What Medicine Means To Me
Topic: Medicine

What Medicine Means To Me (Editorial), Mens Sana Monographs, III-6, IV 1-4, Mar-Dec 2006, p8-9.

 

To Cure Sometimes, To Comfort Always, To Hurt

 The Least, To Harm Never

Medicine has to engage in battle on numerous fronts. To further scientific enquiry without giving up on the art of caring. To find more efficient methods of care, ameliorate disease and attendant suffering, without overriding human rights. To experiment, carry out clinical trials and refine processes of experimentation, without allowing human beings, especially from underprivileged sections, to be coerced, subtly or otherwise, and/or recruited without informed consent. To continue to further patient welfare without snubbing the corporate enterprise of medicine. To further this enterprise, as it holds great promise for scientific advancement, without encouraging its equally great potential for malevolence.

Cure And Comfort

In all this, what does the man of medicine, and all the ancillaries connected with him, do?

It is wise to remember that we attempt to find cures. But this at present is possible only sometimes, and in few conditions. That, however, is no excuse to give up the good fight to find them. This is especially important if well-being is our ultimate goal in medicine. Unless we find cures, how will the person be really well? Till such time as this happens, medicine can at least engage itself spiritedly in the three Ds- reduce distress, minimize disability, and prevent death. It can also offer comfort by both the caring attitude of medical personnel, and more humane and distress amelioration oriented advances of the enterprise of medicine. (For, an enterprise it has become for sure, whether you like to accept it that way or not.)

In other words, to cure sometimes; but to care for, and comfort, always.

Hurt And Harm

There is a further thought which must engage our attention here.  Medicine today holds immense potential to hurt and harm. Corporatisation of medicine can cause this as much as inefficiency of caregivers, dehumanization due to automation of medical care, as also changing social values, wherein the main yardstick of success (even of a medical man) is a balance sheet, and where it is old fashioned to think of medicine as a noble profession.

Hurt is inevitable in medical procedures. Even an injection hurts. A surgical incision does that as well. All medicines can hurt because of their side effects. Even psychotherapy can hurt, as it disturbs stable-unstable equilibriums, ostensibly to usher in better ones.

Hurt is integral to change. In society, in individuals. In disease. Harm, however, is not.

The difference between the two must be clarified. While both hurt and harm involve distress to the other, harm also involves malevolence in the perpetrator. The intention is the culprit. Let us explain with a few examples.

Hurt occurs when surgery is carried out. Harm occurs when it is carried out to keep a hospital running. Hurt occurs when a kidney is transplanted. Harm occurs when it is surreptitiously removed from a poor, unsuspecting, gullible patient. Hurt occurs when properly indicated drugs/procedures cause severe side effects. Harm occurs when drugs/procedures are prescribed/carried out knowing they have great chance of causing side effects in a vulnerable individual, and then heroically treating him, all the time prolonging hospital stay and inflating bills. Hurt occurs when tubes are inserted into the different natural orifices. Harm occurs when it is done to make a sickness appear serious, often creating new orifices, and prolonging hospital stay. Hurt occurs when a patient has to pay for a costly procedure, or when a patient has to pay huge hospital stay bills. Harm occurs when the costly procedure/hospital stay is carried out even if unwarranted, to recover running costs of an establishment. 

Hurt occurs often while we effect cures and offer care.  Harm occurs when manipulation and exploitation is perpetrated by caregivers, when unnecessary procedures are carried out, when bills are unduly inflated, when commerce supersedes care in a medical setup.

The Bottom Line

Every procedure in medicine hurts. The intention should be to hurt the least, and carry out all steps in care and research to see this happens. Developing less distressing modes of therapy is a welcome step in this direction.

But what one must always ensure is that harm is never on the agenda.

In other words, what the medical enterprise of today must guarantee is to hurt the least, but to harm never.

This is all the more necessary as the present environment is thick with man’s urges to prosper and enjoy personal fortune, even while the other’s welfare is trampled upon. And what applies to society applies, unfortunately, also to its caregivers, even the medical man. He has to be especially careful he does not fall prey to this ever-present danger in his new found prosperity of recent times.

 Medicine means nothing if not this: to cure sometimes, to comfort always, to hurt the least, to harm never.

Ajai Singh

Shakuntala Singh

Topic: Music

 

 

This is what I wrote for Sargam July 2006

The President Speaks His Mind

 

 

How To Do Riyaz

 

1. Prayer: Riyaz is like prayer. Switch yourself off all other activities. Don’t attend phones, guests, keep chatting on nonmusical matters at riyaz time. Do not practice when you really do not have the time, or inclination, for it. Those few moments are meant exclusively for music, and let them be so earmarked, preferably every day. How long, well, it is up to you. Just like prayer.
2. Warm-up: Always allow some time for your voice to get warmed up for the practice. For that it’s a good idea to hum and hold on to lower notes for a few moments/minutes before going on to the real song/raga. Ideally, the Sa, and 2-3 notes around it are the best to warm up the voice. Sa-Re-Ga, and/or Sa-Ne-Dha combinations are good to start with, unless the raga doesn’t have them, in which case the appropriate 2-3 notes should be used for warming up. For males the Sa usually is Csharp, for females Aflat. A harmonium or any instrument by which you can get your Sa is useful here.
3. Food: Never practice on a full or an empty stomach. The full stomach interferes with proper rendering and may cause burping while you practice at important notes. The empty stomach will deflect your attention to the food. Just enough to make you comfortable is the key. Avoid fried spicy foods and chilled drinks before practice. All irritants to the vocal cords are to be avoided before practice. Because practice perfects the voice but also irritates the vocal cords, even if it pleases the mind.
4. Start: Always start with songs that have lower notes and then go on to high pitch ones. This is to prevent sudden strain on the vocal cords and prevent them from cracking in the long run.
5. Humming: It is a very good way to start the riyaz of any song/raga with humming. It gets both the voice and the mind tuned to the task ahead.
6. Accompaniments: It is a desirable to have a source of melody (e.g. harmonium) and if possible, rhythm (e.g. tabla/dholak) with you while practicing. Also, a recording device and earphones with a mike to listen to your own voice/singing are useful accompaniments. A recording of the original singer for version singing is equally useful.
7. Listening to the original singer: After having practiced the song a couple of times, it is a useful to listen to the original singer to confirm you are not making any obvious mistakes. Mistakes, when practiced over and over again, become very difficult to erase later. They are better not allowed to creep in at the formative stage.
8. Learning the song by heart: It is a very good idea to have the song written in your song book (You must have a special song book, not practice holding bits of paper you misplace and get frantic about later.). If you listen to the song a number of times, understand its meaning and not only its manner of singing, sing at least 15 times without looking at the book, and over three days (not just one day), you can have the song by heart.
9. Practice earlier numbers: Always brush up on old songs at every riyaz. Suppose you have 30 mins with you for actual practice after the 5 min warm up. Practice 2-3 earlier songs for 8-10 mins, and devote the rest of the time for the new one.
10. How long does it take to practice a new song: In general, you will take 20-30 mins to get the first real feel of a song. In that, half the time is spent in listening, and the rest in writing it down and singing. You will not get the feel of a song without singing it at least 3-4 times. Similarly, with another one. So, if you plan 1 song, spare 30 mins, if 2 songs spare 1 hour, and so on. This is an average figure. Difficult songs may need much more time.
11. Repeat practice: Always repeat the practice of a new song once after 12 hours, second after 24 hours, and third after 7 days, to allow the song to be transferred from your short term memory to the long term one. It is only what is in your long-term memory that can be retrieved when you need it. And need it you will, when you get on stage with your heart in your voice, your eyes at the audience rather than dug into the paper or the music book.
12. Suggestions from listeners: If possible, have someone with a good ear for music listen to you sing before you perform on stage. Listen to his/her suggestions carefully, and carry out improvements in your riyaz before coming on state. But do not get disheartened by comments. In any case, do not have negative and devastating commentators around. After a performance, do listen to constructive feedback, and be ready to work over it during riyaz.
13. The 100 times test: Do not perform on stage unless you have performed the 100 times test I have outlined earlier.
14. Pray: Finally, it is a very good idea to start your riyaz, and also end it, with a prayer, either sung or recited. If sung, the song will become perfect. If recited, it is a reminder to you that music is also one way to establish communion with the divinity around, and the soul within.

 

This is with my good wishes to you on the Guru Poornima celebrations of Swara Sampada for which we have assembled today.

 

Dr Ajai R. Singh

14 July 2006

 

Islam and its Followers
Mood:  quizzical

Is there something in Islam, which encourages violence in its followers?

Caveat: I wish to present certain points for a reasoned, not angry, debate. Please note this is put forward not to hurt any religious sensibilities, but to carry out a reasoned debate on religious issues. For one must believe such a reasoned debate is possible even in matters of religion.

Points for Consideration

1. Islam was born out of strife and war. The prophet's life was a series of fights with nonbelievers. Which he really fought. Christianity, on the other hand, was born out of the suffering and forgiveness of its Prophet, not his fighting.

2. On the whole, proselytization by the followers of Islam has been accompanied by violence, as different from the Christian Missionaries who adopted the humanist route. It is not difficult to understand why if we look at point 1.

3. The concept of jehad (holy war) against kafirs (infidels/nonbelievers) and the butaparasta (Idol-worshippers/heathens) has historical roots in the birth of Islam.

4. There is no provision in Islam for change in secular affairs of its followers. The word of the Book is final. Its writ must run in all matters. Therefore, the followers have no option but to look to the means adopted at the time of the Prophet, and seek all solutions there.

5. Hence, Islam as it is traditionally practiced, and its loyal followers, have no option but to use violence and strife to achieve their goals. And they find nothing objectionable or unjustified about it.

6. This may not be mouthed by the followers in debate with other religionists, but is the way the devouts think.

7. The devout continue to dominate the thinking and action of a major chunk of the followers of Islam. The other more compassionate/tolerant group is a fringe group.

Solution

1. Basic and fundamental changes in Islam's outlook towards other peoples and religionists, wherein they are not considered kafirs to be waged a jehad against.

2. Peoples professing other faiths need not necessarily be the enemies of the believers of Islam. Nor should their faith be inferior to Islam. Each follower has its own right to his faith, and peaceful coexistence is the only way different faiths can harmonise.

3. Accepting that although violence may have been integral to life in the Prophets times, it doesn't mean it was to be furthered or legitimised, but to be reduced since the Prophet himself suffered because of it.

4. Questioning religious sanction to violence as a means of solving issues.

5. Separating secular matters of day to day living from spiritual matters. Secular matters need reform according to the times and circumstances. Spiritual truths remain eternal. (Like, for example, the Hindus have done by separating their shrutis- eternal spiritual truths- from their smritis-secular affairs.)

 

Unless some serious rethinking is done by the ideologues of Islam, and accepted by the preachers, the maulavis in the madrasas, and the common believer, the followers have no respite from a violent way of solving issues.

Neither have those who are in their firing line and have to bear the brunt of methods, which spring from such ideology.

 

 

Ajai

19 July 2006

There are screaming headlines as I look at the morning newspapers:

'Mumbai Attacked. Over 170 Killed, 460 Injured in 7 Blasts. First Class Coaches Targeted. Intel Failure Blaimed'                       (The Times of India),

'Terrible Tuesday. Seven Blasts Hit Rush-Hour Local Trains, 150 Killed, Over 600 Injured; 8 Die in Srinagar Attacks'                    (The Indian Express),

'Nightmare. 7 Bombs. 164 Dead. 464 injured'     (Hindustan Times)

Terrorism keeps rearing its head in India because of unresolved issues like Kashmir, a hostile neighbour, ethno-religious sanction to violence as a means to settle disputes, and a wide network of support by likeminded religious individuals and groups united in the 'cause'. Ease of availability of lethal weapons, indoctrinated youth, compliant businessmen and scientists, and citizens from within who harbour and aid terrorists, all add to compound the problem.

It's a grim battle, really. No easy solutions in sight.

A useful paragraph on Terrorism is in the Wikipedia:

Terrorism refers to a strategy of using violence, or threat of violence to generate fear, cause disruption, and ultimately, to bring about compliance with specific political, religious, ideological, and personal demands^[1]. The targets of terrorist attacks typically are not the individuals who are killed, injured, or taken hostage, but rather the societies to which these individuals belong. Terrorism is a type of unconventional warfare designed to weaken or supplant existing political landscapes through capitulation or acquiescence, as opposed to subversion or direct military action. The broader influence of terrorism in the modern world is often attributed to the dramatic focus of mass media in amplifying feelings of intense fear and anger.

State terrorism more specifically refers to violence and threats of violence, embargoes and other forms of terrorism against civilians by the government of a state.

http://en.wikipedia.org/wiki/Terrorism

The rest of the article is worth a close look too.

The very first Mens Sana Monograph (MSM) was titled:

Psychiatric consequences of the WTC collapse and the Gulf War.

It's available at

http://mensanamonographs.tripod.com/id17.html

Ajai

12 July 2006

The Biological and the Psychosocial: What Needs to be Done?

(This is a response to an email)

Louis,

As I see it (please correct me if its wrong), you have opted to think of psychotherapy as falling outside the realm of mainstream psychiatry and medicine, since it has wider and more challenging roles to perform.

While this is a refreshing and interesting line of enquiry, and I wish you all the very best in the venture, my concerns have been rather more pedestrian.

I see the virtual hijacking of the research and clinical agenda by biological psychiatry. While it has a legitimate place in the branch, the elimination of other approaches looms large as a distinct threat, if not in reality, at least in the perceptions of the rank and file of practitioners.

Both psychoanalysis, and committed practitioners of psychotherapy, have commonly responded by either opting out, or falling in line. Those who opt out claim that the medical/scientific/evidential approach is ill suited to psychotherapy/psychoanalysis, since it cannot capture its rich myriads. Those who fall in line have become recent admirers of the biological approach. And you know how recent converts can be.

Both responses have not really helped the cause. I believe the psychosocial approaches must join the good fight. They must produce strong evidence that they work. They must conduct population studies, use rigorous research design, use biostatistics, and prove that they really help. They must produce their own Diagnostic Manual if they do not agree with DSM or ICD. They must suggest changes to the two if they agree with them in principle but find areas that need change.

How can the legitimacy of the approach be proved except by joining the fight? How can the benefits of the approach be offered to the suffering except by proving that it works? And proving it in a language and manner of discourse that the present world understands? Which is the scientific-evidential world. Admitted, it may have problems, and drawbacks. Still, it is the language of present discourse, and on legitimate grounds. For the present world will only respect evidence, or opinions backed by evidence. All else may be worthwhile, but will not be followed on a large scale. And if the psychosocial/psychotherapeutic/psychoanalytic has to benefit people on a large scale, it must produce scientific evidence that it works.

Only then will there be a renaissance of these approaches. Otherwise lets be ready to accept the decisive shift towards the biological, and confining of the rest to the fringes, to be gradually obliterated. Eventually.

This is my submission to you, Louis. Please feel free to express your self. I am sure you will have a lot to say.

Warm regards.

Ajai
17 June 2006

P.S. Please do also read Psychiatrists as Psychopharmacologists at
http://mensanamonographs.tripod.com/id15.html

Psychiatry and Some Biological Findings
This is a response I wrote today:


CA,

Interesting write-up, and let me appreciate the clear, succinct manner in which you presented it.

Now let us look at the findings of the studies quoted:


1. The number of new neurons formed increases with an increase in the number of ECS, and the new neurons differentiate and survive for at least 3 months (Scott et al, 2000; Madsen et al, 2000; Hellsten et al, 2002).

What does this study imply? Does it mean increased number of ECS should continue? Till when? Till how far is increase in ECS number connected with the new neuron formation? What happens after three months? How specific is new neuron formation to ECS, as different from psychopharmacology, psychotherapy, etc? Were these double blind placebo controlled trials? Any comparative studies?

2. The vascular infrastructure of the hippocampus similarly proliferates, possibly to support the neuronal proliferation (Hellsten et al, 2004).

This is obviously a supplementary reaction. Is it in any way specifically related to new neurons, or would occur even in injury/insult to the brain, or as a reaction to the electrical stimulation itself?

3. Repeated ECS also induces glial cell proliferation in the amygdala. This proliferation remains evident 3 weeks after ECS, when some of the cells show differentiation into mature oligodendrocytes (Wennstrom et al, 2004).

Glial cell proliferation, even oligodendrocyte formation, is a supportive phenomenon. What about neurogenesis? How useful is the former in the absence of the latter?

4. Finally, repeated ECS stimulates vascular and glial (but not neuronal) proliferation in the rat frontal cortex, as well (Madsen et al, 2005).


Rat studies confirm vascular and glial proliferation in frontal cortex. In the absence of neural proliferation, how significant are these findings?

5. Important findings of Hellsten et al (2005) were:
i. Oxygenation did not abolish the ECS-induced proliferation of endothelial cells in the dentate gyrus of the hippocampus.
ii. ECS induced a 30% increase in the total number of endothelial cells, and a 16% increase in vessel length.

Proliferation of endothelial cells is, I take it, is cells of the vasculature, which can be understandable even due to electrical stimulation, even if the hypoxia element is accounted for. How do we connect it with clinical improvement and new neuron formation, if any?

6. In rat models, oxygenation does not abolish ECS-induced proliferation of vasculature in the hippocampus. These findings suggest that similar vascular growth is induced by ECT in clinical situations.

Agreed. Even then, the issue of how is it connected to clinical improvement, and how it is not a non-specific effect of electrical stimulation, remain.

7. Kodama et al (2004) showed that chronic (21-day) but not brief (7-day) administration of olanzapine and fluoxetine increased neurogenesis in the hippocampus, and non-neuronal cell proliferation in the prefrontal cortex. The combined effect of the two drugs was not greater than their separate effects. New cell formation did not occur in other areas, such as the subventricular zone or the primary motor cortex.

Both neurogenesis and non-neuronal proliferation occurred with drugs. Was it temporally correlated with improvement? Did both remain even after drug stoppage? Did both proliferations regress with drug stoppage? Did they reduce with drug reduction? There are obvious long-term implications for therapy in this.


9. It is unlikely that histological effects suffice to explain the mechanism of action of ECT or drugs. This is because the formation, maturation, and integration of new cells take weeks, whereas in most patients who receive drugs or ECT the benefits develop within the first fortnight, itself. It is conceivable that neurotransmitter effects explain early actions, and cellular effects explain sustained benefits.

A neat conclusion.

It is also possible we have not still developed sophisticated enough methods to study early histological changes. Neurotransmitter effects are a good explanation, but they must be correlated with histological changes of some type. Otherwise they may become a convenient explanation, but insufficient on further probing. And they should not, in any case, stymie histological studies.

I think a robust correlation of histological findings with evidential neurotransmitter connection (evidential, as different from speculative) will ensure significant progress in understanding the biological processes underlying both mental illnesses and their recovery process.

We know biological psychiatry has a long way to go. But if its fundamentals are clear, and its adherents unrelenting, something significant should result in a couple of decades. Earlier would be a bonus. Later, well, that's possible, because the two riders mentioned must be fulfilled.

Ajai
30 May 2006

....................................................


andrade wrote:
With reference to:
(Can we have some landmark studies which make you come to these
conclusions, CA? Ajai)

Ajai, this is a SynergyTimes article which I had written earlier this year.
Best wishes,
CA

Jan 27, 2006; Vol 6 No 12

HISTOLOGICAL MECHANISMS OF ECT

Histological mechanisms of ECT have been described. In animal models, electroconvulsive shocks (ECS) have been shown to result in nerve cell proliferation in the hippocampus. The number of new
neurons formed increases with an increase in the number of ECS, and the new neurons differentiate and survive for at least 3 months (Scott et al, 2000; Madsen et al, 2000; Hellsten et al,
2002). The vascular infrastructure of the hippocampus similarly proliferates, possibly to support the neuronal proliferation (Hellsten et al, 2004). Repeated ECS also induces glial cell
proliferation in the amygdala. This proliferation remains evident 3 weeks after ECS, when some of the cells show differentiation into mature oligodendrocytes (Wennstrom et al, 2004). Finally,
repeated ECS stimulates vascular and glial (but not neuronal) proliferation in the rat frontal cortex, as well (Madsen et al, 2005).

Hypoxia is known to induce angiogenesis. Therefore, is the endothelial response to ECT in the hippocampus a result of hypoxia during ECT or the ECT, itself? The issue was studied by Hellsten et al (2005) in an experiment in which repeated ECS with and without oxygenation were administered to adult rats.

Important findings were:
1. Oxygenation did not abolish the ECS-induced proliferation of endothelial cells in the dentate gyrus of the hippocampus.
2. ECS induced a 30% increase in the total number of endothelial cells, and a 16% increase in vessel length.

Conclusions

In rat models, oxygenation does not abolish ECS-induced proliferation of vasculature in the hippocampus. These findings suggest that similar vascular growth is induced by ECT in
clinical situations.

Comments

1. The ECT-induced proliferation of nerve cells, glial cells, and endothelial cells occurs in structures such as the hippocampus, amygdala, and frontal cortex, all of which have been implicated
in psychiatric disorders. If the new cells are well-integrated into the existing brain tissues, their contributions may underlie the mechanism of action of ECT. This is an appealing idea because it could help explain why ECT is effective in disorders with
contrasting neurotransmitter mechanisms.
2. It may be noted that antidepressant and antipsychotic drugs also induce new cell formation in the CNS. For example, Kodama et al (2004) showed that chronic (21-day) but not brief (7-day) administration of olanzapine and fluoxetine increased neurogenesis in the hippocampus, and non-neuronal cell proliferation in the prefrontal cortex. The combined effect of the two drugs was not greater than their separate effects. New
cell formation did not occur in other areas, such as the subventricular zone or the primary motor cortex.
3. It is unlikely that histological effects suffice to explain the mechanism of action of ECT or drugs. This is because the formation, maturation, and integration of new cells take weeks,
whereas in most patients who receive drugs or ECT the benefits develop within the first fortnight, itself. It is conceivable that neurotransmitter effects explain early actions, and cellular
effects explain sustained benefits.

References

Hellsten J, Wennstrom M, Mohapel P, Ekdahl CT,

Bengzon J, Tingstrom A. Electroconvulsive seizures increase hippocampal neurogenesis after chronic corticosterone treatment. Eur J Neurosci 2002; 16: 283-290.

Hellsten J, Wennstrom M, Bengzon J, Mohapel P, Tingstrom A. Electroconvulsive seizures induce endothelial cell proliferation in adult rat hippocampus. Biol Psychiatry 2004; 55: 420-427.

Hellsten J, West MJ, Arvidsson A, Ekstrand J, Jansson L, Wennstrom M et al. Electroconvulsive seizures induce angiogenesis in adult rat hippocampus. Biol Psychiatry 2005; 58: 871-878.

Kodama M, Fujioka T, Duman RS. Chronic olanzapine or fluoxetine administration increases cell proliferation in hippocampus and prefrontal cortex of adult rat. Biol Psychiatry 2004; 56: 570-580.

Madsen TM, Treschow A, Bengzon J, Bolwig TG, Lindvall O, Tingstrom A. Increased neurogenesis in a model of electroconvulsive therapy. Biol Psychiatry 2000; 47: 1043-1049.

Madsen TM, Yeh DD, Valentine GW, Duman RS. Electroconvulsive seizure treatment increases cell proliferation in rat frontal cortex. Neuropsychopharmacology 2005; 30: 27-34.

Scott BW, Wojtowicz JM, Burnham WM. Neurogenesis in the dentate gyrus of the rat following electroconvulsive shock seizures. Exp Neurol 2000; 165: 231-236.

Wennstrom M, Hellsten J, Tingstrom A. Electroconvulsive seizures induce proliferation of NG-2 expressing glial cells in adult rat amygdala. Biol Psychiatry 2004; 55: 464-471.

Posted by psychiatrist400080 at 12:19 AM EDT

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Politicians as Scum?

I suggest we avoid using words like scum for politicians. We are all entitled to our opinions about them, and I know they are the favourite whipping boys of many. But let us not go overboard in the outburst of our feelings.

Let us not forget how we feel when people from the antipsychiatry movement heap vitriol on us. We just stop listening. They may do the same.

And then we, our cause - the Mental Health Movement, and ultimately the welfare of psychiatric patients, suffer.

Whether we like it or not, we have to collaborate with them in many matters. Let's try and get the best out of them.

Calling them names will surely not.

Moreover, to paint all politicians with the same brush is an unproved assumption. We may enjoy doing it, but let's prove it before we accept it. We are scientific people, are we not?

We are very careful in what we say and do with regard to medical and psychiatric terms. Why not do the same with regard to social issues of concern to psychiatry?

Ajai
27 May 2006

Independence and Sponsorship
This is a response I wrote to an interesting issue raised by Gunther(see below) to which Bill (again, see below) responded:

The point Gunther is making is about the 'independence' of the author in a so-called independent study sponsored by an organisation of which he is CEO, not whether he fulfils authorship criteria.

Does occupying a position as CEO potentially compromise his independence? Yes, it does.

A CEO should think ten times before becoming a co-author in a research his company sponsors.

However, that does not mean a CEO should be deprived of the right to be a co-author, which anybody has, if he fulfils the ICMJE criteria quoted by Bill.

In this case, his employer should also express their no objection to the CEO engaging independently in a study they sponsor.

What is the solution?

The CEO must clearly declare:

1. His employment in the sponsoring company as his conflict of interest.
2. That the research work done with regard to the study was independent of his employment with the said company.
3. A letter from the employer, permitting him to be co-author should be obtained prior to the CEOs involvement in the study as co-author. (The prior is very important, for obvious reasons.)
4. The substantial contribution of each co-author should be specified as a note below/along with conflict of interest. (This is especially important in this study, again, for obvious reasons.)

The reviewers should take these points into consideration.

The readers will judge for themselves.

In any case, we must note that such a study, howsoever well planned and executed, will always remain under a cloud as to authenticity.

Hence, potential authors who plan such work need to be be forewarned.

Ajai
24 May 2006

....................................................


"Tierney, William M" wrote:

The ICMJE guidelines for authorship state:

Authorship credit should be based on 1) substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data; 2) drafting the article or revising it critically for important intellectual content; and 3) final approval of the version to be published. Authors should meet conditions 1, 2, and 3."

If Mr. Olivieri was involved in interpreting the data and/or writing the manuscript, then he definitely should be listed as an author. Whether the study itself was truly independent, and if so whether the manuscript is unbiased, is another matter.

-- Bill Tierney
=============================================
William M. Tierney, MD
Indiana University School of Medicine
Co-Editor-in-Chief, Journal of General Internal Medicine
Voice: 317-630-6911 Fax: 317-630-7066
=============================================

-----Original Message-----
From: World Association of Medical Editors [mailto:WAME-L@LIST.NIH.GOV] On Behalf Of Gunther Eysenbach
Sent: Tuesday, May 23, 2006 12:35 AM
To: WAME-L@LIST.NIH.GOV
Subject: [WAME] a sponsor as author on an "independent" study

Now here is a interesting citation from
http://www.seedmagazine.com/news/2006/05/taking_aim_at_scientific_journ.php:

"Olivieri [CEO of Blackwell] served as co-author on a study released last
week - sponsored by Blackwell but carried out by independent researchers
-that found scientists rank lack of access 12th in a list of annoyances
contributing to a lack of productivity."

Now, Olivieri is CEO of Blackwell. How come he is "author" on a study
"carried out by independent researchers"? Either the study was really
"independent" meaning that Olivieri was not involved in the study, in which
case he should NOT be listed as author, or he was involved, in which case
authorship is deserved, but the study can't be called "independent". Or am I
missing something here?


-----------------------------
Gunther Eysenbach MD, MPH

Senior Scientist, Centre for Global eHealth Innovation
Division of Medical Decision Making and Health Care Research;
Toronto General Research Institute of the UHN;

Associate Professor,
Department of Health Policy, Management and Evaluation, University of
Toronto;

Mailing address:
Centre for Global eHealth Innovation
Toronto General Hospital
R. Fraser Elliott Building, 4th Floor, room # 4S435,
190 Elizabeth Street
Toronto, ON M5G 2C4
telephone (+1) 416-340-4800 Ext. 6427
fax (+1) 416-340-3595
geysenba@uhnres.utoronto.ca

Posted by psychiatrist400080 at 11:03 PM EDT

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Psychiatry and its Critics (Contd.)


We can handle critics effectively by:

1. Continuously putting our own house in order.
2. Not indulging in too much self-criticism, although critical self-appraisal is necessary, and welcome.
3. Letting those who get well speak about psychiatry more than we do.

One patient getting well and speaking about psychiatry is worth 100 psychiatrists and their eloquent praise of the branch.

I remember a recent psychiaric conference at Kolkata. The organisers had arranged a cultural prog. It was solely done by former psychiatric patients. The singers, dancers, even most of the musicians, were former patients. After giving a performance, the patient-performers recounted how they were earlier suffering with one or the other psychiatric problem, and how psychiatry helped them out of it.

Apart from their heart warming performance, their courage to speak up, and the gratitude about how they were helped, made for a memorable evening for us all.

Yes. Psychiatry helps. We know.

But they also said it does. That makes it worthwhile to do so much more for them.

Ajai
23 May 2006

One more reply to a response to Psychiatry and its critics


Lalit,

Interesting point.

Would they still go to a doctor who is rendered incapable of his medical practice due to a bypass?

If no, then why? Because the doctor may be in the hospital, or recuperating from the bypass, or rendered incapable of further medical practice because of his bypass, or may decide to quit medical practice because of his bypass.

If yes, because he is fit and fine to administer to the patient inspite of his earlier bypass.

Now, replace the word bypass with psychosis, and you have your answer.


Ajai

23 May 2006
..................................................

lalit vaya wrote:

ajay!

thought occured to me. patients will still go to a doctor who had a by-pass or appendectomy but will they go to one who had a psychotic episode of any kind?

lalit

Posted by psychiatrist400080 at 2:21 AM EDT

Updated: Friday, May 26, 2006 10:20 PM EDT

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This is my reply to a response to Psychiatry and its critics


Beckie,

I hope you give these point a thought:

1. If one has a condition which is life threatening to oneself or others, should one not be restrained?

2. Insulin shock, hydrotherapy, and now ECT. They are progress in therapy. Do surgical procedures remain the same after decades? Do you consider surgery to be one form of torture too? To a person who sees only the operative procedure, it would appear the person on the table is being tortured. But we accept the process because the surgeon is supposed to do it for the good of the patient. Why don't we do the same for the psychiatrist? He does no good?

3. ECT has limitations. So has any medical procedure. Within its limits, it can work wonders. The process itself has undergone modifications, as any medical process does.

4. Psychiatry is a medical discipline. Psychiatrists are trained to diagnose. And help. How the patient will respond, how much will a procedure help, has many variables to it. Two of those, which can be controlled, are physician's expertise and patient compliance. We physicians try and ensure the first, but let the patients/clients ensure the second.

5. A diagnosis is only a label, to come to judgment about therapy and convey sense to co-therapists. It also helps convey to the patient/client what can be done. It is not meant to pass judgment on the patient, to stigmatise, much less ostracise.

6. Diagnostic variations are seen in all branches of medicine, not only in psychiatry.

7. ECT should be a choice. So should surgery. But when one is so severely depressed that one is actively suicidal, when delusions can make one suicidal/homicidal/violently assaultive to others or self, should it still be a choice? Should emergency surgery be a choice?

8. I am sure there are methods and methods of help. Self help groups, relationships, all have the potential to help and even heal. Psychiatry would want to collaborate with all means to help the recovery of patients/clients. The whole Mental Health Movement is geared to first of all bringing about mental health, and also treating the sicknesses that befall some of us. Psychiatry is an integral part of the Mental Health Movement.

Warm regards.

Ajai
22 May 2006

..................................................

Beckie Child wrote:

On 5/20/06, Ajai Singh wrote:
Psychiatry and Its Critics

There is something about Psychiatry that attracts the most vehement protests. No other branch of medicine sees such vilification heaped on it.

hmm...would that have anything to do with the dynamics of power inherent in psychiatry? What other condition besides a psychiatric condition can you be incarcerated against your will if you choose not to have treatment?

When you look at so called treatments over the history of psychiatry--whether it's insulin shock therapy, hydrotherapy, electroschock therapy, etc. many people's experiences of those therapies were experienced as torture. Not to mention what medications can do to people.

I'm not saying that psychiatry hasn't helped some people, but for many of the people finding the help that works for them hasn't been easy--and some people never find help that works for them.

When psychiatrists tell people that just because they have a psychiatric condition (even if it is acute and or long-term), that they can never work, go to school, get married, have a family, or otherwise kill their dreams and hopes, and that they will be sick for the rest of their lives, do you have any idea how demoralizing that is--what kind of iatrogenic wounds that produces? Not to mention the anger that creates?

I've heard and seen a lot of talk about reducing stigma--yet most of the stigma and discrimination I've experienced has been at the hands of psychiatry and the mental health system, and I know that I am not alone in this experience.

We haven't even mentioned the diagnostic process. You can go to different psychiatrists with the same symptoms and come out with vastly different diagnoses. And then all of those diagnoses trail you for the rest of your life. Not to mention that if the help they are offering doesn't work for you, then you get labeled and diagnosed with a personality disorder--rather than saying we don't know how to help you. When people aren't reacting to the treatment in the way that is expected, many people get told they are failing the program--not that the program failed them, and then they get another label.

It's not that I'm opposed to ECT--I just think that ECT should be a choice. It is not my psychiatrist's or any other psychiatrist's place to tell me that the memory impairments are more desired than severe depression. That's a value judgment--and I resent it when other people make value judgments about my life and they aren't living my life.

I don't know where you've been listening--but I've heard many people who get well talk about what has helped them. Most of them have gone through an extensive amount of things that weren't helpful, delayed their recovery, etc. Some talk about how medication changed their life, a number of people who've gotten better talk about the relationships of helping providers that helped them to heal and get better.


beckie

.............................
22 May 2006

Posted by psychiatrist400080 at 2:09 AM EDT

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Music
Mood:  lyrical

What Music Means To Me

Well, one can go on and on about how music is divine, a means to tune in to the consciousness within or to establish communion with one’s inner being, to listen to the harmony of the spheres, to experience calm and bliss, to enjoy with like minded friends, to converse with the great masters of yore, to establish a rhythm of life, to express one’s creativity and give vent to one’s artistic urges. And one would not be far from some profound truths if one does.

My concerns are somewhat more mundane here.

For me, music arouses a myriad of memories. Some of the most tender, and most fulfilling. Besides being important landmarks in whatever little variety that adorns my musical life. I shall list here two formative, defining, influences. One is of my father, the second of my guru. To tune in to them, to actualize the nuances of their performance and reaffirm their ideas about music is the greatest activity that I can possibly perform. And the most fulfilling. That, in essence, is what music means to me.

Here, I shall talk of the first influence.

The First Influence, Father

My earliest memories of music are of my father’s singing. A maverick of sorts, a man of modest means, who would go out of his way to help others, who enjoyed the good life but had a peculiar contempt for the obsession with money and wealth he found around him. He would get into a mood and sing in his rich baritone voice for hours on end, to no one in particular. He was a great fan of the legendary K.L. Sehgal, and contemporaries Pankaj Mullick and K.C. Dey, and a great appreciator of Talat Mehmood, and later on of M. Rafi too. He was one who voiced his opinion in the 60s that he preferred Asha Bhonsale’s voice to Lataji’s because he found her more versatile. This, at a time when Lataji ruled the musical world, and the only person who ever gave a chance to Ashaji to sing was the great O.P.Nayyar. He enjoyed singing new numbers of Ashaji in his rich baritone, almost like Sehgal singing Ashaji’s songs. And while we smiled and felt embarrassed, he carried on regardless. The voice still rings in my ear, the song of a man who sang from the heart, whose voice emoted every word that escaped his lips.

He also had a great sense of poetry. He went to great lengths to explain the subtleties and nuances of the lyrics of a song, and got into the skin of the poet to understand what the poetry conveyed. The first poetry he taught me was a lovely poem by the great English poet Henry Longfellow, which I have by heart:

Lives of great men all remind us
We can make our lives sublime
And departing, leave behind us
Footprints on the sands of time.

Footprints that perhaps another
Sailing o’er life’s solemn main
A forlorn, or ship wrecked brother
Seeing, shall take heart again.

He explained the meaning of the lovely metaphor, ‘Footprints on the sands of time’. He explained what ‘o’er’ meant, that it was a poet’s license for the word ‘over’, so as to help in the recitation. What the word ‘main’ meant (it means the sea). How can life be a ‘solemn main’ for some. Why the ‘forlorn or ship wrecked brother’ sentence. How, when the footprints on the sands are seen, it gives courage to the despondent to take heart and carry on without losing hope. And how, finally, and this was the most important lesson he taught, we should all try to lead our life so that we leave our impress, howsoever small, ‘on the sands of time’.

To the tiny, impressionable mind, it was an ennobling experience to hear him expound so effortlessly on the meaning of the poetry. He did not have to persuade me very hard to learn it by heart. Having understood its profound meaning, I was myself motivated to learn it.

The incident that follows is noteworthy. I must be in the VII or VIII standard. Once the teacher had not come for her class. One of the office staff, a learned senior who had a very good handwriting, came to engage the class. He asked the students to come to the black board and write anything, in the best hand possible. The usual hesitation amongst students was noticeable. Friends egged me on. I just went to the black board, took the chalk piece, and wrote out Longfellow’s poetry quoted above. Just like that. The class gaped in wonder, but what I still remember is the open mouthed look of wonder and awe on the wise man’s face. He was nonplussed. Gathering his wits, he asked almost in a whisper, ‘Who taught you this?’ And I was proud to say, ‘My father, sir.’ The look of admiration on his face for the man who could teach such a lovely poetry to his son at so tender an age, a poetry not in any syllabus and not for any exam but just for the love of poetry itself, that look is still etched in my mind as one of the fondest memories of my childhood.

What applied to English poetry was equally applicable to his music. He could never sing a song just for the music, or for cheap thrills. The meaning had to be heart touching. Then the music had to be soul stirring too. And, finally, the rendition by the singer had to convey the sense of the poetry and the mood of the music. Any disparity, and it would jar him, which he was quick to realize, and point out.

The First Song, of Childhood, and the Farewell Number

For me, the greatest moment in my life was the first Hindi song he taught me, which I, like so many youngsters, was so very reluctant to learn. When a tiny tot. He sat me one day and said, ‘I will teach you a song of childhood’. And proceeded to teach me:

‘O, bachpan ke din bhula na dena…’

Just remembering him sing in his baritone gets the eyes to cloud over even today. In grateful thanks for the great childhood he gave me, and the immortal gift of aesthetics and music appreciation that has been an enduring aspect of my personality.

I had never seen him refer to any book for the words of a song. We did not even have a radio at home. I just wondered how he mastered the words so well. And then I knew. The true appreciator of poetry that he was, the words left an indelible impression on his heart. For it to flow from there to his tongue was, therefore, effortless.

I heard him sing for hours, into the wee hours of the morning at times, without any accompaniment, to no one, for no applause, simply because music welled up in him. He often urged me to sing with him but I was like any typical shy son, imbibing the music, but not adding my voice to his.

There was a traditional farewell function as we were to leave school. College beckoned, and all the excitement of being a young man, and being no longer treated as a mere kid. That was the time he suggested a song. He did not force it on me but said, see if you would like to sing this song. This was the second song he taught the shy reluctant teenager. It was a long forgotten melody even in his time, ‘Ruk na sako to jao, tum jao...’ It goes like this:

Ruk na sako to jaao, tum jaao (Repeat)

Ek magar hum sabki hai fariyaad
Kabhi hamari bhi kar lena yaad (Repeat both lines)
Hum to tumhe na bhool sakenge (Repeat)
Tum chahe bisarao, tum jaao…
Ruk na sako to jao, tum jao….

Jane kab phir mile purana saathi
Jane kab phir mile prem ki paati (Repeat both lines)
Aj bichadne se pahele tum (Repeat)
Ek bar muskao, tum jao…
Ruk na sako to jao, tum jao…

He explained that ‘paati’ meant a letter; it was a poetic license for ‘patra’, and what poetic license meant. He also explained that the original singer said, ‘bichudne’ rather than ‘bichadne’. But the latter sounds better, so it should be pronounced that way, rather than like the original. Even when he sang the Sehgal numbers, he never copied his style and his intense nasal twang. His pronounciation of words was always impeccable. This was an important lesson to learn, for often later singers ape even the mistakes of the original singer, something he strongly disapproved of.

I remember the still silence in my class room in the 11th Standard when I sang this song during the farewell function. The class mates were stunned. After I finished, there was silence for a while, and then the applause of friends. I came to know later that our School Principal had tears in her eyes as I sang.

This was a number by K.C.Dey, the illustrious uncle of the great Manna Dey. It was not a very popular song, ever. But that was not important for him. His likes were never dictated by what was popular. It was solely by what appealed to his heart. And he justified singing as an art where, if the song does not tug at your heart, you have no business singing it.

He had a great fascination for melodious sad songs. He sang the beautiful Talat song to explain why he liked them:

Hain sabse madhur woh geet jinhe
Hum dard ke sur mein gaate hain (Repeat)
Jab had se ghuzar jaati hai khushi
Aansoo bhi chalak ke aate hain (Repeat)

And the Shelley poetry on the Skylark, which said something similar:

Our sweetest songs are those that tell of saddest thoughts.

For the young me that was an important lesson to learn. It helped shape my likes and dislikes at that impressionable age. At a time when the young were busy thinking of cheap thrills and seeking joy through singing only foot tapping numbers, I learnt that pain, separation, and unhappiness could be equally soothing if expressed in music and song. A conviction, which remains with me till date. Not that I abhor the joyous and mirthful, but the depth and intensity that pathos can convey cannot be ever matched by any mirth, howsoever lilting.


Urdu Diction, and Subtleties of the Language

The correct pronunciation of Urdu words, in which most filmi ghazals and other good songs of yester years were written, was a sine qua non of Hindi film singing for him. So that I could know the language, he requested a polished Muslim gentleman who used to visit our house almost every Sunday to teach me the language. This young man had been helped by my daddy to complete his education. He came from a very poor family but wanted to study further. Somehow my daddy came to know of him, and helped him all through so he settled down to a reasonable job. His logic was, well, we Hindus complain that Muslims are in general a violent lot; many are uneducated, and live in dirt and filth. But what do we do to uplift them? So he did his bit for this boy, who was ever grateful to him. The young man, after his marriage, came home one day and sought his blessings. He spoke impeccable Urdu. The Dilip Kumar and Naushad style of Urdu. My daddy welcomed him and invited him to come over whenever he desired. Sundays were the days this young man came, and we all ate special mutton dishes cooked exclusively by my daddy.

One day, the young man said, ‘ You have done so much for me. What can I do in return?’ My daddy was nonplussed. He was not used to taking any return of favours from anyone. He only knew how to give, not to take. He said something like that’s ok, I am so happy you thought of doing something, etc. But the young man was adamant. So he thought for some time and then said, ‘Ok, if you are so insistent, do this. My son is bright in studies. But I want him to sing too. And unless one knows good Urdu, one cannot sing. Will you teach him Urdu?’

He was more than willing. Books were bought and my first lessons in Urdu were started. The correct pronunciations of guttural words, which are a characteristic of the beautiful language, I learnt from this patient gentleman. How ‘saghar’ is not ‘sagar’, how ‘qayamat’ is not ‘kayamat’, how ‘gham’ is not ‘gum’, how ‘phool’ is not ‘fool’, when it is ‘afsana’ and when is it ‘phir’ and not ‘fir’, how it is ‘mujhe’ and never ‘muzhe’, how it is ‘nazaaqat’ and not ‘hajaakat’ – all these subtleties of the language I was fortunate to learn at an early age. And I owe a deep debt of gratitude to both these souls, my daddy for teaching me the nuances of singing, and his protege for introducing me to the delicacies of the beautiful language that Urdu is.

(To be concluded)


Ajai
12 May 2006

Sargam May 2006
The President Speaks His Mind

Something to Ponder
Mood:  sharp

Psychiatry and Its Critics

There is something about Psychiatry that attracts the most vehement protests. No other branch of medicine sees such vilification heaped on it.

And yet, those who are in the system know they are doing the best thing possible for their patients/clients. And it is the one system that is most open in discussing what needs to be improved about it. While most other systems of medicine would dismiss most protests with a shrug, psychiatry is one branch that considers ethical issues, sometimes almost to the point of becoming paralysed for action.

Every psychiatrist knows the benefits of ECT in selected patients. Every psychiatrist knows how psychopharmacology has revolutionised patient care. The grateful patient who has been saved from suicide, who has got rid of his delusions/ anxieties/phobias to lead a productive life is so very well known in psychiatric practice. The whole problem is patients who get well do not talk. They go on with leading their lives, and often want to hide their psychiatric history for fear of stigma.

It’s a rare instance that a man would speak as eloquently about his psychosis and how he got rid of it, as he would about his recent bypass, or appendectomy, or whatever.

It’s not that treatment failures do not occur in other branches. But they are accepted as part of the process. No one wants them. But no one dies a thousand deaths over them. However, in psychiatry, its opponents trumpet every treatment failure so loud as to scare so many more who would greatly benefit by it.

What do we do? Nothing, maybe. Or go on doing one’s bit to the best of one’s ability. And think of the grateful faces of those helped. And wait for saner counsel to prevail in the less charitably disposed.

Maybe it is also time for those who have been helped by psychiatry to speak up.


Ajai
21 May 2006

A poem

phlegmatic

when
last
i
coughed
up
the
obnoxious
phlegm
and
peered
at
the
purulence
i
reluctantly
recognized
myself
and
swallowed
the
insult


Ajai
3 April 2006

Simple and Complex


There is a great beauty in the simple, if only we may stop being complex.

Time, And Occasion, To Redeem Yourself, If You Will

This is what I wrote to the CMA President about the CAMJ:

Dear Dr. Collins-Nakai,

I write this to appreciate some of the effort you have put in vis-a-vis the CAMJ. Bringing in a Chief Justice for an Editorial Governance Plan, appointing an Interim Editor and Editor Emeritus, assuring editorial independence to the incoming editor, being ready to carry out changes in the JOC, are all commendable executive decisions. In the circumstances in which you are placed, and with all the strong pressures on you, I must acknowledge you are trying to put in a brave effort.

I understand the difficult predicament in which you are placed today. While you must carry out damage control, you must also walk the tight rope of protecting Association interests, and also ensure the CAMJ’s credibility as a biomedical journal does not suffer. Difficult situations to shoulder for anyone, howsoever efficient one may be.

However, I feel there is a way out. When the issue becomes very convoluted, and the knots very tangled, often a simple tug does the trick. The solution is at hand shaking distance, if one is ready to remove the blindfold which subsidiary concerns impose upon us. Archimedes tried his intellectual might to resolve the issue till lying in the bath, the ‘eureka’ solution came flooding to him as an insight. Similar will be your condition if you allow yourself the luxury of quiet introspection. And it’s not a luxury, really.

I wish to share that with you. The straight and obvious solution, which often eludes us because it appears uncomfortable to take.

What Need Be Done

Just go ahead and reinstate the sacked editors. Admit it was a mistake. You, as Association caretaker, and CMA Holdings were being embarrassed by all the writings in the CAMJ, true. But you still respect its editorial independence, will stand by its right to publish what it considers the truth if based on evidence and for patient welfare, the only two real pillars of biomedicine. You will encourage it to go ahead and become one of the best biomedical journals in the world. The editor who could make it one of the top five has the potential, and steam, left to make it rise even further. Repose full confidence in him, speak courageously to your Association colleagues and office-bearers that it be done, and be ready to face the consequences of such a bold, but correct, decision.

It is not often that destiny offers such a great opportunity to anyone to redeem herself. It has offered itself to you. Do not let go of it. I know it is not an easy decision to take. But then this is not an ordinary situation to encounter too. And this is not an ordinary opportunity thrown at you in the form of a challenge.

With one stroke, you will have quietened the entire furore. With one action you will have rewritten the entire course of biomedical publication.
We all know how inconvenient editors have been sacked before at JAMA and NEJM. We all know it was wrong, but no one had the nerve to right it. So people accepted, and most have got cynical this is the only way things function. I see this as a great opportunity for you to change it all.

Let’s forget the smaller interests. Let’s forget the clever advice that lawyers and smart alecks will offer you. They are not ill intentioned, but lack the vision that concentrating on the larger interests can lead you to. For at stake is a possible paradigm shift in biomedical publication. If once one upright editor is reinstated, and given full powers to go ahead, it will be written in golden letters in the history of such publications.

If you have the will, and nerve, to take it.

Not taking such a decision is easy. Taking such a decision, which you know your conscience propels you to but extraneous considerations may prevent you from, will be the true test of character that history, and posterity, will judge you by.

If you decide to take it, my faith in justice and fair play will be redeemed. If you decide not to, my conviction that ideals and principles are just empty phrases mouthed by us all to impress audiences will be confirmed.

You have an option. To redeem the noble, or confirm the commonplace.

If you redeem, I have no doubt the whole medical word will rise and salute your courageous decision. If you do not, well, it will be another pedestrian President who went the expedient way in another medical association. All too familiar a scenario.

Destiny Beckons

Destiny beckons. But it won’t offer many opportunities to make your impress ‘on the sands of time’.

This may be your chance.

Please ponder over what I have written when you are very calm, seek counsel over it from your real well wishers (who may be very few, really), and then take a bold decision.

I have known people who are bold but not right. I have also known people who are right but not bold. You have the singular opportunity to be both.

I pray you don’t let go of it.

In so doing, not only will you redeem yourself, you will redeem all that is good and noble in the field of medicine whose ideals have been knocked around, true, but are the only things which sustain it beyond the trammels of hypocrisy and expediency.

Will you rise to the occasion? From the way you have conducted yourself till now, I have a strong feeling you just may.



Ajai
22 Mar 2006

Posted to the Globe and Mail as E-letter


http://www.theglobeandmail.com/servlet/story/RTGAM.20060317.wcmaj0317/CommentStory/#comment145439

Ajai Singh from Mumbai, India writes:

The fifteen editorial board members who have resigned have shown a rare act of courage. They have risked their academic future for the welfare of Canadian medicine in particular and biomedical publication in general.

Upright editors have been sacked in medical journals before, like at JAMA and NEJM. It is for the first time that such a strong counter offensive by members of the editorial board has been launched.

If they succeed, and I earnestly hope they do, it will be written in golden letters in the history of biomedical publication. They need all the support that other publications, and the people at large, can give.

I hope questions are raised in the Canadian Parliament on this issue too.

And I hope guidelines are laid whereby upright Editors cannot be summarily sacked by high handed employers.

Posted 20/03/06 at 10:41 AM EST

Ajai
21 Mar 2006

CMAJ Continued
Why only damage control, why not redeem yourself, CMA?

Damage control exercises by the CMA President are fine, and worth appreciating, given the circumstances in which she is placed. Promises of editorial independence, and reassurances to that effect are laudatory. Changes in the Journal Oversight committee, or bringing in an interim Editor to manage the show, appointing a judge to head a committee on editorial reforms, and appointing an Editor Emeritus, who commands respect having been an earlier editor at CAMJ, and is the founder of WAME (to hopefully quieten any criticism there), are understandable moves by a concerned executive wanting to move on and prevent further damage.

The crucial point, however, still remains. There is no mention of reinstatement of the sacked editors. Why can that important decision not be taken, or a justified explanation for sacking the editors not be given? Because, all such exercises will not cut much ice, for the double standard is evident. While promising editorial freedom, it is precisely that editorial freedom which has been trampled upon in the sacking of the CAMJ editors. While asking people to move on and have trust in the bright future of the CAMJ, precisely those people who were ensuring it have been summarily sacked. With not a word of explanation.

Why can the executive not be bold enough to rectify a wrong decision taken? Or explain how its action is right? That is the crux of the issue, and no amount of dilly-dallying, or skirting the issue, is going to help.

The CMA is at an important cross road. If it decides to reinstate the editors, it will suddenly rise many fold in the eyes of the biomedical world. Contrary to what many may feel, or even they themselves may believe. If it decides to stick to its stand, it will be proved as pedestrian as many other Association heads and office bearers earlier have been proved to be.

The crucial point is whether the CMA, its president, and office bearers realize the great chance this event has given them to redeem themselves, and rise in the eyes of the whole medical community.

No one, until today, has had the nerve to take such a courageous stand.

I hope, and pray, they seize this opportunity.

Ajai
21 Mar 2006

15 Members of CAMJ Editorial Board Resign
WAME POSTING

Dear Colleagues,

Just read that 15 members of the editorial board of CAMJ have resigned:

http://www.cmaj.ca/misc/press/cmaj_release_mar16.pdf

Any more stimulus needed to read the:

PETITION ON EDITORIAL AUTONOMY AT THE CMAJ
at:

http://www.chaps.ucalgary.ca/cmaj.htm

and sign it (its still possible) at:

http://www.questionpro.com/akira/TakeSurvey?id=370917

Any more stimulus needed to come out in their support?

And write about it in your own journals?

Come on, guys, let's have a heart.

Ajai
19 March 2006

What WAME and ICMJE Can Do: Values Backed By Power

The WAME and ICMJE are excellent bodies for they embody what is right and proper in the world of biomedicine. However, as I see it today (especially in the wake of the CAMJ episode), they lack the teeth to implement their recommendations.

Just look at the others.

1. Medical Associations: Medical Associations have committed office bearers who have to cater to the constituency of their members. They have a finger on their pulse, and will go ahead and do what is in their welfare, oblivious of whether it is right or not. Members of such Associations too are very aware of their rights, and see to it they are well protected by their office bearers.

2. Pharmacists: Pharmacists have equally strong Associations, which will go to any extent to protect their members’ interests. Their economic power, ability to coerce drug manufacturers, and vantage position as medicine dispensers makes them formidable adversaries to have.

3. Manufacturers: Drug manufacturers exercise their considerable clout by the huge drug industry they run and the researches they support, for which most researchers and departments, even Medical Associations, are beholden to them.

4. Patients: Patients now have numerous advocacy bodies and activist groups to support them. With wide information available on the net, and legal advice ready to seize the opportunity, patients appear reasonably well protected today. The number of lawsuits being won by them in recent years should be ample proof of this.

What does this leave out? Only two. Editors and editorial board members, and medical researchers. Let us look at editors here, for WAME represents them.

Editors have at least two bodies which represent them. WAME and ICMJE. But where is the power to implement what they recommend? We may say their power is moral, of the Right, of the stature of their members who toil to lay down guidelines and procedures. But when it comes to the crunch, when it come to implementing what they recommend, what powers do they have to pull up erring parties aside from writing letters and petitions? If someone decides to ignore what they say, what power do they have to implement what they, and we all, know, is right?

I say this not to embarrass our office bearers. I am just voicing my anguish, which must be that of many others too, including, I guess, of the office bearers of WAME and ICMJE.

I think both these organizations have a larger role to play, apart from their role to refine research and offer guidelines for editors and researchers. This role they can decide to ignore, but will do so only at their own peril.

This is the activist role. When we know the forces against which we work are so strong and committed to their welfare, irrespective of what is right, how can we be content with only laying down guidelines and writing petitions?

Values, by themselves, are only words. If not backed by the power to implement them, they come to naught. And will be trampled upon in every crunch situation. As has happened with the present CMAJ episode, and happened earlier with JAMA and NEJM.

So what do we do?

What Can WAME and ICMJE do?

Both these bodies are the conscience of biomedical research. They must give clear-cut calls to their members. When they find their members being shortchanged, they must rise in their favour.

What do we mean by clear-cut calls?

1. First of all, take an unequivocal stand. If injustice is done, it must be clearly spelt out it is so. And ask for revoking wrong decisions. Also helping those who are at the receiving end of brash decisions by appropriate legal counsel and possible placements, ad hoc or permanent.

2. Call upon members to resist this injustice by expressing solidarity with the aggrieved. Members must be exhorted to write editorials and welcome other correspondence which sheds light on such episodes. Both sides need be represented of course, but a goal-directedness in such writing is necessary nevertheless.

3. Insist on members reporting transgressions of editorial independence to these bodies, and helping them resist it in their respective organizations. Otherwise, token espousal of editorial independence is all we will ever get. And its perpetual flouting by the unscrupulous is what we should perennially expect.

4. Adopt method of peaceful noncooperation with the aggressor. Associations fire upright editors when they become inconvenient. Pharmacists pressurize Associations to protect their interests. Manufacturers pressurize researchers and institutions by their money power. Why should not WAME and ICMJE pressurize unscrupulous employers by asking for peaceful noncooperation with their efforts by its members? How? By:

i. Not taking up editorial positions in such journals.
ii. Not reviewing papers for such journals.
iii. Not writing for such journals.
iv. Exhorting those who work for such journals, so to save them in the interim, not to do so. For their intentions are honourable, but misdirected at such times. And likely to blunt the offensive.
v. While we recognize the right of employers to hire or fire, they must recognize our right not to allow biomedical research to be directed by the whim and fancy of highhanded employers.

5. Lay down guidelines for editors and employers. Editors need to be on par with the Association Secretary, or Executive Vice-President, whatever, and report to the Executive Body of the Association, and finally to the Annual General Body, rather than to any individual. They can be impeached, even fired, but only after a statutory body of the Association gives them a full hearing.



Signing off, For Now

The promise such problems offer is tremendous. Provided we are ready to rise to them.

ICMJE and WAME have an excellent opportunity to prove they are not, and never will be, paper tigers.

It is only when they realize that the values they stand for can be backed by the power they have, but is still untapped: the strength of their members, and the clear-cut decisions of their office bearers.

I have great hope in the future of these organizations, and request its office bearers to help actualize this hope and the legitimate wish of its members.

Ajai
17 March 2006