The Offer

I will make you scream
Make you call my name
Fulfill your wildest dream
You won’t be the same
See this body of mine?
It can all be yours
These curves, so fine
Much pleasure ensures
Are you full of worry?
A heart filled with care?
You won’t be sorry
Into these arms to dare
So out with the wallet and pay my fee
My love is the best but is sure not free!

Happy Birthday, Malcolm!

“I don’t feel that I am a visitor in Ghana or in any part of Africa. I feel that I am at home. I’ve been away for four hundred years, but not of my own volition, not of my own will. Our people didn’t go to America on the Queen Mary, we didn’t go by Pan American, and we didn’t go to America on the Mayflower. We went in slave ships, we went in chains. We weren’t immigrants to America, we were cargo for purposes of a system that was bent upon making a profit…..When I was in Ibadan at the University of Ibadan last Friday night, the students there gave me a new name….. “Omowale,” which they say means in Yoruba…. ‘The child has returned'”.
– Malcolm X at the University of Ghana, Legon, on May 13, 1964

Black Muslim leader Malcolm X poses during an interview in New York on March 5, 1964. (AP Photo/Eddie Adams)
 Malcolm X

Happy Birthday, Malcolm! You would be 91 today! Admire you for how you turned your life around!

Protocolize It!

We live in the era of big data. With the introduction of electronic medical records, big data is also alive and well in medicine. Mining that data can help establish therapies that are most effective in the majority of patients. The mined data plus results from large scale prospective, randomized studies then result in recommendations and protocols that are supposed to improve patient outcomes.
A majority of physicians have historically looked at medicine as an art. Each physician had his or her way of treating ailments, often tailoring them to fit individual patients.
Medicine however is moving in a direction where the “Medicine as an Art” crowd is on the edge of extinction.
Who is right? Should the practice of medicine be based on protocols or should it be practiced as an art?

I’ll start off the discussion with two examples:
Close to a million Americans suffer from strokes each year and it’s the number 4 killer in the US.
For years, different hospitals and physicians have managed patients with strokes differently. Studies show that if patients having ischemic strokes are given intravenous tissue plasminogen activator (tPA) to bust the clot causing the stroke within 60 min of arriving at a hospital, their chances of survival go up significantly. However, a study in 2014 showed that less than 30% of ischemic stroke patients were being treated this way. On the other hand, hospitals that had established protocols to facilitate this recommendation lowered the incidence of death and disability from stroke.
Another area of concern is that of medical errors. The “To Err is Human” report sounded the alarm bell in 1999. That in part led to the institution of the Surgical Safety Checklist and the “Time Out” for all surgical procedures. A 2009 study in the NEJM showed a drop in death from errors from 1.5% to 0.8% since institution of the checklist and “Time Out”. Inpatient complications dropped form 11% to 7%.

These two examples illustrate the fact that protocols based on science and solid evidence can positively affect outcomes.
Should this then be extrapolated to all of medicine? Should every decision we make be decided by protocols culled from studies and hard data?

Which brings me to the other side of the coin.
Say a study S looks at therapy for say, Prostate Cancer, in a 1000 men. if this therapy is effective in 86% of the men and it gets adopted, what happens to the 14% who do not benefit from the therapy.? if one extrapolates that to a million subjects, that 140,000 men who do not benefit from this new therapy. A good protocol has to allow a physician to cater to this group.
Recent recommendations about two tests that affect men and women have raised the ire of patients. The first is mammography to screen for breast cancer in women and the Prostate Specific Antigen (PSA)to screen for prostate cancer in men. In both cases, based on data, the opinion was that they led to an increase in the false positive diagnosis of a cancer. In other words, patients were thought to have cancer who did not. This led to further unnecessary testing and procedures. With the PSA, it is thought that a lot of small prostate cancers could be diagnosed, which left alone would not grow to be a problem. Now imagine telling a patient:
“You have cancer but it is so small we are going to leave it alone. You will outlive it.”
Sure, in a calm and reassuring manner, a doctor can try to make a patient understand but how many will bear to live with that uncertainty. Then there is also the probability that that small cluster of cells could get bigger….So why not get them out now?
Even if these cancers are small, isn’t it the smart thing to do to diagnose them and follow them? Doesn’t that make these screening tests then necessary? Doesn’t that give the patient a choice?

The point I am trying to make is, in spite of all the data, there are these people called Patients who we are supposed to serve. They are ruled by emotion and are not always as rational as the data and evidence. Is it part of “doctoring” to do whatever is possible, besides causing harm, to reassure these patients?
So on one side are the those who preach a strict adherence to the evidence and on the other those who want to tailor things to the needs of the patient and the habits of the physician.

Into this fray drops Genomic Medicine. This is an emerging discipline that bases therapy on a patient’s genome. It is a well known fact that some drugs (e.g. Plavix) do not work in some patients because of lack of or too much of certain enzymes. Before a particular therapy is initiated, the genetic make-up of a patient is determined. It is now used extensively in psychiatry to get effective therapy.
This shows that in spite of the data or evidence, there are still individual variations.

All these arguments may not matter because of the Affordable Care Act.
The Affordable Care Act has decimated the private medical practice to the point where the majority of physicians are now employed by hospitals. The Act also rewards physicians whose practices are in line with the latest most effective therapy and management modalities. Hospital administrators are then going to compel their physicians to practice in accordance with protocol that fit the best recommendations. In that sense, the autonomy of the physician may already be a thing of the past and patients’ choice may be slowly narrowed to a few options.

All this makes me wonder what role the physician may play in medicine in the future. If every decision we make is based on a protocol, what will happen to the practice of medicine as we know it? Besides surgeons, are any other specialties even needed if all one needs is to follow a protocol? Protocols so simple that even a caveman can follow them? What are we then good for?

Time

If I could turn you back
For just a little while
To take another crack
At things with a new style
With that trend called Hindsight
And Wisdom which is in vogue
The chance to make wrongs right
Mend hearts with one stroke
Squeeze each single lemon
That grew on my tree
My own way, not the common
So Time, do you hear me?
The silence was deep and thick
Broken by Tick, Tock….and Tick

The Four Olds

Exactly 50 years ago today, on May 16, 1966, the Chinese Communist Party, under the influence of Chairman Mao Zedong, released what came to be known as the May 16 Notification:

“Those representatives of the bourgeoisie who have sneaked into the Party, the government, the army, and various spheres of culture are a bunch of counter-revolutionary revisionists. Once conditions are ripe, they will seize political power and turn the dictatorship of the proletariat into a dictatorship of the bourgeoisie.”

This statement is seen by historians as the words that justified and ushered in the subsequent ten-year period of terror, death and anarchy in China known as a the Cultural Revolution.
Mao Zedong and the communist swept into power in China after WWII. In the 1950’s, his Great Leap Forward program, seeking to organize farmers into communes, was a total disaster leading to a famine and the death of about 45 million people between 1958-61. This led to Mao loosing power in the party.
Away from the limelight, he plotted how to regain power and bring his pure brand of communism or Maoism to the fore. His plan was to use young people to force societal change. Even though the opening salvoes of the Cultural Revolution were fired with the May 16 Notification, the violence really started in August of 1966.
He empowered teenagers and students, who came to be known as the Red Guard to go after “the Four Olds” – Ideas, Customs, Culture and Habits. Armed with a book of Mao quotes called “the Little Red Book” and lots of zeal, what followed till Mao died in 1976 was hordes of young people attacking anyone who they deemed as being bourgeoisie. They went after university professors, then party officials and then “class enemies”. Some even turned on their own parents. There were mass killings. Sometimes gangs of Red Guards battled each other. They destroyed historical sites and cultural relics. Even cats, seen as pets of the bourgeoisie, were not spared. It looked like they sought to remove the spirit of Confucius from the collective psyche of the Chinese society.
Mao let the Red Guards run amok until the atrocities got too much. In 1968, he sent the army after them, further escalating a terrible situation. Millions were killed. Some were rounded up and sent to work in the fields in the country (the sent-down youth).
The cultural revolution ended in 1976 when Mao died. In an effort not to discredit Mao, scapegoats were sought for the debacle. They turned out to be the Gang of Four – Mao’s wife and three other men. They underwent sham trials and were imprisoned.
The ten years of terror achieved the opposite effect that Mao sought – the Chinese became disillusioned with communism. When Deng Xiaoping, who had been purged twice by the Red Guards during the Cultural Revolution came into power 7 years later, his push towards reforms that pushed China towards capitalism were widely embraced.
Myriad lessons can be learnt from this period in history – the negatives of communism, the results of dictatorship, the risks of brainwashing the youth and so on.
For me, it brings to fore the importance of the Four Olds – ideas, customs, culture and habits. These four factors underpin any society. Without them, a society has no character and cohesiveness. Sure, one or more of these can be a drag on development. This is seen especially in a lot of developing countries where cultural practices and centuries-old habits seem to hinder modern development sometimes. However, a drastic societal uprooting of any of these leaves a vacuum that is often not easily filled and can lead to anarchy. Maybe instead of aiming for a dramatic removal, one should target modification. Maybe one should tailor policies to include some of these ideas, customs, culture and habits.

The Ascension

Lex197

As she ascended into the heavens, the love she shed filled the air and the force of her smile reddened the sun, illuminating the day…Death looked on, disbelief in his eyes at the force he had unleashed…..He felt powerless as love and light swamped the corners of his dark being….then the end of a life well-lived is a blessing unto the soul and hope for the lives touched…..you see, the good that was done lives for ever.

The Yin and Yang

Ghana on my mind…..Oga was asked a simple question….the answer?…..whew!….

Questions, these questions
Intrusive, irritating
You bore after my intentions
Feeling, baiting
Have I fallen for bribery?
Enticed by the graft?
Do I encourage jobbery?
With most getting the shaft?
Two sides of the same
Reside within
This one body they claim
The Yang and Yin
Do I answer as Yang or as Yin?
Then a trap you do here spin!

It’s been 35 years, Bob!

Keep resting in peace, Robert Nesta Marley! It’s been 35 years since you up and left and your music still has so much spirit, the lyrics so prescient. Prince is up there now. Have you two hooked up yet?

bob_marley_by_cheatingly1a

Like I said:
It’s been 35 years since you walked out of that door,
And the pain sure does knock more:
Ooh Bob, ooh Bob, is it feasible?
We wanna know now, for the pain to knock some more.
Ya see, in life we know there’s lots of grief,
But your music was our relief:
Tears in our eyes burn – tears in our eyes burn
While we’re waiting – while we’re waiting for the Jah Man,
See!
We don’t wanna wait in vain for Jah Man;
We don’t wanna wait in vain for Jah Man;
We don’t wanna wait in vain for Jah Man;
We don’t wanna wait in vain for Jah Man;
We don’t wanna wait in vain for Jah Man, oh!
We don’t wanna – We don’t wanna – We don’t wanna – We don’t wanna -We don’t wanna wait in vain.