Blissful Life

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

Author: akshay

  • Changing The “System”

    People of all kinds routinely blame the “system” for many things. They’re absolutely right. It is the system that shapes human behavior. In a system where certain behaviors are rewarded, those behaviors are repeated. And vice versa. We are all Pavlov’s dogs in that sense.

    That’s why awards and honors are instituted. To reward the right kind of behavior even if that’s not the expected norm. Awards motivate extraordinary people. What motivates ordinary people? The system.

    The “system” is the system that encourages and supports ordinary people to do things that they do in their ordinary life.

    The system includes written laws, unwritten laws, stereotypes, hierarchies, economic condition, political condition, geographic and physical condition, infrastructure, feelings, mythology, myths, news, fake news, communication, … literally everything you can think of forms the system.

    Who builds the system?

    The naivest answer to this and the most convenient answer for “ordinary” people is to blame politicians for building the system. This is especially true for people who consider themselves apolitical. Sadly their politics is that of selfish avoidance of responsibility. It is not always the fault of intention. People who can’t stand oppression and feel like there is so much to do that they cannot be responsible for any of it will unconsciously try to talk about why it is not their responsibility. But often it is selfish laziness.

    The better answer is that “we” build the system. Who are we? Anyone who can be involved in building the system builds the system. By commission or by omission.

    Who can change the system?

    Intuitively, the people who built the system can change the system. True. But not all have equal role in building the system. Neither do all have equal say in changing the system. The people who can change the system the easiest are the people with most agency, privilege, and voice.

    Who can not change the system?

    People who become a slave to the system, who sacrifice their agency, privilege, and voice to the system instead of questioning it. They absolutely cannot change the system.

    Why does the system perpetuate?

    Because it is easier to continue the system than to change the system. Anyone who wants to change the system has to find ways of sustaining and motivating themselves. Then they have to question the system and work against it. They have to do this at the peril of losing access to their accustomed rewards from the system. They have to stand up against their acquaintances who enjoy the benefits of the system. They have to shake things up. They have to stand out. They have to put themselves at great risk.

    The biggest enemies of people who want to change the system are the people who do not want to change the system. The people who benefit from the system usually do not want the system to change, because of inertia, even if they superficially blame the system for everything.

    How to change the system?

    If you agree with most of what I said above, the answer to this is straightforward.

    Prerequisite: Have a lot of privilege. Have the mental space to take on challenging things. Have help, support, guidance. Have plan B, plan C. Privilege is a gift.

    (An aside on privilege. A lot of the privileged folks think that they’re not privileged. When they hear the word “privilege” they imagine Mukesh Ambani’s inheritance with Narendra Modi’s popularity and influence. If you can read this blog post, you’re already more privileged than a lot of people on this planet. Reading is a privilege. English is a privilege. Internet is a privilege. Time is a privilege. Sure you might be facing oppression in many ways. But that doesn’t take your privileges away. Everyone on the planet faces some or the other oppression, and a lot of them face more oppression than you do. It is a lot easier if you count your privileges and use them.)

    The first step is to find loopholes in the system to build yourself sustainable income outside the parts you want to change. This might look like joining pre-existing teams doing what you want to do, finding scholarships or grants, monetizing on a rare skill, etc. Creativity is key here. If you do not have any privilege that you can leverage to achieve this step, then you’re out of luck. The best thing you can do is continue being part of the system and silently help those who are trying to change the system.

    The next step is to find motivation. There is so much to do and so many generations worth of work. Find problems that you can solve. Find problems solving which will give you satisfaction. Find cracks that make it easier to break the system. Define short-term successes. Think and act with purpose.

    Then help others who want to do the same. Amplify voices. Volunteer effort. Offer support. Build friendships. Build capacity. Build community.

    Things not to do

    When thinking idealistically, it can be easy to develop hatred to those who are doing things differently from you. If people are trying to change the system and they are doing it in a way that you do not approve of, engage in respectful debates with open mind. Sometimes they might be doing it right and you are wrong and you can change your ways. Sometimes vice versa. Sometimes both of you can find useful elements to do things differently. Even when there are unsolvable disagreements, it is easier to think about those as fundamentally hard questions with no one right answer. Do not develop hatred for people who do things differently.
    Do not become intellectually arrogant. Intellectual humility is when you keep your intellectual outlook about the world detached from your ego. And you’re ready to take a hit on the outlook at any moment. And you’re willing to change them. Intellectual arrogance is when you refuse to change your outlook from what you formed in early adulthood.
     

    Validity of this strategy

    This may not be the only way to do things. But this seems like a reasonable way, to me, at the moment.

  • Why Politics isn’t for the Honest

    This is not a pessimistic post. I’ll explain why honest people can’t do well in politics. And then I’ll also urge honest people to be political.

    When I say politics isn’t for the honest, I mean that the identity of a politician isn’t for the honest. They cannot win elections on their own. They cannot sway votes on their own. They can’t do anything in politics on their own.

    Why? Because the country is full of human beings who are irrational and we have a first-past-the-vote voting system.

    Winston Churchill probably never said that “the best argument against Democracy is a five-minute conversation with the average voter.” Nevertheless, that’s true. And it doesn’t require you to have contempt for others to agree with that statement. You just have to remember that we are all humans and that we are all bound by cognitive biases.

    We stereotype, we assume, we guess, we make up, we are swayed by public perception, we change our stances under social pressure, we are biased, and we have cognitive blind spots. We are all irrational human beings.

    When it comes to an election we choose a candidate based on our view of the world and our view of the candidates. Both of these are colored by the biases I mentioned above.

    Here’s where the first-past-the-vote system comes in. The vast majority of people won’t vote for a candidate they think do not have any chance to win. “Why waste your vote on a candidate who will anyhow lose?” The elections are therefore already reduced to a two-party (or a three-party) election.

    You can still start a new party and enter the three-party race (like AAP did in Delhi). It requires entering the consciousness of voters at large and, mostly, at once. AAP could do this because of the wide media coverage of India Against Corruption. Another way of attaining this kind of prominence is to split off from an existing party. In essence, being in people’s minds is the first step to being a potential winner.

    Now that is already our cognitive biases in action. And at this point the line between irrationality and reality blurs too. For, how do you do governance if you don’t have the trust of the people. Why should people trust a random party based on their manifesto?

    Trust. Trust could thus be considered the defining force of winning election. And trust is at the edge of what is called irrational. We make up trust in politics based on the circumstances. If we feel like there is a threat of war, we will trust the person/party which appears like it has the ability to win a war to lead us. If we feel like there is a threat of breakdown of social order, we will trust the person/party which appears like it has the ability to keep the society together to lead us. Our trust depends a lot on how we feel.

    This is where politics becomes a game in which honest people have no chance. You can manipulate people’s feelings in two ways – you can change their threat perceptions and you can change their perception about the ability of different political candidates to handle those threats.

    How you feel about the how big a problem terrorism, war, global warming, fascism, or sedition is depends a lot on what you’ve been fed by the world and how rational you are. For example, let me take me. I am a person who avoids news. I do so because I believe that news is about sensationalization of the trivial matters because they’re newsworthy. For me, matters like terrorism are quantitatively less important than matters like road safety. Whereas it is totally possible that another person looks at road safety as an unavoidable problem but terrorism as unwarranted, avoidable threats to the psyche of our nation. The perception of what the largest threats we face are can be manipulated by manipulating the media that people consume – be it news media or social media.

    The next kind of manipulation is one that people routinely employ all around, but is the bread and butter of politicians. Image management. For a politician to succeed they need to project an image of leadership that suits the “largest threats” that we are facing. Image is ridiculously irrational. For example, let us look at very personal things that are all part of the image – clothing, fashion, colors, facial hair, hairstyle, make-up, facial expression, gait, speed of walking, phone, spectacles, … Everything that you can think of affects the “image” one projects.

    Let us take the biggest example in front of us. In 2007, 5 years after Godra, Karan Thapar did an interview of Narendra Modi. Narendra was not so much of an adult at that time and ended the interview at 3 minutes because Karan started with questions about Narendra’s murderer image. A lot of people don’t know what happened after that. In another video, Karan talks about it. The interesting bit is that Narendra looked at that 3 minute interview many many times afterwards to learn from their mistakes and do better. Maybe Narendra gave up and stopped doing interviews instead. But the fact is that playing to their strengths allows Narendra to project an image of a strong leader.

    Every successful politician has done this. They’ve managed the perception they create in the mind of their voters. Barack Obama has done and wrote about it. It maybe interesting to know about how Michelle Obama in the first few speeches about Barack’s presidential campaign was being perceived as an angry person and immediately course corrected with softer speeches (and clothing choices). Rahul Gandhi must be trying really hard to do this after Narendra knocked down Rahul Gandhi’s image.

    That brings us to another point. It is not just your image that you manage in politics. You also manage others’ image. You tell voters how to look at other candidates. You make them look like fools, you win.

    Now why does all of this matter for the honest politician? Can’t they project an image of their own honesty and succeed? Not as easy. If you are an honest politician and if you believe that terrorism is not as big a problem as global warming or road safety, and you take that idea honestly to a set of voters who believe strongly that terrorism needs to be curbed, that is pretty much the end of your political career.

    You will have to bend the truth, if not lie. And bending truth has its limits. There is only so much you can accomplish with bent truths, especially if your opponents are fighting with lies.

    But politics is so important that you can’t give up just because you don’t have a chance to win. What should honest people do about politics?

    First, they have to realize how irrationality rules politics. Then they have to use that knowledge to guide how they approach people. They need to turn the irrationality on its head and make it question the lies. 

    They might have avenues other than politics to reach powerful and influential positions where it is easier for them to sway people’s perceptions. 

    IMO Research is also political; a way of convening influence and is likely to reflect/aggravate/amplify/mitigate unfairness that we see outside research; for far too long it’s been framed as “higher truth”…more on this soon…

    — daktre (@prashanthns) June 18, 2021

    Maybe they can be excellent researchers and use research as a political tool. Maybe they can be good artists. Or programmers. Or doctors. Or teachers. Or anything! Anyone who does their thing well gets some power and influence. And they can use those to sway irrational voters to things that matter.

    Politics is for everyone. And honest people have their own options.

  • Don’t Let Them Dehumanize You, Doctors!

    The society will try to dehumanize you in various ways. And you will feel pressurized to play along too. Don’t let them do that to you, as much as possible.

    —

    Every patient comes to you with the expectation of a complete cure. They do not care that you are human. Reset their expectations. Let them know that there are limits to what you can do. Stay human.

    Once, I was second call in VMH when a patient was brought dead to the hospital. The doctor on duty wanted to send them home in the same ambulance they came in so that they don’t have to be bothered about arranging transport. But the relatives were getting angry that the doctor is not trying to save the life of the patient. I was called in. The patient was “obviously” dead. But it wasn’t that obvious to the people who loved the patient. They were expecting an omnipotent doctor to be able to bring the patient back from dead.

    People will always come to you with unreasonable expectations – whether they express it or not. Preemptively address those and reset those expectations. Don’t let them dehumanize you.

    —

    One patient sees one doctor a day. One doctor sees many more patients a day. Patients do not know this or do not care about this. Each patient thinks that it is reasonable to expect that the doctor prioritizes their care above everyone else’s. Omnipresence is not human.

    When dealing with multiple patients and feeling overwhelmed, let each of your patient know about your situation and limitation. Before they get a chance to complain that you’re not giving them the care they deserve, let them know that you are thinned out and helpless.

    There is a limit to how many patients you can care for. The society wants you to treat this limit as adjustable with a bit of overwork. Don’t let them dehumanize you.

    —

    You might have been taught that it is unprofessional to express emotions in your duty. But it is very human to have emotions.

    There’s a trick I use with anger. I don’t lash out on people with anger. But I tell patients that I’m angry or that something they’ve done or are doing is making me angry. There’s no easier way to communicate!

    I have also used “I am feeling anxious about …”, “I am scared that …”, “It makes me sad too that …”.

    Put a label to your feeling and put it across to your patient. Let them know. Let them know that you’re human. Don’t let them think that you are not.

    —

    You can’t know everything. You can’t remember everything. Open textbooks in front of your patient. Show them the search terms and the apps you use.

    Tell them that you will have to look the answer for that up. Ask them for links to the articles they read to reach at their own internet-guided-diagnosis. I’ve more than once been linked to cutting edge research that I wasn’t even aware of.

    Don’t let the unreasonable expectation of a charismatic omniscient doctor dehumanize you.

    —

    You need to eat. You need money. Whether your patients are rich or poor doesn’t change those facts. But that’s not what the patients think. They think of healthcare as a profitable business. They think of healthcare as a necessary service. They expect you to sacrifice profit. They expect you to sacrifice compensation, even.

    Show them the reality. Show them how you’re saving them money by giving them the right treatment. Show them the expenses you incur in doing so. Tell them how the one hour you just spent with them is already heavily subsidized. (If you don’t realize this, just answer this question after a minute of thinking. “How much, would you say, is an hour of your time worth?” And when you answer it, make sure you account for the opportunity cost you incur by not doing other things that you’re capable of doing.) Give them a lesson in economics. 

    Let them know that it’s not omnibenevolence, but it is self-love that is human.

    —

    Don’t look at the patient-doctor relationship as a purely biomedical one. It is a deeply political one. And a deeply human one. It need not be one way. It should not be one way. Anything that comes in the way of making it complicated needs to be given considerable time and addressed.

  • Giving up Ideological Purism

    I used to be a purist. I would think that socialism is better than capitalism and therefore I should myself shun everything to do about capitalism. I would think that free software is better than proprietary software and use only free software everywhere. And so many other “principled” positions. Then a couple of things happened.

    First, life became unlivable. There was nothing worth doing because everything broke some or the other ideology I had. I can’t start a business because it is not socialism. I can’t put tweets and try to get followers because I am against the concept of popularity and getting more followers. I wouldn’t make videos to upload to YouTube because Google owns YouTube. I can’t build an app because it wouldn’t solve a pressing real world problem. I wouldn’t get a vaccine till all people would get it. I can’t do this, I can’t do that. I couldn’t do anything.

    It is not that I didn’t see contradictions then. I am living in a comfortable house in Bangalore. Where’s the equity in that? By my logic I had to give up all my savings and live like the poorest person. But I wouldn’t do that.

    In some way or the other I was thinking pragmatically. I realized that free software puts software above humans and rethought it. Even came up with feminist software. I had been thinking about putting privilege to use. I had just about figured out that good capitalism and good socialism are almost indistinguishable.

    But the straw that broke the camel’s back is the vaccine issue. There were many reasons I was against getting myself vaccinated – the undemocratic institution of CoWIN, the lack of transparency in approving vaccine for usage, and most important of all the fact that lots of people were not getting vaccine. There were many compelling reasons to get vaccinated too – that there is good science for vaccines in general and these vaccines specifically, that I could be putting others’ life in danger, that I would be of no use to anyone if I’m dead.

    But ideological purism works in mysterious ways. I had chosen that the morally right way was to avoid the vaccine. And my brain would come up with various reasons on why I was right.

    But on one fine day it clicked in my head. I was indeed being stupid. I told Swathi that I’ll start looking for places where vaccine was available. And by the purest of coincidence, a friend from a private company asked me the next day whether I needed a jab in their company’s private drive.

    That’s when it all came together for me. Ideological purism is an unsustainable and self-contradicting position. The only way human beings can live life in the real world is through pragmatism. And pragmatism doesn’t have to be lazy and directionless. Pragmatism is the way of figuring out the good and bad of capitalism, the good and bad of socialism, and the good and bad of all the ways to organize economic activity and to figure out a way to work it out in your life towards your goals of a better world. Pragmatism is the way of figuring out how to use proprietary software, free software, and all kinds of software for making things happen.

    I also figured out I was being lazy. By doing all of these fights against twitter, CoWIN, proprietary software, health inequity, authoritarianism, meritocracy, and so on in my small world, I was not doing anything. I was just sitting in a corner of the world complaining about all this. Sure I was a member of Indian Pirates, Free Software Community of India, etc. I was doing things like organizing calls and camps. I was mentoring people, etc. But all this felt like running away. I was not engaging in a powerful way.

    One of the reasons was the idea that lasting change requires converting people this way from the outside. That we can’t live in the existing systems and change them.

    I still don’t have an answer to that. I don’t have an answer to how I can change the system from within.

    But I’m tired of being outside the dominant systems in all fields. I’m tired of swimming the other way. Let me try swimming this way.

    It is selfish. But hey, we are all stardust anyhow. Let’s see what happens?

  • Is Science The Only Way of Knowing?

     This is continuation of a debate from YouTube.

    The statement that “Science is the only way of knowing” is correct. But it is also arrogant.

    The definition of knowledge that we are working with is “justified belief of independent rational observers”. What I argue in the video is that independent rational observers can come to different justified beliefs when it comes to social science where the observations are made about human behavior. I gave the examples of economics, politics. That when two independent rational observers look at the “market” one comes up with socialism and the other with capitalism. That there is no way for science to figure out which of them is the “truth”. And that this lack of convergence on one justified belief is what makes the argument “science is the only way of knowing” break down.

    But using “logic” (which can also be called scientific method) is the only way for humans to know anything, and that’s right. Those who defy the commonly accepted “logic”s are considered psychotic by human beings.

    Where is the arrogance? The arrogance is in claiming that “science is the only way of knowing” when it is clear that there are very severe limitations for science when it comes to the field of social science. A society cannot be subjected to controlled experiments. What science requires to arrive at the truth, to “know” how a human society will function is a set of observations from which one can draw conclusions. It is impossible for human beings to perform this set of observations in the way that’s required to correctly draw such conclusions and “know” the human society. And that is the fundamental limitation of science.

    To claim that theoretically it is possible to isolate all the variables and test a hypothesis about human beings – that’s useless at best, and politically inappropriate at the worst.

    In the video I try to keep physics, chemistry, etc from the uncertainty about truth that I introduce. But in response to the video Pirate Bady brought up the argument that ‘single’ truth does not exist in even physics. That quantum mechanics, for example, has infinite truths with different probabilities.

    I don’t know quantum physics. I have no perfect idea how exactly Schrödinger’s cat is a paradox. Which is why I omitted talking about this in the video.

    But if physics is also observer dependent, then that’s another argument which weakens the idea that “science is the only way of knowing”. That multiple truths can exist and we won’t be able to come to a single truth translates to the idea that – “we cannot know certain things”. 

    From that it can be argued that if there is a way to know it is only through science and consequently, “science is the only way of knowing”. And that’s a big if clause.

    If there is a way to know, science is the only way

    I can stand by that statement.

    Because it admits that there are times where we cannot “know”. Be it quantum physics, be it politics or public policy. That’s a humble statement. That’s a statement which accepts the limits of science. That is a statement which gives space for “other” ways of “knowing”.

    The only argument against giving space to these “other” ways is that it can lead to irrational thinking in human beings. And I think that’s the argument Dr Viswanathan makes too. And I think that’s also the reason why science has not been able to win people over despite so many accomplishments it has had. That science fails to acknowledge what is fundamentally human. That science, in its ivory tower, arrogantly believes that all that the world needs is science. 

    If only more rational thinkers admitted that there are times when humans can’t know and that science has no role in such times, we can then start negotiating with irrational people and push them to use science in all the places that matters.

    Yes, that means that we will have to tell them that science cannot tell them whether there exists a God or not. But that’s okay. By accepting a humble position like that, you make science more welcoming to all humans. It is by being arrogant that you drive them away.

  • History Taking Through Heart

    I was trying out the Daily Rounds app on Android and came across a case description “Unilateral limb swelling in a 51 year old lady. No comorbidities. KFT normal. How to proceed to diagnosis?”

    This reminded me about how clueless I was about history taking during medical school. I think if I’ve learnt anything well by now, it is on how to take a detailed history. And looking at this question made me realize how much that helps me in coming to diagnoses. So here are some super simple tips to take detailed history while building a personal connection – which doesn’t require any knowledge of pathology or medicine.

    Start with the person

    You might have learnt that asking for name is the way to build rapport. But that’s a lie. Asking for name is so you can write it in your notes. If you want to build rapport, talk to the person in front of you (and not the patient). I’ve found that the question “have you had breakfast?” in their language (adjusted for the time of the day) is a super simple way to build rapport. And the reason is that this is what regular people usually ask each other casually when they are on the road.

    This lets the patient relax and breathe free. With just one sentence you’re telling them that you’re a human like them and you respect them like another human. That their sickness is secondary to their human existence.

    Move to the patient

    Now you let them talk. Unless they’re experienced, they will not have arranged in their mind what to tell you. For the first few minutes, let the patient speak without interruption. Let them figure out what their problem is while they’re talking to you. Use only head nods, and “hmm” to communicate that you’re listening. Make sure you’re looking at the patient and don’t give off an impression that you’re not listening.
    If the patient stops after describing just one symptom, just give it back to them as a question. 
    “I have headache” Long pause.
    “Headache?” with a puzzled, but caring face.
    Awkward long pause.
    “Yes. The right side of my head feels like it is exploding, since yesterday”
    “Hmm. Tell me.”
    “That’s it. I’m unable to get up from bed.”
    Pause.
    “And everything becomes dim and dark to see”
    …
    Once you let the patient figure out that you’re there to listen, they’ll tell you everything you need to know without asking.

    Get the timeline right

    Once you know the presenting complaints, it’s time to arrange them in the right order with dates. Ask specifically about when they were completely alright. Get as specific a date as possible about when things started. (The longer people have been having symptoms, the less specific you can get. But still.) Retrace the course of their illness from day 1 of symptom. Find out the order of symptoms. Find out the progression of illness. Find out what they’ve been doing (I betcha they’ve gone to another doctor already or tried something). Find out why they decided to come to you. (That needs a point of its own)

    Find out why they came to you

    There’s a reason the patient has come to you. This is not the same as the chief complaints. Some are scared and are coming for reassurance. Some are tired and want relief. Some have been referred by someone else for a specific reason. Confirm the reason why the patient has come to you. This becomes super helpful when you’re figuring out the management. As a bonus, it allows you to address the exact concern the patient has.

    Let them know you are on their side

    This is the turning point in the consultation. You have heard the patient. You have understood their concern. You now win their trust by telling them that you are there to help them. And then you start talking a bit.

    Ask your questions

    You should have held the questions in your mind till now. The time to start asking them is now. Start with clarification of symptoms. Ask for negative history. Ask about comorbidities. Ask about past history, family history, socioeconomic history, and so on.

    Asking negative history

    For asking specific negative history, you’ll need to know about diseases. But there is a way to avoid that pre-requisite. Go from head to toe. (You’ll need some anatomy, physiology knowledge). 
     
    Look at the head and ask about all the organs that you see. Bonus point if you touch their head when talking about the head. (But that’s not always appropriate. Use your gut sense). Ask how their sight has been, how their hearing, taste, smell has been. Have they had cough, cold, throat ache? Then look underneath the skull. How has their memory, sleep, thoughts, etc been? (There is hair, tongue, teeth, and so many finer details I’ve skipped for brevity. You will have to be careful not to ask too many questions too. This is just an algorithm to generate questions mindlessly. Filter those questions by applying your mind.)
    Then go down to the chest. There are lungs, heart, esophagus, neck + thyroid. Ask questions about things that could go wrong there. Then the upper limbs.
    Then the abdomen/pelvis. These have so many organs. Liver, spleen, kidneys, adrenals, pancreas (endocrine, especially), and the alimentary tract per se. And depending on your patient, uterus, ovaries, so on. It is easy to forget the back with spinal cord.
    Then there are genitals and lower limbs.
     
    Then there are some general things like fever, bodyache which don’t really fit into this organ by organ thing but they usually come up somewhere in between.
    This is only one way to generate questions. Depending on how much differential diagnoses you have in your mind based on chief complaints, you might be able to come up with questions without using this algorithm.

    Other histories

    The best way to take history like past history, socioeconomic history, etc is to imagine yourself in the patient’s life. What is this person? Where are they coming from? Where are they going? What do they do in their daily life? How’s their life like? What’s their family? What do they do after getting up from their bed till they go back to bed? Do they take some medicines? Do they go to hospitals? Do they drive a tractor? Do they work in three houses?
    This part of the history should ideally go like a conversation that has become really interesting and you “want to know everything about” the other person. But often we don’t have a lot of time to spend here. And it is inappropriate to spend a lot of time here. Just get a fair sense of each slice of your patient’s life.
    What has their relationship with themselves been? Do they treat their
    body and mind well? Do they consume alcohol or use tobacco? Do they eat
    well? Do they exercise? Do they work too hard?
     
    What has their relationship with their family been. Who is their caretaker? Could someone in the family be giving rise to their sickness? What’s the family dynamics?
    What has their relationship with the society been. Are they generally happy with life? What do they do in their life?
    What has their relationship with the medical system been. Do they have
    any diagnoses? Do they have any other doctors? How many times have they
    had significant medical care in the past and why?

    Summarize your idea of pressing issues back to the patient

    By this time you have gone far away from chief complaints and to bring the attention (the patient’s and yours) back to it, you can summarize what you think is the problem the patient is going through to them. And then after you get the patient’s confirmation you can proceed to examination.

    Advantages and disadvantages of this method

    What I’ve described here, like other ways of history taking, is just a template. This one is focused on getting a whole picture of a patient’s life without using a lot of knowledge about diseases. Another advantage is that you can build a lot of empathy. But it is also very time consuming. It often takes 45 minutes to an hour just with the history if done this way.

  • Why Researchers Who Care About Equity Should Use Zotero (and Not Mendeley)

    If you are a researcher, chances are that you write papers. And if you write papers there is a good reason for you to use a reference manager (also called citation manager?). If you use a reference manager and you care about equity, there is a good reason why you should use Zotero.

    Why use reference managers?

    Because the publication systems used by most of your journals are (intentionally) ancient. The internet allows usage of hyperlinks on any word in your article. But the academic society is still worried about putting references in an order at the end of the article. And every journal has their own citation “style” (as if the font style of the journal name matters in the quality of the reference). While all of this is part of a system that wants to continue making creation of knowledge the exclusive privilege of an elite circle, sometimes you might have to be a part of that system. And you’re better off handing to a software the tedious (and useless) effort of keeping track of your references and arranging them in an order and in the right “style”.

    Also because when you’re doing literature review you might want to keep track of a *lot* of references and you might want to tag them, group them, share with others, etc.

    So, use a reference manager and never copy paste references manually.

    Why not Mendeley?

    You might look at the options and you might see this software called “Mendeley”. And you might think, “Ah, this looks like a good fit for my use case.”

    But did you know Mendeley is owned by Elsevier? Do you know how in the age of the internet Elsevier and many other publishers continue to charge people for publishing and for reading? Do you think that these are reasonable charges levied in return of some great effort from their part? If you think so, you have literally no idea how the internet works. 

    See you are reading this blog. It took me zero money to publish this post. And that cost would not have changed a bit if I had a 100 references at the end of this post. This gets published under a creative commons license and that didn’t change the cost from zero either. Once I publish it, I will share the link to it in social media and other places. And people can add comment under it. Remember that most journals don’t pay peer reviewers anything for reviewing posts either.

    So that should really make you wonder what the process of publication in journals are about. My philosophy about journals are simple. Journals give you credentials and privilege. So you publish on them. And the academic society considers publication in journals as the yardstick to measure your merit. And that vicious cycle perpetuates.

    But I understand your plight. Just because the system is horrible you can’t avoid the system. And you’re condemned to the life of a 20th century academician. Fine. Publish. But don’t support Elsevier, Wiley, American Chemical Society, etc. 

    And don’t use Mendeley which is proprietary and owned by Elsevier.

    Use Zotero.

    Zotero is free and open source software. I use free to mean “freedom” as in “free speech”. Zotero is released in a GNU Affero General Public License. Which means that all the source code of Zotero is available to anyone who wants to modify it, add new features, etc. 

    Newton said “If I have seen further it is by standing on the shoulders of Giants”. If knowledge was like proprietary software, Newton would have said “I couldn’t have seen further because the Giants had a license agreement that said that I should close my eyes if I were to stand on their shoulders” and we wouldn’t have heard about Newton either.

    Open knowledge lets everyone stand on the shoulders of each other and see farther. Free and Open Source Software (FOSS) lets new programmers write better software by standing on older software. Zotero is that.

    If you care for equity, you should start from where you are.  If you use and encourage Mendeley, nVivo, and so on, you are
    ceding control to a proprietary ecosystem where the rules are laid down
    by the software “owners”. If you use FOSS like Zotero, Taguette, R, PSPP, etc you are strengthening software that is collectively owned by human kind. And you are making life better for everyone.

  • How To Stay Sane Online in 7 Simple Steps

    The sheer vastness of information online can disorient some people. Fake news and hate makes it even harder for them. These techniques are what I personally use to keep my mind “blissful” despite what is going around me. And yet I get to enjoy all the goodness of internet too.

    #1: Be ruthless in cutting down

    You simply cannot let everything in. The internet is almost a billion people creating content every single day. And you are but one tiny human. It is impossible to follow everyone, it is impossible to subscribe to every channel. Cut down ruthlessly. Curate your life to exactly what you need and nothing more. Make your garden your own.

    #2: Use mute and block liberally

    Muting and blocking are tools designed to protect you. Use them! Block people who push unwanted things on to your face. Block them if they amplify hate. Block them if they give attention to attention seekers. Block them if they don’t understand how fake news spreads and are complicit. Block them if they are lying. Block them if they’re pushing their own image. Block them if their politics is that of selling fear. Block them if they sensationalize. If blocking is impossible (due to reasons), use mute. Prune weed from your garden.

    #3: Unfollow, unsubscribe

    There are so many platforms and so many content creators. You probably started following someone years ago when you were a different person. Don’t let your past hold you back. If you are subscribed to someone whom you wouldn’t subscribe to today, unsubscribe! You have grown, but the people you’re listening to haven’t? Stop listening to them and start listening to new people. Don’t stay connected with someone just because you went to school with them. Break connections. Create new connections.

    #4: Deactivate

    Some platforms simply are not for you. There are a thousand reasons not to have a Facebook account. TikTok exists only because most human beings are interested in sex. Deactivate and delete what doesn’t help you.

    #5: Avoid news

    There is a superb essay by Rolf Dobelli about news. Read it. News is like sugar. Unhealthy, toxic, and unnecessary. If you are using platforms to keep abreast with news, you’re doing it wrong in two ways – platforms aren’t the best way to listen to news, and listening to news isn’t the best way to spend your time.

    #6: Read books

    Books are serious. Books take time and effort. Books take research. Read books.

    #7: Use tools that give you control

    There are technologies like web feeds that put you in control. Use them. Take control.

  • What Patients Don’t Know About Medical Schools

    There are people who assume that doctors who get into medical school through reservation end up as bad doctors. They have no clue how medical school works.

    I won’t go into the reasons why reservation (or affirmative action) exists. That is one of the easiest ways for governments to “do something” towards inequity in the society. This post is about the relationship between medical school and bad doctors.

    Defining bad doctor

    Let’s first define a “bad” doctor. An objective way of measuring that would be – a bad doctor is someone who kills the most number of patients. There’s a problem with that though. A doctor with no patients would then not be a bad doctor. And a surgeon who takes on the most difficult cases (with proportionately higher chances of deaths) would also be considered a bad doctor. So, the absolute number of patient deaths is not a very good measure of the badness of a doctor.

    Maybe we can then take the subjective measure of “patient satisfaction”. The doctor who gets 1-star rating for most consultations is a bad doctor. That is tricky though. The doctor cannot keep only the emotions of the patient in mind. The doctor also has to worry about the medical issues. If a patient prefers that the doctor does not examine their abdomen, a doctor who is dealing with this patient’s “pain abdomen” may score poorly on patient satisfaction if the doctor does consider it important to palpate abdomen. Patients might be less satisfied if the doctor doesn’t prescribe them a few medicines. 

    If “patient satisfaction” is measured in a longer term wherein the formalities of a consultation are forgotten and all that remains is the satisfaction of achieving good health, maybe then it is a good measure.

    People in the profession can also score doctors. I could make up a criteria for scoring doctors. I could say the doctor who practices the most rational, ethical, and cost-effective medical care is the best doctor and vice versa.

    A hospital can say that the doctor who generates the most revenue for the hospital is the best doctor.

    Someone can say that the doctor who works the longest hours is the best doctor.

    It is thus clear that who is a good doctor and who is a bad doctor is a difficult thing to have consensus on. Let us nevertheless choose a popular vantage point.

    Let us call the doctors who are irrational in their care and leads to poor health outcomes as bad doctors. (I had initially included “insensitive to their patients” in that list, but apparently many of us elites think that the fictional (or not?) “Dr House” is a good doctor. So we will first talk about these “good” doctors and later come to whether there are alternate definitions of good doctors).

    Medical school training

    What does a medical school train doctors in? Indian medical schools (at least the south Indian universities I know about) confer MBBS degree on someone based purely on theory exams and practical exams with theory given more weight. The whole training for 4.5 years is focused on what those exams need. And how’re those exams conducted?

    Theory exams are mostly single sentence questions that goes like “Write a brief note on <insert health condition name>”. (You can see many question papers in the archives of this blog). There is no “Higher Order Thinking Skills” involved in MBBS theory papers. The only skill tested is that of ability to memorize a lot and write a lot more.

    Practical exams are slightly better. In the clinical subjects, there would be patients called “cases” who are examined on the spot by the candidate and afterwards an examiner(s) and the candidate discuss the “case”. These practical exams are not scored with an “Objective Structured Clinical Examination” pattern. Therefore, it doesn’t matter how you examine your patient or if you examine them at all, all that matters is that you have the right diagnosis and that you can discuss lots of points about that diagnosis with the examiner. In reality, often the diagnosis of the patient is “leaked” to the candidate before the exam and once that is known the patient is just a prop in the act.

    In summary, medical school tests you on how well you can remember the textbooks – and that alone.

    Does that mean all the training in medical school is towards that? No. There are some islands (in form of an exceptional lecturer, post-graduate or peer) where other skills are focused on. But to a large extent medical school training is towards what is tested.

    In reality, medical school training does not help people perform good even in these tests because medical school training is literally paid doctors who have no philosophy on teaching (let alone facilitating learning) passing their time with by wasting the valuable time of learners. If medical school professors were sent to teach 12th standard biology classes, their students would dropout and re-join 11th standard in the computer science stream.

    (Of course there are some really good people. And the bar is so low that even someone who talks to their students with kindness are considered good professors in medical school. Anyhow, let’s not be bogged down by exceptions)

    How are doctors made then?

    Doctors become doctors not because of medical schools, but in spite of medical schools. It is mostly their interaction with textbooks, peers, patients, and life in general that makes them doctors. And only because the law restricts this opportunity to the confines of medical schools, it is restricted to medical schools.

    The skills involved in patient care – communication, courage, critical thinking, empathy, leadership, etc have nothing to do with medical school training.

    The theoretical knowledge involved in patient care are all textbooks based.

    Procedural skills are learnt by doing (on real patients) with some supervision and there are no special courses to improve or learn these skills in a setting where it is okay to make mistakes.

    Where do doctors really learn their craft then?

    MBBS doctors start learning real medicine towards the end of MBBS (on their own). They get really good at it only after MBBS – either by working as a postgraduate student or by working in hospitals.

    And these opportunities to learn after MBBS are really diverse and heterogeneous. Some work as residents in certain specialty departments where they learn a lot about those specialties (and a bit about medical care in general). Some do this with a gap of a few years (spent in PG entrance preparation).

    From then on they keep getting better at it. Because every new patient they’re responsible for teaches them something new.

    In essence, the 5 years in MBBS has little to do with how good/bad your doctor is. Medical school is a place where doctors learn about the outline and the syllabus of MBBS. After graduating is where they learn to treat people – and that is what decides how good your doctor turns out to be.

    What makes a good doctor?

    Privilege plays a role. If one has the privilege to get trained abroad (or in India) in medical schools that are interested in pedagogy, ethics, and rationality, there is a good chance that they learn to become better doctors. Also if one has the privilege to afford to work with lesser known good doctors within India, again there is a good chance that they learn to become better doctors.

    Scientific temper and critical thinking plays a role. I’m not really certain how one gains these skills. Life experiences that makes one skeptic may help, perhaps? Or reading about science might help too.

    Empathy and emotional intelligence plays a role. Understanding one’s patient and their context is critical to be able to understand what they’re saying. Often the patient is telling the doctor the diagnosis, but the doctor can’t hear because they cannot connect.

    If you’re under the impression that performance in an entrance test is what makes a good doctor, you’ve gotten it completely wrong.

  • Want to Predict COVID? Ask the medical officers or lab managers

    From the beginning of this pandemic I’ve had very accurate predictions of COVID surge, lull, and fall from two kinds of people – PHC medical officers and lab managers.

    The PHC medical officers see anywhere upwards of 200 sick people per day and they get to see how many people are coming in with COVID like symptoms and notice patterns before they are even tested.

    The lab managers keep a track of test positivity rate (and test rate) and can sense that it is getting overwhelming vs underwhelming.

    The only kind of people who haven’t particularly been helpful are the people who draw graphs based on numbers from government sources.