Brain waste, funny taste

An article I came across in the JAMA on health worker migration alludes to what they call ” Brain waste”- skilled migrant workers are unable to find work in their area of expertise and end up working in unrelated low-paying jobs.

Exotic sounding word.No neurons being tossed into the bin.But compelling on the idea of why people mix up career and life.People have very quaint ideas when they make the switch.

While I must admit at forth that I am no sage on this, I have heard mixed views.
For people like DRK, working in resource poor areas was a brain waste.That its no use working for excellence when you are fighting with red tape and cost cutting all the time. It is funny, none of my teachers have given me negative feedback on that.Not Dilip Mathai, not DRK, not Kaka.
Hardik was honest to admit that its all about money.
One friend of mine, now an intern in MI told me that he came here with romantic notions that what he saw in western movies about a open country and ‘promiscuous’ lifestyle was true.
“Tab life mein aish karne ka aise lagta tha”

There’s a whole bunch in KEM and BJ who think the Mah government is going crazy on bond issues, trying to bulldoze its way through on its supposedly moral high ground, and count it as wise investment to rather spend time and money in making it to elsewhere.

Abhijit said he wants to learn interventional pulmono skills.Charudutt said the same thing when he first came.Learning skills.Lot of things have changed since.

Lifestyle is a major draw.But I presume that means cleaner roads, more taxes, being distanced from near and dear ones,loneliness, nice big cars,safety, subtle racism. It is a mixed bag, really.It is about making choices based on priorities.As Dhiraj says,” i would rather be a first class citizen in a second class country than be a second class citizen in a first class country.”
No one person is right or wrong here.Just that ‘results might vary based on experience.’

Many medical students seem to do so because it is a fashionable thing to do.All the batch toppers are doing it.It catches on as a trend in places like MAMC or AIIMS, where Ramadoss has to address the convocation thus:” don’t go away. And if you do, please come back.”In my MD batch I am the only one who chose to give my USMLE. In the batch after mine, half the batch is already interviewing.

Renita gave me a totally new perspective: of parents of unmarried girls equating getting married to someone in the US and going there as being an indicator of success in life. I got registered on shaadi.com, just to test the waters and am already put off and shall be deleting my profile.

These are individual anecdotal experiences, a bit colorful,but unsupported by sexy stats.For a more detailed discussion read the WHO fact sheet on this. But I gather, at least from the Pinoy experience, everything starts with an individual experience, an anecdote, a word of mouth, which people tend to trust.Then when things get big, people become numbers, more reliable.

If anyone does read my blog, your experiences are welcome.

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Yeah…Mukesh Ambani is the richest man on the earth……so?

Territory size shows the proportion of all people living on US$10 purchasing power parity or less a day worldwide, that live there.

And the Sensex touched a sexy 20,000.So?
More such maps and great stuff at worldmapper.

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To give you a sized perspective of things>>>>

Watch the video here….amazing stuff!!!

http://www.micro.magnet.fsu.edu/primer/java/scienceopticsu/powersof10/

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LoveER

Believe me or not. If you plan to work in Emergency Medicine, there is a high chance that romance will strike you sometime or the other, more so if you are tall, muscular, with chiseled features and had suffered personal tragedy in the past.

Brendan Kelly from Department of Adult Psychiatry, University College Dublin does a study where she studied 20 randomly selected medical romance novels. And published her results in………………. the Lancet !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!( Lim-> 1/0)

Lance my conservative heart, you blokes. Holy whatchamacallit!!

And the conclusion:
These novels draw attention to the romantic possibilities of primary care settings and the apparent inevitability of uncontrolled passions in the context of emergency medicine, especially as practised on aeroplanes. These novels suggest that there is an urgent need to include instruction in the arts of romance in training programmes for doctors and nurses who intend working in these settings.

Get me some beer please.

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The new Harry….expectations

We all have grown up on this book figuratively, and literally speaking- ventured through the 14th while looking up to seniors who read the 12th and 13th, snacked on titbits from the 15th( the most extensive edition to date) ravaged the 16th with pencil underlinings and dogs ears and sticky notes, sweaty forearms and contemptuous doodles…and finally here comes the 17th. Waited a long time for this!!

The 16th was probably the one with the most mistakes- ‘non caseating granulomas in TB’, holy mackerel!!- as also the most monoclonal antibodies. It was a colorful cousin come visiting, but we hoped for short time.The editing left a lot to be desired – GI and immunology had a lot of unnecessary chapters, the cover was unimaginative and the colors looked as if they were splashed all over with childish glee, the mistakes were atrocious, and I still like to have an atlas- it is what makes OTM a pleasure to read when line after line of text get to your rods’ nerves.

The 17th will be out March 2008. Priced $199 on Amazon. From what I can see it seems it is packaged as one book.I hope I am wrong, carrying it along will be a pain. And the middle chapters will be a pain to read with print going down into the central gutter.We want to hypertrophy the gyri, not the brachii.

Dr Loscalzo joins the editorial board. That had to be, given that so many of Harrison’s authors are from BWH
The promotional video says there’s a 40% increase in content. This valuable new collection includes even more great depictions of pathophysiological processes, decision-speeding algorithms,( we never needed an overdose of that guys, least of all for something like osteoarthritis, probably the worst flow chart in the 16th. And the emergency medicine section had hardly any!!There’s always Fred Ferri for flowcharts guys. Butt I have to hand it to you on this, endo flowcharts rock!!) clinical photographs, essential radiology images, an atlas of EKG tracings ( thats a great addition), and full color depictions of key pathological specimens( again, I hope this doesn’t get too extensive)

There’s 40 new chapters- including Health Disparities,” “Quality and Safety in Patient Care,” “Hospital Neurology,” “Electrophysiology in Neurological Diagnosis,” “Clinical Management of Obesity,” and “Approach to Heart Murmurs” . All good additions I would agree.

There’s a new section called regenerative medicine ( fancy name!!) which includes Stem Cell therapy, tissue engineering and the works. This had to come I guess. So they take some tonnage out of the outlandishly heavy on content Genetics chapters.

There are three great additions I feel:
1)Paul Farmer makes his debut in a chapter called Global considerations in medicine. All chapters will have a Global Considerations icon, which identifies important epidemiological, diagnostic, and therapeutic distinctions between global regions to aid in the diagnosis and management of specific diseases. This will help Harry shed the America specific image it is perceived to have, and enter the league of OTM. A big round of applause for this one.

2) The classic Introduction to Clinical Medicine section features new e-chapters addressing Patient Safety and Quality, Ethics in Medicine, and The Economics of Medicine; Health Disparities, and more.

3) Bonus content in a DVD, as eChapters. This includes 37 chapters spanning some 300 pages , 90 videos and include content such as an atlas of CTs and a chapter on radiography of the chest,atlases of renal pathology and urianalysis, neurology, vasculitides among others.

Harry also has taken a leaning to putting factual information into procedural approach with the ‘approach to the patient’ boxes since the 16th.They push the pedal on this one with extra additions in form of symptom management. I do not know the details, but this is again a welcome addition form an internist’s POV.

Fact is Harrison is the most popular medical textbook all over.It is a humongous task for the editors to even attempt to cater to all their reader base. But this edition seems to be a great first step.I look forward to March 2008.

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Gandhi the UnNoble

I found this engrossing piece on Gandhi on the nobelprize.org website. Ovyvind Tonneson, the editor of the official site from 1998 to 2000 writes, quoting from personal diaries of the members of the Norwegian Nobel Peace Prize Committee. Nominated 5 times in 1937,38,39 and 1947 and 1948, each time the Nobel Peace Prize Committee shot down for reasons as varied as Chauri Chaura, partition, the rioting that followed, and also the fact- in 1948, when he strongest candidate -that the Nobel Prize had never been awarded to anyone posthumously till then.In fact in 1948 the Nobel prize for peace was not awarded to anyone, the official statement from the Committee being that there was ‘no suitable living candidate’

The earlier committee( 1936) had harsh words about Gandhi, Jakob Worm Muller, an advisory to the Committee had these words to say:
“He is a freedom fighter and a dictator, an idealist and a nationalist. He is frequently a Christ, but then, suddenly, an ordinary politician.” There are many hate sites which say Gandhi’s fight in South Africa was restricted in that he took up cause for the Indians but not the blacks.

Muller probably misinterred on Gandhi’s philosophy including his message of shunning cowardice for violence as being inconsistent on his principle of non violence.It is important to remember that Gandhi was a soul keeper who chose to be truthful to himself more than a politician. When confronted with making a choice between being truthful and being practical, he would choose the former, thus infuriating many of his colleagues, who chose to play the politics game upfront.He was the writer, thinker, Nehru was the orator. Many of the things good or bad that are ascribed to him are actually the INC’s decisions.Besides Gandhi himself accepts that he made mistakes. He accepted to be a part of the British Empire initially.

The exact reasons, deliberations of the Committee are not cited. These are Tonneson’s conclusions. Statute 8 of the Nobel Foundation states, “the deliberations, opinions and proposals of the Nobel Committee with the award of prizes may NOT be made public or otherwise revealed.”

The irony is that eminent personalities, who based their own actions on the pattern of Gandhi’s teachings, were themselves awarded the Nobel Prize in later years — Albert Luthuli in 1960, Martin Luther King, Jr. in 1964, Mother Teresa in 1979, the Dalai Lama in 1989 and Nelson Mandela in 1993.The irony is that Yasser Arafat and Henry Kissinger can be awarded the Nobel prize for peace by the same people who prefered to be holier than thou with Gandhi!!!

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Visual acuity six by sex

This is an uproariously funny Snellen’s chart for testing your acuity of vision!!LOL.No one will be 6/6 on this I guess!!

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E-gad-o !!

Came across this website in the WSJ health blog. Kevin MD does a great job really Digging up stuff from every known place on the www. Well here’s the news: Siemens is offering a 1.5 T MRI scanner to the hospital which comes up with the best video detailing its reasons why it deserves to get one free of charge. Some of the videos are outright hilarious- watch the granny one.I don’t know if it’s intended.

I wonder…….,WTF….., I bite my orbicularis oris….

When we got an MR machine at KEM, it was the first MR machine in a municipal hospital in Mumbai, and one of the best in the city. It stood packed in huge boxes for some time because they could not carry it to the first floor where the MR console is now located. So they had to demolish a part of the wall, use a crane loader to lift it to first level, and then rebuild the wall.Of course, the KEM building being of some heritage value, the paperwork took some time coming through.
And there used to be such a long wait period for MRs in the initial months, this being the place all other hospitals would refer their patients to, people would have average wait periods of 2-3 months!! And getting an appointment for an indoor patient was an equally painful experience. Of course as we started reading MRs with the MR team, we came to be acquainted with each other more. I always had it easy referring a patient for an MR, coz them guys knew my referrals to be genuinely indicated, unlike some other colleagues of mine who had a tough time getting the job done- hehe!

My HP nearly cooked the goose on that one:
I had a patient with a double valve replacement who developed an ADEM like condition after an exanthematous fever. My houseman scheduled an MR, and sure enough Darshana/Yogesh obliged promptly. While rounding in the evening I asked my HP where the patient was. He said, ” woh to MR ke liye gaya.”
“What??!!!” , I stared back as if the great God had smote me down with a huge scimitar, too bewildered to shoot an abuse even. Primum non nocere( first,do no harm) is a cardinal rule we learn on the first day of medical school.

“You”….I fumbled…”bloody murderer”. That was all I could manage for all the venomous upsurge.
” The valve will rip through his chest in that magnetic field”

( Some of you medically educated guys might have got the plot already. Others, come over to edge of your seats and read on as to how the motivated medicine resident saved the day.)

I shat my pants running down to the MR room trying to see if he had got in the gantry already, hoping that a flying Medtronic Hall valve hadn’t damaged the machine besides of course ripping his chest apart.That I presumed was a foregone conclusion. ‘I hope his sutures held strong.God, my license….weird thoughts buzzed through my brain randomly.

I was done. He was inside, with the queer humming sounds emanating from the room.

” Chalu hai?” I asked with bated breath.
” Fir kya?!” Yogesh said.
” Nothing happened I hope”, I asked, biting my lips. “Valve hai uske mitral and aortic position mein”
” Abbe c#%@ye !!! Bataya kyon nahi ” he howled at me open eyed, perspiring fast.Something similar had hit him too probably. Suddenly I felt in my HPs unenviable position, expecting the murderer word to come any moment.
” Idiot, isn’t it your job?” I asked, knowing that it was a weak hit back, but I had an ass to save.

Then it struck both us pathetic retards simultaneously- if it hadn’t happened till now, it wouldn’t happen from now.Man, is it not a great feeling when the heart, that has sunk to your bollocks rises up relieved, beating like a wretched hummingbird!!! We researched and found out that the valves are MR compatible. The patient was discharged a week from then, with around 70% recovery, his valves safe and clicking away merrily. Subkuch TickTock hai.

Another MR story……. to get some dil ki bhadaas out…I mean WTF…a free machine…: a free machine!!:
Anyways:

There are people who work in the BMC who wear the BMC badge all so proudly!! These are the folks who are actually never found at work. They hang out in groups at the canteen sipping chai, gossip, go to ‘aunty’s’ and get drunk in daytime, abuse nursing staff, look out for opportunities to strike work at smallest provocation to their mojo, ally with notorious corporators, act as recommendation guys-” saab, isko dekh ke lo haan, apna dost hai!!”- at OPDs, and make a buck out of it.They would prefer this mode of work to what the BMC pays them for: sweep or mop corridors, ferry patients, help in the wards.
And they will break lines in the OPD and thrust their paper in your face saying, ” Shtaff hai!!”To which I have suppressed many a frustrated “so what motherf@#$er” under gritted teeth and murderous expression.One similar aayabai association chief from Nair Hospital comes to our OPD one busy Monday.
” Saab, MRI karne ka”
” Kyon?”
” Magaj mein dard hota hai”
After I get through a history, I conclude that this lady with a tension headache needs no imaging.So I go, ” karne ka garaj nahi hai.”
” Pan mereko karne ka hai na. Maine NAir mein Shitti scan kiya, Usmein kucch nahi dika. Roj magaj thanthanaata hai. Kaam ko bhi nahi gayi ek mahine se. “( Gasp)
“Kuch to fault hai”( yeah, u have your ass and brain in the wrong places, lets do a bilateral hemispherectomy!!) “Aur mein shtaff hai na, mufat mein ho jayega, aap chinta mat karo kharche ka.”( Gasp, gasp!!)

I refused to write an MR for her. To which she said she knew the Asst Dean. I said I didn’t know him…I said that sacchi.Pronto, the bitch goes to the Asst Dean, a glorified idiot who decided to quit academic pursuits after MBBS was too much for him, and I get a call.
” Karun taak ki. Kaay problem aahe?”
” Sir mala vaatat nahi tila laagnaar.”
” Tujhya seniors la vichaarlas ka?”
” Yes sir” ( you filthy bastard!!)
” Kaay ahe, hi loka nantar khoop problems detaat. Press valyankade gela tar problem hoil re.Asha conditions madhe apan karun takaycha.” ( Yeah yeah, teri bhains ko anda maru…)
” Theek aahe, sir pathvun dya tila”

And then I cocked the ultimate snoop.Dawg!!Vaibhav, my friend was registrar at the ‘headache OPD’- a recent flight of fancy method by Dr Mehta to waste a resident’s afternoon of good reading. I told her,” udhar magaj ke special doctor baith te hain. Unka final hota hai. Woh bole to haan, nahi bole to naa. Chalega tumko?”

‘Bade doctor’ Vaibhav gave her TCAs and a fit to resume duty certificate. no MRI. I did the MR guys a favor. I never got an MR request refused. Thats why!!

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Gautama smiled….

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CABGs from India

I had briefly referred to medical tourism in an earlier post, speculating about how the nitty- gritties would work out.
I recently read a fabulous article by David E. Williams. from healthleadersmedia.com on the future of medical tourism from an American perspective.He makes five important predictions he feels will be relevant to the future of medical tourism. I shall reproduce some of his comments.

( Words in Italics from the original article. Rest, my inputs)

1) Medical tourism will cross over to the insured population in 2008: Insurers are beginning to get requests to cover medical tourism from multiple sources: employers and their benefits consultants, foreign hospitals and governments, medical tourism facilitators, and individual members who want to receive coverage overseas. There are important initial steps in this direction. For example, Blue Cross Blue Shield of South Carolina has added Bumrungrad Hospital in Thailand to its hospital network. Jaslok Hospital has tied up with Cigna.If you thought safety and standard of care were issues, the Joint Commission International has accredited over 100 foreign hospitals.

2) Mini-med plans and small employers–not big health plans and blue chip companies–will be the early adopters: Williams argues that though the big spenders will initialize the process, close to half of Americans work for organizations with under 200 workers. Only 60 percent of employers with fewer than 200 workers offered health insurance in 2006.Smaller employers look at insurance differently. Many are shifting to so-called “mini-med” or “limited benefit” plans that cover day-to-day expenses such as doctors’ appointments, but not surgery. I wonder how they can commodify a medical service offered?Surgery, or a procedure is easier to. A $50,000 angioplasty in the United States costs less than $6,000 in Mohali, India, according to GlobalChoice Healthcare. Yes thats gains of around 42,000 counting airfare and stay.But with mundane spiels like the annual physical,or a pap test, will it be financially prudent to make a 10,000 km trip to Hyderabad?These would form the major bulk of doctor visits by employees and I don’t think thats going to come to foreign shores.Unless you are driving from California to Mexico.I would reason that pathology or radiology would be major gainers here for obvious reasons.

3) Opposition to medical tourism by U.S. physicians will be modest: At the community level, over 25 percent of physicians in the United States are foreign-born. They are familiar with the level of professionalism and training in other countries. U.S. patients are also accustomed to getting their care from foreign physicians. He also draws attention to the fact that a shortage of physicians means the US physicians will be willing to share their work burden with their colleagues abroad.Well said, but the outsourcing juggernaut does whip jingoistic passions among the misinformedly sentimental. There might be patients who will refuse, this has to be factored in.

4) State governments will begin to embrace medical tourism by 2010: Rising healthcare expenses require states to shift funding from other programs or raise taxes, both of which are unpalatable. He gives the example of NY having half a million Dominicans. Santo Domingo, which has some excellent cardiac surgeons and low prices, is a 4-hour nonstop flight away. Why wouldn’t New York at least explore the possibility?Possible. But you never know how politicians think.

5) The emergence of medical tourism won’t have a major, direct impact on U.S. healthcare costs, but the secondary impact will be substantial: If every U.S. resident who could go abroad for treatment actually went, the savings on total medical costs would be about five percent. That’s still a big number, especially compared to other initiatives that are available. But to look at it another way, if healthcare costs are increasing by 10 percent per year, taking full advantage of medical tourism only buys us about half a year.For a country like the US, with the most expensive health care system in the world( around $210billion!!) this might not translate into a very big gain, true.Considering that a major part of this expense is not a public spending, but out of the common man’s pocket, the gains will accrue to demand supply equation that the provider and customer share. Queer are the dynamics of health care in this country, where fair market capitalism dictates that need supersedes want. Of course, no one is aiming for great shifts in any hard indicators of health care. (The US health care system does not figure in the first ten or twentys of the WHO list despite being the most expensive.) It would be ridiculously naive to expect anything more than a drop in the ocean. But for the person who feels the pinch most, a dollar saved is a dollar gained.

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