Annual Primary Care Update - Office Of Continuing: Fill & Download for Free

The simple answer to this question is that there are very few good jobs and poor career trajectory in primary care in India. The healthcare system in India (both private and government) today does not incentivize a new medical graduate to move towards primary care and this option is often taken up as a last choice.General practitioners or family physicians can take care of nearly 70-80% of the healthcare burden in a community in both urban and rural settings. This reduces the pressure on secondary, tertiary and quarternary centers.When new medical graduates finish internship, they are not equipped enough nor confident enough to handle real-life clinical cases independently as their practical training has only been for a year (in internship) and they don't really handle difficult cases independently. Yet if they look to continue in primary care the options available to them areBeing duty doctors in big corporate hospitalsBeing emergency casualty medical officers in private and government hospitals. Both the above pay poorly and are mostly exploitative.An option which is slowly becoming difficult in urban settings is opening their own clinic. That is to become a small time entrepreneur.Another option is to take up government jobs in PHCs in rural areas or central government jobs after writing the UPSC-CMS exams.None of the above options these days, gives medical graduates work satisfaction, respect, autonomy or positive career trajectory. Even the general public and doctor peers are often dismissive of primary care physicians as “just MBBS” without realizing the crucial role they can play in healthcare delivery. This low compensation makes new graduates go away from primary care while the government tries to plug the gaps in the system by introducing bridge course for alternative medical practitioners to practice modern medicine without a degree for it or enforcing service bonds on new medical graduates. It is difficult to carve out your own career in a system that does not reward “real” physicians in primary care.Of course there are some DNB and MD courses in Family Medicine and Emergency Medicine. None of the above are in a lot of demand as it does not improve their remuneration by much and having to spend more years in acquiring those degrees.My father is a family physician and he has been in independent clinic practice since 37 years. I'm sure when he started he would have found it tough but he belonged to a different era when technology and medical care was not as advanced as it is today. He probably learnt a lot during his initial years of practice and has continued to update himself regularly to keep up with the times. It is amazing to see him diagnose and treat an incredible variety of diseases from gynecology to dermatology. From endocrinology to orthopedics. He has a good network of medical and surgical sub-specialists whom he can easily refer to in case his patients require it. His patients get the best bang for the buck because he knows exactly where and whom to refer also factoring in the affordability of the patient. Patients trust his referrals because that trust has been earned over many years being their family doctor. His practice is still growing despite him wanting to semi-retire, showing how much demand is there for his skills. This breed of physicians with my father's range of diagnostic skills is fast disappearing in India due to the reasons mentioned above.As you can see, the skill sets required for primary care and specialized care are totally different. In developed countries there are residencies in general practice or family medicine. The jobs available after that are lucrative, respectful and has better lifestyle than specialist doctors- making it a favoured choice. When I was working in Singapore, the head of the Facial Plastic Surgery department was joking that his son who is a GP in Australia makes more money annually than him, has fixed hours, free weekends and drives a Ferrari. He believed that his son will retire before he reached 50 and hoped that it was after he himself retired. No such luck for GPs in India.The price for not rewarding primary care is borne by everyone else. So nowadays, diabetes is diagnosed by endocrinologists and hypertension (high blood pressure) is diagnosed by cardiologists while specialized skills are not required for doing so. If you go to a neurosurgeon to consult for your headache, you will get the same treatment as a family physician would give but you will have to pay for a neurosurgeon's consultation fees. This increases healthcare expenditure, makes specialists work more and all our tertiary government hospitals get overburdened with patients who could have been taken care of at the primary level.This is of course not to discount the necessity of having specialists. Every healthcare system needs doctors at primary, secondary, tertiary and quaternary levels. So, there is need for family physicians, specialists, sub-specialists to take care of the entire population. It takes several years to be a good sub-specialist and takes more years after that to master those narrow fields in every speciality. Since India's population is so huge, there is enough work for sub-specialists in nearly every field.When I chose to specialize, I took into consideration all the above factors before deciding and once I got into ophthalmology residency, I started developing interest in more niche fields which made me train to be a sub-specialist in Ophthalmic Plastic Surgery and Ophthalmic Oncology.It takes a lot of effort and passion to specialize and then further sub-specialize. There is a severe shortage of residency and sub-specialist slots compared to the number of MBBS graduates coming out of medical colleges in India. Even with sub-specialization it sometimes becomes difficult to stand out of the crowd. It is not easy to get into residency and costs a lot of money in opportunity costs if not actual fees for speciality training.If Indian doctors today are doing it, there is a pretty solid reason for it!

It’s been about 4 months since mine and it’s not something I EVER want to repeat…!Unfortunately, it can be a little different for everyone that has one.Mine started on Monday, October 10th, 2016 at about 8am. After running an early morning errand, I wasn’t feeling well and decided to stay home for the day.I had no chest pain or arm numbness, something just felt “off”.An hour or so later, I was feeling nauseous. My mouth kept overly salivating like when a person is about to vomit. The previous day, I had eaten some fairly rich food (not a norm for me) and thought that I had indigestion or maybe a case of heart burn.I started to hope I would eventually vomit so that I would feel better, but that was not the case. About 2 1/2 hours in, I finally vomited and that’s when I really started to feel bad.I finally had chest pain, but I (wrongly) assumed that it was due to vomiting and stomach acid. It just kept getting worse and worse and more intense.By now I was also having throbbing pain in BOTH arms. Not the “left arm numbness” that many describe, but throbbing pain in both arms from my wrists to just above my biceps.Finally, about 4 1/2 hours into my attack, I called my father to ask him what his heart attack felt like. He was 50 when he had his and he replied with the standard “my left arm went numb and it felt like someone was sitting on my chest”.Nope, my experience was nothing like that. But at 47 years of age, I was having a massive heart attack and didn’t know it.My father said something though that saved my life. He said, “if you feel bad enough, you should go get checked out.”So I drove myself to my primary care physician’s office which is about 4 blocks from my house. I rationalized that the chances of something “bad” happening in that short drive were minimal rather than driving the 4 miles to a local hospital.I walked in and actually said, “I’m sorry that I don’t have an appointment, but I’m having chest pains.” I didn’t know this at the time, but I was my doctor’s very first in-office cardiac emergency.In the next few minutes I was hooked up to their EKG and upon the first pass, my doctor called 911 (I’m in the U.S.) to get an ambulance. She then handed me some aspirin tablets and two nitroglycerin pills which had no noticeable effect.In the 10 minutes or so that it took for the ambulance to arrive, my doctor called 911 two more times to make sure that the ambulance was coming with “lights and sirens”, Code 3 in police/fire/emergency parlance.Once there, the paramedic ran his own EKG and confirmed my doctor’s diagnosis that I was in the midst of a heart attack. An oxygen line and a lot more nitro later, I was finally loaded in the ambulance and on my way.After even more nitro, an IV line, and a morphine drip, I was still in a significant amount of pain. I kept saying “a 7 or 8” on a scale of 10 to the paramedic.Finally we got to the Emergency Room and it seemed like the entire staff was ready for me. In the span of 10 minutes or less, I had a chest x-ray, another IV line installed, blood drawn, an ultra-sound scan done, was disrobed, had a gown put on, and finally was wheeled off to surgery for an Angiogram.Now six hours into my attack, a doctor was finally working to remove the blockage in my heart, but I had passed out at this point.After close to an hour of “digging”, the blockage was cleared, a 3x23mm coronary stent was installed, and I woke up in the hospital’s Coronary Intensive Care Unit with most of the pain finally gone from my chest.One of the first things I remember doing was posting a “check in” on Facebook that I was at the hospital, why I was there, and that I was recovering. It caught A LOT of people off guard, but I figured that it was the easiest way to let friends and family know.I later found out that I had a 100% blockage of my Left Anterior Descending artery (LAD) or as its sometimes referred to, a ”Widow maker” type heart attack. I found out later that Netflix even has a documentary about them, The Widowmaker | Netflix.Just last week I had a nuclear contrast stress-EKG and was informed that I have about 5–10% permanent damage to my heart muscle. This is fairly amazing given the length of time I was having my attack and the type it was. My heart still has most of its inflection or ability to pump blood.I had more than a few people trying to figure out how and why I’m still alive, so here we are and I hope this gives you some insight.By the way, with the exception of a few minutes after the morphine drip was started, I was quite awake and aware of everything that was happening. The fact that I was so lucid, even to the point of making jokes, was one thing that gave me some mental comfort.UPDATE:So 8 months after my heart attack, I was informed by one of my doctors that they understood WHY my attack seemingly happened “out of no where” and possibly why it was so severe.I have a blood and bone marrow disorder where my body produces too many platelets. Myeloproliferative neoplasms is the term I was given. This is what contributed to my blockage.This was detected via a genetic test, in this case one that looks for a Calreticulin gene mutation (CAL-R). The reason the test was given to me was that several months AFTER my heart attack, my platelet count had decreased (as expected) but then it started going back up again into a range (800,000+) that worried my Hematologist and Cardiologist.So the upside of this is that I’m lucky that I did not have a stroke and ONLY had a heart attack. The disorder I have could have caused either.Next up is a bone marrow biopsy to determine a course of treatment. I’ll post more when I know more…UPDATE 2:So now I know with a fair amount of certainty, I have a disorder (some call it a type of cancer) called Myelofibrosis which translates to “bone marrow scar tissue”. For anyone reading this, you can Google it and learn more.So on a positive note, my widowmaker heart attack was NOT caused (at least primarily) by my diet, amount of exercise, lifestyle, smoking, and/or coronary artery disease nor did I inherit any “bad genes” even though cardiovascular problems run in BOTH sides of my family with close relatives having pace makers as well as defibrillators installed in their chests.That said, I basically have a life expectancy of 10-15 years or more, maybe, depending on the course that my disorder takes. So there’s that…UPDATE 3 - One Year Later, 10/10/17:It’s now been a couple of months since my Primary Myelofibrosis Diagnosis. I’m VERY lucky in that I’m mostly asymptomatic for now and I am very grateful for that. My wife and I joined the support group for this disorder on Facebook and judging from the posts from others, I have to admit that I’m more than a little scared at the prospect of when this thing progresses and what it will do to me.Quite honestly, another heart attack is the least of my worries given what this disorder CAN do, but at the same time, a very real concern.Do I try to eat better, yes. Do I do what I can to be active and exercise, yes. Those are things that can benefit anyone.Mostly I go through life thinking about what I can do, even in some small way, to make the lives of others better.UPDATE 4 - 7/14/18:So far, so good. I have joined a support group for people with my same type of bone marrow disorder, but we’re a VERY small group. At any given time, there are about 25,000 people in the U.S. with Myelofibrosis. Relative to the fact that there are over 315 MILLION people in the U.S., we are statistically insignificant.BUT, because my genomic disorder is so specific, it has the attention of drug companies and those working on gene therapies like the FIRST one that the FDA approved on Aug 1st of 2017. So there’s hope of a “cure”, but not much else.The medication to control my platelet level seems to be doing its job. I recently had a test that revealed that I’m only 25% over producing instead of the 200% level I had been at previously. So hopefully my heart attack and stroke risk is reduced, but its not gone.UPDATE 5 - Two Years Later, 10/10/18:I’m still here and OK as far as I can tell, but I did spend the morning getting tests.It’s interesting the amount of increased scrutiny you get as a patient who has HAD a heart attack. Yesterday I complained about some slight abdominal discomfort and pain. And today I’m being checked for kidney stones and other related ailments.I really can’t complain as I’m receiving EXCELLENT medical care. My doctor seems to feel a bit possessive about me and my health since I was her VERY FIRST in office cardiac emergency. When I had my heart attack, I trusted her to take care of me and make the right decisions on my behalf and she did that and more!My doctors are still adjusting my meds to find the right mix, but things seem to be going in the right direction. According to recent blood tests, my levels have been the more normal they have been in over 3 years, so that’s a good sign for a change.Now I just need to lose some more weight, on purpose that is, UGH….UPDATE 6 - 3/27/19:I had my semi-annual check-in with my cardiologist today. He says that things look good for the most part. I still need to lose some weight and he’s concerned a little about my cholesterol level, but overall not bad.He want’s to me to do another treadmill stress EKG exam in a few months to measure the amount of blood flowing in and out of my heart and see if there had been any noticeable long term effects. So I guess my next update will be in a few months.As for my underlying issue, the Myelofibrosis, we’re continuing to monitor that as well. My medications seem to be doing their job and keeping my platelets at a tolerable level (roughly the 400–500K range), but its still a “watch and wait” scenario and I hope that it lasts as long as possible.I did have a rather strange episode over the holidays. I got a sinus infection that actually bled out into the surrounding tissue and partially paralyzed my face. I recovered over time, but I still have part of the right maxillary nerve that is numbed all the time and it feels like my teeth are moving around. I don’t think this is related to my heart or bone marrow issue, but it was just odd nonetheless.UPDATE 7 - Three Years Later, 10/10/19:Still here!My follow-up stress EKG test last July went well. It confirmed that I have about 5% of permanent damage to the bottom most part of the my heart muscle, but otherwise I’m pumping OK.I need to lose a few pound. OK, well, 10–15 would be better, my doctor wants more like 20, but I want to look like Brad Pitt so I’m OK with both of us being a little disappointed.My Myelofibrosis is stable for now. I’m continuing on medication to control my platelet levels in fact I’m due for my next blood draw and CBC. So I’m still in watch and wait mode as far as that is concerned.Medical science is progressing far enough that I may not need another bone marrow biopsy, they might have a blood test in the future to monitor my fibrosis.UPDATE 8 - Four Years Later, 10/12/20:Hi Folks!I hope everyone is doing well in these crazy times we are experiencing.I’m doing OK. I’m doing my quarterly blood draws to monitor my levels and I go see my Myelofibrosis specialist at Stanford University Hospital every January. Except lately my visits have been via video.I maintain hope that medical science and geneticists will find a cure for my particular single broken gene disorder. I watch “60 Minutes” in earnest when they do their updates on curing things like sickle cell anemia and wonder when they will get around to statistically insignificant people with some as rare as what I have.On a positive note, I recently finished a 5 year stint on a Commission in my home town to update and rewrite the city’s General Plan and I’ve been asked to apply to another commission. So maybe this is the start of the next phase of my life.

By definition, a democracy represents the voters. Politicians have no choice but to represent their constituents’ desires. Otherwise, they will lose their jobs!And we the voters are so stupidly greedy that we want the state to benefit us in the here and now - consequences be damned. I will use the USA as an illustrative example. And yes, it technically is a republic, but the people being able to elect representatives makes it prone to the same weaknesses of pure democracies.Take Social SecuritySocial Security was founded in 1935 during the height of the Great Depression with the proclaimed goal of being a social insurance program making retirement easier to endure. It was designed to operate with what I call the “shared pot principle” — namely younger workers put money into a shared pool while older people take money out. When it was founded, people could only get their benefits after they turned 65. This meant that it originally was anything but a retirement program.Why? The average American life expectancy in 1935 was 61.7 years, so most people who spent their lives paying into it had a greater chance of dying before they got any benefits!However, this all changed with two major post-war demographic trends:The post-WWII baby boom followed by rapidly dropping fertility ratesIncreasing life-expectancyDuring the last half-century to the present, these factors have led the USA having an increasingly aging population. Furthermore, Social Security’s retirement age for social security didn’t effectively change since 1935 - only from 65 years to only about 66.5 years! With the average retirement age since 2011 being about 61 with an expected remaining life expectancy of 20.67 years, the number of seniors eligible for and using these benefits has skyrocketed. This is how we get the following numbers:With seniors receiving more money and with relatively less money coming in, the “shared pot” of social Social Security is facing massive deficits - to the point of insolvency by 2026.It Is Fatally FlawedUnfortunately, such structural problems are not only limited to Social Security. They are also propelling other social welfare programs like Medicare towards collapse.Not only do these programs face demographic imbalances, most beneficiaries are taking way more money than they paid in. A 2013 Urban Institute study found that an average-wage-earning two-income couple turning 65 in 2010 would have paid $122,000 in Medicare taxes but will receive $387,000 in benefits - more than three times than they ever paid in!!So while America’s military spending has been decreasing as a percentage of GDP, its combined social safety net spending - Social Security, Medicare, Medicaid, and etc - has skyrocketed:To Define: Mandatory Spending Is Social Security, Medicare, Medicaid, and a few other small programsMandatory spending — that is, social safety net programs — is the biggest driver of America’s national debt!Entitlements and mandatory debt interest payments are literally crowding out all other spending priorities, including national parks, military, welfare, infrastructure, and moreThis is not sustainable. The spendfest needs to endBut if any politician dared to say, “Hey guys, the benefits that were promised to you for years and that you were counting on for your golden years are an unsustainable lie. To balance the books, we have no choice but to raise the eligibility age and cut some,” he would get pilloried.How Dare You!! I Want What’s MINE! You Will Pay!People would be outraged. To them, such a move sounds like someone stealing what is rightly theirs. And since people are experts at motivated reasoning, any attempts to explain that they are receiving (on the average) way way more money than they ever paid in - at the expense of their grandchildrens’ future - would fall on deaf ears. Since seniors are a powerful electoral block, the politician would be quickly voted out.This is why politicians - both left and right - campaign on “protecting Social Security and Medicare.” This is why Trump in 2016 claimed that he wouldn’t cut Social Security and Medicare . They aren’t stupid. They know these programs are a disaster and can’t last.But their hands are tied!Even if they miraculously made some changes, voters would immediately replace them with someone else who would undo their actions under electoral pressure. Thus, politicians play along for another and another term of office and hope that some other guy will be on the hook when the inevitable debt crisis happens.This is exactly what’s happening. No one wants to come to terms with the painful truth there will not be enough money to pay the benefits they were repeatedly promised. The can gets kicked down the road, more people retire and receive them, and more and more people are promised and grow to expect benefits in the future. And the projected $82 trillion bill gets dumped on my generation’s shoulders.It gets worseSince 2008, the Democratic Party has moved sharply to the left.In 2016, Bernie Sanders campaigned with Medicare-For-All as his signature proposal - with an estimated $32 Trillion price tag over the course of the first decade!! Since then, its progressive wing has been in full swing over the course of the course of the past few years and current 2020 primaries with candidates proposing massive social programs and spending.To name a few examples: Warren proposes universal child care (about $70 billion per year), Medicare-For-All ($2.8 to $3.2 trillion annually), student debt cancelation and universal free college ($125 billion annually), and a climate change plan ($2 trillion with $100 billion in aid to poor countries). Kamala Harris proposed a plan for government assistance to help black homeownership in historically redlined communities ($100 billion), increasing teacher pay ($315 billion over 10 years), and a LIFT the Middle-Class Act which would give tax credits to people making under $100,000 a year and would significantly raise taxes on those making more than $100,000 a year (estimated to reduce federal revenues by roughly $2.7 trillion over a decade). Sanders supports a plan to cancel student debt and make all public colleges in the U.S. free ($2.2 trillion). Biden proposed a climate change plan costing in federal funds $1.7 trillion over the first decade. Yang proposes a universal basic income plan to the tune of more than $3 trillion a year, with only the best of intentions.And, of course, there is Medicare-For-All. Candidates Sanders, Harris, Castro, Gabbard, Hickenlooper, Warren, and Yang support it fully while Biden, Booker, Klobuchar, O’Rourke, and Gillibrand all support some version of a multibillion dollar Medicare or Medicaid expansion.[1]The country is already broke with an ~$22 Trillion debt with skyrocketing entitlement costs. How would it pay for all this?“TAX THE RICH! TAX THE RICH!”Right. It is a popular populist slogan but the numbers don’t add up. I read a 2014 paper by Gabriel Zucman and Emmanuel Saez on wealth distribution in the U.S. They are left-leaning economists who write often for the New York Times. They estimated that the nation has a total wealth of $55.2 trillion. The top 10% owns 77% of the nation’s wealth - a total of about $42.5 trillion. In 2017, the federal government’s total spending was $4.0 trillion.So if I went all Russian, confiscated all the top 10% 's wealth, and threw them into a gulag, it would last only for about ten years! The other 23% would go down the drain even quicker!And this calculation is based on the unrealistic assumptions that federal spending doesn’t grow or have major cost overruns — an impossible proposition given rapidly growing entitlement costs and popular spending expansion proposals costing billions and trillions of dollars — and that confiscating wealth stored in investments wouldn’t deliver a massive blow to businesses and the overall economy.It wouldn’t be enoughBut most young people, who are staunchly on the left, don’t know or don’t care and support such proposals en masse. It’s ironic. What has screwed them over? Out of control social programs. What do they want? More out-of-control social programs!And don’t think that the Left or young people are unique, or that the Right or older folks are any better. Oh no. We are all greedy. I established that Medicare and Social Security are untouchable, but the problem goes further than that.In almost every area of government spending, a majority of people are in favor of maintaining or increasing it. They will continue to vote for politicians who will meet their demands. And perversely, politicians have no choice but to give constituents what they want. The hefty bill will be then put on the nation’s tab for the next generation to pay until this game comes to a terrible end. Lovely.So now you can see why I agree with a quote commonly attributed to a December 9, 1951 editorial in The Daily Oklahoman by Alexander Fraser Tytler thatA democracy cannot exist as a permanent form of government. It can only exist until the majority discovers it can vote itself largess out of the public treasury. After that, the majority always votes for the candidate promising the most benefits with the result the democracy collapses because of the loose fiscal policy ensuing, always to be followed by a dictatorship, then a monarchyHe wasn’t the first to notice this phenomenon. About 2,400 years ago, Plato discussed democracy in The Republic. He wasn’t a fan and wrote that voters are sometimes dumb and always self-serving. They would use their votes to grab freebies for themselves and bankrupt the state. He and Aristotle called this parekbaino.And somewhere in heaven, Plato and Aristotle are shrieking with laughter watching voters voting themselves more and more freebies with America propelling itself into fiscal collapse.Welcome to Democracy!Update: I saw this today on Twitter:Another instance of the same old game of politicians bribing voters with the public’s money and dumping the bill on the next generation. I am so not happy.Footnotes[1] https://www.axios.com/2020-presidential-candidates-medicare-for-all-7d958bab-de34-4d8c-921d-b561f201c4c2.html (https://www.axios.com/2020-presidential-candidates-medicare-for-all-7d958bab-de34-4d8c-921d-b561f201c4c2.html)