Bhooshan Shukla Profile picture
Oct 4, 2020 18 tweets 4 min read Read on X
#Decisionmaking
#Medicine

#Thread

As a trainee doctor working in government hospital, working with poorest in the country, I believed that education can solve most problems.

How wrong I was!

A thread on decision making.
As a trainee doctor I saw suffering of people that I attributed to lack of education. They were superstitious, had bizzare (IMO) ideas about illness and recovery, hardly ever followed medical advice esp about follow up of treatment.
I firmly believed that as more and more people get school education, this will go away. People will have access to good information and they will make better decisions resulting in better life.
Then I completed my training and started my own private work. Now my
patients came from educated, mostly urban background and had some disposable income (hence they could afford private psychiatrist)
At the same time internet revolution was sweeping India (circa 1999-2000).
Information was freely available to anyone who could read English and afford internet.
Then internet became cheaper and arrived on phone.

And finally social media and whatsapp happened.
How does it affect my work?

Take simple example of early childhood education.

Huge amount of information is available on internet.
But education dosent help us differentiate information, advertising, propaganda, knowledge and wisdom.
Education dosent include " नीर क्षीर विवेक" (mythological ability of swan to drink only milk and leave water behind).

Ability to read english and access to unprocessable amount of information actually overwhelms thinking ability. This is compounded by lack of time as well.
So we have information overload, poor training, time pressure and emotional situation.

Bingo! You have a decision making hell!

So mind accepts simplest possible explanation that conforms to previous biases.
Add modern insecurity and belief in a world of dog eat dog. You become a perfect fodder for crooks' designs.

Common sense (heuristics) used by illiterate but worldly wise person is likely to be absent in the educated.
Daniel Kahneman+Amos Tversky and Abhijit Bannerjee+Esther Duflo earned their Nobel Prize in economics due to their work on financial decision making.

I dont know if medical decision making will get attention of good people of Swedish academy.
Back to our problem of early childhood education.

Now you will realize why people are willing to pay six figure sums (in ₹) to "coding for toddlers" companies.
People running these companies KNOW and possibly accept in private conversations that it is all about making money.

But anxious parents with huge amount of information and lack of decision making skills get carried away.
If it is so complicated for harmless education, just imagine how harmful it can get for healthcare related decisions.

Forget degrees, we need decision making skills.

Hence @nntaleb :)
A real life story to end this tread.

As a trainee doctor, I treated a patient with bipolar disorder. Like clockwork, he would get an episode of mania every 12-14 months for years.
He lived 300km away in a village. Arrived with his father at first sign of mania.
(This sign was him sitting in village temple and singing devotional songs without break.)

His father insisted on starting electro convulsive therapy on day one (they reached hospital with "nil by mouth" preparation) . He would be okay in about 10-12 days.
My pleas to take lithium regularly to avoid these episodes would fall on deaf ears. His father would give back stock of lithium given to them at discharge. And they would leave only to arrive "nil by mouth" after 14 months.
I cursed their illiteracy, short sightedness and demands for Electro convulsive therapy. I never tried to understand their decision making.

Now I am much older and I appreciate their wisdom in the path they chose.
Now I realize that our education can be a significant handicap.

If I had made effort then, may be i would be on my way to Sweden :)

This is how Nobel prizes are lost :)

Have a nice Sunday.

End of thread.

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More from @docbhooshan

Apr 30
A thread on one of the most popular misconceptions about mental health in India.

1. Most people can identify psychological distress and pain quite quickly. This is the good and easy part.
As humans we are born with the ability to sense emotions in others and sometimes ourselves as well.
2. What the identity as "source" or "cause" of that distress is where all the fun lies.
There entire thinking process and behaviour is dictated by their attributed cause. Entirely dictated by their own perception and conditioning (biases).
3. It is almost universal belief that there is ONE single cause of that distress/illness. People look for agency that will "neutralise" that perceived SINGLE cause.
Read 14 tweets
Apr 27
A thread on medicalisation of grief.

1. In last six months. Five of my friends lost a parent. It can get overwhelming. Being a local to their parent's city i was involved in the process medically / supportingly / logistically.
Here are some observations about wrong use of antidepressant medications for the grieving.
2. Many left behind a spouse. Completely heartbroken and distraught due to the loss.

Unfortunately, their well wishing family physicians advised antidepressant prescription.

I have a serious disagreement with this. Hence the thread.
3. After such a profound loss. Death of a spouse of 40 years or more. A huge void is left in life. Sadness and grief is intense and in indian culture it is expressed by copious crying, re telling of last illness / last moments with every visitor.
Read 17 tweets
Apr 9
#ChildMentalHealth #India

A 13 yr old with severe Obsessive Compulsive Disorder. He has to wash hands to reduce anxiety even temporarily.
It is so bad that his hands are white with painful linear breaks in skin (ulcers).

Referred to a child psychiatrist. Started on single medication (fluoxetine). Cognitive therapy not possible as child lives 250km away.
Excellent response to meds in 2 months.
This should be happy ending isn't it ?

But it is not....
A 🧵-
After those 2 months parents buy the tablet locally and continue for 3 more months and stop using it. All by themselves.

Symptoms come back within a month and they restart meds in half dose on their own for another 6 months. Majority of symptoms go away and some remain.
They decide to stop meds again and same story goes again.

After it all becomes intolerable, they come to me and ask for help.

My first duty after confirming the diagnosis is - to know whey keep stopping the medicine.
1. They can afford it easily
2. There are NO adverse effects of the medicine.
3. Their doctor was available on phone to guide so no issue of costs involved in repeated psychiatrist visits.
Read 10 tweets
Dec 10, 2023
One more suicide.
A young doctor studying at THE most prestigious institution loses life to suicide.
I realised that he was following me on this platform. That realisation makes this even more sad at personal level. Was there any way i could have helped him and prevented the tragedy?

I dont know perfect answers to all these questions.
Attempting to write a few that can be helpful for all young adult students (18-25 age group) -
1. Irrespective of what your seniors tell you, mental health IS important.
It is based on combination of your brain chemistry, your formative experiences and your circumstances. There is no SINGLE cause or simple single remedy.
Getting help from professionals remains single most effective life saver as of now.
2. "Feeling hopeless" is a robust indicator of high suicidality. Anger with or without agitation and consuming intoxicants like alcohol are high risk factors. A combination of these three (hopelessness, agitation and alcohol) is lethal.

Watchout for that in yourself and your near ones.
Read 11 tweets
Nov 24, 2023
A day well spent at Chitale Dairy at Bhilawadi. Thanks to @nikhilchitale and Chitale family.

Their milk and milk products factory is state of the art. Sharing few photographs-
Command centre powered by AI that detects break in pattern and activates action. Image
Packing machines.
A keen eye will notice "Nicrome" a pune based company that pioneered manufacturing of these machines in India @aparanjape rt from
Image
Image
Read 9 tweets
Aug 31, 2023
#Psychotherapy #Reality

One thing that makes therapy relationship different in a beneficial way is privacy.
It is not about "confidentiality " (your information is not shared with others by treating team) only.
Therapy also helps people process their own difficulties in the solitude of their own mind and come up with their own conclusions, processes, emotions. They OWN the solution.

I see this process destroyed quite frequently by well meaning (and sometimes self serving) others in patient's life.

How? Pl read on -
Many adults have friends and family who help them in difficult times. Patients have already discussed their difficulties with these people before meeting a therapist.

For children, parents play a serious supervisory role out of concern and parental authority as well.
When such adults and children enter therapy, their near one's / parents often sit with them after every therapy session, eager to hear what happened in the session and "what did the therapist tell you?"

This is usually done by people who have not experienced GOOD therapy themselves. They are not aware of the importance of privacy to make therapy happen.
Read 12 tweets

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