A Question of logic

Whenever a new medicine is launched in the Pharma-industry, companies hold seminars to promote their brands. Consultant doctors, is the target group and the seminar is followed by either Lunch or Dinner (which is at times a more attractive part of the package) in a decent hotel.

Generally, a guest speaker is called to deliver a lecture and most of the materials including slides are given by the company. The slides contain a lot of scientific data regarding that molecule, with an obvious slant on its positives and a mere look at its negatives.

These are all accepted norms. When the presentations are on, in the dim light, back benchers like yours truly, are busy in commenting and or gossiping either on the medication or the lecturer. The question- answer session following the lecture is at times more stimulating.

“These are all double-blind controlled studies regarding this drug ….. but all of us know that in practice, while dealing with patients, how things are different …..”  Generally the lecturer makes this sort of a comment which relaxes him and his audience.

The double blind, controlled trials with statistical significance levels and various other measures makes many clinicians a little restless if not outright uncomfortable. Agreed, any new molecule needs the strict standards of scrutiny and it has to fit in the established norms of scientific research. But the myth that is (advertantly or inadvertently) propagated in the medical world is, that the research done by these strict, rigid standards is the only ‘Quality’ research.

Obviously, experiential research, qualitative research, even sharing of insights is seen as something of a second rank. Case study method of research is seen with disdain. It is often forgotten that there could be many avenues ( many of them more creative ) to look at the same truth.

At times, though the question-answer session, a great amount of wisdom comes out and it  becomes a truly memorable experience.

While understanding any medicine research model based on essentially Bio-medical norms has its own  place but then the ‘art of its use’ should also find a place of pride in the scenario.

Some months back, I had designed a program for consultant psychiatrists of Pune city on ‘Conventional and newer anti-psychotic’. Major portion of this meet was devoted to a experience sharing and discussion session with three eminent clinicians from three generations. I still remember this session, for the insights that I got from the panel, while I was conducting it. These were people who had seen the medicines act on thousands of people. They had tried, succeeded and failed in their experiments. But their experiences were pure gold and not mere anecdotal.

They had read their textbooks of pharmacology and recent journals, as most of us do (at least near our post graduation) but while dealing with individuals they had synthesized the organized store of knowledge with unique qualities of individual patients.  I am sure, we, all clinicians do this.

In psychiatry, all of us have found some combinations of medicines effective in some or many of our patients. Experience has ‘taught’ us to have a ‘gut feeling’ about the effectiveness of a particular drug in a particular patient.

The textbooks or the strict clinical trials have not advocated this line of treatment. Our experiments at time become successful but never become part of the collective clinical acumen ‘officially’.

2.jpgIn effect what are we doing in clinical practice? We are taking certain clues of effectiveness, side effect profile and such issues, from the biomedical research. Then we apply this to our individual clients. While doing this, we consider specific symptoms-group of that patient. We at times go deeply into the group of symptoms and then try to think of a combination of medicines that will work. At times we think of severity of symptoms, at times its duration, at times frequency…… Are we not going closer to the homeopathic way of history taking? ….. The answer is, Yes.

We also observe the role of personality factor in progress and its speed in a particular client. We now call it an Axis-II component. We change our line and thrust of treatment (medicinal treatment) according to these factors…. Are we not going closer to the Ayurvedic way of history taking based on different ‘PRAKRUTI’s like Kafa- Wata- Pitta? The answer is …. may be, Yes.

In fact, all of us who make these detours on the Bio-Psycho-social tracks are doing something immensely good for the patient’s well-being. But when it comes to officially stating those experiences, many of us get bogged down. We doubt our  sanity and prefer to sit back. With our batch-mates and friends we discuss these experiences at length. That helps us & them but does not acquire the seal of ‘officially known knowledge’. Many pearls of pharmacological wisdom get lost in the process.

In my days as a resident, my teacher ( Dr. L.P. Shah, Dr. D. R. Doongajee)  used to tell us to add a little of trifluperazine (an antipsychotic) or a dash of Amitriptiline (an antidepressant) to the prescription.  We, newcomers used to read text books containing even maintenance dosages as per the ht-wt norms of a average healthy western individual. We used to get shell struck by these improvisations till we saw the intended effect of these changes in the patients. In retrospect, these were the brilliant masterstrokes of these experienced clinicians.

This is what we call ‘propagation & transfer of art in science’ from generation to generation. I see a trend in some international medical journals, where individual experiences, shared in a transparent and lucid scientific style, getting due attention. The branch of psychiatry has its one foot in pharmacology ( premedical research )while the other is in the sphere of social sciences.

Research in social sciences has slowly started dropping its ‘vagueness’ and many creative research designs are now in practice. Psychiatry could be a good meeting ground for both styles of research.

Research was a big yawn for me till my senior friend Dr. Abhay Bang introduced me to its many models and expressions, some years back. Respected world over as an authority on medical research and an Indian who was a guest-editor of Lancet -British Journal of medicine, Dr. Abhay ( and his wife Dr. Rani) talks about medical research as if he is reciting a poem. It seems so rhythmic… his thoughts…. their flow…. the way he conceives research strategies, the pains, the labour, the excitement… His work has been a shining example of ‘synthesis’ of Biomedical & Psychosocial view points in research… a real ‘holistic’ way of looking at it.

“How does it come so clearly to you?” I asked him in amazement one night, at his Shodhagram in distant jungles of Gadchiroli a tribal region of Maharashtra State.

“First, you have to know, exactly what are you searching for … and why? ….” He said in his characteristic unassuming style.

Some logic, I said… and that too, almost universal!


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