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How should we think of medicine as a profession? On the one hand, it's a career path like
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any other. You learn a skill and people pay you for your expertise. But on the other hand,
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it's also thought of as a noble calling. You help other people. You sometimes give them
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the gift of life and sometimes you give them a better life. In India, doctors are mostly
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invisible to us except when we have no option but to notice them. And they can be both villains
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and heroes to us. On one hand, we rail against doctors who overprescribe tests and medicine
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because that's the way their incentives go and patients be damned. We are objects to
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them. On the other hand, we go to them with our deepest problems including our greatest
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anxiety – the fear of death. And I'm not being hyperbolic when I say that over the
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last year, doctors and nurses and other medical personnel have been our greatest heroes. Lacks
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of these frontline workers in India have gone beyond their call of duty, functioning in
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a battleground with limited information, driven not just by money but by empathy and the desperate
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desire to help. They have risked their lives to save the lives of others. When I think
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of those who let us down in this crisis and the politicians are on top of that list, I
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begin to lose faith in humanity. But then, I look at the medical profession and I regain
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that faith. You see, we will beat this pandemic and it won't just be a triumph of science
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and medicine when we do. It will also be a triumph of human beings expressing their humanity.
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Welcome to The Scene and the Unseen, our weekly podcast on economics, politics and behavioral
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science. Please welcome your host, Amit Verma.
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Welcome to The Scene and the Unseen. My guest today is Lancelot Pinto, a doctor and a scholar
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who has come to public attention in the last few months for being a voice of reason in
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this fog of confusion. Lancelot has been clearing doubts and misconceptions since this pandemic
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began and has been especially eloquent in recent weeks on the dangers of over-prescribing
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drugs to COVID patients. Many of the deaths in recent weeks have come because of a dysfunctional
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state and were otherwise avoidable. But some have happened because of over-medication of
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doctors going overboard with medicine that has adverse side effects. Lanc called this
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out early and I wouldn't be surprised if he saved lives not just in his work as a doctor
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but also in his interventions as a public intellectual. Friends of mine have actually
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been patients of his in this time and praise him highly. I was delighted when he agreed
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to be a guest on the show. I wanted to explore a much wider canvas in just COVID though.
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I wanted to explore the practice of medicine. Why do doctors opt for this profession? What
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does a doctor's life really like away from the glamour of Robin Cook novels and ER and
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scrubs? What are the incentives that drive doctors, both as doctors and as human beings?
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How do they stay in touch with the cutting edge of medicine which may be so different
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from what they learnt in their college textbooks? Beyond these general questions, I also wanted
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to talk about some of Lancelot's areas of specialisation. He runs smoking cessation
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clinics and talks about how medicine has now made it easy to quit smoking. He talks about
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the importance of sleep and the unintuitive ways in which our body functions. Did you
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know that a throat muscle can cause erectile dysfunction? This is the seen and the unseen
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right there. So we cover a lot of ground in this episode and only the last half an hour
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or so is actually about COVID-19. I loved this conversation. I learnt a lot from it.
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But before we get to it, let's take a quick commercial break.
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Do you want to read more? I've put in a lot of work in recent years in building a reading
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habit. This means that I read more books, but I also read more long-form articles and
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essays. There's a world of knowledge available through the internet. But the problem we all
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face is, how do we navigate this knowledge? How do we know what to read? How do we put
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the right incentives in place? Well, I discovered one way. A couple of friends of mine run this
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awesome company called CTQ Compounds at CTQCompounds.com, which aims to help people up-level themselves
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by reading more. A few months ago, I signed up for one of their programs called The Daily
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Reader. Every day for six months, they sent me a long-form article to read. The subjects
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covered went from machine learning to mythology to mental models and marmalade. This helped
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me build a habit of reading. At the end of every day, I understood the world a little
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better than I did before. So if you want to build your reading habit, head on over to
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CTQCompounds and check out their Daily Reader. New batches start every month. They also have
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a great program called Future Stack, which helps you stay up to date with ideas, skills,
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start every Saturday. Also, check out their Social Capital Compound, which helps you master
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social media. What's more, you get a discount of a whopping Rs. 2500, 2500 if you use the
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discount code Unseen. So head on over to CTQCompounds at CTQCompounds.com and use the code Unseen.
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Control yourself. Lance, welcome to the scene and the Unseen.
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Thank you. Thank you for having me. I've been seeing a lot of you over the last few months
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and thankfully on television, on YouTube, talking about COVID and enlightening many
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of us on what's happening with COVID medicine and all that. But even though we have mutual
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friends, besides that, I have realized that I know nothing about you. So I am going to
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start with a little bit of an exploration behind this public face that we see. So take
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me back to your childhood. Where did you grow up? What was it like before your journey in
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medicine began? To begin with, Amit, I don't think you've
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missed anything much in terms of my journey, but I grew up in Mumbai. I was born in Mumbai,
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grew up here, born in Bombay, grew up in Mumbai. That's how I like to say it. I was born in
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this suburb of Mumbai called Bhandup. It's a small little suburb on the central line.
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So if you're familiar with Bombay, the suburbs are looked down upon very often, but that's
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where I began. I went to a school called St. Xavier's School and my dad worked in administration
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at Crompton Greaves and pretty much held one job all his life. So that was who he was.
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My mother was a school teacher at the school that I studied in. She was a primary school
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teacher and both of them were migrants from Mangalore. So they moved after they got married.
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My dad was here for a couple of years before that. And I remember my dad telling me stories
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about how he came to the city with nothing, which is so true for a lot of migrants to
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Mumbai. He stayed with his brother who was already here for some time. And that was my
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childhood. So I grew up in a family where both my parents worked. I think there was
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a strong ethos on working hard. I remember my dad leaving home at seven in the morning
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because he worked in South Bombay, which is the other end of town, and would return by
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7.30 or so in the evening. I think education was always very important. There was a stress
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on education. However, I never felt pressure. There was never any pressure to perform or
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there was never any, you will grow up and become a doctor or engineer or anything of
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that sort. Fortunately for me, and I really don't know, I mean, there may be a lot of
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subtle things that help in life, which you don't realize. Fortunately for me, I think
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I liked studying. I was happy going to school. In fact, at the end of vacations, I was looking
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forward to school beginning again. And I was naturally drawn towards reading and studying
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and fortunately did well. Somewhere along, you know, when you reach middle school to
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high school is when you start thinking about what you want to become. And I think I always
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wanted to become a pilot for some time. Again, I guess it's a common thing for a lot of people
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to want to do adventurous things like that. But I think at some point of time, somewhere
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close to maybe my seventh grade or so, this whole thing about taking up medicine became
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real. Maybe it was influenced by the fact that my dad had a bypass when I was in the
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sixth standard. There was some interaction with the healthcare system. Maybe I looked
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up to some of those doctors in awe. And there was a lot of reading of Robin Cook as well,
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which I don't know whether that's a good thing or a bad thing, because that's a very skewed
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presentation of medicine. But it still looks glamorous. It looks interesting. And I think
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I was naturally drawn towards medicine at that point of time. So somewhere around the
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seventh or eighth standard, it was medicine and nothing else for me.
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Of course, you know, growing up in a middle class household in Mumbai, you do not think
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of too many different options as a career. You think of medicine, you think of engineering,
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you think of a few other things. And in hindsight, maybe, you know, my alternative life would
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also include the possibility of journalism, the possibility of being an author, the possibility
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of exploring the humanities in some way, because I think that's a big lacuna in medical education
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that we aren't exposed to humanities. So 10th standard, you know, big year, important
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year, you have to do well. I did reasonably okay. I went to a college called RUYA, which
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is, so that's, that's another recurring theme in my life. I always got into the second best
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college, I think, second best of mostly everything. And we'll talk about that. So, you know, the
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number one college in Mumbai was considered Rupa Rail for the sciences. I didn't make
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the cut. So I went to RUYA. Then 12th standard is another, you know, you realize that it's
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from a pool of 10,000 odd people, about 100 seats are what's available in the public institutions
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where you want to be in terms of an MBBS education. And again, you know, the King Edward Memorial
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Hospital or KEM is considered number one in Mumbai. I didn't, so my percentage was 95.
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And I think KEM stopped at 95 point something. So I got into Cyan Hospital. And Cyan Hospital
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was a very interesting experience in terms of, you know, there was a decent balance of
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extracurricular activities, as well as studies where, you know, it wasn't the typical nerds
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where everybody constantly had their heads buried in books. We had this festival called
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Ashwamedh, which was quite important every year. So we got some exposure to, you know,
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debating to doing a lot of public speaking, etc. And those were good years. That's pretty
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much the early years, if you ask me.
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So you know, what kind of strikes me was that growing up as an 80s kid, I remember back
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in the day, the traditional occupations that good middle class kids were supposed to go,
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as you said, was you do doctor and engineering. And a little later on, MBA also became kind
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of fashionable. And this, of course, is if you didn't sit for the civil services. Now,
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I would imagine that by the 90s, post liberalization, all of this is kind of changing. But nevertheless,
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I think in the second half of the 90s, you decide to go in for an MBBS anyway, and you
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pointed out that you had a natural interest in this. So a couple of things strike me.
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One is that it takes an awfully long time to become a doctor. You do your engineering
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course and you're an engineer. But with a doctor, it's just the years keep stretching
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on. It almost seems like, you know, you're in your 30s before you can actually do anything.
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And even then, there is a survivorship bias where you hear of good doctors making a lot
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of money. But it's not necessary that at the end of that journey, you will be successful.
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So when you made that final call, I mean, obviously, you must have taken this into account.
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So what was the thinking that went behind it? And when you started, did you find that
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the study of medicine was turning out to be different from what you expected? Or you knew
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going in what it was going to be? I mean, as you pointed out, there's a Robin Cook
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influence and all of that. So tell me a bit about your decision making during this time,
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what you expected? What did you enjoy about it?
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So it's a very interesting question you asked there because so one of my closest friends
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in school was a guy who went on to do engineering. And I would spend a lot of time at his house
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and it was a joint family. They had doctors in their house as well. And this constant
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theme that I was reminded of was, you know, you choose medicine, you're just going to
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be studying. You will never make money. You will be studying till you're 30, 35. You know,
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you'll lose your hair, which unfortunately is true right now. But you know, you'll still
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be studying. And then, you know, obviously anecdotes of doctors and their kids giving
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exams together, you know, come to the fore, you know, look at him, his second standard
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son, and he had both giving exams at the same time. So those kinds of stories were constantly,
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you were constantly reminded that, you know, you may not be making such a good choice.
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You know, one of the things that really is very crystal clear in my head was this conversation
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I had with this guy whose wife worked for one of the hospitals in Mumbai. And I don't
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remember whether she was a doctor or what was the context. But he said something like,
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listen, you know, you will become a doctor. Maybe, you know, maybe you'll get into medicine.
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But at the end of medicine, do you know how difficult it is to get a postgraduate seat?
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You know, you will struggle with the postgraduate seat. And everybody who doesn't get a postgraduate
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seat of their choice ends up doing PSM. So PSM is Preventive and Social Medicine. And
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this is when I'm in like 10 standard, I don't even know what he's talking about. Right.
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So he says you will do PSM and all you will be telling people to do is wash their hands.
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And the irony is that for the past year, all I've been telling people to do is wash their
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hands. It's somehow come back a full circle. But to answer your question, I guess there
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is a lot of naivety when you make a choice when you're exactly from the background that
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I am, you know, you are middle class. So you don't have a strong safety net in that sense
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where you can assume that you will study indefinitely and, you know, you will somehow be supported.
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And yet you make this leap of faith. And I think that that decision is a difficult decision.
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And I think some of that is totally naivety, you know, because you don't know really, you've
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seen only the glamorous part of things. You don't realize that for every doctor who's
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probably, you know, in your face looking glamorous, looking good, there are probably 10 doctors
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who are really struggling, who are finding it difficult because it's such a competitive
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field because, you know, everyone is pretty intelligent. So I think that final leap of
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faith is very often made against all advice. And it's made at a time when you really don't
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know what's on the other side. So it's truly a leap of faith in that sense, you know. So
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to answer your question, I think, you know, as fatalistic as it may sound, I've also believed
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that things which don't work out sometimes just don't work out for a reason. So had I
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not got the requisite marks to make it into medicine, maybe I would have just like taken
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it in my stride and done something else at that point of time. But even today, you know,
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so somebody going through the system, even today, where the applicant pool is so high,
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you have to compete so hard to get into the right kind of colleges to get a good education.
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I think there's no simple answer. You know, so if somebody asks me today, if somebody
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in my similar situation, who's in 10th or 11th asks me today whether this is the right
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choice for me, I will place the facts in front of the person, but I will not tell them that
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it's a no brainer, that, you know, this is the best life that you'll ever have because
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it is a tough life. And, you know, I think that that's kind of my answer to your question.
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Yeah, you know, that's very illuminating because just thinking aloud, you know, I had a young
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person come to me for advice a few months ago where his mother wanted him to do medicine
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and he was like, what's the scene? And I said, listen, in the end, of course, it is a personal
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decision, it's up to you. But just putting my economics hat on, I would say that the
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opportunity cost of medicine is far higher because if you decide engineering is not for
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you, you can do an MBA, you can go to a scroll or a wire or a Times of India and say, make
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me a trainee reporter or whatever. There are all those options are kind of there, but medicine,
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you could be 30 by the time you realize you're not going to make it and it could be too late.
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So if all things were equal, set it as parables, it would almost be a no brainer not to do
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medicine. But if that's where your heart lies, that's where your heart lies. Now, my other
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question here is that I've spoken to people who say that we got into medicine because
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of a passion for biology, because of the wonder of medicine. Like one of my friends told me
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that, you know, one of his parents died of cancer when he was young. And he said, I want
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to find a cure for cancer. Right. And therefore he gets into medicine. But having gotten a
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certain way along the academic path, he realized that wait a minute, doctors don't find the
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cure for anything. I need to be a scientist. And then he goes and he becomes a scientist.
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And now he's a successful academic somewhere. So, you know, did you go through that kind
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of process? Because a lot of the things that I guess would attract you, which would be
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intellectually attractive or stimulating about the study of medicine would actually be related
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to science and higher research rather than becoming a practicing doctor to begin with.
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And I'm aware that you have an MSc in epidemiology and all of that, which you went on to do,
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but you are a practicing doctor. So obviously, this has to be something that you then thought
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about. And what then made you decide that, no, I will practice, I will be a doctor, because
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it seems to me that just from the way that I look at it, it feels that in science, you're
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always moving forward, even if it's a little forward incrementally, but you're moving forward.
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While in medicine, it seems that you're running to stand still. You're always trying to kind
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of figure out what is the latest and kind of apply that. So how has that process of
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thinking these things through been for you? So I think when people begin, no matter what
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they begin in terms of their career, I think everybody has a very big canvas in mind. They
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always think that they're going to change the world in some way. So if you met someone,
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if you met me when I was in my 10th grade or in my 12th grade and said, what is evidence
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based medicine? Do you know how will you make decisions when it comes to patient care?
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I think there was no concept of anything like that at that point of time, in the sense,
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on my radar. So most of the decisions are made in terms of what kind of a person do
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you want to be. So I was always attracted to this concept of just working hard and giving
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it your best, no matter what, and let things take care of themselves. Don't be obsessed
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about how much money you're making. Don't be obsessed about what is the so-called return
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on investment, which is the whole argument against medicine, which everyone reminds you
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again and again that when are you going to make money?
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The worst is when you're around 24 years old, where all your friends, the last bencher in
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your school has also suddenly joined the merchant navy and he's making like 20 times the amount
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that you are. And everybody points out that you've clearly made the wrong decision.
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So I think this decision comes from a place of, I think, a larger principle that you enjoy
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at some level helping people. I don't necessarily mean in an altruistic way, or I don't mean
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it in a charitable way. I mean it in a way that somebody comes to you with some sort
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of a problem. You are able to give them some sort of an instant relief. You are able to
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give them solace in some way. And that turnaround time is rapid enough that you get the feedback.
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You feel good about it. You feel that you are making a difference on micro levels. And
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I think that's the model or that's the goal that people are attracted to at that stage
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when early on. Now, whether that will cause a big dent in the world, possibly not. But
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I think those little joys on a day-to-day basis where even though, as you rightly pointed
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out, you're running to stay in the same place when you look at the macro picture. But at
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the micro picture, you're making small moves every single day, which give you a lot of
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instant gratification, which a lot of other fields possibly don't get. This is my perspective,
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and I could be completely wrong. But say if you're a software engineer and you're designing
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software, maybe when the product is finally ready one year down the road, you get a lot
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of gratification and you get a lot of sense of achievement. But during that one year,
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it's probably every single day is tough because you're just writing code maybe. But for a
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doctor, I think there are a lot of small joys in every single day. And I think that's what
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drives a lot of us, especially in your early years, because you've seen, you've yourself
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gone to a doctor at some point of time. You've yourself realized that they give you some
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sort of a salve, some sort of a relief at that point, which makes you feel good. And
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I think that process is something which is very attractive.
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That's really interesting because, I mean, when you think about it, the world is a positive
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some place and we benefit when others benefit mostly, unless, you know, you're in the government
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or your end seeking or whatever. But for most of us, the benefit that comes from our work
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is unseen. It's like really the scene in the unseen, that it's way down the road. Like
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you said, if a software engineer designs some software, even when the software is out there,
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he can't really see the benefit. He doesn't know how much difference his few lines of
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code made. Maybe if he works in Microsoft, maybe that's what made Windows hang. But in
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your case, it's a little more immediate, which is fascinating to me. It also sort of strikes
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me that, you know, when we think of experts, when we think of the professionals, we think
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of them as people who know their field. But I think what often happens is in many fields,
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whether it is medicine or economics or whatever, in all fields, there's a set of people who
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are not really actively engaged in that sense. They are doing the degree, they get the knowledge
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and that is a knowledge they have. And very often it's kind of a static kind of knowledge
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and they don't have the intellectual curiosity to maybe apply their frame to other things
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and constantly broaden, constantly read all of that. And, you know, I noticed this most
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with some economists, you know, there are really two kinds of economists, those who are thinking
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actively about the world, and those who have done the training, who can make the charts
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and do the regressions and all that, but aren't really thinking that actively. Now with doctors
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also, it seems to me that we think of doctors as experts. We have a problem, we go to a
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doc, doc will solve it. But very often, you know, a doctor, say, trained in the 1990s,
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was trained in what was in many fields, very outdated knowledge, for example, nutrition,
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right, where for the longest time, for decades, you know, the sugar lobby funded all these
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studies at Harvard and all that in the 1950s and 60s. And, you know, fat was demonized,
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sugar was supposed to be okay, and the American government released guidelines to this effect
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in the late 1970s and their obesity epidemic begins from there. And then something like
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the last 10 to 15 years, it's kind of become common knowledge that all of this is kind
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of rubbish, we've been obsessing over the wrong things, sugar is the real problem. Now
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one of my friends went to a doctor recently to ask about nutrition, and he got that old
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dogma because she hadn't read up and updated herself on the state of the science. So a
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two part question really that when you were studying, did you notice this difference in
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approach that there are people who just want to understand what is in the books and do
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well in the exams. And there are people who are naturally curious, who are reading more,
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and therefore who are more likely in future to stay updated with whatever the state of
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I think part of that is the problem in which medical education occurs. And you know, it's
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very fact heavy. So let's look at medical textbooks, right? So I mean, most of us have this God
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textbook for every subject under the sun. So if you're studying anatomy, this is the God
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textbook. If you're studying physiology, this is the God textbook. Now, I've been part of
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a process of knowing how textbooks are written. And if you look at how textbooks are written,
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the time gap between when the decision to write the textbook begins to the textbook actually
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being published is usually around two to three years. So when it actually gets published,
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some of the stuff was current and relevant three years ago and is probably already been
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surpassed by newer knowledge or superseded by a newer study which has happened. So if
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you bank completely on textbooks, you're not going to get state of the art knowledge. However,
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medical education gives a lot of focus on textbooks. So that's one example where you
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are taught, keep sticking to the facts which are written in the textbook that's written
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in stone because it's this God textbook. It's this Bible of a particular subject. You are
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not taught the methodology to critique things. You are taught to remember the facts. You
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are not really trained in how to critique facts. So if that training comes into play,
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then you would have this healthy discussion which would constantly happen, which happens
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in academia, right? Where somebody says something and another person points out and says, but
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listen, there was this newer study which was published just two days ago. Have you gone
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through it? And that constant debate, that constant chatter among academics, which makes
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one realize that you need to constantly update yourself is very often lacking in medical
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schools. That is a big problem. So that you are not taught really to question. Now, whether
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that divides the world into two parts, I don't think it's that straightforward. I think most
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of us with a medical education come out again with these same concepts of truths being absolutely
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written in stone. It's when you start practicing, if you are curious enough, if you realize
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that every patient does not fit into a particular mold, if you start questioning why something's
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happening in a certain way when you expected it to happen the other way, if you then get
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into a process of constantly searching, constantly reviewing the literature, I think that makes
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a lot of difference. Now, part of that is also a function of time. So it is extremely
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difficult for doctors to continuously update themselves, which is why it would be nice
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if there were simpler guidelines, right? I mean, that's what we all want. We want some
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sort of a guideline that's constantly updated or some sort of a course which we can attend
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once a year where we get updated and change our practice. Now, expecting a practicing
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doctor to be able to continuously update themselves is a tough task. And the way it works, fortunately
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or unfortunately in medicine is that the older you get, the more senior you get, your patient
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base increases. And there's word of mouth, there's a general awareness of a particular
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doctor for a particular specialty being there. And that just means that you're getting busier
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and busier and therefore having lesser and lesser time to update yourself. And unfortunately,
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this then becomes a common trajectory for a lot of doctors. And, you know, even I hope
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this doesn't happen to me, but that's the natural drift, unfortunately, that you get
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busy, you get popular, you get more patients, less time to read, and gradually you start
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doing things which are outdated. And I think this needs to be rethought, you know, we need
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to figure out a way to get out of this.
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And how does one keep in touch with latest research then? Like, is the internet a game
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changer there? Because I would assume that pre the internet for a practicing doctor to
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want to keep in touch with the latest in the field, especially if you're in India and all
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the latest research and all that is happening in the US is incredibly difficult. But now
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it should be kind of easier. So what are your practices? Like, are they journals you go
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to? Do you spend a certain amount of time reading papers? Do you tell yourself that
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X percent of the time I must devote to updating myself or, you know, leveling up? How does
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that process kind of work for you?
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So I think one of the best ways of keeping yourself updated on the literature is having
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students right and I have the luxury of having students I'm at a teaching institute. So when
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you teach students, you automatically update yourself on the latest literature. If you
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inculcate that hunger in them, students have this natural questioning hunger which they
#
will, you know, they will pose questions to you on rounds sometimes saying that, you know,
#
is this the right way of doing things? And that again needs to be fostered. If you go
#
by the didactic method that it's my way or the highway, you know, this is right because
#
boss says so, you will you will end up having your knowledge not updated because, you know,
#
where you are at is where you will be. Your students will not question you and you will
#
keep perpetuating the same cycle. If you have students who constantly ask you or and you
#
can ask them as well, you know, why don't you read up on this and tell me more about
#
this? That exchange keeps you updated and it's very useful. But then again, I have the
#
luxury of being in a teaching institute. If you're not at a teaching institute, fortunately,
#
there are a lot of I don't know what they're called. They're probably like meta websites
#
which have started compiling literature from all the available evidence. And, you know,
#
the thing that comes to mind, which I use on a day to day basis, something called up
#
to date. So up to date is a website which also has an app on your phone now where they
#
get experts in a particular field to write a particular topic and that expert will cover
#
the topic through and through. The experts are also incentivized to update it every year
#
or so. I think, you know, they're actually paid. I know because some of my supervisors
#
have written topics here and they are incentivized to keep updating the topic. So supposing I
#
have this patient sitting in front of me who I think has this rare lung disorder and I've,
#
you know, the last time I've seen a patient with something like this was about three years
#
back. So clearly I'm not going to be by default updated on the literature because it's not
#
been on my radar. I haven't actively searched for this disease. So I go to up to date. I
#
open it and very often, you know, I will, I will come to know if there's a new drug
#
available, if there's a new therapy that has been tried somewhere. There are links sometimes
#
which will take me to earlier studies and then I can choose to go into a deep dive.
#
So up to date will summarize what the literature is, give me the references for those papers.
#
I can then go and dig out those papers myself, critique those papers, see if they make sense
#
and summarize. But this is not as easy as it sounds in the sense that you're trying
#
to do all of this in the middle of an OPD, in the middle of a clinic. So I have sometimes
#
told patients, let me read up. I open this in front of the patient and I do it, but I
#
can see how a lot of people would feel that doing that would make the patient question
#
their credentials. So I think we need to also create a healthy atmosphere where, you know,
#
the doctor doesn't know all the answers. The doctor will update his knowledge if necessary
#
in front of you. The doctor is someone who will give you the best knowledge as of today.
#
How he gets there could be a journey, could involve some time on your part. He doesn't
#
need to be an encyclopedia with all the answers ready. You know, as long as we start moving
#
to that modality where even patients accept that, you know, accept a doctor who's searching
#
in front of them, accept a doctor who says, I don't know. I think that's great. So when
#
I, when I talk to my friends and relatives, I tell them very often that the doctor you
#
want is the doctor who once in a while, you know, says, I don't know the answer to this
#
question, right? If you have a doctor who knows the answer to every question, then that's,
#
that's, you know, I mean, if it could be exceptionally good, of course, but you know, that would
#
be a rarity. You know, this leads me into a digression on what patients really expect
#
from their doctors. And I think in India, at least they expect a veneer of knowledge.
#
They expect their doctor to be like an expert to have the definitive answers to give them
#
medicines. Look, you know, as you have also pointed out in the past, this is what leads
#
to over prescription and all of that. I remember I read an episode on healthcare with the economist
#
Karthik Murali Tharan and he referred to this study in 2007 where, you know, the author
#
of the study asked a doctor in a slum so that, you know, when someone has diarrhea, what do
#
you give them? And the person listed out a bunch of medicines. And then the guy asked
#
that, you know, why don't you just give them oral rehydration? Because that's enough. That's
#
what WHO recommends. And he said, no, because then they won't come to me. They've come
#
to a doctor. They expect a bunch of medicines. That's what I do. If I don't do that, they'll
#
go to someone else. I lose income. And that's something, by the way, in India that it's
#
not just doctors. It's we expect all our experts to be full of certainty. While the truth is
#
that those who know the most will have the least certainty because they'll know how much
#
they don't know. Whereas, you know, it's a Dunning-Kruger effect that it's often the
#
fools who have the greatest certainty, not to say that doctors are necessarily like that.
#
So what do you feel about this? Do you feel that there is also this kind of interaction
#
where you not only have to find the best treatment, but you also have to live up to the patient's
#
expectations? So is it like a game theoretic problem somewhere where there are tradeoffs
#
you have to consider? Absolutely. I couldn't agree more. So you gave a context in which
#
you have a diagnosis. I often have to face a situation where I tell the patient, listen,
#
we need to do a few tests. You know, we'll do these tests. We'll meet up again with the
#
results of these tests. And then we'll talk about what needs to be done. And on their
#
way out, they very often will turn back and say, but what have you given me in treatment
#
today? And I need to tell them that I don't know what you have. You know, I genuinely
#
don't know what you have. How can I treat you if I don't know what you have? And they
#
still will very often insist that, you know, but just give me something for today. You
#
know, it's, it's almost like this whole interaction is incomplete till there is a prescription
#
prescribing drugs. You know, it's not just a prescription with, with tests. It has to
#
be a prescription prescribing drugs because I've come to you with a problem and you have
#
to give me a fix in some way. So I completely empathize, you know, so I'm, there is no judgment
#
on my part when I see doctors, you know, starting off people on a bunch of medications or doctors
#
being forced to order tests sometimes, because we've, we've created this sort of a culture
#
where, you know, a doctor who prescribes a lot and I get better is the right doctor.
#
The doctor who says take nothing, even if I get better, but he didn't give me anything.
#
So it's not, it's Vasool nai hua, as you say in Hindi, you know, there was, it, it didn't
#
complete the interaction. What did I pay him so much for? You know, why did I waste my
#
time going there? I didn't get anything out of it. So I think this is a, this is a genuine
#
problem and I think we need to start thinking in terms of how to let people know that medicines
#
are not a solution for every problem. And going on and on indefinitely with medicines
#
are also not a solution, you know, and there are, there are some problems which can be
#
fixed. There are some problems to which, you know, there are no solutions. Sometimes you
#
just have to have to accept that. I mean, we talk about all these fancy things and,
#
you know, cutting edge stuff and doing scans. Well, as you look at respiratory medicine,
#
something as simple as cough, you know, there are, there are people who are doing PhDs and
#
cough as of today, you know, after, after, you know, centuries and centuries of coughing,
#
we still don't know what really causes cough in certain, certain circumstances. We still
#
don't know where the receptors exactly might be. We still don't know what is the drug that
#
will actually work. I remember meeting this world expert in cough and he runs a cough
#
clinic and I said, you know, how do you, there was a particular example I gave him and I
#
said, how do you treat it? So he says, listen, my, my clinic's very busy. So I cannot, you
#
know, see people frequently so I can see them maybe once a month. So I take any four random
#
drugs which work on cough generally. I say if week one, you try this, if this doesn't
#
work week two, you try this. If that doesn't work week three, you try this. If that doesn't
#
work week four, you try this. And he says, for all you know, nature cures them at some
#
point of time. And then the patient attributes the cure to that last medication, you know.
#
So that's how it is. You know, people want some sort of a medicine as a solution for
#
every problem. And, and I think we need to do something to, to counter that.
#
No, in fact, you know, what you said reminded me of the common phenomenon of regression
#
to the mean, right? Like, why do, for example, people think homeopathy works? Part of it
#
is, of course, a placebo effect. But part of it is, if you take homeopathy for something
#
that's going to get better anyway, you will ascribe causation, you will say, oh, this
#
cured me. And this could also be true of any cocktail of medicines that the doctor gives
#
you for a particular point where you got better on your own, but hey, you feel this worked
#
and you know, you will give credit to the medicine and therefore to the doctor. And
#
this of course happens in politics also where, you know, Amit Shah recently came out and
#
said that, you know, Narendra Modi has solved the second wave. And I'm like, that's regression
#
to the mean, right? The second wave at some point in time would have gone down in the
#
most extreme case with everyone dying. But whatever happens, a wave would have gone down.
#
So the fact of it going down alone is not reason enough to take credit. But I don't
#
want to draw you into that kind of political stuff. What am I even doing? A couple of interesting
#
things, like one thing that sort of strikes me is that when it comes to the practice of
#
medicine itself, especially I'm assuming in a place like India, I think two things would
#
happen for a doctor and I'm just sort of thinking aloud and you can enlighten me on whether
#
these processes actually happen and all of that. One is because you're seeing a multiple
#
number of patients and you do not have unlimited time for each one. You develop these what
#
economists call fast and frugal heuristics by which you figure out that, okay, this is
#
the symptom and this is likely to be the most common cause for it. And therefore let me
#
try this and all of that. And how does that process work? Because initially as a young
#
person you must be enthusiastic. You want to get to the root of everything. Is there
#
a point in time when you realize that in practical terms it is not possible? And I'll let you
#
answer this first and then I'll go on to my next one.
#
So that's again the unfortunate part of medicine. The better you get, the more successful you
#
get, the larger the volume of patients you have, the larger the volume of patients you
#
have, the lesser time you spend with each one of them. And then, you know, exactly what
#
you said, you're pretty much triaging in your head. Is this person in dire need for some
#
emergent treatment or is this person not so bad? Where, you know, we can just quickly
#
give him something, send him off, you know, maybe nature takes care of it. Maybe he gets
#
better and he comes back. If it doesn't, then he comes back to me. And maybe that second
#
time round is where I really spend more time because now I realized that, you know, that
#
quick three minute consult wasn't good enough. I completely agree with you, you know, the
#
unfortunate part of becoming successful and being good at something, in medicine especially,
#
is that eventually it leads to large volumes. And I think one of the ways in which you can
#
solve this problem is by having a team. So if you have a good second rung, if you have
#
a good bunch of assistants working with you, kind of filter things out, you know, give
#
you a brief quick summary of what's happening and then you act on that summary. I think
#
that makes a big difference because otherwise, you know, exactly what you said, it becomes
#
like quick algorithms. Everything becomes algorithmic and whoever doesn't fit into that
#
algorithm is a problem. So let me give you an example, you know, since we're talking
#
about COVID-19. So one of the things that has been a common problem over the past year
#
is individuals who've come to me with breathlessness, who are actually sighing, you know, because
#
of anxiety, you take a deep breath and you breathe out and that, you know, there are
#
natural processes which lower your heart rate when you do that. There are natural processes
#
which calm you when you do that. So it's almost like an epidemic of sighing that I've seen
#
over the past year. And these individuals, if you go down that same algorithmic route,
#
somebody says they are breathless, you know, do a whole bunch of tests, you know, and then
#
find nothing wrong. Then you try some inhaler, you try something. I mean, you can completely
#
go down that route. But very often, if you just spend like 30 seconds looking at that
#
person and talking to that person, you will realize that during that conversation itself,
#
the person sighs a couple of times, and you realize that the person is in a hospital,
#
the person is anxious, and clearly that person is sighing. You ask them when they sleep at
#
night, do they sigh or get up breathless? And the answer to that is almost always no.
#
So clearly, you know, whatever the problem is, is not happening at night, which again
#
points towards a psychological problem, something that's making the person anxious. And again,
#
if you know, this is why it's important to spend time, this is why it's important to
#
observe patients and realize what's happening.
#
This is mind blowing and epidemic of sighing. Wow. Another question. My last episode was
#
with Kavita Krishna and in that we briefly spoke about Mary Wollstonecraft, the great
#
feminist author of the early 19th century or the late 18th century really. And one of
#
the tragedies there is that she died young because she died during childbirth. In fact,
#
she gave birth to Mary Shelley, who would later marry the poet. And she died three days
#
after childbirth, I think, because the doctor didn't wash his hands, right? Because that
#
basic protocol was not known at the time. That is something that happened in the middle
#
of the 19th century. Ignal Semmelweis said that, you know, correlated not washing hands
#
to disease and people ignored him for decades. And I think if I remember correctly, he died
#
in a lunatic asylum eventually, something really sad like that. And that eventually
#
got figured out. But that that was also the reason that around that time, things like
#
homeopathy and all that alternative medicines became common, because at least they weren't
#
harming people. I mean, of course, there is harm in terms of the opportunity costs. You
#
don't get some other treatment if you take sugar pills. But they weren't harming people.
#
Whereas if you went to a hospital, your chances of dying were insanely high because evidence
#
based medicine, as it were, was simply not at that stage of advancement. Now that, of
#
course, has changed. And today it is. But for most things, how important would you say
#
these processes still are internalizing them and with the washing of hands being the most
#
basic example. But if you think of do no harm, just kind of internalizing them and going
#
with that. I mean, there's a great quote I forget by whom some famous doctor you might
#
know. I just read this recently on Twitter. I think Anirban Mahapatra quoted this person
#
in his episode with me on COVID-19, where he said that at its core, every medicine is
#
a poison. So to what extent does the do no harm imperative of the physician go in both
#
in terms of processes or best practices like washing hands and all of that. And also just
#
being aware that, listen, I'm expected to give a cocktail of medicines to this person,
#
but all of them have side effects. All of them can do harm in different ways. Like we
#
are finding out and we'll discuss COVID-19 later, but if you give steroids too early
#
that depresses the immune system and chances are your fever will go down, but COVID will
#
hit you really hard after that happens, which has happened in so many cases. So how much
#
of a part is just being aware of what not to do as much as what to do?
#
I think it's extremely important to not trivialize any medicine. For some reason, we have this
#
concept of safe medicines and unsafe medicines and what you said was absolutely right. It's
#
the dose that determines what a poison is. I think there's a Latin quote which says that.
#
Things like vitamin D, for example, you can overdose on vitamin D when given as an injection
#
and we've seen patients get admitted with hypervitaminosis D, which is a real thing.
#
It causes confusion. It causes a lot of problems. So even things which are seemingly innocuous
#
may not necessarily be innocuous, may not be innocuous for a particular person. It may
#
be okay for 99. So that's another aspect. Number one, it may not be innocuous for anyone.
#
Number two, maybe what if there is a subset of people in whom it doesn't react well? And
#
we just prescribe it assuming that these words which are used, safe, vitamins, immunity boosters,
#
things that give a person a sense of something is being done and because by virtue of something
#
being done, I am going to be in a better place than I was prior to receiving this.
#
And yes, there is a placebo effect. People do feel better with a lot of different things
#
and that is a challenge for a doctor as well in terms of should I give something because
#
that something will act like a placebo and make this person feel better and therefore
#
my obligation to be a caregiver of some sort should not supersede my obligation to just
#
be absolutely right and proper about not unnecessarily prescribing things. So that's the balance
#
that you have to find. So if somebody comes to me and somebody comes to another doctor,
#
we're talking about a counterfactual where the other doctor gives the patient a vitamin,
#
the patient suddenly feels a boost of energy. He or she is happy. They go back feeling extremely
#
satisfied versus the patient coming to me. I say, you have nothing wrong with you. Please
#
go away in the nicest way possible, of course, but that person continues to suffer in some
#
way. Who's to say who's right in this circumstance, right? This is where the challenge lies. The
#
effect of placebos, should it really mean something to a doctor as well to give a placebo?
#
But based on the fact that we are scientists and based on the fact that we hold on to science
#
for everything that we do, I think we shouldn't be doing anything without a strong rational
#
reason or scientific basis that suggests that something is going to work. And I'm equally
#
passionate making this argument with tests. I mean, possibly even more than medicines.
#
For me, if I order a test, the outcome of the test must influence my treatment decisions
#
in some way. If you look at probability, probabilistically, there was a study done which shows that if
#
you did eight random tests without a pretest probability, so not Bayesian, you just randomly
#
just gave anybody eight tests, 20% of the population that you give those eight tests
#
to would have one abnormal value completely by random chance, right? Now, if you increase
#
that to 16 tests, I think it's about 16 or 20 tests, that probability goes up to about
#
99%. So one test will be abnormal completely by random chance. So if you've asked for a
#
test, you need to know that if the abnormal value comes back, are you going to do something
#
about it? And if the answer to that is I'm not going to do anything about it, you have
#
no business ordering that test to begin with. I think the same flavor holds true for medicines
#
as well. You do not want to give medicines just because you can't leave a prescription
#
blank or you don't know what needs to be done. You give a medicine only when you believe
#
that science has proven in some way that taking that medicine for that individual will improve
#
his or her odds of getting better as compared to doing nothing. I think that should be the
#
And earlier we spoke about doctors responding to incentives from patients in terms of over
#
prescribing and all that. But doctors are also prey to other kinds of incentives. And
#
I'm told this is more of a problem in the north than here, but I'd like your opinion
#
on it, which is that, look, you're working for a hospital in different places from what
#
I've heard. Doctors will get a commission for every test that they order. So they incentivize
#
to order tests. They get a revenue share in whatever their practice brings in within the
#
hospital. So they are incentivized towards asking the patient to do maximum tests, which
#
may be unnecessary with all kinds of overtreatment. And I know that just talking about these incentives
#
makes doctors seem like heartless mercenary beings. And I don't want to give that impression
#
at all, especially because what I think has become visible to all of us in the last few
#
months is that our frontline workers in the healthcare systems, our doctors, our nurses
#
and other medical personnel are our heroes. They are like the firefighters of 9-11. How
#
do you respond to these incentives then? Do these incentives exist? How does someone like
#
you then draw a line and say that, no, I'm not going to do this, which would immediately
#
hurt your income. How does one negotiate that? So I'm honestly fortunate to be in an ecosystem
#
which does not demand any of that to me. So that makes me very comfortable in terms of
#
what I'm doing. My hospital is an ethical hospital. There is no pressure of, I can admit
#
somebody not give them anything and discharge them after five days and there will be no
#
questions asked. That being said, I have heard very often of these incentives being in place,
#
but you know what I think, Amit, I don't think any doctor begins with a place that they would
#
want to do that. I think every doctor possibly starts with a place that, listen, I will do
#
what is indicated. I will do what's completely ethical. And if as part of doing something
#
ethical, I get some sort of a bonus or some sort of kickback, what's so wrong in that?
#
I think that's the starting point for people who indulge in that. The problem is it starts
#
off like that, but this is a line which is very difficult to walk on. I mean, like any
#
other incentive in life, at what point does the incentive drive the prescription versus
#
the incentive being incidental to the prescription is whether you challenge lies. And this is
#
true for anyone. So I mean, I've worked with somebody called Dick Menzies at McGill who
#
would refuse to take a pen from a pharmaceutical company. He would say that the moment I have
#
a pen from a pharmaceutical company, I will be obliged to do something nice in return
#
to this person. You know, I've received pens from pharmaceutical companies and I've never
#
thought of it because I believe genuinely that, you know, this is just a pen. This is
#
not going to influence my practice. But to be honest, who knows at a subconscious level,
#
if that particular pen writes really well, maybe, or that particular pen is something
#
that I'm very fond of, maybe at a subconscious level, I will be more inclined to support
#
that particular company which gave me that pen, you know. So I think these are inherent
#
to the practice. I think the extreme version of it would be to completely not accept anything.
#
But you know, I think majority of us get into a zone where we honestly believe that, you
#
know, a little bit here and a little bit there in terms of, you know, a gift for Diwali,
#
for example, is not going to make so much of a difference. But that's a very tough,
#
that's a very thin line, you know. And I think that's a challenge that most doctors face.
#
Is there a systemic issue here then? Is there a systemic issue that, look, if you want to
#
set up a hospital, you want to maximize your revenue because it's obviously expensive to
#
do so. And this is one way of doing that, that you incentivize the doctors and then
#
it just becomes a vicious cycle. And you've pointed out that your hospital, Hinduja Hospital,
#
doesn't do this. It's a quote unquote ethical hospital. So my question then is that is it
#
possible for new hospitals to come up that are ethical hospitals or are they putting
#
themselves at a competitive disadvantage with hospitals that are unethical hospitals as
#
it were? I'm sure they wouldn't describe themselves that way.
#
I can imagine that if healthcare is treated like the open market, I can imagine how not
#
indulging in such practices would hit your bottom line. I mean, that's that straightforward
#
math. So I can imagine the fact that it's relatively difficult to compete and match
#
up to maybe the incomes of other individuals in other hospitals if you don't play the game
#
by the rules that have been established. So I can see how that could be a problem. And
#
I think that problem arises when you start dealing with healthcare as you would deal
#
with anything else in the free market. And that's the reason, that's the whole conversation
#
around medical ethics, the whole conversation around why patients need to be protected,
#
etc., comes from this whole asymmetry of knowledge between doctors and the persons deriving the
#
services. You cannot treat it in the same way as you would treat any other open market,
#
which is why all over the world, there are safeguards in place to prevent things from
#
happening. I think that's the bottom line. There needs to be something in place to prevent
#
it from being a completely open market. There has to be some sort of regulation. For example,
#
the same pharmaceutical companies, if you take an example, are completely not allowed
#
to do a lot of the things in stricter countries that they are allowed to do in a country like
#
India. And why has that happened? Because of the same reason. The government has realized
#
at some point of time that if you let it open, if you let it work or function like a free
#
market, it's going to be demand supply. It's going to be the same kind of incentivize.
#
It's going to be not necessarily in the consumer's best interest. It's going to be in the best
#
interest of the players. And that's why it needs to be regularized.
#
I would imagine that the solution can also come from within the free market. For example,
#
if you had enough supply, if you had enough, if you had ease of entry and enough hospitals
#
and all that, then some of them would advertise that we are ethical hospitals in these ways
#
that no commissions are given to doctors on ordering tests or blah, blah, blah. And then
#
that would also, it would become a competitive advantage instead of something that you do
#
out of pure idealism. So that is also possible. But anyway, that's a whole different question.
#
Let's kind of get back. I mean, I have a bunch of other general questions I'll also come
#
to before we come to COVID. But I want to now go back earlier in your personal journey,
#
which we left when we took all these digressions, that, you know, you're doing medicine and
#
you're doing MBBS and all of that. What does a journey from that look like? Like, how do
#
you choose what to specialize in? You've specialized in respiratory diseases and so on. You've
#
also spoken a lot on tuberculosis. I also want to talk to you about sleep because, you
#
know, I watched a presentation of yours on that on YouTube and it was extremely enlightening
#
in many TIL moments. But before that, tell me a bit about your journey, that how do you
#
get interested in these things as opposed to other things? And then what prompts that
#
next sort of step where it's not just that you've become a doctor, but you're actually
#
going and doing an MSc in McGill University as you did. Tell me how you're evolving during
#
these years. In terms of the choice of specialization, I think very early on, for most of us, if
#
you speak to most doctors very early on, somewhere at the end of the first or the second year,
#
people kind of figure out whether they want to become surgeons or they want to become
#
physicians. So I think that's, and it's quite fascinating actually, you know, in terms of
#
personalities, in terms of, you know, what kind of individuals are drawn towards surgery,
#
what kinds of individuals are drawn towards medicine. I'm sure it'll make an interesting
#
study someday to do personality tests and figure out who's drawn to what. Even in terms
#
of subjects, in the first year, we have something called anatomy, physiology, and biochemistry.
#
And very often the guys who love physiology end up drifting towards being a physician.
#
The guys who are hardcore into anatomy end up drifting towards surgery. And that kind
#
of plays out further down the course as well. So I think very early on, physiology is something
#
that fascinated me and it still does, you know, just understanding mechanisms is mind-blowing
#
sometimes why something occurs. And I think if you really understand physiology, you really
#
understand a lot of medicine. You don't, you don't need, you know, superlative knowledge
#
in terms of medications and drugs, as long as you understand the basics of why what happens.
#
So I loved physiology. I had a distinction in physiology. It was one of my favorite subjects.
#
And I think that pretty much decided that I was going to be a physician. I also am a
#
lazy guy. So standing in one place for like six hours was not for me. So that got decided
#
Now, at the end of your MBBS, it's the same fight again, right? A whole big pool of really
#
smart people, all of them trying to get into coveted fields. I think a decent chunk of
#
us end up in fields that we get rather than the fields that we initially want. The good
#
thing about medicine though, is that if you really like questioning things, if you really
#
get excited about the body and, you know, small processes here and there, really no
#
matter what you decide to become and where you end up being, where you end up being can
#
be equally fascinating, equally interesting.
#
Because if you take a deep dive into any particular field, I think it can be fascinating. So in
#
my last year, I mean, I was, I fully knew that I was going to become a physician, but
#
I had this gynecology professor who was really, really passionate about teaching. And I was
#
completely in love with the subject in terms of, you know, I eventually got a distinction
#
in the subject. I would read, I would, you know, attend labor, you know, watch things
#
happen, be really passionate about gynecology fully knowing fully well that this is not
#
what I was going to become. And I think that's the passion that a good teacher instills in
#
you that teaches you things about a field that you may not even be interested in pursuing,
#
but you realize is fascinating. So again, to come back to the question, I initially
#
wanted to do internal medicine. That was a broader, you know, head to toe, get an idea
#
of physiology, how everything works in terms of the body systems. And then, you know, possibly
#
super specialized in something else eventually. But again, you know, I mean, as, as usual,
#
I didn't get into the first field of choice. I got into respiratory medicine purely by
#
chance. So I was doing a presentation. I was working at Induja. It was a job that I was
#
doing post-NBBS. I was doing a presentation and Dr. Udwarya, who was the, the chest physician
#
at Induja walked in and listened to the presentation. At the end of it, he came up to me and he
#
said, you know, that was a great presentation, et cetera. And I interviewed for medicine.
#
I didn't make it into medicine. And then the respiratory interviews were happening and
#
I interviewed and, and it just worked out. It just worked out because he remembered me
#
from this random presentation. So it was just, it was good fortune. That being said, you
#
know, I mean, respiratory medicine is very hardcore to physiology. It's very hardcore
#
to internal medicine. It's, it's very central to other body systems as well. So I completely
#
enjoyed my residency. So my residency was at Induja. And again, there is a general perception
#
of public institutes being much better than private institutes. And, you know, so again,
#
my first choice would have been a public institute had everything aligned the way it should have,
#
but it didn't. I got into a private institute, but I must say, I mean, the kind of education
#
that I got here for three years was, was really defining in a lot of different ways. You know,
#
we had Dr. Udwadia and Dr. Mahasur, both of them senior, both of them very good. Dr. Mahasur,
#
who was the head of department of KEM. So he came from a public institute. He had served
#
most of his life in a public institute and Dr. Udwadia, who was at the frontier of research.
#
He was somebody who was very passionate about research. We did this study in 2010. We basically
#
took 106 different practitioners who were practicing in a slum of Mumbai. This was Dharavi.
#
And we asked them to fill up a prescription for a person with a standard weight. So I
#
think we said the weight was 60 kilos. A person with 60 kilos came and sat in front of you
#
and he has tuberculosis, write up a prescription. That was our, that was kind of what we requested
#
them to do. And 106 practitioners, if I remember right, wrote 64 different prescriptions, out
#
of which six were what we considered to be accurate and right based on the current guidelines
#
then. So six of 106 were accurate. So that was an eye-opener as well, you know, and that
#
was when we realized it, it also opened my eyes in terms of tuberculosis and realizing
#
that about 70% of the population, 70 to 80% of the population approached the private healthcare
#
system first when they wanted treatment for tuberculosis. And most of our data, most of
#
our information, most of our guidelines, everything was directed towards the public healthcare
#
system. So it was this mismatch where everybody, you know, thinks about the private healthcare
#
system as being driven by incentives, not being kosher in a lot of different ways. And
#
yet number one, you know, it seemed like patients were preferring us. And number two, there
#
was this chaos in terms of prescriptions, in terms of the way medicine was practiced.
#
So that was a big eye-opener in terms of research, you know, that was, that was the first major
#
publication that, that I had. And, you know, it got me passionate about TB. The other side
#
of course was Dr. Mahashur who taught me some really great things in terms of how to take
#
care of patients. So Dr. Mahashur would insist, you know, we would go on rounds and, you know,
#
I would start saying 31 year old patient who's this, this, this, this, and you would suddenly
#
stop you and say, what's the name of the patient? And then all of a sudden you'd realize that
#
you were caught on the back foot. You didn't know the name of the patient because, you
#
know, everything was just details, right? You're taught to be detail oriented. And,
#
and he was very insistent that we knew every patient by name. We knew a little more about
#
them in terms of their background. We knew what their social circumstances were. And
#
I think that was fantastic. That, that was an eye-opener. I remember a situation where
#
we had this elderly lady who was admitted forever. You know, one of those patients was
#
not getting discharged and Dr. Mahashur would come on rounds and we would pretty much not
#
do anything. So, you know, as residents, you want to have as less work as possible or you
#
want to be streamlined. And we would constantly wonder, you know, why is this lady there?
#
We're not doing anything for her. And then one fine day he told us about the story about
#
how she had problems at home and how she wasn't accepted at home and how she didn't have a
#
caregiver at home. And the moment she went home, she would deteriorate. Things wouldn't
#
work out for her because there was nobody to take care of her. And he pretty much knew
#
everything about the family, you know, which we, despite the fact that we spent every single
#
day with her, hadn't bothered asking her about it all. So I think this balance was great.
#
You know, the balance of, of cutting edge, you know, trying to identify the big questions
#
in research, trying to really work on changing the world in some ways while at the same time
#
being completely grounded to the reality that at the end of the day, you know, we are caregivers
#
at the end of the day. You can be all evidence-based medicine if you want, but if you don't provide
#
comfort to patients in some way, you're not necessarily a good doctor. So I think that
#
made a big difference in terms of my training as far as respiratory medicine goes.
#
Yeah. So, you know, in my episode with Karthik on healthcare, we'd kind of discussed a bunch
#
of studies and what they all showed is pretty much what you're pointing out about only six
#
doctors out of a hundred and whatever kind of getting it right. And that was true in
#
his studies for both public and private. In fact, public fared a bit worse. But my question
#
before we move on is why did the guys who got it wrong, get it wrong?
#
That's a difficult question, honestly. So I think part of that is the fact that people
#
just don't bother updating themselves sometimes. So maybe they weren't up to speed in terms
#
of what the data was telling them, what the guidelines were telling them. Maybe nobody
#
reached them in a way because they were practicing in a place where, you know, the dissemination
#
of knowledge wasn't a priority. It was also a disease like tuberculosis where drugs don't
#
tend to be very expensive. So, you know, pharmaceutical representatives are not coming after you,
#
telling you what you should prescribe and why you should prescribe it because it's not
#
worth their time or effort. And I think a part of it is maybe a lot of them just had
#
standard prescriptions. You know, a lot of TB prescriptions are supposed to be tailored
#
to a person's weight. And, you know, maybe they're just being used to prescribing a
#
certain thing and, you know, just having a standard copy paste prescription for everybody
#
that it just made their lives easier with the volumes of people they were dealing with.
#
Maybe that was one of the reasons why that happened.
#
What also strikes me out of what your wonderful answer a while back was that the study of
#
medicine can take you in two opposite directions. That on the one hand, it can make a person
#
in front of you less human because you're just noting down the details. This is age,
#
this is a weight, blah, blah, blah. And that's something you need to watch out for. And as
#
you said, you were fortunate to have a doctor who, you know, made you cognizant and mindful
#
of these things. But on the other hand, it can also make them more human in the sense
#
that we look at ourselves and the people all around us as if everybody's immortal. You
#
know, we don't consider our own mortality and we even take others for granted for that
#
reason. But I am guessing that once you start studying medicine and it becomes explicit
#
to you that this is a body and this is how the body functions and eventually it kind
#
of breaks down. Does that then change the way that you look at others that that veneer
#
of immortality goes down? And, you know, you might, for example, go to a wedding and your
#
aunt will complain about how your uncle is snoring so much at an earlier date. That is
#
just an endearing detail. But suddenly you are now asking your uncle about his throat
#
muscles, his uvula, does he sleep on his side or not? You know, any thoughts on these two
#
like very different aspects? You've already commented on the first one where you have
#
to be mindful and treat them as actual people. But the other one, does it does it kind of
#
change the way that you look at others and yourself and your own body that there are
#
things that you would otherwise take for granted and you see others take for granted, but you
#
don't anymore because you know enough of the body to know that this is stuff I need to
#
kind of focus on. So that's the unfortunate part at a certain level, because you look
#
at everything probabilistically, right? You start analyzing everything around you in terms
#
of probabilities. So if you know that your loved one has a particular disease, you're
#
already calculating probabilities of hospitalization, probabilities of bad outcomes, probabilities
#
of what might happen. So you're also a party pooper, right? At the end of the day, like
#
you rightly pointed out, you point out things to people who were blissfully unaware of some
#
things and we're living a happy life. And now suddenly you've added to the problems
#
on their plate. And that's a fine balance sometimes, because I run a smoking cessation
#
clinic, for example. Now, you know, a lot of people who smoke clearly know that it's
#
not good for them. So, you know, catching hold of someone and pointing out the obvious
#
to them is not necessarily in their best interests. But you end up nudging people in the right
#
direction. Yes, you know, because you're more sensitized to the fact that, you know, what
#
you, what you are seeing cannot be unseen. So if you're seeing an individual who clearly,
#
like you said, has a neck, which is bulky, fits into a certain profile, you know, you're
#
almost tempted to ask, okay, do you snore? You know, you go down an inquisitive pathway.
#
But I think that has to be done with a lot of sensitivity as well. You know, that's the
#
other thing about life, right? There is a, what we call the natural history of disease.
#
So not everybody with a particular condition is necessarily going to deteriorate. Not everybody
#
is going to follow a particular trajectory. So when you're actually eyeballing somebody
#
and screening them, you're in effect doing a screening test. And your screening tests
#
are solid only if you know the natural history and you know that intervening is going to
#
make a difference. So when I tend to do that, I need to be reasonably certain that I'm giving
#
advice that is going to possibly alter the trajectory of an individual's life. Otherwise,
#
it's a little tricky to get into those situations. Right. One of the things that you kind of
#
also then have to do is confront the limits of medicine. Like the instinct obviously is
#
I want to help the patient has come. The patient also wants medicine. The patient expects treatment.
#
But sometimes you run into these natural limits where there's not much you can do. The patient
#
behavior has to change. You have only so much control over that. Like when I go to my GP,
#
an endearing gentleman named Dr. Kothari in Lokhandwala, who has I think 400 Ganesha idols
#
in his office, a lovely gentleman. And the one thing he will, no matter what I go to
#
him with, he will tell me that, Amit, stop eating outside food or Amit, you must get
#
enough sleep. Both of which are true. But there's a limit to how much control you have
#
over somebody's behavior, which is one of the limits of medicine. And the other limit
#
of medicine is that there are areas in which we simply haven't advanced enough. Like if
#
a particular disease is advanced probabilistically, I mean, you can't be cold and brutal and tell
#
them that these are the probabilities, at best, five years, at worst, six months. That
#
becomes difficult. And sometimes there are diseases where, maybe like GERD, for example,
#
where you can't cure the thing. It's just, it is what it is. So how does one deal with
#
them? Because a patient expectation always is of the doctor as a kind of a God who's
#
got a solution for everything, who better have a solution for everything.
#
I think empathy plays a very important role in that situation where it's a shared journey.
#
It's a shared experience. It's not didactic. It's not one way. It's nudging people in the
#
right direction. And as you rightly pointed out, a lot of them have already connected
#
the dots when it comes to lifestyle choices and lifestyle changes. I think it's useful
#
to just nudge people in the right direction and offer them help wherever possible. Smoking
#
cessation, for example, you know, there are medications which help, you know, and a lot
#
of people aren't aware of these medications. So we tend to, you know, treat them as you
#
would treat any other disease. There's no judgment involved. There's no point of wagging
#
a finger at the person and saying this is wrong. You accept the person for who they
#
are. You try to help them to whatever extent. And then you also, you know, for diseases,
#
as you rightly pointed out, you may not have a cure. So you be transparent in that process.
#
I think it's important not to tell, you know, there is a school of medicine which constantly
#
reassures patients. I very often don't reassure patients in the sense that I say, listen,
#
this is what we are going to try. It may or may not work. If it doesn't work, you know,
#
we will try something else. I have very often offered patients to go and seek a second opinion.
#
I say, listen, you know, maybe you should see another doctor, you know, maybe there
#
are people who've dealt with this in a different way and have met with success. I don't claim
#
to have all the answers. I think that's the kind of transparency that's really important.
#
The other end of the spectrum and, you know, which gets me again, really disturbed is end
#
of life care. Very often, I think it's the, the onus is on the doctor to kind of help
#
the patient and tell them that, listen, this is not a situation in which you need to prolong
#
care. You, you know, you feel obliged to prolong care forever. And that's one thing that really
#
riles me, gets me very disturbed when I see people, you know, in there who clearly are
#
not doing well, who clearly are on multiple drugs, multiple supports. And, you know, the
#
family says, just keep going on, keep going on. I think there's a huge responsibility
#
on the physician to navigate that situation and help individuals realize this is not what
#
you would want for yourself. So please don't subject somebody you love to what you're currently
#
doing. And this, this is a common theme. I ask individuals, you know, who have their
#
loved ones on ventilators and multiple supports, clearly not doing well. You know, I, I very
#
often ask them, I said, would you want this for yourself 30 years from now or so, if you,
#
you were in this situation? And very often the answer is a very absolute, emphatic no.
#
Then I asked them, would you, would, would your loved one, you know, had you had this
#
conversation with them 10 years ago and said, listen, 10 years from now, you will be in
#
this situation. You will be on multiple supports. Would you want everything to be done at that
#
point? Or would you want us to let you go at that point? And they will say, you know,
#
oh, I know my dad, he would definitely not want to be in this situation. And yet we perpetuate
#
this, you know, as you rightly said, you know, this is the same analogy of a disease that
#
has no cure. There are certain situations where there is no hope, you know, or the,
#
or the hope is such that the person will never live a meaningful life again. And I think
#
that's where a physician, the onus is really on us to help individuals make the right choice.
#
Yeah, there's a, there's a great book by Atul Gawande called Being Mortal, which is just
#
about this. And it also strikes me that, you know, one thing that people might not think
#
about so much, but I'm sure you have, and I'm sure doctors do, is that the responsibility
#
is not just to prolong life, but sometimes also to enhance quality of life. And sometimes
#
there is a trade off. And what you must have faced is the difficult situation where you
#
actually have to tell a patient that, listen, stop the treatment. What is that situation
#
like? And also in all your years of practice, are there moments which were difficult for
#
you that were really hard? That made you wonder that why am I putting myself through this?
#
Like I understand the gratification of helping so many people in small, small ways, but there
#
are also these painful moments where you can't help them anymore. So how does one kind of
#
deal with that? Tell me a bit about it.
#
So this to me is one of the most painful situations. And, and unfortunately it's getting more and
#
more frequent having to deal with it, you know, where individuals have reached a point
#
where they clearly are not going to recover, where they are on multiple supports, where
#
life is just being prolonged, but not, there's no quality to that life at all. And yet modern
#
medicine gives us this whole illusion of keeping a person alive, right? The word alive itself
#
is very debatable in this context. I find this extremely difficult to do. You know,
#
I was reading an article recently, the title of the article was how doctors die. And it
#
was a very interesting article, which talks about how when doctors themselves get diagnosed
#
with certain conditions, they choose to just go to a house somewhere in the wilderness,
#
live quietly, spend the last six months, you know, with their family, have quality time
#
and just pass away quietly when they themselves have to deal with situations like that. And
#
yet, you know, we offer a lot more to patients than we should. Now, part of that is, is of
#
course, you know, that there is litigation that everybody is also afraid of, that how
#
could you not do anything in a situation like this? Which is why I think it's very important
#
to have advanced directives, you know, legal advanced directives in place if you've thought
#
about it. And if, if you don't want to be subjected to something when you reach a point,
#
but in the absence of an advanced directive, you know, most doctors will end up doing everything
#
that the patient's family tells them to do. And I find this extremely difficult. So I've
#
dealt with situations where there were individuals who were leading lives where they were almost
#
non-communicative for five and six years, you know, post after a stroke, but the loved
#
ones would want to keep on going on, get them admitted frequently. So there's zero communication.
#
There is no evidence of what we would normally perceive as being a living human being. And
#
yet we would keep prolonging the situation just because, you know, the family has resources,
#
the family has money, the family is ready to pay, you know, so who are you to question
#
this decision? And one of the solutions offered in this article written by this doctor was
#
that if you're uncomfortable with the situation, you need to transfer care to another physician.
#
I've never, I've never thought of doing that, but you know, after reading this article,
#
it really made me wonder whether I should start doing that because it goes against every
#
belief that I believe in. It goes against my training. You know, I trained to become
#
a doctor, not just to save lives, but to add some meaning to those lives, to add some quality
#
to those lives. And as you rightly said, you know, Atul Gawande's book talks about how
#
I think about 50% of your lifetime cost on medicine or medical care happens in the last
#
one month of your life. So it's that stark that just because we have the ability to put
#
people on ventilators to start infusions and bring their blood pressure up, to start dialysis
#
and you know, get their kidneys functioning, just because we have this ability, we've started
#
doing things which are, which are possibly not always in the patient's best interest.
#
Yeah. And also, you know, within the culture, we might romanticize things like, you know,
#
in Dylan Thomas's famous words, to rage, rage against the dying of the light. Whereas
#
I would certainly in that situation just like to have the grace to just go quietly and save
#
everybody and myself the trouble, which, you know, brings me to euthanasia. Like what do
#
you feel about euthanasia? Like some countries have kind of moved towards legalizing it.
#
And for those who don't know euthanasia is where at the end of your life, you choose
#
to just kind of go when you have a fatal disease or such like. And the two issues that the
#
two sort of related questions that come up is that in a country like India, you know,
#
where there is so much jugar and the rule of law doesn't really hold, if you were to legalize
#
it, you know, it could become a pretext for people to just, you know, murder their older
#
relatives and, you know, get the paperwork done to show that it's euthanasia. But at
#
the same time, if one agrees that euthanasia is a dignified way to end life and that we
#
should all have the right to end our lives, then what do we make of suicide in a general
#
sense that, you know, even if you're not ill, you know, suicide of course is criminalized
#
here, therefore becoming the one crime for which you get punished when you fail at it
#
and is often correlated with the mental health issues. And there, of course, you know, it
#
is something to worry about. But at the same time, a completely cold, rational person might
#
say that I'm not ill, but I just don't want to go on and I have autonomy over my body.
#
So, you know, are these are these kind of questions that you've thought about?
#
So I have, there's actually a very interesting documentary by The Economist. So, you know,
#
The Economist does these small documentaries about this Belgian girl who was 24 and chose
#
to get euthanized. It's extremely disturbing, of course, to watch it as well. But, you know,
#
medically, the dilemmas are, of course, whether it's active or it's passive. So active euthanasia
#
is where a doctor plays a role in actually ending a person's life. And that goes against
#
the oath that goes against the Hippocrates oath, where we are not supposed to actively
#
help anyone die. That's not what our skill sets are designed to do. Then there's passive
#
euthanasia, where you set it up for the patient, but the patient presses the button, the patient
#
pulls the trigger, the patient figures out or the person, let's not use the word patient,
#
figures out when the time is right and they want to go down that road. Now, the problem
#
is that I absolutely agree with the autonomy part of things. And I think it's fair. I think
#
it's better to go down that road when it's done as an advanced directive and something
#
is decided not when the time comes, which may cloud your ability to make a calm, rational
#
decision, but it's done in advance. So I think advanced directives are very nice in terms
#
of saying, listen, if I reach a point where you have to do cardiopulmonary resuscitation
#
on me, I don't want that being done. So the no-code principle, right? People have bracelets
#
which say that I don't want a code. I think that's relatively straightforward in terms
#
of ethical frameworks. I think what's more challenging is what you just described, that
#
you're not overtly suffering and yet you've decided that enough is enough and you want
#
to go at your prime rather than go down a pathway where you suffer. I have thought of
#
that. And I don't think there's an easy answer to that, unfortunately, because religion comes
#
into play, personal beliefs come into play, the slippery slope, where do you draw the
#
line? Where is the line at which you say it's okay to do it? And what is our role as a society
#
in terms of protecting the individual from making a step that is so detrimental to them?
#
Do we have some sort of an obligation to protect that individual in terms of counseling, in
#
terms of going through a process? And to the best of my knowledge, the countries that do
#
allow euthanasia also have certain measures in place where you need to go through a certain
#
level of counseling. You need to go through psychiatric evaluation. Everyone needs to
#
be convinced that it's a rational decision. There is a situation which is irretrievable
#
in some way, and only then you're allowed to go ahead with the decision.
#
Yeah, many, many fascinating ethical questions in play there. Before we go in for a break,
#
a question harking back to something that you said earlier, where you spoke about how
#
you'd like to see more of the humanities being taught in medicine. And I completely get that
#
because there is a danger that otherwise, you know, you could just have a one track
#
thing where you know how medicines interact with the body and that's kind of fit. And
#
obviously it's more important to have a more well-rounded approach towards humanity. And
#
also you spoke about almost wistfully of the roads not taken as it were right at the start
#
where you spoke about one could have been an author or whatever. Was there stuff like
#
that in your mind at any point that were you interested? Like what kind of books did you
#
read? What were you outside the context of medicine and the study of medicine? What were
#
you reading? Did you want to be a writer? You know, when you read people like say Atul
#
Gawande or Abraham Verghese or Eric Topol or whatever, do you think that, hey, okay,
#
I should also be, you know, going down that road? Tell me a bit about that.
#
So it's definitely on the bucket list and I do hope I will write something someday of
#
relevance and interest to some readers at least. I think a lot of my passion or my hunger
#
for writing comes out in scientific literature and publications. So that's kind of an outlet
#
in a way. The reason I could be a little prolific was because I really enjoyed writing. For
#
me to construct something out of nothing is very fascinating. But this concept of humanities
#
also comes from how fascinating science is, right? So when I did my epidemiology, I realized
#
that a lot of epidemiological principles actually came from economics and a lot of them came
#
from philosophy. If you look at, you know, we use something called p-value, right? So
#
a p-value basically is a measure of statistical significance, right? So, and when it's below
#
a certain level, like 0.05 is a cutoff, we say that this is something that's rare. This
#
is something that cannot happen by chance. So there is definitely a genuine association.
#
So when you look at is drug A better than drug B, if the p-value is less than 0.05,
#
you say, yes, it's better and it's beyond reasonable doubt or beyond chance. Now, if
#
you go back, the real argument comes from something Latin, which is reductio absurdum.
#
You basically reduce the argument to a level that it's absurd that the alternative is true
#
and then you prove the truth accordingly. So that basically is coming from philosophy.
#
And I think if we were trained in some sort of philosophy, in some sort of critical thinking,
#
I think all of us would become much better doctors because it wouldn't be that this is
#
written in stone. We would learn to question things. We would learn context in a lot of
#
different ways. And this whole realization that, and when I say humanities, I don't necessarily
#
mean the appreciation of art. I mean, things which actually eventually led to medicine
#
in so many different ways. Abraham Varghese, too, to answer your second question, I think
#
Abraham Varghese, my own country was one of my favorite books of all time, probably, because
#
again, you know, it was the empathy that someone working at the start of the HIV pandemic in
#
a small little town, the whole people coming out of the closet at that point of time, I
#
think it was fascinating in terms of contextualizing medicine and not making it just cold hard
#
facts. Complications, again, by Govande was a great, great book. His first book, you know,
#
he's written some after that, which weren't as impressive, let's put it that way. But
#
I thought Complications was fascinating. I pretty much read anything. I don't think
#
I'm very selective about what I read. I think The Looming Tower was the last book that I
#
can think of recently that I really liked. There's this book called Do No Harm by a guy
#
called Henry Marsh, who's a neurosurgeon in the UK. And I thought it was a fantastic book.
#
It's a book I read a couple of years ago, where he's so brutally honest about the mistakes
#
that he's made. And he's so, and he can probably do it because he's relatively senior now.
#
And, you know, some of the stuff that he talks about would have potentially lawsuit material.
#
But he's being so brutally honest about the uncertainties associated with medicine. And
#
I find that fascinating. You know, I think I think doctors need to be a lot more humble
#
than they are, because there is so much uncertainty there is on a daily basis, you know, I see
#
patients in my clinic, I send them off home. There is a small proportion of those patients
#
who anything can happen the moment they leave out of my office, right. And, you know, that
#
uncertainty, I think quantifying that uncertainty and trying to become a better doctor, knowing
#
that uncertainty is out there is what fascinates me. And I think, you know, it's a blend of
#
philosophical, logical reasoning, it's a blend of accepting that uncertainty, it's a blend
#
of this whole principle of do no harm, right. So, the burden of proof is always on us to
#
prove that things work. It's never on, you know, let's try something, if it doesn't work,
#
then let's chuck it, because it's human lives that you're dealing with. And I think that
#
structure of logic and argument also comes from the humanities, which I find very fascinating.
#
So, I had a recent episode with another person who's been a voice of reason in these COVID
#
months, which is Gautam Menon. And Gautam also spoke about bringing different lenses
#
to bear, like, he brings a lens of physics into biology and biology into physics, and
#
he's also got statistical training and all these lenses help. So, do you find yourself
#
applying the lenses and the frames that you've got from your study of medicine into the world
#
at large, and vice versa? Like, do you apply other frames? Like, one book that a lot of
#
my guests seem to have liked and recommended on the show is a book called The Rules of
#
Contagion by Adam Kaczarski. And there, of course, you realize that contagion is not
#
just in the biological sense of our disease spreads, but similar rules and similar trends
#
can apply to even, you know, contagion when it comes to information, for example. So,
#
do you find yourself doing this kind of interdisciplinary sort of applying of frames from one thing
#
to another? And then how much do you feel that that enriches your understanding?
#
No, absolutely. I mean, I can be pretty annoying to a lot of people sometimes because of this
#
inherent cynicism that comes from epidemiology, right? So, everything is in the realm of probability.
#
So, there's no certainty at all. Everything is like, what is the counterfactual? You know,
#
what if this didn't happen and something else had happened is what you're trying to prove.
#
And since you never have a counterfactual, you try to come as close to that counterfactual
#
as you can. And that spills over to everything in life. So, every time somebody is talking
#
about, you know, say arranged marriage is better than love marriage, for example, and
#
you're saying, you know, what are the selection biases? Are individuals who get into an arranged
#
marriage different from individuals who get into a love marriage? What are the confounding
#
variables? You know, are they more wealthy and therefore have a safety net to go back
#
to if they, you know, if it fails versus in one versus the other. And you're constantly
#
dissecting it out in every aspect of your life. And I think that's the fun of the generalizability
#
of the same principles across everything around you. There's this fascinating story, which
#
I love telling. And, you know, I'm going to use this opportunity to speak about it.
#
There was this guy called Abraham Wald. And this was the Second World War. This was 1943.
#
Abraham Wald was a biostatistician, was a statistician. And he was assigned to try and
#
figure out why so many planes were getting shot down. And, you know, how could those
#
planes be reinforced? How could they make those weak spots stronger? He was given this
#
data set where they had this whole bunch of planes and all the bullet holes on the planes
#
were mapped on it. And he looked at all of them. And, you know, it was clearly that the
#
wings, the fuselage and the tails, you know, these were the three areas that were hit the
#
most. And, you know, as one would normally expect, the person would say, you know, reinforce
#
the wings, the tails and the fuselage because they hit the most. And what he said was just
#
the opposite. He said everything other than the wings, the fuselage and the tails needs
#
to be reinforced because these are the planes that came back to the base. The ones that
#
were lost out were obviously hit in the other areas, you know. So that was his survivor
#
bias. The ones that survived and came back clearly did okay despite all the bullet holes
#
in all these areas. The ones that didn't were hit in the other areas. I think that's fascinating
#
stuff. And, you know, these principles apply to everything in life. If you just look at
#
the data set and you don't have the broader picture as to why that data is in front of
#
you and what's the context in which it is, you will end up making a lot of biased and
#
Yeah, that's actually one of my favorite stories as well. And Wald, in fact, served on a committee
#
at one point in time with Milton Friedman and a few other eminent people whose names
#
I forget. But I think Friedman once commented something to the effect of how it felt to
#
be in a room where everyone was smarter than you, which for someone like Friedman to say
#
is pretty remarkable. And, you know, I think I get that feeling from the scene and the
#
unseen as well that every week I'm basically the second smartest person in the conversation
#
if there is only one guest. But we'll now take a quick commercial break and on the other
#
side of the commercial break, we'll continue talking about the practice of medicine. We'll
#
look at some of your pet areas like smoking cessation and sleep, both of which I want
#
to talk a little bit more about. And then finally, we'll talk about COVID-19 as well,
#
you know, where you have always kind of been a little bit ahead of the curve and showing
#
the way to others. So all that after a quick break.
#
Long before I was a podcaster, I was a writer. In fact, chances are that many of you first
#
heard of me because of my blog India Uncut, which was active between 2003 and 2009 and
#
became somewhat popular at the time. I love the freedom the form gave me. And I feel I
#
was shaped by it in many ways. I exercise my writing muscle every day and was forced
#
to think about many different things because I wrote about many different things. Well,
#
that phase in my life ended for various reasons. And now it is time to revive it. Only now
#
I'm doing it through a newsletter. I have started the India Uncut newsletter at indiancut.substack.com,
#
where I will write regularly about whatever catches my fancy. I'll write about some of
#
the themes I cover in this podcast and about much else. So please do head on over to indiancut.substack.com
#
and subscribe. It is free. Once you sign up, each new installment that I write will land
#
up in your email inbox. You don't need to go anywhere. So subscribe now for free. The
#
India Uncut newsletter at indiancut.substack.com. Thank you.
#
Welcome back to the Scene on the Unseen. I'm chatting with Dr. Lancelot Pinto about the
#
practice of medicine, and especially in the narrowed down context of COVID-19 in the last
#
few months. But as we continue this fascinating discussion, Lancelot, I'm reminded of something
#
you said just before the break, which brings me to my next question. But before that, you
#
know, a quick anecdote about the President Harry Truman, who once when he was president
#
said, give me a one handed economist. And he did not mean this in a literal way. But
#
what he meant was his advisors would keep saying to him, on the one hand this, on the
#
other hand that. And he just wanted, you know, he wanted to make decisions, he wanted things
#
straight up. Now you mentioned probabilistic thinking a few times in this episode so far,
#
which is music to my ears. I mean, I was a professional poker player for a few years.
#
And that kind of taught me to look at everything in the world around us in a probabilistic
#
manner. But most people don't, most people crave certainties. And of course, we always
#
ascribe certainty to the past, like after something has happened, it has 100% happened
#
or 0% happened. And it's easy to kind of look at it like that. But even for the future,
#
they want a similar kind of certainty. So as a medical practitioner, how is it for you
#
where you want to explain something in probabilistic terms, but you know that the other person
#
in a manner of speaking wants a one handed doctor? How do you deal with that?
#
This is a challenge I pretty much face on a daily basis because, you know, at the end
#
of every conversation, the patient often will say, but some broad definite statement is
#
made at the end. And they want me to say yes. And I find it extremely difficult to do that,
#
but nothing bad will happen. But you know, in two months, we will get better, right?
#
You know, so it's these definite absolutes that people constantly seek. And it makes
#
the whole conversation a lot quicker if I wasn't a probabilistic thinker. You know,
#
unfortunately I am. So it makes my consults longer as a consequence where I'm trying to
#
explain that I do hope that things get better for you. And I do want things to get better
#
for you, but I can't guarantee that that's going to happen. You know, and that's true
#
for a significant chunk of diseases, especially at a specialist level, you know. So if you're
#
dealing in the community and somebody comes to you with the sniffles, for example, you
#
can say with reasonable degree of certainty that out of a hundred people I treat like
#
this, 99 are going to get better. You know, I can afford to tell all hundred that things
#
are going to get better and be wrong once and, you know, have that guy say, but, you
#
know, listen, you said that I would get better and, you know, have that conversation again.
#
The more specialized you get in terms of, you know, people being referred to you after
#
somebody has had a look at them already, after someone has tried something already, it's
#
not work. Then they come to you. It's not because the person who's tried something very
#
often has done something wrong. It's just that the nature of the illness is such that
#
there's a lot of uncertainty around certain diseases and certain conditions. And I think
#
being a communicator in such a situation is difficult. It's, it's challenging, but I think
#
at the same time, it's, it's, it's a challenge that we need to take on in a, in a positive
#
kind of way, in an, in an empowering kind of way, not so you empower the patient to
#
know about what they are going through rather than look down on the patient and try and
#
say things like, so I've heard this phrase so many times, right? You're, you're a Google
#
patient, you know, like Tom Joe, you go and Google it, you know, and my doctor told me,
#
yeah, this is what you must have got from Google. There are these memes floating around
#
or these jokes floating around on WhatsApp saying Google patients not wanted or something
#
like that. Right. I, I see nothing wrong in that. I see nothing wrong in a person Googling.
#
I mean, it's his or her body. You know, you're going to a doctor, the doctor is going to
#
violate that sanctity of space and, you know, give you something to put into your own body.
#
Why should you not be empowered and educated about what's, what's happening there? You
#
know, so what's so wrong if I do my Google search? In fact, why don't you, I mean, as
#
a doctor, why don't you suggest a better way to Google search? You train the patient, say,
#
listen, don't go to Google. Fine. Google may have taught you this. Don't look down on your
#
patient and say, oh yeah, this is rubbish. Instead say, why don't you go to this legitimate
#
site which has legitimate information and you come to the same conclusion. So to answer
#
your question and very often, I think people have done studies on this also where they
#
look at, you know, what the doctor says and what the patient takes away are two different
#
things sometimes. So no matter how much you try to explain probabilities, the patient
#
often goes away saying, speaking in absolutes, the doctor said things will get better or
#
the doctor says things will get, things are not going to get better. And sometimes, you
#
know, if they go away with the feeling that the doctor said that there's no hope, you
#
know, if that's their interpretation of things, that's the first cue for them to jump and
#
go to another doc. If they find a doctor who deals with absolutes, they're then happy,
#
you know. It is a big challenge and there's no easy solution to this because if I have
#
to stay honest, I have to speak in terms of probabilities. If I go black or white, then
#
I'm not being honest to myself. So, you know, I mean, this is just who I am and hopefully
#
a significant proportion of patients do understand that it's coming from the right and good place.
#
For my listeners who must now all be intrigued and saying that, oh, you know, tell us how
#
to Google. So why don't you, why don't you give us a quick one minute or two minute clinic
#
on how to get information, how to be a Google patient, so to say, like, where should they
#
go? Where should they begin? And what should they watch out for?
#
So most websites are just like up to date is something that I alluded to earlier. Up
#
to date has a patient version as well. So for every article that's there about a particular
#
disease, there's a patient information sheet, which is also available, which is coming from
#
a legitimate source. The second thing a lot of journals nowadays do, so journals have
#
started having their social media sites as well, which are quite active. And a lot of
#
that is targeted towards the end user or the patient. So there will be a professional summary
#
and there will be a patient summary very often. The Cochrane collaboration, right? So basically
#
what happens in medicine is once you have a whole bunch of studies which are out there
#
on a particular subject, what people do is they synthesize this information and do what
#
we call systematic reviews. So systematic reviews are currently considered the highest
#
level of evidence because it's a summary of everything that's out there.
#
And the Cochrane collaboration is one of the collaborations that consistently does systematic
#
reviews on important subjects. And again, on their summary page at the bottom, there
#
is a patient summary. So if you go to the Cochrane collaboration website on a particular
#
topic that you are interested in, you will get a patient layperson summary, which is
#
not technical, which will help you. You can also ask your doctor, because again, most
#
of us are part of professional associations. So when it comes to respiratory, there's the
#
American Thoracic Society, there is the American College of Chest Physicians, there's the British
#
Thoracic Society. All of these societies have layperson versions of most articles that are
#
published there. So I think going through legitimate societies and then trying to figure
#
out what the layperson version is, is far better than looking at an opinion or an op-ed
#
that someone has just posted out there, which may be biased.
#
Great point, sir. Let's now talk about some of your pet themes. But before we do that,
#
a quick word on your MSc, which you did in McGill University, epidemiology, what kind
#
of made you go for that? Because the subject, of course, is fascinating. Like you said,
#
you know, insights from many different fields come to bear upon that economic statistics,
#
philosophy, as you pointed out, all of that. What made you go for that? And then, you know,
#
what drove you towards some of your, like, what are your current, you know, apart from
#
COVID-19, what are your current sort of areas into which you've gone into rabbit holes
#
and become a specialist, so to say, and why?
#
So McGill again, you know, happened by chance because of the TB study, because of the TB
#
work that we've done out here. Madhukar Pai, who's a professor at McGill and is one of
#
the top TB guys in the world in TB diagnostics, he offered me this opportunity to do a Masters
#
in Epidemiology. I got mixed feedback from people around me. A lot of people told me
#
that it was a big mistake because I was stepping out of clinical medicine for two years. I
#
was very jittery about it because, you know, a doctor going away and, you know, going back
#
to school in a way, staying away from patients for two years. Will I be employable when I
#
come back if I decide to come back after two years? It was a big challenge. I think a lot
#
of big deal of the credit goes to Dr. Urvadia, who at that point of time told me that if
#
he were in my shoes and had an opportunity at that point of time, he would accept it
#
in the blink of an eye. And in that sense, it was a leap of faith. And again, the epidemiology
#
almost didn't happen because there were certain math requirements to get into an MSc epidemiology,
#
which I didn't have on my transcript. And it took a lot of pleading and kind of reassurances
#
on the part of Madhupai and other people, which then made them kind of waive off that requirement.
#
So that's how McGill happened. And I had no concept of how important McGill was as a school.
#
I think I realized it once I went out there. So, I mean, as one of the introductions that
#
happen when you go to McGill is that they sell t-shirts outside during orientation,
#
which says Harvard and below that it says America's McGill, you know. So that's the
#
joke they have there. But it's a great university. In terms of respiratory medicine, a lot of
#
good stuff has come out from McGill. It was where William Osler was. So it's a mecca in
#
some ways. It's where the brain was mapped by Dr. Penfield. And the Department of Epidemiology
#
was again, it was a real solid department. So I was coming out of a residency, right?
#
So three years of a residency, you hardly slept, you worked like really hard. So I thought
#
this is going to be a piece of cake. You know, what does a master's, you know, it's like,
#
it's gonna be child's play. And it was grilling. It was grueling two years where, you know,
#
I didn't sleep much because it was assignment after assignment. It was stuff that I had
#
no idea about. You know, you were going back to probability and maths and Bayesian stuff,
#
learning statistical software. It was extremely challenging. And, you know, half of your class
#
is really young and half of half of the class. So I was about 35. And we had a bunch of people
#
who were like 24 who had just come out of their bachelors and were directly doing it.
#
And you know, half of her class is your age. So, you know, and then you have to do group
#
assignments, which people have with people 10 years younger than you. And those 10 years
#
do matter, right? When you're talking about 24 versus 35. So it was, it was a fascinating
#
experience. And again, you know, we had some great professors, we had Madhu himself was
#
a great mentor. He's somebody who's a machine in terms of working, you know, you send him
#
an email at any time of the day, somehow he manages to reply. And I still see that happening.
#
There was great TB work happening. It was a, it was a bunch of people who worked in collaboration.
#
I mean, I truly appreciated the power of collaborative work as well. So people were not necessarily
#
competing with each other. People were all complimenting each other and supporting people
#
to grow. In terms of rabbit holes, I got very passionate about medical ethics. I attended
#
a class by a guy called Jonathan Kimmelman, who was brilliant in terms of ethics. My understanding
#
of ethics completely took a 180 degree, you know, you know, all of us think of ethics
#
as being some sort of a field, which is, you know, does it feel right? Does it feel wrong?
#
You know, what does it feel? Does it conflict with your morals and that kind of stuff? And
#
then I realized that the thing that he kept saying over and over again in the class is
#
that this is a science. This is not based on a gut feel. There is a framework in which
#
it works and you know, something that may be wrong in one framework could be right in
#
another framework. And I think that's pretty much similar to how economics works as well,
#
right? In terms of, you know, it's the framework that matters and decides what's acceptable
#
and what's not acceptable. Even in terms of epidemiology, you know, this whole, it used
#
to have this whole critiquing of papers, you know, which went on for hours, sometimes everybody
#
pointing out how things could be done in a better way, how things could be done differently.
#
And I think that made a huge difference in terms of how I looked at everything after
#
that. So it adds a lot of uncertainty, unfortunately, to your life. So I went there certain and
#
I came back uncertain in a lot of ways. So in terms of the practice of medicine, you
#
know, from knowing all the answers, it came to almost knowing nothing anymore, which in
#
some ways is great, but in some ways is makes you a little cynical, you know, every time
#
there's a new study, I'm like, we'll see, you know, that's my usual answer versus saying,
#
oh, wow, there's this wonder drug, you know, this is going to change everything. So my
#
levels of cynicism have increased significantly, but I genuinely believe that that was a great
#
That is so fascinating. I mean, can you give me a concrete example of where this would
#
apply in your everyday practice that levels of certainty having gone down and which is
#
of course the way knowledge works. The more you know, the more you realize there is more
#
to know. But in your case, in practical terms, how did it change? Like, obviously you would
#
have looked at medicine in a more probabilistic way, but apart from that, how did it sort
#
of change your practice as it were?
#
So let's again, I'll give you a cynical example. Like, so when Rem Desever got announced, I
#
don't know if you remember that moment. It was Fauci at the White House next to Trump
#
and he says, you know, this is a pivotal moment in the history of COVID and it reminds me
#
of HIV and it reminds me of how we changed everything. And my first reaction was, this
#
is the head of NIAID, right? I think that's what it's called, the National Institute of
#
Allergy and Diseases. He was the guy who conducted the study and he was announcing it at the
#
White House rather than announcing it in a publication. So I was like, there's a lot
#
of conflict of interests out there. You know, you need to let the science come out, let
#
the paper come out. We'll have a look at what it says. We'll have a look at whether it's
#
a game changer or not. So this inherent blind faith in individuals, institutions, I think
#
that's been shaken a lot and in a healthy way. You know, I mean, I don't have anything
#
against Fauci obviously, and you know, we all respect him and he's been a great voice
#
of reason throughout all of this. But you know, I've learned to question everything
#
in terms of, you know, the God being in the details in a way.
#
Yeah, and Remdesivir was also, it almost seems like a drug of hope in the sense it was used
#
during Ebola also, if I remember correctly, and they said it's going to be the wonder
#
drug and it really didn't do anything there. You know, speaking of Fauci, just a quick
#
aside, some friends and I had a session recently on conspiracy theories. And Fauci, of course,
#
is at the center of many conspiracy theories and many people claiming he created the COVID
#
virus and all that. These guys are bizarre. So we had like this fantasy situation where
#
Fauci, Sushant Singh Rajput and Subhash Chandra Bose went in a UFO to blow up the World Trade
#
Center. So, you know, you're bringing many conspiracy theories together. But before moving
#
on, you know, everything you say is so fascinating that all these side lights I want to explore.
#
I also want to talk a little bit about that ethics part where you said you looked at it
#
completely differently in the sense that it now gave you a much more clearly defined framework
#
to think about medical ethics and it wasn't just about intuition and whether something
#
feels icky or not. But can you tell me a little bit more about that framework which you used
#
to think through issues of medical ethics now?
#
It's like this whole free market versus, you know, what is governed by the government or,
#
you know, government controlled health care, for example, this whole debate about what
#
is right and what is wrong, you know, so the private sector becomes a very easy target
#
to bash up, you know, saying that private sector is after money, private sectors after
#
incentives. This is a framework that has been allowed by whoever decides what the framework
#
is. Once the framework is in place, I feel it is wrong to criticize a for-profit entity
#
for doing what they try to do to make a profit, right? So it's you've defined that this is
#
the framework. You've defined that you should allow this framework to work. And then deciding
#
what is right and wrong becomes a very blurry line once you've created that sort of a framework.
#
This whole concept of, you know, if you look at what is the worth of a life or what is
#
the value of a life, right? It sounds horrible to say that, you know, from a sentimental
#
perspective, right? But if you look at it in terms of how much are you ready to spend
#
to save that one life, that's how economics works in terms of health care. Everything
#
works in terms of metrics where they look at, you know, the cost versus the benefit
#
for every particular thing. And that again is defined in some sort of a framework. We
#
have accepted, like, I think the UK at some point of time said that one dally or one disability
#
adjusted life year was equal to 20,000 pounds or something like that. So somebody came up
#
with that framework and said that this is what we are ready to spend on an individual
#
in the country paid by taxpayer money to save one year of productive life, right? So earlier,
#
all of these things would have been nauseating in some ways, would have been like, how can
#
you ever look at health this way? But that's the practicalities of the universe. We work
#
in frameworks, we work in some sort of an ethical framework that we choose to decide
#
is acceptable to us as a society. And once you accept that framework, then the whole
#
argument about right versus wrong, good versus bad has to happen within that framework. You
#
can't start making arguments outside that framework and saying something is wrong. So
#
that's what the whole ethical principles made me realize this whole training in ethics,
#
whatever little I did in ethics, made me realize that there are different ways of looking at
#
the same thing. And there is no right way, you know, this whole utilitarianism versus,
#
you know, some other other schools of thought, where it's not just the utility of a particular
#
thing that's being analyzed, but it's something else. And I don't claim to understand all
#
of it. It's clearly, you know, it's esoteric stuff. But it just makes you realize that
#
to call something right or wrong or to call something ethical or unethical should not
#
come from a gut feeling or should not come from a place of emotion. It needs to come
#
from a framework in which you analyze these parameters.
#
Yeah, and these frameworks can be complex and subjective. For example, just a thought
#
that comes to mind that supposing you're in a hospital where COVID patients are rushing
#
in and you don't have enough beds or oxygen and you have to try as you have to choose
#
who do you give treatment to. So on the one hand, you could say the old people are more
#
vulnerable, give oxygen to them. On the other hand, you could say that the young people
#
have more productive years of life left, give oxygen to them instead. And then you start
#
weighing up, you know, what is the probability of old person surviving or dying? What is
#
the probability of young person surviving or dying? How do you put a value on each extra
#
year that each person might have? So implicitly, you know, you are doing it now, whether you
#
do it in an explicit way where you put numbers to this or not, or you do it implicitly and
#
you go with whatever your moral instinct as it were is that no, we have to save the old
#
or no, you know, or the other way around. You are making these icky decisions. So what
#
sometimes we need to do is we need to sort of be explicit and try to actually think this
#
Right. So take the other example of schools, right? So I have twins who are six and a half
#
years old, who've missed one year of school, who are very likely to miss the second year
#
of school as well. And, you know, in an ethical framework in terms of, you know, what is right,
#
what is wrong, we always speak about our responsibilities towards children, right? They are the vulnerable
#
in the society. So we have to speak on their behalf. We have to lobby. We have to fight
#
on their behalf. And they've not really had a voice in this pandemic, right? We've just
#
decided that despite the fact that children hardly ever get affected. So it's an extremely
#
small proportion of kids who fall sick enough to be hospitalized or sick enough to have
#
worse outcomes, extremely, like it's almost negligible. And yet we are subjecting them
#
to two years of a lack of social interaction, two years of meeting their friends, two years
#
of sports, two years of everything with the argument that it's being done to protect the
#
elderly because they're going to go back home and the elderly are vulnerable. They're going
#
to have people who have other vulnerabilities at home and we need to protect them. Now,
#
this is where ethics comes into play, right? I mean, this is a, this is a difficult question
#
to answer. What is the worth of those two years of social interaction and education
#
in a child's life versus protecting an elderly individual? And, you know, there's no straight
#
answer. There's no easy answer to this, but it's interesting when at least you generate
#
a debate around these things. Yeah. And the sort of problem I've always had with utilitarianism
#
is that utilitarianism depends on calculating the utility of different actions, which is
#
impossible to do. Like it's incalculable. If a kid is losing two years of a school life,
#
it is incalculable. You don't have any idea. By incalculable, I don't mean incredibly,
#
infinitely high. I just mean that you literally cannot calculate it. You don't know what the
#
psychological impact will be. You don't know what the human capital impact will be in terms
#
of what they might have learned or how they are socialized and all of those things you
#
simply don't know. So if you are just going to take a utilitarian calculus, then eventually
#
you will be putting subjective values out there in terms of this is how much I would
#
value this and all that, which will go down to your own biases and therefore become completely
#
unscientific. But yeah, it's a really fascinating and muddy field. Let's come back to, you know,
#
one of your pet subjects, which is sleep. Like you mentioned how in your practice you
#
wouldn't sleep enough and you thought the masters would be easy, but you found that
#
during the masters also you're not getting enough sleep. And that is a classic instance
#
of a doctor not following his own advice because your advice to people constantly is that get
#
enough sleep. Sleep is incredibly important and a subject close to my heart because I
#
have sleep apnea, by the way, I'm, you know, on a CPAP machine and it changed the quality
#
of my life in multiple ways, which I'll kind of get into. But I just think that this is
#
something that everyone needs to be aware of because especially when we are young, the
#
notion of just working constantly and staying up nights and all that is so romanticized.
#
Even in some corporate jobs, it is like considered natural that you, you stay till late night
#
and all of that. And, and these lifestyles have an impact, not just in terms of the short
#
term impact of, oh, you're sleepy the next day, but they have a massive long-term impact
#
on health, including possibly as people are finding out, raising the probability of Alzheimer's
#
getting Alzheimer's later on. So tell me a little bit about this because it just seems
#
to be such an important area that there is not enough public awareness about.
#
So sleep is fascinating, right? I mean, if you look at the raw data, we spend a third
#
of our life sleeping and that would convert into with an average lifespan of about 70
#
years, you're effectively about 20 years of your life, you're asleep. And yet the field
#
of sleep medicine took off somewhere around the seventies. You know, that's where a lot
#
of research happened at the University of Chicago. Sleep apnea was described for the
#
first time and it's, it's a fascinating field for in many different ways. And a lot is being
#
still researched. So simple things like reaction time. So there were experiments where they
#
looked at, you know, Tetris as a game that, you know, you gave a bunch of people, let
#
them play Tetris. Half of them fell asleep. Half of them didn't, were not allowed to sleep
#
and you make them play again. And the ones who felt asleep, there was extreme consolidation
#
of these patterns and memory to an extent that they did much, much, much better the
#
next morning versus the group that didn't fall asleep. So that's short term. That's
#
quick, quick results. You know, things like attention span, things like memory. I think
#
there have been studies which have shown that one extra hour of sleep in school going kids
#
can reduce the incidence of attention deficit hyperactivity to a great extent because kids,
#
unlike adults, when they are sleep deprived tend to get more irritable, tend to get more
#
what we call hyper as compared to adults who would just, just be sleepy. A lot of road
#
traffic accidents have been attributed to the lack of sleep as well or to sleep related
#
disorders. These are like the low hanging fruit, right? But as you rightly pointed out
#
that people are looking at associations between sleep apnea and the development of cancers
#
in the long run, for example, because it's what happens in sleep apnea is you have intermittent
#
periods of time in the night where your oxygen levels are low. So your cells are deprived
#
of oxygen and then suddenly you wake up subconsciously and then your oxygen levels shoot up again.
#
So this, what we call intermittent hypoxia that you're getting oxygen and you're not
#
getting oxygen has been postulated to play a role, even in the formation of cancers.
#
So pretty much every field. So again, the low hanging fruit, the initial study showed
#
the strong link with high blood pressure, strong link with stroke, possible link with
#
heart disease as well. So we've picked up the low hanging fruits and now the research
#
is going into the subtler things. Unfortunately, to pick up subtler things, you need larger
#
studies which involve lots of money and you know, it takes a longer time to prove these
#
things. But we're realizing it more and more that sleep is crucial to health in a lot of
#
different ways. And you're absolutely right. We romanticize lack of sleep. We almost use,
#
you know, wear it as a badge to say that I worked so hard that I barely slept last night.
#
But clearly the science suggests that it's not something to be proud of and it's something
#
that we really need to pay attention to.
#
Yeah, and I'll link to a fascinating talk on YouTube that you gave on this, which had
#
a bunch of insights. And one of the insights I got on that was that in the US vehicular
#
accidents caused by drowsy driving exceed those caused by alcohol and drugs combined.
#
So you know, it's not that you don't just need to ban drunk driving and people high
#
on cocaine driving, but you also need to sleep enough. Everybody needs to sleep enough. Sleep
#
apnea for those who don't know is an extremely common condition. What really happens is that
#
because of a bunch of complex biological factors, which you mentioned in your presentation,
#
so I won't go through that here, that your breathing keeps getting interrupted because
#
of a temporary blockage in your airway, because of which you keep waking up through the night.
#
And one sign of sleep apnea, possible sleep apnea is snoring. And of course, 30 to 40
#
percent of people snore and only 10 percent have sleep apnea. So it's not necessary that
#
if you snored, you have sleep apnea. But so I got myself tested for it and I got a CPAP
#
machine and the sleep apnea problem just solved. But another interesting thing happened there,
#
which I've never actually spoken to a medical practitioner. So I don't know if it's even
#
a good thing, but it completely transformed my quality of life, which is that for years
#
since childhood, I would often wake up in the morning with a sore throat and a blocked
#
nose. And the reason I figured out much later was GERD because of acid reflux. And the moment
#
I started using the CPAP machine, this just stopped. I presumed it was because when rushing
#
into my respiratory system, it stopped the acid reflux. I mean, it didn't come all the
#
way up to the nose and the throat, but it completely transformed my quality of life.
#
Because before that, there was not a single day in my life that I hadn't woken up with
#
a sore throat or a blocked nose, which I initially used to assume was I didn't associate it with
#
GERD. I thought it's a random respiratory thing. When I was a kid, my mother even took
#
me to a homeopath in Pune, which is kind of funny. So and I'm thinking that at one level,
#
it's a good thing that treatment for something else has happened to have this impact here.
#
But at the other level, it's a bad thing, because what it is treating is a symptom.
#
And the underlying causes of GERD, which I might need to do something about whether it's
#
losing weight or whatever, is stuff that I'm not handling. So do you sometimes see this
#
in your practice that you're treating something but something else gets sorted or something
#
counterintuitive like this happens? Like in this particular case, what would your reaction
#
There are a lot of associations with sleep apnea. Before I get into that, just to add
#
to something you said earlier, there was a study which looked at blood alcohol levels
#
and sleep deprivation. And they actually did it in medical students and found that medical
#
students post-call who were sleep deprived, in terms of their cognitive performance, performed
#
very similar to people who had a reasonable amount of alcohol in their system. So that's
#
how bad sleep deprivation is. So there may be a lot of teetotallers out there who work
#
really hard and feel that they're not drinking, but they're probably causing an equal amount
#
of damage by depriving themselves of sleep.
#
So to get back to your question in terms of whether sleep apnea is connected to a lot
#
of things, there are lots of fascinating things that happen. So sleep apnea basically is obstruction
#
of the windpipe at the level of the throat, right? So it's generally fat at the base of
#
the tongue, at the back of the tongue, which causes an obstruction out there. So what happens
#
essentially is when you breathe in sleep apnea, so your windpipe is shut and you're breathing
#
against the resistance of a shut windpipe. So imagine, you know, if you think about that
#
experiment where, you know, you have a diaphragm below a bottle and you pull the diaphragm
#
down and the balloons fill up inside. I don't know if you've, you know, we've done this
#
in school. This is like you're shutting that and you're pulling the diaphragm down, but
#
you've shut down the way for the air to enter. So that puts a lot of negative pressure inside
#
the chest. Now this negative pressure inside the chest surprisingly causes the heart muscle
#
to stretch. When the heart muscle stretches, it releases a substance called atrial natriuretic
#
peptide, which causes you to basically pee. So it's very interesting that people with
#
sleep apnea very often will pee three or four times every night in the severe form or at
#
least once or twice every night. And the moment they start using the CPAP machine, that completely
#
stops. So something that you wouldn't even think is related, right? You would think why
#
is my peeing frequency gone down when all you've done is push air down my throat? But
#
that's how fascinating the human body is. There are so many things which are interconnected.
#
So GERD is a very common comorbidity with sleep apnea, because again, you know, obesity,
#
GERD and sleep apnea, you know, kind of form a triangle. And the treatment of sleep apnea,
#
it's very often gets rid of a lot of these corollary symptoms, which you otherwise would
#
not have thought directly associated with the disease. Blood pressure tends to come
#
down by a few points, you know, heart rates tend to get better post sleep apnea, you know,
#
something that's not spoken about. Erectile dysfunction is sometimes very common in individuals
#
who have sleep apnea as well. And that gets, you know, and we have a lot of urology referrals
#
to us. So urologists who are up to date with the literature and sensitized enough to this
#
connection have sent me patients of erectile dysfunction, coming to a person, getting their
#
sleep apnea treated, and then, you know, their erectile dysfunction getting better as well.
#
So it's fascinating how things are related sometimes, you know, and it may not be very
#
obvious in terms of physiology that it's air going down the respiratory system. So all
#
its effects have to be related to the respiratory system.
#
Yeah, you know, that's completely fascinating. So the fact that there are people out there
#
with erectile problems, which are caused by a throat muscle, something that I should is
#
insanely fascinating. I didn't actually imply that my sleep apnea and GERD were necessarily
#
linked. I think I've always had the GERD, but this just turned out to be the CPAP machine
#
just turned out to be a Jogar solution in whatever way it works for that. And that got
#
me to thinking about Jogar solutions, because one of the other like interesting things that
#
I learned that you sometimes recommend is that you recommend that your patients with
#
sleep apnea that they sleep on the side, because then they are less likely to feel the effects
#
of it. And to make sure that they do that, you sometimes ask them to sleep with tennis
#
balls sewn onto the back of their shirt. So they can't possibly sleep on their back even
#
if they want to. So as a doctor, do you find yourself thinking creatively for these kind
#
of Jogar solutions that come from commonsensical thinking? Do you kind of do this a lot? Or
#
and how do patients react to it?
#
So the next level of Jogar, by the way, for the same solution is to wear a bra in the
#
opposite direction and stuff it with tennis balls. Right. Okay. I mean, but you don't
#
want to open the door to the pizza delivery guy, of course, when that happens. But that's
#
a Jogar again, you know, I mean, that's an easier Jogar rather than sewing sometimes.
#
But you know, people obviously, you know, stare at you when you say things like that,
#
wondering if something's wrong with you. But trust me, I mean, it does work very well,
#
because sleep apnea is clearly worse when you're on your back versus when you're on
#
your belly or in your sides. That's the same solution in indirectly we're trying to apply
#
for COVID as well, right, making people sleep prone, because the airway opens up, the lung
#
opens up a bit and it improves oxygenation. A lot of medical grade equipment often is
#
very expensive. And, and, you know, all of us do try to work with some sorts of solutions
#
sometimes to help people deal with their lack of ability to sometimes purchase that kind
#
of medical equipment, but to do it in a way that that gives them the same relief. And
#
you know, I think I think there's a lot of innovation happening in these kinds of spaces
#
as well, which suggests that it doesn't have to be that expensive, you know, sometimes
#
things which are which are not expensive also work well. For example, in asthma, we use
#
inhalers, right. So inhalers, the traditional inhalers, which you press and you take a breath
#
have to be coordinated perfectly. So the second you press the inhaler, if you don't breathe,
#
you end up getting a mouth spray, nothing goes into the chest. Right. So the solution
#
to that is something called a spacer. It's like this round plastic transparent box at
#
the end of which you attach the inhaler, you press it, so the drug is locked into the space
#
and then you breathe at your own convenience. Now the jugard for this, which I've seen people
#
do is use a bed bottle, you cut the end of the bed bottle. So you stick the inhaler to
#
that end, you keep the mouth of the bottle in your mouth, you press the inhaler and you
#
breathe through it. And again, it takes away the problem of coordination. It's a total
#
jugard in that sense. And from what little I know it, it seems to work really well as
#
opposed to a spacer, which is a more expensive device.
#
That sounds really fascinating. Let's go on to, you know, one of the other subjects in
#
which you've been active, which is you've spoken of your smoking cessation therapy.
#
And recently, in fact, you tweeted, quote, most individuals who consume tobacco know
#
it is harmful, but continue to do so because of the highly addictive nature of nicotine.
#
What we need to do is not offer such individuals a sermon, but a science based way to overcome
#
the addiction. Stop quote. And of course, part of the reason that you're into, that
#
you care about smoking is you're into all these pulmonary diseases of the lungs, which
#
are caused by smoking. So it is a big deal. You don't just want to treat symptoms. You
#
want to get to the root cause, make people stop smoking. Tell me a little bit about this.
#
Like what are the approaches that you make? Because most of the approaches towards to
#
make people stop smoking is sort of to guilt them into stopping. What do you guys do?
#
Right. So I'm just going to throw some statistics. So there was a study called the global adult
#
tobacco survey. It's called the GATT survey. When it was done in India, it was found that
#
more than 90% of individuals, even in rural India, even with literacy levels being questionable,
#
more than 90% of individuals knew that tobacco was bad for them. In the survey, around 50%
#
of individuals admitted to having tried to quit in the year prior, in the previous year.
#
This clearly suggests that there is not a knowledge problem. So whenever you want to
#
change behavior, there are three things that are generally needed for changing behavior.
#
From what, again, what I understand of behavioral sciences, you need the knowledge or you need
#
the motivation and you need the confidence, right? The problem is as doctors, when we
#
see patients sitting in front of us who admit to smoking, we think it's a knowledge problem
#
for some reason. And we give them a sermon about, you know, listen, this is bad. This
#
can affect you in this way. It can affect you in that way. When the data clearly suggests
#
that they already know that. So you're working on the wrong part of the problem. The second
#
is the motivation. And third is the confidence. And if you speak to people who smoke, their
#
confidence levels are abysmally low because they've tried many times in the past and they've
#
failed. You know, most individuals will, will not even admit to trying. They will not even
#
admit to their own spouses and their own loved ones that they are trying. They will do it
#
quietly because their confidence levels are so low that they already know it's not going
#
to work when they start. Right. Now, the reason for that is that nicotine is a highly addictive
#
substance. Nicotine addiction is an addiction. It's not a habit. It's not. So we use these
#
words like habit, lifestyle, choice. We use all sorts of words to make the burden of guilt.
#
Like you said, you know, to make the person feel guilty, to make the person feel responsible
#
for where they're at, where the science clearly shows you that it's an addiction and should
#
be treated like any other addiction. So when, when you see a person who is in front of you
#
and I run a tobacco cessation clinic, so they come to me reasonably motivated already, which
#
is great, you know, so I don't have to work on that motivation. Now that may be a different
#
story altogether, how you work on that motivation, but, but once they are motivated enough, they
#
do not need that lecture or that sermon or that guilt trip or that, you know, the, the,
#
the guilting, what they need is a solution and the solutions are science-based. So all
#
over the world, the standard therapy for smoking cessation has been defined. There are drugs
#
which are designed to work on centers of the brain to give you the same pleasurable experience
#
that a cigarette gives you, whilst at the same time, not giving you the thousand other
#
things that a cigarette gives you. And most of these therapies have been used for about
#
three to six months. So it's a, it's a defined fixed therapy for three to six months, which
#
a person adheres to according to a certain plan. That plan ensures that they don't get
#
irritable. They don't feel cravings. They don't feel terrible. So, so the bottom line
#
of a smoking cessation clinic is that you are able to quit comfortably. Anybody can
#
quit, right? But that quitting is so uncomfortable usually that people get back thinking that
#
it's easier to continue rather than going down that path. And if you look at the statistics
#
there of a hundred people who decide to quit within a month, 97 have started smoking again.
#
Only three succeed. And if I had to guess, those three would be individuals who are doing
#
it after say a bypass surgery, after a major life event, after getting diagnosed with something
#
that really shakes them up. And that's not where we want people to be. We want people
#
to be able to do it comfortably and there's a science to it. Now, again, you know, it's,
#
it's unfortunate that we have specialized clinics and I have to do it. Like I have some
#
secret mantra to it. Whereas all over the world, it's general practitioners. It's being
#
done as part of routine healthcare. There is no great skill to this. And what I've been
#
trying really hard in terms of training sessions, we've been working with, with people as well
#
is to de-specialize this. You know, this is something that your general practitioner should
#
be able to offer you without any judgment, without any yarn you smoke and you want to
#
give up smoking. This is what you need to do. And it should be as straightforward as
#
that. And this is again, you know, this is something that's been done all over the world.
#
This is not something special.
#
And what do these medicines do? Like, do they tackle the dopamine receptors of the brain
#
or something or how do they kind of work?
#
So the most fascinating molecule in this group, which has shown the maximum amount of success
#
is a drug called varinicline. So basically what happens is when you smoke a cigarette
#
or you consume tobacco in any form, the nicotine goes and binds to a receptor in the brain,
#
which eventually leads to the release of dopamine. Now dopamine is a pleasure chemical, you know,
#
and it's not only is it a pleasure chemical, it comes out in response to some very primal
#
needs. So, you know, hunger, thirst, sex, these are the times when dopamine gets released
#
in the brain. So it has a very strong pleasurable element as well as a very strong primal evolutionary
#
role in human beings. Nicotine binds to these receptors and causes that dopamine surge.
#
So when an individual smokes, he gets that surge of dopamine, which keeps him stimulated
#
in some ways, which feeds into that pleasure activity. Now, varinicline goes and binds
#
to the receptor called the acetylcholine receptor, which eventually causes the release of dopamine.
#
So it gives you that kick, which you would normally get, and it gives it to you in a
#
sustained way. So a person who smokes or consumes tobacco really craves it when the nicotine
#
levels hit a nadir, hit a really low level. By virtue of this drug constantly stimulating
#
that center, you do not reach those low levels and therefore the cravings don't generally
#
What's fascinating is also that if while you're on the drug, you decide to smoke, the nicotine
#
in your cigarette smoke does not have any receptor to bind to because the receptor has
#
been blocked by the drug. So you don't experience the pleasure that you would normally get.
#
So I've had a lot of patients come back to me and say, I did smoke, but you know, I stopped
#
at half a cigarette and I just threw it away because it wasn't doing it for me. So this
#
is what we call a partial agonist antagonist. You know, so it not only stimulates, but it
#
also blocks the receptor.
#
I think the physiology again is fascinating. This is one of the drugs that we use. You
#
can also use combination nicotine replacement therapy. So a patch, which generally tends
#
to work for 24 hours in the background, again, preventing those low levels of nicotine combined
#
with either a gum or a lozenge or an inhaler to be used as and when you have cravings.
#
So that's another strategy we employ. And sometimes we use a combination of both strategies,
#
but again, this is not based on a gut feeling. So there are certain predictors of addiction.
#
You know, so supposing you've started smoking in your teens, supposing you smoke within
#
the first five minutes of waking up, if you smoke more than 10 to 15 cigarettes a day,
#
you are likely to be more addicted and you very often need a combination of drugs in
#
Yeah, this is incredibly fascinating. And of course, it's a smoking specific solution
#
because the molecule would bind to the receptor that nicotine binds to. And so, you know,
#
it wouldn't be useful for other kinds of addiction. There's an amusing story I have. It's not
#
amusing. It's kind of sad about how I tried to wean a friend of gambling addiction because
#
the mechanisms are the same, right? You're pushing chips forward, dopamine rush in your
#
head and all that. So there's this guy who was a banker who lived in Worli and the location
#
is relevant. So he was a banker. He lived in Worli. He used to play these underground
#
cash games with me back in the day. And it was clearly he was just addicted. He wasn't
#
using his brain. He was just losing big. And I liked him a lot. I was a very sweet guy.
#
And I could realize that bit by bit he's blowing his savings up. His wife is pissed off. So
#
I called him home one day and I live in Andheri and this is also relevant. And at the time
#
I called him, you know, he was playing at this video game parlor in Bandra. So even
#
when you know, there were no live games, he would go to this video game parlor and play
#
video poker there. So anyway, so he came home and we chatted about it. And as you said,
#
the knowledge wasn't a problem. He understood it was an addiction. I went took him through
#
the biochemistry and all of that. And I said, we have to figure out some drastic ways of
#
stopping it. This is what I recommend that you call your wife right now and you tell
#
her that you are giving her the credit card and all access to the bank and everything.
#
And you're just topping all your access to money. She has to give you pocket money every
#
day for whatever taxi or Uber you take. And that is it. You have no other access to your
#
money. And he agreed. He called his wife. She was delighted at the suggestion. And I
#
think she also told him, Matumareli chicken banati watch come for dinner. So he was very
#
excited. He said, Amit, you know, you might just have saved my family life and all that.
#
And then he leaves home. But the problem is this. And this is why the locations are important
#
that to get from Andheri to worldly, you have to cross Bandra. And three hours later, another
#
friend calls me and he says that, bro, your friend, he's sitting at this video parlor
#
playing for the last two hours. So that didn't kind of work out well. And I guess, you know,
#
is there any kind of pharmacology for for general addiction? Because so many people
#
are also addicted to social media, you know, or even something like Tetris or whatever.
#
So, you know, but I guess there's nothing you can do for that in terms of medicine yet,
#
right? In the domain of psychology, I know that cognitive behavior therapy is being tried
#
in a lot of addictions. Hypnotherapy claims to have some success. But, you know, again,
#
these things are not very consistent. So you're not really sure in terms of the literature.
#
That's one of the problems of of sciences that are not pharmacotherapy based, right?
#
So the drug, the dosage mode of delivery, when a clinical trial is conducted, all these
#
are very clearly defined. So therefore, all over the world, anyone can try to replicate
#
that. The problem with behavioral sciences sometimes is that it's the person whose expertise
#
it is, it's the way they deliver it. And to translate that sometimes is a little challenging.
#
So let's talk about COVID-19 now, because COVID-19 is clearly an incredibly difficult
#
problem for a doctor to deal with, because you're having every day to make decisions
#
on matters that involve life and death. And in terms of information, you're in the fog
#
of war. You don't know what the hell is going on. You know, someone like you would be looking
#
at the latest research, trying to figure out what is a virus? What does it do? But even
#
there, how does one treat COVID? So tell me a little bit about your experience over these
#
last few months. How did your thinking on this evolve? What were the dilemmas you faced?
#
Just what was it like for you guys?
#
I think the worst part was clearly the first two, three months, right? Because there was
#
complete uncertainty. We had no idea what was going to work. We started using steroids
#
about a month or two before the recovery trial got published. And we used it in these prolonged
#
fevers that were happening in the second week, sometimes where the oxygen levels were dropping.
#
We used it purely based on a gut feeling at that point of time. And a little bit of literature
#
that was coming up from small reports from China saying that, you know, methylprednisolone
#
was used in a couple of studies. And we saw positive results and that reinforced, I believe,
#
in the appropriate use of steroids at that point. But again, you know, I mean, it was
#
one center doing something by themselves based on what you could call trial and error to
#
a certain extent. As time passed by and the literature started accumulating. And that's,
#
you know, you have to give immense amount of credit to people who got drug trials and
#
these adaptive trials up and running within a few months. You know, being a researcher
#
myself, I know how extremely difficult it is to do simple, small little studies. And
#
these guys, you know, like the solidarity, like recovery, they did trials on a nationwide
#
scale with multiple centers, got everybody on board, got randomization to occur, protocols,
#
you know, submitted to ethics committees. To do all of that in the time span that they
#
did it is nothing short of a miracle, you know, and that needs to be lauded, which also
#
possibly reflects how prepared they were for something like this. You know, the systems
#
were in place to roll out a study if need be. Possibly they had thought about this in
#
advance, may not be in the context of a pandemic, but in the context of any study for that matter,
#
that if they wanted to roll out a study within two months, they could do it and do it really
#
well of a high caliber. As the results of these studies started coming in, it became
#
a lot easier in terms of what we definitely know and what we definitely do not know. So
#
there's still uncertainty. For example, you know, the use of blood thinners is still an
#
uncertain area. A couple of studies published just in the last week, one showed that aspirin
#
possibly doesn't work. One shows that when you use blood thinners in a treatment dose,
#
which we call a therapeutic dose, a high dose doesn't work. But this is still evolving.
#
So you know, there is still uncertainty. But as and when the large trials showed us that
#
things definitely don't work, I think gradually things started becoming clearer. This is one
#
of the places where being an epidemiologist kind of possibly helped me because the cynicism
#
was the default. The default was never, you know, let's try this new thing. Let's try
#
something else. The other thing that was constantly reassuring was that the number of individuals
#
who got hospitalized, the number of individuals who got severe enough was still a small fraction
#
of the total number of cases. When that first zero prevalence study came out, for example,
#
it said 57% of people in slums had already been infected. And if you extrapolated to
#
that, you realize that the fraction of individuals who got admitted was a really tiny fraction.
#
It wasn't really big if so many people had antibodies already. So there were two reassuring
#
things therefore, right? One was that this was a disease which spared the majority, which
#
did not cause a majority to die. Had it been a disease which did cause a majority to die,
#
we would have been in big trouble, because then we would have to make constantly make
#
very difficult choices. The reason we could go to what is called masterful inactivity
#
or watching, you know, closely observing, monitoring is because we knew at the back
#
of our minds that a majority of individuals are going to do very well without any intervention.
#
That was one thing that was very useful from a treatment perspective. The second thing
#
that was very useful was the data that kept coming in and telling us what didn't work.
#
So when plasma got thrown out and we realized it didn't work, when drugs like remdesivir,
#
there was more accumulating evidence to suggest that it didn't work, lopanavir, ritonavir,
#
there were a lot of hydroxychloroquine, all these drugs, reasonably quickly there was
#
information out there to tell us that we shouldn't be using it. So I think the combination of
#
a low severity disease in that sense, as an absolute fraction, combined with the rapidity
#
with which evidence was synthesized, I think really helped us gain confidence as the pandemic
#
You know, one of the things that we sometimes talk about in public policy is this flawed
#
mindset of we must do something, this is something, therefore let's do it. And I guess to some
#
extent that is a pressure which would have hit doctors during this period because you
#
would have been under pressure to medicate, to give some medicine or the other. And therefore,
#
even if you are skeptical of say last year, one would have been skeptical of hydroxychloroquine
#
and this year, you know, during the second wave, we've had ivermectin, remdesivir, plasma
#
all lauded as sort of therapies. I guess one, there would be pressure on doctors to prescribe
#
them because relatives would be saying, no, no, you know, that doctor prescribed this
#
for my uncle and so on. How does one deal with that? Because one of the things that
#
I noted was that there was this panic on social media with these hundreds of messages every
#
day or hundreds that I saw every day about ivermectin needed, remdesivir needed, plasma
#
needed. Well, we know they don't work. And the problem is that frantic relatives going
#
out to get them are actually catching COVID, standing in line somewhere and trying to get
#
the damn medicine, therefore compounding tragedy on tragedy as it were. So as a doctor, how
#
did you deal with that? Did you face that kind of pressure from your patients?
#
It was an extremely difficult period. And to a certain extent, it still is. It's just
#
that when you when you gain a voice that is that has a little more credibility and respect
#
with time, people tend to trust you a little more. But, you know, it was extremely difficult
#
at the start to tell people that observation to say that monitoring and, you know, to constantly
#
handhold them and say that we are monitoring you. We are not saying don't do anything and
#
just, you know, leave it to God. We're not saying that. We're saying that we are monitoring
#
you. Steroids came on very early as life saving drugs. So we said that we knew that if you
#
do deteriorate, we have something that might work. Tocilizumab, at some point of time,
#
there was evidence to suggest that it works. So we did have drugs for when people deteriorated.
#
But to tell people to just stay put was extremely challenging and not just challenging. It was
#
challenging. It was time consuming. It was fatiguing as a doctor to have the same conversation
#
over and over and over again. And it would give me nightmares at some point of time,
#
you know, because I am the guy who's telling somebody that you don't do anything, knowing
#
fully well that there, you know, a fraction of the don't do anything is going to deteriorate.
#
The unfortunate part is that I have no control over that deterioration. I don't have a
#
drug that can prevent that deterioration. I don't have the drug that can make the person
#
better today. So that deterioration doesn't happen. So I am telling a person that I offer
#
you nothing today, knowing fully well that, you know, a small fraction of these individuals
#
who got nothing would deteriorate. And then in hindsight would clearly blame me as being
#
the person responsible for their deterioration, not understanding that that deterioration
#
unfortunately would have happened no matter what, you know. So that was very scary to
#
sleep at night knowing that there was a cohort of patients out there who you were handholding,
#
not giving anything and knowing that, you know, when you wake up in the morning, there
#
would be a WhatsApp message once in a way saying that, you know, this person's oxygen
#
levels fell the previous night, got admitted. And you hope, you know, you hope that their
#
faith in you was strong enough that they realized that you did nothing wrong. You know, you
#
were following the science. And, you know, fortunately, I think a lot of my patients
#
got it, but it takes a lot of time in terms of counseling and handholding as well. That's
#
what I resent to a small extent that, you know, I was the one having to explain why
#
I was doing the scientific thing while the guy next door who was prescribing 10 drugs
#
had no explaining to do. He said, oh, you come in, you got COVID, take these 10 drugs,
#
go patient happy, doctor happy, you know, life moves on. Nine out of 10 of his patients
#
also got better because that's the nature of the illness. One out of 10 who didn't get
#
better would probably say, you know, but my poor doctor tried everything and still I didn't
#
get better while I was unfortunately the bad guy. And, you know, that, that was one thing
#
that I, that I didn't really like in terms of having to explain being scientific. I don't
#
think that's how, how medicine works. You know, the burden of proof should be on the
#
drug. The drug has to prove its worth. I don't have to prove the fact that my scientific
#
choices of not giving you a drug because there is no drug that works need to be justified
#
Yeah. And I can totally see why any doctor would be incentivized to give that cocktail
#
of drugs just to avoid the blame because that is what the patients expect. And that's kind
#
of tragic. So tell me quick digression before we come back to COVID. How does one deal psychologically
#
with patients taking a turn for the worse and dying over the years over so much medical
#
practice, especially for a doctor, like you pointed out where you've been trained to when
#
you try to look at each patient as not a collection of statistics of age, weight, whatever, but
#
also as a human being, you know, their names, you kind of, you're chatting with them about
#
their lives and, and then at some point they go and some of the time you can't do anything
#
about it. Some of the time you can in hindsight know that had I done something different,
#
it would have worked out differently. So how did you deal with that kind of a process?
#
Is it still hard after all these years or, you know, does one kind of build a system
#
of mental defense where, you know, you can just get on with things?
#
I mean, the probabilistic thinking and the uncertainty kind of is what you use to soothe
#
your conscience when it does happen. Because, you know, at the end of the day, you have
#
to soothe your conscience in some way, otherwise, you know, you are not going to make peace
#
and you're not going to be, and if it shatters your confidence completely, you're not going
#
to be able to offer the best to the next patient, you know. So I think that the probabilistic
#
thinking probably helps in some ways in that situation, because I've seen doctors swing
#
from one direction to the other. So you have one person who beats the odds and something
#
really bad happens, and then you become extremely defensive after that. Sometimes it's because
#
of litigation. Sometimes it's just because of a conscience, which can't make peace with
#
the fact that something like that happened. And if it serves to grow, great, you know,
#
which is, which is what it's all about, you know, on a daily basis, all of us are growing.
#
I would be stupid to say that, you know, I've done everything right. All of us have made
#
judgment errors. All of us have, you know, sometimes relied on our instinct when our
#
instincts have failed us. And as long as we learn from them in a way that's not hugely
#
detrimental, you know. So let me give you an example. When we give drugs for tuberculosis,
#
if you give it in a young individual, three out of a thousand individuals, the drugs will
#
affect the liver. Now, if that makes me start doing liver function tests on all the thousand
#
to prevent that, to pick up those three early, firstly, there's no, there's no reason to
#
believe that I would be able to pick up, pick them up early. But, you know, because symptoms
#
manifest when the liver doesn't work function properly, and maybe the symptoms come before
#
you can pick it up early. But if I, you know, have one patient out of a thousand, get a
#
bad liver, get a bad episode of hepatitis, get admitted, for example, and it completely
#
shakes up my belief system. And then I start doing liver function tests on every single
#
patient who comes. I don't think that's fair as well. You know, I mean, it's, it's okay
#
to feel that something bad should not have happened. But you also know that that was
#
within the probability that's been described the world over. You need to accept that that's
#
what happened. Maybe your education skills need to get better. Maybe you, maybe the patient
#
came in too late. Maybe the patient could have come a day before when they started noticing
#
symptoms rather than wait. So it's great to audit what went wrong. It's great to look
#
back and try and figure out what went wrong and how can we improve on things. But that
#
balance of not therefore, you know, doing a U-turn and completely going the other way
#
in terms of being overly, being gung-ho about investigations, being very, very defensive.
#
I think that's, that's a challenging balance. That being said, I mean, it's, it's, it always
#
shatters you when, when you lose someone unexpectedly. And that's the uncertainty that medicine
#
is all about. You know, there are, there are some individuals who you will lose on your
#
watch with zero expectations of you losing them. Those tend to be rare events, but when
#
they do happen, you have no clue in terms of, you know, was that going to happen anyways?
#
Did it happen because of something that I did? Could I have done something better? Was
#
I not serious enough in terms of, you know, investigating a little more, pushing a little
#
harder? Did the message not come out clearly? And that introspection is, is unfortunately
#
part of the deal, you know, and, and, you know, fortunately shockers of events, which
#
completely fall outside the probability of what you think are rare, you know, fortunately
#
they're rare, but when they do happen and, and, you know, that's the, the, the busier
#
you get, the larger your base of patients, such events do happen with an increasing frequency
#
of what, what would happen once in two years, maybe starts happening once in six months,
#
but you definitely lose sleep when that happens. You, it shatters you, it completely disturbs
#
you for a few days and, and you never forget that. So that you will never forget when you
#
talk about, you know, your past experiences, you will never forget a person who, who behaved
#
in a way that you completely didn't expect.
#
And you mentioned litigation a couple of times, like, is that something that's an issue in
#
India that you have to worry about litigation? Are you in probabilistic terms, how likely
#
are you to get sued? And, you know, also just in general to deal with relatives of patients
#
when things don't go right. Like we've heard of stories of shocking stories of doctors
#
and nurses being beaten up when recently when patients have died of COVID-19, but in general,
#
how big is the litigation issue and just dealing with relatives of patients?
#
It is a big issue, not in terms of, you know, the, the volume of cases that, that get registered,
#
but it's a big issue in terms of even if one case gets registered, the way the system is
#
designed is that, you know, you're almost guilty unless you prove your innocence. And,
#
and that's, that's, that's very challenging. So most of us have gone through it once a
#
couple of years or so. And when we do go through it, it's extremely biased against us is what
#
most of us tend to agree on. So let me give you an example. So in the city of Mumbai,
#
for example, if, if somebody wants to file a case, they can simultaneously file it in
#
three different forums. There's the consumer forum, there's law, and there's the medical
#
council. So you can simultaneously file the same case in all three and the doctor has
#
to make appearances in all three simultaneously, you know, and it's not that the decision in
#
one can influence the decision in the other, you can get three separate decisions. So once
#
you go through something like this, it does make you a little defensive for sure. It does
#
change the way in which you, in which you naturally treat patients. And, you know, I
#
do understand that patient rights have to be protected at all costs. I do understand
#
that, you know, doctors make, make mistakes and have to pay for it when they do make mistakes
#
in some form. That's the only natural way to do things. You know, we all have indemnity
#
insurance to accept the fact that we will make mistakes, you know, no matter what. And,
#
and therefore the compensation needs to be covered by indemnity. But as long as the process
#
is fair, I think good will come out of it. As long as the process is skewed to such an
#
extent that doctors start second guessing every move that they make, it's, it's, it's
#
going to go in the U S way where everything is so defensive that the system will get expensive.
#
It's the example I gave, I just gave you, right? So if I want to make sure that nobody
#
gets hepatitis, I'm going to just make 1000 people do LFTs to kind of say that, you know,
#
I covered my grounds, I covered my bases. I did what I had to do despite that this happened.
#
Okay, you know, I can't help it. And do it just from that perspective, do it not because
#
it's going to help my patient, do it not because I genuinely believe it makes a difference,
#
but do it only because on paper, I have done it, you know, and that's, that's protected
#
me. So I really hope it doesn't go that way. But unfortunately, you know, there are indicators
#
that it might be going that way.
#
Let's get back to COVID. And you know, one of the very valid points that you made, and
#
which I kind of want to underscore is that if someone is using medicine, the burden of
#
proof is on that person, that you got to show that the medicine works. And the reason, you
#
know, that deserves underscoring is that it's not that if a medicine doesn't work, it doesn't
#
work. Medicines have tons of side effects. Like, you know, in the case of steroids, as
#
we now know, and as from what I recall, you were earlier than others in pointing out vociferously,
#
that there's no point in giving steroids in the first week of infection and all because
#
people will get a fever and then they'll fight the fever and then they'll get better most
#
of the time when they don't get better when they deteriorate when there are oxygen issues.
#
That's where steroids like dexamethasone and all can be useful. The problem with giving
#
steroids early on is that it will actually work in getting the fever down, but it will
#
also get the immune system down. So COVID will actually hurt you more. And it's in the
#
second week where you could just completely collapse. And it's literally because of the
#
medicine that was given to you. So now what I'd like you to do for our listeners is take
#
them through how you look at this whole treatment cycle of COVID. What is recommended? What
#
is not? Like at a bare bones level, I know that in the first week, if you just have fever,
#
you got to monitor your oxygen and you got to take paracetamol and that's it. Right.
#
So just kind of go through that kind of protocol for people who might be listening in and especially
#
people who are not in big cities, who don't have access to doctors and all of that. How
#
should they approach it? What should they do? You know, because people tend to panic,
#
you know, you'll have an epidemic of sighing all over again.
#
So I think the reassuring thing that all your, all the listeners need to know is that we
#
still believe that a majority of individuals get better with nothing. Right. If you look
#
at the recent study, in fact, from the US, which was the antibody cocktail study, they
#
found a hospitalization rate in high risk individuals. So individuals who had at least
#
one risk factor in the placebo arm of that study, it was about 3% of them who got hospitalized.
#
So it's not even the traditional 15% that we talk about. It's possibly a lot lower.
#
If you include the seroprevalence studies in India as well, I'm sure the figure that
#
we arrive at would be somewhere around 3% of hospitalization. So 97 out of 100 individuals
#
will get better at home without anything being done. And I think that's very reassuring.
#
Now what happens is the typical cycle of COVID is that the first week is where the virus
#
enters the body. The first week is where the virus multiplies for some time. The first
#
week is where the body launches an immune response against the virus. And that immune
#
response, just by virtue of the fact that 97% people probably get better, suggests that
#
that immune response does its job in most of the cases. Somehow antibodies are generated.
#
They neutralize the virus. You could feel fatigued. You could feel tired. You could
#
feel low energy for some time, but by and large your life will move on. By and large
#
you will return to baseline in a month or so. Now in that first week, what are the things
#
that have been shown to work? One of the things that may have a role is an inhaler. An inhaler
#
of steroids, but steroids at a very low dose inhale directly into the lungs, in some way
#
modulates the inflammation, helps in some way. And there are a couple of small studies
#
which have shown that it may work. Again, the caveat is that these are small studies,
#
maybe down the road that we may realize that they aren't necessarily wonder drugs or great
#
drugs. Maybe it's a small role. That being said, inhalers are extremely safe, right?
#
So the safety profile of inhalers has been established for a long, long time now at the
#
doses that's being recommended for COVID for a short period. Again, we don't anticipate
#
any major side effects. So the inhalers work in the first week, especially if you have
#
a cough, especially if you have lower respiratory symptoms. The other thing that works in the
#
first week is the antibody cocktail. So the antibody cocktail is basically preformed antibody.
#
So normally what your body would do, generate an immune response that one to two or one
#
to 3% of individuals in whom that immune response doesn't work for some reason, they might benefit
#
with boosting their immune response with an antibody cocktail injected into them. Now
#
this works when given within the first seven days of symptoms. So it has to be given early.
#
It is recommended in individuals who have risk factors. So it's not recommended in individuals
#
who otherwise also are likely to do well. So if you have heart disease, if you are elderly,
#
if you have underlying kidney disease, if you are immunosuppressed in some ways, if
#
you are obese, if you have diabetes, you know, these are the risk factors in whom you could
#
consider the antibody cocktail. Of course, it's very expensive. It costs about 60,000
#
rupees for a dose, but it may have a role. So that's what works in the first week. Now
#
by the end of the first week, majority of individuals would have recovered. The fever
#
would have settled. The cough would start getting a little better. Their oxygen levels
#
would be rock solid throughout. They would never have dropped. And these are individuals
#
who don't need to do anything at this point. You know, if the cough has settled, they stop
#
the inhaler as well. In this small fraction, a small proportion of individuals at the end
#
of the second week, what happens is a hyperimmune response. So the body's immunity has kicked
#
in, but it's overzealous for some reason. It's over enthusiastic. It does too much.
#
And that hyperimmune response causes the oxygen levels to go low. That causes a person to
#
get breathless, the cough to get worse. This is the stage at which problems occur. This
#
is the stage at which individuals often get hospitalized. If your oxygen levels are low,
#
this is where the steroids work. So the oxygen levels low mean that your lung is full of
#
immune, immune cells. They could be white blood cells. They could be antibodies. This
#
whole cytokine storm that we talk about, there are lots of immune cells which are trying
#
to fix the lung, but are actually doing harm. And they are suppressed with the use of corticosteroids.
#
So steroids suppress your immunity at this point where the immune response is too much.
#
If you do the same in the first week, when your body's natural immune response is trying
#
to fight it, those same steroids will suppress that natural immune response and leave you
#
completely exposed to the virus, right? So the virus has an unopposed position where
#
it can multiply. There's no natural immunity. The steroids have suppressed that. Sugars
#
also go up with steroids. So it's a great environment for the virus to proliferate.
#
At the end of the first week, very often there's no virus left in the body or there's miniscule
#
virus. So therefore it's safe to use steroids to suppress the immune response. Now, if you
#
deteriorate further, so if despite giving you steroids for about one to two days, there
#
are certain markers which also help if your CRP is above 75, you might be a candidate
#
for a drug like tocilizumab because that's a drug which supplements the use of steroids.
#
It tries to suppress your immunity even further. Some studies are also looking at higher doses
#
of steroids. So the doses of steroids which are currently recommended are six milligrams
#
of dexamethasone once a day. But there are some studies which suggest that if despite
#
the dexa you're deteriorating, 12 milligrams could be attempted. You can double the dose
#
of steroids, especially if you don't have access to tocilizumab or again, it's a very
#
expensive drug. Oxygen is lifesaving. If your oxygen levels are low at this stage, being
#
on oxygen helps. Sleeping prone really helps because it helps improve oxygenation. Being
#
on either non-invasive ventilator or high flow nasal devices also help in helping your
#
lungs recover, giving you adequate oxygen while your lungs are on the pathway to recovery.
#
And if things still don't recover at this point, then you get onto ventilation, then
#
you get onto whatever salvage modalities are feasible.
#
So that's fascinating in the picture emerging here is that a lot of these people, it's not
#
the virus that is killing them directly. The virus is setting off an immune response, which
#
is more or less eliminating the virus by the end of the first week or reducing it substantially.
#
And then the cytokine storm really kicks in or other, you know, the overactivity of the
#
immune system is what really gets you and it's a downward spiral from there. Unless
#
all of these treatments come in. And of course, when you have oxygen shortages and it's basically
#
the system killing you because otherwise those people won't have died. All incredibly fascinating.
#
So you know, we are almost at the end of the time that you had allotted me and of all my
#
guests, I would feel incredibly guilty about taking too much more of your time. So just
#
a couple of questions, the one on COVID and then one back to medicine in general. And
#
the COVID question is that you guys have just managed to get the official guidelines of
#
the government actually changed to reflect what you feel the treatment protocol should
#
be, which was earlier, not the case earlier. The case was science would find something
#
and then the bureaucracy would catch up later. The treatment protocols would catch up later.
#
But now hearteningly, one is finding that even the official guidelines are along these
#
lines that don't do over treatment, don't use all these random plasma, ivermectin and
#
all that, which don't work. But instead this is a protocol to follow, which is kind of
#
exactly what you laid out. So how easy or hard is it to sort of work with these kind
#
of authorities where bureaucracy is an issue, where again, the cover my ass incentive may
#
get in the way where they might be wary of not recommending something. What if something
#
happens? Why not just put all the medicines out there? So what is that process like of
#
dealing with government, of dealing with the authorities like that? Because in some capacities
#
even you have given at least informal advice, right?
#
Right. So I cannot take any credit for the change in the guidelines. Unfortunately, we
#
don't know who the authors were also, because I think all of us want to pat their backs
#
and all of us want to say thank you, but we don't really know as of now who to thank.
#
But that being said, it's a great move forward. The process, I wouldn't know what was the
#
process which actually led to the final change in policy. But I think all of us, in whatever
#
capacity possible have been trying to push people towards rational cures. I think some
#
of it also is a consequence of bad outcomes happening. So I think the mucormycosis pandemic
#
sensitized a lot of people to the fact that steroids were being possibly used for prolonged
#
periods of time, possibly being used inappropriately. And that was an eye opener. So I think it
#
took a second pandemic of the mucormycosis to realize the inappropriateness of steroids.
#
Now, it's unfortunate that that's how it happened. But in this case, I think that was a nudge
#
towards shifting to evidence-based medicine as well. I think the rushes for remdesivir,
#
the black marketeering that people saw for remdesivir, also was a nudge in the right
#
direction in terms of people realizing that it wasn't just a science problem. The science
#
problem led to actual bigger problems in terms of this belief that it was life-saving, this
#
exploitation of individuals who were at their most vulnerable. And I think that was an eye
#
opener as well. Plasma, I think it was finally, after saying it over and over again in different
#
forums, I think different... Plasma was actually unfortunate also because India, that was one
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great trial which came out of India. In the midst of this pandemic, we still managed to
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do one good trial, which was Placid, which was related to Plasma. We proved that it didn't
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work and we still didn't take it off our guidelines. So that was unfortunate in a way. But I think
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people pointed it out over and over again. After recovery published their data from Placid,
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I think that changed as well. It's not been easy, but I think there's a network of individuals
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who have the ability to influence the right people, the people on committees, the people
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on guideline committees, the people in positions of creating those guidelines. And I think
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the gradual soft influence that everyone had around possibly nudged them in the right direction.
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So I wouldn't know the exact process in which it changed, but I think it's a great move
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that it changed. And let's hope that whatever thought processes opened up these doors would
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still stay in place for future updating of the evidence.
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That's a fantastic last point that you don't just want it to be this one-off where they
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did the right thing and whatever, but you want those processes to remain. So it is always
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science-based and evidence-based. And by the way, in an earlier episode, I mentioned about
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Remdesivir being slightly dubious. And one doctor actually wrote in to me, I don't remember
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if he wrote to me or he put a Twitter comment, but he basically said that, why are you spreading
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wrong information? I have used it on my patients. It works. To which I, if someone like that
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is listening to this, I would just say, go back to the start of the episode and listen
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to what we said about regression to the mean. And also one should not quickly ascribe causation.
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Maybe it is some other medicine that actually helped. So we never know counterfactuals there.
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So my final question is this, and it's a broad question about medicine in general, which
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is, so when we look back to the 19th century, we know the state of medicine was so dismal.
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And we think of today and we say, oh, we have advanced so much, but it is another fallacy
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that humans tend to commit. They think that where they are now is a peak of human progress.
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And the truth is that a hundred years later, when we look at the state of medicine today,
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we are going to say, oh my God, what primitive people, what are they even doing? Right. And
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it strikes me that we are at an exciting time, perhaps even an inflection point for medicine.
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And I'm sorry if this is naive, please correct me. But I say this completely as an outsider,
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but just looking at, for example, what our understanding of genetics and the genome,
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the insights that we've gotten from that, or what artificial intelligence is doing.
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Eric Topol has a great book, Deep Medicine, about that. It strikes me that there's a lot
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to be excited about the future. Now you are, of course, on the cutting edge of all of this
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in terms of reading up on it and understanding it and all of that. So looking ahead, what
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is the future of medicine? Like, what do you think 20 years later you will be doing differently?
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What are the ways in which your life will be better? I mean, some people speak about
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an mRNA vaccine for cancer and all that. That would be really nice. Please bring it on.
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Hopefully sleeping enough will prevent Alzheimer's for those of us who sleep enough. But apart
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from these frivolous asides, how different will the future of medicine actually look?
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And another context in which I kind of bring that up is that in India, most people don't
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have the privilege to go to a doctor. The vast majority of India is completely underserved
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or served by quacks. And the vast majority of doctors also will not know treatment protocol
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for basic things, as I discussed in my episode with Kartik Muralidharan. So actually what
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most Indians do is that they just get by in one jugaru way or the other for minor things.
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And it is only when something major happens that they actually land up at a hospital and
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all of that. So that is their medicine. Is there hope for them? Is there hope for, say,
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AI and all of that to help empower them with information and knowledge and those kinds
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of resources? Some of the changes are just to allude to what we've already spoken about.
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So something like sleep apnea, for example. So if you see 20 years ago, so that's roughly
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within this. I was in MBBS 20 years ago. The machine used to be about 10 kilos in terms
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of weight. It used to be really bulky, really uncomfortable masks that people couldn't wear.
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Almost everybody was cribbing and complaining. You look at where we are today, right? It's
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a 400 gram machine, which is now currently available. You get a download, which clearly
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tells you what was the level of obstruction before, what it is today. There is feedback
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in terms of whether there's a leak, whether you want to change those settings, how you
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want to manage things. So just in terms of the sheer information that's currently available
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to us to tweak things, to improve comfort, to improve patient adherence, all this has
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improved within a span of less than 20 years or so.
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So tuberculosis, for example, another disease where once upon a time, when the MDR epidemic
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or the multi-drug resistant TB epidemic began, we would do cultures. The cultures would take
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about six to eight weeks to grow. Then we would do drug susceptibility tests, which
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would tell us what is sensitive, what is not sensitive. Now we have cartridge based tests
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with which within one and a half hours tell us whether you have MDR TB or not. So there's
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been a lot of progress, which we've already experienced in the past 15 to 20 years. Unfortunately,
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the point that you make is very valid. So progress at the cutting edge does not necessarily
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percolate down to progress for the vast majority. However, I mean, something like telemedicine,
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for example, has the potential of reaching people in remoter areas. I think COVID has
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normalized telemedicine to a certain extent. So I work with IIT and we've created this
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digital stethoscope, for example, which when given to a primary healthcare center, the
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person can apply it to a person's chest and I can listen to the sounds via Bluetooth,
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via an app somewhere else in the country. So I can literally auscultate a patient I'm
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not seeing. These are potential things that can make a difference, but it's not only technology,
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it's also the human skill that needs to develop. If we've realized, you can give people thousands
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of ventilators, but even at an institute like mine, it takes a certain level of skill to
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use a ventilator and I cannot claim to have complete expertise. I probably have 50% expertise
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because I'm not an intensivist. It's the intensivist at my hospital who really knows how to handle
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a ventilator. So to assume that somebody who's not even at a tertiary care institute in a
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smaller center would just be given a ventilator and the person would be able to handle the
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ventilator is not necessarily true. So I think the improvements in terms of technology has
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to go in parallel with the improvements in terms of human expertise as well to use those
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measures. When you talk about molecular genetics, when you talk about phenotyping individuals,
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so for sleep apnea, there's a potential of a new drug which can cure sleep apnea in a
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certain subset of individuals. So even a CPAP might look bulky, even the current CPAP might
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look bulky and redundant 20 years from now if you have a pill that's going to fix it.
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But that level of what we call individualized medicine, personalized medicine, that level
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of phenotyping to try and figure out who fits into which basket is going to be expensive,
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it's going to be difficult to interpret, difficult to manage. So we struggle with letting evidence
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based medicine for a disease that has basically five drugs or six drugs, if we struggle with
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that percolating. Imagine trying to communicate the sophistication that you get from a whole
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genome output and trying to explain the nuances to anybody. I'm not looking down on somebody
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or I'm not talking about me being superior to somebody else, but we are going to be as
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illiterate about things like that as anybody else and to constantly be able to update yourself
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and to then be able to make that reach the lowest rung of society, I think that's going
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Yeah, I mean, these are very wise words in the sense that, you know, I am as optimistic
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as you that science will keep marching on forward, but the state and the society also
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have to keep up and advance similarly. And what I would also point out is that many of
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these treatments that will come out from understanding the genome better or using the insights of
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AI are something that privileged people like us can access really easily. But that is not
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the core problem. The core problem is something else and the core problem is just getting
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it out there and especially in India with the state of both our state and our society.
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It's worrying, but hopefully science will empower us and we'll get the job done. Lance,
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I'm so privileged and lucky to have three hours of your time of all people to talk to.
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So thanks so much for sharing your insights and more power to you for all the amazing
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Thank you, Amit. Thank you for having me over. I know this is a great podcast and all of
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my friends and family are very excited for me being a part of this. So thank you for
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It's my pleasure. Thank you so much.
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If you enjoyed listening to this episode, check out the show notes, dive into rabbit
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holes, a lot of fascinating stuff in there. You can follow Lance on Twitter at lancelot
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underscore pinto. You can follow me at Amit Verma, A-M-I-T-V-A-R-M-A. You can browse past
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episodes of The Scene and the Unseen at sceneunseen.in. Thank you for listening and hey, take care
#
Did you enjoy this episode of The Scene and the Unseen? If so, would you like to support
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the production of the show? You can go over to sceneunseen.in slash support and contribute
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any amount you like to keep this podcast alive and kicking. Thank you.
