Sunday, July 5, 2015

Waiting For The Doctor

Waiting For The Doctor

A friend on twitter was recently moaning about the time she spent waiting outside doctors rooms as some of the most stessful periods of her life. I agree with that sentiment. Never mind the fact that you are anxious to go in there and find out from your doctor whether you have a life threatening disease or not  the very fact that you are sitting surrounded by other obviously sick people with no hope of a happy ending in sight will give the heebie-jeebies to anyone. Including me. I too like everyone else have spent time waiting outside doctors rooms even though its more out of a sense of delicacy on my part not to announce myself as a colleague and just barge in ignoring others waiting in the line.
Anyway this post is not about the people waiting outside doctors rooms but about why doctors make people wait outside their rooms? A few pointers

1)    Ego- Yes the number one reason why you spend hours waiting outside your doctors room is to satisfy your doctors ego- the ego to be wanted, needed and validated as someone worth waiting for. I know this might shock you but its the truth. The reason is, its not easy to get people to wait outside doctors rooms for them to turn up as the competition in medicine is killing and there are umpteen number of doctors out there waiting to see you whenever you want to. To be recognised as a good doctor it takes a minimum of ten years hard work, of hours and hours spent alone in the clinic waiting for that solitary patient to turn up for a consultation, hours spent peeking outside the curtain separating the inner room from the waiting hall everytime a mild footstep is heard imagining that atlast here comes the patient who will pay for this months rent atleast so you can still continue practicing at this same palce next month and so on and on. And after all this long struggle when the doctor reaches a place where he becomes recognised- he turns the tables on the very people he waited for and gets a perverse pleasure in making them wait for him. Believe me when i say that there is nothing to equal the joy felt when you walk into a consultation room and see it full of patients waitng for you. It makes you appreciate the sweet success of having arrived. It stokes the ego and gives you a feeling of being invincible and god-like for the only other place people wait so patiently for a glimpse is at the temple.  So even though doctors know they can manage their time better and stop wasting others time, still to satisfy their own cravings for popularity they will intentionally make you wait hours to meet them. The bitter truth.

2)    The medical representatives- if you see a bunch of medical representatives waiting outside the doctors rooms with you to meet the doctor be assured that your doctor is going to wantonly make you wait outside for hours. The reason is simple- just like politicians need people at their mass meetings to show the media their power and popularity to draw a crowd, similarly doctors need crowds of patients to show medical representatives their drawing power as busy practioners with loads of people waiting to meet them. Medical representatives are by far the biggest gossips of the medical field- they are the ones who go around spreading stories about which doctor is popular with a dozen people waiting outside and which one is sitting alone in his clinic – despite being a good time manger and being prompt in seeing his patients off rather than making them wait. And guess which doctor gets that all expenses paid trip to egypt to see the pyramids – sponsored by the drug company? Yes, its the same doctor who will make his patients wait for hours showing off his overcrowded waiting hall as a sign of popularity.

3)    Other patients- yes this might be a shocker to you but the biggest time waster in any practice is the patient who went in just before you. I have had many patients who have made me want to physically throw them out for wasting my time but have survived because i remembered the hippocratic oath in time. Some women are the worst offenders in this. They come in with their husbands and children and a whole bunch of people and after consulting for a small problem and paying the fees instead of leaving promptly they stand by the door and then casually start discussing the assorted medical problems of the hubby, the first kid, the second kind, the mother in law, the next door neighbour and everyone else on the street on the mistaken assumption thant once having paid a small fee for a single consultation the rest of it should be all free advice on the basis of – well we are just talking, arent we, you re not actually seeing the patient, so it doesnt count- never mind that all this talk consumes the better part of an hour or so just to make sure she doesnt poison someone with her home remedies. So blame those people who troop into doctors rooms with an army of supporters and sympathizers who have no business being there.

4)    The unexpected – yes things like surgeries which can sometimes throw in complications which no one can anticipate- remember every individual is unique with a unique anatomy and blood vessels and nerves can never be found in the same place as shown in textbooks and you can appreciate why surgeons can be late for appointments.  And add the occasional friend or realtive who drops in to talk only at the busiest time of a doctors  practice and can never be got rid off politely and fast and you can see how the unexpected can impinge on your doctors time.

5)    Greed- and now we come to the one reason which can be altered by your doctor if he really wishes to- over selling appointments. If your doctor appreciates that your time is every bit as valuable as his- he will never over book appointments and try to fit in everyoone at the same time. It is simply callous time management and can never be tolerated in any other field. To see three  patients in one hour is different to seeing three patients in three hours. The difference can be life saving for you and can certainly save you a load of money in hospital bills in future if your doctor can spend enough time concentrating on you and you alone for the fees you pay instead of shunting you out as fast as he can to get the next patient in. Believe me,  no doctor – however  popular he or she is-  is worth your time and money if they act like that because they are going to miss catching your disease at its earliest stages if they are in a hurry and you will be paying the price for it later. Its better to change over to a another doctor who even if he dosent have a reputation as the best will atleast lisen to you patiently. Remember its your health and your life and you are paying the bill for it.

So to conclude i leave you with the thought that all that waiting outside doctors rooms is not accidental but a well thought out strategy by your doctor. Doctors are rarely helpless when it comes to efficient time management – they can stop wating your time or not. And if your doctor chooses not to then its time to stop waiting for him or her and simply move on to someone else who knows the value of others time and respects paying patients enough to give them their attention to. So choose a doctor who is satisfied with seeing three patients a day and buying a maruti suzuki rather than the one who sees thirty patients a day to buy a mercedes benz.  The first one might or might not save you but the second one will definitely kill you. Be wise and move on to a better doctor.

Monday, June 22, 2015

Communist Medicine In A Capitalist World

Communist Medicine In A Capitalist World – The Evidence Based Medicine Conundrum

Any casual reader of history or anyone at all with any general knowledge know that the discredited philosophy of communism and its paramount creation the soviet empire were both destroyed because both economically and even with common sense it beggars belief that decisions can be made in central committees and by fiat be implemented in all places and in all situations without a single thought for local conditions or differences. Crops to be sown, fertilizers to be used and harvesting times were all imposed on farmers from afar by fat-cat bureaucrats sitting in distant Moscow committees who thought they knew better than the local farmers born and bred up on their lands for generations. The result was total collapse of the agriculture sector and widespread famines everywhere in Russia. Production quotas and processes to be implemented in factories led to so many shoddy products that anyone who was just anyone at all in Soviet Russia preferred to use imported products for everything from shavers to ovens.  Rule by distant committee was comprehensively proved to be the stupidest idea to have ever been invented by the human race and believe me we as a species have made many, many more such mistakes.

So if I now told you that the same discredited theory of communism is now being touted as the only way to practice medicine what would you say? I kid you not- search evidence based medicine on the internet and you would find plenty of laudatory articles as the way to go for practicing medicine as per modern protocols. But read past the platitudes and rule by central committee is exactly what you would find.  And just because the committee distributing it is the internet itself it finds its greatest advocates on the net who tout it as the only way to go and not as one more way as it really is. Now enough with all the historical references and let me start explaining what evidence based medicine really is all about.

Sometime in the last decade of the last century (the 1990’s anyone?) there arose a new system of medicine called evidence based medicine. As with everything else when it was first introduced the intentions were noble and its advocates were sincere and it was definitely a step forward to the future. Doctors everywhere welcomed it because it seemed to offer a way forward during those times when doctors most need help- decision time. Evidence based medicine involved putting up the results of large scale clinical trials on the net to help doctors everywhere follow those same guidelines in their treatment for their own patients. It showed what worked or what didn’t work to others who were hard pressed to make difficult clinical decisions in real time. As such it definitely was a step forward. It even helped simplify which drugs to prescribe or which not to. For instance many of the old time doctors used to rely heavily on antibiotics where were popular during their heydays often not realizing that such antibiotics were no longer active due to an effective resistance built up by bacteria continually exposed to the same drugs for so long. Hence evidence based medicine pushed the medical fraternity into discarding old, tried and tested beliefs and adopting newer treatments. And that’s when things started going wrong.

When the popularity of evidence based medicine picked up worldwide big pharma was as usual right there to swing things in their favor. They started sponsoring the large clinical trials needed to get their evidence – often using low cost outsourcing firms in under developed countries where patients signed up for medical trails for a pittance- and used the results of such biased trials to push heavily in favor of their own drugs which had been used in such trials. Other drugs, even tried and tested ones didn’t stand a chance because all the latest evidence (sponsored of course) freely available on the net pointed towards such and such drug – as the only one with enough evidence available to show it worked. If a doctor wished to use any other drug which he felt could be equally effective he stood in grave risk of being taken to court by the patient for not following “internationally accepted standards of care available on the net”. Which led to all the doctors falling in line cowed by threatened medical malpractice suits and patients reading up the results of such biased trials on the internet and demanding of their doctors the same treatment that recommends.

If to take an example you have constipation and I as your doctor want to recommend to you a single plantain (local banana) every night and you go on the net and read that florida oranges grown in glass rooms in chilly Alaska when given to 5000 people led to 4000 people rushing to their toilets every morning and you quote that study to me and demand that I prescribe only Florida oranges to you- imported straight from Alaska- then I have no choice except to write a prescription of the same. Because I or anyone else for that matter have no evidence at all that bananas work, forget the fact that every single individual we know all around us for thousands of years have used bananas to evacuate their bowels. There is no large clinical trial for local bananas- no one paid money to large groups of people to eat a banana and shit in the morning and hence no evidence for banana which makes it a false treatment under the evidence based medicine guidelines and if despite this I want you to eat a banana, god help me, I would end up losing my license for practicing medicine- for not asking you to eat imported Florida oranges which might beggar you with just one months treatment cost. And this is the literal truth and I am not exaggerating. The costliest drugs are the ones which drug companies prefer to send for large clinical trials by recruiting thousands of patients. Hence when the results come out its the same costly drugs which become the default treatment option worldwide and any doctor who differs is branded a witch doctor for not following the evidence. Individuality has been stamped out and creativity rooted out in the name of the evidence based medicine fad.

Just like communists used to prescribe their guidelines from a central committee for everything, evidence based medicine has a central treatment guideline which every doctor has to follow to save their own skins or woe to them. Such evidence gathered in distant populations does not take into account individuals or their idiosyncrasies. Medicine is not an exact science and most prescriptions are based on informed guesses but that doesn’t mean that in the name of standardization a one size fits all variety of medicine becomes the only way to practice. The evidence based medicine fad has been taken to such ridiculous levels that surgeons who often make small incremental advances in surgery by trying out newer and innovative surgical techniques on individual patients cannot publish their results anymore as case reports and case series- which are about smaller groups of patients – are increasingly being not published or downright derided in favor of larger clinical trials. Surgeons are being forced to fall in line with the same efficiency as robots and an individual surgical technique (even surgical flair) is being eliminated in favor of standardization.

The day is not far off when patients can print off their own prescriptions off the internet from a published list of symptoms to treat themselves and a doctor (or a middleman) becomes superfluous to medicine. Is that a step forward? Or will it lead to more chaos? Based on the history of communism I am very skeptical of the future of evidence based medicine as it is now. But I can’t speculate on what the next medical fad will be. Will evidence based medicine escape the stranglehold of big pharma and sponsored clinical trials and evolve into something more inclusive and egalitarian taking into account individual knowledge. Or will it act the monolith and seem impregnable till it suddenly implodes on its own like communism did? Only time will tell.

Sunday, June 7, 2015

That Ugly Truth

That Ugly Truth

I answered a question on Quora yesterday – in the plastic surgery section-about the importance of beauty in our society and our double standards we show in our daily life. The question asked, although I am paraphrasing it here as short as possible, pretty bluntly “why do ugly people live? why don’t they kill themselves off? Or at least get plastic surgery to make themselves look normal?” I will come to my answer on quora later in this post. Right now I wish to discuss a bit more about this question here.

The first thing I checked when I read the question was the person who asked it and I was not surprised to see that the doubt had come to a girl, all of 19 years and living in India’s most cosmopolitan city Bangalore. Why I wasn’t surprised is because I know men, ugly to them is just another categorization- men will check out, wolf whistle, oogle at any girl regardless of her beauty or lack of it- she just has to be a girl, any size, colour, frame will do.  Men mostly are fair in giving every women a chance with zero discrimination and still getting panned for low standards and lack of taste.  Women on the other hand. Have you ever heard any man rejecting a girl who proposed to him by giving the reason that she was too ugly and he couldn’t show her off to his friends? Its women who can be so forthright and downright cruel when they shrug advances off ugly men by telling them so pointblank.

Of all my years practicing the fine art of esthetic surgery I have never had ( I am just sharing my own experiences here) any man bring in his wife and requested me to do plastic surgery on her because he is not satisfied with her, the way she is. But I have had lots and lots of women who bring in their (looking like lambs to the slaughter) husbands and ask if I could do “anything” for them to make them look more presentable, as if they were stuck with defective products which they were now giving for servicing. If there is something that my profession has shown me in all these years it is just that when it comes to relationships people give lip service to things like compatibility, kindness and all that gooey stuff people share as internet memes. The real wants of women when it comes to prospective partners are  - being good looking and handsome in early twenties, being at least ok looking in end twenties and ok eyes closed someone to marry in their early thirties to I just want a baby the man doesn’t matter in their late thirties. With men their wants are simplicity itself - it’s just a girl in girls clothing- be it early twenties or late fifties- that will do for all men. 

And as for my quora answer I told the girl to basically “go f**k herself off” in as polite a way as I could before she demands that 90% of the worlds population die off just to satisfy her esthetic senses.  There are not enough plastic surgeons in the world (or for that matter surgeons) if everyone who is dissatisfied with the way they look wanted to be better looking than nature made them. Do you for instance think that I would look the way I do given what I do if there was indeed a practical way of doing it? I know for a fact that I don’t intend to spend the next fifteen to twenty years and spend all of my fortune (and my ancestral fortune thrown in) just so some random person on the street will judge me as good looking. That will be madness. Compared to that looking ugly is a better option. At least I get to call out everyone who worships beauty as the only thing in life as shallow, mean minded persons, don’t I?

It’s the ugly truth, but there, it is the truth.