Burnout in Medical Students

As every whining medical student knows- life as a medico is tough and trying. This was well documented and analysed in an article in Annals of Internal Medicine(abstract).

The article has been reviewed by Sydney Spiesel at Slate.com

The study included more than 2,000 students at seven medical schools and looked for evidence of burnout and suicidal thinking. About half the medical students reported the feelings that define burnout (emotional exhaustion, a feeling of a loss of personal identity, a sense of poor personal accomplishment). Many showed signs of depression and a decreased mental quality of life compared with peers not in medical school.

He attempts to explain the findings and further offers possible solutions to the problems as in

We need to be alert to the signs of burnout, depression, and suicidal thinking in medical students and to make available the mental-health services needed to help with these problems.

Even though the factors in India are quite different from the US medical schools esp. regarding the debt(largely subsidized); I would be surprised if the findings are much different. the full article is here.

(Thanks to Cartoonstock.com for the pic)

Lessons from Sharks on reducing infections.

Interesting article in the Wall street journal health blog

The ocean is full of slow-swimming creatures covered with algae and barnacles. But some slow-swimming sharks stay pretty clean.

A University of Florida researcher thinks that has to do, at least in part, with the microscopic pattern of shark skin, which makes an inhospitable environment for the critters that want to make a home there.

The researcher, Anthony Brennan, hopes to make products whose surfaces mimic that property, and he’s working with a couple of Denver businessmen on a company called Sharklet Technologies. This morning’s Denver Post has a story on the business.

The company says it’s already figured out how to make silicone surfaces with a sharklike pattern that’s resistant to the growth of bacterial films. Sharklet hopes to sell the technology for use on things like catheters, a common source of hospital-acquired infections.

It’s early days still for the technology, and it’s unclear whether it will get off the ground…

Hope that this cool idea works out! Urinary tract infection following catheter insertion is certainly a frequent complication in hospitalized patients. The concept of preventing infection by disabling bacterial adhesion and migration (biofilm formation) is gaining grounds with few other materials being tried out.

(image from the Denver Post)

From the Denver Post via WSJ health blog.

Richard Wright – Shine ON…

Richard William Wright died on the 15th of September 2008 following cancer at the age of 65. He was the lead pianist, keyboardist, lyricist and one of the original members of the band Pink Floyd. Wright had the lowest profile of any member of a band known for their disinclination to seek individual attention. He kept the details of his illness private as well.

Pink Floyd was (is) my favourite rock band.

He also had two solo albums Richard Wright’s Wet Dreams(1978) and Broken China to his name. And this song is one my favourites from his albums.

Rest in peace Rick Wright ..and sail on across the sea!!

Internet Companies sued for Sex Selection Ads

Given the fact that male to female ratio in India is grossly skewed having reported a child sex ratio of 927 girls to 1000 boys in the
2001 census, against a world average of 1045 women to 1000 men.

In some
States this is even worse including in Punjab, Haryana, Gujarat, Himachal Pradesh, Delhi,
some districts of Tamil Nadu, Maharashtra and recently Karnataka, the
sex ratio has declined to about 900 girls per 1000 boys in the 0-6 age
group. In some districts, the ratio has plummeted to less than about
850 to 1000 boys.

The preference for male child continues and in recent times has been assisted by mail order/ internet companies who are able to defy safeguards by operating from outside the country. So it was just a matter of time that someone pointed this out. This news was published in the New York Times today.

Microsoft, Google and Yahoo were issued notices by India’s Supreme Court on Wednesday, following a complaint that they were promoting techniques and products for the selection of an unborn child’s sex through advertising and links on their search engines.

There is a deliberate attempt by these companies to target Indian users with advertisements that claim to help in the selection of a child’s sex, said Sabu Mathew George, the petitioner in the case, in a telephone interview on Thursday. Read the rest of the article here.

Update: Internet giants Google and Microsoft have pulled adverts for sex selection products and services considered illegal in India after being threatened with legal action, activists said Thursday.(from Yahoo news)

cholecystectomy as day-case.

With the advancement in laparoscopic techniques,increasing proficiency of Surgeons in their use and economic pressures there is an increasing trend of cholecystectomy (removal of gall bladder) being done in clinic procedures with the patients being discharged the same day. There is an interesting article in the recent British Journal of Surgery concluding day-case (i.e. no overnight stay in hospital) laparoscopic surgery to be safe and effective.

Meta-analysis of randomized controlled trials on the safety and effectiveness of day-case laparoscopic cholecystectomy.

Br J Surg. 2008; 95(2):161-8 (ISSN: 1365-2168)

Gurusamy K; Junnarkar S; Farouk M; Davidson BR
Hepatopancreatobiliary and Liver Transplant Surgery, University Department of Surgery, Royal Free and University College School of Medicine, University College London and Royal Free Hospital NHS Trust, London, UK. [email protected]

BACKGROUND: Although day-case laparoscopic cholecystectomy can save bed costs, its safety has to be established. The aim of this meta-analysis is to assess the advantages and disadvantages of day-case surgery compared with overnight stay in patients undergoing elective laparoscopic cholecystectomy.
METHODS: Randomized clinical trials addressing the above issue were identified from The Cochrane Library trials register, Medline, Embase, Science Citation Index Expanded and reference lists. Data were extracted from these trials by two independent reviewers. For each outcome the relative risk, weighted mean difference or standardized mean difference was calculated with 95 per cent confidence intervals based on available case analysis.

RESULTS: Five trials with 215 patients randomized to the day-case group and 214 to the overnight-stay group were included in the review. Four of the five trials were of low risk of bias. The trials recruited 49.1 per cent of patients presenting for cholecystectomy. There was no significant difference between day case and overnight stay with respect to morbidity, prolongation of hospital stay, readmission rates, pain, quality of life, patient satisfaction, and return to normal activity and work. In the day-case group 80.5 per cent of patients were discharged on the day of surgery.

CONCLUSION: Day-case laparoscopic cholecystectomy is a safe and effective treatment for symptomatic gallstones.

Such has been the practice at our center for 3 years now and there has been no cause of regret. In patient having excessive adhesions or difficult dissection or having anaesthesia related problems can be held back overnight. The patient can be assessed in the evening at the time of discharge and if comfortable can go home with instructions in case of any difficulty. I suppose the figure of 80 percent is about right.

As this study illustrates there is increasing trend towards shorter stay and early discharge. there are many centers in the US where such operations are done in office setting assisted by recent advances in intraoperative Ultrasound which is replacing cholangiography( unaware of such practice in India). Variations in the anatomy of cystic duct, hepatic duct and CBD and consequent mistakes while cutting the cystic duct can lead to dreadful and expensive complications.

WHO issues a surgical checklist.

A lot has been written about surgical errors during operation including incidents of left behind surgical instruments, wrong site surgery, operating on wrong patients and so on.

The WHO has issued a checklist which it hopes will go a long way in reducing such errors by enforcing a ‘time out’ when all personnel participating in a procedure will check and mark on the checklist ensuring compliance of necessary formalities. Such checks are further made at the end of procedure.

I agree that such checklists and timeouts will be quite helpful in reducing the number of errors but surgeons are resourceful and dogged of determination; they will find a way around this.

As an aside if you have read books by Atul Gawande you will be aware of his fascination for idea of checklist similar to those used by the Aviation industry(very effective) to reduce medical errors. His Harvard group and folks at IHI and The International Society for Quality in Health Care have been quite active at getting this off the ground.

WHO Safe Surgery Saves Lives ChecklistTechnorati Tags:

Second opinion at a distance

There is an interesting piece of new in todays USA today about taking second opinion for health conditions online from experts. You send your medical records with or without your primary doctor’s help via internet to Experts( places providing paid service) and get their opinion after a week or so.

Online second-opinion services offer patients consultations from specialists based on the medical records that they fax, mail or send via the Internet. The average cost, payable upfront via credit card, is $500 to $1,500, depending on the number of radiology or pathology interpretations required. Patients then receive online access to a second opinion in about two weeks.

What I find very interesting is the amount of changes in treatment or diagnosis as per this article.

More choices, ‘more peace of mind’

Not all remote second-opinion services require that a patient’s local physician participate. The Cleveland Clinic, for example, delivers consultations directly to a patient, while POSC shares them with the physician first and then with the patient.

In Harlow’s case, her physician “welcomed” the idea of a second opinion. Harlow says she opted for the whole-breast radiation treatment, based on the report from Lawrence Schulman, a leading oncologist at Dana-Farber Cancer Institute,

“In about 5% of the cases, we actually change the diagnosis of the patient. In 85% to 90% of the cases, we alter the treatment,” says Jonathan Shaffer, managing director of e-Cleveland Clinic. “What we are able to do is give the patient more treatment options and hopefully give the patient more peace of mind,” he says.

Shaffer says people are beginning to realize the convenience of e-health technologies. “It continues to grow every year.”

Considering the rapid progress in internet technology and telemedicine these are bound to increase. Radiology is quite in the forefront. But is it viable in the long run?

Quite a majority of cases are such where the diagnosis and the treatment is not in doubt and the physician is quite comfortable in following through the treatment. It may happen that the patient remains unsatisfied and may want a second opinion or alternative treatment. And why not? after all it is his money and body. He might remain dissatisfied with the second opinion as well.

Physicians have been taking second opinion unofficially and consultations officially whenever they are unsure about management of a particular disease or presentation; but will they follow up on perceived unsolicited advise?

Do not expect the primary physician to follow and carry out the advice given by the Case manager /Second opinion provider unless he himself (or herself) co-initiated the consult. It is quite apparent that the second opinion will also be a medical consultation with its attendant liability and responsibility unless waived off by the patient( and then that has its own consequences).

The need for second opinion arises more in evolving fields like Oncology or where there are multiple treatment options under evaluation. For example- If the patient remained unconvinced by the doctor providing second opinion then what? back to square one..Patients need to have faith in their doctors and the doctors need to have knowledge to get that trust.

Whatever shape it takes in future; there is money to be made and does fill in a perceived need so will catch on.

Read the complete article from USA Today.

Pic from http://www.flickr.com/photos/luca_eos/

Wild East

Kaziranga National Park – Tiger Attack – Complete Video.

This video clip was being shown with embellishments today on IBN 7 network hawked as something fresh. Turns out that the said incident is almost 4 years old. Interesting though.

The forest department was combing the area with five elephants to locate a large female tiger which had killed two cows near their village. The team cautiously moved almost 20 feet where she was growling away. They took a shot at it with a dart gun and missed. This enraged the tiger so much that she charged and took a “flying” leap 12 feet above the ground on to the elephant’s head. What’s even more amazing is what happened next.

The full story and the relationship between mahout and his elephant can be read here http://www.wildlifetrustofindia.org/html/news/2004/040609_joymala.htm Technorati Tags: ,

Reversible Vasectomy

At present Vasectomy is the only reliable method of male contraception. While it is relatively simple procedure and quite cheap besides the fact that the government pays you to get it done, yet it is not that popular. 

The reasons for that is the irreversibility of the procedure and the perception of loss of ‘manhood’. Male desiring further children have to undergo recanalization which are not always successful and is expensive ( vas may block again, antibodies to sperm may develop etc.). So any reliable alternat e  method  is bound to be popular and in the  news. from rediff.com

Once upon a time, a scientist, rather an engineer-cum-doctor, toyed with an idea — what if there were a male contraceptive? What if a simple injection to a male prevented unwanted pregnancy?

His ever-active brain started thinking and years of research followed. And after 30 long years, RISUG (Reversible Inhibition of Sperm under Guidance) was born.

The credit goes to Indian biomedical engineer Dr Sujoy K Guha and his group at the Indian Institute of Technology-Kharagpur,

In this situation a method of reversible blockage or sperm inhibition would be a wonderful thing; increasing the usefulness and acceptance of male contraception. This is where the method of RISUG comes in. Though still in advanced trial stages it is quite promising. It consists of partial blockage of the vas deferens lumen(the conduit passing sperm from the testes to the ejaculate) using polyelectrolytic compound and can be effective upto 8-9 years. The block can be reversed when desired by flushing using solvent or local stimulation.

The method is pioneered by Dr. Guha at IIT Kgp. In case you need to know more you can visit the Risug site or

Reversible inhibition of sperm under guidance – Wikipedia, the free encyclopedia.

(Pic from iitkgp )