Medicine Matka

Being Healthy is Not a Lottery

Fasting Before Contrast Enhanced CT Scans – Changing Practice Patterns – I

A standard protocol for all contrast enhanced studies is to ask patients to fast for 4-6 hours prior to the study. Over the years, the fasting is no longer rigorous and reasonable hydration has been recommended to prevent deleterious effects of intravenous contrast on the kidneys (thought that too is debatable).

Nevertheless, it has always been a paradox that while we talk about fasting, we also give 500-1000 cc of oral contrast prior to CT abdomen / pelvis studies.

The reason for people to be fasting has essentially been to reduce the risk of aspiration if there is nausea and vomiting. Given oral contrast in any case makes this reason redundant.

This nice recently published paper examines this issue and compares people who were asked to take a light meal prior to the study versus being asked to come fasting for 4 hours.

It actually finds that those who fast may land up with more problems due to issues with fasting (though their population was an oncology patient population) that those who don’t. Since the incidence of nausea and vomiting in the current era of iso-osmolar intravenous contrast media is low anyway, aspiration was just not an issue.

Perhaps it is time for all of us to examine this practice and to perhaps go easy on fasting instructions.

Exercise and All-Cause Mortality – Get Off Your Ass – I

This is a theme we will keep coming back to again and again. There is yet one more article published this week that discusses how moderate to vigorous physical activity (MVPA) produces substantial health benefits.

This is based on the 2008 Physical Activity Guidelines for Americans that recommends at least 150 minutes per week of moderate of 75 minutes per week of vigorous intensity physical exercise.

This study was done to figure out whether 10 minute bouts of more sustained activity make a difference over and above the usual amount of regular activity. The conclusion the study reached is that it doesn’t matter how the exercise is done, as long as it is done. If these results are correct and replicated, it means that people and trainers can focus on methods of exercise that don’t necessarily include bouts of increased training.

More importantly though, the message again is the same. The more you exercise, the better the mortality benefits are with the benefits tapering off once the exercise levels reach a certain peak (in this case 96 mins / day) for Q3 and 147 mins/day for Q4), though this study measured exercise using an accelerometer and hence also included daily regular activity, rather than a structured activity routine.

In 2012, in the Lancet, Wen CP and Wu H  put this in perspective, with this telling graph that shows how physical inactivity is as bad as smoking.

So essentially, we come back to the same refrain. Get off your ass. Do something…anything and it helps.

The Tragedy of The Intelligent

I recently interacted with a highly intelligent lady with carcinoma breast who believes that the only way to manage the disease is with alternative therapy.

I don’t really want to argue with the choice she has made – if you intelligently decide to follow a line of treatment, assuming of course it is done with the full knowledge of all data available, then so be it.

Her tumor is growing and she wants to compare its progression / regression. She has been doing so with successive breast MRIs and when I was asked to look at the breast MRIs, my first reaction was, Why…. why would someone do breast MRIs for comparison when the standard of care is PET/CT, given that she has metastatic breast cancer with bone involvement?

The answer I received was that she was scared of effects of the radiation from PET/CT.

And I felt sorry for her. She was misinformed and making bad decisions based on some delusional understanding of the ill-effects, if any, of radiation.

Diagnostic radiation has been around since 1895. In the last 120 years, there has been no data and I repeat no data that links diagnostic radiation to cancer. We are not talking of 10 or 20 or 30 years…this is 120 years. All the hype that comes in the newspapers and lay press is from extrapolation of nuclear blast data, which is unscientific and has no basis.

And even for a moment, assuming that diagnostic imaging related radiation does cause mutagenesis with the possible chance of cancer, this would take 20 odd years to manifest, by which time this 55 years old lady would have been 75.

I may have sounded mean, but I actually blurted out the fact that it was unlikely she would be alive for another 20 years and hence not doing a PET/CT was really just a completely rubbish decision.

Sometimes I feel it is best to not know a lot and to have some faith in modern medicine and data and clinical judgement calls. Ask the right questions, but also accept facts and management directions when presented by people who do know perhaps a little more.

Informal Medical Workers (Quacks) Providing Healthcare – The Challenge

I am always conflicted when people talk about alternative medicine practitioners. When those trained in alternative medicine start practicing allopathy and caring for patients, or when there is talk about integrating them into the mainstream, the uneasiness grows even more.

There is no question there is a significant shortage of doctors / healthcare workers in India. We have 1 doctor per 1700 people instead of 1 per 1000 as mandated by the WHO for low income countries, with 80% of the doctors clustered in cities and urban areas, which worsens the already bad patient:doctor ratio in the rural areas. To add to this, the primary healthcare centres are short-staffed with rampant absenteeism, and this is not getting any better.

A large number of viral and bacterial diseases are self-limiting and would heal irrespective of whether there is a doctor or not. Doctors make a difference in trauma, acute emergencies (appendicitis, etc) and infections that need active management. Chronic diseases can be controlled, but very often doctors really just provide support systems that can also be managed by others under supervision or with training.

To that end, nurse practitioners have made quite a difference in the management of both acute and chronic conditions, so much so, that a nurse practitioner-managed ICU has the same results as a resident-managed ICU.

There is no nurse practitioner program in India, with a denial from the Health Minister in 2015, changing to a positive commitment in June 2016. The nursing council has created a 2-years curriculum as well, with the hope that they will get a green signal soon to implement this.

With the larger healthcare problem in mind, the Government of India (GOI) at various times has tried to introduce programs that train people to manage basic health care issues, like the Bachelor of Science (Community Health), which have met with strong resistance from the Indian Medical Association (IMA) and a variety of other medical stakeholders. The general fear is that given the state of the law in India, these health workers will start calling themselves doctors and and practice advanced medicine, even though not trained to do so, eventually to the detriment of the patients.

Proposals to allow practitioners of homeopathy and ayurveda to practice allopathy after a one year course have also been met with strong resistance.

Wading into this mess, is a new paper in Science, by Jishnu Das and Abhijit Chowdhury titled “The impact of training informal health care providers in India: A randomized controlled trial” that describes an experiment where formal training was given to a group of informal health workers (quacks), with a monitored control group that was not given training, with outcomes compared to those of doctors in the public sector.

Outcomes for trained informal healthcare workers

These graphs show that even with just a 56% mean attendance, the trained informal workers managed cases more effectively than those who were untrained and closed the gap with those in the public sector. While this could partly be because the public sector doctors also probably need skill upscaling, the fact remains that most diseases can be taken care of by simple training of health workers.

Priyanka Pulla, in The Wire, wrote about this study in 2015, when it was first started, ( The Liver Foundation in Kolkata has been conducting this training. The caveat is that once trained, to allay the apprehensions of the IMA, MCI and other “doctor-based” stakeholders, these health workers are to stop using the prefix “Dr”.

In a utopian world, that would be the perfect solution. But, in a country where we can’t even stop two-wheeler riders from riding on the wrong side of the road and beating up traffic policemen, where an aromatherapy healer with some rubbish diploma also starts calling herself “Dr” with impunity, that really seems to be a tall-order.

Therefore, while the study has shown that training “quacks” improves outcomes, practically, we would be legitimising quackery, hoping these workers will agree to a demotion from being “doctors”, while in reality they would likely use the training to add another diploma acronym (DLFT, or something like this) to enhance the “Dr” prefix.

Perhaps the nurse practitioner solution is the best. Nurse practitioners would be able to provide basic healthcare in under-serviced areas, work under the supervision of doctors and most importantly, would not suddenly start calling themselves doctors.

Like I said at the beginning…I am quite conflicted. We have a huge healthcare problem that needs to be solved and yet solutions that don’t involve doctors or seek to legitimise those who have entered the system surreptitiously or illegally, leave me with quite some unease.

Bull-Headed Doctors – Yes, We Are and Proudly So!!

Last week, the Union Minister of Health and Family Welfare, whose name apparently is “Fag gan Singh Kulaste” called doctors “Kuchra Bail”, meaning “bull-headed”. 

His problem apparently is that doctors don’t listen to anyone and when they are asked to fall in line they resign and leave.

He is not the first one to feel so frustrated.

No one really knows what to do with doctors. Politicians, private equity, hospital administrators, ministers, social workers…all of those who work with health care policy and business and growth, intrinsically hope for a system where doctors are redundant and everything can be managed by easily controllable nurses, technologists…and management.

Like it happens in all other industries! There are workers and there is management. Management decides policy and gives orders and workers have to obey and work.

In healthcare, unfortunately, there is a third layer…doctors, who are highly intelligent, perhaps more than all the others that I have just mentioned, have the ability to earn more than them as well and if challenged at some point will fight back, because they know there will always be another buyer for their skills.

The only way to manage healthcare policy is to work with doctors. Many politicians hope that by increasing the number of medial seats, they can create a glut of doctors, which will then lead to commoditisation and the easy ability to control them…forget it. If there are too many doctors without jobs, they will move into the public services, into upper management and into politics and eventually displace all those non-doctors who currently want to control doctors.

Remembers, Mr. Bashar Al Assad is an ophthalmologist…(not a very great example, but it’s just to let non-doctors know what doctors are capable of)

And doctors make the best hospital administrators

As well as entrepreneurs.

If you have saved even one life in your life, you know that decision making under pressure is what doctors do.

Don’t call it bull-headedness, when someone smarter and more qualified challenges the decisions and policies of those who have no business perhaps to be making them in the first place.

Work with doctors. That will be good for everyone in the long run!!!

Say No to Staff Abuse – Don’t Abuse and Don’t Accept Abuse

When patients and relatives abuse doctors and hit them or indulge in looting and arson, it makes the news. Video clips go viral, doctors go on strike, arrests are made and the newspapers tend to give adequate coverage to these incidents.

What doesn’t get reported is the increasing incidence of verbal abuse that the medical staff has to face from patients and relatives…paralleling the increasing intolerance and rage pervading our society, with people losing their temper in all kinds of situations, on all sorts of workers, including policemen, airline staff, toll-naka workers, truck and cab drivers, bank employees, call centre operators…anyone providing a service.

While a lot of this physical abuse happens in emergency and trauma wards given the heightened emotions and the likely extreme injury / stroke / heart attack and the possibility of death (which still does not justify in anyway any kind of violence or abuse), verbal abuse usually happens in non-emergency situations. Health-care establishments and their workers including doctors, present such easy, soft targets that it becomes easy to lose one’s temper without the immediate fear of repercussions.

The reasons are invariably one of these

  1. Increased waiting time
  2. Delayed reports
  3. Instructions, addresses not conveyed properly or misunderstood
  4. Reports misplaced
  5. Reports exchanged
  6. Patient not attended to in time or properly
  7. Patient or relative not spoken to properly
  8. Tea or coffee not up to the mark
  9. Too many forms to be filled
  10. No discount being given
  11. No parking facility available

and the list goes on.

The problem may be as trivial as extra waiting time or a little more serious as with exchanged reports or not being attended to in time.




If a patient is not happy with the services, or has a problem with the staff or the way things are being managed, he/she can escalate to a senior, to the doctor present, to a manager or the CEO of the hospital or the head administrator of the facility or whoever…

File a complaint, hell, file a lawsuit, if necessary…but NO ONE CAN SHOUT AT THE STAFF. There is no justification.

I have been impressed by the posters at most London tube stations that promise severe penalties against those who abuse transport workers.

Poster at a London tube station regarding staff abuse

Poster at a London tube station regarding staff abuse

I have been mulling putting similar posters in our premises, warning people that they can’t abuse the staff whatever the provocation, but have so far refrained from doing so because what may seem apt for a tube station may not necessarily be ideal for a medical facility.

Finally, with Dr. Hemant Morparia’s help we have come up with a series of cartoons that we hope can humorously get this message across.

Anti-Abuse Posters

It is important for all patients and their relatives to understand that abuse is only counter-productive. It makes the staff defensive, changes the methodology of management usually to the detriment of the patient and leads to situations where the staff is unwilling to be proactive, especially if the patient comes back the next time, which in turn causes more aggravation. In the end the only loser in all this is the patient and his/her health.

It also changes the environment at that time. It affects, usually adversely, the other patients and relatives who are waiting their turn, and has a cascading effect on the shaken workers, who are likely to make more mistakes, which in turn may result in poorer care for the remaining patients in that shift or the whole day/night or throughout the period of stay.

Visits to medical facilities and hospitals are never easy. Patients and relatives are often nervous, scared, worried and the slightest provocation or perceived lapse in attention can make one angry. And yes, the staff may be out of line, the doctors may not behave properly, the facility or hospital may be rapacious or the reports may be erroneous.

Then, walk away. There are always better or equal choices. Or sue, like the person who thinks that one of the city’s hospitals is collecting unnecessary surcharges. Complain. Email. Write. Tweet. Broadcast. WhatsApp.

But abuse, verbal or physical, is not acceptable. We have empowered our staff to politely ask people to leave if they start shouting and it has worked well so far, though of course, these patients have never come back for tests.  No one should abuse and no one should accept abuse as well.


The Sugar Conspiracy – Killing Sweetly

The big news this week, is the article in JAMA Internal Medicine that describes the way the sugar industry in the 1950s deliberately shifted public focus from sugar to fat to make people believe that fat (including eggs) was bad. A whole generation has grown up gorging on sugar-based food products, while believing that all fat-based food is bad.

It is worthwhile reading the New York Times piece on this and also the long read that came out in the Guardian earlier this year.

Tainted research has always been the bane of good medical practice, but more about that with specific examples in future articles.

What this has led to, is the proliferation of an entire industry where virtually every packaged food item that we find on grocery shelves has extra sugar. This in turn is the reason why the individual sugar intake has risen to around 71 kg per year in most high-income societies.

It is this increased sugar intake that is part of the world-wide problem related to the increase in obesity and cardiometabolic health and policy makers everywhere are devising innovative strategies to reduce the usage of unnecessary sugar in foods as well as the intake of sugar by people through a combination of regulation and education.

What can we do to reduce our sugar dependence? There are many sites with suggestions, both official and otherwise but the simple facts to follow would be

  • Cut back on adding extra sugar to beverages (especially tea for us Indians) and food
  • Cut back on cola and similar fizzy drinks
  • Cut back also on fruit juices, both natural and more importantly the packaged ones
  • Reduce the intake of all packaged, processed foods (chips, cookies, etc) to the extent possible

Hopefully, these measures should allow us to control our sugar intake, which in turn would go a long way to help us maintain a low-carb diet, which in turn would help with controlling weight and pushing back cardiometabolic problems.

Bariatric Surgery vs Low Carb Diet for Type 2 Diabetes

Diabetes and Bariatric Surgery

There is a recent article in the New York Times with a very provocative title, “Before You Spend $26,000 on Weight-Loss Surgery, Do This” aimed at those who believe that bariatric surgery is now the best option for diabetics.

This is because of the new 2016 guidelines endorsed by a group of clinicians and researchers (75% of them non-surgeons) that advocate the use of bariatric surgery in the treatment of type II diabetes.

This is also because of the general thinking that lifestyle intervention does not help much over a long period of time.

However, there is growing data that suggests that a low carb diet without caloric restriction can go a long way in helping to control HbA1c levels. The New York Times article by Sarah Hallberg and Osama Handy essentially focuses on this and ends with this quote “We owe our patients with diabetes more than a lifetime of insulin injections and risky surgical procedures. To combat diabetes and spare a great deal of suffering, as well as the $322 billion in diabetes-related costs incurred by the nation each year, doctors should follow a version of that timeworn advice against doing unnecessary harm — and counsel their patients to first, do low carbs.”

This cannot be more relevant in the Indian context. As of 2015, there were 69 million adults with diabetes in India with 1 million deaths per year. Essentially one in 11 adults in India has diabetes.

I reached out to Dr. Roshani Sanghani , an endocrinologist trained in the US, working specifically with diabetics, who runs Aasaan Health.

“This article is very relevant for for the Indian context. The average Indian consumes a carbohydrate rich diet and pays for his/her healthcare out-of-pocket. Everyday I see patients with type 2 diabetes and obesity who eat more carbohydrates than their bodies can handle. Prescribing the latest drugs and offering complicated surgeries are options available to us as doctors, but these options cannot be used in good conscience if we do not advocate the power of reducing carbohydrate intake. “

“I have treated patients of varying ages, cultures and education levels who came with uncontrolled diabetes requiring prescriptions of two or three different tablets (or at times, insulin). By learning Diabetes Self-Management, many who had long-standing type 2 diabetes were able to self adjust their carbohydrate intake, which allowed me to reduce the medication burden and quite often, stop their insulin.”

“It is not true that diabetes prescriptions need to keep getting longer and costlier. Type 2 diabetes can certainly be reversed to a larger extent by lifestyle change than most healthcare providers make centre-stage. I cringe at the word  “low carb diet”  because that makes it sound like it’s a set of rules that needs to be prescribed to patients, and that further might imply the patients need to follow my rules indefinitely. “

“We as doctors can support much more empowering and long-lasting behaviour change when patients start monitoring their own blood glucose levels, and learn to take the responsibility of changing their diet in a way that suits them.”

“Instead of unilaterally telling patients to “stop eating so many carbs”, encourage them to first, figure out why they are eating so many carbs and second, notice the difference in their hunger, energy and blood sugar levels in the “high carb + low protein + low vegetables” versus “low carbohydrate + adequate protein + adequate vegetables” menus. This keeps the solutions and decisions in the hands of the individual which results in more sustainable behaviour change. Think about it: how did it go the last time you kept doing something you didn’t want to do?”

In short, before advocating costly drugs, insulin, bulimia tubes and bariatric surgery, perhaps a little change in lifestyle and diet might go a long way in making a huge difference to the management of diabetes.

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