Time the healer

They say "time heals all wounds". Does it?

It certainly heals a lot of wounds, sometimes very efficiently. Grief, anger, hate etc gradually subside and may eventually disappear. At other times scars are left. You stop hating somebody but keep avoiding him. Your grief disappears only to be aroused when memories are brought back.

Problems may be solved by the mere passage of time. A bad neighbour may decide to move away for his own reasons. Financial hardship may be solved by unexpected inheritance or a job coming into your way without you planning for it. The ancient Chinese proverb: "If you sit by the river long enough, the body of your enemy will float by" may sometimes be true but certainly not all the time and not even most of the time.

In spite of the immense healing power of time, it certainly does not heal all wounds. As someone commented sarcastically, "if time heals all wounds, why the hell am I paying for health insurance?" Waiting is prudent in some situations, but action may be needed to solve a problem, improve relations between opponents, ameliorate severe grief or intense anxiety. Actions may be effective, may not be and may even worsen situations. When to wait and when and how to act needs a lot of wisdom which not many people are endowed with.

In medicine:

Many illnesses recover spontaneously. Infections like influenza, sore threat, various diarrhoeas may recover with time merely as a result of the natural defence of the body. Many obscure symptoms come and go without being diagnosed and without treatment.

Diagnosis of an obscure illness may become more obvious with the passage of time hence the well known saying by physicians: "wait and see". Acting too early or interfering too much may bring unnecessary suffering and may itself produce complications. I remember one of my teachers saying during a clinical round: Patients do better the less you interfere with them! His saying was not intended to mean exactly what it says, but rather to stress that decisions to interfere should not be taken lightly and should be restricted to what is necessary and be on a good ground.

On the other hand waiting for time to cure an illness or to help in making a diagnosis carries the risk of development of complications or making a diagnosis too late for treatment to be effective. Decision to wait or to act depends, like all decisions, on weighing the benefits against the risks. This is at the core of good clinical judgment.

لا تصدق كل ما ترى

"لا تصدق كل ما تسمع" قول مألوف. "لا تصدق كل ما ترى" ليس قولا مألوفا فقد أعتاد أكثرالناس أن يحصروا شكهم على السمع ويعتبروا الرؤيا دليلا قاطعا يقولون: رأيت ذلك رأي العين أو رأيته بأم عيني ويقصدون بها عادة رؤيا الواقع التي كانت هي الغالبة. أما الان فان كثيرا من الناس يقضون ساعات من يومهم يحدقون في شاشات التلفزيون والكومبيوتر يشاهدون كما هائلا من الصور وافلام الفديو تنقلها الانترنت والفضائيات ويسهل بالتقنيات الحديثة التلاعب بها وتشويه حقائقها وتضمينها أمورا كاذبة لا وجود لها. كثيرا ما نرى في هذه الافلام أمورا يصعب على العاقل تصديقها يدعي عارضوها انها حقائق. يعمل ذلك احيانا لغايات بريئة واحيانا اكثر لغايات سيئة. علينا الان ان نقول ونكرر: لا تصدق كل ما تسمع ولا تصدق كل ما ترى.

Active passivism

In dealing with patients doctors decide on certain management actions when they judge that the probable benefits outweigh the probable harms. The same is true in life in general. However in some situations the only available course of action that promises significant benefits carries also significant risks of harm that may exceed the benefits. Pure objective thinking may favor avoidance of the action creating a difficult situation in the absence of a good alternative. One is left with the much less satisfactory option of trying to ameliorate symptoms, explain and support psychologically and hope for the best.

A subjective factor is sometimes added to the risk benefit equation. That is the tendency in all of us to do something significant to help. Consequently an action may be attempted (a drug is given or an operation is advised) to satisfy this impulse in spite of the improper balance between possible benefits and harms.

Resisting this tendency in such a situation is not easy and makes one feel and appear passive. This resistance is an active process though it results in an apparently passive stance. I like to call it active passivism!

The same thing occurs outside the field of medicine, in general life. Sometimes you do something not because you are convinced it is the proper thing to do but because you feel you must do something significant and obvious and that other people expect that from you. Abstaining from this is active passivism.

A right answer to a wrong question

“Judge a man by his questions rather than by his answers.” ―Voltaire

“The scientist is not a person who gives the right answers; he's one who asks the right questions.” ―Claude Levi-Strauss.

When I was a medical student, we started studying internal medicine in the fourth college year. This changed later and students started to learn their internal medicine in the third year. A meeting of medical teachers of the various Iraqi medical colleges was arranged one day in Baghdadto discuss which of the two ways is better and whether we should go back to starting in the fourth year. The discussion concentrated on the training of fourth year students and whether having studied medicine in their third year has benefited them. In other words the assembling teachers were trying to answer the question: Are fourth year students better in internal medicine if they have started studying the subject in their third year? The meeting was convened early during the academic year. All attendants agreed that the level of fourth year students is better when they have studied medicine in their third year; an obvious finding that should go without saying! Students who had some training in the previous year should be better than those who are starting afresh. The teachers went on from this to conclude that it is better to start training of internal medicine in the third year. Nobody tried to answer the right question: Are students who start their training in the third year better than those who start in the fourth when they graduate or at least at the end of the fourth year? It is quite possible that during the fourth year (or the years after) students starting in the fourth can catch up with (or even pass) those starting in the third year especially if they have more hours during the fourth year as is usually the case if training starts in the fourth. I pointed out that the meeting was addressing the wrong question but no body seemed to care or to see the difference!

I am not claiming that starting in the fourth year is better than starting in the third or vice versa. The answer to this is to be left to specialists in medical education and should be built on properly designed studies. I only wanted to say that asking the right questionis more important than knowing the right answer of a wrong question.

BASICS OF ACID BASE BALANCE 1

(To our junior colleagues and students)

كاتب عدل مرة أخرى

أذا كنت عزيزي القارئ قد قرأت المقالة السابقة المعنونة "وكالة" فسوف تفهم ما أقول بصورة أوضح وأعمق. أحتجت الى كاتب عدل مرة اخرى ولكني كنت هذه المرة في مدينة اخرى في بلد اخر. دخلت على الانترنت من حاسوبي المحمول في غرفتي وطلبت اسماء كتاب عدول في منطقتي. أجابت الانترنت بعدد من الاسماء مع ارقام هواتفهم وعناوينهم وخارطة اماكنهم. أخترت احد القريبين من سكني وادخلت عنوانه على موقع الانترنت لأحدى وسائط النقل العام فشرح لي الموقع كيفية الوصول اليه: رقم الحافلة ومن اين استقلها واوقات وصولها والفترة التي تستغرقها.. ألخ. ذهبت الى مكتب الكاتب العدل فأستقبلني السكرتير وكنت محظوظا حيث لم يكن لدى الكاتب العدل أحد في ذلك الوقت فدخلت عليه. ألقيت التحية وجلست فرحب بي وسألني بعض الاسئلة عن بلدي من باب المجاملة ثم سأل عن سبب مجيئي فأخبرته أن عندي تعهدا ينبغي أن أوقع عليه أمام كاتب عدل ويصادق عليه. سلمته التعهد فقرأه ثم طلب مني بعد ان تأكد من هويتي أن أوقع في المكان المحدد لي وأخذه وكتب اسمه في المكان المحدد له ووقع وختمه بالختمين الخاصين به وسلمه الي. سلمته المبلغ المطلوب (ولكي أكون عادلا ومتوازنا فان المبلغ اكثر بكثير من المبلغ الرمزي الذي ندفعه في دوائر الكتاب العدول في بلدي). شكرني وشكرته وانصرفت عائدا الى بيتي. لم أجد في الطريق بائع رقي ولم أكن في حاجة اليه!! ولكنني تذكرت معاناة الوكالة التي عملتها عند كاتب عدل في بلدي فابتسمت وقلت لا حول ولا قوة الا بالله.

Measuring blood pressure

(To our junior colleagues and students) 

1. Patient should be comfortable, lying or sitting with the arm supported. Actively holding the arm up by the patient raises blood pressure. The patient should avoid smoking or drinking coffee or tea shortly before measurement as this may raise blood pressure.

2. Mercury sphygmomanometer is reliable. Aneroid sphygmomanometer is reliable if calibrated against a mercury one.

3.   Apply the cuff neatly around the upper arm well above the cubital fossa (to leave a place for the stethoscope). Any of the two arms may be used. However if the pressure is measured for the first time, especially in an elderly patient, it is advisable to measure it in both arms and consider the higher one as the true representation of the patient’s blood pressure. It is not uncommon, especially in elderly people, to get a lower reading in one arm as a result of atherosclerosis in the arteries supplying that arm. Subsequent measurements in such a patient should use the arm with the higher pressure.

4. The arm should be at the same level as the heart. The pressure inside the brachial artery decreases when the arm is raised and increases when it is lowered. The position of the sphygmomanometer is not important because the cuff and the tubing are filled with air and the pressure in a container filled with gas (unlike liquid) is the same at any point regardless of its position.

5. If you find (more often in women) that rolling up the arm clothing will constrict the upper arm and it is not practical to ask the patient to undress, then it is better to apply the cuff over the clothing provided it is not thick. Thin clothing does not significantly impair transmission of pressure from the cuff to the arm or transmission of sound from the arm to the stethoscope.⁽¹⁾

6.  It is advisable to develop the habit of measuring blood pressure by palpation first. It has the following advantages:

a)      It gives an idea about the systolic pressure so that when you take it by auscultation you only raise the pressure to a little above the systolic before starting to deflate. In this way you avoid raising it too high which is painful and may result in a reflex rise of blood pressure.

b)      It avoids the possibility of raising the pressure in the cuff to a point in the silent gap (in patients who have a silent gap) and starting deflation. You will then wrongly consider the reappearance of sounds (phase three Korotkoff sound) as the systolic pressure.

c)       It makes you check the pressure twice which is advisable. The second measurement has been found to be generally lower than the first and more representative of the real.

7.     Apply the stethoscope over the brachial artery in the cubital fossa and avoid inserting it between the cuff and the arm. The hard structure of the stethoscope may interfere with the even distribution of pressure on various points of the arm circumference.

8.  Deflation of the cuff should be slow to give time for the mercury column or the dial pointer to change position as the pressure drops. Too rapid deflation gives a higher reading as a result of inertia of the mercury or the pointer causing it to lag behind the decreasing pressure inside the cuff.

9. Diastolic blood pressure (as measured intra arterially) falls between phase four (sudden muffling) and phase five (complete disappearance) of Korotkoff sounds but nearer the latter. So it is better to take disappearance of sounds as the diastolic pressure except in the occasional case when the sounds persist down to a very low level or zero.

(1) Hovsrpian R.,  Al-Haddad M.,  Abdulla K., Comparison of blood pressure measurements in bare arm, clothed arm and forearm,  J. Fac. Med. Baghdad, 1996, 38, 221-224.

Confidence Interval

(To our junior colleagues and students)

Confidence interval is a statistical term frequently encountered in papers describing various kinds of medical research. It is one of the terms that postgraduate medical students need to know.

The following examples serve to explain it.

If you want to find the mean weight of a group of 30 men, you measure the weight of each one, add the figures and divide by 30. The result is the mean weight of the group.

If you want to find the mean body weight of men residents of a big city, it is not practical to do the same because of the large number involved. Statisticians get around this by taking a random sample of the men in question. They calculate the mean weight of the men in the sample and consider it a satisfactory representation of the required mean of the total. They may take e.g. a thousand men, chosen randomly from various districts of the city, measure the weight of each and then add and divide to find the mean. They consider this representative of the mean body weight of the men of that city. Now imagine yourself to be the person who requested that mean because you wanted to assess the nutrition status of the people in the city and you asked a statistician to do it for you. Imagine also that the mean weight of the thousand men was 60 kg. You may then have the following dialogue with the statistician:

·         Are you sure the figure you gave me is exactly the same as the figure you would have obtained had you taken all the men in the city?

·         No, most probably it is not, but it is very near that figure and is sufficient for your purpose.

·         How near is it? How much is the difference?

·       I cannot tell you the exact difference because I do not know the true figure of all the men in the city. We statisticians usually deal with probabilities. I can tell you the probability of the difference being of a certain magnitude. I can work out from the data of the thousand men a figure we call the Standard Error (SE). In fact I have already done that and found the standard error of the mean of the sample to be 2. We know from statistics laws and rules that the probability of the difference being not more than one standard error (1SE) is approximately 67% and being not more than 2SE approximately 95%. In other words I can tell you that I am practically 95% confident that the true figure of the mean weight of all men in the city is within 2SE above and below the figure of 60 i.e. between 56 and 64 kg. That is what I mean when I say the mean body weight of the sample of men is 60 kg. and its 95% Confidence Interval (CI) is 56 - 64.

The 95% probability (or confidence) becomes approximately 67% if you choose 1SE above and below the mean as the limits of your confidence interval and approximately 99% if you choose 2.5 SE. The 95% (i.e. mean ± 2SE) is commonly used and if the percentage is not written it usually means 95%.

I used the mean as an example to explain the confidence interval. The same applies to other parameters like proportions when samples are used instead of the total.

Evidence based medicine

When I came across the phrase “evidence based medicine” for the first time many years ago, I was somewhat bewildered. Was medicine we had learned in the college and practiced since not based on evidence?! Are there two types of medicine, one evidence based and one not?! Shouldn’t all medicine be evidence based?!

The key to the answer to these questions lies in the word “evidence”. Like almost any word in the language (any language), evidence can mean different things to different people or in different contexts. In the field of medicine, evidence can come through reasoning from known (thought to be known) pathophysiological facts. For example, in heart failure the heart does not pump blood to the tissues efficiently. Digitalis increases the force of myocardial contraction. So digitalis should be useful to patients with heart failure. Evidence can be the result of opinions of experienced doctors who obtained it from their practice. It may come from opinions of patients who expressed their satisfaction or dissatisfaction of a certain medical intervention. Evidence can also come from planned scientific experimentation.

During the last century and especially in the latter half of it, a trend towards examining medical interventions (drugs, surgical operations, diagnostic tests, life style changes etc) in a planned scientific way following the steps of the scientific method appeared and evolved. It aimed at properly evaluating the benefits and harms of various medical interventions. The trend became more powerful with the evolution and increasing use of clinical trials (including controlled clinical trials). Doctors, and increasingly the public, are not any more satisfied with the results of mere reasoning or opinions of experts. Reasoning that an intervention should be useful because it sounds logical according to our knowledge of medical facts is not enough. Our knowledge is not necessarily complete or perfect and usually, if not always, it is not. Opinions of experts and patients can be, and usually are, biased. The intervention should be tried on people under strictly controlled conditions and the results interpreted in a proper scientific way to find out if the intervention is really useful. And even if it is, we should make sure that it has no adverse effects that outweigh its benefits.

Medicine based on this kind of evidence is what is called evidence based medicine. This should not mean that the rest of medicine is not based on evidence but it means that the evidence for it is not satisfactory. The phrase does not express this in a clear unambiguous way. But that is language, however meticulous and careful one tries to be, language remains liable to be interpreted in various ways!

Should we conclude that evidence obtained from properly controlled clinical trials is infallible? Certainly not. We regularly hear of drugs withdrawn from the market and processes abandoned after being properly and scientifically evaluated and after years of use. Nothing in life is infallible.

Why Iraqi doctors should be interested in research

In spite of the various research difficulties described in the previous article (Why Iraqi doctors are not interested in research), Iraqi doctors should, in my opinion, be interested in research for the following reasons:

1.     Answers to local problems:

Local research even if it is a simple survey sheds light and may produce answers to some local problems. It does not have to produce important discoveries on a worldwide scale. After all, among the huge amount of research published in thousands of medical journals worldwide, very few constitute really important discoveries.

2.     Experience for the future:

With time, research experience accumulates and results are likely to improve.

3.     Education:

Research is highly educating. Knowledge is gained by reading and discussing the subject of research and related subjects. The researcher also learns the ways of obtaining knowledge like searching the internet and using the library.

4.     Promotion of scientific and critical thinking:

By following the scientific method of making a hypothesis, collecting data and modifying the hypothesis, research promotes scientific thinking. The researcher learns how scientific knowledge is obtained and realizes that so called scientific facts are in fact hypotheses with various degrees of convincing power. They are not certainties and that is why they keep changing. This develops in him a skeptical and questioning mind which is important not only in research but also in practice and in life in general. Knowing how various workers frequently differ about the same subject is a warning that one should not take everything he reads in a book or a journal or hears in a lecture as established facts.

5.     Reflection on practice

a.     The scientific method is not confined to research. It should be the basis of practice too. In fact the clinician is involved in research daily by trying to make a diagnosis of his patient’s illness and find solutions for his problems. Fever in a patient, for example, is a scientific problem. A hypothesis about its cause should be made after the initial information. Data is then collected through history taking, physical examination and various tests to strengthen or modify the hypothesis once or more times. Actions are then taken on the basis of the final hypothesis. This is what the scientific method is all about.

b.     Awareness of observer error and observer bias, common precautions in research, is reflected on interpretation of clinical findings and various tests made during daily work.

c.      Awareness that association is not necessarily causation, a common precaution in research, reflects on clinical work. Jaundice in a patient with a positive hepatitis virus BsAg is not necessarily caused by hepatitis B virus.

d.     Knowing how reference values are obtained makes interpretation of patients’ figures more intelligent. You may e.g. accept a figure slightly outside the reference range because you know that 5% of normal people are so.

e.      Research improves logic and shows its limitations. Treatment of various illnesses is based on trials done on a number of patients somewhere in the world and the results are generalized to include all patients all over the world (induction in logical terms). Why should your patient behaves in the same way as those patients?! In fact induction is the logical basis of most medical knowledge, not only treatment. One should therefore not be surprised to find so many differences between practice and the book. What should be surprising is the presence of so many similarities!

Why Iraqi doctors are not interested in research

Iraqi doctors are generally not interested in doing research. Many have a negative attitude towards it and argue that:

1.  Time spent in research is better spent in patient care.
2.  In our poorly developed situation, research is unlikely to produce significant results. Important discoveries have been made and can only be made in developed countries that have the facilities and the expertise.

These are some possible reasons for the lack of interest and the negative attitude:

1.      Lack of experience:
Most doctors lack the necessary experience:

a.       They were not involved in research during their training, unlike doctors in developed countries who get involved in research done by those who supervise their training.

b.      Most professional postgraduate degrees in clinical branches, including those from developed countries, do not include research in their requirements. (There are exceptions like the certificate of the Iraqi Board of Medical Specialties.)

c.       Earlier education in Iraq in primary and secondary schools is generally based on memorizing (one of the Arabic words commonly used to mean study is “istithkar أستذكار” which means remembering). Thinking and reasoning do not have prominent roles. The student becomes used to accepting what he is told rather than developing a skeptical exploring mind which is the basis for research.

2.      Lack of time:
Doctors are usually busy people. Their time is occupied by care of patients in government institutions and in private practice.

3.      Lack of incentive:

a.       Research is not financially rewarding.

b.      Except in universities, it does not promote the position of the doctor in the place where he or she works.

c.       Most of the problems in medical practice in the country are not medical. They are administrative, political, cultural and financial. These are less likely to be solved by medical research.

4.      Difficulties in research:

a.       Research is time consuming and mentally demanding.

b.      Technical facilities (laboratories, radiology etc.) in our hospitals and medical institutions are not satisfactory.

c.       There is no good medical record keeping and good follow up of patients.

d.      Good libraries and references are not widely available.

e.       There is no sufficient funding for research.

f.       Cooperation of patients and non medical people is generally poor. Importance of research is not widely recognized in our culture.

g.        Animal research is not generally available except on a very limited scale in universities.

h.      Ethical and legal restrictions on research on humans are not well defined and properly legislated and not carefully observed. This can create problems which may sometimes be serious.

Readers may be able to add other reasons that I may have missed.

عون في الشدة أم شدة فوق الشدة؟

من الأحبة والاصدقاء من يكون عونأ في الشدائد، يساعد اذا استطاع وينصح برفق اذا استدعى الموقف النصح ويتعاطف او يتفهم اذا لم يستطع غير ذلك وفي هذا أيضا عون كبير. ومنهم من لا يفعل شيئا من هذا وإنما يلوم ويؤنب دون مبرر مقنع ومعرفة دقيقة ويجدها فرصة لإظهار حذقه ومعرفته بإعطاء صاحبه موعظة في كيفية التصرف التي كان عليه اتباعها وإذا كانت العلاقة بينهما قريبة جدا فقد يفعل ذلك بانفعال يؤدي الى انفعال مقابل ومشادة كلامية هي آخر ما يحتاجه شخص مكروب.

فكم من الاحبة والاصدقاء من هو عون في الشدة؟ وكم منهم من هو في الشدة شدة فوق الشدة؟

Right and wrong, good and bad

This is not an article in the philosophy of ethics and not meant to discuss the controversies in the meaning of the terms. It is about the attitude of people towards them in everyday life.

Most opinions, plans, solutions or actions are compound and have several aspects: good, bad and all grades in between. Good or right and bad or wrong are also relative. Good to somebody may not be so good or even bad for another. The same opinion may be praised by those who look at its positive aspects and deemed wrong by others who look at the negative aspects. The ultimate value of the opinion depends on the sum, the net result, of its various aspects. We generally label it good when the positive aspects prevail and bad when the negative aspects prevail. There are grades of goodness and badness or rightness and wrongness. Two opinions may be different. Nevertheless both may be right with an equal or a different degree of rightness. The good or the right in any matter is not necessarily one. You can go up the hill via different routes. You can move from point A to point B by more than one way and all may be right.

The problem is that many people think and behave according to a concept that any opinion is either right or wrong and if an opinion or plan is right then any one that differs from it is by necessity wrong. They do not conceive of the presence of grades of rightness or wrongness. They have duality of thinking: white and black, no shades of greyness in between. For them there is one right opinion about a specific subject, one right solution for a specific problem. I sometimes hear two people arguing violently, every one claiming his opponent is wrong when, to me as an observer, both opinions seem of similar value each having some positive and some negative aspects.

If these facts are realized and accepted many differences of opinion may be better tolerated.

Defeating the purpose

 When anyone of us does anything, he or she usually has a purpose for doing it. Whether the action succeeds in achieving the purpose or not is another matter. But sometimes the action not only fails to achieve the purpose but be the means of actively defeating and destroying it! I say this having in mind many doctors who work so hard in their clinics in pursuit of money which supposedly will bring them happiness. If they are enjoying their intensive work, that is fine. But many of them are not. They spend most of their lives overworked, tired, tense and miserable. They seek happiness by being miserable!! It is an outstanding example of actions that defeat the purpose.

Approaching the patient with oedema

مناقشة بحوث الطلبة

في مناقشات بحوث الطلبة في العلوم الطبية كبحوث طلبة المجلس العراقي للاختصاصات الطبية او طلبة الماجستير او الدكتوراه في كليات الطب يلاحظ المرء ان بعض المناقشين لا يملك رؤية واضحة لهدف المناقشة وكيفية الوصول اليه فتراه يصرف الوقت في تبيان ما يعتبره أخطاء في البحث وقد يقضي كل الوقت او جله في تصحيح اخطاء لغوية أومطبعية أوما يعتبره نقصا في المعلومات المستقاة من الأدبيات (literature) فيضيف ويصحح ويأخذ دور المتكلم ويترك للطالب دور المستمع أي انه يمارس دور المحاضر الذي اعتاد عليه وينسى انه الان ممتحن وليس محاضرا وعليه ان يسمع اكثر مما يتكلم. ومنهم من يهاجم الطالب ويوبخه أو يستهزء مما كتبه او يقوله. وهو في كل ذلك لا يمس جوهر البحث كحسن اختيار المشكلة موضوع البحث واتباع المنهج العلمي السليم في جمع البيانات وتحليلها واستنباط النتائج ولا يختبر فهم الطالب للاطروحة وقدرته على البحث العلمي.

أن الغاية من مناقشة بحوث الطلبة هي تقويم البحث والطالب (والتقويم هو تقدير القيمة)  واعطاؤهما الدرجة التي يستحقانها باعدل ما يمكن. وبيان اخطاء البحث ونقاط ضعفه ليس غاية وأنما هدفه سماع رد الطالب عليها من اجل تحقيق غاية التقويم.

أن البحث الجيد هو البحث الذي احسن اختيار المشكلة فيه وحددت بصورة واضحة (والمشكلة في البحث العلمي تعني السؤال الذي يجرى البحث للاجابة عليه وتحديدها هو الخطوة الأولى في المنهج العلمي السليم) والبحث الجيد كذلك هوالذي وضعت له خطة صحيحة تجنبه الاخطاء التي قد تنجم عن اختيار العينة (sample selection) او اختلاف المراقبين (observer variability) أو انحيازالمراقب (observer bias) نتيجة معرفته وميوله الشخصية ثم حللت نتائج البحث بصورة صحيحة وتوصل الباحث الى استنتاجات منطقية مستخلصة من عمله وليس مما هو معروف من المصادر ومن عمل الاخرين. ولا يحكم على البحث بكثرة ما فيه من بيانات او فحوص معقدة ومتطورة فهذه قد تكون ذات قيمة كبيرة اذا احسن اختيارها وجاءت في مكانها المناسب وقد تكون عديمة النفع وربما ضارة ومشوشة اذا لم يحسن استخدامها او لم تكن ذات علاقة بهدف البحث. والبساطة والوضوح وتحديد الموضوع وتجنب كثرة الاهداف ليس منقصة وانما هو من عناصر الجودة.

ان من صفات الكتابة الجيدة الاختصار والتقيد بالموضوع المحدد والكلام البليغ هو الكلام الذي لا تستطيع ان تحذف شيئا منه دون ان يختل المعنى ولا يقاس البحث بطوله وكثرة الصفحات التي كتب بها.

ان تأنيب الطالب وتقريعه اثناء المناقشة لا يخدم التقويم العادل بل يعيقه نتيجة تأثيره السلبي على نفسية الطالب وخفض معنويته وارباكه واشاعة جو من التوتر يؤثر على التقويم الموضوعي الهادئ غير المنحاز. وليس من صفات المناقش الجيد التهجم على البحث او الاستخفاف به واحتقاره. ان عمل وكتابة بحث جيد ليس بالامر الهين ومن يشك في ذلك يكفيه ان يلقي نظرة على ما ينشر.

يجب ان لا تقتصر المناقشة على اظهار نقاط الضعف في البحث وانما يناقش الطالب في مواضع مختلفة من البحث لمعرفة مدى فهمه لما هو مكتوب وقدرته على الدفاع عنه والتاكد انه لا يجهل اجزاء مهمة من البحث كانت قد اعدت له من قبل المشرف أو المختص بالاحصاء ولم يكلف نفسه عناء دراستها وفهمها.

وثمة مسألة اخرى. ان المبدأ الذي يتبعه بعض المناقشين في شجب تكرار بحث مشكلة ما أذا كانت قد بحثت سابقا من قبل باحث اخر مبدأ يجب اعادة النظر فيه فالبحوث في العالم تكرر وقد تكرر مرات كثيرة من قبل باحثين مختلفين وفي اماكن مختلفة وقيام باحث ما او مركز ما ببحث مسألة معينة لا يعني ان على الاخرين ان لا يبحثوا فيها وقد يكون العكس هو الصحيح اي انه دعوة للاخرين لتكرار البحث فيها لتأكيد نتائج الباحث الاول أو تغييرها أو نقضها خصوصا اذا بحثت في اماكن مختلفة وعلى مرضى اخرين. وتعتمد قيمة البحث الجديد على رصانته وجودة أنجازه وما قدمه من اضافه او تغيير في تحديد المشكلة والهدف واسلوب البحث ونتائجه وعلى الباحث الجديد ان يشير الى من سبقه في بحث ذلك الموضوع ولا يدعي لنفسه الاسبقية فيه ضمنا او تصريحا. ولهذا الامرأهمية استثنائية بالنسبة للبحوث التي اجريت في بلادنا فيجب ان لا يغفل ذكرها الا انه ينبغي كذلك ان نتذكر صعوبة العثور على البحث العراقي لعدم توفر فهارس سهلة المنال بالبحوث التي أجريت وتجرى هنا.

وكالة

اردت عمل وكالة الى شخص ما. وبما انني قد عملت ذلك سابقا في هذه المدينة فقد كنت مطمئنا انني سانجز المهمة بكفاءة! في تجربتي السابقة وجدت ان الزحام عند الكاتب العدل المسائي اقل من الصباحي مما يجعل أنجاز الوكالة أسهل ولذلك أنطلقت بعد ظهر يوم شديد الحرارة من ايام صيف العراق المشهودة الى مكان الكاتب العدل. فوجئت بعدم وجود زحام بل لم ار شخصا واحدا على الباب مما اثار الشك في نفسي. دخلت المكان وتنقلت بين الغرف حتى قابلت شخصا يرتدي بجامة اخبرني ان الكاتب العدل قد انتقل الى مكان اخر. وبعد تحر واستفسار وانتقال من مكان الى اخر عرفت المكان الجديد واوقات العمل التي اختيرت بعناية لتكون في احر ساعات النهار (الواحدة الى الرابعة بعد الظهر). ذهبت بعد ظهر يوم اخر شديد الحرارة مثل سابقه فوجدت زحاما عرفت منه اننى اهتديت الى المكان الصحيح! لم ار كتاب العرائض الذين (لمن لا يعرف اجراءات العمل في دوائر الدولة العراقية) يخبرونك بما تحتاجه المهمة ويهيئون لك الأستمارة الخاصة والوثائق اللازمة لتأخذها الى الموظف المختص وتبدأ سلسلة التنقل من شباك الى شباك حتى تنجز المهمة (اذا لم تصادفك عقبة غير متوقعة توقف كل الاجراءات). سالت عن كتاب العرائض فدلوني على غرفة في الجانب الاخر من الشارع. ذهبت اليها فوجدتها غرفة ابعادها حوالي اربعة امتار في اربعة فيها شباك صغير واحد وليس فيها وسيلة للتبريد. يجلس داخلها ثلاثة كتاب عرائض وراء مناضدهم يحيط بهم حشد من المراجعين يملؤون الغرفة  الى بابها وكل منهم يستعمل اوراقه كمروحة يدوية يهزها امام وجهه الذي يتصبب عرقا. حشرت نفسي داخل الغرفة وبعد دقائق شعرت انني اوشك ان يغمى علي فخرجت. وبما انني أعرف من خبرتي السابقة ان كتاب العرائض عند الكاتب العدل الصباحي يعملون في مكان واسع مفتوح ومغطى وعددهم كبير حتى ان كل واحد منهم يحاول اغراءك بالمجيء عنده حالهم في ذلك حال كتاب العرائض في مختلف دوائر الدولة العراقية فقد قررت ان أذهب صباحا الى الكاتب العدل الصباحي لأهيأ الاوراق اللازمة عند أحد كتاب العرائض هناك ثم اتي بها مساء الى الكاتب العدل المسائي! وفي صباح اخر خرجت متوجها الى دائرة الكاتب العدل الصباحي وعند وصولى ألى المكان تفاجأت مرة اخرى بعدم وجود ازدحام وعدم وجود كتاب العرائض. وعندما سألت اخبروني ان الكاتب العدل انتقل الى مكان اخر! ولم استطع معرفة المكان الجديد بعد. في بلدنا تجاربك السابقة لا تفيدك! عدت الى البيت خائبا مرة اخرى وفي طريقى شاهدت بائع رقي (بطيخ في لغة بعض البلدان العربية الاخرى) ولكي اشعر نفسي بان خروجي لم يكن فاشلا تماما وقفت واشتريت رقية. وعندما وصلت البيت سألوني مثل كل مرة: هل أنجزت شيئا؟ قلت: نعم. اشتريت رقية! 

Are we copies of our previous selves?

On the same theme of the previous post (the dynamic steady state of our bodies), another thought may be entertained.

Our bodies are changing all the time and are in a tightly controlled balance with the environment. Every substance in the body is continuously lost and replenished. The input equals the output and the body remains in a steady state. Water which composes more than 60% of our bodies is lost through the kidneys, skin, lungs and intestine. It is replaced by the water we drink, water in our food and water produced in our bodies as a result of food metabolism. The water in our bodies today is not the same water that was in them days or weeks ago. The same thing applies to other elements and compounds that compose our bodies. Everything is lost and replaced by a new thing continuously. After a time the whole body has been replaced keeping the same design; the same architecture imposed and governed by our genes. Slow and gradual changes in design occur as a result of aging. Rapid changes occur sometimes as a result of disease and accidents. In other words every one of us is not exactly the same person he was sometime ago. He is a copy of his previous self. If you see a friend that you have not seen for a year you are in fact not seeing him but seeing a copy of him! To be more precise a copy of you is seeing a copy of him!! A somewhat disturbing idea to sleep on if you are reading this article late at night.

Kidney failure and the steady state of our bodies

When I told a group of students that the kidneys of a patient with kidney failure whose condition is stable excrete normal amounts of waste products and other substances like normal kidneys, they responded with a kind of disbelief: why then does the patient develop manifestations of kidney failure and why do we call it kidney failure?!

The answer is this.

If a patient or a person is in a steady state i.e. he or she is the same and his plasma urea and creatinine are the same today, tomorrow or after a week, then the input of any substance (entering or produced in his body) must be equal to the output. In the case of urea and creatinine the production in the body by tissues must be equal to the amount excreted by the kidneys. In other words if the blood urea and creatinine are constant over a period of time (regardless of whether they are in the normal level or elevated) then his kidneys must be excreting all that is produced, otherwise the level must rise. The critical point here is that the failing kidneys excrete normal amounts in spite of their reduced glomerular filtration because the level of the substance in the blood, and consequently in the filtrate, is high; so a reduced volume of glomerular filtrate contains the same amount of urea or creatinine as a larger volume with a lower concentration. If for some reason kidney function deteriorates and filtration drops further then the balance between production and excretion is disturbed. Urea and creatinine start to rise. The patient now is not in a steady state. The level goes on rising resulting in increased excretion until the amount excreted in the reduced volume of filtrate becomes equal to the production. The rise in the serum level stops and the patient reaches a new steady state at a higher level of plasma urea and creatinine. In other words failing kidneys excrete normal amounts of various substances on the expense of a higher plasma concentration of these substances.

To make an analogy, think of a tank with a hole in the bottom and water flowing into it from a tap. The level of water in the tank depends on the balance between the water flowing in and that flowing out. If the hole in the bottom is made smaller the balance is disturbed, the inflow exceeds the outflow causing the level in the tank to rise. The rising level increases the pressure driving the water out from the smaller hole. The water outflow starts increasing. The change goes on until the outflow becomes equal to the inflow. The level of water in the tank then stops rising and stabilizes at a new higher level assuming a new steady state.

The ability of our bodies to keep their composition and various characteristics constant (i.e. in steady states) is remarkable. Think of body temperature, body weight, the number of various blood cells, skin cells, intestinal cells, the amount of water in our bodies, the amount and concentration of various chemical substances in our tissues etc. etc. Everything is kept in a steady state; a dynamic, not static, steady state. The essence of it is to equalize the input and output.

Inverse epidemiology

It is a common knowledge that high body weight, high blood pressure, high blood sugar and high blood cholesterol are detrimental to health. In epidemiological studies (studies of disease in the community) the higher these are the higher the illness (morbidity) rate and death (mortality) rate. Put in a different way the lower they are the lower the illness and death rates. The relationship is a direct relationship. But is that always the case? Do illness and death rates go on decreasing with decreases in these variables without limits? Is a body weight of 40 kg. better than a body weight of 60 kg. or a blood pressure of 70/30 better than 100/60? Obviously not. A decrease in these variables is associated with a decrease in illness and death rates within certain limits. After reaching optimum levels the relationship becomes inverted and lower figures are associated with higher illness and death rates. The epidemiology is now inverse (so called).

I must say I came across the term “inverse epidemiology” for the first time when reading about the relationship between blood pressure and cardiovascular outcome in patients with end stage renal disease on maintenance hemodialysis. I am not sure of the use of the term in the general sense I described earlier. But it seems to me it applies just the same outside the situation of patients on dialysis and outside the subject of blood pressure.

In fact it also applies to aspects of life outside the field of medicine. Direct relationship becomes inverse after certain limits. Too rich, too powerful, too beautiful etc. may become a curse rather than a blessing!!

Yemen uprising. Who represent the people?

The ability of the Yemeni president to launch massive demonstrations in his support struck many people. It made the simple minded wonders; if so many people want him to stay then what is the evidence that the majority of people want him to go?

In politics the majority of people are silent. A minority speaks.  One of the ways in which they speak is demonstration. The size of the demonstration gives an idea about the proportion of people the demonstrators represent. But is it an accurate representation??

The question reminds me of the wisdom of random sampling in statistics! For a sample (the demonstrators) to be representative of the whole (the people) it should be a random sample. So in an ideal theoretical situation we should ask expert statisticians to choose a proportion of the community using random tables or whatever method of proper random sampling they suggest and we then ask the opinion of the individuals in the sample about the matter at stake. Their opinions will then represent the opinions of the nation. Of course this is all imagination but it helps to clarify the fact that demonstrators are not accurate representatives of the people. They are, in statistical terms, selected (not random) samples. The man in power has got a clear advantage in recruiting people to his demonstration. He can intimidate, threatens and bribes. His followers can demonstrate without fear of being jailed or killed. On the opposition side, demonstrators risk being jailed or killed and those who recruit them have not got the power to defend them and cannot offer them material advantages. So although the majority of people who want the Yemeni president to stay and the majority of those who want him to depart are silent, the proportions who speak are quite different in the two sides. It is much larger on the side who is in power. A thousand on the opposition side may represent a larger section of the community than ten thousand on the regime side.

I wish random sampling of statisticians can be applied in politics. That is of course a day dream or, if you like, a mental exercise!

تقكير علمي ام حقظ معلومات؟

   من فضلك انقر على المقالة وان لم تفتح انقر على اليمين وافتحها في شباك منفصل.

الاصيل والقيم والمفيد في الترقيات العلمية في الجامعات العراقية

الاصيل والقيم والمفيد كلمات مالوفة لاعضاء الهيئة التدريسية في الجامعات العراقية الذين يقدمون طلبات للترقية العلمية. انها من المفترض ان تمثل درجات في سلم تقويم البحوث التي يقدمها طالب الترقية. ترسل البحوث الى مقومين يطلب منهم اعطاء كل بحث الدرجة التي يستحقها في هذا السلم وتكون نتيجة التقويم في العادة اهم اساس في الترقية.

فهل تمثل هذه الاوصاف سلما من درجات متسلسلة؟؟

اذا اردت ان ترتب اشياء او اشخاصا في رتب متدرجة فان المنطق يقتضي ان ترتبهم حسب صفة واحدة  حتى يمكن ان تعطي كل واحد درجة في تلك الصفة ولا يقع واحد في اكثر من درجة. فلو اردت مثلا ان ترتب اشخاصا حسب الطول فيمكن ان تكون الدرجات: طويل، ومتوسط الطول وقصير (وتضع حدودا لكل درجة) فلا يمكن عندئذ ان يقع شخص ما في درجتين او اكثر ويكون طويلا ومتوسط الطول او قصيرا في نفس الوقت او ترتبهم حسب الثروة مثلا الى غني ومتوسط الغنى وفقير او حسب الذكاء الى ذكي ومتوسط الذكاء وغبي وهكذا ولا يصح ان يتكون السلم الواحد من درجات من اوصاف مختلفة كان تكون درجات السلم: طويل ومتوسط الذكاء وفقير لان شخصا ما قد يقع في الدرجات كلها ويصبح السلم عديم الفائدة لا يحقق غايته في المفاضلة والمقارنة.

فهل الاصيل والقيم والمفيد درجات من صفة واحدة؟ ان الاصالة شيء والقيمة شيء اخر والافادة شيء ثالث. وان بحثا ما يمكن ان يكون اصيلا وقيما ومفيدا في الوقت نفسه وان اعطاءه ايا من هذه الصفات لا يجعله ارفع او ادنى من بحث اعطي صفة اخرى منها. واذا كان المقوم غير عراقي لا يعرف تأثير كل وصف في انجاز الترقية فانه سيحتار اين يضع البحث؟ أن واضعي تعليمات الترقية العلمية والعاملين فيها اعتبروا ان الاصيل اعلى من القيم والقيم اعلى من المفيد وان القيم ليس اصيلا ! والمفيد ليس اصيلا ولا قيما ولا يصلح للترقية! كل ذلك بحكم تفاهم غير مكتوب ناتج عن طريق الاستنتاج مما رتبه القانون والتعليمات من نتائج على كل وصف من هذه الاوصاف بغض النظر عما تعنيه كل كلمة من الناحية اللغوية وكيف سيفهمها المقوم والاخرون وكأن ذلك لا يهم!!

هذا السلم موجود منذ عشرات السنين وقد تم تغييره لفترة ما في الثمانينيات فاصبح البحث يصنف الى اصيل وغير اصيل ويصنف كل منهما الى جيد جدا وجيد ومقبول أو نحو ذلك لا اذكر بالضبط. وهذا تصنيف افضل فهو يصنفها حسب الاصالة اولا ثم يدرج كل صنف حسب الجودة ثانيا. ولكن هذا التصنيف لم يدم لا اعرف لماذا واعيد الوضع الى الاصيل والقيم والمفيد. اتمنى ان يتغير هذا السلم الى سلم اخر يقبله المنطق السليم او يعاد الى التغيير المذكور الذي حصل في الثمانينيات.

تبقى اسئلة اخرى في موضوع الترقيات العلمية الشائك. ما هي المعايير التي تحدد ان يكون البحث اصيلا او قيما او مفيدا؟ وكيف يتم اختيار المقومين؟ وكيف يضمن عدم معرفتهم والتاثير عليهم من قبل طالب الترقية او غيره؟ وهل من العدالة ان نطبق في ترقيات التدريسيين في جامعاتنا نفس المعايير المطبقة في الجامعات الغربية المتقدمة وان نتوقع منهم ان ينتجوا بحوثا في مستوى نظرائهم في تلك الجامعات رغم الاختلاف الكبير في الامكانات البشرية والمادية خصوصا في الحقول العلمية؟ واسئلة اخرى لا يتسع المجال لذكرها او الخوض فيها في هذه العجالة وتحتاج الى بحث ونقاش وتبادل اراء بين الخبراء بالموضوع. أنه حقل شائك حقأ!!

Approaching hyponatremia

Our concept of disease entities

There is no sharp line between health and disease. (See a previous post in this blog “The concept of health and disease” please). Deviations from what we consider as “normal” that are detrimental to the individual are labeled as illnesses or diseases. The ways in which a person’s condition deviates from normality take innumerable forms and shapes. Every patient’s disease is in fact unique. There are similarities and differences between diseases of different individuals. Because we think that similar diseases may progress in similar ways and respond to our intervention in similar ways we try to group them into one disease entity and give it a name. There are grades of similarity between the individuals in the same disease entity. We might see patients whose diseases fit very well with the classical description of that entity and patients whose diseases differ from the classical description to various degrees. There are no sharp lines of separation between disease entities. Some diseases may not fit well into any of the artificial entities that we create or fall in the boundary between two entities or more.  We then either force them into one of the entities that we consider the nearest possible or include them into more than one entity or create a new entity with a different name to accommodate them.

These facts explain at least partly the differences between doctors about the diagnosis of a patient’s disease and why in many instances a patient’s disease does not behave in the way we expect it to.

Much of the controversy in medical discussions is about language rather than fact. It is semantics. Nevertheless it is important because language dictates our acquisition of knowledge. It is the language, the names, that makes it possible for us to learn about diseases and to get the help of the book or the literature to guide our prediction of prognosis and our management. It is not an ideal situation but that is the case with almost everything in life.

MS & Ph.D debates in our universities

Two phenomena are commonly observed during MS and PhD debates in our universities.

1. The student usually prepares a food and drink party in front of or beside the debate room to celebrate, with friends and relatives, his distinguished success before the start of the debate!! The psychological pressure of this on the examiners needs no comment.
2. Most of these debates end with granting the candidate an (excellent) grade! One candidate became furious because he was given a (very good) grade!!

Isn’t it time to stop these shameful practices to give our postgraduate degrees some recognition and respect?  

Judging doctors’ competence!

People frequently judge doctors by the progress of the patient following their intervention. If the patient improves the doctor is competent. If the patient does not improve or deteriorates the doctor is incompetent.

Many illnesses especially acute ones like viral infections are self limiting and not affected significantly by treatment. The condition starts and gradually worsens over days until it reaches a climax, then it starts to improve until it recovers. If the patient sees a doctor in the beginning of the illness he is likely to deteriorate in the following days irrespective of what the doctor does. The doctor may be blamed for the deterioration. If he then sees another doctor when he is at the climax of his illness he will start improving irrespective of what the doctor does. The improvement may then be attributed to the second doctor. The same thing applies to many chronic illnesses because they have a fluctuant course with spontaneous exacerbations and remissions. Justice is rare in this world. It is a sad fact of life.