Blissful Life

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

Author: akshay

  • What Next?

    I am privileged. I was born into a higher middle class family in Kerala. I have not been discriminated against based on my family’s religion/caste/colour/whatever. I am male. My parents are both alive and work in public sector. I even had access to internet at a very early age. I was allowed and assisted to dream.

    Precious copy of my life plan (written after 10th standard)

    My father is a doctor. I became a doctor. Natural. It was not incredibly difficult. I did not have to fight unfair situations. I had plenty of help.

    I think it is because of my excellent background that I am able to even recognize these privileges.

    Consciously or not, much of my life’s philosophy is influenced by this. My obsession with free knowledge, is a good example. I may not be able to erase the advantages I already have, but I try to avoid relying on them.

    There is no point in beating myself too much either. I am not responsible for my privileges. But I am accountable. Having had all this, if I do not make the best out of them, I am wasting them. When life gives you lemons, make lemonade. But what if life gives you apples?

    I have a few straightforward options.

    • Become a specialist/super-specialist doctor. Work in one or two hospital(s). Make a lot of money. Help a lot of people.
    • Go back to SVYM. Help build a resurgent India.
    • Join some other organization/hospital/research project which can benefit from a clinical doctor.

    None of these are mutually exclusive options either.

    Yesterday I was coincidentally discussing with dad a verse from Gita which has many different interpretations.

    karmaṇyēvādhikārastē mā phalēṣu kadācana.
    mā karmaphalahēturbhūrmā tē saṅgō.stvakarmaṇi৷৷2.47৷৷

    Specifically, it is the last part we concentrated on. “You should not not do your duties.” How do you know what your duties are, though?

    Every person plays multiple roles in their lives. They would have multiple roles each inside family, work, society, and any other sphere of their life. There are duties in each of these. Is there any way you can prioritize one above the other?

    I have never been good at prioritizing things in the past. I usually get distracted by the most visible task and forget rest of my duties. I sometimes am able to note them down and come back to them. But this is fixable.

    24 hours is what everyone has per day, on Earth. There are indeed people who get a lot accomplished in that 24 hours. If they can, so can I. I will have to organize my time well and get disciplined. And more importantly, I will have to choose the right commitments.

    That is what we are coming to, aren’t we? Commitments. What are the right commitments for me now? What should I do next?

    I keep reading “A Guide for Young People: What to Do With Your Life By Leo Babauta” now and then. The gist is this:

    The idea behind all of this is that you can’t know what you’re going to do with your life right now, because you don’t know who you’re going to be, what you’ll be able to do, what you’ll be passionate about, who you’ll meet, what opportunities will come up, or what the world will be like. But you do know this: if you are prepared, you can do anything you want.

    Prepare yourself by learning about your mind, becoming trustworthy, building things, overcoming procrastination, getting good at discomfort and uncertainty.

    You can put all this off and live a life of safety and boringness. Or you can start today, and see what life has to offer you.

    Lastly, what do you do when your parents and teachers pressure you to figure things out? Tell them you’re going to be an entrepreneur, start your own business, and take over the world. If you prepare for that, you’ll actually be prepared for any career.

    Is this advice for me? Am I already at that point where I should be knowing what I’ll be doing and who I am? At the end of my final MBBS, I thought the one year of internship will be the time when I finally understand what I will do with my life. But I was wrong. During FHM, I got a few ideas on the kind of life I do want to pursue. I am sure I will not be going back to a university in a few years. And then there are a few preferences.

    I sort of want to do things that create massive impact. That is why I got bored of clinical work. It was the same thing happening every day. Sick patients, some diagnosis, some treatment, some outcome. At the end of the day, not much has changed in the way things are.

    I want to do creative things as well. I do not want to be remembered for things I did. I want to be remembered when people use things I built.

    I love internet. It is a technology that has immense potential. I want to utilize it.

    I love computers. Computers (including the small ones called smartphones) are all over the world. Sooner or later they will take over the world. I definitely want to be a part of this take-over.

    I love teaching and learning. I want to help people learn all they want to. Knowledge should not become monopolized. 

    I believe I am good at a few different skills – programming, writing, clinical care, teaching. I want to do things that utilize all my skills. If I do not utilize all the skills I have, I am wasting those skills. That would be running away from “duty”.

    In fact, I have a few ideas in my mind which are aligned with all these preferences. I want to build free software (free as in freedom) that bring the power of internet and data science to healthcare. I want to enable people (especially the ones in healthcare) to achieve more through the use of technology. I want to make sure this immense power (of technology) does not get accumulated in a few hands. And I want more people like me – I want to ensure there are hundreds of thousands of people with me who do things like me (or better!).

    These can’t happen if I am alone. I need to connect with people. I need to build on collective strength. I already know a few people I would love to work with. Almost all of them are in the Silicon Valley of India. What makes perfect sense for me to do next is – move to Bangalore and start talking to people. That’s what I am going to do as well.

  • Way Forward

    On 30th of June, SVYM organized a one day session on careers after MBBS at Vivekananda Memorial Hospital.

    Interns and/or final year students from Mysore Medical College, Bangalore Medical College, Hassan Institute of Medical Sciences, JSS Medical College Mysore were among the ones who were in the audience.

    After the SVYM video, it began with introductory remarks by Dr Chaithanya Prasad, the director of VMH.

    Then Dr MA Balasubramanya talked about administrative careers after MBBS. The gist of it was that as doctors, we are already administrating. There is no running away from it. We should embrace that reality and go forward with it.

    Dr Kumaran K took the audience through the story of his life in research and thereby had them thinking about how to pursue a career in research.

    Dr Ravindranath motivated the audience to take up surgery as a career and showed various alternatives to the MS degree to become a surgeon – majorly about options in various other countries.

    Dr RK Nair talked about his passion for emergency medicine and how to go about it as an Indian.

    Good lunch in between, and then a snippet on Fellowship in HIV medicine.

    Dr Dushyanth P who is the technical lead of SVYM’s palliative care talked about careers in public health and palliative care.

    Dr Seetharam MR and Dr Kumar GS and the audience brainstormed on the direction where healthcare is headed or should be headed.

    Later the participants were taken on a walk around the SVYM Saragur campus and the interactions continued over various tourist spots in and around.

    Downloads

    The presentations [Powerpoint, Google Drive]
    Recording of Dr Kumaran’s talk [Soundcloud, audio]

  • First PEP – Days 7, 8, 9, 10, and so on…

    Well, I lost count.

    I didn’t miss a single tab. But I have, as usual, missed on writing the experience.

    There are indeed some highlights.

    First, a house surgeon and his friend from my college came all the way to Nugu and our hospital after reading my posts. I guess I put enough philosophy in his head that he comes back and joins here later.

    Then, I’m making good progress in my thesis work, interviewing patients about their perspectives on how they became sick. I have interviewed three patients till today. Each interview gave me a completely different story. I have even moved to Asha Kirana hospital asking permission to interview patients there.

    Also, Amazon made three deliveries. My favourite book – The Emperor of All Maladies, my favourite stethoscope Dr Morepen ST 01, and Tripti Sharan’s Chronicles of a Gynaecologist. (all affiliate links) 

    Finally got a hard copy. Horror stories one after the other. Chronicles of @triptisharan200 pic.twitter.com/0Y3D1LFwLf

    — Akshay S Dinesh (@asdofindia) May 17, 2018

    I started managing my tasks with any.do, and it’s going well till now.

    Somehow, I’m on a streak!

  • First PEP – Days 4, 5, 6

    Days fly by as usual. It’s already day 6 and I’m wondering what I did on day 5. (I slept all day).

    Day 4 – Monday, 30th April

    I had general OPD duty. In essence I was jobless almost the entire day. I sat in the injection room and saw some 10 patients.

    This morning I had tried to swallow the LPV/r without any water. It wasn’t a very good idea as one of it got stuck to the throat and I almost had to do Heimlich on myself.

    It’s the day we went to Nugu and savoured garlic bread and churmuri prepared by all the ladies.

    Busy kitchen at the ladies’ place
    Not conspicuous: Ram struggling with pepper powder in his eyes

    On the way back Kishan & Suchitra ran out of petrol. So I had to empty a 1 litre bottle of water into my throat and fill petrol in it. Swathi and I went on a scooter ride after about an year today.

    Day 5: May day

    All I remember of this day is sleeping all day. I tried to get some useful work done after waking up in the evening. But having finished dinner, I slept again.

    Ah, ah. I also sent an email to the canteen manager regarding the legality of “cooling charge”.

    Day 6: May 2, Wednesday

    My first shift in the new ED. I spent half an hour with the new defibrillator. Skanray as they call it. Sankar Ray as I call it. Sliding out the adult pad for getting the paediatric paddles was the most interesting part. Still wondering whether the whole machine can act as an AED.

    Only 3 cases came to the ED today. One of them was a lady in labour and I sent her straight to labour ward. The lady with fracture of leg? Straight to x-ray. The sad one was the man with MDR-TB, diabetes and cellulitis of a limb, had to send him to Mysore as well.

    The computer network in the hospital was in partial disarray today thanks to the lightning and thunder last night. Oh, man! Yesterday there was a bolt of lightning and ear-deafening thunder right outside my window; I thought I died. One can only imagine how the poor electronics must have felt.

    The thunderstorm is back tonight. I came to the hospital to finish this blog post as the power supply keeps getting disturbed in my room. And there it goes, another strike on the radio station above us. I sure will need an audiology check-up soon.

    Earlier when I was in my bed, I felt my calf muscles ache. Myalgia is an early sign of acute HIV, you see. Had to brush up on the basics of acute infection. Also had to read three studies on the failure of PEP in health care workers. Seems like the right regimen wasn’t chosen or there were adherence issues in most of the cases. I might also have been part of a world record by receiving PEP at around 15 minutes which I think is the earliest anyone has ever received PEP.

    I might be having some minor reaction to the PEP as I feel abdominal discomfort (in the form of flatulence) and feel like the stools are coming out faster than usual. But apart from that, the pickle in the canteen is making me eat very well.

  • First PEP – Days 1, 2, 3

    After having done the “Perfectly Messy Prefect” series and “Jog Journal” series, I have now gotten the opportunity to start a new series – on Post Exposure Prophylaxis.

    Let’s start with the good news. I put a central line in a patient (that’s my first time after MBBS and the first time I was confidently doing it on my own).

    This patient who’s been admitted with Cryptococcal antigen showing 3+ in their CSF needed lots of amphotericin for two weeks. Putting amphotericin in a peripheral venous line is okay, but it can soon lead to thrombophlebitis and both patient and doctor will have a hard time managing it. So we decided that it must go through a central line.

    And it was imperative that this happened in the new emergency department that was inaugurated the same day. Dr Ram was around and his guidance is better than the ultrasound guidance he gives.

    I will put a better picture of the new ED in a future post

    First thing we settled was whether the artery went lateral or medial to the vein. Of course it goes lateral in the femoral canal (NAVY). And nature will never let us have easy mnemonics that apply everywhere. That means artery should go medial to vein in neck. Yet I guessed that it went lateral. Anyhow we immediately confirmed with the USG that the common carotid went medial to internal jugular. The vein was there large and compressible just below the skin.

    After pressing the vein some 21 times to get the point on the skin where I had to prick, I pricked a bit lateral to that point. Yet, thanks to ultrasound I could move a bit medial and get into the vein in one go. In went the guidewire, then dilator and then the catheter itself.

    Having placed the catheter, I just had to put two sutures on the clips to hold it in place. I don’t know what made me choose a round bodied cat-gut. Or I do know – it was the cheapest among the suture materials that were lying around. A round bodied needle never goes easily into the skin. And the way I hold a needle, I do not get enough pressure on the tip. No matter how many times I have tried to correct it, I hold the needle wrong every time.

    And the holder slipped just enough for the needle to go through my glove and make a tiny cut on the distal phalanx of my left ring finger laterally. It wasn’t deep at all. Maybe one layer of skin was cut out. The direction was tangential. But it left a cut big enough for everyone to see.

    And I’m also fortunate to have good colleagues who spoke sense in to me and prevented me from neglecting the prick. I removed the glove and confirmed the prick. There was no blood or anything. Yet I put the finger under running water for more than 5 minutes. And straight I went to the counselling room to get my PEP regimen.

    Tenofovir 300 + Lamivudine 300 0-0-1, Lopinavir/Ritonavir 200/50 2-0-2 it would be. 5 pills a day is a lot of pill burden for a person who hasn’t had a paracetamol tablet in 5 years. But I was really curious about experiencing PEP.

    And within 15 minutes of the prick, I had swallowed the first set of three tablets. There was no nausea or giddiness or anything for that matter. I also got my baseline investigations done. My CBC was perfect except for high eosinophils. I do suspect there are some worms inside me. Maybe I should get an albendazole also, anyhow I’m getting bombarded my antibiotic this month. Creatinine, SGOT, SGPT everything was okay.

    I woke up to alarm next day. I didn’t want to wait 16 hours before taking the second dose of LPV/r. I took it at 14 hours. I had kept some Bourbon biscuits last day because I knew I would not get breakfast that early. I even had a masala dosa at around 9 am. Didn’t feel much of nausea. But my bowel was irritable. I think it was irritable much before all this began. From the day we attended that marriage at Saragur town. Anyhow the masala dosa kept me asleep throughout that morning.

    I had kept another alarm for 6 pm Saturday. This one was for the TDF+3TC that I had at 26th hour after the first dose. And then the LPV/r at 8 pm. I don’t know if it was gastritis or nausea, but I wasn’t really feeling hungry and had only an apple to eat with these.

    And then it was today. I woke up at 6 (yesterday’s alarm memory?) and slept again. The 7:30 alarm went off and I was actually up when Swathi called me to make sure I woke up and took the tablet. I took the next two LPV/r and went for breakfast.

    Right after breakfast I left for Mysuru. Did feel nauseated in the bus that took half an hour to start. Not sure how much of that can be attributed to reading on phone screen in a moving bus. Anyhow, once sleep crept in, there was no other feeling.

    At Mysuru I went with a friend to this really nice place called “Khushi”. It’s a home converted into a hangout cafe. There I had ragi pancake, oats with almond milk, and peanut butter smoothie all without vomiting.

    On the way back to bus stand, I dropped in at KR Hospital. Went to the medical ICU to see a patient we had referred here the previous day. Also went to the casualty OT and found it the same level of activity at 2 pm as it used to have 2 years ago – an intern or first year PG struggling to put a catheter in, the ortho intern proud of the slab he put, and patients with tubes running out of various orifices.

    I came back to Saragur in a sunny bus ride and was really hungry. Quickly had my tablets and then a full plate of rice and sambar. The mango pickle these days in canteen is coming closer to real mango pickle from back home.

    2 from the big one and one from the small one

  • Patient Inclusiveness in Rounds, Sex Between Serodiscordant Couples, Role-plays, PrEP, PEP, Anti-Retroviral Drugs, Drug Resistance, and what not!

    This weekend was fun! I am grateful to a lot of people for it being so.

    It started Saturday morning with grand rounds, as usual. We were joined by Dr Ramakrishna Prasad (RK), Dr Ashoojit, and Dr Praneeth Sai. RK was leading the rounds. And he introduced the concept of patient/family centred rounds wherein we include the family in the discussion and make them feel a part of the process.

    That meant I talked to the patient in front of everyone and let him describe his problems in his own words. This allowed gleaning certain facts of his life that were also much useful later in the day while talking about other aspects of care in HIV.

    What followed was journal club by Dr Swathi in the training hall. She presented “Living with the difference: the impact of serodiscordance on the affective and sexual life of HIV/aids patients” a topic that greatly interests her.

    They interviewed 11 carriers and based on the theme of sexuality after HIV infection between serodiscordant couples found four topics articulated:

    1. Fear of Sexual Transmission to the Partner
    2. Sexual Response Alterations
    3. Sexual Abstinence
    4. Sexual Life Maintenance.

    Based on this experience, there was a role-play session where Dr Praneeth volunteered as an HIV positive patient and I as his spouse and Dr Swathi would counsel us about our sexual life.

    That’s when the groundbreaking reality of U=U was introduced by RK. Apparently, studies like HTPN 052 has shown that when the viral load is undetectable as a result of ART, the virus is untransmittable! This must bring great joy to serodiscordant couples who have been having poor sex life after diagnosis.

    With that in mind, the role-play went ahead in letting the couples know the latest science and choose what they like to do going ahead – abstinence, safe sex, or unprotected sex. (Of course keeping in mind that other STIs can get transmitted through unprotected sex).

    Then we spent about an hour discussing on thesis topics that we would want to work on for our fellowship using frameworks like the logic model and SMART criteria.

    I had fancied the concept of using technology (phone alarm) to improve adherence to ART. Based on that initial concept our discussion took us to a mixed method study on the pattern of adherence, associated demographics, need for adherence support, and factors for poor adherence because we thought there is no answer to these questions in our setting. [I can imagine myself interviewing patients admitted in the ward probably due to an opportunistic infection they got as a result of poor adherence leading to poor immunity, trying to draw themes on the reasons why they don’t take medication; and also probably finding correlation between parameters and good adherence]

    Next, Dr Swathi finalized that her study would be on the topic of sexual life of serodiscordant couples. She would find out the fears these couples have. She would also take the latest science (U=U) and collect reactions.

    Dr Praneeth would be working on PrEP and PEP, how counselling improves the rates of PEP or PrEP, their effectiveness, and so on.

    We all agreed on a rough timeline – two months for proposal and ethics clearance. Two months for data collection. Two months for thesis writing. And then we had lunch.

    The initial schedule for the evening was theory classes by RK on various topics which he morphed a bit into Feynman technique of learning. We were asked to take up a topic and explain using the white board. And whenever we hit a roadblock he would come up with answers/questions that would help us understand the topic or the lacunae in our knowledge. (One of the many inspiring techniques RK would demonstrate in these two days).

    Swathi went on with acute HIV. How does acute HIV look like? Can we diagnose HIV based on symptoms? How soon can we diagnose it? What is the natural history of HIV like? (The graphs we had to come up with showing CD4 count and viral load over time in HIV, merit a post of their own)

    Then I had to talk about anti-retroviral medications. I tried to draw the lifecycle and then explain where the various drugs acted at. And then, while trying to give examples for each class, did I realize that I knew very few ARVs. TLE, ZLN, over. There seems to be a world much beyond just these.

    On demand PrEP vs Daily PrEP. This was what Dr Praneeth talked about. He’s been behind PrEP and PEP for a while as evident from his research interest. While I had no idea about Pre-Exposure Prophylaxis (PrEP), let alone the different modes of administration. Anyhow, here’s an article that says on-demand PrEP is as effective as daily PrEP.

    Next, Dr Ananth introduced PRIME theory of motivation in the context of smoking cessation and we did a little role-play on a smoker and doctor counselling them to quit.

    Sunday morning Dr Ashoojit and Dr Praneeth joined rounds and we listened to the stories of two patients – one who had their son living separately for the fear of catching the disease, and the other who had the story of TB but just not the evidence

    Then we had a test.

    1. Sita, 26 y/o F, from HD Kote, presents to SVYM after she finds out she is pregnant (LMP 4 months back). Married 6 years back. Husband: Construction worker. Her HIV ELISA returns as REACTIVE
      How will you approach her care?
      – Key history & examination
      – Investigations
      – Counseling messages
      – Therapeutic interventions
      – Health promotion/disease prevention
      (3 marks for each point)
    2. Her husband, Ravi, is 31 y/o M. Further questioning reveals that he is known HIV Positive, but never told Sita. He says he got it from an older married woman he was sexually active with in the past. He was diagnosed at age 28. Reason for testing: Wt loss (10 kg) (Wt at diagnosis 54 kg), oral thrush. Initial CD4 count: 76. Treated with TLE. Denies alcohol use, reports never missing his doses. <A graph with CD4 count showing improvement in the first year of treatment, till 154, then falling back to 38 by 3rd year. Corresponding fall and rise in weight>
      – Develop a problem list (2 marks)
      – Choose 1 clinical hypothesis that is most likely to explain the clinical picture (2 marks)
      – What investigations would you like to send for? What results do you expect to find? (6 marks)
      – Given your knowledge of the husband’s case details, will you manage Sita’s care differently? (5 marks)
    Here’s the much more beautifully laid out original

    We wrote answers to these questions in half an hour and self evaluated. A discussion ensued on what each person missed, and what each person wrote. This was fun as well as thought-provoking.

    And then, Dr Varsha took the fastest and most interesting 15 minutes of the whole weekend to talk about genetic mutations and drug resistance in HIV.

    Screengrab of the Stanford HIV Drug Resistance DB

    She was evidently excited about the Stanford HIV Drug Resistance Database and talked about 3 mutations that she wanted us to read about – M184V, K65R, K103N. Her explanation of what protease does, and how NRTIs and NNRTIs act opened my eyes to a whole new world of possibilities.

    There is more to write about each things I have mentioned here. Maybe another day. Do reach out to me if you’re impatient.

  • Cough Up Some Patriotism, Please!

    Many Indians have a “respect” problem. To them, respect is physical. Bowing down, touching feet, keeping legs uncrossed, standing up, using the words “sir” or “madam” in every sentence, and so on. On the other hand they also have great difficulty in respecting others’ time, personal space, or opinions.

    They are ignorant of their hypocrisy. And this is what makes them intolerant when it comes to topics like national anthem being completely out of place for movie theatres.

    To them standing for 52 seconds for national anthem is their duty towards their country. And their duty ends there. They don’t feel the need to stand up against corruption by not paying bribes. They don’t feel the need to stand up against bureaucratic inefficiency by demanding rights. They don’t feel the need to stand up and be a good citizen in a democracy.

    Kindly stand up for the flag when you are reading this part of the post.

    Because, you see, like respect, concepts like participative democracy, growth and development, efficiency, and creativity are totally alien to them. They are used to one kind of lifestyle – that of meek subservience. They make it clear that they do not like to be forced to think outside the box. They are comfortable in their zones and are not to be disturbed by provoking thoughts. Their emotions are liable to get (butt)hurt if you consider poking.

    You cannot blame them for this. They have been brought up like that. Punishments were the most used tool for teaching and while growing up. And so, everything is tied to fear. And fear manifests as slapstick respect and all the irrelevant physical things that many Indians do to “show respect”.

    Maybe some of them are literate. Maybe they understand. My sincere piece of advice to them would be to replace respect and fear with love. Love thy country. Love thy countrymen. Let love guide you into doing wonderful things for the country and humanity in toto.

    More importantly, don’t judge my patriotism by your standards. Stop slapping people for not doing things exactly like you want them doing. There are multiple ways to be a good citizen. Forcing people into doing things to prove themselves will only do harm. Sitting or standing, national anthem is just a symbol. If you really respect your country, show some real respect for the democracy.

    Related read: The National Anthem and the Supreme Court’s Popcorn Nationalism

  • Documentation in Medical Records

    I have documented my love of documentation elsewhere. I blog to document my life.

    I’m not perfect at it. Nobody ever can be. Because perfect documentation would take more time than the original act of knowing.

    Imagine. If you were documenting a visit to a nearby tourist attraction. How would you document it perfectly? You could definitely write about it in much detail. But how much detail is enough detail? Would you be writing about everything that you saw on the way? Would you be writing about your thoughts on what you saw? Would you document the planning process? Would you care about other sensations like smell, warmth, etc?

    Recording a video might capture more detail. But a video can’t really capture your thoughts unless you speak into it. Even then it can’t capture your reflections unless you reflect loud while shooting yourself. But how much can you videograph? Where do you store these videos

    Maybe it’s possible to categorize and selectively review any moment from the past using a futuristic memory capture program like shown in Black Mirror. But, seriously, who has the time?

    Perfect documentation is not equal to complete documentation. Documenting all the tiny details would not be relevant at times. But sometimes the tiniest detail can be very relevant.

    This is especially true in medical documentation. Patient’s cousin is a diabetic – relevant. Patient had a day old chicken curry in the morning – relevant. Patient was advised to take so and so medication before food two times a day for 5 days and review if his problems didn’t subside – relevant. Patient is anxious – relevant. Patient reached hospital at 9 am – relevant. Patient teaches in an anganawadi – relevant.

    Documenting all the relevant information is important.

    But, when there is too much information, organization of this information in an accessible manner itself becomes important. Because ultimately, the purpose of documentation is to preserve information for the future so that when one looks back in time, it is possible to accurately interpret history (and avoid controversies. Did Swami Vivekananda’s speech at the Parliament of World Religions get voice recorded?)

    Courtesy: Some CS Professor (Reddit)

    I once saw my consultant Orthopaedician write the timeline of a patient’s visits to hospital and management in her case sheet. This was not really necessary for him to document because none of the information was new or not available elsewhere. Her discharge summaries and OPD case record had all those details. But what the consultant did by summarizing all that in a single page is make it easier for recalling everything at a single glance. The timeline itself added value to the documentation.

    Elsewhere, A Country Doctor writes in his blog:

    Family doctors had the patient’s active problems and their medical,
    surgical, social, family and health maintenance history on the inside
    left of the chart, along with medications and allergies. Our office
    notes, filed in reverse order to the right, were to the point and only
    dealt with the things we had time to talk about that day. But the
    background information was always in view and on our minds. We even used
    to scribble little side notes, like the names of pets and
    grandchildren, hobbies or favorite travel destinations and sports teams.
    The problem list helped us see our patients as individuals, not just
    “the chest pain in room 1”.

    This was an eye-opener for me. I am used to knowing patients’ name by their case record and calling them by their name. But many times than not, I would never know the name of the person accompanying the patient, let alone their children or pets.

    Documentation is an art. It can be perfected only when you know the subject deeply. And when it comes to medicine this amounts to spending quality time with the patient and getting to know them rather than just their illness(es). Like artists, make your documentation picturesque. And people will enjoy it.

  • My Obsession with Free Knowledge

    I have a peculiar attachment with free knowledge – the concept that knowledge should be free of conditions and unencumbered by geographical, economic, cultural, and any other avoidable barriers. This often puts me in a position where I strangely reject certain well meant advices simultaneously appearing stupid and arrogant to others.

    For example, a good friend and fellow citizen once suggested to me that I join Landmark Forum, a 3 day course that helps people understand their hidden biases and become more productive people. I listened to their forum leader speaking about how the course works and the psychology behind it and I was sure it would be a fantastic idea. But, when it came to registering for the course and participate, something prevented me from doing it.

    The other day I asked a pharmacologist friend if she knew any prophylactic treatment for syphilis. She went to UpToDate (or I’m not sure if it was some other similar service) and started looking up the information. I was curious what she was using and whether I could have it in my phone too. She said it would need a subscription, but she was willing to share her username and password with me. I said that I didn’t want access to it.

    Yesterday a close friend suggested Dr Thameem Saif’s lecture series on basic concepts in medicine for me. She said that it was really good and helps to grasp basic concepts really fast, saving a lot of time. I agreed with her on all that and said I wouldn’t attend the lecture series.

    Additionally, I hate the concepts of entrance coaching, tuition, etc.

    The pattern I see emerging is that I have constant disregard for knowledge that is held behind restrictions, especially if tied with a business. I don’t consider making a business out of knowledge evil. But I hold a pet peeve against using that kind of knowledge for my personal benefit.

    To understand this attitude, you need to look at the other things that I value and principles that I care for.

    Free software

    Free as in free speech, not free coffee. Here is an interesting paragraph from gnu.org about free software:

    The idea of the Free Software Movement is that computer users deserve the freedom to form a
    community    . You should have the freedom to help yourself, by
    changing the source code to do whatever you need to do. And the
    freedom to help your neighbor, by redistributing copies of programs to
    other people. Also the freedom to help build your community, by
    publishing improved versions so that other people can use them.

    I have been an ardent user and advocate of free software for the past 8 or so years. The idea that there is collective ownership of software and people being able to make and share improvements on the software with each other thus creating a better product for everyone is addictive. So much that once you subscribe to this philosophy you feel grudge and guilt if you were to use or be forced to use non-free software for any task.

    I can still use Microsoft Word on my parents’ computer running Microsoft Windows to type a letter. But it simply won’t feel right.

    Open Web

    The Open Web is that part of the world wide web which is open for anyone to use, create, and innovate in irrespective of their location, race, gender, economic status, etc. according to me.

    Internet has enabled human dreams far quicker than any other invention. Internet is a great equalizing force. Internet has elevated human life to a higher level. And Open Web is the most important pillar of this success.

    With the Open Web, it is far more easy and quick for people anywhere on earth to share and receive knowledge. Collaboration is cakewalk. Building upon each other’s ideas becomes rule rather than exception. Charles Darwin and Gregor Mendel worked on two critical pieces of the theory of evolution at around the same time. But they never knew about each other’s work. Won’t ever happen in the internet age.

    When I see internet services that are “app-only” or requires sign in for viewing, I wince. They are justified in trying to retain users. But it simply won’t feel right for me to use such a service.

    Open Access

    With internet, the cost of publishing came to almost zero. And so one would think that science literature would become cheaper and cheaper to access. But the opposite is the truth. Scholars expend their lives trying to expand the horizons of science and publishing industry locks down their contributions to select few who are willing to pay exorbitant amounts of money to access this.

    People who fight these are killed. But their spirit cannot be killed. Open Access movement is gaining large amount of followers. When enough academicians hold fast to the promise that they won’t publish in money-thirsty journals, there will be a tilt in the way scientific literature is published.

    Science needs to be set free. And open access to scientific articles is crucial here.

    I’ve not published anything yet. But when I do, it will be open access. And I keep asking the people I have any influence over, to keep their contributions to the knowledge base that humans have built to be open access.

    Free Knowledge

    It is in this backdrop that free knowledge enters.

    Organizations like Wikimedia, Creative Commons, and even YouTube have done a lot to advance free knowledge. “Imagine a world in which every single person on the planet is given free access to the sum of all human knowledge.”

    If you have been reading carefully till now, you know that free culture is my culture. And free knowledge is an inalienable part of free culture.

    From as early as 11th standard, I have been using the internet and all the wonderful resources in it to learn. I fell in love with MIT’s OpenCourseWare. When NCERT textbooks weren’t enough I would run to OERs like CK-12.

    But when I joined MBBS I faced the greatest challenge ever. To date I have not been able to find any good collaborative (or not) open textbook online for medicine or any subject that medical education includes. There have been very good attempts like Ophtho book, Path Bites, Radiopaedia.org, etc. But the information is usually so scattered that it is very difficult to get a comprehensive understanding of the subjects.

    In this scenario, I was forced to resort to traditional textbooks. I made it a point not to purchase expensive textbooks. I’ve scraped all the corners of the internet to find out useful PDF files.

    And at the same time I made a pledge to myself that I will leave the condition a bit better by organizing the information that I find and making it possible for a future student to click on links and get access to various information as required. That is why learnlearn.in was born.

    Now that I have finished MBBS I no longer am under duress to stick to textbooks to avoid prolonged stay at a not-so-nice place. But, in the spirit of pirate philosophy, I continue to access resources that are required even when they’re not free knowledge. But I have set a personal restriction that I will not be using resources that aren’t obtainable from the internet.

    By doing this I am expecting to create a path which can be followed by others. I want success, but I want only reproducible success. I don’t want to be successful because I had access to a particular resource by virtue of my geographical, economic, cultural, or any other privileged position.

    So what about things I learn at VMH? Well, my plan here is to put everything that I learn here online. Also, a point to note is that at VMH there’s no package of knowledge that is sold. It’s all experiential learning that occurs here. And people are welcome to work and learn from here.

    Can’t you do the same with Forum, UpToDate, and Dr Thameem? Well, not impossible. But, like I said earlier about using Windows as a free software advocate, it just doesn’t feel right.

    But more importantly, by striving to learn exclusively from free knowledge resources, I create a demand for free knowledge thereby encouraging creators to produce more content in free domain and also allowing people who come after me to have a road that’s been taken before them.

    Let’s build a society where knowledge is free.

  • Fellowship in HIV Medicine – Interview

    A day before independence day, after the long wait of more than three months, the FHM interview took place at SVYM office.

    I was on duty and was checking on a newborn with tachypnea (probably transient tachypnea of newborn) when they called me upstairs for the interview. I had others fill in for me and ran to the interview room.

    My friend Swathi went in first and sitting outside I could hear them talking about the challenges faced by a clinician and public health worker in managing HIV because of the stigma associated with it and how by consistent effort we can influence at least families of HIV infected people to look at it like any other disease.

    I had practised multiple times the answer to why I wanted to join FHM. I look at it as a course in infectious diseases and India is a country still struggling with infections. My personal interests and career choices are probably going to take me to places where being good at managing infectious diseases would be an advantage. Also, SVYM is a great place to be at. The clinical, academic, and overall atmosphere here is wonderful. The kind of people whom I get to work closely with – no mention. Not to forget, I was never interested in a PG seat (till I started working here, that is).

    The conversation then came to how I should rigorously finish my dissertation, starting early and keeping good quality because Indians can also contribute to the knowledge base that medicine is built on.

    I didn’t mention my unrealistic perfectionism that kills most of my research ideas. Maybe articles like this will help me look past RCTs as the only study worth doing. Wish me great productivity.