Blissful Life

Category: research

  • The Overcompensating Sociologists of Public Health

    Reflexivity. That’s a word very dear to sociologists. It just means how we look at the world is influenced by who we are. But like many things sociology, you give it a word and then you make a big deal out of it.

    So much that some of the sociologists reading this post are already raising their hand saying “Hey, but you’re talking about ‘positionality’. Reflexivity is actually about how we take into consideration our positionality in our research”.

    Shouldn’t the fact that how we look at the world is influenced by who we are automatically also mean that we should be cognizant of that and take that into consideration in our research? Apparently sociologists can’t do that automatically without having a different word for it.

    Or maybe they can and I’m just stereotyping them. After all, my identities put me in the positionality of an anti-academic-sociologist.

    This post is not about sociologists who don’t care about the world. And therefore I am not going to write about how there are some of them who just keep doing esoteric debates funded by public money in public universities.

    This post is not about the superficiality of academia. And therefore I am not going to write about the publication game.

    This post is about the sociologists who overcompensate for their identities.

    It starts with privilege. By their very nature, there are a lot of people in academics and sociology who come from very privileged backgrounds. For some of them, academics might have led to their understanding of their own privileges. This can probably explain why they keep going back to jargon to describe the plight of the world, because it appears that without the words given to them by academics they find it hard to understand or describe the wrongs in the world.

    My conjecture is that when they look at a subject like traditional medicine in the context of pluralist health system in India, they go “Oh, I’m from a privileged background and therefore I should compensate for my biases against traditional medicine. I shouldn’t be part of the ‘undemocratic’, ‘elitist’, and ‘self-centered’ biomedical field of this country, I should rather side with the ‘downtrodden‘” because I cannot imagine any other reason for one to claim that traditional medicine being sidelined as “unscientific” is because of the “political economy of knowledge production” and that scientific community has to devise ways to legitimize traditional medicine.

    Modern medicine has several problems. The practice of modern medicine is riddled with problems too. Knowledge production in modern medicine has a definite politics. But to use these as arguments to promote traditional medicine is a sophisticated form of whataboutery. And some of these academicians do this as well so as to talk about traditional medicine.

    I call these people “the overcompensating sociologists of public health”. Their “solidarity with the oppressed” is more about their own struggles than about the struggles of the people. They would rather stick to their arguments romanticizing traditional medicine (getting applause from the cult of anti-science orientalists) and have people die eating roots and leaves than have their praxis in the form of advocating for better access to quality healthcare.

  • Does Medicine Need a Paradigm Shift?

    Let’s start with physics

    As my brother’s T-shirt says “The Pulse of the Earth is in Physics”. Physics is a fundamental science. Also called “pure” science. That is a fancy way of saying it is reductionist. When you think of an apple falling to Earth in physics, all you think about is its mass and the forces acting on it. Everything else is immaterial to physics, including the questions like “Is the apple rotten/ripe?”, “What is the probability of the apple falling on a rabbit and killing it?”, “Are there hungry people waiting for the apple who won’t get to eat it?”, and “Is the apple cursed?”

    The question whether apple is rotten can be answered by another branch of science called biology. Physics and biology are called natural sciences. These are branches of science which rely on observation of the universe to reach at inferences on how the universe works.

    The question on probability would fall under mathematics. Mathematics is a bit different from natural sciences. Because it is based on axioms and logic. Such sciences are called formal sciences.

    A hungry class of human beings not getting to eat apples and the reasons behind it would be the matter of study in social sciences.

    The cursed apple is a subject of religion and superstition. These are, by definition, not questions for science to answer.

    What kind of science is medicine?

    Medicine is not a pure science like physics. It is an inter-disciplinary, applied science. Medicine uses several branches of science like biology, chemistry, and mathematics in its own goals.

    A medical practitioner has to know several sciences like anatomy, physiology, biochemistry, pharmacology, and microbiology to be able to practice medicine well. They would also need skills in probability, reasoning, and logic. Also critical are skills like communication, empathy, leadership, and management.

    There are also several other forces in play that influence the practice of medicine – education, medical training, health systems, politics, economics, religion, human resource, war, and so on.

    The question of a paradigm shift in medicine is thus complicated. Which part of medicine would the paradigm have to shift in? In the numerous sciences that make it up? In the way it is practiced? In the way people are trained in it? In the way the systems around it are organized?

    Science is the only way of knowing 

    What is science? 

    The opening statement from Wikipedia is: “Science is a systematic endeavor that builds and organizes knowledge in the form of testable explanations and predictions about the universe.”

    Science is what allows human beings to operate in the world. It is the sum total of all that we know about the universe through thousands of years of living in it and observing it. It is the reason why we know that if I strike a lighter in a particular way with a knob turned on the gas from a cylinder will come into the stove and start a fire. It is how we cook and eat. It is the reason why we know that elephants can lug trees while cats or dogs can’t. It is the reason why we are able to talk to each other over the internet.

    Everything we know about the world is through theories and observations that confirm those theories. When we come across observations that contradict those theories, we are forced to come up with better theories. But till then, we seem to be able to live on earth with the old theories.

    Is there any other way of knowing about the world? Think about it. Everything that you know about the world would come from your own observations and theories, or those by others that you have read about. There is simply no other way to know facts about the world.

    You might say, “Oh, to know whether it is raining, I just have to look out of the window. No science involved”. But hey, what you’re doing is observation. And then forming a theory that it is raining. What if there is a film shoot going on and they’re pouring water with a hose and that is what you’re observing through the window?

    The whole experience of seeing water drops falling down from sky and knowing that “it is raining” is based on science. It is based on human observation since time immemorial of the natural phenomenon called rain. Even when you’re looking out of the window to say whether it is raining, you’re using science. And it is science that allows you to say whether it is actually raining or a film crew pouring water.

    You might also say, “Hey, I know cycling, is that science now?”

    When you say you “know” cycling, the knowing refers to a particular sense of muscle memory that you have developed through practice. But this is not the kind of knowing we are talking about. We are talking about knowing how the universe and everything in it works.

    Read a related post about this question of whether science is the only way of knowing, where I argue that if there is a way to know, then science is the only way of knowing. Consequently, there are some things we cannot know, and this question would not apply at all.

    Queering science

    While indeed science can be seen purely as methods of rationality as above, it is has to be acknowledged that science is ultimately a human endeavor and thereby it reflects all the faults of the human society almost as it is.

    I’ve dealt with this human aspect of science in an earlier blog post and so I won’t repeat those points here. Suffice to say, there is an intersectional approach to the practice of science that’s missing in mainstream science.

    What about applied sciences?

    When it comes to an applied science like medicine, the problems seem to compound. Many of the sciences that make up medicine are all super hard to study. The tools we have are limited. And the institutions that we have are very problematic spaces (in terms of patriarchy, violence, oppression, and discrimination).

    When faced with such a complex challenge, many people prefer to run away and find comfort in places that nobody is finding faults with (although they would be riddled with even more issues). That’s why many people turn to Reiki, Homeopathy, Ayurveda, and so on. This gives them psychological comfort. But this is no solution to anyone’s problems. We will talk about that later.

    Applied sciences deal with the real world. One that is filled with uncertainties. One where perfect knowledge is impossible, but action is inevitable. It takes a lot of interdisciplinary thinking to operate in the field of applied sciences.

    Let us look at what some people call Evidence Based Medicine. EBM is misunderstood by many. They give undue stress to the word “evidence” and think that a randomized control trial is the be-all and end-all of EBM. These are the people who assume that medicine is based on a paradigm of large numbers. What they do not know is that there are three pillars of evidence based medicine:

    • Clinical judgement
    • Relevant scientific evidence
    • Patients’ values and preferences

    Clinical judgement is where the practitioner comes in. The validity of medicine rests on the practitioner making the right observations and judgements about a particular situation. Similarly, we need a body of evidence, a body of science before us to be able to make any intelligent observations. And considering all of this is about a patient, it is imperative to keep their preferences in the whole matrix of evaluating what to be done.

    Let us talk about relevant scientific evidence a bit more because that seems to cause a lot of confusions in the world. (Even in an otherwise brilliant talk about integrated medicine, Ravi Narayan equates medicine to controlled clinical trials, for example. (19:30 in the video)).

    It is all about knowing the truth, as we discussed in the beginning. How do we know what to do in a particular situation. When someone comes in front of you with cough, weight loss, and fever, what do you do? What if you also found in the sputum of this person the organism that is known as Mycobacterium tuberculosis? What do you do? How do you know what to do? That’s the important question.

    If you knew magic, you could perhaps try that. You could get rid of all the M. tb from their body magically! That would help them. You might save them from certain death.

    But if you didn’t have the evidence built over centuries of human beings struggling with this disease called tuberculosis, how would you even know that this person would die soon?

    It is only the scientific method of knowing the universe that can guide us to move even an inch forward towards helping those who are struggling.

    The alternative to science

    The alternative to science is the pandemonium of opinions and beliefs. There are people who consider these as ways of knowing the universe. But they don’t critically think about their own philosophy.

    Firstly, whose opinion counts? Who is authorized to make opinions? Is it reserved for people who meditate in the Himalayas? Can you and I do it? Does it have to be done high on weed? How do we measure whether someone is legitimate in claiming that the shit they pulled out of their ass is the correct knowledge about the world?

    Secondly, when you have two people claiming two shits that are contradictory to each other, what do you do? Let’s say person A says eat leaf A, while person B says eat leaf B when confronted with the patient we saw above. Which leaf should the person eat? Both leaves? No leaf?

    The only way to evaluate anything and arrive at an actionable prediction about the universe is through science. If you look at what’s typically called pseudoscience, things like Homeopathy, what you can see is that underlying all these are certain theories that are of very low quality. These theories are sometimes not verifiable. And if at all they’re verifiable, they end up to be false. Proponents of these pseudosciences typically take comfort in the space where they come up with a theory, believe in that theory, and don’t bother verifying those in the real world.

    Paradigm shift in medicine?

    Having said all that, let us come to the question of the need for a paradigm shift in medicine.

    It is easy to speak in vague terms about “holistic” approaches that incorporate a paradigm of being “more rigorously attentive to the individual while keeping in view the larger picture”. But when it comes to practice, we can quickly see how rhetoric like these are hollow.

    Does attentive to the individual mean using genetics and personalized/precision medicine? Does it mean just taking patient preferences into consideration? How scientific and rigorous do you have to be when you say “rigorously attentive”? If a person says “I think homeopathy will work for me” and you diagnose tuberculosis in them, what do you do?

    What about the other question. How many people practicing modern medicine are actually practicing evidence based medicine? How many do rely on science and evidence to manage their patients? How many randomized control trials did people use to prescribe drugs during COVID. How many RCTs are followed when people prescribe platelets and antibiotics for dengue? How many RCTs are followed when people diagnose typhoid with a single Widal test of 1:40?

    Does the “larger picture” include social, political and economic determinants of health? But does it also mean that the focus should only be on distal determinants? Would you not worry about Anti-Tuberculosis Therapy in someone with TB or will you only keep saying “nutrition!”, “nutrition!”, “nutrition!”. Fine, nutrition. But how? Will you feed this person out of your pocket or will you keep saying the government should come with food security schemes? Fine, the government should come with food security schemes. But will you work with policy makers on making such schemes a reality or will you keep writing about it?

    Yes, a paradigm shift is necessary. A paradigm shift that puts people first. A paradigm where sacrificing rationality for practicality and/or sacrificing science for pluralism doesn’t kill innocent people. A paradigm where working on social determinants goes hand in hand with treating now those who are suffering now. A paradigm where paternalism and saviour complex are replaced with solidarity and praxis. Nobody can say no to that paradigm shift.

    ***

    Footnote: There’s a human tendency to come up with alternative hypotheses to explain seemingly miraculous phenomenons. When I was 16 years old, I came up with “ASD rays” to explain telepathy. Thankfully there was a group of people who explained to me that my theory, however “sound” explains a phenomenon that’s non-existent. At that point in time James Randi offered a million dollars to anyone who can demonstrate paranormal claims. And nobody won it, of course.

    As long as people think that things like homeopathy actually are more than just placebo, they’ll come up with theories that go into sub-atomic realms to explain how these work. That’s natural. And they’ll keep struggling to understand why rational people reject their theories. If you are empathetic to them, you’ll realize that to them it is inevitable that these theories must be true because otherwise how do they explain to themselves their “miraculous cure” that others believe is charlatanry?

  • Science is Broken Because Scientists Can’t Think Rationally

    Scihub is being sued in Indian courts by the journal industry. There are some people worried about it. But it is funny how our knowledge system works. Take this tweet for example:

    Scientific publishing sure is rigged & broken. But hoping that the very bandicoots that are getting fat from the status quo will take hints and improve the system is beyond naive. The telling lack of collective resistance from scientists too enables this perverse model to thrive. https://t.co/ye9SuxlYQM

    — M D Madhusudan (@mdmadhusudan) December 24, 2020

    The reason why journals charge exorbitantly and still get away with it is because almost all academicians publish only in those journals. And why do academicians publish in those journals? Here comes the greatest hypocrisy/logical fallacy of academicians.

    They think that publishing in “prestigious” journals bring “prestige”. They even have a way of measuring prestige without making it sound like it’s an emotional thing – impact factor. It is all part of the same logical fallacy – argument from authority. A cognitive bias that makes humans think that “authority” is right.

    The only purpose of journals in the internet age is to exude authority.

    The same purpose of universities.

    If scientists step down from their pedestals and start looking at the world without bringing in their cognitive biases (like every scientist should be doing), there can be a world where knowledge is produced and consumed with lesser hurdles.

    There definitely is a side to this where the omnipresent, omnipotent “system” is oppressing academicians and forcing them to continue with this prestige based publication. After all, scientists are humans who would rather give in to the way the world works than stand up against anything.

  • What to Make of Itolizumab?

    It is the worst of times. Science is suffering an identity crisis. The world is in dire need of science. Science isn’t used to being rushed. “It is a giant and slow churn”, said a friend once, “and spews a breakthrough once in a while”. Is it possible to make the process faster? That’s what everyone is wondering. And praying. And waiting, eagerly. Science isn’t used to getting this attention.
    “Coronil is 100% effective”, said Patanjali folks. “Favipiravir is 88% effective”, said Glenmark folks. How to know the truth? Seeking truth has never been easy. Never has it been easy for journalists, scientists, or the common person. In some sciences there are multiple truths. Is medicine one of those sciences? Can there be a single truth in medicine?
    I won’t use words like epistemology and ontology in this post. (Because I still can’t remember which is which). But the question is essentially two:
    1. Is there a single truth?
    2. Is there a way to know the truth?
    I believe medicine is a dangerous subject because of these two questions. Biology is extremely contextual. A drug’s effect on a person with any particular infection can be influenced by a thousand factors including – that person’s biology, the day, where that person is, what that person is eating, what other medicines that person is taking, the virus that infected them, all the infections they’ve had in past, other diseases they currently have, the health of their body organs, and so on.
    When there are so many things that keep changing, how do we know whether a drug is going to be useful for a person or not? Most of medicine today is an approximation. Many drugs are used because when given to n random people it worked better than it not being given. A gross measurement, if you allow me to call it. Put something in a balance and see which side is hanging lower.
    Not that medicine is all guess work. He he. There are some theories. There are some “well-known” pathways. There are some molecules which we understand. There are some we don’t. There are some drugs we know act on some molecules in some of these pathways. Sometimes we don’t understand some parts of how a drug acts, but we fill in those gaps with the “random” trials as described above.
    For example, let us take Paracetamol which is a drug commonly prescribed for fever. And the only drug that many people need during COVID (and Dengue, and many other viral fevers). We don’t know how exactly it works. But we have a rough idea on the pathways that it affects. We also have very rich clinical experience in using the drug successfully for fever.
    The reason why we don’t rely a lot on theory in medicine is that we don’t have a lot of theoretical understanding about the biology of our body. We do know a lot. But there are still so many known unknowns. And who knows how much unknown unknowns.
    We know a bit about molecules called “interleukins”. We seem to know about a molecule we call Interleukin 6. It seems to have a role in acute immune responses. It may very well make sense to somehow block IL-6 to decrease the damage that could be caused by what is called a cytokine storm (which, as it sounds, is a storm that wrecks havoc inside the body) in sick COVID patients.
    We seem to know about a class of drugs called monoclonal antibodies. These are molecules (which can be natural or artificial) that target specific kind of molecules. There are some mAbs which seem to be able to target a type of cell called CD6 cells, including Itolizumab.
    Now, here is the deal. If Itolizumab can act on CD6 and decrease IL-6 and if IL-6 has a role to play in cytokine storm in COVID, then the inference could be drawn that Itolizumab can help sick COVID patients not die. That’s the theory.
    But the problem with medicine is that theory doesn’t always work. And sometimes what presents as reasonable with our current understanding of the body sometimes becomes dangerous when we actually try it.
    As for Itolizumab, Biocon seems to have given it to 20 patients with COVID and moderate to severe respiratory difficulty. And they all seem to have survived. Of the 10 they didn’t give it to, three people apparently died. I’m sure they’re doing this study on more people at the moment.
    According to them this is “statistically significant”. I don’t have a very deep understanding of statistics. Here, let me do the math.
    The way I read it is that based on that data we can be 95% sure that if someone with moderate to severe COVID-19 ARDS takes the drug their chance odds of survival is somewhere between 0.8802 fold to 415.9060 fold the chance odds of their survival without taking the drug.
    Didn’t I tell you this is the worst of times?
    Update: Don’t look at my math. That was not the point of this post. Also, my math sucks. Here is why:
    At a sample size of 30, the power of this study is like 30% which means it is completely unreliable. I think. I don’t know.
    Update 2: As per this article, and as per my understanding of beta, if p-value is already acceptable, then it doesn’t matter whether beta is high as all that power makes sure is that we don’t miss the effect when there is an effect.
    But then, am I confusing myself because in this study the effect of the drug is protective? I am 70% sure that the power of this study is not to be worried about.
    Update 3: Maybe the contradiction is resolved if we consider this as a type S error.

  • Double Standards – Patanjali vs Glenmark; What is the Point of Ayurveda?

    A couple of days back Glenmark made a press release about Favipiravir which made it sound like they have a “game-changer” and “magic bullet” (according to various media houses). This was based on little evidence about its benefit. There is virtually nothing in public domain that shows that Favipiravir is useful in COVID. CDSCO explicitly approved Glenmark to do this.
    But today Patanjali is receiving flak and even has been officially asked by government not to advertise a drug they name “Coronil” which has very similar “research” to back it up. In fact, a quick look at the (?) methodology puts a placebo controlled trial by Patanjali at a better position to support the claim that their drug is useful.
    Such double standards of Indian people and government.
    Is this to do with Ayurveda?
    We have no issue with Ayurveda. We have elected a government which set up a ministry for Ayurveda. In fact, this ministry was one of the first to come up with “prophylactic measures” for COVID drawing on Ayurvedic and Homeopathic medicine.
    I personally believe Ayurveda is a science stuck in the ancient past. Thereby it is no longer science. But just because there are remedies mentioned in Ayurvedic textbooks, those do not become just Ayurvedic medicines. If those are tested with modern scientific methods, they are modern medicine too.
    If not for research into Ayurvedic medicine that helps improve modern medical field, what is the point of running 250+ Ayurvedic medical colleges in India?
    Is this to do with commercialization of Ayurveda?
    Patanjali (and other companies) has been in the business of selling Ayurveda products commercially for so long. Surely, commercialization of Ayurveda isn’t a crime.
    Is this to do with private interests during a public health crisis?
    Hasn’t every damn thing we’ve been seeing in the past 6 months or so been about that? Can you name one thing which has been selflessly done for public health? If you named something, I bet it involves an individual or a group of individuals caring for the people right around them. I mean, if you see people suffering right in front of you but you are developing a solution for some others, tell me that there is no private interest in there.
    Is this to do with scientific rigor?
    Where was the question of scientific rigor in approving Favipiravir? Is any data available for that? Was evidence taken into consideration? Was it considered whether the people who generated the evidence were also the people who were going to market the drug? Has there been a peer reviewed publication?
    What makes Coronil any different from Favipiravir? Is it that Patanjali’s claim is 100% while Glenmark’s is 88%? What if Patanjali claimed 99%? What is the right number for this game?
    Is it that anything that has a name that sounds Greek and Latin is inherently good?
    Like “hydroxycholoroquine”, “azithromycin”, “favipiravir”. Is it the name?
    Is it the fact that these drugs sound “modern”? What makes some chemicals modern and some chemicals ancient? Why can’t all chemicals be just “chemicals”?
    All these are rhetorical questions that lead us to the main part of this post.
    What is the point of Ayurveda?
    What are we doing with Ayurveda? What is the role of Ayurveda in today’s world? Can we modernize Ayurveda taking the good parts and plugging out weaknesses?
    Is there a way to re-imagine Ayurveda through modern scientific methods?
    Can we apply the same standards when looking at evidence in both Ayurveda and modern medicine?
    Have we extracted, examined, and integrated all the useful knowledge available in Ayurvedic textbooks into modern medical practice already? Is there perhaps a rudimentary theoretical framework in the way Ayurveda looks at wellness and illness? Can we build on that with the technological advancements that we now have to arrive at new theories on how to think about a human body?
    I mean, is there a central theory in modern medicine? Except at the molecular level where there is DNA->RNA->Protein, what kind of dogmas do we have in modern medicine? Isn’t there a need for such dogmas?
    I’m not saying Ayurveda has a correct theoretical framework. In fact, if you go down the slippery slope, you might say that I will say that homeopathy also has the potential to provide a theoretical framework. I’m not saying that. From my limited understanding of homeopathy and dilutions, homeopathy seems to have nothing in it.
    But Ayurveda is a different beast. Ayurveda was fairly useful during its time. It has sufficient nuance in its management algorithms to qualify for a thorough analysis. All I’m saying is, perhaps there is something to extract from it. And I’m saying this from my limited experience interacting with Ayurveda practitioners.
    Nevertheless, why double standards?
    Why do we trust “modern” medical “research” by default and distrust Ayurvedic “research” by default?
    I mean, what does it tell you that a country which has no issue in pharmacies selling Ayurvedic medicine for every other condition says foul when an “innovation” is attempted for dealing with a pandemic that nobody has a clue how to handle?
    When will we stop lying to ourselves?

  • 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!

  • 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.

  • MAA grant

    The medical education unit room in the first floor of Platinum Jubilee Hall is a neat place.

    There is a projector with a flexible base that stays where you put it.
    There are excellent rotating chairs and static cushioned chairs with nice tables that go along.

    And last Thursday the room hosted the MAA grant interview of candidates.

    There were 17 projects which sought the 10×10000 and 2×5000 grants by 1961 batch and 1984 batch respectively.

    Dr Manjunath had already informed everyone how their presentations should be outlined.
    Dr Shekar, Dr Balu, and a few elders from 1961 batch was present to discuss the presentations.

    It went in alphabetical order except for a few changes.

    I was second to present my “Study on the Respiratory Effects in Road Construction Workers”.
    Somehow the title had to include the word “prevalence”. Also, unlike what Dr Sumanth, my guide, and me thought, there is some problem with smokers and non-smokers being included in the study.

    The inclusion criteria should not be one year. It should be more considering how chronic bronchitis is defined to be two years.

    And peak flow meter can measure only obstructive diseases.

    Totally, I was apparently “just coming and doing research” which is “not the way research should be done”.

    To be frank, I felt like I am going to be better off not wanting to do any research. After all, I’m not going to be patient enough to do data collection. I should rather switch to statistical analysis (my opinion). That’s where all the fun is. And that won’t have to go through all these trouble of convincing people about ethicality and practicality of stuff.

    Others presented projects about tobacco, birth asphyxia, and stuff.

    From today, I’m a research analyst :p