Sunday, March 29, 2015

Depression in Indian Dialysis Patients: a problem begging to be addressed



This morning, as I browsed through my Facebook wall, I was alarmed to see a friend's post that he was trying to enjoy the last few days of his life! This guy is on dialysis and has been on dialysis for a year. I was wondering what could have happened that he thought these were the last few days of his life?

I called him immediately and realised that he was thoroughly depressed. I tried to cheer him up and realised that many people on dialysis are very depressed.

Unfortunately, in a country like India, where there are hardly a thousand nephrologists for a population of more than a billion, doctors do not have enough time to spend with their patients and give them 'all-round' care. A dialysis patient has multiple problems - the basic issues around dialysis itself, diet problems, co-morbidities, psychological issues. There is just not enough bandwidth for a doctor to attempt to address all these problems!

The patients themselves find it hard to grapple with a multitude of problems. Add to that the horrible problem of paying for treating all this.

"Its all in the mind", goes the adage. Now, there's proof to back this. A paper in Nephrology, Dialysis, Transplantation states, "scores on the emotional components of (Quality of Life) questionnaires are in fact strong predictors of patient outcome." A study quoted in this paper actually found that "patients with scores of 0–37 have twice the relative risk of death than those patients with scores of 51 or higher".

In India, what can we do to address this very significant cause of patient mortality among the dialysis population?

First, we need to acknowledge that this problem exists. We need to at least start tracking depression among our patients. It is not very difficult. Standard questionnaires are available. A beginning can be made by administering this questionnaire to our patients and then figuring out the magnitude of the problem at hand in our country.

Subsequently, steps can be taken as arranging support systems for those affected. We, as a country, may not have the resources to treat every patient who is depressed. Let us at least make a beginning. Rome was not built in a day. Treating dialysis patients is honestly, a more arduous task.

The medical community owes this to the patients. Dr. Victor Gura said, in response to a question on how working on the WAK helps him:

"Why would somebody go to medical school for any reason except because you want to alleviate pain and suffering or save lives. If you go to medical school that's what you want. And I would be basically fulfilling my endeavors and my hopes of becoming a physician. Alleviate suffering, make life better and hopefully save a few lives."

Saturday, March 14, 2015

Improving outcomes and QoL in patients on long term dialysis: what is the secret?

I was recently a panelist on a discussion at the Indian Society of Hemodialysis Conference on the topic, "Improving outcomes and Quality of Life in patients on long term dialysis".



I have been on dialysis for almost eighteen years now. I lead an almost normal life. I swim every morning. I work full time. I travel regularly. If you asked me what the secret ingredient in this recipe is, I would unhesitatingly say, "hours, hours, hours". The number of hours you spend on the machine, in my mind, is the most important factor.

I could not make that point as forcefully as I would have liked to in the discussion. In any panel discussion, even without Arnab Goswami as the moderator, there is a limited amount of time that each panelist gets to make his or her point. With Arnab, you have a second or two before he would interject and then make your point for you even if it is not really your point!

But, I digress.

There are two things dialysis removes - fluid and toxins. You can use a better dialyzer to remove toxins in a better manner. However, for fluid removal, even the best dialyzer in the world is restricted by the physiology of the body. The human body can only handle about 400 ml/hour without any complications. Stretch this limit and you are setting yourself up for a variety of problems like cramps, low blood pressure and some heart issues like Myocardial Stunning.

More hours on the machine also means you have less time between treatments. This means lower inter-dialytic weight gains. The normal human body has about 5-6 liters of blood. When someone consumes about 2 liters of fluid without removing it, it means almost 40% extra fluid for the heart to pump. This puts a lot of load on the heart causing it to expand (Left Ventricular Hypertrophy) and eventually fail. That is why most dialysis patients die of Cardiac issues and many of them die during the 'long-gap' between sessions. For patients on thrice a week dialysis, this typically is the 'killer weekend' - the Sunday-Monday gap or the Saturday-Sunday gap.

So, how much dialysis should one get?

I would say, "however much you can practically get!" I get about seven hours each night, six nights a week. That's at least 42 hours per week! Compare this to those who get five hours, twice weekly or four hours, thrice weekly. I get a lot more. Yes, there are a large number of people who have survived for a lot longer than I have on these modalities. But we must not get swayed by a few odd cases. The vast majority of patients who get low hours per week have poor survivals and quality of life.

Even when it comes to toxins, middle molecules can only be removed by more hours on the machine. These are the silent killers when it comes to long term dialysis.

I strongly believe a lot more effort needs to be made by the Indian dialysis community in getting patients more hours on the machine. Yes, patients here have financial constraints. Yes, we have a resource crunch. But if we honestly ask ourselves the question, "Are we giving optimal (not just adequate) dialysis to every patient who can afford it?", I am sure the answer is a big "No".

Are we giving enough hours to patients covered by private insurance? No!

Are we giving enough hours to patients covered by Government reimbursement schemes? No!

Are we giving enough hours to patients to patients who can afford them? No!

Where is the financial constraint for patients here?

I rest my case.

Sunday, February 22, 2015

My take on the AIB roast



A lot of water has flown down the Ganga since the AIB Roast first hit the headlines. People praised it to begin with and called it "Indian stand-up comedy finally coming of age". Most people found it funny and bold. Then someone decided it was indecent and actually filed an FIR against those who produced it and participated in it. Since then, every few days we find someone or the other voicing their opinion on this. We have had Aamir Khan, Twinkle Khanna, Shah Rukh Khan, Varun Dhawan and many others give their two cents on this.

I have actually seen the entire Roast on YouTube before it was pulled off. So, unlike many others, I at the very least have the legal sanction to comment on it!

For me, it worked only in parts. I honestly don't find abuse funny. Merely mouthing expletives just doesn't cut it for me. No, I am not against using expletives but I don't find them funny by themselves. The Roast depended a lot on people finding expletives funny by themselves.

To be fair, there were some really good jokes. But all in all I found it pretty average in terms of humour content. I don't think this was 'Indian stand-up comedy coming of age'. If anything, it served to highlight that Indian stand-up comedy still relies heavily on expletives that appeal only to immature imbeciles who have had a less-than-perfect schooling.

Almost all the jokes that targeted Karan Johar were about him being gay. To be fair to him, he took these jokes very sportingly and what was probably the worst-kept secret of Bollywood is now completely out in the open. Then there were jibes galore at skin colour, religion and relationships.

This brings me to the reaction to the Roast. All I can say is that it was wholly unnecessary. It was on YouTube. There's much worse on YouTube and this elicited the kind of response it did only because of the names involved. Poor Karan Johar had to have the High Court restrain the police from arresting him for this! Please give the poor guy a break!

If you get offended by such jokes and language, you have a very simple choice: click on Stop!

Friday, February 20, 2015

A productivity hack that is really working well for me



As an organisation grows, individuals who have started it have to take on additional responsibilities. As a result, the number of things on your to-do list grows significantly. You often have multiple urgent things that you need to do NOW. You are always picking one over the other saying you will come back to the other. Your list of things left undone grows.

The number of emails you need to attend to also keeps growing tremendously. You are away from your computer for a few hours and by the time you get back to your computer, you find 50-60 emails that have hit your inbox and need to be responded to.

I have this policy of 'Inbox 0'. This means that I always need to have no emails in my Inbox. When an email comes, I need to read it and do one of four things:

- Delete it if it is not needed at all (promotions, alerts etc.)
- Just move it to an appropriate folder if I don't need to do anything about it
- Respond immediately and move it to an appropriate folder
- Add an item to my to-do list and move it to an appropriate folder

This adds stuff to my to-do list and I was looking for a way to optimise how I manage my to-do list which was getting just too long and unmanageable. I use Wunderlist for managing my to-dos (and might I add, evangelised many of my colleagues at work to use this great tool as well - it syncs your to-dos among your phones and computers, has multiple lists and easy prioritising).

Then, one day, on Quora, I got this article in my email alert: As a startup CEO, what is your favorite productivity hack?

Now, now, Vikram, I can see you raising your eyebrows! I am not CEO of a startup, but I am a co-founder of a startup. So, I thought might as well read it as I was looking for ways I could be more productive.

Here is what I have started doing after reading the article. The article recommends other tools but conceptually what I am doing with Wunderlist is the same. It is not rocket science and after reading this, you might say: Much ado about nothing! But then, most great ideas seem simple. The fact is I was not doing it until I read this and after beginning to do this, it has helped a lot!

So, I have an "Inbox" list on Wunderlist. Here is where all new to-dos go to. Every week, on Monday morning, I go through this list and move to-dos to my "This week" list. These are things I would really like to get done this week. Then, every morning, I go through my "This week" list and move to-dos to my "Today" list. Then I take up things from my "Today" list and then actually do them. At the end of the day, it feels really nice to see that most of your to-dos are done.

I have tried this for a couple of weeks. It has worked really well. Yes, it might be early days yet but I am going to persist and continue this. Many things that were pending for a long time have got done. Earlier, all I was doing was responding to email. This meant OTHERS were dictating what I did in my day. With this method, I am dictating what I do with my day! This is really important!

There are many productivity hacks that people use. It is important that you pick something to make sure you get things done which are important to you. Many of us end up doing things that are unimportant to us and just react to emails and things others want us to do. That is not what we are meant to do!

A stupendous success!

The First ever Dialysis Olympiad in India organised by NephroPlus was a huge success. Almost 350 patients and their attendants participated in the event this Sunday, the 15th of February in Hyderabad. Right from the morning, patients started participating in the various events that were conducted with great enthusiasm and a 'will to win' which was the theme of the event. Here are some pictures from the event:












For more pictures, click here.

Friday, February 13, 2015

Is the AAP Delhi victory going to usher in a new kind of politics in the country?



Never before in the history of an Indian election has such a decisive mandate been given by the electorate to any political party. The soon-to-be-installed Arvind Kejriwal Government will have practically no opposition in the Delhi assembly.

Many analysts express deep concern on how a party that tends not to shy away from acts that cause people to describe it as 'anarchist' would behave when there is no opposition. Recent signs however show that Kejriwal and his team have learnt their lessons. They seem to have mellowed down, become more mature and sensible.

How did they manage to get such a huge mandate?

Conspiracy theorists claim that the BJP intentionally lost this election. Well, if it really was so, they would never have unleashed PM Modi during the campaign. Why would they want to tarnish his reputation of winning elections? The truth is that the people really wanted an AAP Government.

Is this is a referendum on the Modi government? I highly doubt this. People these days differentiate between the Centre and the State. Its been under a year since the Modi government took over at the Centre. Its performance, despite the huge expectations has not been bad. I don't think people would swing from a 100% verdict for the BJP to an almost 100% verdict against the BJP in such a short span of time.

Now, coming to the larger issue - of the impact of this election on national politics. Unfortunately, I don't think we are going to see much change in the way politics is run in much of the rest of the country any time soon despite the AAP victory.

The reason for this is that the AAP would first focus completely on Delhi and make sure that the promises it had made, especially with regard to a clean, corruption-free administration are fulfilled. Any attempt to look at other states would take away the focus on this. AAP is a young party with a very poor organisation structure beyond Delhi. It would be foolhardy of them to expect similar successes elsewhere due to this major handicap.

Despite PM Modi's best intentions on the issue of corruption, the BJP is pulled down by the baggage it has carried for all these decades. There are just too many people who are from the 'old-school' who believe in the culture of entitlement that afflicts the traditional political class in this country. And this is why he will fail when it comes to providing an administration that is as clean as one that the AAP can provide.

About other parties in the country, the less said the better.