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It takes an odd gumption and a total mastery over the medium to make a film like ‘Dunkirk’. You can’t think of anyone better than Christopher Nolan to do this.

Provided with the barest minimum of background, the viewer is hurled into the terse action of a World War II incident. It’s all around you, all the time. The scenes over the skies, in the sea and the beach are breathtaking. Background score is brilliant, drums pounding out the inevitable doom unless when they accelerate tempo to signify visceral action. The staccato of the machine guns, the pounding of the cannons and the empty sound of the sea engulf your heart not the ear.

The way Nolan converges three parallel plot timelines with different tempos (a few days of a soldier, a few hours of a civilian rescuer and an hour or so of a fighter pilot) inexorably into the very climax is superb and must be a cinematic highpoint. What a master storyteller!

There’s hardly a skeleton of a story. No strategy rooms, no lonely soldier pining for his beloved from the trenches, no martyrs wrapped in flags to gun salutes. There is no invincible hero fighting behind enemy lines or evil enemy commanders. Indeed there is no filmy heroism or villainy.

But there’s emotion, raw and nearly all of it understated: fear, despair, desperation and glimpses of grit. There is very little drama not when men do good under duress, but when they crack. There’s no celebration at crisis resolution: only acceptance, tired faces, hung heads and relief.

And above all there’s character: in the father, who lost his first son three weeks into the war, who sails into ground zero in his private boat to rescue stranded soldiers with his second teenage son; in the British admiral who stays back to evacuate every man in his watch and then waits to help the French soldiers; in the RAF fighter pilot who saves the day going after a Luftwaffe bomber though he has run out of fuel and in the boy who forgives a war-stricken soldier who accidentally killed the boy’s mate.

This is pure war. And pure cinema. Whoever thought that you could say so less yet tell so much!
Just don’t miss this beauty!

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IMG_2088Paul Beatty’s 2016 Man Booker winning book, ‘The Sellout’ is actually an outrageous rant on ‘post-racial’ America. By structure it is barely passable as a novel. Here, in a tone that’s somewhere between hilarious and satirical, Beatty points to all things that are racial in the United States at the precise time when – ironically – the first black president of the US was in office. Lightning pen in hand, Beatty demolishes the myth of Integration like Darth Vader severing Skywalker’s arm (the nod to Star Wars is there!)

The book has a meagre and absurd storyline. As I said, for a large part the novel is actually a series of savage, bizzare and humorous outages on Unmitigated Blackness, as he calls it. But the lack of a coherent plot doesn’t bother you because of the vividness of the verbal broadsides and a myriad incisive allusions Beatty makes in half-jest simply blow your imagination.

‘Bonbon’ Me is a “farm nigger” (In his own words – oh, Beatty overwhelms you with the N-word, more often than plaits on an African woman’s hairdo, don’t you worry about me!), born to a half-mad professor of behavioral psychology and grows up home-schooled, doubling as a guinea pig to his dad’s many social experiments on Racism. That he survives this psychological trauma and ends up as a Camus-quoting, fruit growing, clear-headed maverick can be attributed to his high quality home grown weed varieties which he calls with whacky & imaginative names (code red, Ataxia, Anglophobia!) and on which he’s perennially high.

So, after his dad is shot by LAPD, the hero comes up with a bizarre plan to bring back his blackest black ghetto town (Murder capital of the world) named Dickens (oh, irony! Take that Jim!) which has disappeared under the conspiratorial mushrooming of white suburbs around. He decides to revive it by ‘reverse-segregation’ and ends up being tried in the Supreme Court. I won’t give away more spoilers than these.

The caricatures he creates – Hominy Jenkins, the last surviving actor from The Little Rascals, a racist children’s TV show of the yore, Marpessa, a could-have-been-brain-surgeon, Kafka-reading bus driver girlfriend of the hero who’s married to a rapper & Foy Cheshire, a manipulative black pseudo-intellectual – are comical, outrageous and lively all at once.

The high-point of Beatty’s novel, apart from the Oreo-black angst, is the language. The silly ease with which he brings out irony, sarcasm, weirdness, rhetoric and comedy, flipping from mood to mood (never sadness though), often in the same sentence is a delight to read. Sample this ‘The incessant magic tricks that produced dollar pieces out of thin air and the open-house mind games that made you think that the view from the second-floor Tudor style miracle in the hills would soon be yours are designed to fool us into believing that without daddies and the fatherly guidance they provide, the rest of our lives will be futile Mickey Mouseless I-told-ya-so existences’. This is no trick-writing, this is head/heart to pen magic. There’s so much literary energy in the book that the plot becomes irrelevent and seemingly whimsical at most times.

My main gripe about the book is this: Of the humongous number of references to cinema, books, rap, skirmishes and LA urban folklore that Beatty uses to effortlessly adorn the book, I couldn’t recognise more than a tenth. Reading the book with Wikipedia open would have probably allowed me to enjoy the book even more.

Fabulous read! Go for it!

A dear friend and colleague, Dr Vivek Baliga has written this very informative article about heart attack on his blog.

Here’s the link:

http://heartsense.in/chest-pain-and-heart-attacks-what-to-do/

Coronary Stents
Coronary stents have been around for a few decades. They are used to treat narrowed arteries of the heart to alleviate cardiac chest pain, termed angina, and during a heart attack while performing life saving coronary angioplasties. Nearly all of the coronary stents are made of metal and crudely resemble a spring inside your ballpoint pen. The best long-term results are seen with drug eluting stents (DES) that are essentially the metallic stents coated with special medicines to improve performance.
Downside of metallic stents
Metallic stents including DES, have a few perceived drawbacks. The main ones are:
1. A metal is left behind after an angioplasty. Some patients are conscious that they are carrying a foreign object. This is perhaps the least of the concerns.
2. Very late stent failure (>1 year after implantation) and Very very late stent failure (>5 years after implantation) are known to occur. These are related to presence of the metal or the adhesive that binds the metal to the drug.
3. Coronary arteries have dynamic physical properties. For example, expansion of calibre when more flow of blood is needed termed vasodilation. They also possess biochemical properties such as secretion of local hormones that are beneficial. The metal from the DES cages the artery from inside this preventing it from demonstrating these properties.
4. If long segments of coronary arteries are treated with metallic DES, in the event of a subsequent Bypass surgery, the cardiac surgeon has difficulty finding a place to stick the grafts.
Case for Stents that dissolve after their job is over!
 A stent that would stay for 3-6 months after implantation and disappear after that would be an ideal foil to address these problems. This was the premise with which scientists invented Absorbable Stents. The basic material used to build absorbable stents could be either metal (magnesium, zinc) or polymer (Poly-L-lactic acid, PLLA) that has appropriate degradation characteristics.
Absorb™ BVS
The absorbable stent that has shown the best performance is the Abbott’s Bioresorbable Vascular Scaffold (BVS), Absorb™. Absorb is the only fully dissolvable stent system approved for clinical use (also received FDA approval in July 2016). The clinical evidence for its efficiency and safety comes from a series of clinical research trials called as the ABSORB trials.
In ABSORB trial 29 of the 30 patients who underwent implantation of the BVS, first reported in 2011), continued to​ do well at 5 years. The comparative study of the BVS with Abbott’s own best performing metallic DES, Xience™ called ABSORB II showed that as late as 2 years on, the two stents were more or less similar in efficacy and safety. The patients with the BVS had similar relief from symptoms and somewhat similar, low failure rates. But it was really the results of the ABSORB III a large enough study for doctors to generalise conclusions from that really proved that the BVS performed as well as the DES. The abrupt and gradual failures​ of the BVS were seen in a few patients more than with the DES but the statistical analysis suggested that it was due to chance rather than a true difference between the stents. With these results, and the USFDA approval, the BVS was ready to go places. In India and some European countries the Absorb BVS was already popular even before the USFDA approval.
Is there an issue now?
While superficially the promise seems to hold, of late some mixed signals are emerging with the use of Absorb BVS. The 3-year results from ABSORB II trial showed a higher rate of heart attack and stent failure with the BVS compared to the metallic DES. The difference was so striking that the trial’s lead investigator, Dr Patrick Serruys termed these results as unexpected and disappointing. The setback seemed more alarming because it happened in patients who were not expected to have these complications. In fact, these were the patients who were being regularly followed up and had shown no warning signs of problems!
Are there signals from ABSORB lll?
The ongoing trial ABSORB III has also shown some issues when the BVS is implanted in coronary arteries of smaller calibre. The lead investigator of that trial, Dr Stephen Ellis has cautioned against the use of BVS in smaller vessels. The manufacturer Abbott Vascular seems to endorse this view, at least partially.
What happens now?
Experts acknowledge that there are some niggling issues with the current iteration of the absorbable stent. Clearly, they cannot be used in all types of arteries from all types of patients. So over enthusiastic implantation regardless of patient type just because of patient’s request or affordability is a definite no!
Secondly, Absorbable Stent technology is a definite breakthrough. Further research from scientists will certainly iron out the issues faced by the first generation of dissolvable stent systems. Until then, bioabsorbable stents are meant for very select individuals in carefully monitored environments such as research trials and registries.
Cardiac doctors have been very perceptive and careful in examining and reporting even minor failures. It is this culture of scientific temperament that has lead to tremendous advances in cardiology. We look forward to great times ahead.
SanthoshSanthosh Padmanabhan, Runner, ‘monk’, teacher to the underprivileged at the Ananya & Thulir schools and the chief coach from the running club, Runners’ High of which I was once a part, wrote a mail to me asking me about the appropriateness of routine health checks for runners who were newly joining him. This was my reply.
Dear Santhosh,

In this mail let me address the issue of preventive health checks.

I am aware that there is a large debate in the realm of public health whether preventive health checks are effective/useful or not.

What do people who are opposed to health checks say?

The detractors of health checks seem to point out that
a. Preventive health checks do not truly prevent diseases or their complications
b. On the contrary, they actually increase the number of diagnostic tests, medicine use & even increased number of surgical procedures.

I’ll give two examples to support the above concern:
1. There is a condition known as sub-clinical hypothyroidism, where the thyroid is mildly dysfunctional but not enough to cause biological abnormalities. Some and not all patients of sub-clinical hypothyroidism progress to develop actual thyroid disease and its complications. Routine health checks targeting thyroid disease can detect sub-clinical hypothyroidism. This in turn triggers additional hormonal and antibody testing by the doctors reading the test results. Also a number of physicians prefer to prescribe medications on detection of this sub-clinical hypothyroidism.

Yet, there is no clinical evidence that any of these testing or prescription of hormonal replacement benefits the patient!

2. Mammography is a routine health check test as many of us know. It is said to detect breast cancers very early and thus prevent breast cancer related deaths. Typically, very early cancers detected by mammography necessitates a counseling session and in most instances such counseling leads to the patient opting for limited surgery i.e.,removal of the affected breast.

Recent evidence, however has shown that about 50% of very early cancers detected by mammography disappear over a period of time, indicating that body’s own immune mechanisms are able to weed out many of the cancerous cells.

Logical projections have allowed public health scientists to conclude that:

If we do not detect these very early cancers, i.e., not perform routine mammography, but employ clinical methods of breast cancer surveillance, like self examination or periodic physical examination of the breasts by experienced physicians, that itself would lead to detection of cancer early enough to offer limited surgery. Technically this means that avoiding mammography in routine health checks would avoid unnecessary breast removals in 50% women without putting the other 50% to any disadvantage.

In both these above instances, imagine the psychological trauma, additional testing/ treatment and above all the huge healthcare cost burden to the society.

Does this mean that all health check is bunk?

No.

Complete health check or full body health check is not a panacea to all ill health. However, in specific disease entities early detection has been shown to change the course of disease. I’ll again give two examples:

1. Hypertension: Early detection of severe hypertension and its treatment has been clearly shown to be a very important and cost effective public health initiative. Such detection and proper treatment reduces complications like kidney failure, heart failure and strokes. This has been proven beyond doubt.

2. Screening for cervical cancer in women by Pap smear detects such cancer pretty early. It has been adequately proven by public health research that such screening allows very early treatment, surgical and otherwise, of women with cervical cancer. And such early treatment not only saves lives, but also saves a lot of money which would have been otherwise spent in treating, in futility, advanced cervical cancer.

So what do these examples tell us?

That there is no generalization possible on usefulness or otherwise of preventive health checks. In high end private clinics esp in western countries, tests such as whole body CT or MRI scans and other high cost tests are included in such health checks and are obviously useless and may even be harmful.

On the other hand in a country like India, where basic health awareness is poor health checks (which include testing of blood pressure, examination of the heart for possible valve disease and holes, testing for blood sugar, blood cholesterol, screening for cervical cancer) are not just useful, they should be made compulsory. In fact, with years of experience, I have realized that a large number of patients who come to us for ‘preventive health checks’ mandated by their insurance company or their employers etc have never undergone even basic screening earlier. Indeed, but for this compulsion, many of these individual would not have got their blood pressure, cholesterol or sugar checked. In India, where nearly 14% have diabetes, 10% have hypertension and about 8% have some form of cholesterol abnormality, such neglect would be a massive public health blunder.

The topic of preventive health check is very complex. Indeed, there is almost nothing preventive about such health checks. Such checks actually, give an accurate view of the problems that the patient already has.

Let me clarify: preventive health check will not prevent diabetes or hypertension. On the other hand, it will diagnose a hitherto undiagnosed diabetes etc and help prevent the complications.

So in my opinion, we need preventive health checks as long as they are designed to detect health issues for which early prevention is beneficial. We certainly do not need fancy tests like whole body scanning.

Towards the end of this mail, I should still address the issue of your runners needing health check. I do not know, if RH knows this: there were 4 patients who had heart attacks and one who actually died during our last annual long run of the city. And this wasn’t even a half marathon. We (Fortis is a medical partner for a large number of running events) realized that, often our runners are fueled by zeal rather than meticulous training. A reasonable number of runners believe that running absolves them of all sins: many smoke, a lot have poor eating habits, some sleep badly and most have work stress.

Testing our fitness for the events at hand is imperative under three circumstances:

a. If you are embarking upon a new endurance activity like long distance running, especially after a certain age (I would peg it at 30 years in India, as against 40 in the Caucasians, due to our inherent genetic risks) you must ensure that you have no medical issues.

b. People with risk factors like high BP, sugar, cholesterol, smoking, family history etc should certainly test themselves before starting ANY exercise program

c. There are unsuspecting conditions such as valve diseases, hypertrophic cardiomyopathy etc which will not be detected even on a routine health check. Special tests like echocardiography are required to exclude these conditions, which are often fatal. A 1500 rupee test once in a life time to make sure you are not going to collapse on the race? Far cheaper than the travel insurance which you keep buying for 110 rupees every time you fly domestic!!

Lastly, as an organization, Santhosh, there will be a question of liability, if one of the runners should develop a problem during a training run. While it is easy to absolve yourself with a declaration from the runners that you are not liable for any issues they have or develop during training (like how how the running events take a declaration from the participants during mega events), I believe that people like you, who have been responsible for making running popular among public, are justified in taking precautions to ensure that running does not get adverse publicity by untoward events on the track.

So as a cardiologist practicing in a country which is now declared the capital of heart diseases in the world, I’m entirely with you if you (autocratically) mandate that your runners have health checks before long distance running. In fact, I believe, you are doing them a favor by insisting on such testing!

The sweeping allegation of corruption against doctors in Aamir Khan’s talk show was something that was waiting to happen. Too many people believe that a good number of doctors are out to get their money, by hook or crook! Clearly the show itself was one-sided: there are a large number of doctors that are not corrupt; even where individual cases of alleged wrong practice was projected on the show, the accused were given no chance to defend themselves. Aamir was judge, jury and the executioner. Despite this, the criticism of the manner of the show is not to say that all doctors are honest.

This piece is not about whether or not doctors are corrupt. This is not even about why they are forced to be corrupt. A chain email is already doing that job of condemning ‘Satyameva Jayate’, and extolling the greatness of doctors toiling under adverse educational, vocational and financial circumstances. I am just examining how some doctors end up indulging in malpractices and dishonesty in their professional lives.

Most of the doctors I know are personally fine people. There is far less lying, adultery, cheating, scandals and financial scams involving doctors than say, film actors! Yet, like any government clerks, private IT managers and bankers, some doctors are unscrupulous in their work.

Root cause analyses will lead us to two factors: Comparatively poorer remunerations across the nation and across private or government sectors are given to doctors when you consider their age, qualification and training. A 30 year old MD who puts in six and a half years in graduation and another three years in post graduation is offered thirty thousand rupees (less that $600) a month in private hospitals. Government service provides even less! A ‘software engineer’ even without a post graduation, a CA who is much younger earns at least twice this amount in Metros at start up. A professor in the prestigious AIIMS who teaches life-saving skills to younger doctors while actually treating Governors and Supreme Court Judges would barely receive a 6 figure salary at retirement. Compare this with the professors at IIMs and you will realize, similar skills do not yield similar remunerations.

In smaller towns and villages the situation is worse. If an MBBS doctor charges Rs five for a consultation (very frequent in rural Karnataka), imagine the number of patients he has to see just to bring home groceries worth Rs 4000 a month! The examples can actually go on, but the fundamental issue is doctors feel, and often justifiably so, that they are underpaid, while the world around them seems to have a great time!

Of course, that you have less money is no excuse for turning to burglary or kickbacks. But, on the other hand, when has affluence prevented greed & gluttony? All around us, we see people who are illegally wealthy, yet continuing to indulge profiteering. The mining scam in Karnataka or the 2G controversy are huge examples. This brings us to the other fundamental point:

Some doctors are corrupt, not just because they are underpaid, but corruptibility is in the grain of our society. I would really like to go back in time and see if during the time of Lord Rama, people in India were honest and just. But at least, during my own lifetime – I’m 45 now – I haven’t seen many Indians around me that are honest or transparent! Our society seems to be full of people whose only aim is climbing up the social and financial ladders at any cost. Morality and honesty are sacrificed at the altar of selfish personal gain. How, then, do you expect the doctors alone to be clad in pure white? Have you ever waited at midnight for the traffic lights to turn green, when all around you, others are driving through the red light, just because there are no cops? How long can you hold on to your principles there, without looking like a moron who is not ‘smart’?

After all, when a doctor finishes medical school, he doesn’t come out trained in malpractice. It is the community around him that urges him to issue a bogus medical certificate, offer kickbacks for referring tests to a laboratory and even abort a female foetus! So the society reaps as it sows. In fact, it is a testimony to the doctor community’s integrity that only a few among them succumb to these temptations!

It is very fine for people like Aamir Khan to want doctors to put patients before themselves, others before their own families and to feel that doctors must serve and not think of money! But doctors too live in the same society which demands bribes and kickbacks. No registrar gives a discount to the doctor on the bribe amount for registering a property! Shows like Satyameva Jayate appeal to the viewer by ‘sensational’ expose’s but fail to address more fundamental issues. If you look close enough, you realize that when it comes to the moral fabric of the society, it is only Mithyameva Jayate! Given the size of that problem, it is well nigh impossible for medical practice to totally rid of dishonesty and corruption. So, don’t expect this problem to go away. It will only change with society. Or Armageddon! Also be thankful that despite so much pressure to be otherwise, a large majority of doctors are actually honest and incorrupt!

ImageAspirin is arguably one of the greatest drugs invented. Only antibiotics have saved more human lives than this wonder drug. In the history of cardiovascular medicine itself, aspirin has prevented more deaths than all bypass surgeries and angioplasties put together. Considering the low cost of this drug, and the immense cardiovascular benefits it provides, one is not exaggerating when aspirin is spoken of as a public health measure than a mere miracle drug.

The simplicity of the aspirin’s action lies in its ability to prevent platelets, small blood cells, from clumping together and forming clots within blood vessels. Typically, it is these clots in the arteries that cause heart attacks and paralytic brain strokes. Needless to say, both heart attacks and strokes are often fatal.

In patients who have already had myocardial infarction or stroke, aspirin treatment is mandatory to prevent recurrent events. This is spoken of as secondary prevention. Given the impressive cost-benefit ratio, doctors have always looked at aspirin as a potential drug to prevent first heart attacks and strokes in patients who have never experienced cardiovascular events. This ability to help in primary prevention has been a matter of study, now for decades.

The flip side to daily aspirin treatment is its side effect. By virtue of its ‘blood thinning’ effect aspirin is capable of causing unexpected bleeding. Often, the bleeding is from the stomach & intestine, (‘peptic ulcer bleeds’). But, any internal hemorrhage can result, including rare instances of brain hemorrhage in some patients. Some minor injuries, which may otherwise be well tolerated, can result in serious bleeding in patients on aspirin therapy.

Traditionally, patients who were deemed to be at a higher risk for developing heart attacks and strokes were put on aspirin on a regular basis. Typically, these were patients with diabetes, hypertension, high blood cholesterol, smokers and patients with family history of heart attacks. Higher the risk – e.g., a diabetic who is also a smoker with a family history, greater was the benefit provided by aspirin therapy. In an analysis published in 2011 (link), investigators from Brisbane concluded that the aspirin not only protected against heart attacks and strokes, but reduced overall risk of death.

However, a new meta-analysis of a number of previous studies, published in the Archives of Internal Medicine has contested this traditional wisdom. Prof Kausik Ray from St George’s University, London, who is the senior investigator of this analysis, has spoken extensively on the new conclusions arising out of this analysis about aspirin (link). The paper says that in most instances aspirin only protects against ‘non-fatal’ heart attacks. Regular intake of aspirin does not protect against mortality. And, the worst part of it all is that aspirin caused an increase in the risk of ‘non-trivial’ bleeding (translates as serious bleeding needing hospitalization, blood transfusion, necessitating surgery or leading to death).

With this the debate as to whether aspirin should be prescribed to patients who are perceived to be ‘at risk’ for heart attacks & strokes has come to a full circle. Traditional wisdom is being questioned.

But given its intuitively attractive risk-benefit ratio, as far as protection against heart attacks are concerned, my personal opinion is that one can’t be categorical about whether aspirin should or should not be used.
Individuals have varying risk of developing heart attacks based on their medical history. Some are at very high risk whereas some have a negligible risk. Likewise, bleeding risk too varies between individuals. The trick with preventive cardiovascular medicine is to identify patients at high risk of cardiovascular events but lower risk of bleeding and offer primary protection with aspirin. Higher cardiovascular risk can be identified with use of risk calculators which are recommended by experts in the USA or Europe.

In the practice of cardiovascular medicine ‘cure’ has never been cost effective with burgeoning hospitalization costs for angioplasties and by-pass surgeries. With cardiac disease prevalence assuming epidemic proportions, one can safely say that the day is not far when not enough hospitals and doctors will be available to treat all cardiac patients especially in a country like India. Thus, despite (?over)cautious observations such as this report, primary prevention with aspirin will continue to hold a key for the future.

(Image courtesy Harvard Health Blog)

Dr Chandrashekar

Being a cardiologist I am often called upon to give free advice to friends, family, newly made acquaintances, practically anyone around about nutrition. I have had to give opinions about various foodstuffs and eating practices and many times I have to make an effort to give sound advice and yet not scoff at many hare-brained ideas people seem to have.

This is about the time when I got terrific insights into certain aspects of nutrition by a well known medical practitioner, Dr Chandrashekar. Dr Chandrashekar is a pediatrician, physician and diabetologist by qualification (MBBS, MD, DCh, PGDDM) and in addition he is most passionate about dietetics.

The reason why I am writing about the good doctor is because, somehow I think his theory holds the key to the question as to why people in the Indian sub-continent and especially the south Indians are at such a high risk of developing diabetes, Dyslipidemia and heart disease.

Here’s his theory:

Dietary fibre is an essential part of human diet. Fiber is available from plant sources in two forms: soluble & insoluble. Both these forms of fiber are beneficial by modifying the processes of digestion and absorption of food in the stomach & intestines. The overall impact is stabilization of blood glucose and prevention of lipid absorption into the body.

Experts recommend that adult daily diet should contain around 30gms of dietary fibre. Dr Chandrashekar strongly argues that progressively Indian diets have been depleted of its fibre content. Rice is polished several times to give a ‘refined’ appearance, wheat flour is refined and re-refined to minimize fibre content. The blame for this transition from a fibre-rich diet to practically fibre-free diet should go to us, he says. We go to a restaurant and ask for rotis or naans (Indian breads) and if they are not extra soft we get annoyed. The softer the rotis, lesser will be the fibre content. Similarly unpolished or semi-polished rice would appear reddish brown and is not appealing in appearance to us. We prefer the fine white grains of rice and that has very less insoluble fibre content.

Dr Chandrashekar has numerous case examples to offer. I saw some patients requiring high doses of insulin. These patients were convinced to change over to unpolished rice and wheat flour straight after milling without putting it through a fine sieve. Insulin requirements have come down dramatically. In some cases patients requiring over 50-60 units are now requiring much less than 15-20 units. There are a few patients who have been taken off insulin completely and are doing well.

It seems quite a plausible hypothesis that if the dietary fibre is increased systematically in the diets the incidence of diabetes in general population and the severity of diabetes in diabetics will come down. Dr Chandrashekar has quite a number of other radical dietetic tips. Systematic study on these issues is highly relevant for our population which is getting more sedentary by the day and consuming more unhealthy diets each day.

In addition to this Dr Chandra is an avid teacher at PES Medical college. For details about his pathbreaking ideas on nutrition and dietetics you can write to him at drchandra59@yahoo.com.

Firstly, apologies for not blogging regularly. No excuses, but have a new resolution to be more frequently at the keyboard.

The one issue which has forced me out of my cocoon will be debated in the coming months: often in hushed tones in the medical and pharmaceutical circles. That is the newly renewed guidelines to the medical doctors about their relationship with the pharmaceutical industry. The text of the “Indian Medical Council (Professional Conduct, Etiquette and Ethics) (Amendment) Regulations, 2009 – Part-I” (Ref: No.MCI-211(1)/2009(Ethics)/55667) is available in the Indian Gazette, but I first read it here and gratefully acknowledge the author of the blog.

The summary guidelines say:

“In dealing with Pharmaceutical and allied health sector industry, a medical practitioner shall follow and adhere to the stipulations given below.”

a. Gifts: A medical practitioner shall not receive any gift from any pharmaceutical or allied health care industry and their sales people or representatives.

b. Travel facilities: A medical practitioner shall not accept any travel facility inside the country or outside, including rail, air, ship, cruise tickets, paid vacations etc. from any pharmaceutical or allied healthcare industry or their representatives for self and family members for vacation or for attending conferences, seminars, workshops, CME program etc as a delegate.

c. Hospitality: A medical practitioner shall not accept individually any hospitality like hotel accommodation for self and family members under any pretext.

d. Cash or monetary grants: A medical practitioner shall not receive any cash or monetary grants from any pharmaceutical and allied healthcare industry for individual purpose in individual capacity under any pretext. Funding for medical research, study etc. can only be received through approved institutions by modalities laid down by law / rules / guidelines adopted by such approved institutions, in a transparent manner. It shall always be fully disclosed.

e. Medical Research: A medical practitioner may carry out, participate in, work in research projects funded by pharmaceutical and allied healthcare industries. A medical practitioner is obliged to know that the fulfillment of the following items (i) to (vii) will be an imperative for undertaking any research assignment / project funded by industry – for being proper and ethical. Thus, in accepting such a position a medical practitioner shall:-
(i) Ensure that the particular research proposal(s) has the due permission from the competent concerned authorities.
(ii) Ensure that such a research project(s) has the clearance of national/ state / institutional ethics committees / bodies.
(iii) Ensure that it fulfils all the legal requirements prescribed for medical research.
(iv) Ensure that the source and amount of funding is publicly disclosed at the beginning itself.
(v) Ensure that proper care and facilities are provided to human volunteers, if they are necessary for the research project(s).
(vi) Ensure that undue animal experimentations are not done and when these are necessary they are done in a scientific and a humane way.
(vii) Ensure that while accepting such an assignment a medical practitioner shall have the freedom to publish the results of the research in the greater interest of the society by inserting such a clause in the MoU or any other document / agreement for any such assignment.

f. Maintaining Professional Autonomy: In dealing with pharmaceutical and allied healthcare industry a medical practitioner shall always ensure that there shall never be any compromise either with his / her own professional autonomy and / or with the autonomy and freedom of the medical institution.

g. Affiliation: A medical practitioner may work for pharmaceutical and allied healthcare industries in advisory capacities, as consultants, as researchers, as treating doctors or in any other professional capacity. In doing so, a medical practitioner shall always:
(i) Ensure that his professional integrity and freedom are maintained.
(ii) Ensure that patient’s interests are not compromised in any way.
(iii) Ensure that such affiliations are within the law.
(iv) Ensure that such affiliations / employments are fully transparent and disclosed.

h. Endorsement: A medical practitioner shall not endorse any drug or product of the industry publicly. Any study conducted on the efficacy or otherwise of such products shall be presented to and / or through appropriate scientific bodies or published in appropriate scientific journals in a proper way.

It was time that these guidelines were issued and adhered to. Medical profession has too much into disrepute because of the various enticements the drug companies offered and are accepted. The freebies include gifts ranging from pens to motorcars, local and foreign trips to local and international destinations often thinly disguised as academic tours (“conference”), cash and sundry other goodies. A very innovative medical company once offered to start an SIP in my name in return to what they called an ‘exclusive support’ to one of their products.

I have no doubts that any sane person, which includes most doctors, would welcome these restrictions, but I have a couple of points to make:

  1. Along with all the greedy, unscrupulous medical practitioners, genuine academicians have been needlessly restricted by these guidelines. For instance, in my own field of interventional cardiology, the premier academic conferences which propagate new techniques and technologies are held in Europe and the United States. In the absence of any structured training or opportunity to dabble with emerging technologies, this restriction will now condemn us to archaical practices. Of course, since I’m in private practice and because of the pressures of learning new technologies I personally will fund my own training abroad. But with typical conference expenditure between Rs 150,000 to Rs 200,000, how does a typical cardiology faculty member from AIIMS or PGI manage to go to these conferences? True, the government sponsors few faculty members with lots of limit on the expenditure, no of days of attendance, no of times one could go attending conferences, but that kind of scanty attendance would hardly suffice for learning on a large scale. Moreover, governmental funding, already abysmal on research will further fall because huge increases in conference funding.
  2. While the guidelines exhort the doctors to stick to ethical conduct, there doesn’t seem to be any directive towards the pharmaceutical industry. The New Year has started and I am already tired of refusing gifts and overseas conference offers. Representatives of various companies go around asking doctors as to which conference they would like to attend ‘this year’ so that their companies can plan their ‘annual budgets’. Strangely, they don’t seem to acknowledge the existence of these fresh laws to the doctors. So many doctors who are unaware of the laws may accept gifts or conference invitations and may be later on punished.
  3. Despite the MCI formally coming up with the guidelines, the average neighborhood doctor is unlikely to be aware of the existence of the rules and the type of reprimand or punishment they are likely to face in the event of a violation. These laws were reported in some sections of the media. I personally am not aware if the MCI is making any attempt to make doctors aware of these laws. It should. If it has already done it, then there should be more visibility of the awareness program.

Comments are welcome.

bcpRecently, Hema my niece sent me this chain mail and asked my opinion about it

“PASS THIS ON EVEN IF YOU DO NOT USE IT

Recently this past week, my cousin Nicole Dishuk (age 31…newly graduated student with a doctoral degree about to start her new career as a Doctor…) was flown into a nearby hospital, because she passed out.

They found a blood clot in her neck, and immediately took her by helicopter to the ER to operate. By the time they removed the right half of her skull to relieve the pressure on her brain; the clot had spread to her brain causing severe damage.

Since last Wednesday night, she was battling… they induced her into a coma to stop the blood flow, they operated 3 times… Finally, they said there was nothing left that they could do… they found multiple clots in the left side of her brain… the swelling wouldn’t stop, and she was on life support…

She died at 4:30 yesterday. She leaves behind a husband, a 2yr old Brandon and a 4yr old Justin… The CAUSE of DEATH – they found was a birth control she was taking that allows you to only have your period 3 times a year… They said it interrupts life’s menstrual cycle, and although it is FDA approved… shouldn’t be – So to the women in my address book – I ask you to boycott this product & deal with your period once a month – so you can live the rest of the months that your life has in store for you….”

The mail goes on to name the products by trade name and asks people to boycott them. Hem wanted me to opine on this. Here is my reply to her:

Every drug has side effects. But in general, modern drugs will undergo many checks and tests in order to be extremely safe. So it is unlikely that hundreds and hundreds of women who take birth control pill drugs are dying such horrible deaths regularly.

Let me illustrate safety of important drugs with an example. A patient of mine, who has a serious heart disease,  is on aspirin for many years. We know that aspirin prevents death due to heart attacks and strokes. So, it is possible that this guy lives on thanks to aspirin.

Now, the other day this patient started vomiting blood and was rushed to the hospital almost in an unconscious state. Fortunately we were all there and despite the fact that he had vomited over one and a half litres of blood we managed to transfuse blood to him and take him up for a test called as endoscopy. This test showed that he had a huge ulcer in the stomach which was continuously bleeding. That bleeding was controlled by endoscopic treatment and the patient went home after 3 days of recovery time.

I can easily make a huge story about this and send a chain email which says: Aspirin causes big bleeding ulcers and you can die of a horrible death, so all you heart patients please stop taking aspirin! And also I could request ‘everyone who cares about your near and dear ones to forward this mail to as many people as possible and prevent hundreds of deaths!’ Yet I prescribe aspirin to literally hundreds every month because it saves too many lives

If you ban birth control pills based on such sensational stories then you will have a billion people in each state of India and we will all die because there will not be enough food to eat for all of us!

It is possible that this story is true. But whoever wrote it up made it look so  gruesome to you tend to vilify the drug. And when you read this, you are not reading the positive side of this drug. Worse, people maybe forwarding such mails to their contacts without even verifying if it was true thus causing panic and misinformation about drugs.

As I said at the beginning, every drug has side effects. Thanks to research and regulations modern drugs are very safe and serious side effects are extremely rare. Rather, far more lives are saved by the good effects of drugs than are lost due to their adverse effects. Patients who take medicines should consult doctors and learn about the positive and negative effects of drugs, balance the possible risks with possible benefits and then take the decision to use the drug or not, rather than being tricked by such mails!

If you have more chain mails on medical stuff, send them to me. Let’s look at them objectively.