Risks, Benefits and Trust

In a heart condition called atrial fibrillation, electrical activity in the upper chamber of the heart goes haywire. The squiggly muscle contraction generated does not pump blood effectively. Resulting blood stasis predisposes these patients to blood clots which can break off and reach the brain causing stroke. In these patients with atrial fibrillation, you may be able to prevent stroke by using blood thinning medications. One of these, aspirin, does so by reducing stickiness of platelets which have a major role in clot formation. It generally has low risk of bleeding and does not need monitoring blood tests. Another medication, warfarin, does so by reducing chemical substances involved in clot formation. Warfarin carries a significant risk of bleeding, especially with injuries, and a blood test has to be done regularly to ensure a safe dose of warfarin. Warfarin is more effective than aspirin for reducing the chances of clot (and stroke) while there is a higher risk of bleeding. 

Which one do you choose?

It is a complicated decision. Not everyone has the same risk of stroke with atrial fibrillation. So a risk-benefit assessment is employed. In lower risk patients aspirin is preferred while warfarin is used in higher risk patients. It turns out age and certain comorbidities accurately determine risk. In clinical practice, there is a scoring system called CHADS2 which gives certain points for these characteristics and overall score is used for treatment decision:
    Score 0: Give nothing or aspirin
    Score 1: Use aspirin or warfarin
    Score 2-6: Use warfarin
Let's say my patient scores 2. Untreated, the annual risk of stroke is 4%. Aspirin use reduces annual risk to 2.5% and warfarin to 2%. Is warfarin use a risk worth taking for 0.5% risk reduction? Does the study that came up with these results take into consideration peculiar circumstances of my patients: bumpy roads where you routinely levitate few inches out of your seats stretching blood vessels in the brain, need to climb trees to fetch fodder for cattles, availability of money to do blood tests, availability of blood tests nearby,...the list goes on. All these factors make warfarin a risky choice because of increased likelihood of life threatening bleeds. But is the risk justified for the benefits? 

If this exercise has been confusing, it indeed is. You hope and pray your doctor has done this exercise for you. 

I do routinely see atrial fibrillation patients taking warfarin at my hospital's outpatient clinic. When I ask them why they are on it, many of them answer their doctor asked them to take it or they were discharged with this medication after the hospital admission. They faithfully do blood test (which is required every 2 weeks many a time) and come for warfarin dose adjustment. If you allow, I would venture a guess that my patients have no idea about above risk-benefit calculation (if it has ever been done). But they are doing it because their doctor told them to, that it may be good for their well-being and longevity. 

This is just an example. Our clinics abound with patients suffering from non-communicable chronic illnesses. The treatment decisions entail risk-benefit calculations. What is the potential long-term benefit? What are the potential risks? These are more or less abstract notions both for patients and doctors but especially for patients. A patient with high blood pressures is treated to reduce the risk of heart attack, stroke, in future. Why should one agree to take medications daily for something that one cannot feel? What are these patients actually taking medications for? Are they calculating their risks? Many of my patients don't even know that high blood pressures can increase the risk of heart attack. They have been taking medications because they reduce the blood pressures to normal values. How did these abstract notions about benefits of normalizing blood pressures come? Is it a transmitted knowledge from others experiences? Is it a transmitted notion of benefits of their doctors?

Whatever it is, it expresses as a faith  in doctor's recommendation in my day-to-day patients. However much we hear about increasing lack of trust between doctor and patient in our debates,  in daily doctor-patient interactions, most of the decisions are done by reflexive trust of patients to their doctors. When I think about it, as a doctor, it is an overwhelming responsibility, to deliver to that trust. 

Especially humbling in the setup I work is the fact that our power structure is oblivious about this responsibility. Rather, I sense a feeling of entitlement among us doctors and administrators who hold the power. It is not uncommon to hear, in one of our grand eloquence, that the root of the problem in several of our disorganized institutions is illiterate, irresponsible janata (people) behaving haphazardly. We can elaborate on every solution that does not involve ourselves.  As I see a swathe of patients navigating the torturous disorganization of a public hospital just to see a doctor who will tweak their cholesterol medications, I have been increasingly disillusioned about the idea that our patients are illiterate. It is time that our doctors be literate.  

Article

This article might be of interest regarding emigration/retention of Nepalese doctors: 
http://www.bmj.com/content/345/bmj.e4826

Public Transport in Kathmandu

If you have been used to thinking yourself as a dignified individual, you are better served shedding off that illusion before you embark on public transport system in Kathmandu for a ride. In a journey from Maharajgunj to Purano Bus Park you are a lump of flesh worth Rs 15 and from Purano Bus Park to Lagankhel, Rs 17. Microbuses will stop at any place if you give a slightest hint of potential ride but stopping at your destination is a different matter. Availability of space is a secondary consideration. I have come to a conclusion, space in our microbuses is an abstract notion. It is almost limitless. Gas in your belly that can be squeezed out counts as available space. In these flesh carrying machines, if you have been stacked somewhere in a seat close to the corridor, there is a good chance someone's butt will rub against your face. And if this soul has Giardia swirling in his bowels or has devoured a sumptuous meal with fresh radish salad, you are toast. Even if you have been prudent to find a window seat in the second or third row, scourge of wet cough remains. A peculiar snorting sound heralds a maneuver which entails delicate opening of the window and spitting out into the open, throwing droplets of phlegm into the air, some of which may find way into your face if you are not agile enough to close your window on time. Furthermore, resemblance of the sound of cough to many of my patients with TB offers no consolation. 

A Tale of Trouble

My hospital reeks of violence these days. We are used to suffering inflicted by violent diseases and injuries. But not the violence borne of testosterone infused stupidity.

Muscular males garrisoned the protest area instead of the regular folks. I am told, they are political folks supporting the newly appointed vice-chancellor. They are looking for trouble, someone warns. Protesters are asked to go to the attic of the hospital instead, for the regular one-hour protest.

One of my colleagues tells me there is a trouble at the ICU. A very sick man with liver failure from alcohol abuse died. There are men who blame the hospital for death. They are seeking compensation. He tells me these are people who negotiate compensation with the hospital and split the money between the family and themselves. I don't know the truth. The chaos outside is fertile for these kinds of things. It won't be surprising if true.

When I go to see patients at the outpatient clinic, hallway is packed with patients, clogging the entrance. My first patient is an 83 year old man who took a microbus from Balaju to come to Patan Hospital. He says, he has been coming to Patan Hospital for more than 15 years. Only the medicines given here help me, he declares. Another patient is a woman again in her 80s from somewhere close by. Sharp as a tack, she comes to show me a medicine because it looked different from the ones she was used to. Patient after patient, it is a different story, a different suffering, a different ailment. We attempt to negotiate solutions. In this relationship, I look for those muscular men. They are nowhere to be found. Where are they? What is their vocation? Why are they outside? 

Laxmi Puja

The city that suffers perpetual darkness beams with colorful lights tonight. Decorative lights have replaced traditional candles and diyos. Kathmanduites appear unperturbed by unreliable electricity. They are adamant about taking chances on the stringed decorative lights in lieu of the more predictable candles.

Attempting to keep the government promise of unobstructed electricity for Tihar, our lightbulbs danced in and out of illumination for most of the evening today. Perhaps the hydropower turbines missed the memo.

It is late into night now. Electricity is more stable; peak demand has dissipated, I presume. People keep their doors, lockers open to allow unimpeded access to the goddess of wealth Laxmi on this festive night. They stay up late.

For a public hospital employee on a fixed salary, this proposition does not sound too lucrative. Rather, warm blanket in this cool night offers more appeal. As I head to my bedroom, a familiar screeching sound of microphone emanates from nearby. This is a deusi bhailo group, a more sophisticated one, which has set up loud speakers to do an elaborate program. Loud noise (?music) reverberates the whole neighborhood. I guarantee you, they are not aware that this can be bothersome to someone else, especially someone trying to sleep. You better learn to sleep in loud noises.

Protests at Patan Hospital

We have heard of the King Midas from Greek mythology. The one endowed with the Midas touch. Everything he touched turned into gold. Whatever the long-term implications were, the power was a reward Midas had asked for. In an instant, he could turn anything into coveted gold. 
 
What if you had the same power, but this time you were able to turn things into disarray? More like Tony Soprano from the television show Sopranos: I'm like King Midas in reverse, here. Everything I touch turns to shit.
 
Unfortunately, our current political system exhibits Tony Soprano characteristics in abundance. Here is an example:
 
Patan Hospital has a lot of desirable things. In this hospital, if you go to the emergency room sick, you are guaranteed a treatment whether you can afford it or not. Unlike other hospitals in Kathmandu, you are not asked to go buy everything before you can get treatment. It is the same in the wards too for the most essential stuff. You are billed at the end. If you cannot pay, social services department generally helps. In this way, they have been able to care for many sick patients who would otherwise have difficulty elsewhere.
 
They have been able to do this by faithfully abiding to the core principles they agreed upon at the outset: to take care of the patients regardless of their ability to pay. This conviction forms the spirit of the institution and people ascribing to it work together to achieve the goal.
 
The hospital as it stands now is a legacy of Christian missionaries' charity work.  It started as a clinic in 1950s gradually evolving into the current ~400 bed hospital. It is surmisable how much of hard work and sacrifices must have gone into establishing a non-profit organization serving poors. Expanding on its role in training health care personnels, Patan Academy of Health Sciences (PAHS) was established in 2008. While managed earlier by United Missions to Nepal (UMN), currently, Patan Hospital is administered by a board and PAHS is an autonomous public institution whose vice-chancellor is appointed by the Prime Minister of Nepal.
 
I joined PAHS just about the time the tenure of founding vice-chancellor was ending. There were small squirmishes between the administration and the hospital unions regarding salaries and benefits. It did not bother me much. I found a core group of people who were selflessly dedicated to the institution. It was wonderful working with them, bound by common aspiration to serve and better the institution. "Espirit de Corps," one of my colleagues used to say when we were discussing some changes that would be difficult. It was during this excitement that I left the country for nearly one and a half month. A new vice-chancellor had  just been appointed at that time. Folks were not excited about her but I did not hear any outright opposition. 
 
When I returned, I was shocked by what I saw. Almost everyone was against the new vice-chancellor. They wanted her to go away at any cost. And for that, they had ample reasons. 

Allegations were flabbergasting. Bypassing the executive committee, she single-handedly appointed a friend from outside institution as the Rector and informed only after the appointment while there were much more qualified persons within who understood the missions and goals of the institution better. She was disparaging to the people who have worked numerous years designing a novel curriculum and selection process for MBBS students geared towards producing doctors for rural community. Ignoring the established tradition of group work and raising a suspicion about her motives, she decided to centralize all procurement decisions to herself. She went to the senate with a proposition to centralize all the power to her without consulting with the executive committee (which was rejected by the senate). She lies, speaks disrespecfully to the officials, teachers and students of the institution. 

The hospital is in protests now. So far, clinical services have not been interrupted much. Vice-chancellor is not allowed within the premises: protestors stay at the gate from 8am to 4pm. Her office has been padlocked several times. We see riot police in our hospital premises, clad with riot gear. Some of our students have received baton charged already when trying to padlock vice-chancellor's office. Protests are bound to grow. I see interruption of non-emergency services coming. From what I understand, vice-chancellor has got to go.
 
Why did this happen? When my colleagues went to the Prime Minister, they were convincingly told how he had caved in to the complexities of maintaining a coalition during this political transition. He assured them he knows Patan Hospital is a different institution. That's why he even held signing the name recommended by the selection committee for 2 whole weeks. But he did not hear anything from Patan Hospital so he went ahead and signed. They were tremendously impressed by how attentively he listened and empathized with them. Had Patan Hospital lobbied for someone, would this situation have been averted?
 
The inside story of the appointment, which I tend to believe is this: The vice-chancellor is politician Sarat Singh Bhandari's relation. It was by political lobbying through him that she got the post. It is for sure, she was not given the position because of her credentials. And it is increasingly clear she has no skills to hold a leadership position.
 
I go to hospital searching the excitement I left with. Everything is at standstill. When the clinic is closed from 10-11am, I join the protests with my colleagues, hospital staff and students. Many of them are animated and excited. I have no doubt they are excited for the cause. But I can't avoid thinking, how much the fact that they don't have to work during that time is responsible. A look at similar other public institutions where protests like this are commonplace offers no solace.
 
We have been given a Tony Soprano. I still subscribe to goodness in people and believe that this blatantly unqualified vice-chancellor will be removed sooner or later. My worry is how much damage the whole exercise would have inflicted upon the institution by then; and will it be able to pick up from the place where it left?

Some Notes from the Past I: Election of Baburam Bhattarai to the Prime Minister of Nepal (Written on--August 30, 2011)

Baburam Bhattarai is the new prime minister of Nepal. His election to the post appears to have lifted spirits of people- as I gather it from the blogs and the news. Why not? He has always been a person people have looked up to. I, myself, in my youth, have received numerous lectures from my mom to aspire to be as studious and smart as Mr.Bhattarai. Folklore has it that he always scored highest in his class throughout the grade school and even in the Intermediate of Science (ISc). This was held in special regards because he came from a lower middle class peasant family. He epitomized the success of hard-working peasant kid: the barriers that could be navigated through, promises each child toiling the snaking trails to reach a school in the middle of nowhere held. Mr. Bhattarai did not stop there; he proved to be a grand idealist. He questioned the very society; he saw injustices, inequalities, exploitation. He devoted himself to struggle for what he envisioned as a better society. The culminating overthrow of monarchy and establishment of republican Nepal is claimed by many as a success in that direction. Now, he is not just an idol of academic success but, many claim, of political success/ideological success. It is not hard to understand why the spirits of the countrymen are high.

I sincerely wish for the success of Mr. Bhattarai. And I will gauze it only by two things: completion of inclusive constitution writing and conductance of elections for the parliament during his tenure.

But, I am afraid, the ecstatic nation is headed for a disappointment at the least. First off, the notion about Mr. Bhattarai appears to be almost fantastical, almost godlike. This is too big a burden to start with. No single person is capable of transforming a society as heterogeneous as Nepal in a magical way. Transformation of Nepali society is going to be a systematic process with all her citizenschipping in. I imagine more banal-appearing work and changes before the structures are in place for the progress of the society. But I doubt that our expectations from Mr. Bhattarai carry along this acceptance of banality, we are in for a radical overnight transformation.

Secondly, we do not fully understand Mr. Bhattarai. It is easy to wishfully imagine this man in light of his academic achievements but we do not yet have hard evidences at our hands to attest to his capablity to lead in a democratic setup. Fourteen thousand people lost their lives in the country in the bloody conflict that contributed to the overthrow of feudal monarchy. There will always be some of us who will question this as achievement, when such gory violence was used. Perhaps, many of us will be able to close our eyes and succeed in suppressing the memories of these dark days if the political process progresses to a better end. However, this much is clear, the violent political movement carried out by Mr. Bhattarai and his ilk does not qualify as a clear success. If anything, it attests to a violent inclination whatever his ideological defenses might be.

In any case, Mr. Bhattarai has been elected to a position with historical challenges and huge burden placed on him by unrealistic expectations. It is an opportunity to see this man of almost mystical image work. My sincerest hope is that he succeeds. My greatest fears are consolidation of tyrranical aspirations of Maoists. A

Some Notes from the Past II: Wandering Peacocks (Written on-- June 16, 2011)

 As I am preparing to take out pork stir-fry for dinner from my refrigerator there is an unusual, and loud crowing noise from outside. There are two peacocks in the lawn. A woman is on the other side with a camera, it looks like she is videotaping. The two birds appear completely oblivious- that they are in the middle of an urban human settlement where men and women do not generally venture out of their privacy to their lawns lest they disturb the privacy of fellow beings, or expose themselves in the open space to scrutiny and interpretation of unknown souls. One of the bird is close to the window of an apartment. I am not sure what its vocation there is, it does not appear to be feeding itself, just gazing, with it's neck bent in the shape of "S" and long beaks protruding out. The other one is in the lawn, moving mostly, picking the ground at times, perhaps some insects invisible to me. They did not stay for long. Without any declaration, they moved out, slowly, in pair, crossing the road, watching the traffic perhaps, onto the other side, and then out of my sight. Where will they go? Do they know where they came from, and do they have directions to return back to their homes if they have any? What if they don't? Perhaps they just travel. Each day to a new place, with one grazing, and the other gazing out with neck bent in a "S" shape and beaks protruding. What were they looking for in my settlement? What did they see?

Some Notes from the Past III: Goodbye (Written on-- June 16, 2011)

She has an extremely rare form of cancer. It is called adrenocorticalcarcinoma and is a cancer of the adrenal gland. Within a span of two weeks her cancer had grown from 9cm in size to 20cm. She underwent surgical resection which was essentially a complete resection. However, within two months cancer had spread to her liver, spleen and lungs. I had initially seen her right after the diagnosis, in preparation for surgery. Post-surgically I was involved in her care for treatment with a drug called Mitotane that is generally managed by endocrinologists. She has failed this treatment. Experimental study that she participated in another center also did nothing to halt her disease process. Now she is participating in a combination chemotherapy with quite toxic medications that will be managed by oncologists.

I saw her two days back in my clinic. She was not crying, she was not disheveled, she did not appear desperate, she did not appear depressed, she did not appear hopeless.. She smiled as always and was extremely polite and pleasant. I learned, her father passed away the day before yesterday. She was planning to go to funeral the next day. I wanted some blood tests which had to be done in the morning. She told me she will do this in the morning before going to her father's funeral. Depending on this blood test I was planning to make a decision about one hormonal medication, which could be stopped if her cancer was producing it in excess. After that, there was no point for her to see me, and undergo all the trouble one has to take to see a doctor, since there was nothing more to offer her from my specialty.

Today, I got the results. She does not need the hormonal medication; cancer is producing it in excess already. I called to let her know about this.

She is dying, in a few weeks to months. This is an unusually aggressive cancer for which there is no effective treatment available. The measures used are desperate ones but without any consistent benefits. Death is fairly rapid. At the end of the conversation I found myself scrambling. This is a goodbye, at it's true meaning. This is most likely my last conversation with her. What do I say? Goodbye? It sounds like a mockery to her plight. A mere word authenticating her doom. Consolidating inevitability, as if one has that authority. Does one say, good luck? As if the fate had not been clear enough to remind her of the injustice. Does one say, I hope you feel better? When, in fact, she has arrived at your clinic the day after her father's death, aware of her own diagnosis of terminal cancer, smiling and cheerful, conscious not to be pitied upon. What word will actually say bye, and a good bye?