Category Archives: medicolegal

DOCTORS IN THE DOCK

A recent incident in an Indian hospital: A baby is declared dead, stillborn, and after several hours, discovered to be alive. The doctor in charge was the one who saw the baby in the early hours of the morning, and saw signs of life. The nurse in charge had declared the baby dead the night before. Incidentally, no resident had seen the baby. The doctor in charge was apparently unavailable on phone till the morning. The media had a field day, roasting the hospital and the doctor alive for the ghastly event. The hospital has stood behind the doctor.

In another episode, a doctor gave the wrong cancer drug into the spinal canal of a patient, resulting in paralysis and a possible death. The doctor was told by the nurse that she was giving him the correct drug.

In the second case, the doctor was hauled over the coals, while the hospital concerned tried to shift the onus entirely on the doctor, as if all it did was provide the four walls and roof for the doctors and patients.

Obviously, in both the cases there is likely a strong element of human error or negligence on the part of the physicians concerned. However, it is a disturbing sight to see a hospital put the doctor in the dock and try to absolve itself entirely. This is one of the many instances where corporate hospitals and doctors find themselves in conflict. Recently, a corporate honcho berated a famous doctor blogger (one you may possibly know) for writing allegedly adverse comments about it, even hinting at legal action.

What do you think?

A NEW FREEDOM FOR THE FUTURE

There is a bomb girl who frequents the same gym I go to. She looks like a movie star, and works ferociously at the various sculpting machines there. She keeps looking back at an imaginary fold of fat at the waist, and keeps whining to the trainer, “I am putting on weight!”
This beauty is spending money, time and effort to beat a non-existent disease: obesity. She is also, potentially, damaging her joints and heart when she pounds the treadmills and pumps the weights. Shouldn’t someone stop her before its too late?
There is another girl I know who wants to trim her inner labia. She seeks a cosmetic gynecologist who does vaginoplasties. And another one who wants a surgery to make her a virgin again, before she gets married a few weeks later. These girls are looking to seek potentially dangerous and complication-prone operations that treat no disease. They are merely expressing some inner wish to change their structure, though there may be nothing fundamentally wrong with them.
I had previously highlighted how the American College of Gynecologists (ACOG) is hotly after the man who has made vaginoplasty a commercial money-spinner. This merely illustrates the fact that there are people in the world, including medical experts, who want to stop procedures that alter one’s physical state. Sex change surgery is another example. There are countries where this is illegal.
The future is fraught with potentially more complex and controversial issues like using genetic engineering and cloning to create a new type of human being that may be peculiarly enhanced. For example, a mother may be able to select a baby who is genetically engineered to see in the dark. Or one who will be free of certain deadly diseases. If you have not read my article on ‘Disruptive Medicine’, this is your lucky day. Check it out.
A Swedish organisation called Eudoxa talks of this morphological freedom, defining it as “an extended right to your own life, including your body.”
Why would a man or woman want to alter his structure for overtly trivial reasons?

We express ourselves through what we are becoming.
Self-development is an intense motivational factor for most humans, and by its
nature this is a very personal and challenging achievement.

Look at tattooing. The way many conservative people see it, it is a kinky and perverse thing to do. It is, however, considered quite cool and contemporary by much of modern society.
It is a personal morphological alteration without specific reasons beyond an individual’s personal choice and freedom of expression.

But wouldn’t genetic modification of children alter society and endanger it? Should we not stop this before it is too late?

Recognizing the right to choose among the many options made available through
morphologic freedom also supports the right not to choose them; the positive and
negative rights are two sides of the same coin.
Purely negative goals like the EU Commission’s directive on children’s right to be
born with unmodified genes will often end up in conflict with positive goals such as
providing children with the best possible medical attention. This right is also
mentioned by the Commission, but is undermined by the negative goal.
One of the many ways this positive goal can be attained is through surgery in the
womb for certain congenital defects. This type of operation changes the body and
the potential person much more than any genetic modification we can bring about.

In other words, apart from the issues of personal freedom and choice, these same disruptive technologies that could change future generations could also save countless lives and improve the lifestyle of the suffering. For example, see the use of intelligent prostheses for amputees that work better than normal limbs.
For more details, check out this link and download a pdf of the statement of Eudoxa.

Whatever be one’s views on this, this issue is a sure one for the future. You haven’t heard anything yet!

SENT HENCE TO DEATH BY DOCTORS!

In this post, I present a fascinating discussion by some experts on the issues surrounding physicians being involved in judicial execution. This is a topic on which I have been thinking of posting for a while, but I will not offer my views on this now. Just read the transcripts of the interview, which I have taken from the New England Journal of Medicine. If you don’t have the ten minutes needed to read this, I suggest you come back when you do.
A video of the same may be seen here.

THE PROTOCOL

Dr. David Waisel: The three-drug protocol is based on what was considered a normal induction of anesthesia when it was developed. [The first drug is] thiopental, also known as sodium thiopental or pentothal, which is a barbiturate, which is designed to put you to sleep, create amnesia and anesthesia. Second comes pancuronium bromide, which is designed to paralyze the muscles. And the third drug, which is not a drug used in anesthesia, is potassium chloride, which is designed to rapidly stop the heart. The doses used are massive compared to the doses that would be used in a normal anesthetic induction.

Dr. Atul Gawande: You raised, Dr. Truog, [the question of] whether these are the right drugs.

Dr. Robert Truog: We’ve taken a pretty strong stand that paralytic agents have no role in end-of-life care. The concern is that they can mask the behavioral signs that we look to, as to whether or not a patient is comfortable. And we are deeply committed to making sure that patients are comfortable and as free of pain and suffering as possible during the dying process. And since we have medications that do relieve pain, that do sedate perfectly adequately, there’s no need to be introducing paralytic agents into end-of-life care. . . . It’s completely inappropriate to treat those signs and symptoms with a paralytic agent. I think that’s just as true in the execution chamber as in the hospital.

Professor Deborah Denno: According to the state, pancuronium bromide is used in order to enhance the dignity of the inmate who’s dying, because without pancuronium, there might be some jerking or involuntary movements that would disturb some of the witnesses. That I find problematic, and Justice Stevens certainly did.

Dr. Truog: From the point of view of the inmate, the argument seems bizarre. Imagine saying to the inmate, “You have a choice. You can either be assured of a pain-free death, and you may have some twitching and grimacing, or we can expose you to the risk of an excruciating death, but we’ll make sure that you don’t twitch or grimace.” I can’t imagine that an inmate would actually consider that to be a real choice.

ALTERNATIVE APPROACHES

Dr. Truog: The number one alternative that’s been proposed has been a very large dose of a barbiturate. A number of experts have said that 2 or 3 or 5 g of pentothal is absolutely going to be lethal. The fact is that, at least in this country, none of us have any experience with this. And if you look at a country where they do have some experience with it, their findings are pretty concerning.

If we go to Holland, where euthanasia is legal, and look at a study from 2000 of 535 cases of euthanasia, in 69% of those cases, they used a paralytic agent. Now, what do they know that we haven’t figured out yet? I think what they know is that it’s actually very difficult to kill someone with just a big dose of a barbiturate. And, in fact, they report that in 6% of those cases, there were problems with completion. And in I think five of those, the person actually woke up, came back out of coma.

LETHAL INJECTION AND THE EIGHTH AMENDMENT

Dr. Gawande: Professor Denno, [you’ve written that] in turning to this three-drug protocol back in 1977, “The law turned to medicine to rescue the death penalty.” What did you mean by that?

Professor Denno: Lethal injection came about in 1977, a year after the United States Supreme Court decided that there would no longer be a moratorium on the death penalty. And there had been acknowledged problems with electrocution and lethal gas, because of the visual side effects of those methods.

By virtue of coming up with a method of execution that makes an inmate look serene, comfortable, and sleeping during the death process, the death penalty in this country was rescued. The presence of doctors, their involvement, and the association with medicalizing the procedure enhanced its Constitutional acceptability.

Dr. Gawande: What does it mean to be not cruel and not unusual punishment [in compliance with the Eighth Amendment]?

Professor Denno: The Eighth Amendment has never said, nor have the petitioners ever argued, that executions are to be pain-free. The question is whether or not that pain is unnecessary, whether there are alternatives.

Dr. Gawande: Chief Justice Roberts asked, “Do you agree that, if the protocol is properly followed, that there is no risk of pain?”

Dr. Waisel: Define “properly followed.” In other words, the protocols list that this should happen and that should happen. But does that mean if everything happens correctly, if there are no problems with insertion of intravenous catheters, if there’s no problem with mixing up the medications, there’s no problem with delivery of the medications? Then, yes, it would be pain-free.

RISK OF ERRORS

Dr. Truog: I think the issue here is that people go to school for a long time and do years of training in order to be able to do this well. And certainly, everything that I’ve read is that the training for the people that are doing it in lethal injection is nowhere near adequate.

Dr. Gawande: In Kentucky, they have responded to the request by physicians not to have physicians involved. And so it’s staffed entirely by phlebotomists and emergency medical technicians. So how likely is it that errors will occur? By one measure, there have been 40 botched executions out of a little over 900, which suggests a 4-to-5% rate of failure.

Dr. Waisel: We have no idea what the error rate is, because there is no oversight, there is no public reporting. And the information [I] hear worries me. For example, I believe the case was from Missouri, in which they pushed the three drugs, and the inmate didn’t go to sleep. And [they] realized the strap holding the arm was functioning as a tourniquet. So they loosened it up, all the drugs came in at once. Now in that case, I’m highly confident that the inmate experienced a great deal of pain from the potassium chloride. And so I think that your 4-to-5% number is dramatically underestimated.

Dr. Truog: Putting an IV in is not as easy as it may sound. And being certain that it continues to remain in the same place also requires quite a bit of experience, because these catheters can become dislodged, they can go into the tissue, and then they won’t work anymore. Furthermore, we know that many of these inmates, by virtue of their history of drug abuse or obesity or being muscular, can be very difficult to start IVs in.

In a hospital setting, we have a lot of different ways of approaching the situation when we can’t get an IV in. Most commonly, we’ll just put in a central venous line. But that requires a great deal of training. The mixing, the administration of the medications [are] routine in any operating room in this country, but far from routine if you haven’t done it before.

One of the mistakes that I know has occurred happened to me early in my training, when I injected the paralytic agent too quickly after the pentothal, and they precipitated in the tubing. The tubing turned into a piece of concrete. Suddenly, I had no IV. And thank goodness, I was surrounded by very experienced anesthesiologists who stepped in, within moments had another IV. But I know that that has happened in executions, and it could be a disaster.

Dr. Gawande: The petitioners [noted that for] the 3 g of thiopental, no one makes 3 g syringes, so you have to constitute it from small vials of 0.5 g of powder. And several times, whether it’s doctors or non-doctors involved, they’ve simply mixed it up wrong and ended up with much lower doses than they thought.

In Kentucky, the risk of IV infiltration is exacerbated, because they use several feet of tubing, and everybody leaves the room and sits behind a screen where you can’t see the IV sites or monitor how well things are flowing in. And finally, they didn’t have a plan to monitor the depth of anesthesia when you don’t have anybody standing there. And to the extent that there is someone there, they’re not used to being able to assess this.

PHYSICIAN INVOLVEMENT

Dr. Gawande: Now we come to this fundamental question of whether physicians should take charge, to make death less painful. Dr. Truog, what’s your take on [Dr. Waisel’s] question: if you were to be executed, wouldn’t you rather have a capable, specialized physician doing this job?

Dr. Truog: If I think of the kind of a hypothetical where you have an inmate who is about to be executed and knows that this execution may involve excruciating suffering, that inmate requests the involvement of a physician, because he knows that the physician can prevent that suffering from occurring, and if there is a physician who is willing to do that, and we know from surveys that many are, I honestly can’t think of any principle of medical ethics that would say that that is an unethical thing for the physician to do.

Professor Denno: If we’re going to be executing people, I would prefer to have a method of execution where medical expertise would not be necessary. If we’re going to, however, have a method that would be cruel and constitute suffering if we didn’t have doctor involvement, then if there are physicians in the country who are willing to be involved, I would like to think that they would not be chastised or lose their license or be punished by the medical profession for volunteering to take part in an execution, to relieve suffering.

Dr. Truog: There’s been a lot written about whether physicians should participate in torture. And of course physicians shouldn’t participate in torture. But fundamentally, it’s because torture is wrong. And this is [similar] to my views about physician involvement in capital punishment. While I think at one level we can justify it, I think it’s to miss the bigger picture. I really believe that capital punishment is ethically wrong.

Living in the bubble of the United States, it’s easy to lose sight of just how much of an outlier our country is. We stand among a small group of countries that still do capital punishment, [and] I really don’t think we want to be in their company.

REMEDIES

Dr. Gawande: When we come to this question of where can the remedy be found, the directions that seem to be posed are: We involve physicians more and let them treat the prisoner as a patient, or we come up with alternative protocols that don’t involve physicians at all.

Professor Denno: My recommendation has been that there be a panel of experts who would propose a viable method of execution.

Dr. Gawande: It makes me deeply concerned, though, imagining us sitting around a table at a conference, trying to figure out various ways of executing people, and then the prospect of what that becomes, that we figure out that physicians have to be continually actively involved, and we create a specialty of the execution physician.

It may not be possible for the court to say that doctors would be allowed to really treat inmates as patients — control protocol, make judgments about how to make the suffering less or more — and leave them free to have that professional role.

Professor Denno: They’ve been doing that for 30 years. There have been physicians involved in lethal injection since the very first execution in 1982 in this country. Because of secrecy, we’ll never know the full involvement of doctors. But we have many examples of doctors having been involved, who have made these kinds of discretionary judgments about drugs or chemicals and what should be done.

Dr. Gawande: If the court says “We need this to go to an expert panel, with physicians, lawyers, public citizens, to determine a new protocol for execution,” would you participate on that panel? And should other physicians participate on that panel?

Dr. Waisel: It should be wholly permissible for physicians to participate if they wish. I would have to think about it very carefully. A large part would depend on the intellectual freedom involved in the panel, the ability to write a dissenting opinion from what the panel comes up with, and moving away from certain constraints that are put around this that seem not to permit what I would consider to be successful ways of nonphysician involvement.

Dr. Truog: I would not participate on that panel, because I don’t think that capital punishment is ethical. I think other physicians should be free to participate on that panel. And while I wouldn’t want to prejudge how they might come out, I can’t imagine that they are going to be able to develop an evidence base for any other approach that is likely to be successful without the immediate presence of a physician. And then I think we have to grapple with the ethics of that.

GETTING TO THE HEART OF ENHANCED CLAIMS

The recent controversy about the ENHANCE study is an important illustration of a serious and long-standing problem with the medical profession, and its allied siblings.

What is the ENHANCE study all about? Surely not a penis-enlargement issue, my readers may be forgiven for wondering even fleetingly. Well, it is a study on two treatment modalities for patients with high lipid (cholesterol, for example) levels. But, first, the basics.

You may have high lipid levels because of genetic reasons, or because you eat, drink, or smoke too much. Many of us are obese, too. Traditionally, if you have high cholesterol, apart from the usually discarded ‘lose weight-do exercise’ kind of advice to the patient, your doctor would give you drugs. These lipid-lowering drugs are called, broadly, statins. One of the most common ones today is Lipitor (atorvastatin).

Why is it important to lower cholesterol? Because high cholesterol can lead to fatty plaques being deposited in the coronary arteries (atherosclerosis), leading to a heart attack.

Statins are prescribed to millions of patients around the world, including those with heart disease, hypertension and diabetes (conditions commonly associated with high lipid levels). All statins act by blocking a liver enzyme that normally results in the formation of cholesterol.

The problems with statins are mostly with their cost and side effects. In addition, in a number of patients, they don’t work well enough. Increasing the dose may increase the side effects. So, what can your doctor do in this kind of scenario?

Enter Ezetimibe. This drug reduces the absorption of cholesterol from the intestines, which bear the brunt of all the cholesterol-rich good things in life that the mouth (along with the mind it carries) chases relentlessly.

With me so far?

So, you have statins that reduce cholesterol, and you have ezetimibe, that also does the same in a different way. Why not combine the two? Will surely work better, and reduce the fatty deposits in your coronary arteries, logically. Merck did that in collaboration with Schering-Plough, with Zetia (ezemitibe) and Vytorin (a $5 billion product).
A 30-day course of Vytorin costs around $100, while Zetia costs $93, compared to $32 for a course of generic simvastatin.

That is what the ENHANCE trial was supposed to prove. Unfortunately, it did not show any such benefit.

However, some experts are discounting the trial, saying it is not a fair representation of the truth, that it is botched, and that they would wait for further trials before changing their prescriptions away from Zetia. Around 60% of doctors, however, are likely to stop prescribing the drug. Obviously, it would be a catastrophe for the company, reeling as it still is from the Vioxx losses. Merck stocks have slid down after this trial has come to light.

The important issue that has come up again in this debate is captured in two quotes:

The main problem is that after six years on the market, there are no data for ezetimibe demonstrating any health outcome benefit. In the absence of any demonstrable effect beyond LDL lowering, nearly one million prescriptions per week are written for ezetimibe. Is this rational?

If the ENHANCE trial had shown regression of atherosclerosis or slowed progression, both the company and advocates of ezetimibe would be trumpeting the results as a landmark study. Now that the trial has failed, they describe ENHANCE as a small and unimportant imaging study. You can’t have it both ways!

THAT, ladies and gentlemen, captures a huge truth. Much of what we do as doctors stems from trials that prove one or the other. Products become available commercially, too, and we are tempted or habituated to use them, especially if treated well at cruises and exotic junkets. However, as clinicians, we would still want to do better for the patient, and refine our treatment methods as evidence improves. Therefore, it is vital that we know which data is proven, and which is putative, suggestive or alleged.

That, however, is a tall order!

(Sources: Heartwire and Medscape)

BLOODY LAWS!

The Indian Government has now slapped a punishment of imprisonment for professional blood donors. Anyone who sells his blood for money will be sentenced to three months imprisonment. What is more, the license of the blood bank will be forfeited. Full story here.
The rationale is that professional blood donors often are the worst sources of blood. They donate repeatedly, within days of the previous one, with their own body running short of the life-source. They do this simply because they need the money for sustenance. Many a time, they need the extra cash for drugs or alcohol. Blood from these people is liable to be tainted with HIV or hepatitis viruses.
So, all in all, this looks like one good move by the Indian Government, doesn’t it?
Not really, no. I think this is another idiotic act.
Professional blood donors may contribute as much as up to 30-40% (figures of uncertain veracity) of donated blood. India is chronically short of blood. People die because of lack of blood, following blood loss in accidents, shootouts, and surgeries. Is attacking the existence of these people going to do Indians any good when they need blood?
Around 6% of HIV and hepatitis cases are said to be due to transfusion of tainted blood. Is donation by professional donors the problem? Or is the failure of the Blood Banks in detecting these infected samples the problem? It is clearly the latter. The failure of the State in enforcing its own laws and the judgments of the Supreme Court have led to this mess. As it is, the country suffers from a major shortage of blood products. How has the decade-old ban on professional blood donors helped the problem? Have transfusion-related complications come down?
The problem with tainted blood is underlined by several other major deficiencies of Indian society. One is the abysmal standards of education, resulting in a huge lack of trained technicians to man the Blood Banks. Another is the poor state of the legal defence system, because of which unscrupulous private blood banks are left scot free even after failing in their duty to provide for safe transfusion.
A trade is a voluntary activity between individuals. One’s body and its components are one’s own property. If one cannot dispose of them or treat them as per one’s conscious choice, then who has the right to do so? The Courts? Whom are the courts protecting, and why? From the looks of it, this ban on organ trade seems to be a case of the Law deciding to protect the citizen from his own self!
Not surprisingly, countries the world over are squeamish in acknowledging the property rights of the individual to his organs. Take the recently publicised case of donor eggs in the ‘surrogate motherhood’ issue. It is illegal in the US and UK to sell your egg, though you are free to donate it.
Here is a Wikipedia entry on organ trade:

In compensated donation, donors get money or other compensation in exchange for their organs.
In the United States, The National Organ Transplant Act of 1984 made organ sales illegal; regulation by the OPTN has probably eliminated organ sales. In the United Kingdom, the Human Tissue Act 1961 made organ sales illegal.
Recent development of web sites and personal advertisements for organs among listed candidates has raised the possibility of selling organs once again, as well as sparking significant ethical debates over directed donation, “good-Samaritan” donation, and the current U.S. organ allocation policy.
Two books, Kidney for Sale By Owner by Mark Cherry (Georgetown University Press, 2005); and Stakes and Kidneys: Why markets in human body parts are morally imperative by James Stacey Taylor: (Ashgate Press, 2005); advocate using markets to increase the supply of organs available for transplantation.
In 2006, Iran became the only country to allow individuals to sell their kidneys, and the market price is US$2,000 to US$4,000. The Economist and the Ayn Rand Institute approve, and advocated a legal market elsewhere. They argued that if 0.06% of Americans between 19 and 65 were to sell one kidney, the national waiting list would disappear (which, the Economist wrote, happened in Iran). The Economist argued that donating kidneys is no more risky than surrogate motherhood, which can be done legally for pay in most countries.
Two European conferences in 2007 recommended against the sale of organs. In Pakistan, 40 percent to 50 percent of the residents of some villages have only one kidney because they have sold the other for a transplant into a wealthy person, probably from another country, said Dr. Farhat Moazam of Pakistan, at a World Health Organization conference. Pakistani donors are offered $2,500 for a kidney but receive only about half of that because middlemen take so much. In Chennai, southern India, poor fishermen and their families sold kidneys after their livelihoods were destroyed by the Indian Ocean tsunami two years ago. about 100 people, mostly women, sold their kidneys for 40,000-60,000 rupees ($900-$1,350). Thilakavathy Agatheesh, 30, who sold a kidney in May 2005 for 40,000 rupees said, “I used to earn some money selling fish but now the post-surgery stomach cramps prevent me from going to work.” Most kidney sellers say that selling their kidney was a mistake.

Clearly, vultures exploit the miseries of the poor people who are cheated in this transaction. That, in itself, does not mean the trade is unethical. The cheating of the donor is what is unethical. However, these examples are often the reasons public sentiment is stirred up to implement bans of the kind in question.
David Holcberg argues in The Economist article:

If the law recognises our right to give away an organ, it should also recognise our right to sell an organ (as long as there is no coercion involved). Those who could afford to buy organs would benefit at no one’s expense but their own. Those unable to pay would still be able to rely on charity, as they do today. If the government upheld these rights, many of the thousands of people now waiting for organs would be spared hideous suffering and an early death. How many? There is only one way to find out: set these people free.

Blood donation for pay is one example of trade in body parts. The larger ethical issues seem to be all solved, and the world seems to have embraced the philosophy of control of the individual’s rights to his own decisions. Therein lies a deep malady!

Lateral reading:
1. Nita’s article on autotransfusion.
2. Mine on Immaculate Conception.

IN BAD TEST, DON’T MIND!

Loud Disclaimers:
1. This post was not written by me.
2. It is entirely hypothetical. Therefore, it is likely to be truer than the real news you read in the papers.
3. The blog owner, unlike his moniker, is not really a doctor.
4. If he is, he is one mean son-of-a-bitch (a Rambodog), who will likely be condemned by the honorable medical profession for besmirching its fair name.

Read at your own risk.

So you are unwell, and your doctor has ordered some tests? No? Maybe you need to take an executive health checkup or a pre-employment checkup: a clearance that will take your career to the next level?

Whether or not you hate hospitals, doctors and needles (for few are able to hate the nurses), you are going to be subjected to some tests one of these days.

This post is not meant to be a detailed exposition on medical labs. I will merely reveal some of the lesser known aspects of tests.

* Comprehensive health checkup, something that has been popularised by many leading hospitals, is a big rip-off. Not only do the hospitals make money doing so, but the down side is that diseases are revealed, when they probably would not have needed treatment at that time, if ever. In other words, not all abnormalities need to be detected or treated.

Let me give you an example:

Ajanta was a 26 year-old executive who was asked to undergo a health checkup at one of these modern Indian hospitals. An x-ray of the chest revealed a spot like a coin in one of the lungs. The doctor asked her to go for more tests to diagnose it.

“Is this cancer?” she asked, trembling.

“I can’t say, but it could be in some cases”, replied her doctor.

A CT scan of the chest was done, and the lesion was biopsied with a needle. Unfortunately, the needle went into a blood vessel, as well as into some airsacs, and Ajanta started getting faint and breathless as the blood and air kept leaking into her chest cavity and compressing her lungs.

Rushed to the emergency room, a tube drain was placed surgically into her chest to evacuate the blood and air. As she recovered from this mishap, more bad news came in. The biopsy was inconclusive. Another one would have to be done.

Alarmed, Aparna Ajanta left town for the best center in the country. Another scan-guided needle biopsy was done. The biopsy was again inconclusive.

Now she was heading towards surgery to remove and biopsy the coin lesion. The job was done cleanly by an experienced thoracic surgeon, and Ajanta recovered. The biopsy result?
Hamartoma, it said.
“What’s that?” she asked. Her doc replied that it was really not much except some abnormal tissue that was not a cancer.

If she had not known of this, she would possibly not have ever needed surgery for it.

Aparna was a Victim Of Medical Imaging Technology. VOMIT, in short.

VOMIT syndrome is now a well known complication of fruitless testing that throw up diagnoses that would often have been better left alone and unknown. This is one major reason why ‘let me find out if everything is okay in my body. Doc, I want all the tests, including the scans” is NOT a great idea. Treatment of many conditions is undertaken only because tests (like the chest x-ray in Aparna’s case) are done without indication, and doctors feel obliged to treat the newly diagnosed ‘disease’. Indeed, why do the tests if we are not going to treat what is found?

Other aspects of medical testing include:

* Poor standardisation of labs results in wrong reports that are sometimes dangerous.

Most labs are run with poor equipment. The tests are often done by unqualified technicians, and the pathologist or biochemist comes in only to sign the report. These doctors are rarely paid well enough for them to give much time at a lab. They, therefore, rush out of the lab after signing reports. Another center, same story. End of the day, some money has been made, but a bunch of useless or misleading reports are sent out.

* Labs, usually the ones not doing particularly well, give a hefty cut to the referring doctor, usually a medical specialist (internist). Of course, any one, from a general physician to a neurosurgeon, may avail of these ‘interpretation charges’ (‘IP’ in marketing jargon). Unfortunately, they might refer the patient to the highest bidding lab rather than the best one. Many doctors have their own lab, which could be another glorious example of the above prototype.

* In many Indian cities, of which Mumbai is a particularly obnoxious example, labs cheat patients, as exemplified by the Cheaterjee Labs. Look at this:

The marketing exec of the Cheaterjee Labs is telling the GP:

“Sir, we will cater to all your patients, rich or poor.
Please follow our system for the best results:
If you don’t really need the test, write out the tests in blue ink; we will just type a report and not waste our resources doing the test. In this case, we will give you 50% of the costs.
If you need us to give you a favorable report (for example, a higher blood sugar report, or a positive test for syphilis), please write in red ink. We will give you 40% of the costs of the tests.
If, however, you actually need us to give you accurate results, write in black. Your IP charges will be 30%.
Sir, here is a compliment from Mr. Cheaterjee, our Director. Please accept this set of three pens!”

Our GP is one smart cookie. He mainly treats the migrant laborers of Kurla, a Mumbai suburb. The Biharis and Bangladeshis are his patients. Illiterate, these poor, unsuspecting idiots think there is only one answer to their ailments: injections and glucose infusions.
For any problem, the GP admits them in his local hole-in-the-wall nursing home, and gives them the expected ‘treatment’. If the ‘customer’ is possessed of a little more cash, then tests are done. Now, the three-ink plan comes in handy. If the doc wants to squeeze some dough out of the patient, he can get a positive report for, say, syphilis, and then keep giving regular injections of penicillin, making a buck every week. A few such patients, and he has his sight on his next mutual funds investment.

* Most Government labs are horribly run. Exceptions are some of the good teaching hospitals in major cities.

* Most of the top private hospitals have decent facilities, but reports may vary. In case of cancers, it is the skill of the pathologist that makes the difference between right and a grievous wrong.

* Almost all healthy young patients below 40 years who need a routine surgery need NO pre-operative tests (useless, expensive, and wasteful). This international recommendation is zealously ignored by 99% of doctors.

There, I said it. Will I be a leper in the community of doctors now? Oh, I forgot, I am only a virtual one!

THE HIV-POSITIVE SURGEON AND YOU

It was a hot summer morning of 1992 when a bright young surgery resident stood up to address the Department of Surgery. The venue was a Government Medical College auditorium in Bombay, and the young resident was going to talk on a new subject: ‘AIDS and the Surgeon’. Listening with curiosity (for AIDS was only just beginning to register in Indian minds) were students, postgraduates and teachers of the Department of Surgery.

The resident talked of the HIV virus and the disease, and turned the topic to something far more interesting. “Given that the risk of getting AIDS through a contaminated needle prick during surgery is very low, how much lower are the chances of an HIV positive surgeon transmitting the disease to his patient? Should an HIV positive surgeon be allowed to operate on patients?, he asked.
That resident was me. Those questions were unanswered then. Today, prompted by Ergo’s post, I will try to answer them.

Look at the issue from a rights perspective. A patient deserves to be informed about his or her risks to be incurred during or after a surgery. For example, if you undergo a bypass surgery, you should know before you sign the papers that there is a risk of a lung infection or bleeding or dying from something else. Would you not like to know if the surgeon you are getting operated on by is HIV positive or not? Not unlike your wanting to know the HIV status of the guy (or girl) you are going to marry.

Looking from the perspective of the surgeon or dentist, any disclosure of a positive HIV status would spell the end of his career, and a major chance of starving to death. Because surgeons are generally not good for anything besides their own craft. Now, how reasonable is it to expect a man to condemn his existence by being honest and truthful to his patients, saying “I would like to operate on your prostate tomorrow, but I would like you to know that I am HIV positive. Don’t worry, I will take care….hey, where are you going? Please come back, lissen, will ya?”
Surprisingly, this has happened in real life. Professor George Browning, an ENT surgeon, was allowed to operate on his patients at a hospital in Glasgow back in the 1990s. His patients were considerate and understanding, and signed consent forms where his HIV positive status was clearly mentioned. He was the first known HIV positive surgeon to be allowed to operate. But would others be as well treated as he was?

The risk of the virus going from the surgeon’s body into the patient’s is said to be very, very small. However, the case of American orthopedic surgeon Dr. Scoles comes to mind. He was thrown out by his hospital because, as an HIV positive surgeon, even though the risk of his transmitting the virus to patients was very low, he was still a “significant risk”. Allegedly, there was a significant chance of his blood coming in contact with the patient’s.
Scoles lost his career, though he won a court case against the corporation owning the concerned hospital.
It is interesting to note that while he was discriminated against on the grounds of the principle that “the only acceptable answer is: no risk”, the hospital concerned had a significantly high death rate when cancer patients were admitted into their intensive care units. So did the hospital inform its patients before admitting them that they were twice as likely to die of pneumonia than in some other center? You bet not!
Scoles’ defendants asked: “With this in mind, who faces the greater risk: [..the hospital’s] cancer patients, or those seeking orthopedic surgery from an HIV-positive surgeon with an unblemished record?”

As a patient, you expect your surgeon to possess certain skills and standards. However, as a human being, is he a risk-taking type? Does he do drugs? Does he get drunk sometimes? Does he abuse people when agitated?

Would every patient be entitled to such personal information about their surgeon, because in specific cases it may be life-saving? Where does a surgeon’s right to privacy end and the patient’s right to know begin?

I have known of ‘great’, macho surgeons being absolute drunkards outside and inside hospitals. They have operated while being piss-drunk, or sniffed anesthetic gases before and after surgery, and no one really knows how many they have killed.
Therefore, these questions do have a valid, rational basis, though they may have sounded far-fetched at the outset.

My opinion is that an HIV positive surgeon, while maintaining his own confidentiality, should shift to mainly consultation, or do minimally invasive procedures, where there is minimal risk of his coming in direct contact with his patient’s blood. He should also keep a back-up surgeon in case something goes wrong and an invasive, open procedure is needed.

In recent years, the issue of HIV positive surgeons is being tackled in a pragmatic way. Various UK Government Health bodies have opined that “…it is no longer necessary to notify every patient who has undergone an exposure prone procedure by an infected HCW because of the low risk of transmission and the anxiety caused to patients and the wider public.”

I started off by talking about a young surgeon, back in 1992, giving a talk on ‘AIDS and the Surgeon’. He ended his talk by advising the audience to wear double gloves to protect themselves against accidental inoculation with HIV-tainted blood. His Professor then took the mike for expert remarks. The Professor said, “…He has given us new issues to deal with. However, one thing I must tell you: as a surgeon, you must do everything you can to prevent getting AIDS from patients. And the best way to do that is….USE A CONDOM!”

*General disclaimer: this blog and its owner have been certified as HIV negative*
*For a fascinating account of the Scoles case, read this article.*