Blissful Life

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

Author: akshay

  • 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”.

    • Consent of the Pediatric Patient

      Last week, an interesting question was raised in our primary care fellowship ECHO session. “Can you give consultation to a minor without the guardian’s consent?” A simple scenario could be when a 15 year old girl comes to your clinic alone, anxious, and asks for a consult. Would you proceed normally? Would you ask her to call her parents and come back? What would you do?

      During the session I quickly searched and found an article in Indian Pediatrics, which said that “A child between 12-18 years can give consent only for medical examination but not for any procedure”. But then, I went back to see on what legal basis this was said. They seem to have referred Legal Aspects of Medical Care, a book by RK Sharma. I unfortunately do not have this book to figure out which source in law RK Sharma has used.

      So I started searching more. In National Medical Journal of India, Karunakaran Mathiharan goes through various clauses of multiple statutes and state that there is a need for clarity, specifically that “The Indian Penal Code is silent about the legal validity of consent given by persons between 12 and 18 years of age”

      In a “special article” in Indian Journal of Anaesthesia co-authored by a couple of anaesthetists and a lawyer, they say “A child >12 years can give a valid consent for physical/medical examination (Indian Penal Code, section 89).” (sic). And then they give reference to “Rao NG. Ethics of medical practice. In: Textbook of Forensic Medicine and Toxicology. 2 nd ed. New Delhi: Jaypee Brothers Medical Publishers (P) Ltd.; 2010. p. 23-44. ” Sure enough, Rao NG’s book does mention this on page 35.

      But, unfortunately, Section 89 of IPC doesn’t really say so. Section 89 talks about “Act done in good faith for benefit of child or insane person, by or by consent of guardian.” (emphasis supplied). In my reading of section 89, it only applies to acts by guardian or by the consent of guardian. A doctor doesn’t become the guardian or “other person having lawful charge of that person” at no time in their usual work. So this is just propagation of errors.

      There is a “Scientific Letter” in Indian Journal of Pediatrics, which reads only sections 87 to 90 of IPC and boldly claim that a child above 12 years age can give consent for routine elective surgery. The authors have affiliation to departments of forensic medicine or pathology. I agree with their interpretation of the sections, but I have to warn others that this does not ensure that a judge will agree with this interpretation. I could not find from sources I have whether this interpretation has been tested in any court.

      The other side of the story is that according to Indian Contract Act, only someone who has attained age of majority is competent to contract. Age of majority is 18 in India. The doctor patient relationship is a contract – implied or explicit. Therefore, a minor cannot really enter into a doctor patient relationship. But in my opinion, this should only matter when there is a question about the legality or the validity of the doctor patient relationship. To just talk to a minor, there needn’t be a doctor-patient relationship.

      Here is a link to the Indian Penal Code. Read sections 87 to 90 and form an opinion on your own.

      If you ask me what I would do when a 13 year old comes to me for a consult, I would say “I would go ahead and talk to them to see what they are here for, but I would not do any procedures or anything that could (even theoretically) cause harm”.

    • The Case of Dr Payal Tadvi or the Case of India’s Healthcare System?

      Dr Payal Tadvi committed suicide exactly a week ago. She was a postgraduate student in Obstetrics & Gynecology. Investigation is going on about the death. There are quotes from family members that she was being harassed on the basis of caste by seniors. Those seniors have written their side blaming workload. (Please go through the links if you do not know the details)

      Let us leave them aside and ask ourselves a few questions now.

      Is their discrimination in medical colleges?
      There is. All kinds of it. Economic capacity. Skin tone. Age. Seniority. Language. Region. Residence in the state where the medical college is in. Category of seat. Every damn kind of discrimination. There is discrimination in medical colleges.

      Is their caste-based discrimination in medical colleges?
      I think the answer is yes. I haven’t seen much first hand. But, there is definitely discrimination based on reservation. And since reservation is based on caste, it can indirectly be told that this is caste-based discrimination (I guess).

      Reservation is seen as giving unfair advantage to people. People who get their seats through reservation are seen as people who do not deserve the seats. When they get low marks this is brought up again as the reason (and not that most people end up with low marks in medical colleges, no matter which kind of seat they got while entering).

      Is their excess workload in medical colleges?
      Undoubtedly, yes. This is a complete failure of the public health system of our country. Have you seen the medical OPD of a government tertiary care hospital at 10am? The doctor there has no time to even breathe. Patients with any kind of condition – simple/complicated are referred/self-referred to tertiary care centers necessarily/unnecessarily. This kills the efficiency of government tertiary care centers. And on the other hand, primary and secondary level centers go underutilized. Not many hospitals have the system to reject patients. I have heard NIMHANS does this. They screen, they accept/reject patients. They refer back to lower hospitals as soon as possible. This perhaps prevents NIMHANS from going crazy (pun intended). But what about other big government hospitals?

      Is this workload issue exacerbated by seniority based hierarchy?
      Yes again. Medical colleges work on the principle of infinite delegation. The Head of Unit delegates to Professor. Professor to Assistant Professor. AP to Senior Resident. Senior resident to final year PG. Final year PG to second year PG. Second year PG to First year PG. First year PG to Intern. Intern to the patient, sometimes, even.

      When the delegation culture is accepted, there is no way adding more staff helps, either. If you are a new staff and you don’t delegate, you are an idiot.

      Is ragging accepted?
      Yes. The entire system is a form of ragging. The hierarchy I just described, that is the foundation of it. That a junior is the slave to the senior is the concept that underlies the hierarchy. The sort of visible ragging that is prohibited through law is just tip of the iceberg. This visible ragging is the initiation step into the hierarchy. The catch-them-young process of making people subservient. The training phase for silent acceptance.

      If it is so bad, why does nobody speak about it?
      Can’t you see the irony of the situation? The system is designed to prevent people from asking questions. From the first day of medical college people are taught to stop thinking for themselves, to mend in like sheep, to stay low and not attract attention. (This happened to me. I was overjoyed on the first day of medical college about the fact that I am finally in a medical college and I was wearing a small smile on my face in the histology lab when attendance was being taken. One of the faculties was offended by my smile. A “helpful” old faculty suggested to me that I change my ways. Literally on day one.)

      Who do you think, trained “well” in such a system, will come out and criticize the system? Only those who could keep their spirit alive throughout, or those who could rekindle their spirit afterwards. How many of us are capable?

      Plug: Is this herd mentality also the reason why people are stuck in the race for specialization?
      You answer.

    • The Power and Limits of Classification

      Link to journal article:
      My comment: 
      In our work with transgender men and women and other gender minorities, this was the common opinion among all "categories" of people – to stop categorizing them.
      Here is another illustration. HIV prevention and control efforts in India has a certain stress on prevention among high risk groups. For many people in the field, "LGBTQ" is a high risk group. If you look at it, the only thing common among the members of this "category" is that they are all gender minorities. By using the term "LGBTQ" many lesbians and transgender men who are actually "low risk groups" get mischaracterized as people with risk of HIV and gets repeatedly asked to do HIV testing.
      The people we talk to have all been affected by the medical system's lack of ability to deal with the full spectrum of gender. They strongly ask for developing a framework for healthcare providers to use when it comes to gender, such that there is neither negligence nor over-cautiousness.
      This article does leave a few hints on how that framework might look like. Thanks for that. 

    • The Ideal Physician AI Assistant

      When I hear “Artificial Intelligence” and “Healthcare” together in a sentence, it is usually never a pleasant thing I’m listening to. There almost always is some kind of reinvention of wheel where Google’s hardware cycles are spent in trying to solve something meaningless.

      For example, it is futile to differentiate between tuberculosis and cancer from an image of the chest where the answer may never lie in the image, but rather in the symptoms of the patient. Even if AI tells the physician that the ECG it is reading is normal (which the physician probably noticed on their own), the physician still has many reasons to refer the patient to a higher center.

      These are isolated examples. But it is the isolation that makes these good examples. AI’s role is not in isolation. AI’s role is in integration. AI (or computers) should come in and fill in where humans struggle – processing large amounts of data. (Processing data, not for the sake of figuring out patterns that humans have easily learned, but for the sake of figuring out patterns, perhaps within an individual, that a human cannot easily learn by going through information)

      AI can be a very good physician assistant. I have previously written about an intelligent EMR. The only barrier to using digital EMRs is the user interface. There are ways to optimize that interface. An intelligent combination of predictive suggestions, tapping rather than typing, reading data from text, etc will help.

      Once physicians can start using EMRs the possibilities are endless. Here is a list of things that come to the top of my mind:

      1. Intelligent to-and-fro symptom/sign/examination suggestion (that physicians can use to not miss important symptoms)
      2. Standard treatment guidelines based suggestions on medications and investigations
      3. Drug interaction checker
      4. Locally relevant and contextual antibiotic resistance patterns
      5. Patient’s past reports based insights, trends, analytics, etc
      6. Medical records exporting, highlighting important information, etc.

      If you are interested in building something like this with me, let me know.

    • On Libraries

      Sunil K Pandya asked on NMJI “Are Libraries in Our Medical Institutes Dead?“
      Badakere Rao responded to it with his memories of physical books.
      I had this response:
      The article on libraries and your response to it was a sweet read
      to me. The school in Mattanur that I studied from 1st standard till 10th
      standard had a large library (when I went back last month, it felt
      small. Maybe everything was much bigger when we were smaller). If my
      memory serves me right it had 4000+ books. The most beautiful thing was
      that when any student has a birthday they would celebrate it by donating
      a book (or more books) to the library and their names would be
      announced in the school assembly. This kept the number of books keep
      increasing. Perhaps it became a prestige issue for parents to send only
      quality books with their kids for their birthday, because all the books
      so donated were usually good and new books. From as far as I remember my
      favorite pastime after school (and free hours during school) was to go
      to the library, pick up a book, and read. The competition with other
      students who used to read more books (by numbers noted in the library
      register) only helped propel the habit. When it was time to leave and
      the library teacher would come tapping on the shoulder asking me to
      leave, I would take the book home if it appeared interesting.
      I
      still remember one Sunday when I read The Diary of Anne Franke (C
      edition, I think) from cover to cover at home. Now, this book has an
      interesting side story that makes libraries not just a collection of
      books and something much different from digital book reading devices.
      There are a few sections of the diary in which Anne Frank touches upon
      sexuality. One particular such page which has some graphic description
      (which I do not remember now) was so often read by the library users
      that the page had become dog-eared. In fact, you could open the book
      randomly and there was a very high chance that page would open up. And I
      promise I read that page only a few times. That worn out page perhaps
      was a silent broadcast to all the readers of the book about the
      curiosity in everyone’s mind. There are mechanisms in digital world
      which allows people to “scribble on margins” which can be read by other
      readers on their digital devices. But I do not think any digital
      mechanism can have dog-eared pages.
      When I was
      in ninth and tenth standard, I had become bored of my school’s library.
      Also, I would play football right after school and by the time I was
      done the school library would have been closed. That is when I
      discovered the public library in Mattanur bus stand. More than the books
      there, it was the librarian there who I spent time with. He was
      preparing for IAS examination and would talk to me about Sweden and
      Malayalam literature and so many other things that was happening in the
      world. I took War & Peace from this library once and it was so
      boring that I never read past the first chapter. Finally when I stopped
      going to the library, the book remained in my home’s bookshelf for more
      than an year. I later got a postcard from a new librarian who wanted the
      book back and also made me membership charge for that entire year.
      The
      school I did 11th and 12th in also had the ritual of birthday book
      donation. And the library there was huge too. But somehow I never used
      this library. And of course, there was “entrance coaching” to attend
      after school leaving very little time for actually going to the school
      library.
      Joining Mysore Medical College changed
      a lot of my expectations from “education system”. A library without
      general books was one such new experience for me. Yet, I would frequent
      the college UG library. In fact, Swathi and I have spent a lot of
      evenings in that library sitting across each other and holding hands
      while reading. Sunil’s mention of the pleasure in finding a hidden gem
      is amazingly accurate. Though MMC library’s “gems” were mostly old
      editions of Gray’s anatomy, I particularly remember one physiology
      textbook by Vander which explained some of the concepts in ways nobody
      had ever taught me till then. It was one of those treasures you value so
      much that you would show it to nobody else and try to hide it in some
      corner of the shelf. But fortunately I didn’t have to do any of that
      because not many of my friends were interested in the library, let alone
      a textbook that no teacher had recommended to them.

      My
      favorite book is “The Emperor of All Maladies – a Biography of Cancer”.
      If you ask me, it is a textbook of medicine (especially public health)
      that every medical student should read. But I can make a fairly
      reasonable bet that the college library wouldn’t have that book, even
      today. But, I also know for a fact that it has multiple copies of all
      the editions of a book titled “Companion for 1st MBBS” (and also 2nd
      MBBS, 3rd MBBS, and 4th MBBS). This is a question bank which contains
      past questions asked in the university exam. It is perhaps the most
      widely read book by the undergraduate student in Rajiv Gandhi
      University. And that speaks volumes about what our education system
      prioritizes. Libraries are only victims to the same.