At Peace

My Lifetime Stories in blog

Saturday, August 19, 2017

Immeasurable Experience

Today was my last attendance at the Thadhani lab meeting. I presented my research findings that I have been cooking with Jess for the last 6 months. It's actually kinda sad, knowing that I would not be able to join the meeting anymore.
The lab is having its regular research meeting update every 2 weeks. There are at least 20 ongoing different researches at this lab only, spearheaded by Ravi himself. That does not include other labs that involves other consultants. That's how strong the research component here. Being presence among the researchers who have their papers published in NEJM, JAMA, KI etc is priceless. I got to know their views on certain topics, freely discussing on novel or controversial ideas in research. Ravi himself is actually quite a funny guy. There was no lab meeting that does not have laughter in it. He knows every single person in the group and acknowledge them (there are easily 20 people in each meeting). He is so humble that if the seating is full, he will get up and get the chair from outside himself. He listens to others.
Today, he touched a bit on sample size, but not in the usual calculative way. It was all about why and when is enough and whether it is hypothesis generating or comfirming hypothesis. It was not dry. Listen to the data, he says - even if the p-value is not significant.
The group do not just focus on a single research theme. Meaghan is doing something about hep C and CKD, Kabir is analysing data on sickle cell and ckd/cvd, Jess is doing something on pregnancy, Cammille is looking at gestational diabetes, Sagar is doing calciphylaxis, andrew is on hepatorenal, and christian is doing something with website - all different sorts of things. Of course Ravi cannot be good at each and every single clinical topic, but from thinking and research direction perspective, he has a lot of experience and superb at presenting his view.
I use the analogy of Naruto when I came back from Dublin. Come to think of it, it was not even close. It is more like Boruto, still in infancy, still there are a lot of things that I will need to learn, and that learning process should not stop once this sabatical period ends.
When I first arrived here, people said 6 months is not enough to do a good research project. I learnt so much more than just the need to publish a paper (which hopefully will also be a reality, Insya Allah). To immerse myself in a surrounding that constantly think about why things happen and find the inner push to do something different - this is an unmeasurable experience. More importantly, it provides me with the time to reflect within myself, what do I want to see in the future.

Friday, August 18, 2017

Re-evaluating Evidence-based Practice

I have been the proponent of evidence-based medicine since graduating from the medical school. In fact, my view on pathophysiology of diseases changes tremendously the more I read about evidence-based practice. I look at the observational and cohort study as just a hypothesis-generating exercise. Testimonial - aarrghh, not even in my book of evidence. Many things have influence my thinking, for example statin- although it is commonly quoted as LDL lowering treatment, its effect on mortality reduction cannot be just through that mechanism. This is because, other medications that clearly reduce LDL, do not reduce mortality like statin does. So, pathophysiology plays an important role to understand the mechanism, but certainly it is a work in progress.
Then come my attachment at MGH. I rarely heard they talked about guideline this and guideline that. What they talked about is the mechanism behind a disease. If it involves B cell, they would try Rituximab. If its is complement activated, may be the new therapy would help. Cyclophosphamide, despite its benefit, is hardly used here given its side effect.
Then I attended a course on complementary medicine(like the traditional chinese medicine). How can a institution like Harvard Medical School promote such a therapy without RCT-based evidence? Are they being paid? Then I realised more and more RCT is being done. The evidence is emerging, but why did I make up my mind even before the evidence is clear? Am I being blinded?
Then I read a book that discuss about the philosophy of science. How "a factual fact" may not be true, based on our logic.
1. Conclusions based on limited observations are not absolute.
2. Scientific conclusions are based on limited observations.
3. Therefore, scientific conclusions are not absolute.
So, what we have is always a work-in-progress, hopefully a step towards understanding the absolute truth. So, we have to keep our minds opened.
Then I read about testimony (definition: what others said), how despite me being very skeptical about it as part of evidence, we cannot run away from it. Our scientific fact is full or at least part of testimony. The thing we read in the book or journal, although the methodology is clearly explained, still it is based on the description by the authors - testimony. Picture of a circular earth, is a product of photography taken by others - testimony, unless we have direct observation from outside how earth looks like, and so with evolution etc. So, whether we like it or not, our lives depend on testimony of others. So the question is not whether testimony is part of evidence or it - IT IS!! But when to believe a testimony? It is usually when the one who speaks has the authority/is an expert in the area (especially if multiple unrelated experts) and we can trust the person.
This has nothing to do with those who lie to promote their products, at the expense of other people's health. This is to provoke on how we view 'factual information' and be opened to the new findings. And don't be obnoxious that we are the only person who's right, based on our 'scientific fact' and others are wrong.

Friday, August 11, 2017

Disagreement in Medical Community

It is sickening to see the public display of childish behaviour among our religious leaders/celebrities. It trickles down to their followers. A child would ask, why can't they just have one opinion? But as we grow old, we know that as long as we are human, differences in opinion will happen. The only thing we can do is how to learn to disagree like a grown-up adult, to tolerate different opinions. Like the famous quote, 'agree to disagree'.
When I was a kid, I remember very well the 6-steps of performing wudu' and 13 steps of praying. Then when I was opened to the world around me, I know that those steps are an extension of the understanding of previous scholars. And scholars differ, most of them in a very respectful manner.
I enjoy being in a medical community whereby we are free to express our opinions, despite being different to others. Of course, we can have consensus and guidelines, but they are not set in stone either. For example, the old (Malaysia) hypertension guideline promote the use of a combined ACEi and ARB, while we know based on latest evidence, that is wrong in majority of situations.
Dealing with pregnant women with kidney disease forces me to read on guidelines on pre eclampsia, hypertension in pregnancy and how to deal with glomerulonephritis etc. One interesting section is the thromboprophylactic use in post-partum period in women who are deemed to have moderate-high risk to get DVT or PE. This is the use of heparin/LMWH in post partum period. Recently, there was a shift (at least for me, as I just heard it) regarding giving 10-day prophylaxis LMWH injection in women who have 2 or more risk factors. This may include age >35 and parity>3 - which many women would have (among others).
Major guidelines (including Malaysian) were written advocating this practice. However, it is interesting the exchanges between them when there is a small group of authors who refused to agree with the guidelines. In a scholastic manner, they started by saying, that this is not personal and they have utmost respect for the opposing party. And they give their reasons, within the realm of their expertise, without going out of a tangen to smear the personal views and resort to name-calling.
Same thing when we speak to others who did not agree with our religious principle, that we say 'I understand your concern, but from Muslim perspective, this is not allowed. etc". That partly remove the direct personal insult- that it is not me saying it to irritate you, but that's what God has commanded me to do.
Of course, this also means that we agreeing to certain extent to the liberal philosophy, that gives right to individual liberty and freedom, instead of the authoritarian principle which 'you must agree with what I say'.

Tuesday, August 08, 2017

Prefix to Our Names

During one of Raya Celebration, I was introduced to a new friend, "Please meet Dr Hafiz, Nephrologist from UMMC." It feels awkward being introduced in a social gathering with the prefix DR.
Similar things; friends from your previous schools that you eat and play and share beds together, started to call you DR. Some of the distant family members address you as DOCTOR in social media.
Fast forward to Boston. Your boss obviously did not call you doctor, no surprise there. But your colleagues and other researchers, they also did not address you as doctor. Your boss even, everybody calls him by his first name. Recalling back to the time in Ireland, the intern or the SHO (similar to houseman and MO in Malaysia) certainly did not call you DR. Perhaps only the consultants were being called Dr, unless you were close enough with them.
Previously, I was quick to say that I prefer people not calling me doctor, certainly not by my own family, friends and co-workers. Despite being persistent (probably not enough), the nurses are still calling me Doctor. It makes me wonder, why is it so difficult to drop the prefix, especially in social situation?
Come to think about it, it may be down to a single factor - culture. In the western world, they do not practice having prefix like Uncle, Cikgu, Dato', Cik, Tuan. Some even call their parents or elders by their first name. In Malaysia however, I have to say even for myself, it is weird to call somebody by their name directly. You just have to add Abang, Sis or Bro, Pakcik etc. Nobody calls a person by his/her first name if the age gao is huge. It is a sign of respect. A teacher like my father, even after he has retired, he will still be called Cikgu. And it seems okay. I wonder if they did not use cikgu, what will they use? Abang? Pakcik? Encik? It sounds weirder.
Whatever it is, I call people by their prefix - Prof, Dr,etc, due to overwhelming respect that I have for them. I also call many people by their first name to feel that closeness that we share together. But what I certainly do not want is the feeling of arrogance that my status is better than others, just because I have the title.
The story that my father told me many years ago is still fresh in my mind. He met one of his ex-students working in a clinic. My dad recognized him and called him by his name. But the person ignores him, until he was called with the prefix doctor, and he insisted on it.
My name is Hafiz. I am a Nephrologist.

Tuesday, August 01, 2017

Urine - Windows to Our Soul?

Nephrologists deal with urine a lot. Nowadays, we use urine to confirm diagnosis of nephrotic syndrome, glomerulonephritis and can be very suggestive for rhabdomyolysis, pre-renal/intrinsic AKI or even electrolyte imbalance. It can be used in other specialties like in pregnancy for preeclampsia and endocrine for diabetes (mellitus and insipidus).
I came across a historical article that put urinalysis or uroscopy practice into an interesting perspective. No doubt that physicians of the old, as old as the Sumerian and Babylonian, have been noticing the colour or smell or the urine changed with certain diseases. Sanskrit medical work described 20 different types of urine. Hindu cultures were aware that black ants were attracted to sweet urine (sign of diabetes mellitus). Hippocrates describe bubbles on the urinary surface as a sign of kidney disease (proteinuria). Infection may cause a lot of urinary sediment. Blood may be due to ulcers etc.
A Persian physician popularised the concept of 24-hour urinary collection for better delineating of the disease. He used a vessel shaped like a bladder to collect the urine, believing that the liquid will behave similarly as if it is in the body. Matula, which is a glass container with shape of a bladder was introduced by King’s Royal Physician in France. The Matula was famously ascribed to physicians in movie and films, with a scene of holding up the glass of urine against the light to examine it.
Of course, the physician in the middle age still believe in the theory disease due to imbalance of 4 humours – namely fire, air, earth and water. Some believe if the imbalance element are light, like fire and air – it will rise to the top and presentable in the urine.
The uroscopy has been so famous that books were published and became available to common people (Google, anyone?). Self-diagnostic colour wheels were included for people to diagnose their own condition without seeing the physician. Of course, doctors are no different. Some also used only urine to diagnose a condition (hence the famous quote: Treat the patients, not the disease/lab results). Unqualified medical practitioner, called leches, were rampant with the easy access to diagnostic tool, like the urine colour wheels (Sound familiar?).
The people were so obsessed with urinalysis that it spiralled uncontrollably. Physicians and leches started telling fortunes and predicting futures with urine, a practice known as uromancy. They read bubbles on the top of urine to tell the future.
With all these hypes, no wonder it causes a backlash. In 1637, activist Thomas Brian published a book Pisse Prophet that mock all these concepts to the extent that Physician seen with a matula became object of ridicule.

CONCLUSION1. Human observations are powerful. Some observations gave rise to factual information, like in urinalysis. So, open our eyes.
2. For centuries, the imbalance of 4 humours as cause of disease predominated the mind of physicians. Many lived and died without even knowing the idea of glomerular filtration etc. We may die without even realising some of the concepts that we believe in are totally wrong. So, open our minds.
3. A false and absurd idea will not go well with intellectual capability that God has given us. Although people can be fooled by the surroundings.
4. Newton 3rd law states that for every action, there is an equal and opposite reaction. If we are too forceful in combating things we don’t like, there will be an equally strong force resisting the change. Look at the issue on feminism and prior inequality of women, the right against science by the religious community and the rise of secularism, the issue of Wahabi/Salafi vs traditional understanding of Islam. Be in moderation.

Sunday, July 30, 2017

Bread & Butter

After 7 years or so, i got to taste the toasted bread with butter and sugar again. I forgot how yummy it tastes like.
There was one particular house I remember well - Masri, Isma, Joe and Payen, they thought me that a welcoming house is truly a house that is available 24/7 for u - for a game of pro evo or two (or probably 100s), a constant supply of never-ending nasi and lauk, britney spears and boybands (that's probably only for Masri), and most importantly, how to enjoy a simple food like a toasted bread with butter and sugar.
I'll forever be greatful, and I may not know where some of you have been or how life has been treating you now, but I hope that we'll be able to enjoy a good bread, butter and sugar again in Jannah.

Sunday, July 02, 2017

Superstition in Medicine

It is a universal phenomenon that many people believe in or perform certain rituals that give them extra confidence in doing certain things. Scientifically, at least from the viewpoint of direct evidence, none is logical. In Ireland,often we hear people said and do - 'fingers crossed' or 'touch wood', when they hope for good luck. In Malaysia as well, we hear certain things being practiced, like - wearing red during on-call time will make you super busy (include anything red at all), cannot jinx things by saying things are awfully quiet as you will be super busy later. And these people who somehow develop this bad luck will be called 'Jonah'.
I probably would never know how the superstitious came into being - especially wearing red during call. Wikipedia mentioned 'crossed fingers' can be traced back to the early centuries of Christianity when some of them crossed their fingers as a sign of invoking power associated with Christ's cross for protection. It was also a secret sign when they were prosecuted by the Romans.
'Touch wood' originates from pagan belief that many spirits inhabited wood, trees, rivers etc. Or some believes it means the cross of Christ. So, by touching/knocking on wood, it's kinda of letting them know seek their blessing, or some people said, it is to mask the spirits' hearing from knowing, hence warding off the evil.
And there are many more interesting origin of many beliefs (superstitous or not), like number 13 etc.

SUPERSTITION AND BENEFIT
Do I believe in superstition? Previously, I tend to answer No, as it makes no sense. But to think about it, it really depends on the definition. Prayers can be considered by some as superstition, as there is no direct physical evidence that it may help. But I still do it as I do believe it can make a difference. Then it hit me, that things I believe in may not be shared by others - and I am in no position to judge, except for stating what I believe and what make sense to me.
Scientifically, studies have been performed to see if certain rituals improve performance. Consistently, it seems that certain rituals like crossing your fingers improve performance!! (Damisch L et al, 2010). Now, they did not say that the actual act of crossing your fingers made that different, but they talked about how it increases your confidence by changes in perceived self-efficacy. It was described like a 'boost'. It buffers against uncertainty and anxiety.
While I can say I understand if people continue to want to 'cross their fingers', (though I think from Islamic point of view, it is problematic) - I cannot understand this 'wearing red' thingy. I was told that certain doctors were asked to change their clothes if they go on-call wearing red!
Searching for evidence of whether wearing red may affect on your busy schedule failed to reveal satisfying evidence. Interestingly, some studies (though not consistent) suggested that women tend to wear red during ovulatory phase. They relate this finding to the natural changes that happens (like more attractive voices, faces and odour etc) to attract the opposite gender (Blake KR, 2017). But still, even if we agree with this finding, still it did not explain why men who wear red still attract patients (if you believe so)? In fact, men wearing red were viewed as aggressive (and may hinder patients)!
Another way to explain this phenomena is through cognitive bias. We have the natural ability to connect the dots, even when there is no real line there. The mother of all cognitive bias states that we, as human, tend to highlight the thing that conforms to our belief, and suppress things that don't. So, just may be, because of all this notion of wearing red makes you busy, we tend to remember the times when we are super busy while wearing red, but forgot the times we were super busy wearing other colours. Even if we tried once wearing red in order to shatter the superstition and we got really busy, that is still questionable finding, as being busy is subjective. We are the one wearing red and we analyse the finding? I sense some definitive bias there. Plus, the night can either be busy or not busy - so 50-50. I remember reading a study on this issue, but I failed to find it again. It must have been from Malaysia, as no other country seems to have similar belief.

JONAH
Personally, I dislike calling people Jonah. It may have become a term with no real meaning, but it originates from prophet 'Yunus'. Both scriptures (Bible & Quran) mentioned prophet Yunus/Jonah as a prophet who was sent to his people and he fled due to difficulty before Allah permits him to do so. While on the boat, they cast lots and he was condemned. Then he was swallowed by fish. From him, the Muslims learnt one of the most beautiful prayer that we recite during distress - Surah al-Anbiya 21:87
"... he cried through the depth of darkness, (saying): "There is no God but You, Glorified be to You! Truly I have been of the wrongdoers."
Hence, it gives me a bit of a jolt, when a prophet of God is being used to label a person with bad luck, in a joking/derogatory manner. We may still use it, but perhaps in an optimistic way, like "Don't worry, things will be better. Just like Jonah/Yunus." (Smiley face)
At the end, we decide what we want to believe. Some may be harmless, others may not.

Placebo Effect

One good thing being here is that, any talk that you listen to, most probably is being given by the world leader of such topic. Recently, I listen to a short talk on Placebo effect by Dr Ted Kaptchuk. He participated in a lot of interesting and 'weird' trials and also an expert in understanding traditional chinese medicine, especially in acupuncture.
Placebo is usually defined as a tablet that has no effect, given in a trial that mimic the investigated drug, in order to make the patients feel that they are not being left out. Not using placebo in studies opens up to a lot of potential biases, which may render the result not applicable to the general masses.
His understanding of placebo is slightly different. He believes that so-called inert tablet DO have effect. He proved this by showing few publications that compared active treatment, sham treatment and no treatment. In one elegant study on asthmatic patients, patients who has exacerbation of asthma were treated either with b2 agonist (proper treatment) or 'faked' B2 agonist or 'faked' acupuncture procedure or no treatment (literally just observation). From objective improvement of FEV1 viewpoint, only those patients treated with B2 agonist improved. But from symptoms/subjective improvement, all patients improve except for those who did not receive any treatment at all. (Wechsler, NEJM 2011)
In another example, he mentioned that patients who were given morphine by nurses 'face-to-face' has much more improvement in pain symptoms compared to those who were given in 'secrecy'.
Recent study using functional MRI suggested that genuine acupuncture and sham acupuncture triggered different region in the brain, but subsequently leads to symptoms improvement.
He is also actively doing study using 'augmented placebo' to see if irritable bowel syndrome can be improved. He believes that the effect of placebo is real, and partly can be explained by that interaction that medical practitioner has with patients - something that he called 'augmented' placebo in his trials.
How is this going to help me? Previously, there was some ethical dilemma (for me) in terms of prescribing certain medications like vitamins to patients in certain situations that I know there may not be much of benefit, but unlikely to cause harm either. Now, with this possible placebo effect in mind, it can actually make some difference.