My bias declared publicly. Could you declare yours?

For quite sometime I have been active in quality improvement, leadership, patient safety, human factors and related areas. My interest includes discrimination in general but healthcare in particular and especially doctors. This relates to discrimination in the western world particularly in the UK. We know bias plays a part in this discrimination. Government and organisations have taken efforts in dealing with discrimination, this takes the form of law, training in equality and diversity and monitoring selected data. We are told how to deal with discrimination and how to avoid discrimination.

We were never asked to assess, quantify and declare our bias.

Bias is a part of life. For better or worse our history, legacy and as humans our capacity to pattern match means that bias gets in. We could even argue that bias is a normal part of life. However when bias affects the career, livelihood, reputation and freedom of certain segments of the population, it ceases to be normal. While bias could be accepted as normal, the positive or negative effects of bias that affects segments of population repeatedly can never be accepted as normal.

How do we prevent bias from affecting others?

In my opinion unless we assess our bias by a common method and then declare it publicly we cannot begin to tackle discrimination.

Once our bias is published publicly, then we can start having methods to take that into account in our decision making by appropriate counterbalances, algorithms, adjustments etc.

I cannot ask others to publicly declare their bias unless I have done so myself.

Currently, the Harvard Implicit Association Tests are a good (but not totally proven) method to assess our bias. https://implicit.harvard.edu/implicit/takeatest.html

I have taken the test that relates to race and I am posting the results by screenshot here.

I am aware that this test relates better to the USA and refers to the black-white races. I also took this test thrice; twice the same result came up that I had a moderate automatic preference for white people and once the test showed no preference between white and black people; on the occasion that the test showed no preference, I had deliberately slowed down to take the test.

So does that make me a racist? I do not think so. Does that make me biased? May be it does, but since I have known this for sometime now, I make deliberate conscious effort to overcome my Harvard IAT data based moderate automatic preference for white people. I think very deeply on how my actions are impacting. I take extra effort to review decisions before implementing them with the awareness of my bias to ensure that my actions do not affect black and minority ethnic people adversely.

If I was an examiner, investigator, police, judge, etc I would want my decisions to be counterbalanced by a formal algorithm to prevent my bias from hurting BME people.

I am not in an unusual category as far as my bias is concerned; I am part of the largest category of persons who have taken this test. How does this affect the society?

We need to start somewhere.

I encourage you to take the test and post it publicly. I am happy to add your test result to this blog if you send it to me. Let us make a change. Let us reduce bias. Let us take the first real step by publicly acknowledging our own bias.

Here is the list of persons who have agreed to go public with their bias tests. My sincere thanks for permitting me to add their names:

Dr Kim Holt: 'slight automatic preference to black people over white people'

Dr Joe Karthikapallil (Ophthalmologist) : 'moderate automatic preference to white people over black people'.

Dr Joydeep Grover: 'no automatic preference between African Americans and European Americans'

Dr Vivek Chhabra (ED): 'no automatic preference between black people and white people'

Mr Bhavik Patel (Financial Sector) - ' slight bias towards white individuals compared to black individuals'

©M HEMADRI

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Doctors in India: Villains or Victims?

"We have not lost faith, but we have transferred it from God to medical profession"

- George Bernard Shaw

The doctors community in India, both in public and private sectors, is in a state of unrest. Every few days there is news about brutal attacks on doctors and these are justified by patients’ family and friends as attributable to alleged medical negligence. Thanks to social media, copycat attacks are becoming frequent. The members of the medical fraternity very actively exchange news/ideas, devise strategies to overcome the problem, go on transient strikes, get assurances from the powers that be that concrete steps would be taken to contain such attacks; only for the cycle to restart after a short period. In a study that was conducted by IMA a few years ago three fourths of the doctors surveyed said that they were physically attacked at least once. In a study published in the national medical journal of India last year, not only significant number of doctors are getting attacked but it is also grossly under reported. The trend is getting worse.

Doctors were considered Gods at one time, when did the doctors become demons? From being the rakshak why did they become raakhshas in the public perception.

"Vaidhyaraja namasthubhyam, Yamaraja sahodara!! Yamasthu harathi praanaan, vaidhyah praanaan dhanaanicha!!"

(Meaning: Salute you doctor, brother of Yama, for Yama takes away only our lives, you take away our lives and wealth too) Sanskrit subhashitha.

The problem started when the health care started shifting from public sphere to private. Up to early 1980s patients were get treated in the private sector but when they had major ailments depended on government and teaching hospitals for their treatment. With the advent of corporate hospitals who were capable of providing care for an extended range major ailments, health care cost escalated and high end health care became inaccessible to a majority of people in India. In the absence of national health insurance scheme many citizens make out of pocket payment (OOP) which pushes 32 to 39 million people every year into Catastrophic Health Expenditure (CHE), which is defined as health expenditure which threatens a family's basic standard of living. The situation is only getting worse by the fact that the government's expenditure on health is just at 1% of GDP. (MOHFW2009).

Doctors who work in private hospitals in India know very well that one of the important triggers for irrational behaviour by patient and families is financial issues, especially when the patient outcome is not favourable. The potential for catastrophic health expenditure could cause psychological havoc.

"The huge gap between the rich and the poor, globally and within nations is not only morally wrong, it is also a source of practical problems"

Dalai Lama.

A patient who is at the risk of eliminating his/her financial resources to obtain healthcare, does not realise medical science has its limitations, every illness cannot be cured and there will be an outcome which is unacceptable in some cases. Good counselling of the exact nature of the problem and probable or definite poor outcome including mortality can mitigate this misunderstanding to some extent. Most of the doctors in India have realised the importance of this only in the recent years. As we are battling out issues like large volumes of patients, limited resources and poor infrastructure in almost all public sector providers and most of the private hospitals; effective communication and empathy could be one of the ways to keep situation under control at least partially and temporarily.

"To effectively communicate, we must realise that we are all different in the way we perceive the world and use this understanding as a guide to our communication with others"

Tony Robbins

Even as we doctors condemn unacceptable behaviour by patients and their relatives, can we absolve ourselves of wrong doings? Doctors say that there are some irregularities by a few individuals and a few hospitals and that should not be reason enough to portray the entire community adversely. True, that should not be the case but is it only a few individuals or hospitals? If we believe so, then we may need a reality check. Have we not heard of hospitals expecting their consultants to work to a target? Are we not aware of conversion rates, referral fees, unnecessary laboratory investigations by doctors and cross referrals, indicated or not?

"I am dying from treatment of too many physicians"

- Alexander the great.

This commercialisation and greed has become worse by the entry of unscrupulous businessmen, liquor barons and politicians into the ‘business’ of medical colleges and hospital ownership. Some/many, with their clout seem to flout every rule, manage accreditation yet unable to provide infrastructure or sufficient human resources.

"I have always tried to avoid politics because most politicians I know are quite dirty in terms of human dignity, ethics and morals"

- Steven Seagal

The reality is, when an idealistic young doctor comes to practice with noble intentions he/she is caught in this web of helplessness because of the lack of the right conditions needed practice his/her profession. This is highlighted by Dr Arun Garde, from Pune, in his book in Marathi "Voices of conscience from the medical profession".

"Every truth has two sides; it is as well to look at both before we commit ourselves to either"

- Aesop

So who are the one who get attacked and is physical attack of doctors justified?

The ones who are attacked are residents, doctors who are on duty in high risk areas, especially in government  hospitals, charitable trust hospitals, small nursing homes and occasionally resident doctors on duty in bigger corporate hospitals though the vicarious responsibility of treating these patients rest with the consultants. The corporate hospital owners or senior consultants who are in many ways responsible for the impression (or truth) that hospitals are primarily profit seeking places, never get attacked. Like every battle, it is only the foot soldiers who get attacked. By doing this the patients further alienate the residents who are already overworked, under suboptimal working conditions which results in worsening of already acrimonious situations.

"Soldiers win battles, generals get credit for them."

Napoleon Bonaparte.

(In this case they get attacked!!)

Are patients justified in attacking the doctors, whatever the grievance? If money is an issue, why do such attacks take place in government hospitals where treatment is free? While there may be many reasons, here is mine. We are living in a society which is becoming increasingly uncivil and aggressive. There are many people who throw shoes and slippers at politicians; vandalise houses of cricketers when there is something as trivial as defeat in cricket match. So when a major tragedy like a loss of life of a dear one happens they indulge in violence. Further, many of them come to a government hospital after exhausting their financial resources they have, this results in their desperate but bad behaviour.

The health benefit schemes introduced by some of the state governments have benefited the private hospitals and insurance companies; that government money could have been better used to improve the infrastructure in major hospitals. In a recent survey by the citizen engagement platform more than 40% of the participants said that they don't trust the private hospitals but 80% visited private hospitals when there was an illness in the family.

"There are far too many silent sufferers.

Not because they don't yearn to reach out but because they have tried and found no one who cares"

- Richelle E Goodrich

The media do not play a constructive role. The police choose to stay away because they believe it is natural for the patients to be distressed and use that as a justification. In some cases the hospitals and doctors don't help their own cause by criticising the treatment given at another facility either because they are not thoughtful enough or they think it will help in their own defence, thereby indulging in medical jousting. The already vitiated atmosphere is made worse by this, making an irate mob, violent.

"We are all connected, when one arm or foot is poisoned the whole body is infected"

Suzy Kassem.

We doctors often become defensive or even play the victim and say we sacrifice everything to continue as a doctor. Every profession in this competitive world has its own difficulties. Because we deal with human lives we seem to run the additional risk of getting attacked immediately by a crowd which gets provoked when things happen contrary to their expectations. However, we can demand stringent laws and better security in the work place. This is more easily said than done.

"Doctors are only doing KRIYA, that is earning their livelihood through this profession, not doing KARMA, that is doing charity for betterment of mankind"

Dr Pankaj Chaturvedi, quoting Bhagavath Gita

The educated people rarely resort to this kind of physical violence against doctors. I know of instances where frank negligence on the part of  doctors resulted  in mortality and morbidity. I know how a middle aged executive became disabled because of inordinate delay and inappropriate treatment; an elderly surgeon who succumbed to negligent care following a surgery and another elderly gentleman never recovered from an easily treatable problem because it was identified late. All these hospitals are well equipped, high end hospitals and what happened there was definite provable negligence. The families of these patients because of their education and politeness did not indulge in unruly behaviour despite spending huge amounts of money for treatment.

"Human behavior flows from three main sources, desire, emotion and knowledge"

- Plato.

Is it not an option to go to the consumer forum? According to a study, cases in the consumer forum has gone up by 400% in the last decade, the inordinate delay to get justice in Indian legal system adds to the frustration. Recently there was consumer forum ruling which was pronounced in 2017 for a case filed in 1998. More over the economically underprivileged ones are left with very little to fight a legal battle after they have spent their money in treatment, so they resort to their version of instant justice.

"Do not expect justice where might is right"

- Plato.

We are not Gods and cannot save all patients, we live at a time and age where practice of defensive medicine is almost a norm. We have not been able to address our issues of poor patient doctor ratio, infrastructure, abysmal working condition and inappropriate financial compensations.

Too many questions. Too few answers. The way forward.

We need a mechanism where we can make the patients our partners and communicate our difficulties to them. We have to spread awareness among public the factual and realistic capabilities and limitations of today's medical science.  We ought to stop advertising treatment modalities which may not be of benefit. We have to stop advertising treatment which could be inaccessible to many.

The doctor - patient trust and relationship is at its lowest point. Is the only way ‘up’?

While we demand a civil behaviour from our patients, it is important for us to do some soul searching and take that extra step and walk that extra mile to restore the trust and confidence of patients in doctors, medical profession and hospitals.

This in no way is a justification of violence against doctors. Every challenge is an opportunity and this is an opportunity for doctors for course correction where appropriate. The argument is advocatus diaboli.

"As doctors we generally don't tell outright lies. We don't speak the truth fully."

Dr.Allan Hamilton.

Are the patients ready for it? More importantly are we doctors ready for it?

Dr Usha

Physician

Hyderabad, India

All views in the above write up are the personal views of the author (and not that of this blog site)

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Why current healthcare will be obsolete and what we need to do about this

The writing is on the wall.

The last few decades have seen 2 groups of people: One group that is “dying longer”, yes some might call it living long but not healthy. As a physician I call it dying longer. These are folks who are disabled, obese or emaciated and depressed or demented, with multiple medical issues spending a quarter of their life in the medical system, and the last decade of life in a long term care facility. Everyone knows someone in the family that is taking a multiple medications and is still sick and needing care. 

The other group has people whose symptoms similar to their sick family members but want to resist going down the same path of chronic illness with multiple medications. Since the traditional system seems to offer nothing beyond a pill for every ill these folks are seeking alternative healing pathways.

Why are they not using the constantly advancing medical system? It is because medical system is making advances in leaps and bounds on diagnoses and management of diseases with AI (artificial intelligence) however what they are failing to see is people do not want to have the next best treatment or the greatest new drug. They simply want to be and feel well with no medications and have complete resolution of their symptoms.

Here comes the total disconnect: A system that is creating newer tests and drugs and a clientele that is interested in partnership and cure and not a patriarchal dispensing of drugs.
 
This has created a new group of “healers” who have taken to the social media and the web with personal experience of healing themselves as the only qualification needed to become an “alternative health care provider”.
 
How did this shift happen? Why did this shift happen?
The shift was slow and steady and now it has exploded (reaching that critical mass). Everywhere you turn there are several online courses to help you finding healing opportunities. Courses that help you heal your thyroid. Courses and providers who help you heal your metabolism and your gut. Businessmen, actors, activists, who have created apps and tests to address your true weight gain issues, hormone issues, autoimmune issues and the list is endless. Not only are they providing what the public is looking for they are also creating this distrust in the current medical system.
 
As with everything else that starts off with a noble cause like climate change, like animal rights, like alternative energy, seeking great health is a valid cause, but is now being monetized by everyone. And when people are desperate they will find themselves spending a lot of money and taking a lot of ill-advised treatment till they find the right solution or they actually harm themselves in the process, and become skeptical of the whole system.

The shift happened because the medical system is behind in times. It is not held to other service
industry standards where the clients’ voice is heard.
Clients I do not believe want a cable TV in their hospital room. They do not want their powdered
scrambled eggs on a platter, for breakfast. They simply want to feel well. They want results not another surgery or pill for their ill. They are tired of being tired and sick. They are tired of taking another medication or adding another supplement to their
armamentarium.
 
On the other hand today’s medical world is considered a great place to stay employed for a long
time. It costs 16 to 19 % of our GDP and yet the outcomes are a growing list of chronic medical
conditions with rising costs and insurance premiums with no end in sight. Our development is trying to put the care into the hands of the patients using apps, artificial intelligence and the growing field of telemedicine where we are educating people that their care is a click away. We are educating people to look for sickness and quick relief of symptoms when they are seeking permanent wellness.

So how do we sort through this dynamic shift?

The medical schooling needs to change. We need to embrace the need to understand how and why the body shows symptoms not simply identify and suppress this instantaneously with a drug that can only potentially cause another problem.
 
Hospital profitability needs to change. When a hospitals’ profit is tied to full beds (healthy people
do not occupy hospital beds) we will be promoting illness not wellness. Hospitals should be fewer and most of the hospitals should become healing sanctuaries where people are admitted initially for acute care they need and then transferred to the sanctuary part, where they address the root cause of illness. Here, they should educate and engage the patient in change in life style addressing stressors and the outcome being getting the body back to health.
 

This would be the best of both worlds where the provider is educated in the art of true healing and the study of the science of disease.

The medical industry is riddled with contradiction. We are trying to “cut medical costs” by getting mid-level providers to provide early detection and not true prevention( primary care), we are trying to emasculate the image of a physician by making them data collectors and with increasing regulations, in the name of efficiency(standard guidelines and EMR). We also promote the newer drugs and more expensive testing and surgeries. The medical associations
are living off the support of “Big Pharma” that thrives off of illness.

So what do we really want? What business are we truly in and who is our ideal client?

This should be our food for thought.
 

Nisha Chellam M.D. ABIHM 

Internal Medicine

Find out more about Dr N Chellam's work at this website http://holisticicon.com/ 

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Ebbinghaus Illusion : Philosophical and Human Factors thoughts

The Orange Circles, both of them are exactly the same size. However, at a quick glance, it is very obvious that one looks bigger than the other.

Philosophical questions

The first question is which orange circle would you like to be? Small fish in a big pond or big fish in a small pond? Why? If you are the fish, do you realise that the fish is the same irrespective of the pond. Are you living in hope? Are you living in false hope? Do you think the big pond means that you have a great opportunity etc? The size of the pond does not allow the fish to become bigger or smaller.  Is it a protection mechanism that you are using? Small fish in a big pond, are you trying to hide to protect yourself? Are you trying to be insignificant? Do you fear that you might be attacked by predators? Big fish in a small pond, are you the predator? Are you trying to show off and dominate? If you are, what impact is that having on your eco-system?

Political questions

If you are surrounded by ‘small’ people it may make you seem/feel big and if you are surrounded by ‘big’ people it may make you seem/feel small – would you be aware of that? How comfortable would you be with that? What would upset you? How can you use it to your advantage?

Human Factors perspective

What goes on around you can distort your perception. We also know that our perception is our reality. We face adverse effects for ourselves and create adverse effects for others by distorted reality.

Let us say you are selecting someone for a job or a promotion and you faced this distortion and always picked what you thought was a bigger orange circle, you would be causing chaos and confusion. Let us say both the orange circles are urgent medical conditions and you constantly chose the ‘larger’ one you would continuously disadvantage one particular group of patients.

Similarly, when gearing up for tasks, you could be under prepared or over prepared depending on how you perceive. You could then face surprises, nasty surprises that could harm. It is this kind of illusion that results in over estimating our strengths and underestimating our weaknesses.

It is okay for poets to talk about the moon being larger and closer or smaller and farther but when it comes to operations of any kind but especially in healthcare - Measurement and objectivity are important, they become even more important in complex situations.

©M HEMADRI

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M Hemadri’s mini e-book 'Standardised Management Conversation' is available - click http://www.amazon.co.uk/Standardised-Management-Conversation-Hemadri-ebook/dp/B018AWBJTU 

Ref:

https://en.wikipedia.org/wiki/Ebbinghaus_illusion

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