Apparently, getting the patient back home was more important than the correct treatment in the present situation.I had followed the Social Indication (rather than the Medical Indication) rule to give a less effective drug for a disease condition.

Indication,in medicine, is defined as the basis for initiation of a treatment for a disease or of a diagnostic test;may be furnished by a knowledge of the cause(causal i.),by the symptoms present (symptomatic i.)or by the nature of the disease (specific i.).(Stedman's Medical Dictionary, 28th Ed).In simpler terms,an indication is a term describing a valid reason to use a certain test, medication , procedure or surgery.

All throughout my undergraduation and postgraduation days (MMC, Mysore and KIMS, Hubli respectively,both Govt hospitals) I have been lucky enough to work under professors and teachers who had a penchant for social indications.I have seen them use their authority and intelligence to employ it at various situations.I have seen patients not being discharged from the hospital just because they did'nt have the money to go home, old people being admitted to the hospital just because there was nobody in the house to care for them, prolonging the placebo tablet treatment just to keep the lady from being beaten by her husband,admitting dying patients because the immediate relatives were not bold enough to give a satisfactory end of the patient and so on.I believe I have learnt from them as well as from my own mistakes and interest to fit social indications wherever they might feel right.

In the same way as we doctors and surgeons respect the ethics of our sacred practice(to be correct and accurate always) we should also respect the situations people are in, or are going through, which is most of the times, quite a big challenge.

To err is ...Surgeon!

My post graduate students frequently squabble with me regarding the 'chances' they get to operate.Ours is a teaching hospital and I perpetually encourage discussions and learning.Though teaching is a part of my profession I have always considered myself an eternal student.Surgical skills are largely obtained by constant practice at surgery, but we have to understand that it is not the only way of learning to cut.I like to teach my students the required surgical skills and also the lessons surgery teaches us with respect to life.

Surgery, as far as I'm concerned has two important things(which are not covered in textbooks), the skills concerned with it and the confidence one develops to do such surgeries, but before doing that a surgeon has to be sure of what he is trying to do and how and why he is doing it(which will be given in various textbooks).

As you can expect,the part which is learnt from textbooks is the easier part(mind you, its not the easiest part!), and the part which cannot be be learnt from books is the more challenging part.But as a surgeon becomes more experienced and as he matures, I believe a third aspect of his life emerges which is the toughest part to learn.This part, quite surprisingly, is the part where the surgeon learns to value the life of the patient being operated.Very often, it is said that the concrete step in becoming a surgeon is when the person appreciates 'when NOT to operate on a patient'!. Absolutely true.

Only when a surgeon develops the third component is he considered an efficient surgeon. Fortunately and unfortunately this skill comes into the individual only with experience.Fortunately because it gives great benefits (more than anything else, monumental satisfaction and peace of mind and not to neglect the increase in patient numbers and monetary gains) as one learns this and unfortunately because it might be ages when one acquires this and the person may not be in a position to reap the benefits at that age!

The question which arises immediately is 'how do we acquire this ability more quickly?' or 'how do we acquire experience swiftly?', for the time gained is what makes the huge difference.

The answer lies in learning from others mistakes!,it may sound quite simple or ordinary, which it is, but unfortunately I have found out that this is the most neglected issue among we surgeons.We dont quite appreciate the wrongs done by our colleagues! Be wary that it could take much longer time to achieve success than what you think.

To err is human ...and as surgeons are humans too(breaking news!) all surgeons commit mistakes by default.Well, thats the good news. The better news is that we can always learn from somebody else's bad surgery and the best news is that there is nothing to come off worse and everything to gain from it.

Happy learning!

Valentines Day Special:- Changing with the Cartoons!

The first thing I do when I pick up my morning newspaper is to read the Comics!I believe in starting the day with a little smile on my face!

I think ever since I began reading, and ever since we got newspapers in our house I've been a big fan of cartoons.First (mid 80's) it was the 'Praja Vani' with Phantom and Mandrake placed at the bottom of the middle sheet, and Mandrake the Magician and Raman in the Kannada weekly 'Sudha'.We still get Sudha and its no surprise that I'm still reading Phantom from it!During my high school days I read Archies and other comics which were available in our school library.During my graduation and postgraduate days at Mysore and Hubli I was hooked to the cartoons in the various newspapers which were available in the college and hostel reading rooms. The Hindu was and is my favorite newspaper and I still hate it for not having cartoons, I hate Times of India but love their cartoons and comics.Garfield, Dennis the Menace and Calvin and Hobbes always make me laugh whenever I read them.Well, why am I talking about cartoons anyway?

My preferences and interests in certain cartoon characters has evolved over the years and my favorites have shifted over time.

During my childhood I wore my chaddi and tied a towel around my neck and jumped off chairs and tables thinking I was Superman and was whizzing past the planets and saving earthlings from all the troubles they were facing.I wanted to become Superman when I grew up!I think this 'fascination' also led me to believe that bringing justice to people was very important.'I want to becoming a lawyer' during my later years of childhood was also based on the same thoughts I believe.Phantom was the same like Superman but with slightly more realistic 'justice provider', he lived in this world like the rest of us and was much more real than Superman.

My favorites shifted to Archies and Blondie during my college years where I found Veronica and Betty very attractive. Blondie(middle aged blonde with two teenaged kids!) too was very beautiful for my eyes.I loved Daisy(the Bumsteads dog) for her antics.Elmo was the most brilliant kid around and his dscussions with Dagwood always gave me stomach cramps from laughing.Of course Mr Dithers was the one I hated the most!

Another favorite of mine during those days was Garfield with the owner Jon Arbuckle who always found it difficult to find a girl for himself.Though I laughed at him whole heartedly I never wanted to be in his place.I pitied Jon's dates and learnt a lot of lessons about girls from him!I loved and hated Garfield in the same way Garfield loved and hated Jon!

My most recent favorite(after my marriage) has been 'Molly and Moose Miller'.Molly and Moose (parents of a teenaged and two young kids) are fat, financially broken, unemployed, always struggling to meet ends, have to look after the whole family(Molly's mom plus the kids,plus her younger brother, plus lots of pets the kids have), Moose has to frequently escape from the bill collectors and they have a broken house to add to the problems.

The only thing they have is their love for each other!This keeps them smiling and happy always.The Millers demonstrate that LOVE overcomes all the sorrows in this world.

I just wanted to tell you how preferences and priorities change overtime.I have tried to capture these things by taking Comics and Cartoons as examples.

I wish you a very happy Valentines Day.Enjoy.

Cancer!

Cancer!.....thats a scary word, isnt it?

Stastistics shows that about 3 lakh people in India die every year due to cancer.About 20 lakh people have cancer at a given time and about 7 lakh people are newly detected to have cancer each year. India is finding it difficult but challenging to take care of about 15 lakh people who need investigations, diagnosis and treatment yearly.You can estimate the economic hardship the country is facing due to this dreaded condition alone.

Being a surgeon and working in a tertiary hospital I come across cancer patients almost daily.I feel sorry for the people who have cancer.More than anything else, most of them are probably unlucky to get it.Sometimes I think, maybe as humans we deserved it!. I sometimes also feel that nature may be punishing us for the sins we have created(and still creating).Rapid change in human behaviour and lifestyle, urbanisation, changing eating habits, pollution, tension filled professions, increased population etc. etc., Are these responsible for cancer? My answer would be a resounding YES!. Nature is finding different ways to tell us that we have to be careful, especially to care for our health.

On The World Cancer Day let me assure you that cancer is a 'no big deal' thing, only if you are cautious to avoid certain things and clever to learn some more.Cancer is curable and treatable in most of the cases if it is detected early and some cancers can be prevented. My focus will always be on these aspects.Prevention and Early Detection, the two pillars for cancer awareness.

Prevention is simple, just avoid tobacco and alcohol.

More than 90% of cancers in India are directly attributed to tobacco alone! Tobacco in various forms like gutka, paan, beedi, cigerettes is to be avoided and if you are presently a smoker it is never late to quit smoking.Studies have proven benefits for early quitters.Mouth and lung cancers, which are the top two cancers in males in our country have direct relationships with tobacco.Treatment of these cancers may require money amounting to a familys income for a generation.Many of the Indian families have been doomed trying to treat a family member suffering from cancer.The next generation of the patient has suffered due to the patients inability to stop smoking! If you dont care for yourself atleast care for your kin!.Be notified to approach a doctor if there is white patch in your mouth which has come up recently, be doubly careful if you are a smoker.Also approach a doctor if you find small painless swellings in your neck, armpits or around your genital regions, which may have come up recently.These may be lymphnodes which may have cancer cells in them.

Alcohol is another factor very much influencing cancer. It is quicker than tobacco in ruining a family! Most cancers have direct association with alcohol intake. Quitting alcohol is good for your health and your pocket as well. Sadly alcohol along with tobacco consumption is alarmingly increasing in women.

For the ladies the main cancers to worry are(along with the mouth and lung cancers) Cancer Cervix and Breast cancer.Preventive measures are general genital hygeine and protective sexual behaviour. Breast feeding for adequate duration is protective and beneficial for the infant as well.Breast self examination has to be practised regularly and systematically, and a doctor maybe consulted in case of any lump in the breast.Approaching a doctor for a doubt is better than regretting for life later.Never feel inadequate to get a clarification anytime.Never be ashamed in such matters.

Now with this small bit of information you can surely be not as scary as before I guess.

Ignorance Eclipsed!

It was a plan which was not planned much!.I reached Jawaharlal Nehru Planetarium at about 11.45am where my friend was already waiting for me.I was amazed to see the view close to the planetarium.Though I had expected to see few people at that place I could now see many cars parked all along the road adjacent to the planetarium...I immediately turned towards the building and was shocked to see a 'jaathre' of people,thats what it looked like to me!I approached closer and heard the enthusiastic noise the huge number of people produced. My friend and I quickly walked towards the large number of people to try and do what they were doing.

During my morning ride in the city bus to my workplace I could sense a significant drop in the number of people who were traveling.There were no morning peak hour traffic jams and buses reached there destinations before there due times.I had thought that the people were all staying home watching the grahana on TV and observing fasts and conducting prayers and offering poojas and things like that.I was wrong, the people were all at the planetarium!

I didnt know what that feeling was which I experienced but that was wonderful.Seeing people appreciate something good was a step forward for our countrys development.Accepting science and logic rather than blind beliefs and false traditions was what I noticed there.I saw people and more people, toddlers, grannys, standing, supine, professionals, amateur photographers, youth and kids... whose faces were brightly coloured with joy and enthsiasm and also painted were spots of relief, of having learnt something new today.Yes, relief, that was what I felt too!

For how long can truth be subdued?For how long can men and women be left unenlightened?When is the time when we accept nature in its true senses? When will education prevail over ignorance and orthodoxy?Logic and science over blind beliefs and false traditions?Not long my friend, not long, and the evidence is right in front of us.The crowd, the number of people at the planetarium is the answer to the questions.

I happily spent about 3 hours at the planetarium and relearned a lot of my high school physics.I watched the eclipse through the no 14 welders glass and also through the glasses I bought at the place, did 'the pin hole effect', saw hundreds of 'pinholes' created by the trees,saw the virtual image on the projected screens,took a lot of photographs of the eclipse,saw my shadow edges go hazy,etc, etc,... which gave me immense joy and satisfaction.But the most important feeling was the relief!

Request to my dear friends.

After having seen people talk about 3 Idiots, I felt my need to say something as well!
Jumping directly into the question(based on the CNN.IBN Face the Nation question): Is the movie 3 Idiots an accurate depiction of the present higher education system in India?....my answer would be:- the question is irrelevent!
Is there a relation between the movie and the education system?... No.
Is ther a relationship between the movie and public entertainment...Yes.
Is this a chance to talk about our depleted education system( elementary to our higher education) (ragardless of what the movie depicts)?...Yes.

3 Idiots according to me is yet another movie which is typically intended to earn money for the producer and entertain the common man.We should not try to glean anything else from it as it provides nothing for the thoughtful people.The credit issue apart, Five point someone was a remarkable book in all senses.Unlike the movie it gives us a feeling of gratefulness towards our esteemed educational institutions and the teachers, also providing us with enough entertainment.We should be thankful for many people who have encouraged such learning systems and processes.

Amir Khan has let down his progressive oriented fans by acting in a movie which does not qualify for his stature.The movie seems to be a complex mixture of Munnabhai, Dil Chahta Hai, Taare Zameen Par and all such movies without their positives!
Chetan Bhagat had had each component(like...emotions, humour, sex, love) of the novel in the right proportions to make it entertaining and thought provoking as well.

Of course our education system needs a revamp....but not through the 'aam aadmi' oriented 3 Idiots,please!

Indians, atleast most of us watch movies purely for entertainment....we like to forget the movie as soon as we come out of the hall. 3 Idiots does not disappoint us in this regard as it provides nothing to carry forward.

As far as I'm concerned I do not want to worry much about the issue whether the movie is inspired or based(or whatever it is called) on the Chetha Bhagat novel.If it is a copy then it is bad that the movie makers have not carried forward the good intentions Chethan intends in the book....and if it was not a copy it is still the same as they have not been able to provide anything for the intellectuals.Vidhu Chopra must be the happiest man on earth now as we fight over a issue which is unconcerned but is all profits to him by all means('bitti' publicity,without any benefits reaching the common man)...probably the common man is paying bucks to Chopra for simply trying to find positives in the movie! The producers might have never thought of this movie as educational at all.

The build up the media is providing regarding this issue is probably not that embarassing as some my think it is, as it is providing us an oppurtunity to go through our education system once again.Though, I'm sure the dust will settle down very soon after everybody has said his say and before anybody has done any good!

My request to my dear friends would be ...why dont we forget the movie and concentrate on moving the education system forward?