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A couple of years ago, during COVID's second wave, my father died in an intensive care
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unit. It was in a COVID ward, visitors were not allowed and he effectively died alone,
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as perhaps we all do. I have had friends spend time in ICUs, some as patients and some as
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doctors tending to many who are losing their lives and perhaps losing their senses before
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that. And these medical care professionals also have to tend to the relatives of the
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patients, struck by panic and grief, facing the truth of their mortality and perhaps asking
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if love is futile. It's hard being in intensive care whether you are on a bed or standing
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besides it, weighing up the balance between treatment and care. My guest today has had
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over two decades of experience in intensive care units and he says in this episode that
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he has never saved a life, he has only postponed death. Perhaps this is the only consolation
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we have when we lose a loved one. We will all die. And a lesson we could take from this
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is that while we are alive, we must all be fully alive, uncompromisingly, unblinkingly,
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excruciatingly, wholeheartedly, passionately alive. What we have will be taken away. Hold
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Welcome to The Seen 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 Seen and the Unseen. My guest today is Nitin Arora, a specialist in intensive
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care to the point that he's written books on it and is considered one of Britain's top
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experts in the subject. He lives and works in Birmingham and we have a fabulous conversation
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on a subject most of us would prefer to ignore, but one day he will almost certainly have
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of intensive care units. He speaks about what intensive care involves, the differences between
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Britain and India, why India has both the best and the worst doctors, how he has dealt
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with patients and relatives, how he dealt with COVID and the subject of PTSD among ICU
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survivors. At least as many ICU patients later suffer from post-traumatic stress disorder
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as do soldiers who have been to war. And you will find in a massive TIL after the three
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R mark that it's far worse for women. In the first part of this conversation, we speak
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of Nitin's journey from Punjab to England and why he now speaks more Punjabi in Birmingham
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than he used to do in Amritsar. Much insight here, but before we get to the conversation,
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let's take a quick commercial break.
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Hey, the music started and this sounds like a commercial, but it isn't. It's a plea from
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me to check out my latest labor of love, a YouTube show I am co-hosting with my good
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friend the brilliant Ajay Shah. We've called it Everything is Everything. Every week we'll
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speak for about an hour on things we care about, from the profound to the profane, from
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the exalted to the everyday. We range widely across subjects and we bring multiple frames
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with which we try to understand the world. Please join us on our journey and please support
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us by subscribing to our YouTube channel at youtube.com slash Amit Verma, A-M-I-T-V-A-R-M-A.
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The show is called Everything is Everything. Please do check it out.
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Nithin, welcome to the scene and the unseen.
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Hi Amit. I've been a fan of your podcast for many years. I've spent endless hours listening
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to your podcast and I am very, very happy to be on your podcast.
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Thank you so much for coming on and I'm a little feeling a little guilty now that you
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spend many hours on my podcast because the work that you've done in the last few years,
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especially as a senior intensivist in the UK during COVID, training other people, running
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your own operations, not just being, you know, one doctor among many is so incredibly important
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that now I'm beginning to worry if there has been any huge health impact of my podcast
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being heard by people like you, but I will presume you had the discretion to listen to
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I have. I have. And actually it was one of the healthiest things I did listening to your
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podcast. I would suggest that listening to your podcast and to listening to, and I won't
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name him, the former editor of the Indian Express and the former writer of Rude Food.
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That's the three things that kept me sane during the last three, four, five years.
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Good to hear that. And you know, Shekhar Gupta and Veer Singh, we are both very fine people.
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I presume you're referring to them. And Veer, of course, has been on the show.
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I think they both do sterling public service and so do you. And I'm glad to have you on,
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but before we get to talking about your sterling public service or before we get to talk to your
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career in medicine, I want to get to know you, Nitin Arora, the person a little better. So take
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me back to your childhood. Where were you born? What were your early years like? Give me a sense
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of that. Okay, so my parents are both doctors. I was born in PGI Chandigarh. Nitin, I'm sorry to
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interrupt you. I never interrupt, but I was also born in PGI Chandigarh. So that makes two of us.
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I also studied in DAV Chandigarh. That I didn't.
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So I was born in PGI Chandigarh because I was a complicated pregnancy.
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So, and my mother was a resident over there. However, then my parents
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and my grandparents all were from, what do we call it now? We call it pre-partition Punjab.
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So they all migrated from pre-partition Punjab from the other side to this side.
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And obviously there were tragedies, there was familial trauma, what we now tend to call
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intergenerational trauma. And they ended up in an area around Ferozpur
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in Punjab. So that's where I spent most of my childhood. I spent most of my childhood actually
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in a little town, which is actually famous for being the birthplace and the hometown of
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a former president of India, Giani Zal Singh, Fareed Kut. So I spent
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probably about 12 years in Fareed Kut.
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I was just like you. I was a child of privilege, born to two doctors who worked in government
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service, who had a little bit of private practice on the side and basically studied in the best
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school in the district. And you will understand what that feels like.
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And at that point, it didn't feel like privilege. It felt like everyone else. It felt like
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when this is what all of my friends are like. But now 40 years later, 50 years later,
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I realized how big a privilege it was. And then I studied in a school where,
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and this is small town India, when Fareed Kut had a population of less than 80,000 people
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at that point. And this school that I studied in, where I was at one point the head boy,
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and I was the class prefect for about four years, we had a two rupee fine for any time that you
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didn't speak English. You know how it was like in 80s Punjab, if I can speak in Punjabi.
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So to translate, you talk in English to your pets, you talk in Hindi to your kids, and you talk in
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Punjabi to your friends only. And yeah, that was the sort of extremely snobbish,
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privileged school that I went to. And then I was
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educated in loose terms, very loose terms. But I learned a lot of book knowledge. I was
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a very privileged child in that I had an almost photographic memory.
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I can still tell you what page 249 of my Punjabi textbook in class eight looked like.
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So I was, yes, I was extremely privileged, both in terms of
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family circumstances and my memory. However, for some reason, I decided to go into medicine,
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possibly because both of my parents were doctors.
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That could be a good reason. However, you didn't go into civil services, did you?
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No, no, in fact, I became a staunch libertarian and enemy of the state despite my father being
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in the U.S. So there you go. Yeah. And I am an enemy of medical education.
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So I did decide to go eventually in favor of medical education. So I did my MBBS
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from Amritsar in Punjab. And as you will understand and as most people listening in India
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will understand that in the late 80s and early 90s, Amritsar was, let's say, the hotbed of
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extremism. Would you agree with that? Till the mid 80s, yeah. I mean, after that,
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the sub-teacher, but late 70s, early 80s, for sure, it was from the outside, it seemed like
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a place fraught with a lot of violence and so on. It was not uncommon for my medical college to be
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shut down with arch strikers. So he just did that. He just did that. There was no option really.
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Now, before I heard your podcast for the first time, I had never heard the word libertarian.
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When I heard your podcast, I realized that I had been a libertarian for a huge amount of time
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without actually understanding that word. So my parents were both professors in the medical
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college I studied in. I understood how controlling they were. Can I talk about
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personal stuff here with you? Absolutely, absolutely.
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So my first girlfriend, when she found out, my parents called her into the office and said,
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Oh, you know how life works in India, and especially in 80s and 90s India. And then
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I went through my MBBS. So when I degree, I start applying for postgraduate interviews
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and exams. And I fall in love with someone that lives two houses away.
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So this is this is the 90s. So there is no Skype. There is no video chat available. So what we do
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is both of us take our cordless phones out and go to the roof. And so we can see each other and we
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can talk to each other without having to shout. So we call that video chatting. Lovely. Wow.
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So this is video chatting in the 90s. We get married without consent offense.
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And then basically, I have to threaten my professor and my wife's professor at one point with going
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to the media. Why were your teachers behaving like that?
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My parents were professors, both of them in the same medical college that we were both training in.
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We married without consent because, well, sorry, no one can marry without consent.
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I would rephrase that. We married without permission from our parents because no one
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can marry without consent from your partner. And my parents were not happy that I was marrying
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someone that was slightly older than me and had been divorced in the past.
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And as you as you will know, in in 90s India, a marriage, but essentially a love marriage and
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and also a marriage where one partner has been
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divorced in the past was a complete no, no. So it was a huge, huge problem. And so
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what happened was that my parents, because they were very influential and they were both
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professors in the medical college, they tried to influence others. The, I managed
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Punjabi me bolo. Bolo sir.
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Toh main basically thakka lagaage waise di te karadhi.
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Teeke degree poori karadhi.
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It was and at one point our professors told us very clearly
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that unless you leave each other, we will not give you your degrees, you will not pass.
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At that point, I said, okay,
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mujhe kar do fel. And actually,
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they did that. That happened to me.
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But yes, my wife passed. She was appointed as an assistant professor at Amritsar Medical College.
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But then when I decided that I wanted to, that I wanted to do intensive care in the UK,
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she chose to come with me. So that's a huge sacrifice when a prestigious government college
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in India is huge. So I decided to come to the UK to do intensive care. And then I first did my
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MRCP. So that's my medical training. Then I did FRCA, which is my anesthesia training.
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And then I did DICM and FFICM. So that's my intensive care training. So basically it
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took a total of nearly eight years.
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This is a medicine, anesthesia or intensive care to do intensive care in the UK for the last
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five years. Now, I have been chair of the education division for the intensive care society.
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So I'm an elected member of the executive board and I've been chair of education for
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a number of years now. We do a lot of, through COVID especially, we did a lot of webinars,
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we did a lot of online teaching stuff, and we did a huge amount of both online and offline,
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depending on how you describe it. When are emails online or offline? I don't know.
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But we did a lot of teaching around COVID. And because after Italy, Britain was the next
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country that got a huge big wave of COVID, the Indian Society of Critical Care Medicine
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somehow decided that they wanted to invite me as an external advisor on their
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online teaching webinars, all of that stuff. So I ended up doing a lot of work around there.
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Now, I have, if I had my choice in the day, remember in the late 80s, so you are only
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what, three years older than me, something like that. So you remember that at that point
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at that point in India, your choice was, okay, will you become a doctor or an engineer?
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Or do you remember anything different? No, it was pretty much the same. And after a
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certain point, you know, MBA, MBA options opened up, but doctor, engineer or civil services were
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the only options. The third option was, okay, go to St. Stephen's in Delhi.
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That was your almost guaranteed entry into the civil services. And obviously, because
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you come from a civil services background. We didn't have any university before my parents.
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So our civil services was a distant dream. So it was a case of will you become a doctor or
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an engineer? So okay, fine, let's become a doctor. But my first love was history. My second love was
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physics. And interestingly, they've both come in handy. Because
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what I ended up doing during COVID was helping because I was already an,
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I was already chair of the education division in the intensive care society of the UK.
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And I was an external advisor at the Indian Society of Critical Care Medicine
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and in a number of states. And I'm actually not allowed to say what states. But I
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ended up advising a lot of people about oxygen delivery, about
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some interesting facts in the UK. So as you know, when you have a big oxygen tank
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with liquid oxygen in it, if oxygen evaporates, the rest of the liquid oxygen will become
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warm because of latent heat. So we actually had to install
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sprays around it. India, it's the other way around. Because the temperature is 45 degrees.
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So for instance, in Rohtak, they had to put cold water sprays on it, on the oxygen tanks,
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so that they would not get over pressurized, if that makes any sense.
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is an intersection essentially of physics and medicine. That made, I think it made a difference.
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Maybe that's just my ego talking, okay.
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However, what we are primarily after today is talking about
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end of life care in India, isn't it? So should we shift from my background?
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Let's in fact go much slower. We'll cover all of these topics in detail, COVID, intensive care,
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end of life. But I want to kind of take a step back and ask some broader questions,
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taking off from what you were speaking about. And the first of my broader questions is this,
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that in our lives, you know, we often judge people for what they are, like somebody is
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a particular way, and they occupy a fixed spot in our mind. It could be a parent,
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it could be an elder, it could be a friend, and they are exactly that. And, you know,
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and we judge them as being that. And we put a label on them. And that's pretty much what they
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are. And it is often only much later that we look back and begin to peel the layers and see what
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made them. And there is, I think, a physical analog of this, which doctors go through in the sense
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that we take our bodies completely for granted. But at some point, I presume, during your medical
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education or medical practice, you begin to understand the body for what it is, how the
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different organs work in different ways, how people's behaviors can be impacted by little
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minor things that don't seem consequential. But, you know, slight change in the chemical
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balance in your brain could make you a completely different personality. And you begin to understand
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a body not as just, you know, one random thing out there, but as a collection of parts working
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in particular ways, and everything has a cause and everything has an effect, and so on and so forth.
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And the other analog of that is looking at people in that way. For example, for me, it would be
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thinking back in time. And, you know, my father was always like a fixed spot in time. Okay,
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that's my father, and that's a word, and he is one particular person, and a particular personality
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comes to mind, did too with my mother, did too with other people in my life. But now I can sit
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back and I can look at them through their many phases. I can look at my father's pictures when
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he's 20, when he's 18, when he's 25, and see the evolution of a person, and begin to kind of
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understand what kind of goes on there. So I'm curious to learn about that process for you,
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because it is analogous to, in a sense, I think, understanding the body, which you begin to
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understand in systematic ways. But when you look back at the people in your past, like when you
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look back, for example, at your parents, or the way they behaved, or when you think of
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what you described as intergenerational trauma, you know, coming down from there,
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what do you see differently? Do you see clearer now? Is perhaps some of your anger or sadness of
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that time dissipated? Can you see the different layers of them? How do you relate to them? How
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do you relate to the past? How did this process happen in you? Because it did not happen to me
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when I was young. It took me a lot of time to grow older and begin to sort of have the ability
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to look back objectively with a little bit of wisdom and see what's going on. So tell me a bit
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about that. It took a long time. It took a very long time to get over this, over the intergenerational
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trauma. And you have to, and what I missed saying was that my grandparents were from,
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all four of my grandparents were from West Punjab. So from what is now Pakistani Punjab.
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So they all went through partition, migration, living in refugee camps, having to essentially
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hold their hands out for food. And eventually, yeah, okay, they turned out fine. But that was
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a traumatic experience for both grandparents and parents. And I believe that that
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actually shaped some of their personalities. But some of it was just about
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how India was in the 70s and 80s. So some of, I have heard a lot of stories, including,
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okay, I'm not going to say exactly who, but one of my wife's relatives, basically
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decapitating his daughters before
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migrating to India, because he was afraid they would get sexually assaulted on the way from West
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Punjab. And that sort of, and there's loads of stories, including my, another one of,
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one of my mother's relatives who didn't, who basically
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forget tattoos, put bits of, chips of diamond and gold under her skin
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before coming to India. And then had them took out so she could preserve essentially the family
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wealth. And that sort of thing is something that you cannot ever forget.
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I mean, I know you're not Punjabi, but you lived in Chandigarh for half of your life, didn't you?
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Actually, I'm half Punjabi and my father was born in Lahore.
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I'm culturally Bengali. My mother is Bengali and my father was brought up in Kolkata where they had
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a ruling. So I'm culturally Bengali. That's what I thought, but I didn't realize that you were
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actually, you know, at least generationally or genetically Punjabi. Yeah, he was born in,
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I think Shekhupura, which is on part of Lahore, where one of my uncles was born.
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And you lived in Chandigarh, but I was studying in Chandigarh.
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And I was born in PGI, as were you. So I was born in PGI. Yes, yeah, exactly. So,
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yes, lots of similarities. Okay. So where were we?
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You were talking about the intergenerational trauma and where it came from.
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So I think as much as I can talk about intergenerational trauma. Now, you said you
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had about five things to double click on. So the intergenerational trauma was the first one,
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was the next one. The next one I'm very curious about is, you know, you mentioned that you were
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brought up in privileged elites, much as I was privileged English speaking elites. And
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one of the bad attitudes I kind of picked up was this sort of language snobbery, where, you know,
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obviously my English was great. And I was like, you know, for me, Western culture was a pinnacle of
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everything. So for a few years, I almost had this kind of snobbish attitude towards local culture,
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local stuff and all of that, which thankfully I outgrew. And in fact, I regret not having that
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as a bigger part of my life so far. But you mentioned about, you know, you mentioned in
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your beautiful Punjabi about how, you know, you speak English to the dog and Hindi to your
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children and Punjabi to your friends. So tell me about, you know, and in your school, you were
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fined if you did not speak in English. So tell me about, you know, that aspect of you, like,
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was that something that you had to work on doing in terms of sort of embracing who you are and
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embracing your Punjabi to say, because we contain multitudes and it is sometimes tragic when we
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ignore some of those and focus on others. So what was that process for you like in terms of forming
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or defining your identity? Who am I? Am I an English speaking kid who's done medicine and
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I've gone to Birmingham or whatever? Or am I basically a trade Punjabi in this? A lot of that
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left in me, you know. Tell me a little bit about that process of, you know,
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being comfortable in your own skin. It's really, really, really difficult. And actually, my wife,
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Ira, and I have spent ages talking about this over the last, what, 20, 30 years.
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So we've spent a huge amount of time talking about this and it's a case of,
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and this is one of the very rare moments where I will agree with Chetan Bhagat.
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When he says India is divided into two classes, the English speaking class and the non-English
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speaking class, and that is actually correct. In my school, if we spoke anything other than
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English except in our Hindi or Punjabi period, we were fined. And unfortunately, that leads you
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to the English speaking upper middle class elite snobbery where, you know, you talk to your cousins,
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you talk to other people and they, if they don't speak great English or if their accent is not
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BBC or Voice of America, you think they're not smart enough or they're not in your social class.
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I think that that is more accurate in your social class. And it took me a very long time.
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It took me until my late 20s to understand that a lot of my patients, and it was only after,
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so unfortunately, I did not get self-realization while I was a student. It was only after I became
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a doctor that I realized that a huge number of my patients and their relatives actually understood
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what I was saying, even though they did not speak great English.
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Because until I went to medical school, my interaction with
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non-English speaking upper middle class people was very limited. And I'm sure it was very,
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you must have had a very similar experience until you went out into the wider world.
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Your interaction with non-upper class
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English speaking people is minimal, isn't it?
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So yeah, it took me a long time to get over that prejudice, thinking that
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in India, only people that can speak English are worth talking to. So
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then I had to make a conscious effort to actually start talking to people, talking to patients,
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talking to their relatives, and talking about lots and lots and lots and lots of serious stuff
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in Punjabi, Hindi, English, whatever. However, I speak more Punjabi now.
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No, let me clarify that. I speak more medical Punjabi now than I did when I lived in India.
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Because in India, in Punjab, in good hospitals,
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a Punjabi would rather die than speak in Punjabi to their doctor. They will speak in English.
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Whereas when I work now, about 60-70% of my patient load is from either side of Punjab,
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so either Indian Punjab or Pakistani Punjab. And Indian Punjab, as you know, is only,
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what, two, two and a half crores in population. Pakistani Punjab is 13 crores in population.
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Because they all understand Punjabi. So I speak more Punjabi in Birmingham
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than I did in Amritsar, which is so weird.
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Sorry, I have forgotten. You asked me about five questions and...
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No, no, this was the second. I'll go one by one.
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I only went for the first two.
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No, no, no, no. I haven't asked the others yet. I'm going in order. But yeah, about sort of coming
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to terms with language and all of that. And it's fascinating that you should speak more
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Punjabi in Birmingham than in Amritsar. I think that does say more about Birmingham than...
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It says a lot about both Birmingham and Amritsar as well.
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So my next question is this, that, you know,
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at our time, with the same options, whether to do medical or engineering,
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whether to become a doctor or an engineer, today there are way more options.
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And today I remember a young distant relative was just choosing to do medicine and all of that
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and going full time into studying for, you know, doctory, as I say. And a predominant opinion,
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though he eventually went for it, but the predominant opinion among other family members
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I noticed is that don't do it because it will take many, many years. It will take a decade and a half.
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You also said, you know, four years of medicine, four years of anesthesia,
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four years of intensive care.
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You're working like a complete dog. All your peers in engineering and MBAs and whatever are
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getting ahead, going abroad, buying flats. You're just working like a dog day in and day out.
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And then at the end of it, you never know if you'll actually make it to the top.
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So it could all be wasted and you would have had no more options and you'd be in your 30s.
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So that's kind of one view that one gets of the risk that it takes to become a doctor.
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And therefore my assumption is that, you know, that if you really want to succeed as a doctor,
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it is not just enough to have the qualities necessary to be good at the subject, whatever
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those are, but also you need to kind of have a passion for it and an accurate view of what it
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entails. Like some people might get carried away by the romanticized notion of the successful
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doctors they see, which would be falling for selection bias. And then they would,
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you know, want to do medical for that. And very soon they find out that fuck, it's not quite all
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that, but it's too late for them. Or others might come in because they are fascinated by the science
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of medicine, but then they realize the practice of medicine is different from the science of
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medicine. And now you're kind of stuck in that sort of field. In your case, I imagine with both
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your parents being doctors, practicing doctors, you would have sort of gone into it with your eyes
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open. So tell me a little bit about like, it's a two part question really. And one is a personal
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part that how was it like you were you always in love with the subject or having gotten to it,
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you were just diligent and you got the job done. And the second is that, you know,
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what is it about the system that more than any other profession, this basically requires you to
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go all in. You're in your thirties by the time you're done. And if you don't make it,
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you're screwed because there are no other options. Whereas engineering, you can do MBA,
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you can do this, you can do that. But here you're kind of, you're almost going all in into
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the profession. Okay, so that's, that is truly a two part question. And let me tell you the truth,
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if I had a choice, and if my parents didn't live in a small town in Punjab,
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okay. So if my parents were living in say, Delhi, I would have after my 10th standard or 12th
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standard, I would have applied to probably St. Stephen's to do history. My first love
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and my, and it's actually not just first love is wrong. My everlasting love is history.
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I'm actually writing a book on the history of medicine, on the history of intensive care,
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actually. But my first love was always history. So, but at that point in India, in the
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late 80s, early 90s, history wasn't a real career option. You had, you know,
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three, four, five historians that had made it, but everyone else, you were
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destined to be essentially a school teacher, if you did history.
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The option, it was a case of, okay, the only realistic career options were
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medicine, engineering or civil services. Never wanted to do civil services. So then it was
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even though my maths was pretty good, my maths was better than my biology.
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So the reason, I think, why people do medicine is twofold. Okay. And I think I can view it from
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two angles, both from the Indian angle and from the British angle. So in India, it's a case of
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if no doctor ever dies poor, you will never be mega rich, but you will never be poor.
#
So you will always be, and most states have enough government medical jobs which pay
#
enough for essentially an upper middle class salary. So it is a very, very, very safe career.
#
And it is very unlikely that you will ever be poor. So it makes it a very safe career.
#
It is possible that you may become mega rich, but that is unlikely. It happens only to
#
very, very few people. But you will always be in the top, you know, 2% of the society. So
#
which I suspect is why a lot of people
#
go into medicine. The other reason, obviously, as you would expect a diehard medic to say,
#
is vocation. It's a caring profession. If you want to do it, you want to do it.
#
So if you want to help people, if you want to look after people,
#
you will do it regardless of the money. Well, the money is important, which is why you have
#
doctors striking sometimes, but a nurse is strike. But it's not just about the money.
#
It is about yeah, okay, fine, you are in the top two, three, 4% of the earning population.
#
But you are also making a difference rather than catch up investment banking.
#
Or you're helping with takeovers and laying off people. What are you doing with your life?
#
Where is your? So a very long time ago, about 30 years ago, someone told me,
#
one of my seniors said, can I say this in Hindi? It sounds better in Hindi. He said professional
#
That is your professional satisfaction.
#
That is your satisfaction.
#
Third is, what kind of difference have you made to a lot of people's lives?
#
Okay, that is professional satisfaction. And the last one is,
#
how many, how much of it, sorry, it's not the last one. How much of difference have you made
#
to society? And the last one is, okay, if you think you've made a difference,
#
how many people have you taught to make a difference?
#
And you decide. And it is different for everyone. What do you think? I mean,
#
you know, at some point during this podcast, we're going to have to talk about the
#
World Test Championship.
#
Because I cannot finish a conversation with you without talking about cricket.
#
Definitely. I love this formulation of professional satisfaction. And for me,
#
it would actually be only the third and the fourth. As far as money is concerned,
#
if I have enough to get by and live comfortably, which, you know, by the grace of this
#
Flying Spaghetti Monster, I do, and by the grace of my listeners who support the show,
#
you know, that's good enough for me. But it's really the third and the fourth. And you've kind
#
of made me think a little bit more about this. But I want to ask my next question also, sort of
#
based on this, which is key. It's a secured job. You'll be in the top 2% of earners in the country.
#
And that's a respectable reason. The second is that you consider it a vocation and you're
#
driven by idealism and you want to help people in a tangible way. By the way, I must defend
#
investment bankers and say they are also good for society. I've got an old episode on the importance
#
of finance with Ajay Shah. I'll link that from the show notes. I agree. Investment bankers are
#
important. They are very important to society. Yes, but leaving that aside. So these are the
#
two kinds of reasons. One is that it's great job security and it guarantees you a certain income,
#
even if it won't make you mega rich. The second is vocation. Even in the vocational part of it,
#
what can happen is you can get in there for idealistic reasons. I want to help people,
#
I want to heal people, I want to make people better in all of those ways. But it can soon
#
get into routine and drudgery and hard work and all of that. And that's also a risk.
#
And my experience really with any profession is that in literally every single profession,
#
except professions, perhaps like the creative arts, where people are more driven by passion
#
or whatever, but even there, but in every single profession, there'll be a very, very large
#
percentage of the people who are going through the motions. They're ticking the boxes, they're
#
doing what they need to do, but there is no deeper passion. For example, you could become a doctor,
#
but not really stay in touch with the latest in medicine, not read the scientific literature,
#
not read the papers. Like one of my recent guests I was very impressed by, known as liver doctor on
#
Twitter, Abby Phillips, you know, does that every day, he'll read the latest papers on the subject.
#
So he's really updated. Lancelot Pinto, who's been on the show does exactly that, you know,
#
he'll keep himself up to date, but 99% of doctors frankly don't, you know, their education is
#
outdated and they don't know what the latest is. So that passion is in there. In your case,
#
there is a lot of passion in terms of you're keeping up to date with the latest stuff,
#
you've written a bunch of books, you are involved in all these different kinds of organizations,
#
you are coming to India and doing seminars and helping people here as indeed you did during
#
COVID, you're clearly involved. But my impression is that just as in any other profession,
#
95% of the people in your profession would just be going through the motions, doing enough to get by
#
and are not involved at that deep level. Maybe some of them, and I'm not pointing it out as a
#
weakness in character, maybe the job of a doctor is so difficult in demanding that you cannot
#
give the time to, you know, get more involved than that. So I understand that. But what is
#
your sense of this within the profession? That are you an outlier in that sense? And, you know,
#
and does it does this kind of involvement, like you are also bringing interdisciplinary lenses to
#
bear, like the physics that you pointed out, where you are controlling the temperature of
#
the oxygen cylinders, depending on local conditions, because you understand physics,
#
or you're looking at the history of medicine, which I would imagine makes you so much more open
#
to change and open to a lot of stuff that is happening. So what is your sense of this
#
within the profession? And do you have to make an intentional effort to be involved and to keep the
#
idealism active? Okay, now, I am going to first put out a disclaimer that this is not I have not
#
worked in India for over 20 years. So I don't know what the condition of medicine in India is
#
currently, except for the colleagues that I keep in touch with, who are who could possibly be
#
outliers, because they are very much in touch with what is going on.
#
In the UK, you are subject to annual appraisal. And you have to demonstrate that you have made
#
an effort to attend, you know, to obtain a certain number of professional development points, each
#
point is roughly an hour and, you know, stay in touch and professional growth. So every year,
#
in addition to your pure professional performance, you have to demonstrate
#
that you have attained continued professional development. Now, I understand that in many states
#
in India, now, the medical boards, the registration bodies, essentially, now ask for,
#
again, a certain number of development hours every year. And I think that is really useful.
#
Now, I would. OK, for two seconds, I'll put aside humility and say, yes, I am an outlier,
#
because I'm rather than someone who's the recipient of professional development, I'm one
#
of the people that develops the learning programs. So, yes, I'm slightly an outlier.
#
I write books, I write lots of stuff. I'm writing actually a nonfiction book about
#
intensive care with patient and family consent, which will hopefully come out next year.
#
But who knows? It depends on how slow I write. You've read a couple of my stories.
#
You've never given me any positive feedback.
#
No, no, I was going to give you positive feedback on something you wrote about
#
your latest paper appearing into the soul, but I was going to save it later for the sharehold.
#
But anyway, so we'll talk about it when that particular subject comes up.
#
Absolutely, absolutely. But I think that a lot of this is about self-reflection,
#
and some of it is about regulation. So a lot of people, a lot of medical professionals
#
want to stay in touch with what is going on, because they want to be better at what they do.
#
Obviously, and it pains me to say this, some don't. So what you need is regulatory pressure,
#
and medicine like law and finance and lots of other things is a heavily regulated profession.
#
And I think that some people try and stay in touch because it is so heavily regulated.
#
Now, in some parts of the world, medicine isn't so highly regulated. So people actually just go
#
with what they've learned 25 years ago rather than today. And the only way to make it happen,
#
make it better, I should say, is through better regulation. And again, in India,
#
some states regulate the medical profession better than others. And in answer to one of the
#
things that the liver doctor says, I would argue that one of the ways of controlling violence
#
against hospitals and doctors in India would be
#
better regulation and easier
#
civil litigation. Because at the moment,
#
if families are aggrieved, oh, sorry, number one is better communication. And we will come
#
to communication in a little bit. So communication and better regulation and better civil
#
litigation. Because at the moment, people, if they feel that they have not been treated
#
well in hospital, resort to violence because they don't see any other alternatives.
#
If they could see that there is other sorts of recourse, it could probably be better to go that
#
way. But who knows? This is just my personal opinion.
#
I can tell you that in 22 years in the UK, I've faced, I've never ever faced even threat of
#
violence because the system is so highly regulated that A, I can call the police or B,
#
the patients or their families can call the police or go to the medical council
#
rather than coming and beating me up or breaking windows.
#
I think the greater threat our friend, the liver doctor,
#
Abbie Phillips faces is not so much from disgruntled patients. So he had one instance like that,
#
but really more from many of the quacks that he calls out so courageously, the homeopaths
#
and the Ayurvedic frauds and all of those kinds of people. But just to sort of respond to the
#
point on regulation, I would say that the problem in India, what tends to happen with it is that
#
number one, there is a massive rent seeking mentality. So whoever the regulator is, it is
#
likely that it will become a tool for rent seeking in their hands and they'll just be
#
all around corruption. Any metrics that exist can easily be gamed. And the second problem is that
#
there will be regulatory capture, vested interests will take over. For example, at a very old episode
#
on how the, I think with Pawan Srinath and how the medical council of India at the time,
#
I think it's changed now, but similar processes exist at the time, would restrict the number of
#
doctors in the country by determining what can qualify as a medical college and what can't,
#
and therefore artificially constraining the supply of medical education in the country,
#
and therefore artificially constraining the supply of doctors so that there is less competition,
#
which is a classic example of vested interests taking over the regulatory apparatus.
#
So, you know, of the three things that you mentioned, I am skeptical about regulation
#
really helping given the state of India and given the way it is. I'm also skeptical about
#
civil litigation working here, given the state of our courts and how the process is often the
#
punishment, whether you're in the right or in the wrong. What really does need to be made much
#
better, and this is where I want you to sort of elaborate and talk a little bit, because you've
#
been very eloquent on it in the past, is better communication, because one of the things that,
#
you know, one of the themes that you've spoken about is how we need to learn not only the science
#
of medicine, but also the art of medicine, and the art of medicine involves how do you communicate,
#
A, with your patients, and B, with the patient's relatives, so that you can help all of them come
#
to inform decisions that are made together, and this obviously means there is no rancour later
#
once they understand exactly what has gone wrong, once they understand, you know, what are the
#
probabilities involved, and so on and so forth, and Abby's episode of course has a lot about this,
#
Lance also talks about this, and the complication that it seems to me here that I'd also like you
#
to address is that there is a trade-off, that by not giving much time to the patients, but just by
#
using, you know, what economists call fast and frugal heuristics, you can actually get through
#
more patients, and therefore serve more people, but the level of service per patient would be
#
much less, or you can spend a lot of time with each patient, but that way you get to see less
#
patients, and therefore, you know, there are more people who are going untreated, but the level of
#
service that you're giving to your patients is higher by talking to them individually, because
#
even many busy doctors will say, I have 80 patients in a day, I can't sit and chat with all of them,
#
and explain the details to all of them, so you know, I take a more efficient way out,
#
so what are these trade-offs like, and how do doctors kind of navigate them, and tell me also
#
about that better communication aspect, like is this something you knew all along, or is it that
#
you learned during your journey of becoming a good doctor? Okay, I don't know if I'm a good doctor,
#
um, you would have to ask my patients. The second is,
#
but fewer patients, not less patients.
#
So, what I would say is that I am in, as opposed to the two doctors that you have interviewed
#
previously, so Dr Pinto and the liver doctor, I am in a very, very, very, very privileged position.
#
They have perhaps 10 minutes, 15 minutes to spend with every patient, possibly 10 minutes.
#
In my case, I work in intensive care, and the UK Intensive Care Society, where I helped to write the standards.
#
The rule is that you have a consultant and a junior doctor for every 10 to 12 patients.
#
So, in a 10-hour shift, I have one hour, or perhaps, you know, 30 minutes to spend with the patient,
#
and 20, 30 minutes to spend with the relatives. And actually, what happens is that, for instance,
#
my ICU is one of the biggest ICUs in Europe. Actually, it was the biggest ICU in the world
#
when it was built 15 years ago, but obviously, other ICUs have been built since then. And what
#
we do is, because my patients cannot talk to me, because I'm in intensive care, which is again
#
different from a lot of other patients, other specialties, my patients cannot talk to me.
#
So, we talk to families. And typically, we only talk to about 30% of families.
#
Why? It's because, for instance, in one of my, so I work across three ICUs, in one of my ICUs,
#
we have 2,500 admissions a year, 2,500 admissions every year. Of that 2,500 admissions,
#
every year. Of that 2,500 admissions, approximately 12 to 1,500,
#
basically COVID had reduced a bit, so that's why I'm saying 12 to 1,500,
#
basically it used to be 1,500, are post-surgical patients. So, someone has had lung resection,
#
surgery, 99% of them are going to survive. And they're going to be out of intensive care within
#
48 hours. So, I don't need to sit and communicate with the family. We have one-to-one nursing,
#
bedside nurse, junior doctor, someone said that everything is going well, we'll discharge them.
#
So, you don't, there's not a huge amount of communication needed.
#
And what happens is, you don't even remember those patients' names,
#
because they only stayed with you for 24 or 36 hours or 48 hours. What happens is,
#
we still have a 20 to 25% mortality in our intensive care. And that is the other 40% of
#
patients, of whom half will die. And they are the ones that are going to stay in our ICU for 4, 5,
#
6, 20 days, whatever. And they are the ones where you need to manage communication with families,
#
where you need to manage expectations, where you need to talk about how there is essentially
#
more than 50% chance of their family member dying. And one of the things that I have noticed,
#
which is different between ICUs in India and ICUs abroad, is visiting and communication.
#
The treatment, I mean, the technical features of treatment, honestly, I can tell you,
#
I have visited lots of ICUs in India, and it is absolutely not worse than European or American
#
ICUs. However, however, it's the visiting and communication that is the problem. We have 24-7
#
visiting in ICU. So two family members per bed, per patient, they can be there 24-7.
#
We actually have four rooms for relatives that are, you know, who can't afford staying in a hotel
#
or something. So we have four rooms actually in the hospital, four ensuite rooms in the hospital.
#
And we had a charity drive recently a few years ago to update those rooms. So we have rooms in
#
the hospital for people who can't afford to stay in a nearby hotel or something, or who don't live
#
nearby, because most of our population lives nearby anyway. So it is, and we allow 24-7 visiting.
#
We are very open, because I think part of the reason is, because there's no financial incentive.
#
I don't care if 90% of my ICU beds are full or only 50% of my ICU beds are full.
#
So I will be open and honest with all of my patients or prospective patients and their families
#
that this is where we are going. And this is the likely
#
prognosis. And then we talk very, very, very openly about end of life care,
#
which I think is the third thing that is different from what my colleagues tend to do in India.
#
And this is not a secret. I've talked about it extensively at various conferences in India.
#
In India, the tendency is to hide bad prognosis. Why? Probably because of commercial reasons.
#
I'm not blaming anyone. I'm just stating the reality. It's commercial reasons. Because if
#
you say this person is likely to die in the next few days, and their family will take them to
#
another hospital, or another person who will promise or give hope of a better prognosis.
#
Does that make any sense?
#
Yeah, yeah, absolutely. And I was going to, in fact, ask you to double down on that next.
#
Because I'm very curious in the ways in which the incentives for Indian doctors seem to differ
#
from the incentives for doctors elsewhere. Like you've pointed out, your incentives would not
#
be about keeping the ward full or keeping as many customers as such. You can look at them as
#
patients and human beings and not as customers. But in Indian hospitals, what one hears about is
#
one hears about horror stories of how doctors are incentivized. You know, and you have to guarantee
#
a certain revenue to the hospital you are with. And therefore that incentivizes you to not be
#
completely honest with the patient to make them do more tests than is required to make them,
#
you know, and one of the great tragedies is I forget the number, you will know the number.
#
But a significant chunk of people's savings are actually spent in their last year of life
#
or the last few months of life, when actually there is no hope anyway, and they might as well
#
not do it and leave the money for the family and figure out a peaceful way to go. We will talk
#
about that. We will talk about that. Yeah, finance. Okay, I've written it. You've written it.
#
Now, so. So, tell me a bit about how these incentives differ and how can they be
#
fixed? Because one obvious way in which they could be fixed is that Indian hospitals would
#
simply stop these sort of extortionary practices if there was much more competition, because then
#
they would have to compete with each other to give good honest treatment and you wouldn't have
#
this situation. But you have this situation because they can get away with it and there's
#
not enough competition. And that's just a much deeper problem. And it's a policy problem. And I
#
won't ask you to elaborate on that. But just in terms of incentives, like where do you what would
#
you have been a different kind of doctor if you were in India? Yes. And yes. Okay, so I will start
#
off with I'm not a health care, a public health care policy specialist. So that is my disclaimer.
#
However, I have thought a lot about this. And remember, when you look at, say,
#
pure research saying, okay, what's the best 10 health care systems in the world?
#
They are all socialized health care. So unlike many areas of public policy,
#
health care is one of those systems which seems to actually work better when it is
#
socialized. And I am sorry that this is the one thing that I disagree with you on,
#
where the market does not work. Well, you don't actually disagree with me, because as you would
#
have figured from my episode on health care with Kartik Mullitharan and others, my point is not
#
that it should not be socialized. My point is you also let the private players operate and let that
#
play out. And that part of it doesn't really happen. But what you need is, okay, I'm going to
#
switch to Hindi. So in five and a half years of medical school, do you know how much time was spent
#
on ethics? My guess is zero. Five hours. Five hours, okay.
#
And how much time was spent on biochemistry, which I have never used in my life? A lot more.
#
Basically, two hours every day for one and a half years.
#
800 hours, 900 hours, something. Okay. You are right. Your math is good.
#
And how much time was spent on how to communicate with patients?
#
So what we need is, we need to get a lot better at communicating with patients.
#
Things like biochemistry, basic sciences, all of that can be learned later. But what you need
#
to do primarily, and as soon as possible, is professionalism. And professionalism is being
#
honest and communicating well with your patients and your families.
#
So let me butt in here. I'll come back to my incentives question later. But while you're on
#
the subject of communicating better, tell me a bit about your journey in learning how to communicate,
#
because you said medical school zero hours, but then over the course of your practice, you must
#
have learned, you must have messed things up, you must have got things wrong, you must have learned
#
from them, you must have figured out first principles, you must have figured out best
#
practices, take me through that journey of yours. That is a really interesting question. So I think
#
one of the major problems with communication that I had in my early years was,
#
I was working in a government hospital for a long time. After that, in a charitable hospital.
#
It was a case of, even though I never thought about caste, but when I think back,
#
it is a question of privilege, isn't it? And you would agree with that.
#
Upper middle class, upper caste, so higher social economic status. So patient, the patient is,
#
you do not consider your patients unless you are in a corporate upper class hospital.
#
You do not consider the patient as an equal human being to yourself.
#
And that means that you do not communicate with the patient as an equal human being.
#
And I think that happens in a lot of professions. Would you agree?
#
Yeah, yeah, absolutely. And absolutely. So if you do not see the patient as an equal human being
#
to yourself, then you are going to treat them as essentially a lesser person,
#
their families as even lesser people. So you are going to be rude, dismissive,
#
and possibly even, and I regret to say this, possibly even less than truthful,
#
especially with the economic incentives involved.
#
Whereas what I learned over time was, especially after me, my wife, my parents
#
have suffered various illnesses over time, is that it is
#
so much better to respect your patients and their families, and to be very honest with them.
#
So if someone's going to, if someone is unlikely to survive, why hide it? And it is much easier,
#
I will admit, in the health system I work in, because it's not like they will move the patient
#
to another ICU, where someone will promise that, oh, no, no, no, no, we will try our best to save
#
this patient. So it is much easier for me to communicate honestly with people, whereas I know
#
in India, in India, in India, in India, in India, in India, in India, in India, in India, in India,
#
honestly with people, whereas I know, in India, even my own relatives, they've had this experience
#
and then someone else says,
#
okay, no, no, no, we will do it, we will do something else, and they go there and they spend,
#
end up spending tens of lakhs of rupees on that, which is non-evidence-based treatment,
#
but it happens and there is realistically no way around it.
#
So, communication with families and honest communication, because my communication tends
#
to be unlike your previous medical interview, so, Lawrence and the liver doctor.
#
Lancelot, sorry, sorry, sorry, sorry, sorry, Dr. Pinto, Dr. Pinto, and I am going to apologize
#
to Dr. Pinto in five minutes through text. So, through your previous medical interviews,
#
their communication tends to be with patients and they tend to see a lot of patients every day.
#
I only see, I'll be very honest, I only see 10 to 15 patients a day, but I spend a lot of time
#
with them because I work in intensive care. During COVID, I saw twice, thrice,
#
possibly four times as many every day, and that caused me a lot of trouble.
#
But we talk to families, we spend as much time talking to families as we do with the patients,
#
and we are completely honest as a unit. We tell them exactly, you know,
#
your, okay, let's take an example. Your dad has pneumonia, he is 78. He has diabetes and hypertension,
#
and he's had a heart attack before. His chances of survival are probably 20% at the moment.
#
So, basically, you need to be prepared that he's going to die. And if he survives, that's
#
great. We would be extremely happy. But the chance of mortality here is about 80%.
#
We would never lie about that. We would never try to sugarcoat that, because we do not have
#
a commercial motive here. And I agree that that goes against, and I count myself as a
#
as a libertarian. And that actually goes against market theory. But
#
I would argue that there are some things, some sectors that
#
should be against market theory.
#
Well, I mean, that's a discussion for another day, and we'll save it for later. But I think
#
the market often can set great incentives. So, you know, India is a really bad example. And it's
#
not even a completely free market in that sense. And there are so many things wrong with it, which
#
is just a whole different policy story. But I want to sort of come back to this question of
#
talking to patients and talking to the relatives also. Like, one is that we have this instinctive
#
sort of denial of our mortality built into us, right? I mean, in that sense, a mortality rate
#
for all of us is 100% given a long enough span of time. But we tend to live as if we are in denial
#
of it. And secondly, when you speak about, like, if you were to ever be my doctor and tell me about
#
my chances, I would want you to do it exactly as you just mentioned, where you give me the
#
probabilities and then you break it down in more granular detail. But most people can't grok
#
probabilistic thinking. You know, they can't figure out what you mean that, okay, your chances of
#
survival to more than five years are 11%. More than 10 years are 3%. Three years is, you know,
#
24%. And there's a 60% chance it's over in three months. Most people can't grok that they can't
#
figure it out. What do we do with it? So you know, what are the kind of responses that you get from
#
both patients and relatives? Is there a situation where you decide that the patient may not be able
#
to take it? So you have to tell the relative alone, which is a judgment liver doctor,
#
Robbie Phillips mentioned that he has made some times that it's better to talk to the relatives
#
and keep the patient out of the loop. And I felt a little uncomfortable at that, because I think
#
that you it just feels that you always have to be upfront and honest with the patient.
#
So what are your sort of personal experiences in this which have shaped the way that you think
#
about this? Have you had any really difficult moments? Lots and lots of really difficult
#
moments. And I would actually, I mean, okay, I work in a different country from Dr. Phillips, so I will
#
definitely not even try to criticize what he said. Okay. However, what I would say is,
#
and of course, I work in intensive care. However, hiding things from the patient is something that is
#
expressly against UK law. As long as the patient has capacity, you never ever hide anything from
#
the patient. If the patient does not have the mental capacity to take their own decisions,
#
then it's different. But as long as the patient has the mental capacity to take their own decisions,
#
you never ever, ever, ever have the legal authority to hide anything from the patient.
#
So that is one thing that is expressly forbidden, actually, in most of Europe,
#
and in most of North America as well. And actually, I do not think that there has ever been,
#
I am not sure that there's ever been judicial recognition of hiding things from patients who
#
have capacity in India. It is just that our courts often give vague decisions and after 30 years,
#
vague decisions and after 30 years, so they amount to nothing. However, I would argue that
#
if a patient has capacity, so if they have mental capacity to make decisions,
#
so if they can say, I do not want to go to intensive care, I do not want chemotherapy,
#
they are the only people that get to make the decision. And hiding a diagnosis,
#
and I texted the liver doctor this morning to apologize for criticizing, but if a patient
#
has capacity, hiding a diagnosis from a patient is technically a criminal offense
#
in this country. I just want to add to that, firstly, forget criminal offense, I think it
#
is wrong. I think you should always let patients know exactly what the scene is and there should
#
be complete honesty as long as they are not incompletely incapacitated, I agree with you.
#
But I also want to, for those of my listeners who haven't heard my episode with Abhi, just give a
#
little bit of context there because he was talking about complicated situations where, for example,
#
patients would come to him with severe liver cirrhosis. They were from lower income families.
#
They were definitely going to die within three months, four months, whatever. And a liver
#
transplant surgery, say, would cost 20 lakhs and the family only has 10 lakhs. And if they get an
#
extreme debt to kind of fund it, then he's going to die anyway and they're going to be in severe
#
debt. So all he would do is really sit with the family and explain the implications and then let
#
the family take a call. So I am not for that. I would always tell the patient because I feel
#
that's just what you have to do. So I'm with you on that. But it is not as if he is facing a very
#
difficult moral dilemma. And because I'm not in his shoes, I don't, you know, I totally understand
#
where he's coming from. I just wanted to clarify that for my listeners. And I would completely
#
agree with Abby. And I am going to apologize on your life, on your podcast. It is a question of,
#
well, it is a multifactorial thing, isn't it? Depends on, okay, are you in a socialized
#
medical system or are you in a system where a small chance of survival could mean financial ruin
#
for your family? And they are two very different things, aren't they?
#
Exactly. So deeply complicated for that reason. Yeah. Which is why I always say that I
#
am very, very hesitant to compare different medical systems because a socialized medical system
#
versus a semi-socialized medical system like in, I mean, half of America is semi-socialized
#
medical system and an almost completely non-socialized medical system like in India.
#
They are three very different things. And again, in India, we have,
#
we have a medical system that is very different between socio-economic classes.
#
And that is very different from anywhere in the developed world, isn't it? I'm sure you
#
agree with that. No, no, absolutely. And also there is, I think, the added complication,
#
and I'm just thinking aloud of other kinds of triaging dilemmas that can come up. Like let's
#
say in a situation like this, which is not socialized, you have a desperately poor family,
#
maybe they have 10 lakhs of saving and operation will take 20 lakhs with zero percent chance of
#
saving this person. So the decision seems pretty straightforward. I just don't do it, don't bother.
#
But I can imagine that even in a completely socialized system,
#
there is a number at which it falls apart. For example, let's say somebody has a 0.5 percent
#
chance of survival. How much will you spend to save that person? Let me finish. How much
#
would you spend to save that person? You would say $10,000? Of course. $100,000? Let's think
#
about it. $10 million? No, because then there's an opportunity cost on other situations as well.
#
So those kind of triaging decisions would also come into play, right?
#
Absolutely. And in the UK, there's an organization called NICE, the National Institute of
#
Clinical Excellence, which basically puts a value. I'm sure there's someone in the world
#
that would say this is unethical, but they put a value on human life. So they put a value in qualities
#
so that is quality added life years. So not just survival life years, quality added life years.
#
And they put a numerical value on it. It varies from year to year with inflation and something.
#
A few years ago, it was 35,000 pounds per year.
#
So basically, if spending 350,000 pounds on someone would add 10 good quality years,
#
so not just years in a wheelchair or a bed, 10 good quality years to their life,
#
then it would be birthed. So that is how essentially socialized medicine would work.
#
And if it added nine years, would the treatment be turned down?
#
Maybe, maybe not. So basically, there's sort of green zones, amber zones, and red zones.
#
It's hard. And you will remember that in America, they called these death panels.
#
These committees were called death panels, whereas they are actually life panels.
#
What you're deciding is, okay, this person cannot afford this treatment privately. So
#
can the state afford to provide this treatment?
#
And it's hard. You have to pick a metric. And the metric most of Europe has picked is quality.
#
So quality added life years. And if you look at the best health care in the world,
#
in the world, for the general population, I think most of the top 10 are in Europe, aren't they?
#
I would completely agree that the top 1% in America get better health care.
#
There is absolutely no doubt about it. But the other 99% get worse health care than most of Europe.
#
And it's the same in India. When there are great hospitals in India, I know a lot of
#
fantastic doctors in India. However, the system is rigged against them.
#
So, sorry, we got off the topic.
#
Yeah, no, I'd say look in an ideal world to avoid these kind of dilemmas and these
#
decisions taken by life panels, as you would call them, is for health care to be affordable
#
and people to be prosperous, so people can make their own choices. And both of those
#
affordable health care and prosperous people can only be delivered by markets.
#
Absolutely. I will totally agree with you that a free market is the way. I am a libertarian.
#
And I will agree that free markets are the way to go.
#
I wasn't even getting into that discussion. Instead, I was leading into a break that
#
we should get back to talking about your personal journey. And I'm especially fascinated by knowing
#
much more about the history of intensive care and your experiences and that and you are, of course,
#
I would say one of the world experts in that having written so many books and holding the
#
positions you do in Britain. But let's take a quick commercial break and then we'll come back
#
and we'll resume talking about your life and your fascinating journey.
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Welcome back to The Scene in the Unseen. I'm chatting with my good friend Nitin Arora,
#
the good doc who's been telling us all about his life and the medical profession and so on and so
#
forth. Nitin, I want to now move on to talking about intensive care particularly, like you know
#
break ke pale incentive tha bhi intensive ho gaya hai. Tell me a little bit about this field,
#
which is actually sort of a relatively new part of the medical profession. Till the middle of
#
the century, it didn't really exist and then it kind of came on for a while in response to
#
you know a particular local challenge of polio when you had heart-lung machines and so on and then
#
it again in the 1980s it got revived because of heart disease and all of that. So take me a bit
#
take me through the history of intensive care which also seems to me to be a particularly sort
#
of almost moving in a different direction from the rest of medicine in the limited sense that
#
while the rest of the medical field has seen hyper specialization where every specialist is dealing
#
with a particular kind of disease and a particular kind of patient and so on and so forth. You guys
#
are like generalists, you have to know everything, you have to do everything and you have to deal
#
with everything in its most acute form. So you know I may sort of provoke the historian in you
#
and I know you're writing a book on this and I can't wait to read it but give me a potted
#
history of intensive care. Okay so basically as you said intensive care developed during a
#
polio epidemic in the 1950s where patients who had severe polio who couldn't breathe for themselves
#
they were put on heart-lung machines and in intensive care and
#
uh some of them still survive and one of my very good friends
#
Matt Morgan has actually written a book about the history of intensive care
#
and I'll send you a link which you can put in the show notes. So
#
it is a relatively new specialty and again as you said in the 60s and 70s
#
once the polio vaccine came in intensive care declined in its importance and then
#
again in the late 70s when we started doing lots of heart surgery
#
intensive care came back essentially and then when we recognized that a large number of people were
#
dying of sepsis in the 80s so infectious diseases sepsis respiratory failure so intensive care
#
came back and from then on intensive care has been on an increasing journey and from basically
#
you know less than one percent of hospital beds slowly slowly we found that currently about four
#
percent of hospital beds four to five percent of hospital beds in the UK about six percent in
#
the EU and about ten percent even though they define it slightly differently in the US
#
of hospital beds are intensive care beds some sort of intensive care beds and in America
#
now about 70 percent of hospital deaths happen in intensive care
#
because everyone gets admitted to an intensive care at some point in the UK and in most of Europe
#
what you find is if you go and see a patient you have because there's this again we come back to
#
the difference between commercial and socialized medicine so if you go and see someone and you see
#
that they are almost certainly going to die in spite of whatever you do in intensive care
#
you just say no because there's no
#
commercial reasons involved that's putting it very gently so it is yeah so it's been a long
#
complicated history however intensive care came into public light really during covid
#
before covid no one gave a shit about intensive care during covid suddenly we found oh yeah
#
intensive care exists and actually i am slightly extremely sorry for my emergency medicine and
#
general medicine colleagues that dealt with more covid patients than we did but they somehow
#
did not get the media recognition that intensive care did and yes it was an extremely stressful
#
time for intensive care what we had was we quadrupled our numbers so my my icu grew by four
#
times at times we and and we had to transfer patients to other hospitals when we ran out of
#
capacity with the same number of consultants but this at this point we were resident there 24 seven
#
so we were working twice as hard we were looking after four times as many patients
#
our anesthetic and medical colleagues did their best to help us and what we had was my icu normally
#
has a mortality rate of about 20 percent so you increase my icu by four times and then you have
#
a mortality rate of 40 percent in covid icu so that's an eight times increase in absolute deaths
#
yep what does that do to your colleagues mental health
#
so we started the pandemic with 18 icu consultants we finished the pandemic with
#
three who retired early
#
one who went to dubai and two that no
#
okay two that decided to leave intensive care
#
and of the other 12 five have been at various times been on sick leave with mental health
#
essentially burnout problems including you including me and i am currently off work again
#
again because of burnout and so it's it's been an extremely difficult time for all of us
#
and it's it's the numbers for our icu nurses are again very similar
#
so it's it's it has been an extremely difficult time can i can i tell you why what the biggest
#
thing for me was tell me i was i i will later tell you some funnier stories as well and let me
#
say for clarity this is all with patient or next of in next of kin consent so
#
so during covid as you can imagine
#
normally we have 24 7 visiting so patients families can be there all the time except when
#
we you know request them to leave if you're doing procedures or something or if they have to go to
#
scans or stuff but normally we just have 24 7 visiting for families during covid
#
visiting was suspended and actually even if visiting had been allowed a lot of family members
#
themselves had covid and so they couldn't couldn't possibly be allowed to visit anyway
#
i was on a night shift and i came in at nine o'clock at about half 10 the nurse in charge
#
talks to me and says there's this guy who's called three times today and he has covid himself and i
#
and possibly needs to come into hospital so i was like okay what is he confused about
#
and i am told that this guy is constantly ringing to ask about his wife
#
his wife who was in our intensive care with covid and obviously this guy has covid
#
as well so he can't visit and his wife died two days ago
#
so and somehow with the pressure of numbers dying at shift change time no one told him
#
for months i had nightmares that my wife had been admitted to intensive care and
#
died and no one told me for two days
#
it is so far below the standards that we would set for my intensive care or any intensive care
#
for that matter that it affected me hugely but
#
did you tell that guy yes i ended up having a one hour discussion a one hour talk with that man
#
and then i ended up talking at midnight to our hospital's legal advisor as well
#
because he threatened to sue no he didn't he was actually so nice that i almost cried at how nice
#
this guy was but because the hospital you know has legal liability and so i had to talk to
#
to the executive on call the one of the executive directors and i had to call speak to the
#
to the legal team but actually this guy did nothing he came and he was like very very very
#
understanding of course for the first 10 minutes he swore at me and said all sorts of things but
#
again communication is about apologizing sometimes and sometimes even if it's not
#
your fault it's your team that missed something and you end up apologizing for everyone on
#
everyone's behalf so i apologized profusely on behalf of the whole intensive care team
#
and actually the the next day the guy came in to collect the death certificate and he
#
spoke to one of my colleagues and he was absolutely fine so it it wasn't like he
#
threatened to sue he didn't he was very understanding that this was essentially a
#
a whole health care system crisis if that makes any sense
#
tell me something i'll come back to intensive care i'll come back to this narrative but
#
brief digression that and it's always fascinated me about doctors that at one level the people
#
you're seeing are people they're all different from each other they're real flesh and blood
#
people with feelings with emotions with fears with insecurities and so on and so forth at another
#
level they are objects for you to you know use your craft on to make them better you know they
#
have bodies you have to be in a certain sense clinical which is such a cold term but you have
#
to be coldly clinical in figuring out what's wrong with them and helping through them through that
#
and in this second aspect when a death happens a death happens probably probabilistically people
#
you are looking after will die in your case because you're in intensive care many more than
#
other doctors may face and you also spend a lot of time with each of your patients
#
and their families so you get to know them how does one manage that trade-off like at the one
#
hand to be able to do your job properly i am guessing that you have to be emotionally a
#
little detached and just look at the problem on hand which is what is going on in their body
#
but on the other hand can you really fully do that i mean it you mentioned this one traumatic
#
incident but i'd imagine that trauma visits daily where you are how does one deal with that what
#
are the kind of defenses you build up that is a really really interesting question and that
#
is a question that we deal with every every single day so when i was a medical student
#
we were told or we were taught or we were actually inadvertently taught because no one expressly
#
no one expressed this no one talked about this it was like patients are subhuman they don't exist
#
they are just there so you just emotionally detach yourself they are not human
#
as i grew up essentially patients became human
#
and then what i found was and this is what i tell all of my trainees medical students everyone
#
and this is what what what modern medical practice would look like is that yes patients are human
#
if one of your patients dies and you are sad about it it is okay to feel sad it is okay to
#
feel the emotion it is okay that you are disappointed you are sad you are angry you have grief because
#
if you are actually not in touch with their emotions it is it is hard to be a good doctor
#
and this is something that i believe that our previous generation of teachers of medical teachers
#
got wrong where they believed that you had to be completely emotionally detached from your patients
#
personally i'll tell you when i'm an when i'm on intensive care i speak to four five six families
#
every day some of it is good news some of it is bad news i cry personally once or twice every day
#
that i am on intensive care i know that our nursing staff cry regularly with the families
#
and that actually is healthy it is giving expression to your emotions rather than bottling it in
#
and i think that is one of the problems that caused my current burnout which is that during covid
#
because we didn't have families visiting you couldn't sit and talk to the families
#
so the first thing i normally do when i talk to families is i ask them okay so what was
#
so you know your relative your dad your son your uncle whoever or your mom or your aunt
#
what were they like tell me a little bit about them what did they like doing what did they
#
enjoy doing what were their hobbies how was their relationship with the family
#
what it does is it humanizes the patient for me and once it humanized well okay and somewhat
#
selfishly it also forms a rapport and a connection with the family but it it humanizes the patient
#
for me and it tells the family that i am actually i i actually how do i put this nicely
#
i actually give a shit that this is not just bed number nine this is mr kurashi
#
okay and i believe that makes a huge huge difference
#
making making sure that the family know that this is not bed number nine this is mr kurashi
#
and you know that okay he he likes to you know go for golf or go jogging in the morning and
#
you know loves his dog whatever it is because i can't talk to my patients my patients are
#
sedated they are on a ventilator so how do i make sure that they are not just slabs of meat
#
lying on a bed i have to humanize them somehow and and this is not just me this is this is all of
#
my colleagues we all try and do this and yeah that's that's how you try and humanize people
#
the problem with that is once you humanize people you develop
#
an emotional connection with them and basically i said we have normally a 20 percent
#
mortality rate in icu but actually the other 80 percent or 60 70 percent this come to icu this
#
day for one day or two days you never talk to the family because or you talk to the family for two
#
minutes at the bedside and you just say yeah he's doing very well we will move him or her to the
#
ward later today and they'll get discharged from the hospital in three days the only people you
#
remember are the ones where you've spoken to the family seven times and you have
#
basically gone through the various stages of grief yourself as well as the family has so you've gone
#
through and you've experienced the family stages of grief you know about denial about anger about
#
shouting at you and you've you've absorbed all of that that takes a huge amount of emotional energy
#
and you have to be yeah very mentally strong as an intensivist but yeah sometimes you come
#
you you reach your limit and which is why as i said i am currently off work
#
you said earlier that you believe that if you're not in touch with your emotions it's hard for you
#
to be a good doctor and i love this humanizing process and i can see how it helps you in terms
#
of connecting with the relatives of the family and helping them to come to terms with what is
#
going on and reassuring them that it's not bed number nine it's mr kureshi but does it also help
#
you in your actual practice being able to humanize this person because i would imagine at one level
#
a doctor could easily say that okay there is a lung infection these are the medicines i have to
#
get to give it out of you know out of the way these are the vitals i need to keep an eye on
#
and that's it and then if you keep your emotions out of it it's much easier on you to actually
#
treat them as a slab of meat so does knowing those little aspects of their personality
#
actually help you better treat a person who is anyways irritated and can't really converse with
#
you in any case yes and this is where we come to what what we started with so a few months ago
#
we had a whatsapp conversation about end of life care and that is where you and i agreed to have
#
a podcast and so far we've just talked about intensive care and me and we're just getting
#
started we're just getting started so this end of life can come at the end of podcast yeah and
#
then i'm kidding but this this this is the key so humanizing people also includes
#
knowing what they are like what they enjoy what they would want so if
#
if six members of the family
#
and actually i'll come back to this one in a minute but okay if six members of the family
#
together tell me that dad would dad was you know an army officer and discharged from intensive care
#
in a wheelchair and you know being having to be having to have 24 7 nursing care including toilet
#
care would be extremely degrading and would would be basically unacceptable to dad then that has to
#
can you spell that out for me okay let's start again so i go to see a patient
#
on the ward who someone has said could probably need intensive care
#
so i go to the ward i talk to the patient the patients in their 70s 80s whatever they
#
need to have a leg amputated because they are
#
basically they've got a major infection and then after that they are going to need to come to
#
intensive care to be ventilated i go see the patient ask the patient okay you're going to
#
have a leg amputated then you're going to come to intensive care your chances of survival are
#
whatever percent and then after intensive care
#
you will very probably need you know six eight ten months of
#
intensive physiotherapy and you will probably still be for life confined to a wheelchair
#
many of my patients will at that point say
#
actually i do not want this operation
#
just keep me just keep me comfortable but does that mean they die they've chosen to die
#
they've chosen to die yeah just keep me comfortable i don't want to go through all this pain
#
and with a really poor quality of life
#
i have to make that decision i have to tell the patient that actually your chances of survival
#
are so low and this is where we come back to the the trumpian trope about
#
trumpian tropes yeah death panels sorry i just got lost in the trumpian trope because that that
#
that sounded so good it's a wonderful alliteration yes yeah sir sir sir to to to about about the death
#
panels where basically i decide or you know the intensive care consultant decides who gets
#
admitted to intensive care just like a cardiac surgeon decides who they will operate on
#
so if i think that the patient has very very little chance of survival
#
or in after discussion with the patient
#
if they have a very poor chance of survival then i have to say no
#
i will not admit you to intensive care how poor is very poor like what would qualify
#
it's really hard but basically anyone that comes to intensive care leaves worse
#
leaves worse than their baseline so if you have someone who is say in a nursing home needing
#
assistance with um daily toilet facilities they are not coming to intensive care
#
what happens when you tell them like what what what experiences have you had
#
oh um actually most because to say no is to just but to say no is to condemn them to death right
#
immediately and they know it to to say yes is to condemn them to a protracted death
#
so what you're going to do is basically one option is you're saying okay
#
i am really sorry but there is nothing we can do for you so it's like a stage four cancer patient
#
where a surgeon says there's nothing more we can do for you so basically we'll just give you
#
painkillers and keep you comfortable the other is to subject them to a variety of painful procedures
#
and torture them and their families and then they're going to die anyway so what would you
#
rather have a few hours or a few days in comfort with without pain with the presence of your family
#
essentially be subject to medical procedures that are not really going to help you
#
or are very very unlikely to help you and then die sedated possibly in pain and possibly without
#
your family around you what would you prefer
#
no i mean are you asking me i thought that's a rhetorical question no i would that's not a
#
rhetorical question i'm asking that's a real question no no no i would i would of course and
#
people can note this as my wishes if something like that were ever to happen that i would just
#
prefer to go peacefully and not you know prolong it unnecessarily exactly so on and so forth and
#
remember the four pillars of medical ethics they are the first one is non malfeasance which is
#
often described as first of all do no harm okay so if i'm admitting a patient to intensive care
#
and subjecting them to lots of procedures where it is unlikely to do them any good then i'm doing
#
harm okay the second one is beneficence so that is try and help people so if i think that whatever
#
i do is not going to help people then i don't admit them the third one is called autonomy so
#
the patient gets autonomy so if a patient says i do not want resuscitation or i do not want
#
to go to icu i do not want cancer treatment then they get to decide you cannot force
#
treatment on a patient that that would be legally criminal assault and the fourth one
#
is justice now justice is the hardest one in especially in a socialized health care system
#
you have one icu bed left in the whole region so inside your whole transfer region because normally
#
if we are full we can transfer patients out to other icus within our region you have a 23 year
#
old with a stab wound and you have an 85 year old with a heart attack who do you admit you have one
#
bed left i don't know the right answer i've been doing this for over 25 years i still do not know
#
what the right answer is the fourth pillar of medical ethics is justice and i still do not know
#
so what i do what i would do is i would try my hardest to admit everyone
#
that has a realistic chance of survival if they do not have a realistic chance of survival
#
then the fourth pillar justice would say that the patient with the that if you're in a crisis
#
if you do not have enough resources the patient with the highest probability of survival
#
is the one that gets to intensive care
#
and we did that during covid we've done that previously during bomb blasts and that is
#
classic military triage so you basically look at people and see who is
#
likely to survive who is extremely unlikely to survive and i
#
i'll probably get a lot of social media criticism for this but
#
basically if you're extremely unlikely to survive then and and we have a crisis of resources then
#
we should not be putting we have to use our limited yeah we have to use our limited
#
resources the best however however as one of my colleagues taught me or corrected me when i said
#
this many many years ago about 15 years ago he said you can say we will stop active treatment
#
and what you never ever ever can do is to stop care so people say we will stop
#
care and you can never stop care actually what you do is you increase care for that patient
#
when you know that the patient's going to die
#
you do not you stop active treatment so you can stop treatment but you can definitely
#
yeah so we try very hard not to triage but sometimes it is inevitable the unfortunate
#
reality is when you say to someone on the ward to a patient or their family
#
or their family that you are not going to admit them to intensive care
#
it is essentially a death sentence you're telling them that
#
you're going to try very hard to keep them comfortable on the ward but
#
because we have what we call an intensive care outreach service so our nurses will go and see
#
them and we have palliative care so we try our best to keep the patients pain free and comfortable
#
but they are going to die now if you ask the population whether they would have what would be
#
would be essentially a futile painful medical procedure or die comfortably my understanding is
#
from published research that most people would actually say they would like to die
#
pain free ideally at home surrounded by family and friends rather than be subject to unnecessary
#
medical procedures however that doesn't always happen and the reasons why it doesn't always
#
happen tends to be but it tends to be multiple reasons the Americans call it the cousin from
#
California have you heard that phrase before no no no no okay so basically it is daddy is admitted
#
in intensive care all organs are failing we are talking about stopping treatment
#
or at least putting in a do not resuscitate order and a cousin from California or you know someone
#
who basically hasn't seen one of the children that hasn't seen daddy in 20 years but is now
#
guilt-ridden over that comes in and starts objecting about it and then you have to
#
go over the whole reality of cpr what is cpr cpr is when we basically insert
#
a breathing cube into the patient and start compressing their chest now for a young patient
#
with whose otherwise healthy cpr is great it works for someone who already has respiratory cardiac
#
and renal failure all it is going to do is it is going to do it is going to break ribs
#
when you compress the chest and essentially basically it is torturing your patient to death
#
and sometimes it can be very hard to persuade distant relatives or relatives that have not
#
been in touch recently but are now guilt-ridden so it can be very difficult and until recently
#
until recently in India you could not actually say do not try to resuscitate or do not do cpr
#
so until about three years ago in India you could not request that as a family or as a patient
#
she was admitted in an intensive care unit with sepsis pneumonia uti lots of lots of problems
#
multi-organ failure essentially and she was on 100 oxygen on dialysis nothing was working
#
and I have my wife's permission to disclose this one so we actually requested
#
I think requested is a mild word we actually begged the hospital to
#
to put in a dnar or to not do cpr and they said that it was a legal necessity
#
so it was absolute pure torture for my wife to witness when her mother's heartbeat stopped
#
which is which it was going to we knew because she was in multi-organ failure to sit there and
#
stand there and watch while her ribs were being broken through cpr and I am so glad that now
#
we have rules about do not resuscitate orders in India because futile treatment futile treatment
#
is actually torture and that I'm glad one of those things has changed and I am exceptionally
#
grateful that the Indian Society of Palliative Care and the Indian Society for Critical Care
#
Medicine they have at various times asked me to come and talk to them about this sort of stuff
#
because the just like I treat intensive care like neurosurgery
#
so or cardiac surgery or whatever you will so you go and assess the patient and you decide then
#
you have to decide in consultation with the patient and their family
#
what their chance of survival is
#
and what resources you have
#
would want to go ahead regardless of what the chances are however then comes the difficult bit
#
what your resources are
#
and that's where triage comes in and that is where the emotional decision-making component
#
and the emotional load comes in and that is where you then have to think about okay
#
well actually you you don't you have to think about a lot but that is the burden that you carry
#
but that is the burden that you carry so many years ago five of my colleagues we decided
#
we started with a blog which was called those we carry and basically it is everyone that works
#
in intensive care has ghosts that they carry with them and because that's that's the hard
#
decision making there when you are short of resources
#
what are you going to do who do you remember the first time you had to do that
#
yes i'm not going to describe it but what i can tell you is actually it is much easier to do it
#
in person when you are a junior doctor because you can ring up the boss at home and the boss
#
carries the responsibility because you can just write in the notes discussed with the consultant
#
and not for icu because of very poor prognosis or very poor chance of survival or whatever
#
however when you become a consultant then suddenly all that load is on your shoulders
#
so you get a phone call in the middle of the night how do you decide on the phone you want
#
to go and see the patient so you do that so for the first many years you go and see patients
#
and then you realize okay there are some registrars that
#
you know depending on the grade and reliability of the registrar you have on the night shift
#
you can decide whether to go in or whether to just trust them on the phone but it is really hard
#
however the responsibility is always yours and can you get sued sorry can you get sued oh
#
absolutely so i go to court roughly three to four times a year
#
so it is it is extremely extremely extremely common
#
however because the the judicial system works a lot more quickly than in india
#
okay i generally remember the patients when i get there rather than you know having to rely on
#
15 year old notes and and it tends to be very very reasonable so the coroner will generally
#
especially if you've got two or three consultant opinions the coroner will just will accept your
#
decision it is very uncommon to be to to have a formal adversarial confrontation if that makes
#
any sense so it tends to be initial coroner hearing and that's about it
#
it it has only happened a couple of times that my insurance company has had to pay out
#
and they actually both times paid out with and this has happened with my colleagues as well
#
they pay out with a non-disclosure agreement basically not admitting liability
#
and paying out a small amount of money but basically
#
but we will write an agreement which makes sure we are not admitting fault
#
we are just paying you to go away this is a a settlement so basically it is a case of care
#
okay if the if the amount of money is less than the lawyer's fees basically just
#
pay up and let them go and again i'm not personally paying it's the insurance company
#
it's the insurance company but it it has only happened twice in 25 years so it is very very
#
uncommon let's double click on one of the four principles we spoke about which is a principle
#
of autonomy which of course as every good libertarian would know is like our supreme
#
principle that you know with the right to self-ownership we own ourselves all our freedoms
#
kind of emerge from that and therefore autonomy is supremely important now there are other context
#
to this one is of course deciding on the do not resuscitate or an informed patient saying i
#
prefer this treatment over no treatment or just keep me comfortable and that's one aspect of
#
autonomy there are two other aspects of autonomy which strike me as interesting and they're perhaps
#
going along a continuum and at some people people will get you know uncomfortable with
#
with those and and one of them of course is euthanasia that supposing i have some kind of
#
fatal disease even if at the moment i'm okay i decide i want to end it now i know i'm going
#
to die anyway i should have the right to do so i believe in switzerland you can rent out a
#
particular facility where they put you to death in a particular humane way and blah blah blah
#
but you choose when you want to die which seems to me to be something we should all be allowed
#
to do because hey we own ourselves and the state doesn't own us and therefore it is up to us
#
and from this then comes the other question of suicide for example if we have the right to
#
our own life we have the right to take it as well and often of course suicide comes out of mental
#
health problems but sometimes it can be you know i can say that hey i'm rational i am sick of this
#
world i want to go and why can't i and this is something that most people will say no no like
#
in india for example suicide is the one crime for which you only get punished if you fail at it
#
so you know so what what are sort of your thoughts on these two because i think the logical extension
#
for most reasonable people would be to say that yeah i agree with euthanasia and all of that then
#
you should have the right to rid yourself of pain and rid your family of pain but they won't take
#
it that one step further i mean at the end of the day life is a fatal disease anyway so why should
#
you not not opt out when you want to you are absolutely right and i have often joked that i
#
have never ever in my life saved a life i have never saved any lives all i have ever done is
#
postpone death wow because that is all you can do you can never save lives
#
no one can save a life all you can do is postpone death the the the second thing you said
#
about suicide i agree that unless so if you are
#
if you have severe mental health issues and you are not capable of rational decision making
#
i would say that if if a psychiatrist judges you to be
#
to be incapable of making that decision you you can be put in protective custody
#
but if you are rational if you are capable of making a decision you have autonomy
#
and i understand i'm not completely up to date with indian law in my time in india 25 years ago
#
we actually had to report every attempted suicide to the nearest police station
#
i understand that the supreme court has now upheld that you can if you are
#
mentally competent an attempt to suicide is not a criminal offense i could be wrong i don't i don't
#
know i am as i said i'm not up to date completely with indian law on suicide however it is interesting
#
that even in countries where suicide is not a criminal offense that is most of europe
#
america you still have to wear a helmet when you're riding a motorcycle
#
and to have a seat belt on when you're in a car why because you you could count that as an attempt
#
to suicide and just speaking of incentives steven landsberg in one of his early books i think i
#
forget the name some economist was in the title but steven landsberg in one of his early books
#
spoke about how accident rates went up after seat belts and helmets were made compulsory because
#
people who wore them felt safer and drove more rashly so it can also go the other way it could
#
but yeah on principle i get your point yeah these are different things yeah and and actually helmets
#
for motorcycles are great because helmets mean that have you seen the study that said that
#
that more motorcyclists made it to the hospital after helmets became compulsory
#
they still died but their organs could could be donated so helmets essentially made donor cycles
#
rather than motorcycles
#
yeah helmets may not save the lives of those who wear them but they save the lives of others
#
because the organs are intact yeah helmets save lots of lives yeah wow this is a good way to sort
#
of think about it tell me more about end-of-life care because my like my father in his last years
#
i remember a year before he died and he was kind of going off parkinson's eventually he went in an
#
intensive ward when he got covid during the second wave among other things that he had but he would
#
keep urging me to read atul gawande is being mortal and he was saying not enough people talk
#
about this and we should talk about this i am so grateful that you've mentioned atul gawande
#
because atul gawande is being mortal not because atul is the best palliative care
#
or end-of-life specialist in the world but because of because he is such he's probably the most
#
well read medical author out there so i am very grateful to atul for having written that book
#
and yes more people should have choices around how they treat their end-of-life
#
do you want to get admitted to hospital do you want to be admitted to essentially a palliative care
#
care a palliative care facility do you want some sort of home care and there is a huge
#
amount of evidence both from europe and america there isn't much from india because the the the
#
facility does just does not exist in india that people with incurable diseases or people who are
#
going to die anyway actually survive longer and are happier with some sort of hospice or
#
palliative care facility and that can arrange in in many ways so
#
and i'm not going to pull any punches here we like to pretend that oh
#
there are a lot of instances where you know in spite of being in joint families and having had the
#
advantages of joint families in their younger life people do not look after their elders so
#
so what we have is you can have end-of-life care so palliative care you can you can start it from
#
okay when you start getting slightly disabled so you can either privately or publicly funded
#
whatever it is depending on your health care system you have carers that come
#
so initially you start with
#
everyone has a cleaner and no one has to wash their own dishes but initially you can start
#
with someone that comes in twice a day helps you cooks for you and helps you bathe change your
#
clothes then you go over to you know four times a day two people coming in three or four times a
#
day to take you to the loo change your clothes keep everything clean then you go over to you
#
know 24 7 care then you go over to 24 7 care which is more specialized which is rather than
#
you know untrained workers you need a nurse who is going to give you your medication
#
who's going to look after you then you and and then you go to 24 7 care with
#
prescribed medication prescribed pain medication or should i say prescribed
#
uh licensed pain medication so not just paracetamol and barufin but some sort of
#
so some sort of opioids which have to be licensed so you you can have a variety of these things
#
and what you need is to have really access to a spectrum of these things and ideally
#
as indians this tendency to not plan about the future
#
we have this tendency to say if you
#
every time i've suggested to anyone in any of my elders and okay i'm nearly 50 now so
#
this was a few years ago but every time i suggested to any of my elders that they should
#
have a bill they should have succession planning they should have an end of life plan they should
#
think about you know a dna or anything like that it was always
#
so we have this thing where we do not like to plan about the future we do not like to have
#
unlike the army does where you know you have our crisis plans we do not like to
#
personally plan for our future which is crazy what we should have is we should have
#
a will and we should have a financial plan a retirement plan most people's retirement plan is
#
unless they are in a government job with a pension and you should have a medical plan
#
and a living will some sort of indication to your family insurance some sort of indication
#
and and and definitely actually not an indication an expressly written thing about okay what do
#
i want to do if i am severely ill and incapacitated where i cannot tell you my
#
wishes so they are written down here expressly they could be do not do anything i am
#
um i've lived in enough i do not want anymore or okay talk to the doctors talk to talk to
#
the health care professionals and if it is likely that i'm going to be severely disabled let me go
#
or whatever you choose it is autonomy isn't it we were talking about autonomy this whole
#
discussion started around autonomy and again i firmly think that the word you used earlier
#
euthanasia is a very loaded word
#
i personally when i teach i talk about a
#
either so i i talk about what you would conventionally call it use call euthanasia
#
so euthanasia is if a patient is on a ventilator i talk to the family i tell them that the patient
#
is 100 going to die so we should switch off the ventilator now is that euthanasia
#
that's just end of treatment it's not really euthanasia i mean to me euthanasia is
#
when i know that i'm going to die in nine to twelve months but i say hey i'm not going to
#
spend too much money keeping myself going so you are so now you have defined the word in your
#
words however to most of the public euthanasia there are two types
#
of euthanasia passive euthanasia so passive euthanasia is when we say okay this patient
#
is dying so they're going to die in 10 12 15 hours anyway why are we torturing them
#
with more procedures let's stop now that is passive euthanasia does that make sense
#
make sense then you have active euthanasia and in my
#
mind and as you said okay active euthanasia is when you go to dignitas and say okay i want to stop
#
things so i the problem is that a lot of people unlike you when you say euthanasia they
#
think of it as death panels or passive euthanasia or all of that stuff so euthanasia is a very very
#
loaded term and i never ever use that word just because euthanasia to me is okay have you seen
#
platoon yeah oliver's room
#
yes yes absolutely absolutely here's a question for you so you know autonomy yes and the interesting
#
thing is autonomy can actually be used differently by many people and it can be used differently
#
from how they state they'd use it for example economists have this term called revealed
#
preferences where they look at your preferences not by what you say but by what you actually do
#
and earlier you had spoken about degrees of being unwell so degrees in sense of
#
then two nurses will come and they'll bathe you every day and so on and the degrees get worse
#
and worse and i think the human tendency would always be to think that this degree is tolerable
#
if it gets much worse they'll choose to go so when you are actively making those decisions
#
you will essentially leave it until it's too late for you to decide anymore and what must
#
be also stopping people from putting a dnr on themselves unless you've thought about it as
#
much as you and i have but what would otherwise stop people from putting a dnr on themselves
#
is just a thing of that there is a borderline beyond which they do not want to be resuscitated
#
but before which they would want to would want another chance and they would be scared
#
that the people in charge might err on the other side or wherever they draw that line and in
#
revealed preferences i think many people would actually uh you know
#
but then when the time comes they'll choose because they want to live live live you know
#
so that also i mean do you think that that's like a psychological barrier that people who otherwise
#
profess support for it won't really do it in their own cases and similarly the instinct not
#
to make a will might be coming out of this illusion of immortality where you imagine that we all in a
#
sense we live in a way as if we imagine we will live forever though rationally we know we won't
#
but we imagine we will live in that way you know so uh i never say that but i'm just saying we
#
should if anyone's heard the liver doctor episode you should know that daru should be strictly
#
avoided but have three cups of black coffee a day that's very healthy yeah so i i work in the
#
biggest liver i see in europe you you you should know what i feel about this but yeah huh i agree
#
that i mean i'm a huge so about 20 years ago i read free economics
#
which introduced me to the whole concept of behavioral economics and actually behavioral
#
economics is behavioral psychology and it is behavioral medicine so yes i've tried to incorporate
#
many of the principles into my personal practice lots of people have written about it and as you
#
know that behavioral economics has actually and and q theory have played a part in how
#
organ transplants waiting lists are done in both europe and america india metasera
#
it is a different story so i am sorry i cannot relate this to india but yes i agree that
#
tends to be hugely strong and a lot of people are prone to the optimism optimism bias and
#
i do not know why but asians
#
tend to be more prone to that
#
end of life decision making may be problem and i don't exactly know why why we do why we culturally
#
making forward-looking decisions the only forward-looking decisions that i see
#
our elders making is investing in real estate nothing else
#
and that's a backward looking decision because real estate mostly especially in india is a
#
liability not an asset i completely agree with you i completely agree with you however that is
#
just what what happens you know fixed deposits real estate that's about it so there is some kind of
#
bias against forward thinking and this is something that actually i think you and possibly shruti
#
rajgopalan could have a better idea than i could because i don't know man no man i have no idea
#
about the why of it especially what you just told me that is not only indians in india it's also
#
indians there who have more of an optimism bias and their counterparts and i can't figure that
#
out why what are you what are your candidate reasons i have no idea it is
#
that is the only two things i can think of
#
i can't think of anything i think all explanations including these and explanations like oh they
#
think on a longer time scale because they believe in rebirth and whatever i don't i don't buy any of
#
these explanations because i think that reveal preferences would indicate that these are not
#
the case and in other contexts indians can actually be quite forward thinking and canny for example
#
you know a marwari with his money will be extremely practical and rational and canny
#
so why should the same marwari not be that way with his life
#
what was the will made by dhirubhai and what happened to his children
#
dhirubhai must be your brother i don't know
#
look basically Tata's Ambani's someone has made the will properly
#
after dhirubhai Ambani's death there was a fight between sons
#
so if the richest man in india after having two strokes still did not make a will
#
okay you tell me about revealed preferences
#
yeah i i can't dispute that i can't come up with a reason for it but this shows both a lack of will
#
and a lack of will and i i don't have a reason for it here but this is this is so i am just
#
being not being a psychologist or an economist i am just going to call this asian mentality
#
mentality this is not just india because i see
#
so i basically live in what in a tv serial was called the capital of british pakistan
#
so basically and and and we often forget that indian panjab only has a population of two two
#
and a half crores pakistani panjab has a population of 12 crores and lahore is as big as delhi
#
my population is basically india pakistan bangladesh
#
india pakistan bangladesh china especially hong kong chinese malaysians singapore
#
so basically it's all it's pan asian rather than just ethnic group mr kureshi plays golf
#
so i don't know why this is as i said i i am not an economist i'm not a psychologist
#
i don't understand why but the brits the europeans the americans are much more likely
#
to have forward planning in terms of end-of-life care in terms of bills than
#
are most asians are and that is not just india it is as i said most asians and i don't know why
#
so you know fabulous insights on sort of end of life and let's take a step back and you know
#
continue talking about intensive care and so on and one of the sort of interesting things that
#
you've pointed out about the journey of intensive care is that back in the day when you had started
#
out and you always assumed that you know as time goes by there'll be better drugs there'll be more
#
technology the science will evolve but over time you've realized that intensive care really
#
involves fewer drugs less technology and one of your most resonant quotes i think it came from
#
one of the simplified episodes which are linked from the show notes where you say that it's a care
#
not the treatment right i wanted to sort of elaborate on all of these absolutely so what
#
we found is over time we in in the 80s 90s early 2000s so until about 15 18 years ago
#
we were looking for wonder drugs we were looking for miracle treatments we were looking for magic
#
bullets silver bullets to kill vampires so we were looking for magic solutions to stuff
#
and then what we found was just like you know how many medals britain wins in cycling in every
#
olympics and what they did was it was small things it is not one big thing and that the term by diff
#
the term by diff brilsford was the aggregation of marginal gains absolutely thank you that is
#
exactly what i was going for except i did not want to sound too conceited by saying that
#
so the aggregation of marginal gains is exactly what intensive care is about
#
so over the last 20 years what we've learned is less is more so you do not look for magic
#
solutions and you realize that actually we do not understand human physiology as well as we think
#
so the less we do the better it is so instead of for instance and i use this i've used this
#
this analogy on multiple lectures podcasts whatever so for instance in the 1990s we would
#
try when we were ventilating someone to give them normal lung volume you are giving normal lung
#
volume but half of your lung so normal breath volume half of your lung is filled with pneumonia
#
so what you are doing is you are overstretching the other half of the lung
#
so basically if you have a balloon you over inflated 25 times what happens to the balloon
#
yeah it gets wrinkled less stretchy than before or more stretchy than before basically it becomes
#
deformed so we used to do that we used to try and you know inflate the lung to a normal volume
#
and then we realized that actually after a big big study proved that actually lower lung volumes
#
lower breath volumes actually improve mortality because otherwise what you're doing is if you're
#
over inflating the half of the lung the healthy bits of the lung you are essentially you are if
#
you over inflated that will also get inflamed so basically you are destroying the healthy lung that
#
you have so lower volumes actually improve mortality in the same way we discovered that
#
lower blood pressures are actually slightly better for you especially if you are actively
#
bleeding because if you are actively bleeding and your blood pressure is high blood will keep
#
pumping out if we risk if we keep if we start giving you blood until we have controlled the
#
bleeding we should actually have a lower blood pressure for you so essentially it's a case of
#
less is more so it is about care rather than treatment it's the same with a lot of other
#
things so a lot of things that we do come in what we call care bundles so we talked about
#
ventilation it also comes with regular suction regular repositioning of the patient
#
avoiding pressure sores if we have a pressure sore in on a patient that is a major incident
#
i can't remember the last time we had a pressure sore on a patient so the patients have to be
#
turned every two hours you have to have pneumatic mattresses it's about the little things so
#
intensive care is essentially as you said about marginal gains about the little things and then
#
trying to individualize treatment
#
i'm also curious about another aspect of it and this goes back to perhaps my earlier question on
#
how many doctors are ticking boxes and going through the motions and how many are actually
#
staying in touch and it seems to me that a lot of what you have to do especially in
#
intensive care is stay in touch with the actual signs think about the actual signs think about
#
the why and not just the what you know just in the case of why it is better to have like lower
#
breath volume that this is why we were wrong this is why we must do this or as in a case i think
#
you discussed with our mutual friend about how his dad in intensive care was given
#
oxygen saturation levels that were kept at 100 where actually today we know the optimal thing
#
is don't keep it at 100 keep it in the 90s and you know so on and so forth that the ones who
#
are kept at 100 actually become worse which indeed unfortunately happened to his dad and
#
i'm thinking that there is like a two-way thing here one is understanding the signs understanding
#
the basic principles which is something that you know apart from history you mentioned your other
#
great love was physics which obviously indicates that you have a love for foundational principles
#
so at one level i'm guessing that understanding the science and keeping in touch with it will
#
make you a better doctor per se but at another level at a different level understanding those
#
principles will also help you do things on the fly do you know for lack of a better term or
#
improvising conditions which might not be optimal just like in for example where you need to cool
#
the oxygen cylinders instead of heating them so tell me a little bit about the importance
#
of doctors always sinking on their feet whether it's regard to applying the science to their
#
medical treatment and care or whether it's with applying the science to adapt to different kinds
#
of circumstances and always being nimble that way like how many doctors are actually like this
#
you know does the healthcare system they're operating in like the english system being
#
you know demand having that kind of regulation that you keep upgrading yourself does that also
#
matter and is that something you have to be intentional about or is it very easy to slip
#
into a groove okay now this is going to be a long one okay please please go what i will say is
#
that the best doctors i've worked with or worked yeah worked with in my life
#
have been in india and the best doctors the best jugadu doctors especially
#
problem is that the worst doctors i've worked with have also been in india
#
so some massive variance and the difficult conditions make the best very good because
#
they adapt but the bad education and the difficult conditions also make the worst very bad
#
that is exactly right i would add poor regulation to that and yeah but but you
#
you're absolutely right i would agree with that it is about that the really good ones
#
actually have a chance to get better and the the conditions actually give them a chance to innovate
#
and actually in some ways the lack of regulation also gives them a chance to innovate because they
#
don't have to jump through 300 hoops to for to do something new whereas over here yeah you would
#
have to go through a hundred ethical committees to do that stuff but the
#
bad ones get kicked out by the system over here while in india they just keep going
#
so i would suggest that the average level of doctors over here is better than in india but the
#
really good ones in india are extremely good they are yeah they are extremely good
#
so you know i've taken a lot of your time today and there's one particular mystery subject which
#
you have offered to do a full episode with me on a few months into the future which demands a full
#
episode of its own so let's not touch upon it now but one of the things that i really enjoy about
#
you know those few conversations that we've had are really the kind of storytelling skills you
#
bring to the table so i will and you said you have at least three or four really interesting
#
stories which one can draw lessons from which have learnings and blah blah blah so so let's start
#
okay some of it will be actually mildly amusing some will be
#
slightly darker so one of my hobbies for almost 15 years was i ran an icu follow-up clinic
#
so icu patients who get discharged
#
so have you ever thought about how many soldiers who have been in active battle
#
how many of them have ptsd a significant number is what i believe right yeah more than 20 percent
#
do you know that icu survivors have a ptsd rate of over 30 percent wow more than soldiers
#
that went to afghanistan wow because that is the metric i have to compare to because
#
so the metric i have to compare to is because we are the uk's defense medical center as well
#
so the metric is that my normal icu patients have just as much or more ptsd than soldiers that were
#
in active battle so far so fighting lord yama is much harder than fighting the taliban
#
yes pretty much yes and that results from a number of things it is my mother was admitted
#
to covid icu two years ago so we're starting with the dark we'll go to the funny later
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my mother was admitted to covid icu two two and a half years ago in india luckily
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i have contact so i was able to arrange a bed for her and stuff like that and
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the specialist the intensivist and the charge nurse would let me
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video chat and you know give me videos of send me photos and videos of test results and stuff
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however my mother came back with significant trauma and one of the things was she
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said that she'd been and i've i've had this with a lot of people but i can say this about my
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my mother because i have permission
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to be sexually assaulted in intensive care why
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you are in intensive care you are half asleep so you're half sedated
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someone puts a catheter in you a urinary catheter
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someone is cleaning you up after you have past stools
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so basically multiple times a day people are touching what you would
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very gently say is intimate areas of your body and if you are half sedated and you do not
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understand what is going on what would it feel like and this is one of the things that we do not
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and a lot at least 20 to 30 percent of icu survivors remember this
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and they remember it in a really bad way and you have to essentially push them
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to get the memories out of them
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so this is this is one of the things that we never think about or hardly ever think about
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and especially if you are not working in intensive care
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this is mind-blowing to me it's like the first time i'm hearing of this and yet it seems so
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logical and and obviously way way worse for women and a man probably wouldn't even think of this
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yeah yeah absolutely absolutely and then you think about menstruating women
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who have their periods while they are in intensive care while they are sedated so it is it is
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they are sedated so it is it is it is a significant thing that we do not talk about
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because we we just we just ignore it about 20 to 30 percent of my patients in icu follow-up clinic
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end up having to be referred to a psychologist or a psychotherapist whatever you want to say
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because they have ongoing issues with
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what happened so for instance and this is anonymized and i've given this talk at three
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three different conferences so i had a patient called amy who came to us
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with a severe infection was ventilated stayed in icu for a couple of weeks
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and then about a year later her family came over to talk to me
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and said that she was having significant mental problems
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so we talked to her and it was basically she did not believe that she had been in intensive care
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she believed that she had been kidnapped by colombian drug lords
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and she'd been taken to columbia by a ship and that her family had been ransomed her and then
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while during her time in columbia she had been tortured and sexually assaulted
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how does this work then i asked the family if she would come in
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and she did and it still didn't make any sense so we looked back through her hospital records
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at that point this is pre-brixit we had a significant number of spanish nurses
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so what was happening was so you are sedated you have
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nurses talking at handover in spanish
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a lot of people call it the drug chart
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so you're saying drug drug drug drug chart okay and the ship thing we have pneumatic mattresses
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so air mattress which basically rolls the patient around a little bit so the boat ship
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thing is very common in our icu survivors so you put all of that together you're talking and
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you're sticking needles into the patient every day you're cleaning the patient you're changing
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their menstrual pants you're putting a urinary catheter in sexual assault you put all of that
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together and suddenly it's like yeah okay so i was on a ship there were people talking about drugs
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there were people sticking needles into me so torturing me and there was sexual assault going on
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and once we put it together and managed to explain it
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she got better i still get christmas cards from her this is 20 years ago and i still get christmas
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cards from her lives in australia now and as i said suitably anonymized and with permission
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on the other hand one of my consultants one of my bosses about 15 years ago told me
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that i am destroying personally i'm personally destroying human evolution you yeah
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okay so this is a weekend i'm on burns intensive care and we get our first patient the first
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patient is someone who has very bad lungs lung cancer so he's on oxygen
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in a wheelchair so oxygen tank is on the back the wheelchair and he has oxygen on his face
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nasal prongs and while on the oxygen he decides to smoke
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as soon as he lights up the lighter basically oxygen cylinder everything blows up
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so he comes to burns icu we spent about five hours stabilizing him
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so as soon as we finished stabilizing this guy i get a phone call from another hospital which
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doesn't have a burns icu so they want to transfer the patient to us where the story is this patient
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got throat cancer laryngeal cancer from smoking so he has a permanent tracheostomy
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so what he's done is he's fashioned sort of plastic contraption to so that he can smoke
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through his tracheostomy oh my god you put a darwin's law you're getting at right this is why
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you're messing with evolution their genes would have been like wiped out and you're keeping them
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going and then as he's smoking he coughs and he happens to inhale the burning cigarette
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the burning cigarette so now he has burns in his trachea and bronchi and so they have
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they transfer him to us we have to actually put a bronchoscope in and get the cigarette out
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first time i've heard of a guy inhaling a cigarette itself wow wow
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and burning his trachea after having surgery for throat cancer because of smoking okay so
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i've run out of sympathy there have been many sad stories in your episode doctor
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but i've run out of sympathy for these two guys so so that evening when the boss comes for the
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rounds he says nitin you are messing with human evolution
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yeah but on the i mean i mean obviously your boss was joking but if these people aren't reproducing
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which i guess they'll have trouble reproducing after this you're not really messing with evolution
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the genes aren't getting back in there yeah so good okay yeah and then i'll tell you about how i
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stopped the irish war from from restarting kindly explained
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so again we had a patient who was with us for a couple of weeks now this will need a visual
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so i'll i'll email it or whatsapp it to you so basically you know that there was a very
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prolonged conflict in ireland between protestants catholics ira so we had a patient and at this
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point i worked in manchester so we had a patient who was with us for a couple of weeks got better
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went home his family contacted me because i was running the follow-up clinic and they said
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that his brothers and cousins want to kill him
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because he was a protestant now he wants to become a catholic why
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i said okay fine get him in got him in and he says well because i was going to die
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you all told me i was probably going to die and the only reason i survived is that there were
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nuns praying for me like what because protestants don't have nuns catholics have nuns so he wants
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to convert to catholicism now and we're like what what is this then we said okay why don't you
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do you want to come and see have a tour of the icu because we do that with a lot of our patients
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and his wife remembered what bed he was in because we didn't remember what bed he was in
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so his wife he was here and we went to that and it was fine and then i walked up to the head end
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of the bed and opposite wall now we have oxygen cylinders in icu which are about four foot high
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they are black with white shoulders
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he said okay so how many he said sometimes there were three but there was always at least one
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because we always keep one oxygen cylinder sometimes three and that oxygen cylinder
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to a half sedated person would look like a nun in her black and white habit and kneeling because
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so he wanted to become a catholic because he mistook oxygen cylinders for nuns
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and we've said there's another topic that we will talk about definitely another point in a
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few months before i let you go a penultimate question my ultimate question of course is
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pre-planned but my penultimate question is taking off from that very disturbing first story that
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you mentioned about you know all these women imagining that there was sexual assault happening
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because in a sense when they are half sedated they do find their you know private parts being
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invaded as it were when they don't really know what's going on and they haven't explicitly
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consented and that's actually a really disturbing situation because you don't want to leave anybody
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with trauma of that sort what are the ways to mitigate it like what are the ways to
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make sure that i mean what can one do about it because i generally recognize that we live in
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a world designed by men for men and everything right down to the air conditioning temperature
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in offices is designed for men and i imagine that in a previous time something like this would not
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appear to be a problem because no man would feel like this and he would just gaslight the women
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but this is this seems to me to be a real serious problem if women are left with the trauma and the
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memories of sexual assault even if it wasn't actually sexual assault so you know what can
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be done to mitigate this okay so one of the things that we have very consciously tried in the last
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many years is that we keep sedation as light as possible and we try to have our patients
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to be able to understand what's going on and
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before you touch a patient before you approach a patient all of our nurses all of our doctors
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what we do is we explain to them we try and talk to them and again it is it is difficult because
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you have to have a certain level of sedation to have all the tubes and the ventilator in
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so but what we do is we try and explain every time before we touch the patient what we are
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trying to do we talk to patients all the time we try and have their families there for a lot of
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time and what what what we found is that having families and this is what made covid icu harder
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because there were no families there what we found is having families there 24 7 or whenever they
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want and talking to the patient actually helps a lot because that makes them feel not just connected
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to the world but also safer and before you do anything intimate or anything painful to the
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patient you explain it to them you explain it to the family and before you discharge the patient
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you also explain to the family that there are but to the patient obviously and to the family that
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it is likely there's a 20 25 chance that they'll have some sort of ptsd delirium something
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and that we have a follow-up clinic and we will follow them up on the ward as well and you
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and the family have to keep explaining that they were sick they were in hospital they were having
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medical procedures rather than memories of what you could understand as sexual assault
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so that is the key it is about it is all about communication as we've said before
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and as actually you said it quoting me from earlier that intensive care is about care
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more than treatment yeah and and and these are very wise words and in the long run perhaps
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treatment is not possible at all because we're all going to die anyway as you said you've never
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saved a life and you know i mean earlier i said that i never want to die in an intensive care unit
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but i wouldn't mind dying if a columbian drug cartel was to kidnap me and try experiments on
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me that would be a funky way to go so no you're shaking your head you don't think so you've
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experienced columbian drug cartels it seems so on that wonderful note we've had a great
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conversation i feel like there's a lot else to talk about which we will save for the next
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episode so listeners have something to look forward to but i'll ask you to end the show
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by recommending for me and my listeners books films music any kind of art which means a lot
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to you not it doesn't even have to be about your subject but which means a lot to you and you'd
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love to share with the world okay i will suggest two okay actually i will put a thread on twitter
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later i'll share a thread with you which you can put in the show notes done but the two that i
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would definitely recommend actually there are three uh two by atul gawande one is the check
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checklist manifesto the checklist manifesto the other is being mortal and the third is when breath
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becomes air and the fourth one actually which which which should have been first is the classic
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book on behavioral economics
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i mean i've read so many books on behavioral economics before that even came out that in my
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mind there are just a whole bunch of them so so by danny kanaman and currently thinking fast and
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slow is what you're talking about that's the one that's the one that is the one so you just
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thought slow it's okay i mean yeah i thought slow but that is classic and that actually happens
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you know a behavioral heuristics are a real thing and these guys
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basically invented this whole field or discovered this whole field because it was probably invented
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20 000 years ago when we started talking absolutely so nitin it's been such a pleasure
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talking to you you've made me determined to to die in dignity i completed the sentence i could
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have put a full stop at die but it's it's uh i've learned a lot from this conversation i'll listen
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to it again and i'll kind of process it over time and there was at least one mind-blowing
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til in that towards the end so i learned a lot thank you so much for your time thank you so much
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for having me it has been a pleasure and an honor to be on your podcast and i'm looking
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forward to coming back next year thank you if you enjoyed listening to this episode send it
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to whoever you think might be interested check out the show notes enter rabbit holes at will
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you can follow nitin on twitter at aurora d r n this will also be linked from the show notes
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and you can follow me on twitter at amit varma a m i t v a r m a you can browse past episodes
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of the scene and the unseen at scene unseen dot i n thank you for listening
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