Monday, November 24, 2014

Mr Murphy joins me in my trip - Mumbai-Agra-Chennai-Mumbai

Murphy's law: "If anything can go wrong, it will"

So  the very same Mr Murphy sneaked in with me on my trip (I had to deliver a lecture in a pre-conference workshop on research methodology). I had to go to Agra via Delhi, then to Chennai and back. Of course I must admit that most of the time Mr Murphy was reasonably well behaved, but he did keep doing bits of "Tamasha" off and on. :)

Actually, he started it even before my trip. I have a niece in Agra. That was an attraction. An added attraction was that my niece has the friendliest 1.5 year old daughter. I think this baby thinks that the whole world is her friend. More about her later

When I told my niece I was coming, she was delighted and we had agreed that I would stay from Thursday afternoon (after my workshop) till Sunday. Soon, other plans crept in, and I had to be in Chennai on Saturday. So I told her "Sorry - one day less". And then it turned out that there were no suitable flights to Chennai if I left Agra on Saturday morning, so I had to cut out one more day. My niece said "As long as you don't cancel it, that's fine"!

I set off out on Wednesday. I landed in Delhi at 1.20 PM - earlier than the scheduled time, thanks to the 'Indigo Standard Time' that the airlines loves to talk about. Two doctors from Kolkata joined me in exactly half hour and we set off by a pre-arranged car for the 4-5 hour ride to Agra. For no reason at all, I had imagined that the new expressway (it is about 2 years old now) made the trip as short as 3.5 hours, and I was surprised when the driver said it would take about five hours. He obviously knew why it would. He had planned it with Mr Murphy :) He stopped at some place just before the express way, mumbling "I will just be back". The "just" turned out to be a little over half hour. He came back and we continued. We later had another break for tea, and so it did indeed take us five hours!

The two doctors were booked in one hotel and I was booked in another - Hotel Japyee Palace, the venue of the conference. Dr L who had arranged for my booking (she was arriving later that night) had written an email - "If there is any problem, please contact Mr. S, and he will help you". I guess Mr. Murphy had some inclination about Dr L's mail and took advantage of it. When I reached the hotel and gave details, there indeed was a problem :). So I called Mr. S, had to wait for about ten minutes and in spite of Mr Murphy, it got sorted out.

Hotel Jaypee Palace is shaped like a quadrilateral - with gardens inside. My room was reachable with a reasonably short walk, (realized that much later) but the young executive who escorted me, must have also had a pact with Mr. Murphy. Or - he must have thought..."this lady does not exercise enough"! And took me by the longest route possible. By the time I reached my room, my husband called. And I told him "Dear, I have made up for missing my morning walk today". He very gallantly said "Maybe you should stay on there for some time".

And then, having settled in, I decided that I was not getting out any more and opened the room service menu. I glanced through and decided to order only the Amritsari Paratha (everything else seemed to be just too expensive, whoever was paying. And I knew that I alone would not be able to finish it, which meant that food would be wasted). Usually any restaurant serves at least cut onions, some raita and/or a bit of vegetable with a paratha. When mine came, I had only some pickle as an accompanying dish :).  I told Mr Murphy - "Okay, I am going to relearn a lesson I learned... be happy with what you have. Do not crib about what you do not"! And I thought "That's one up to you, Mr. Murphy!"

As I got comfortable and was about to turn in for the night, Dr L. messaged me "Our workshop has been rescheduled from the  morning to the afternoon"!  Okay Mr Murphy - you won this round. My time with my niece was coming down to less than 12 hours.

The next morning, I caught up on a fair amount of work in my luxurious hotel room. Mr Murphy - I suspect you were tired and caught up with your sleep at this time and some more:). At lunch, I was thrilled to meet Drs Bhavin Jankharia and Ravi Ramakantan, who had come to conduct another workshop. They are both from my city of Mumbai, but I rarely get to meet them there :D. Having some time to catch up with them was indeed a bonus.

By now, Mr Murphy woke up. Our workshop was supposed to begin at 2.00 PM (One notice said 1.30 PM, another said 2.00 PM, so we gave the benefit of doubt and chose the latter). But... the people who were conducting the previous workshop must have bribed Mr. Murphy and they had no inclination to finish. We then told the young event managers to be firm and get them out, and they did! We got our hall by 2.30 PM. And - the next... we had a really low turnout. Dr L and the two others from Kolkata who had done a lot of work to organize this, felt really sorry, but obviously some of the work they had delegated to the main organizers had not been followed up. But, all of us enjoyed conducting the workshop and so did the small focused group of participants.

And then Mr Murphy must have thought - "I have had my main dish, (low turnout), but I need some dessert". And from the time I met my niece and family, went to their home and left it next morning, he really got some choicest dessert! The cab driver who had promised to take me back to Delhi the next day, suddenly backed out. (I wonder if the young Sardar, got to know about Mr Murphy's date with me, and was worried). Dr. A from Kolkata and Dr L spent a few hours alternately cajoling drivers, till one of them finally agreed :) And the next morning he landed at the Air Force base gate by 9.30 AM, though he was asked to report at 10 AM. And I thought - Aah , I have beaten Mr. Murphy at his game :)

Little did I know that he had to have his last laugh (well not quite, but I will come to the last, later). The driver called from the gate, as instructed, handed over his phone to the Sergeant who spoke with my niece and got her approval to send him in. But in a couple of minutes the driver called again and said that the Sergeant would not let him in. She quizzed him and learned that...... "the driver did not have his license!!!" (He had a substitute challan, but the Sergeant could not accept that. According to rules, he was supposed to keep the original license and give it back to the driver on his way out)

Okay Mr Murphy - you did have an additional helping of dessert :)

My niece then arranged to drop me at the gate and she remarked "Aunty - this driver looks like a kid". I told her that I could not care less if a new born dropped me to Delhi airport that day - I just had to get there :). To give him credit, young Vikas drove *very well* at a steady 80 kmph. He played old Hindi songs, taking care to lower the volume every time I had a phone call, and brought it down still more, when I dozed off for a bit. He got me to Delhi in exactly four hours.

"Aah - Mr Murphy - bye for now", I mumbled. "Huh," he said. "Are you kidding. I need to come all the way with you to Chennai and then back to Mumbai." I pretended not to hear that.

I got into Delhi T1 thinking that I had a good two hours to catch up on some reading. After all now, airports are declared silent - with no announcements. But I had not bargained for their doing a MAJOR renovation.  And the sound of drills going wheeeeee wheeeee all over, was what I had to put up with for the next couple of hours. Good bye my book!

I tucked into some sandwiches that my niece packed for me with love, and then thought of some coffee. Then I decided - "Indigo gives me black coffee at Rs 60/- and I am not getting milky coffee at double the price". Guess what happened in the flight??  When they started serving, there was some turbulence, the seat belt signs came on, and the stewardess announced "We regret we will not be serving hot beverages, due to turbulence".  I settled for Nimbu Paani (again telling myself to focus on what I got, instead of what I could not get).

I opened the bottle and took a sip, savouring the cold drink, telling myself "maybe this is better than coffee". And.... the seat belt sign goes off, and the stewardess opens the flask of hot water to serve another passenger.... you guessed it... black coffee! I could sense Mr Murphy having an expression of a 100% glee, thanking the hostess for not saying that she was not serving hot beverages only for a few minutes"

For the rest of the three hour flight, I practised not thinking about the coffee!

I reached Chennai and my little-less-than-two-days-stay there was great. I think the lovely weather  (something rare in Chennai) made Mr Murphy take a break. I even hoped that I would leave him there, but he somehow found me and quietly accompanied me on my Meru cab to the airport. For the first time I tried paying online through the app. It took some time for me to get the acknowledgement, by which time, the driver was politely impatient - telling me that if he stayed longer, he would cross the mandated 5 mins and get to pay a fine. I paid him in cash. Just as he got in and drove off, I received the acknowledgement :) :) Okay, okay Mr Murphy - I noticed you. You need not seek so much attention!

I got into the plane and set Meru an email explaining this and asking for a refund. They responded soon telling me they would. "Yay - Mr Murphy - you lost this one!" And I decided - "I am having nothing on this flight (I was full anyway, after a great family get together and lunch) - and I will not give you an opportunity for mischief here :)"

We landed in Mumbai early last evening, and the baggage arrived on to the belt before we did. In all the din in the baggage hall, I did not hear Mr. Murphy singing loud and clear "Vasu ma'm - I have saved the best for last" (Vanessa Williams, if you did not sing the song as well as you did, I would have hated it from yesterday :>)

I came out of the airport terminal. I called my driver. The call would not go through. He has a 2nd number and I called that. It rang and I disconnected it as is our usual protocol. He would drive to the pick up point as I walked out there. Suddenly my phone buzzed. It was his wife saying "Ma'm this phone is with me today. If you like I will call him for you". I said okay to her as I could not connect to his other number. To cut a long story short, no one could. His wife, my mother in law, my son and my husband (from Chennai!) - none could reach him.

I waited for a good 40 minutes, hoping he would at least think of coming and checking out, but apparently he did that just after I got into an auto :) Soon after I reached home, he called (from another phone), and my mom in law told him I had reached and asked him to return. Apparently he had a new cell phone, and had done some setting change, by which he could neither make nor receive calls! (I still have not figured out how he managed that, but he got it corrected this morning) :D :D :D, With that, Mr Murphy must have decided "enough is enough". I had a couple of hot dosas for dinner, had a lovely chat with my mom in law and turned in for the  night - back in my cosy bed!

Epilogue: Had this happened to me about 10 years ago, I may have cribbed, raved and ranted at every step. Life has since taught me a lot, and I was able to laugh as things happened and as I related the set of events to people in the last couple of days. I was a teeny bit irked in Agra when the cab to Delhi was not getting organized, but that was only because I felt I could not get enough time with my adorable grand niece.

Let me add a bit about her. She was asleep when her parents came to pick me up at the hotel. When we reached home, she woke up. She saw me, gave a beaming smile and waved to me! I don't think I have seen too many toddlers wake up with a smile, less who smile at strangers, and only this one who smiled and waved. When her mom set her down, she chose to 'get into my shoes' - literally. She wore them and walked all over the house for the next half hour :). She spent the next three hours with me, chattering away in her own lingo. And the next morning, she woke up in time to yap some more and say "Bye" with another huge smile. God bless you little Raaga!

And finally - "thank you Mr Murphy, for the practice sessions! Without them, how could I know that I have learned all that I have read in wisdom literature, or heard from wise folks? I know for sure that I came out well. I am still beaming about the fact that so many things could happen unexpectedly and teach us to value all that happens right. Mr Murphy - does that make me a winner? I guess it does - but let me generously call you one too". After all life is all about Win-Win" 

The focused participants (the two in front were faculty)
- we hope they will change research!


My grand niece - stepping into my shoes - literally :)
A part of the Agra Fort - clicked from the cab!

Sunday, November 16, 2014

Attack on doctors. Is the basic flaw that we are all getting increasingly judgemental about everything?

It started with Aamir Khan's Satyamev Jayate's episode on Medical Malpractice. The bashing of doctors. Well it obviously happened earlier too, but this was a big trigger. For patients (all health care receivers, sick or healthy) to start discussing how terrible doctors were. And for doctors to become anti Aamir Khan. Both may have been right within their perspectives. What are the long term outcomes of such episodes. I honestly do not know the patient perspective, but every now and then I see a doctor's post in Facebook, with an update about something that was not a doctor's fault, and it almost always ends with "Now Aamir Khan - where are you?" The hurt and hostility is high.

For those who do not know me, I am not a doctor. But I do work a lot with health professionals. I teach them how to stay updated with medical literature. I have, over about 20 years got to know about their lives in depth. I can reasonably confidently say that any lay person who does not have a doctor in their immediate family would have no real idea about what it takes to become a doctor. And almost always, when one of them makes derogatory or even generalized negative comments about doctors, I give him or her a gist of the toughest parts of a medical student's / doctor's life. And almost always the person's jaw drops.

The recent episode of the sterilization deaths is another incident that brings up muddy waters. The media bashing doctors. And the doctors retaliating. When it was first reported, I paid practically no attention to the news. I must add, that in the last few years, I have more or less stopped reading newspapers. I cannot stand the mass-negativity and the "news for the sake of news" items that are being published (predominantly rapes, murders, violence, cheating and the like). I believe that the news I really need to know will find me. Either via my husband or through social media. Anything else I need to know in context is traceable through the Internet (being a search specialist helps!). Or again through social networking, where I ask and get an answer.

When there was one of the shows on TV where the issue was being hotly debated, I still did not know enough. In fact my husband actually thought I was nuts, not keeping abreast of something about the beneficiaries of my work. And then, the Facebook statuses of several medicos gave me answers - all linked to resources that mentioned the faulty medicines. By then the media had bashed the doctor concerned. Badly. Okay - later they talked about the faulty medicines. The 'bashed doctor' may become old news. But some things have long term repercussions.

I am not going into the complete details of this episode of the mass sterilizations. In fact when I write this post my focus is not so much about doctors and patients, but more about about what I believe is a common trait among most of us, that leads to such situations in any context. And that trait is...

Most of us are judgemental most of the time!

I say this after a few months of observation. Sometime back a friend on Facebook challenged himself and others. "Can we stay without a) complaining and b) being judgemental for one or  more days"? I started observing myself. I noted that without realizing I was being judgemental very very often. I may not have always verbalized it, but I still was. I have been working on it ever since.

How does this relate to Satyamev Jayate or the current sterilization fiasco? Aamir Khan - if he had only presented facts and asked for opinions *may not* have raised so much animosity. He was being judgemental (and I felt that in this show he was being more judgemental than in the other episodes, but that is my observation and not my judgement). In the current scenario - the media jumped on to being judgemental, with headlines like "Botched sterilizations claim 56 lives" or with details that nailed the doctor. Earlier in another case a lawyer made a comment "We have all at some time suffered in the hands of doctors". Just yesterday, I heard a milkman tell our building watchman about how he had to spend a lot of money going to a doctor for a fever. And he said (in Hindi) - "I wonder how doctors are made today"!

Aren't all these statements judgemental / highly generalized, when made without proper research and evidence? Okay - there ARE bad doctors. But that does not mean that all are bad!

And what is the consequence of all this? However well Aamir Khan may do his other episodes of SJ, he has lost the support of a lot of doctors - including good ones. Rural women who need healthcare will not go to doctors even if good ones are around. Worse still, they will now be so scared of sterilization procedures that they are going to either keep bearing more kids or spoil their health further, or maybe both. In my building, the watchman told the milkman "Don't go to a doctor if you have fever.. there is no need"! I shudder to think of what more can happen. 

I recently came across an expansion for THINK, which is worth thinking about. Think before you speak...

T- Is what you are saying True?

H - is it Helpful?

I - is it Inspiring?

N - is it Necessary (to say it out)?

K - is it Kind?

More about this here

I believe that if we even apply only the T, H and N, we'd be doing a lot.

And let us focus on talking about the good doctors we know. There are plenty of them, working silently and doing tons of good for their patients. If we really count there will always be more of the good ones - not just doctors, but people from any profession. Stop and think - for every bad professional or person you know - how many good ones you do. In majority of cases, I am sure you will know more of good souls.

Now, am I generalizing? :) Yes, I am. But that's fine, when it is about good stuff!

Saturday, November 15, 2014

My journey into Evidence Based Medicine and Cochrane Reviews

I was a medical librarian in the PD Hinduja National Hospital & Medical Research Centre, Mumbai in the 1990s, when we first subscribed to Medline on CD-ROM. We got the sanction for the subscription in 1994, after two years of proposals, discussions with 'the management' and more.

In 1994-95 I did everything to learn all about searching Medline effectively. At the back of my mind, I always had the query - how would a doctor actually figure out which of the abstracts and articles would be most useful? There were times when the search results were conflicting. Some abstracts would give certain facts and others (from equally reputed journals) would give almost opposite facts (for example about the comparative efficacy of two drugs). Some young doctors even asked me whether there were any criteria to decide. I of course knew nothing about it, and all I could tell them was that maybe we needed to see which journal / author was more reputed, and base the decision on such factors.

In 1996 I was librarian of HELP - a Consumer Health library. Here we had access to the Internet and  I became a member of the Medlib-L mailing list, which had a large number of medical librarians. I first heard of Cochrane Reviews and of course understood exactly nothing about them. Cochrane was then a fairly new concept. There was so much more to learn about online medical information that I did not do much about Cochrane

In 2000, I attended the ICML - the International Congress on Medical Librarianship, in London. This was the first time I attended an international conference. I was super-excited. Looking through the website, I skimmed through the preconference workshops and one called "Critical Appraisal Skills" caught my eye. "Aha" I thought. "Now I will learn how to choose the most relevant of search results I can choose once I do a good Medline search". I registered for the Basic Course and not the Advanced one, because each course cost 50 Pounds :)

It was after I attended this half day workshop, I realised that there WAS a method for searching for Evidence based publications and it was after we retrieved these, that we could actually appraise them. I learned the basics of appraisal in this course. On my return to India, I searched to check if there was any online course on finding evidence. I was thrilled to find one for librarians - "searching the literature for evidence based medicine" I enrolled for it right away (paying $150 then. The same course costs a lot more today) It was conducted by three librarians in the US. It was one we could do at our pace, and if I remember, I completed it in 4 weeks and also got 10 Credit Points (which were really applicable for US librarians). And thus I made my baby steps into searching for evidence.

Soon I started exploring the Cochrane Library. At first it made no real sense to me. (There was no one to explain it, you see). And the only thing that struck me was that majority of the reviews' abstracts had a conclusion that said "there is no clear evidence about......" And so I felt - abstracts in PubMed have stronger conclusions. Maybe it is better to stick to those!!

In 2007, I was introduced to Dr Prathap Tharyan of CMC Vellore. (He had then just set up the South Asian Cochrane Centre). We had a brief discussion and made some random "future plans" of working together. I was added to their mailing list. I used to keep getting emails about "Protocol Writing Workshops for Cochrane Systematic Reviews". And the only line that caught my eye every time was "This workshop is open to those who have registered a title for a Cochrane Review". And I felt - "I am never going to do this one"!

Year 2008 - and there was an Evidence Informed Symposium organized by the SACN. I registered for this one, and was delighted to see one of the sessions was on Navigating the Cochrane Library. I attended this one, conducted by Ruth Foxlee (who I met again years later in 2011 and again this year), and her colleague. This was an eye opener and I finally learned what a Cochrane Review was about, and what the other five databases were about!

2010 - time for another symposium at CMC. This time Dr. Prathap organized a two hour session for UG students on all four days and I had the opportunity to do the session on searching the literature! This event brought me close to a group of students and at the end of the symposium when we all had discussions with Dr. Prathap, he encouraged all to attend the next Protocol Writing workshop. I asked him "Can I attend this, more as an observer"? And he said "Yes". Little did I know what I was in for.
Came February and I went to Vellore with all excitement. The workshop was for five days. On the first day, he made the fundamentals of a Cochrane Review even clearer. Actually crystal clear. But as days progressed, the dreaded statistics and more came in. When we reached the fourth day, I was all ready to quit. However, the psychiatrist in Prathap played up and he did all he could to make out as if I were the bravest soul around and I would definitely make it through, till the end :).

Manu Mathew, Ravi Ranjan (two students of Kasturba Medical College at that time; now qualified doctors) and I registered a title. We worked hard on it for two years and finally had to withdraw the review. At another point, I was invited by another group to be part of a Cochrane Review, and this one too fizzled out. By this time I had also attended the same workshop two more times and almost gave up about every getting through a review. However I did sharpen my searching skills. And I delivered talks on how to navigate the Cochrane Library in three ICMR centres in India. I have also included an introduction to Cochrane Reviews in all my lectures on literature searching.

And then, finally about a year ago, one more title happened and this week (November 2014) it has turned into a published Cochrane Review!

Gene therapy for hemophilia
  1. Akshay Sharma,*
  2. Manu Easow Mathew,
  3. Vasumathi Sriganesh, 
  4. Jessica A Neely,
  5. Sasank Kalipatnapu
What was my role in it? I am not an expert on the topic. But I did play a significant role in the literature searching, and coordinated with librarians in the US to ensure that I did good strategies. I went through the whole text thoroughly and commenting on part of the content. I played a role on how to reference everything right. I also managed to find a couple of technical errors and get them rectified. Slowly the Cochrane Methodology - the nitty gritty of it is sinking in. Psst - I still refused to touch the statistical bits :>.  I have miles to go. This is a beginning!

Thanks Prathap Tharyan for egging me on every time I was ready to give up!  Thank you Akshay for inviting me to be part of this review. Thanks to the other co-authors - I learned bits and pieces from all your work.

Aside from bravely being one of the authors of a Cochrane Review, I have attended two Colloquia - one in Madrid in 2011 and one this year in Hyderabad (2014). The learning escalates with every such event and I hope it continues. This year, Dr Paul Garner of the Effective Health Care Research Consortium asked me if I were supporting more authors and I said "not yet, because I need more mentoring". And he promised to put me in touch with a mentor. As I said - there is lots more to learn - miles to go!

My message to medical librarians  and to the Institutional heads in India is - "Librarians have a huge role to play in helping authors from India, with systematic reviews. We need to find a way of training lots more librarians to learn more and more, step by step.

Sunday, May 18, 2014

Don't crib. Do something about it!

I got inspired to write this post after two events.

- One was when I listened to a talk by Ashwin Mahesh. His key message is "We need to build a problem solving society together. Everything else is secondary".

- The other - I read a blog post by Bhavin Jankharia titled - The top 10 things we can do to help Mr Modi Reboot to India 2.0. I strongly recommend that everyone reads the blog post and visits Ashwin Mahesh's website

Let me admit - I had been a cribber for pretty long. A lot of which happened because it is also fashionable to crib. It is easy to do it. And if we add analysis and researched facts into our act of cribbing, we also sound intelligent. We believe that we are having intellectual discussions.

Over the years I learned to do something about things I cribbed about. If I could not do anything about it, I learned to accept situations / things / people. Accepting does not mean that the people / situations are right. Accepting is just acknowledging. And being open to the idea that they CAN be changed. One thing that I refuse to do, is to think "this can never change/improve". 

So - if we wish to crib - let us ask ourselves - Can we...

  • Do something about it right away or in a short time?
  • Research and see what can be done in a longer time span?
  • If none of the above seem possible just now - support others who are doing something? 
  • Give them some time to achieve something?
  • Not criticize them if they make mistakes?
Let us get responsible enough to do something, support others - directly or indirectly - by not criticizing every effort of theirs. If we can do neither, let us learn to shut up and do something else productive!