Monday, June 22, 2015

Communist Medicine In A Capitalist World

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

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

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 Now enough with all the historical references and let me start explaining what evidence based medicine really is all about.

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

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

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

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

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

Sunday, June 7, 2015

That Ugly Truth

That Ugly Truth

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

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

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

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

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