Blissful Life

When you apply skepticism and care in equal amounts, you get bliss.

Year: 2019

  • Fixing the World is Whose Responsibility?

    This week I attended a session on quality improvement in healthcare practice. The definition of quality is subjective. What may appear to be “high-quality” to me, may not stand up to external scrutiny. There could always be room for improvement. But this is not a big problem. Some level of objectivity can be attained in measuring quality by using tools like standards. We can easily figure out areas that are below par and areas that are good enough. Identifying problems and areas to work on is not a problem at all.

    The real challenge is in identifying responsibility. Whose responsibility is it to fix the problems? Sometimes fixing a problem is much easier than figuring out who the right person to fix the problem is. Most often it is not. Most often fixing problems require persistent effort and continuous follow-up. It takes time, energy, even money. And depending up on the scale of problems, these things can easily blow up. There are also some problems which have quick-fix solutions that are less sustainable than the proper but energy-intensive solutions.

    After some months of joining Vivekananda Memorial Hospital, there was one evening when I was in the reading room. Dr Kumar who is now the CEO of SVYM walked in and asked me how things were. The conversation somehow came to my anger at the medical education system and how there was a lot of corruption in medical colleges. I was furious about my own alma mater and told him how I would never want to step foot in that college again. Dr Kumar, incidentally, had done his post-graduation in the same college and could relate to what I was talking about. But then, he told me the story of how he worked with, through, and for the system and made it better. He told me how he would challenge and oppose, yet be dear to the administrators. He told me how he could improve things at least by a bit while he was working there.

    The transformation in my mind was instant (similar to how MAB once made me rethink the way I look at a disinterested audience). I, who was seething with anger at the system, suddenly saw possibilities. I could see the difference between productive contributions and blind criticisms. More importantly, I learned the concept of agency. I was no longer feeling helpless or like a hapless victim of the system. I was feeling like a person who could bring about change but was not yet utilizing my full powers.

    The stories of Ananth Kumar, SVYM, Taru Jindal, Lalitha & Regi, and every other inspirational stories I’ve heard in the recent past demonstrate that simple principle. That if you put energy and effort, things will change. That even one individual matters.

    I think the question of whose responsibility is it to fix things can arise of two things. One, the feeling that I cannot fix something because I’m powerless. That is a logic consistently proved wrong by many of these people I mentioned in the previous paragraph. But there is a second, more difficult reason people might choose not to fix problems. That is when I choose to not fix a problem because I don’t have the time/energy to because I devote it elsewhere (in a place that I think is more important to focus on and solve problems in).

    This second reason, is in my opinion, the bigger problem. This is the reason why even talented people can fail to deliver. Changing the system through innovation or persistence requires dedicated effort. It requires someone to show up regularly and stand up for the cause. It is the same as making a successful startup or raising healthy young children. It requires a lot of smart work. It requires productivity.

    It all should start from the realization that every great person who has walked on this planet has had only 24 hours in their day – the same number of hours everyone else has in their day. What really matters is how much we can draw out of those hours. And for various reasons, not everyone is equally privileged to draw the same value from their days.

    But what is really worth thinking about, is whether we are drawing the maximum value we can. Because if you can find a way to cut the cruft and get more work done, you might find just enough time to fix the world too.

  • How to Travel In Bangalore – Get A BMTC Bus Pass

    I've now spent more than an year using the public transport in Bangalore and made the best investment only this month. That is the BMTC bus pass.

    Previously my commute was fully reliant on metro, but recently I joined MetaString foundation where I have to take the road to reach. There is a direct airport bus from where I stay to the office. The BMTC app gives a fair sense of where the buses are and how quickly I have to run to catch them. But giving 80 rupees in change every time I take a ticket was a pain. And unlike the metro, BMTC hasn't introduced smart cards yet. That's where the passes come in.
    There are three classes of bus pass. The cheapest ones are 1050 including tax and lets you ply only in ordinary buses (non-AC). The next slab is 2363 which allows you to travel in volvo buses as well, but doesn't let you get on Vayu Vajra (airport bus). For the last category there is a 3570 rupees pass that lets you "yelli bekadru odaadubodu" (run around anywhere). But even that gold pass won't let you go in Bangalore Rounds bus (I have never seen a Bangalore Rounds bus). On the other hand, gold pass gives you a travel insurance which covers accidents.
    I got my gold pass from Majestic (Kempegowda Bus station). But just getting the pass is not enough. You also have to get a BMTC id card. The ID card can be obtained on the other side of the bus pass issuing window of Majestic. You have to give a stamp size photo, your address, and phone number here which they enter sloppily in a register. The ID card has to match the pass and that's how they ensure that two people don't use the same pass.
    The biggest advantage the bus pass provides me (even though it makes no economic sense for me who don't go to the airport every day) is the mobility. WIth the bus pass you can get on any bus and travel for any distance. This lets you make on-the-fly (pun intended) decisions about changing route/direction/bus. If there are better buses starting from the next stop, you can get on in any bus in the current stop, get down at the next stop, and switch to the better bus.
    Additionally, the conductor can no longer make you feel guilty about not having change.
    And above all, you save the environment. Less the Uber, less the traffic, less the pollution, faster the buses.
    PS: I also got a new wirless keyboard. I'm now composing this blog post from a Vayu Vajra bus through my phone.
    PPS: Also checkout "moovit" app which is a citizen app for travel information.

  • Lessons One Should Learn From Shehla Sherin’s Death

    If you do not avoid news like me, you would have heard about the tragic death of a 10 year old in Wayanad a couple of days ago. You can search the name and find the story on your own, but a few facts are established already.

    1. Shehla Sherin had her foot go into a hole on the floor of her classroom and was afraid a snake bit her in that incident
    2. There was delay in taking her to the hospital
    3. Anti-Snake venom was not administered at the local hospital, and the child was referred to a tertiary care center at least an hour away.
    4. Child died on the way.

    I won’t unnecessarily go into speculations on what other things happened on that fateful day, but having managed emergency department in a rural hospital for over an year, I will use this sad death to illustrate two very important lessons for every doctor.

    Lesson 1: Never take any complaint lightly, even if the circumstances lead you to think otherwise

    There are two ways patients can come in. There are people who exaggerate, and people who downplay. Take all symptoms seriously.

    There are no insignificant complaints. There are no insignificant findings. Whatever the patient tells you has to be taken seriously. Even if the patient asks you to not take it seriously. At the height of experience and confidence you might be able to predict that something isn’t as serious as it sounds, but be really really careful before making that decision.

    I had once a patient come to the casualty with a swollen foot. The patient had intellectual and speech disabilities and therefore there was no proper history. The bystander (who apparently takes care of the patient) told that “someone must have hit him”. My colleague suspected a snake-bite because of the way the swelling looked, but nevertheless ordered a whole blood clotting time test and a foot x-ray to rule out a fracture. My shift was about to start and while I was taking charge from my colleague I inspected the foot of this patient closely (in the x-ray room). I could see two small points of bleeding close to each other – fang marks!

    We immediately told the bystander that this is not “someone must have hit him”, it is a snake bite, and that the patient will die unless something is done immediately. This bystander did not look like they liked the patient very much because they asked me “please do whatever you can here itself, don’t refer us to higher center”. We knew that the best we could do was given anti-snake venom (which we immediately started doing) but the patient might require blood products which weren’t available and required referral. So, we took a stand and sent the patient as soon as the ASV went in.

    There was this other patient who came at noon on a different day with severe chest pain, as if he was going to die the next moment. He was a smoker and alcoholic with a very good chance of having a heart attack. He wouldn’t even lay still for us to get a proper ECG, and whatever leads we could obtain looked like there were ST elevations all over. The MI protocol kicked in, we gave all the painkillers, anti-coagulants, and sent the patient to the nearest cardiology center. News later was that he was just having severe gastritis due to alcoholism. But, we did what we should have done.

    We’ve had a patient with vague headache/chest pain admitted for observation die on us under strict observation. I’ve had a patient with diarrhea go into dehydration and shock. I’ve had a lady who could perceive fetal movements but have no fetal heart activity on ultrasound. We’ve had a person with cellulitis of lower limb go into septic shock and die while we were on rounds. We’ve had a bystander who missed anti-epileptic medication die after getting seizures and aspirating. I’ve examined a kid with high fever who had febrile seizure on the way out. We’ve had a kid admitted for being dull after vaccination die in front of us, despite our best efforts. We’ve had a child in waiting area who wasn’t breathing well arrest by the time they were identified by a patient care worker to be requiring urgent attention. I’ve had a patient with vague thigh pain turn out to be deep vein thrombosis and die next day.

    Always have the worst outcomes in mind when making decisions. Be mindful about patients who you haven’t even seen yet. Communicate a lot. Err on the side of cautiousness.

    Never be afraid to wake seniors up from sleep. When in doubt, ask for help. If you are not sure about something, check it again. If something happens while you could have done something which you didn’t, you’ll regret that your entire life. And that is a pain.

    Lesson 2: It is a privilege to have access to the miracles of modern medicine. When you have the power to use things, please also have the courage to.

    There is always going to be a risk. It is risk that makes the work of a doctor exciting. If you’ve chosen to be a doctor, there is no way you can avoid risk. Even if you become a dermatologist, you can land up in soup. As a doctor, the only way to avoid risk is by quitting professional life and meditating inside a cave.

    Risks shouldn’t hold you back from attempting something that’s required for your patient. I got this lesson the first time when I was still an intern, and was in KR Hospital’s Medical ICU. I was trying to insert a catheter into someone’s jugular but I was going too superficial. My senior then told me “Always remember, what you’re doing is for the benefit of the patient. You’re only going to harm them by not doing it confidently. The patient will die if they don’t get this line. So you may as well put it in boldly.”

    There is a definite role for experience and knowledge in being able to build the confidence to do things. But neither of that will come unless you want to do those things for your patient. If you are shy of cutting, you can never be a surgeon. If you are scared of side effects, all the pharmacology you know is absolutely of no use.

    Too many doctors think that by not committing something they’re keeping themselves safe. But their fake sense of safety comes at the cost of the patient’s suffering. Laws of medical negligence apply to acts of omission as well as they apply to acts of commission. With all your training you may as well do something and fail, than be a mean coward. That’s what your license is for.

    Use anesthesia (ketamine + midazolam, if you will) when draining breast abscess. Give powerful analgesics when people are in pain (don’t give diclofenac for MI/fracture. Give something like pentazocine). Use second line and third line drugs when the first line fails. Give aminophylline or magnesium sulphate for COPD/Asthma. Steroids and immuno-suppressants are in various guidelines for a reason – use them when indicated. Even newborns may need anti-epileptics. Benzathine Penicillin is the best available cure for Syphilis. “Higher antibiotics” are not reserved for higher centers. Use vasopressors (and for heart’s sake not fluids) in hypotension where failure needs to be considered. Use nitroglycerine to control high blood pressure. Use heparin. Use atropine. Use adrenaline. Use BiPAP. Resuscitate. Use oxygen. Use fluids. Give vaccines. Conduct deliveries. Splint fractures. Suture large wounds. Intubate and bag till the ventilator in referral center. Use all the things you’ve learnt to deliver care. That’s why you’re a doctor.

    And if you feel you’re under-prepared for any of those things even after MBBS, work with sincere people in rural hospitals (like VMH or THI or BHS). Learn the skills. Learn the craft. Understand pain and suffering. Care for other humans. Become a good doctor. Then do whatever you want to.

    Epilogue

    I had a rule when I was working in ED – “Nobody dies when I’m on duty”. The only exception was patients admitted for palliative care. Imagine if every doctor in our country made rules like that for themselves.

  • Permanent Record (Book Review)

    You could call it an autobiography of Edward Snowden or you could call it a manifesto for democratic citizenship. You would be right either way. This book is a how-to guide for becoming a hacker (in the realest sense of the word), a good parent, and a good lover.
     
    A fair bit of caution advised though. The book will leave you paranoid. Once you realize the perverse amount of surveillance that you are subjected to without your knowledge, it becomes surveillance with your knowledge, and I don’t know which is better.
    I had once written a blog post titled “When Doing Good is Bad For You” from my own experience. In that I talk about how social revolutionists will perpetually face the dilemma of not doing anything versus fighting the system and putting themselves at risk in the hope of being able to improve the system. I have seen many others face the same dilemma. Edward Snowden also faces the same dilemma and we know what path he chose.
     
    But till I read this book, I could not make that connection. That Ed Snowden is a human just like you and me. That he went through situations just like you and me. That the choices he had to make are the choices that confront us all similarly. That we are all perfectly capable human beings who can do great things.
    It also gave me another realization. That the democracies we live in are very far away from ideal democracies. And that forgetting this can have real life consequences. And that despite all that it is necessary to continue the fight.

  • Understanding Adrenaline Dosage

    Have you ever administered adrenaline for anaphylactic shock? I’ve never had the unfortunate need to. I’m sure anyone who ever does will forever remember the correct dosage. But for me, it is always a confusion. Every time I vaccinate someone at my clinic, I look up the dose of adrenaline just to be sure.

    The first problem is the dilutions. Dosages of adrenaline are (or were) mentioned in dilution. 1:1000 & 1:10000. There begins the confusion.

    Firstly, let us understand where the 1000 comes from in 1:1000. Have you seen a small vial of adrenaline? That is 1mL. It has effectively 1mg of epinephrine/adrenaline. But why is it called 1:1000? Because 1mL of water = 1g of water = 1000mg. So, the 1:1000 actually refers to 1mg of adrenaline : 1000 mg of water. Unnecessarily complex!

    All you had to say was 1mg in 1mL. And that is why this labeling is now being followed in some countries.

    So, there you have a small vial – a 1mL vial – with 1mg of adrenaline in it.

    Now, let us look at the other form epinephrine comes in. Epinephrine also comes in a big syringe of 10mL. But even this 10mL contains only 1 mg of adrenaline. The total amount of adrenaline in this 10mL form is the same as a small vial.

    What is different then? Well, when the volume increases without increase in amount, the concentration drops. The 10mL form is more dilute than the small vial. Can you guess the dilution? It is 1:10000 or more easily expressed as 1mg in 10mL.

    So, the first thing to internalize is that the small 1mL vial we see has 1mg of adrenaline (it may say 1.8mg of an adrenaline salt, but the effective amount of adrenaline is 1mg). And this is a concentrated form of adrenaline.

    What that also means is that the 1mg/1mL adrenaline is never used directly IV! The reason is that this can cause an arrhythmia or other damages to the heart muscles.

    If you’re bored reading text, watch this youtube video telling these same things.

    Now, the dilute form and the concentrated form are for slightly different uses. The concentrated form is given IM in anaphylactic shock. The dilute form is given IV in cardiac arrest.

    When giving IM adrenaline for anaphylactic shock, the dosage in adults is almost always 0.5mg (0.5mL of the concentrated vial). If you can remember this fact it is easy to calculate the pediatric dose as well. The adult dose can be thought of as if it applies to a 50kg person. So 0.5mg for 50kg = 0.01mg/kg and that is the pediatric dose. (This 50kg adult approximation applies for many other drugs in calculation of pediatric dose. Let me know in comments below about other drugs that can be calculated this way).

    When giving in cardiac arrest, in which case the dilute form (1mg in 10mL) is used, the adult dose is the entire 1mg (or 10mL) given intravenous and repeated based on the protocol you follow.

    That is all there is to know. Just a 0.5mg and a 1mg.

  • The Curious Case of Consultation Fees in General Practice

    Today as I was returning home in metro two lawyers occupied the seats next to mine. I was reading A Reader on Reading by Alberto Manguel. But I distinctly heard one of them tell the other “I have two cases tomorrow evening”. That set me thinking.

    Advocates have “cases” and so do doctors. Advocates have “clients” and so do doctors. (Some doctors call their clients patients because some clients are indeed patients. But some doctors call even their patients clients, appreciating the fact that ultimately the people who come to them are dignified individuals seeking a service and with autonomy in choosing service providers.)

    Advocates are also notorious for charging sometimes lakhs for an “appearance”. But here doctors have itt slightly different. Doctors also get called money-minded and unscrupulous, but they get called so for charging much less than what advocates usually charge. Why is this so?

    I came up with various possible reasons. One, the huge lawyer fees that we hear about usually are in big courts for defending big crimes. Perhaps the stakes are really high in those situations. To add to that, a court case is usually once in a lifetime situation for most people and one they probably have never encountered before. Therefore the clients are in a much more vulnerable situation and would be willing to pay a lot.

    This “high stakes” reason appears correct because there is similarity in healthcare. When you go to a hospital with a heart attack, you don’t care how much the hospital charges are going to be, you just want your (chest) pain free life back. But when you have a cold (which is probably the 14th time you are having it in your lifetime), you know it is going to be better in a few days and there is no real reason to spend lots of money.

    That probably explains why the market rates in general practice is very small. People usually present with simple illnesses and a sense that their illness is a simple one. Therefore there is not much value they are seeking from the doctor – most clients are in for quick relief from symptoms, if possible.

    Therein lies the complexity of general practice too. I’ll explain that in a bit, but first let us look at one more difference between lawyers and doctors. Lawyers take money from clients and work for clients by being sharp witted and coming up with strong legal arguments. But their “appearance” is in front of a judge. The favorable outcome is defined by the client but realizing that outcome requires very little of the client’s participation. Usually, the judgement made by the judge also unequivocally settles the judgement on the lawyer’s performance.

    Now let us talk about general practice. In general practice, your client does not just pay you, but also has to work with you for their own success. There is no third person involved. The client has to believe in the doctor, has to believe in the advice given by the doctor (that the advice is for their own good), has to follow the advice strictly, and also has to make a judgement about how good the entire process have been. This is where the previous point comes in.

    The reason why clients come to a general practitioner is often for quick relief from their symptom. Most of the time in medicine there is no quick relief which is also good. For example, painkillers are quick relief from pain due to strain. But the good thing to do maybe in many cases to take rest and allow body to recover. Common cold may slightly improve with nasal decongestants, but overuse maybe harmful. Sometimes sticking to medicines which cause nausea, vomiting, diarrhea or many other tolerable side effects are required in the face of greater dangers like multi-drug resistant tuberculosis.

    Sometimes the right thing to do in the view of a doctor maybe different from what the client thought would be the right thing to do. This would not be a problem for a lawyer as the client does not have a role in deciding the success of the lawyer’s approach to the “case”. But when doctors are in this situation they have to use all the skills they have in convincing the client about why there needs to be a change of expectations. And the success of the treatment itself relies on this “winning over” of the client.

    And after all that exercise, the client has to pay. ICUs, OTs, and emergency departments have it easy. There is a lot of money to be paid, but most of the work is done by nurses or doctors and the sick person usually just has to lie down on a bed (conscious or not). General practice? Totally different ball game.

    With that context, how much is a reasonable consultation fee in general practice? 50? 500? 1000?

    Before locking our answer, let us look this from another side. The general practitioner is a small entrepreneur. The GP has a home and has a life. The GP needs to make money to survive. But the GP is also a doctor. No conscientious doctor can do injustice to their profession or their clients. They cannot simply symptomatically treat diseases without thinking about root causes. Diseases have to be managed correctly. Counseling is an important aspect of treatment. And all of that requires time – time to be spent in consultation. And time is money.

    The question on consultation fee thus has to be somehow linked to the consultation duration. What is the minimum time a doctor should spend with their client to fulfill their obligation/duty? There can of course not be a single answer to this as every consultation is different. But practically, from my experience, in a single person clinic the doctor (who is the single person) has to spend at least 20 if not 30 minutes in a consultation for there to be some quality.

    How much of that can be delegated? Whom to delegate to? Of course in a single doctor clinic the only person to delegate to is the client themselves. Can clients prefill questionnaires about their health condition? Can clients read informational pamphlets instead of having to listen it directly from the doctor? Does trust suffer in attempting such time saving measures? These are all questions with no definite answers.

    Does building a healthcare team help? It can definitely help. At Restore Health we have a multi-disciplinary team where a lot of tasks are shared. But still there is considerable amount of time spent by each person of the team in providing care to a client. And we charge 500 in general practice consultations. Are there people who think that is too much? Definitely, yes. Including sometimes our own doctors. But there are times when we have saved the client a lot of money and good health and spent considerably more time in the process. We do not have “dynamic pricing”.

    Perhaps there needs to be more thought put into showcasing all the value that is created by a GP and monetizing some of that at least. All this while treading on the right side of ethics and not breaking the delicate thread of trust that connects a client to a doctor. Who says general practice is not challenging?

    My train of thought was derailed when the train I was sitting in reached my destination. As I stood up to deboard, the lawyer next to me took my seat. Perhaps she was thinking about how much to charge her next client. Perhaps not.

  • Healthcare in Consumer Protection Act 2019, VP Shantha and why you should read the source

    There are good journalists and bad journalists. It is the reader’s duty to discern between what is right and what is wrong. The problem in the 21st century is that that duty is completely thrown into water under the guise of “forwarded as received”.

    There are a lot of articles in newspapers talking about dropping the world “healthcare” from the list of services under the consumer protection act of 2019. Many of them have fancy headlines suggesting that healthcare will not be a service that falls under the ambit of the new consumer protection act. At least some of them have written objectively stating where the word is dropped from without going into judgement on what this means.

    But many doctors are reading headlines and thinking that the consumer protection act will not apply to healthcare henceforth. What they need to read to know they are wrong is just one judgement by the Supreme Court in the “Indian Medical Association vs VP Shantha, 1995” case.

    That judgement was specifically about settling the question of whether healthcare is a service that falls under the definition of service as defined in the consumer protection act (the act of 1986). For ease of reference I will quote the definition from the old act:

    “ “service”
    means service of any description which is made avail­able to potential users
    and includes, but not limited to, the provision of 
    facilities     in connection with banking, financing insurance, transport,
    processing, supply of electrical or other energy, board or lodging or both,
    housing construction, entertainment, amusement or the purveying of news or
    other information, but does not include the rendering of any service free of
    charge or under a contract of personal service;    “

    Notice that healthcare is not specifically mentioned. Supreme Court read this definition and confirmed that healthcare is included in the broad definition of “service of any description” and spelled out conditions where it would be excluded.

    Now, here is the definition from the new act:

    ““service” means service of any description which is made available to potential users and includes, but not limited to, the provision of facilities in connection with banking, financing, insurance, transport, processing, supply of electrical or other energy, telecom, boarding or lodging or both, housing construction, entertainment,amusement or the purveying of news or other information, but does not include the rendering of any service free of charge or under a contract of personal service;” (emphasis for words that have been added)

    Where is the “healthcare” word dropped from then? Well, it is from the draft bill that was introduced.

    Now you can read the full judgement on how the new definition also includes healthcare in it.

  • Meftal-Spas vs Meftal-Forte for Menstrual Pain

    I was recently asked by someone whether Meftal-Forte is a better drug than Meftal-Spas for menstrual pain.

    I hadn’t heard about Meftal-Forte till then. So I looked up. 1mg told me both the drugs are manufactured by Blue Cross.

    The page about Meftal-Spas gives us what I knew already – it is a combination of Mefenamic Acid 250mg and Dicyclomine 10mg.

    The page about Meftal-Forte told me that it is a combination of Mefenamic Acid 500mg and Paracetamol 325 mg.

    Based on this, the quick answer is “No. Meftal-Spas seems to be better suited for menstrual pain in people who find relief by using it. But self-medication may not be the best way to manage menstrual pain.”

    The longer answer is that dicyclomine is an anti-spasmodic that is widely used with anecdotal evidence supporting its use in primary dysmenorrhea. Mefenamic acid is an anti-inflammatory drug that is indicated for use in primary dysmenorrhea. Paracetamol is not really indicated for primary dysmenorrhea. Therefore if forced to choose between these combinations, the one with dicyclomine makes more sense to be used in primary dysmenorrhea. But self-medication is mostly not the right thing to do because a lot of dysmenorrhea maybe secondary to things like endometriosis and maybe better treated by other drugs under the guidance of a family doctor or a gynecologist, and sometimes just mefenamic acid (in the right dosage) might be enough to control primary dysmenorrhea.

  • Practical Career Guide for First Benchers

    This is partly a response to “All That Glitters” by an IITian and partly a message to my brother who is an IITian.

    Although I used to sit mostly on the back bench during school, I fit the first bencher stereotype more – good scores, liked by teachers, great expectations. I currently have a career tragectory that I am happy in. It hasn’t stood the test of time and that is a caveat, but otherwise I’m perfectly qualified to write this guide.

    The problem

     

    What to do in life?

    The dilemma is faced by every first bencher just after their schooling and throughout their college years. For me it extended till about an year after that.

    Image by moritz320 from Pixabay

    It is a dilemma because there is choice overload and there is opportunity cost. There are virtually an infinite choices on what to do in life, especially so for the first bencher. The “back bencher” has it easy because a lot of choices are eliminated by steep barriers and therefore their options become simpler. But the first bencher knows nothing called impossible. They feel that they can do anything if they put their mind to it. And so they have all the options they can think of.

    But the opportunity cost is real. No matter how productive you are, you can’t sleep 8 hours in 4 hours. There is an opportunity cost to every damn thing. And that’s where the crux of the problem lies.

    What to choose to do in the limited time alive? What things to prioritize? Happiness? Sure. But what brings about happiness? Does money bring happiness? Does autonomy, creativity, and intellectual satisfaction bring happiness? Does good relationships bring happiness? Can one not have all these? What if I do what everyone else is doing for a while and figure out in some time? What if I get stuck in that rat race? What is the meaning of life?

    Existential crisis apparently is sort of depression.

    Potential solution

    I’m very wary of prescribing one size fits all solutions. There is one approach I have followed in my life which I’ve found to work very well for me. I call it “being ambidextrous”.

    The fundamental tenet of this approach is to shun exclusionary thinking. Exclusionary thinking is when you think “if I take up a 9-4 job, I can’t become an entrepreneur”, “if I get married, I can’t do adventures”, or “if I become a doctor, I can’t become an engineer”. There is always a way to pursue two or more interests together.

    The challenge is in finding that way. Sometimes it is hard and will involve moving geographies, spending money, losing sleep, etc. But once you find a way to follow your heart in all directions your heart wants to go, you will have a happy heart.

    Should I not make money?

    There are a few basic things you need in life

    • Food
    • Clothing
    • Shelter
    • WiFi

    You really need to take care of this. And that involves making some money. But the money required for meeting these basic needs is trivial to make for first benchers.

    Then there are some other needs which also require money

    • Friends & Family
    • Health
    • Entertainment
    • Transport

    These are some areas where frugality really helps. With good accounting of income and expenses, careful planning, and hard work the money required to take care of these can be kept low. When you don’t need a lot of money, you don’t have to make a lot of money.

    What about ambition?

    There are two ways to look at this. One is that ambition is bad/unnecessary. That success is hyperromanticized. In this outlook, you try to make time for simple things in life. You call ambition as society’s unreasonable expectations from you.

    The other is that ambition is helpful. That it gives a direction in life. That it gives meaning to life.

    But do you notice the circular reference in that latter approach? How do you choose your ambition?

    Here also being ambidextrous has helped me. It is important not to go too much behind meaning. It is also useful to have a few ambitions. Maybe a better word is goals. Not all goals need to be achieved. Goalposts can be shifted. In fact, if you grow up, you’re bound to realize some of your goalposts were wrong.

    Footnote

    I’ve had two mentors tell me that confusion is a sign of thinking mind. So if you’re confused, that’s a good thing. Another thing is that the confusion never ends. Mid-life crisis occurs at all ages and at all junctures in life. The approach to deal with this that I suggest above is greatly influenced by Zen Habits.

    • How Did I Become A Programmer?

      Arya asked me from Germany, “How did you start with programming? Maybe write a blog about it? Your learning strategies”.

      To those of you who know me as a doctor, I’m a professional programmer who can work on any part of the stack (and even off the stack), and a free software advocate. To those of you know me as a programmer, I’m a professional modern medicine practitioner who can manage any kind of illness (including emergencies in the appropriate setting). To those of you who do not know me, I do much more than what I just described.

      But how does one become a doctor and a programmer? As it takes indeed some explaining to do, the suggestion to write blog was excellent and here it is.

      I have written about my privileges previously. So I won’t repeat that. But it is important to know that some of the things I’m going to describe maybe either much easier for you or much more difficult for you depending on where you are in your life. In other words, your mileage may vary. But do read on, as there are some common principles which should apply to everyone.

      Start early
      I started in fifth standard, I think. With a simple programming language called MS Logo. I didn’t know what a programming language was back then. All I was doing was moving a small turtle move on the screen and draw shapes. But the only way to move that turtle was by writing commands.

      FD 50

      The turtle would move forward 50 steps

      LT 90

      The turtle would turn left

      FD 50

      Another 50 steps forward, but this time to the left of your screen

      You could write this 4 times each and get a square.

      But soon you will feel like you are writing too many commands and that sometimes these are repetitive. For example, drawing the square above required the same two steps (FD 50 and LT 90) four times in a row. What if you could tell turtle to repeat the same?

      REPEAT 4 [FD 50 LT 90]

      That would make a square in logo! And that is what a loop is (pun not intended).

      Loops are the biggest fundamental concept in programming. If you can understand a loop, you can understand the entirety of programming. That means, if you could read the above section and make sense of it, you have everything that is required to become a programmer. Only time and effort can hold you back now.

      But there is so much more about it, right?

      True.

      Let’s not digress. Where did we stop? Logo. Check this article/tutorial on logo. Don’t try to run it or anything. Just go through the entirety of it. When you see the complex fructals that gets drawn towards the end of the page, you should be able to realize another big and fundamental truth about computers or programming – you can make the computer do anything, but only if you tell it exactly how to do it.

      Well, that is what programming is, you see. Telling computer every single step of what needs to be done. The computer is insanely smart and insanely dumb at the same time. It can do anything and everything, but you have to tell it how to do it. And you have to tell it every single step of how to do it.

      Imagine you are teaching the computer how to make tea. Let us have an imaginary conversation with the computer on how to make tea.

      You: Make tea
      Computer: How?
      You: Heat water. Then put tea dust. Then put milk. Then put sugar. Then stir. Then pour to cup.
      Computer: How to heat water?
      You: Take water in a vessel. Then keep the vessel on the stove. Then switch on the stove. Then wait till the bubbles start coming in the water.
      Computer: How to take water in vessel?
      You: Move vessel under the tap. Switch on the tap. Wait till the vessel is filled half. Switch off the tap.
      Computer: How to move vessel under the tap?
      You: Find out where the vessel is. Pick it up by the handle. Find out where the tap is. Move till there. Keep the vessel perpendicularly under the tap with empty side up.
      …

      You get the point, right? If we go down this route till the level of physics, we will have made an electronic teapot. It will unfortunately not be able to make coffee though.

      But that is all there is. Break down a problem into individual single steps till the point where a computer can natively “understand” what you mean to say. CPU is a rock that we tricked into thinking. It only “understands” electricity. All that we see in the computer world is manipulation of this electricity into configurations that we want it to be in.

      But, that’s so deep? How can we break down everything to such great level of detail? Is it even humanely possible? That brings us to the second fundamental tenet about computers – you build on the work of others.

      You literally cannot build a computer all alone. There are thousands of parts to a computer which were made through even larger pathways that are possible only due to the combined human investment of effort in the past thousands of years. If you could take all the knowledge that exists in world today and go back a 1000 years, it would still be impossible to build a computer.

      You build on the work of others. That’s what you do in programming. People have built operating systems, libraries, applications, programming languages. There already is a lot of what you want to do out there in the world. Instead of trying to figure out everything by yourself, you build on others’ work.

      Even learning. People write about what they have learned. You can then use their learning as your learning. The programming world is an excellent model of co-evolution. A communist utopia.

      You want to build a website? There are libraries and frameworks available for that.
      You want to build a business? There are e-commerce frameworks.
      You want to write a blog? There are blogging software.
      What about that teapot? Well, you can build on existing work for that too.

      There is one thing, though. You can’t learn programming without doing programming. It is like cycling in that sense. You have to start slow, fall a lot of times. But once you get a hang of it, you can keep improving till you start doing tricks that make you look like a pro.

      One approach that has helped me a lot is not giving up. Every programming task appears daunting in the beginning. But once you break it down into smaller steps and start working on each piece, you feel a bit more confident. And then you inevitably run into trouble. But there are literally thousands of resources on the internet to help you.

      Understanding what exactly your problem is, and then looking for solutions to that problem helps. At this point, I will be less of a hacker, if I don’t link to ESR’s article on how to become a hacker, instead choosing to repeat what has already been accomplished. While you are at it, also learn how to ask smart questions.

      Still feel like you need a prescription? Here you go:
      Set up linux on your computer.
      Pick up python or javascript.
      Find out a problem you want to solve, and use python or javascript to solve that.
      Keep repeating.
      Pick up other technologies on the way.
      Don’t leave anything as “I don’t know that, it is not for me”, instead tell “I don’t know it yet, so I should learn it now”.