I am product of big bang

  

As I have grown older, I have come to realize that nothing in my mind truly belongs to me. From my understanding of physical therapy to the way I perceive other individuals, all of my knowledge has been acquired from centuries of evolution. Even the thoughts expressed in this blog are not solely my own, but rather a culmination of ideas that I have read, contemplated, and understood from various sources throughout my life. My ability to write in English is a skill that I learned from my aunt, books, and schooling, all of which were passed down through generations of individuals who acquired knowledge from others before them. This chain of knowledge and learning stretches back to the beginning of time, perhaps even to the Big Bang. Without this cosmic event, there would be no planets, and without the cooling of the Earth, there would be no life. If that first fish had not dragged itself out of the water, if the Neanderthals had not reproduced, if Homo sapiens had not migrated to South India, my thoughts and ideas would be vastly different. It is humbling to consider just how interconnected and interdependent we all are, and how our collective knowledge has evolved over time.

I have come to understand that nothing truly belongs to me, not even the knowledge that I possess or the wealth that I have acquired (for the sake of this discussion, let's assume it's cognitive knowledge). I realize that the reason I was able to acquire this knowledge is because of the opportunities provided to me by my mother, who had an education and a good job. She was able to obtain this education because she was the firstborn in her family, and her parents placed a strong emphasis on education, unlike her siblings who were forced to drop out after only completing 5th grade for various reasons. As for my reading skills, I learned to read English books slightly later in life when I moved into a new house that my mother had built. My new friends, who came from upper-middle-class families with different aspirations and attitudes, introduced me to a reading culture that ranged from classics to silly pulp fiction. This exposure to reading likely helped me to improve my reading skills and, in turn, my understanding of PT. It is clear to me now that everything I have acquired, including my knowledge and wealth, is the result of a complex web of circumstances, opportunities, and people that have shaped my life.

I recall my mother telling me once that I should feel blessed if I am able to read real books in my middle age, not just pulp fiction. Out of all the things my mother told me, this statement stuck with me, and I always wanted to achieve that goal. I often wonder why this statement impacted me so deeply, and why I did not follow through on other things my mother suggested. Perhaps it is because of my Tamil teacher who taught me the Thirukkural, which contains a poem about education and scholars that I still remember to this day. I wonder what it was that made this particular poem stick in my mind, while others did not. Why did I not remember the gods and prayers that I was taught as a child? Why do I view prayer as something childish? The truth is that none of these thoughts or beliefs are truly original. They are all products of the knowledge and experiences that I have accumulated throughout my life, which were borrowed from others. The workings of the human brain are complex, and the reasons for our memories and beliefs are not always clear. Nonetheless, it is important to recognize that we are all products of our environment and that our thoughts and beliefs are influenced by the knowledge and experiences that we have borrowed from others.

Original thinking is fucking hard. Not now or millions of years back. If you have a original thought it should be the greatest think you have done- ever/ 

what does all these mean- My thoughts and beliefs are not truly original, but rather a reflection of the knowledge and experiences that I have borrowed from others. It is important to recognize that the self is an illusion, and that we are all interconnected and influenced by the world around us. While it is tempting to think of ourselves as unique individuals with our own ideas and beliefs, the truth is that we are all products of our environment and the complex interactions that have shaped our lives. By acknowledging this fact, we can begin to see ourselves and others in a more holistic and interconnected way, which can lead to a greater sense of empathy, understanding, and compassion.

  

OMG my sentiment

The notion of hurt sentiments has become a new mantra for many groups, and it seems that almost anything can be deemed offensive these days. In India, it has become common practice to include disclaimers before telling a joke, just in case someone's sentiments are hurt. This seems rather silly given that there are so many pressing issues that demand our attention. For instance, there are 45 million people living below the poverty line in India, and the level of inequality and poverty is shocking. Furthermore, we have criminals and even dacoits in positions of power, yet we are still preoccupied with the idea of hurt sentiments. It's time for us to focus on the real problems that affect our society and work towards creating a more equitable and just world for all.

This has become a pandemic now with the advent of the right wing in all religion- from the Morons of the islam to the idiots of Hinduism- well they are abundant in Christianity also- but they are just waiting for dan brown book to become a useless movie.

Why do we prioritize protecting our sentiments related to caste, religion, and cultural practices over issues that actually affect us, such as corruption and poverty? It is ironic that we get offended and hurt by something as trivial as a joke or criticism, but turn a blind eye to the injustices and inequalities around us. The notion of protecting our caste or religious identity seems to be deeply ingrained in our society, to the extent that it blinds us to the real issues that need to be addressed. We need to shift our focus and start addressing the systemic problems that hinder our progress as a society, instead of getting caught up in the trivial matters that distract us from the real issues at hand.

How did we become a bunch of jokers with no humanity. Everyday some comment is hurting people on social media- really in social media- a media which it seems to abuse people- we are hurt by it. Words hurt but it should not be taken to heart about silly things.  Well what is silly thing- everything is silly if it just affects your sentiment. Every social change from marriage age to education- all is because some one dared to hurt the religious sentiments- just go and read about how marriage age was changed in India and who were crying or how savithribai phule fought to educate the masses.

We need to hurt sentiments to change. I also think you can hurt sentiment just to make fun for a laugh. It is okay. I know the left is also full of cry babies when it comes to hurt sentiments- just a bunch of whinny cry babies. 

It's important to remember that our beliefs and identities are indeed constructs and not inherent truths. However, it's also important to acknowledge that these constructs hold immense power over people's lives and can deeply affect their sense of self and belonging.

As for the hypocrisy of some people who claim to follow a religion of love and then engage in hateful behavior, it's unfortunately a common phenomenon. It's important to hold people accountable for their actions and not let them use their beliefs as an excuse for harm.

Similarly, while free speech is important, it's also important to consider the impact of our words on others and to recognize that speech can perpetuate harm and discrimination. It's a delicate balance between protecting free expression and being mindful of the consequences of our words

 I read this book called unifying Hinduism- ( i do recommend to anyone who wants to understand the rich Indian philosophy and evolution of Hinduism) in that the author writes there were different sects of religious ideas and one of them were pasupaths. They were a fascinating bunch of people, i did some further reading also. The "monks" in that sect would sometimes stand in the middle of the town and talk nonsense- well hurt sentiments , so the towns people could abuse them or even spit on them. This was done to remove the self.

 what a fall!  

Enjoy language - it will not hurt, ideas don't hurt- money hurts Get hurt when it affects us materialistically not just the ego. 

PS- well if you abuse my ideas- i dont have any problem- I dont care about any politician or philosopher, but i do love some of the teachings- they are not mine- i dont get hurt if you abuse or dont agree- it is okay -they are not mine, it is very difficult to have a original thought- all my thoughts are borrowed so..

but if my self is hurt hahhaha 

we all have the same Dukkam

Every day, I realize that I was an idiot the day before, even in instances where objective truth is easy to discern, such as in medicine or physics. The illusory passage of time allows the brain to make changes in its network, making me feel like I was foolish in the past. For example, the other day, I learned about how electricity travels, and I immediately thought about how foolish I was before. I even questioned the quality of education that my physics teacher received. In the early 2000s, I was very confident in my knowledge of stroke rehabilitation, and when I wrote my book, I felt that I was very close to the truth. However, now I realize how naive I was. It's not that my basic premise was wrong, but there is so much more to explore before I can confidently close the book.

One way of looking at our problems is that we all believe our issues are unique. Whether it's a physical ailment like back pain or a personal struggle like family or money issues, we tend to think that our situation is different from others.

In the medical field, patients often believe that their pain is unique and requires a specific treatment. However, even though there may be some outliers, most cases of back pain have average patterns and can be treated in similar ways.

Similarly, in our personal lives, we tend to think our problems are unique. However, Freud believed that most issues stemmed from sex, while J.K. may say that it's our perception of self. Intelligent people understand that our problems are generally the same, and they either fall into the median or have similar underlying causes.

Our perception of self plays a significant role in the problems we face. The self emerges when we are in a particular context, but it's just a collection of memories and other constructs that have developed over time. To change the self, we need to peel away the layers like an onion, which can be a painful process. But, ultimately, it's necessary to overcome our problems.

Depression is a common issue that many people face, and the symptoms can include self-pity and loss of confidence. Although the causes may differ, the underlying problem is often a narcissistic focus on the self.

Changing ourselves is challenging because our biology resists change. It takes months of practice to alter our habits, and our brains may even resist change because it helped us survive in the past.

In the end, we're all human, and our problems are generally the same. The solutions may seem insane, but they're often similar, and we can learn from others who have faced similar challenges.

  

Judging the world

 what colour is the apple is a wonderful story. So, what colour is the apple- red, green- and the child answered white. The teacher thought her, see dear it is either green or red. The child bite it and showed it.

Most of the time it seems our perception is superficial. We never want to really listen or understand. It is also not useful to understand others- it is just a headache if we want to "hate" them. So we never see the real, it is better to see the paint job.

You may ask me - come on you are the king of hating others. Haha- well the colour of the apple is not green or red. But i do judge people- very badly. Some of them i see once i just think they are a ass without any rhyme or reason. I need to change that. I do see people and think how does this idiot sleep without falling down, as he/ she seems to have no brain. Well what a drag to judge people. What a smallness of mind. But that what the self has developed into.

Need to change it. But it takes so much of my energy. You know the whole world has cause and effect- but how do we learn to "effect" - judge- someone without explicitly "causing" anything. Well the conditioned brain has learnt to pick small things which trigger something in the limbic system? and well you know the rest.

well sometimes i do like judging and feeling superior to the poor sucker. Well its fun. Well and many a times they are idiots- how is that for a paradox. well enjoy judging idiots- but remember the one who is judging is a construct of the context, nurture and genetic- so well it is not who is judging. well that has come full circle.

But well i have to reduce my judging of people- but for all the people who know me through social media- i dont hate - i do judge 

Well that thought has not occurred- good

The happiest thing about todays review is -well dont worry it still seems to be under control. No need for mood stabilizers. Thats a relief. Lithium is what i was thinking i may be prescribed. It just makes you thirsty and i usually sweet like a pig, well do pigs sweet, poor things always get stuck in the insult family of animals. By they way they are quite delicious- i recommend crackling and bacon for the uninitiated. Dont worry out of the all the things we do which is against "god" food is nothing to worry.

One of the wonderful things about having a consult is the doctor telling you- its okay. So when she asked- do you - you know have those thoughts. Even in a psychiatrist consultation "suicide" is just a difficult word. So i said- lucky me i dont have them. What a relief- the self is still thinking it is okay- i will still try. How weird it is to think thats the bottom life.

anyway- i should do something valuable with my time. I should probably learn to paint- that seems a thing i might get better if i learn. But like reading, it seems to a sole affair and i think its time- i move to more socializing again. 

So i know i usually dont follow up with advice- this time also it might be the same

any way through in your suggestions other than politics which seems to be tough and you need to remove the brain at home- so no

.  

existential crisis

 I fell better for the last 2 days. Dont have a clue why? The mood swings are back and they are just weird.

I started reading about existential crisis after I saw some European movies of that theme. I could not get it. The whole idea was alien. I always thought life is for living to its fullest- what I think as fullest.  I enjoyed smaller things, from eating out to movies. I thought why could anyone have existential crisis, there is so much to do and enjoy in this world.

Well, depression brings existential crisis and i am unable to shake it off. What am i doing? what's the point of all these? If the self is so muddled, and you remove that the context seems to stand without any meaning. When the context is beautiful what does the self do? 

Learning something- little as i do in many areas which always made me happy- still do, but why am i doing it? Well earlier i used to teach to others hoping it was useful for them- and it also made me happy. Now it all seems a drag? earlier i used to have this motto I learnt from the horrible book - GITA. It is a horrible book but it understands randomness effectively and puts it elegantly so that infantilization of god is easy. It says doing is what you can do, you cant expect the outcome you think you want or assume you will get. Again that book is just evil which says some horrible and evil things which ruined us for a millennia and still will. 

But, even the doing seems to be pointless with or without the outcome. I need to stop that. I need to do , not sure what that is. Welcome to existential crisis 101. 

The circus is back

 anhedonia is back. How naïve of me to think all these are behind me. so the circus in town.  I am so sorry for my wife- she is going to have a tough time dealing with me. Well, lets see how this time I am managing. 

When i was learning about Nagarjunas middle path, I was awestruck by the rationale ability of the man without being a Nihilist.  As you know I like to think of myself as a man who likes to "see" evidence. Of course some one stumped me by asking -well do you have evidence someone loves you. Well Now i know the answer - I have experiential understanding. I know in a ideal world thats not evidence but sadly the conscious itself is a subjective experience hence it is difficult to go objective. 

I know it seems like i am rationalizing, and you may be correct. The problem is the thinking of self is a complex issue. In advaitha from what i understand little- there is this pure conscious- which i can imagine- un spoilt by context, evolution, the viruses which affected us millions of years ago- who are part of our DNA- without its influence - they call it athma- the god. So, the self deep within may be god? Okay if my understanding is correct. I thought it looked childish to see it as god. But i can see the value in it- we can try to behave like god rather than sad sentients. But it seems even the guru who wrote it seems to have not able to do it. He was still a casteist, intellectual bully- well i understand the last part- i do love a intellectual bully- the best of them was Nagarjuna and Hitchens. 

The Buddhist idea of self is little complex and different. They reject the idea of athman or self as you cant find the self. The self it seems is empty. The arguments for these are pretty amazing - in one instance he says okay leave your body out and just enter with your athma, if your athama is self why do you need a body and much more- these are what they call- vidhanda vathum. Well i think this is used as a derogatory term- at least thats how my mother used it when i was talking atheism when i was a kid. Well we all know when you cant answer the questions what people do- they have been doing it for millennia-   calling the person who asks questions - you know 

When i thought of the self- who i was in some simple sense- i used to think i was this sweat to some people, selfish, educated, do no harm to anyone, athletic, happy go lucky guy, who loves to teach- as though i know best. Well where was this self- well i thought it was "in" me- in my genes. Well that is a stupid- it should be in my neural network i thought- when i got older. Well the first thing which the self lost if my athletic and then regained - well when i lost i was still the same and regained some i am still the same.

I lost my love for fun, lost my confidence in my intellect- became worried- I am still the "self". How am i thinking this is still me. Nothing- is the image i see on the mirror. If i lose my face- will i think i am someone else or my self is lost. Is the face my self? Well if the information i process is my self- it seems to be easily perturbed by some simple hormones- so am the hormones? Is my self so fickle that a hormone can change it- with me having no control.

I like the idea the pure conscious is inside all these façade i have built. But if thats god- what the fuck is he inside and doing nothing? Is he that infantile? well it seems emptiness seems to be answer. Please dont take emptiness literally. If you see it clearly we all end up as something good human. Nagarjuna says if we remove everything- you will be ........... I agree, i can see that. But i dont want to go there. I am sure i cant go there. I cant even come closure by a mile to where he wants us to go.

I dont want to be good human- being good is more difficult to live,  I just want my useless self i have built- the arrogance in saying i know more than you, the kindness i can show, the mild bourgeois attitude .

But all these learning and meditation has allowed me to be self aware - i am spiraling - next stop learn to control them effectively without lithium- well I am coming dear lithium- i am coming for you for now.

probably should pray to the gods of dopamine and serotonin.    

The poison arrow

If you have not heard of poison arrow story- here it is. It basically says when someone is struck with an arrow- will you worry about who did it, what was his caste (that tells you it is a Indian parable) from what distance and so on or find a cure. well, in a way it tells you how Siddhartha was a genius, but today I am going to remind myself what is the lesson from this parable.

When a patient comes with persistent pain- he wants a management of that and if you are just telling how and what and the other neuroscience you learnt- he will think what the duck is wrong with this idiot. As Mr. S or Ramana said first find the answers for the basic question and then you can move on to whether there is heaven, rebirth and other nonsense. 

If you patient feels- these pain science teachings (what a horrendous misnomer)  are mere words- you are not doing what is valuable for them at that point. You are just describing who stuck the arrow- not the treatment for it. In the macro sense- as of everything about EBM starts with Buddha- ask your patient whats the problem for which he needs answers. So dont do useless studies like is IFT better than US or rubbing is better than licking or some other stupid topic you chose for your Phd. Believe me whatever you choose it is mostly just a toilet paper and we dont use toilet paper in India- so it cant even clean shit.

Put simply, much of the BPT syllabus is useless because we mistakenly believe that more knowledge is always better. Subjects like biochemistry, pharmacology, machine physics, and current are included (so we know where to plug in the machines), along with endless amounts of physiology books and trivial questions. Instead, we should focus on practical knowledge that will help us treat wounds. It's frustrating that we lack the courage to prioritize what is truly useful for our education and career, making it difficult to call ourselves doctors or practice in places like Canada.

The modern approach to research prioritizes addressing problems that have a significant impact on a large population, particularly from the patients' perspective rather than solely from a medical standpoint. In other words, focus on treating the injury, not worrying about who caused it with the arrow. It's clear that many of us are not equipped to conduct research. If you need more convincing, perhaps it's time to consider a career as a cowboy.

As a reminder, only about three out of eleven which i published was patient centric , while the others may serve other purposes, such as satisfying the self.  

Mr. S thought me a whole book and endless seminars in a sentence - the man was just a pure genius 

love

Hariohm

Its all empty

 Yesterday was probably one of the worst days in a while- not as bad as the first 2 years -but it was bad. I felt completely defeated. Dont ask me what is my war in which I was defeated, I never had any war or huge asperations- even then I felt defeated. It is a strange feeling. My friend who must be in her edge of patience send me this:

Then in the evening i read a book. I just enjoyed it so much. It seems there are different ways of debating and all the types have a name: basically sustain your point or oppose your oppositions point and sustain yours or the last one- oppose everything- dont have any stance - as there is no stance. We still use that word in Tamil- vidhanda vathum. Basically saying everything is wrong- as there is no stance - in philosophical stance. This great Nagarjuna a Buddhist monk wrote a lot and i just read one of his book- not the complete book- that should take probably 6 months- which is full of why i am wrong. He kicks ass when it come to god and other magical things. He has a wonderful way of refuting everything. He gave a full blown kick in my frontal brain and said ... well something.

Well it felt like- i woke up. But it did not change anything. Went home and meditated- still nothing changed felt so tired and slept- woke up and was astonished with Nagarjuna. Everything is empty. Every thing- why worry. Well sadly serotonins and dopamine did not get that memo. But seems the dog has stepped back. Well, it feels so good when you feel kinship with someone who lived 1400 years back. The universe still seems to defeat me- still feel like she has the upper hand- but at least I know people who lived thousands of years back kicked her and had a full life-  thats a weird statement.

I know this seems to be rambling on and on about nothing- well as l said earlier- these are when i get my degeneration of my mental faculties- to look back. 

Seems like i am waking up my friend at least for now- everything is empty- shuniya everything and that is bliss

https://archive.org/details/nagarjunatwelvegatetreatisehsuehlicheng_891_l/page/82/mode/2up    - this is the book if you want to pull your hair and get your mind blown. 

The dog is still hungry

 The black dog is getting restless. It has started chewing the carpet. Now i know when patients with persistent  low back think they have recovered and do the exercise regularly and they get a recurrence. It is a freaking nightmare.

The relentless of the dog is just surprising. It know what should be done to pull you to the abyss. The google map it has is just wonderful. It takes the least traffic path and travel is such fun if you like being dragged when you are tied to the dog.

The lesson is I am always going on a trip- just dont when and where- the bags are ready, sadly the bags are just not ready enough. The newer thing is i can observe when i am being dragged as though i am watching me in a video going down drain. That is just weird.  

I know there is no abyss, i know the beauty is all around, the truth seems to all around- sadly as Buddha pointed out - the mind creates so much of illusion it is just hard to see. You know what they say- just because you know does not mean - you know or change. We all know we should not be a ass hole- but we always behave like that once in a while. 

This is the best time in my life- hoping the euphoric feeling i should be feeling comes. The universe always treated me wonderfully, sadly I have feeling it is asking me back. I dont know what it is asking or i have anything to give? probably should ask Darwin.

Black dog at the door

The black dog is here since the last 3 days. It is not very ferocious, i don't know why, but it is here. This time it made me realize it loves me so much it is not going to go away whatever I do. Even though i am cat person- cant send away the dog which wants to be with you. Black dog seems to be very loyal.

This time- i was aware he is at the door. The 3 days as usual i had mood swings and feeling of blue. This time the blue the dog brought was lighter- it just makes me gloomy and go quite. This time i was so sure what he wan
ts, and to some extent i was able to starve him. I also learnt to be mindful - which is making things weird and fascinating. 

I could see what is happening to me when the dog wants to plays. The things it brings are always the usual, but to see what it happening to me was a profound. I could feel the mind not wanting, the mind not opening when i meditate. Like a good dog does not want to open the gate (you know as they say of the gate without the gate). I also find it hard to hear the heart sounds- that was really a different feeling when you are sitting quietly in a room. 

The other thing I seem to have adapted is not allowing the dog to pull me in the direction it wants. It usually makes me scream or go completely numb. This time- i was aware I am going numb, I am going to scream- the value of learning to "observe" the thoughts. Still lots to learn to adapt to having a black dog. 

The most confusing thing this time is- i just dont know why but i am freaking sad, just blue when i look inside i cant see the reason- the dog without causal relation just a confusing dog- even if the cause is just a made up construct of my mind

Still long way to go before finding equanimity when the dog is at the door- but hopefully.

Love

Hariohm 

What the duck is in the moniker?

 For 50 years, we are doing what we are told, after 30 years upgraded education we still do what we are told, 25 years of masters - we still do what we are told. Most of the places the only work which the Therapist do can be done by a trained monkey- on and off the switch- so i think we can all keep calm and just shut our mouth until we grow spine. I am talking primarily about the therapist who work in GH. 

Why this- well some one wrote doctor and they were told they were therapist and we all got our panties in a bunch. We have not got autonomous practice but we think we are part of health care? sadly no- we are still trained monkeys. Sadly after 25 years of graduation- we including me are trained monkeys. Nothing has changed for the PTs responsibilities and  having propriety over our treatment and patients. 

Of course some clinicians have autonomous practice- sadly it is still not got critical mass- and i blame the GH therapist. Why - well job security, and also you have a mouth but never opened it for any rights other than - where is my pay slip. Why cant other be blamed- well if can be sacked the next day - what will they do? 

So the next time fight for autonomy - not some nomenclature or moniker- what are still 19 years old and unhappy when someone called you kid? The amount of poor education about the society and medicine is rampant in PT. As a first step the "leaders" of the associations should just get a chill pill and get a reeducation on what the hell we need. This is not a new issue- from the time i went to college, until today we have some extremely stupid objectives. We waste our money, we clap our hands when people say PT are important (the self confidence just does not grow), cant ask where is our money to some idiots in the CEC or some old useless therapist and want to call ourselves "doctor". Why? from the next day- we will all become autonomous? next day the switch operators will become health care workers? 

This education mafia uses the nomenclature to get some poor parent and student to make them in a college were the prof, will ask how much is education. We are a microcosm of the society we live in. Every day some one is offended. But we are not offended- our patients hardly get "physiotherapy" but some silly "current" or the society, which hardly get offended by the people living on streets but by imaginary friends (i meant the god- from all the useless religions). 

Fight for things which changes our life- not just moniker . What will happen if someone calls me royal highness Hariohm or better "still all knowing guru "- i will still be the same arrogant SOB. 

I know i most of the therapist in GH are hard working and are helpless- hahah no i was kidding if we have no posting in GH none of the patients will miss because what you give is not PT. I know you will say- thats what we are prescribed- well I could have had some sympathy if you had fought for it once in your life time- so no..

PS- i know many of classmates are in GH- haha- well thats the way it is nothing personal. I also know some places where the therapist do good work- well sadly you need Hubble telescope to find them- I am sorry i had to include you also. 

I know you will be angry after reading it- well please write to hariohm@idontgiveaduck.com    

Love

Hariohm

  

Why we need to be the best

What is best in clinical practice? How should i assume i am doing the best i am doing? There are many definitions of best- as a adjective it is ambiguous. We clinicians undoubtedly do thing for money. Hence most of the time we hide behind the veil of "patient satisfaction" and believe either we are doing the best or what makes the patients happy.

What makes patient happy is varied but we ideally it should be "recovered fully". But the path to recovery can be made faster, with less discomfort and less effort. That is where I think we tend to take short cuts and make grave assumptions and don't do our best.

The first assumption in PT seems to be "10 days" and "daily". You know what I am talking about. We all are conditioned to think LBP, Neck pain, heal pain, and much more - 10 days daily, then only you will recover. We all are taught 10 days is a magic number. Sadly we are never told what is the recover time for different conditions we treat. We also have this notion we cant say - every patient is different. The last statement is all time favorite statement euphemism for  " i did not go to college on that day" or what you have data for those, i have never read them. I just hope the uneducated "physicians" surgeons who "prescribe" PT and also the PTs who all want to be more than that can read and empower the patient about it.

Why this is important- well truth is what will set you free isnt it. Also that reduces the anxiety of the patients. We all have the patient who comes and tells us i went to mr. X I took the drugs for 10 days it has not reduced or I had IFT for 2 weeks still it has not got better. In this scenario- There are 2 issues- one is not making understand issues like OA, knee or PA shoulder or chronic pain is going to get better in "10 days" and apparently the low value care we all believe is next to god. i mean the IFT, IPT for lbp, or the rubbing of miracle points- I am talking about the nonsensically named trigger point, or -well we all know the list i usually put.

The next argument why we use is- The treatment I give is the best- that is it reduces the recover time and makes you comfortable. This is a common argument in surgical medicine also. I will stick on to conditions which we treat. Now as we don't know the recovery time so- this claim seems have no leg to stand on. We are never taught or take to read the natural history of many disease like LBP, Neck pain, stroke etc, and then without that we assume our treatment is better than no treatment or rubbing people claim it is better than cup and cup people claim they are better than IFT people and IFT people mostly are well that's is important how else will you get better. We also have never seen or shown any data one treatment is better than another- but we just accept that was some sort of truth when we hear it in the workshop or from the teacher- why?

The worst argument of all is- this is what my patient wants argument. Or my patients like it. My patients want "passive movements or stretching" is a common comment i hear from neuro PTs . Ortho practice is just full of these self defensive dialogues. As Balumahendra dialogue in marupadium goes something like this- Well for this song the audience may like it when all the dancers are naked- but i wont do it. Even when art is not catering to just what your patient wants health care cannot be just catering. You make the patient understand the treatment choices, make him understand when the treatment choices or unequal. When they choices are equal then you make him chose which rarely is the case in PT- but may be important in surgical medicine. 

So,  the best treatment is what science "proves" is the best. The best treatment is the one which makes recovery faster then natural recover or other treatments.  The best treatment is not the last workshop you attended, it is not the last treatment you learnt form a white person with a tie, or the well most of what you learnt in your college. 

The best treatment needs effort from the therapist to search, read and empower the patients. The best treatment many a times is active- it involves the patient - not just lying on the couch. The best therapist should be following the best available evidence when ever possible. I know many a times our hands are tied by the ortho- who as i have already stated need to go back to reading- then practice. But sadly the university or college hospitals - who is stopping you? why are you a bunch of uneducated wuss? why cant you read - most of they day you just sit and gossip why cant you read or supervise your students? why are you the worst of us? just sad isnt it and then we complain my son has poor teachers in school and well wait you send them to college- they will be taught by bunch of idiots like you.

omg- that was a angry rant- hahha. anyway- be the best- try to be the best, your patients deserve it

Love 

Hariohm

Its been 8 years

 I have made some good choices and some ehhh choices. Even before finishing college, I was sure i wanted to teach. To overcome my inability to speak smoothly in front of a crowd I did take some classes for my juniors. When i taught, weather my students accept it or not- it came naturally for me. I was in my elements. My introvert behavior did vanish slowly. Sadly, teaching was a constant battle with me getting into trouble with the management or the Principal. When I was pushed out for the last time- I said enough of this. I had enough of working for uneducated and insecure principals. 

My wife was pushing me to start a clinic and even found a wonderful place which was way beyond our budget. But we took it. We started it today 8 years back. I had no idea what or where to but anything necessary for starting a clinic. Saravankumar took care of everything from the weights to couch. Just before the starting of the clinic i went to Europe to study- so from the board to the furniture - everything was done by my wife. As usual the only thing I did was sit in the chair. Like everything else this could not happened without to my wife

As i have a awkward and blunt way of taking- it suited the teacher in me not the clinician. So the transition had its own headache. My patients still don't like my way of talking, some have cried, some I have told them to go and find someone else, as I find them incorrigible (thats a better word). Well after 8 years - less people cry, but I still send away more patients.  Some patients don't like it that i don't see the "prescription" some dont like something -well humans are always different. None of it mattered when I taught. If a student did not like me- my attitude was there is the door go home and cry to mama. But cant do that with patients. My depression has also not helped sometimes- I will not answer phone calls from patients and prospective patients or just close it half way and go home and sleep. 

The other issue I had with starting my own practice was "will I be able to practice EBM". When I was mulling this over, Richard told me something very important. He said "well if you are going to give something low value make your patient understand that". So, Whenever i had to make a choice between money and value- I told my patient- this is not that useful, but the exercise which i taught is the "treatment". I know some of my patients did not get it- but hey that was my starting point. 

But still I think I have a "loyal" following of patients. I have patients who bring patients so that i can say the "truth". I have learned to be more smooth when it comes to giving bad news. I have learnt to be patient with "listening" to patients. Learnt not to worry if the patients don't like "my" way of treatment. I have nearly stopped electrotherapy and told my patients if they want it- they can go 2 street down the road. I have also learnt if lose patients who call me asking do you have IFT- my answer still is I have but I am not selling it or this is not a pharmacy or no madam I give PT not IFT- depending upon how rude they are or how irate I am. I do want to change that- and I am. I am now politely saying please find some other PT clinic. 

In the meantime I had Revathi who is clearly my intelligent student in years and the best of what i can teach as a clinician. I still believe she will make me proud and one of the departments where she works she will apply what we did in my clinic- do high value care with all the limitations the system imposes. 

Teaching and research which I thought was my calling- became boring, brought about probably by midlife crisis and nihilism but I do love treating patients. Boring them to death teaching the importance of active life style, explaining low back pain in Tamil and English, telling them it is not eating calcium it is exercise which makes you stronger and much more. 

I also love to shout from the top of the mountain- I do high value evidence based treatment. Here are some of it:

1. LBP- exercise and some advice and enabling education 

2. Always told any patient with Adhesive capsulitis - It will take anywhere from 3 - 6 months- patients dont mind hearing the truth

3. Never followed someone's plan- followed the best science- still patients dont run away

4. Never did passive treatment for neuro-rehab

5. Never told them -10 days IFT or 10 days exercise and you need to "attend" my clinic

6. I always give them the option- do your exercise at home- I even allow them to video the whole exercise routine- or come here and do it, if you need it.

7. I don't have treatment for this- patients with no activity in the upper limb, trigger finger and some others ( no the world is still standing) or this will go away in 2 -7 days by itself - like a simple strain 

8. So, what are the disadvantages- well as i said some patients will not happy -as the "doctor" told them or that what they have been doing for years- so you lose some patients. You also have to "work" not just on and off the switch. 

and much more- but I like to assure young people you can still do high value care. If someone says otherwise- make a fist and extend the middle finger. 

படிப்பது ராமாயணம்; இடிப்பது பெருமாள் கோவிலா? no you dont have to do that

Enough of bragging about myself. 

Its our anniversary- Thanks to:

1. Saravankumar

2. Revathi

3. Miya

All my patients who have faith in me. I assure you- I am doing the best science possible

Love

Hariohm 

A neuro-rehab story

 I do love to digress and tell stories. Sometimes, i connect with the topic discussed sometimes i forget to connect. I dont know what the audience or students think, but i do enjoy a good story telling with a fact nugget inside it. So here goes,

I have joined BPT and had gone to this one building college which was smaller than my zoology dept where i was studying BSc. We rarely had classes and all morning we have to be in the OPD which  was amazing and also painful at the same time. We were there to do just observe and do simple work what our intern tells us to do- you know basic allakai* (that's a Tamil word- use google translator) work.

The college had a patient- whose name sadly i could not remember - lets call him Mr. Annan. So , he was probably in his late 40s. I think he had a head injury. As you know in many cases with head injury you get a frontal lobe affliction and many patients have issues with orientation. He also sadly had some orientation issues, and many a times will zone out. He was beloved and in those days patients were treated with so much care and understanding (i assume now also). OO, i digress. He was treated diligently by one of my seniors (as I have not asked him will not say his name) who really a big man- I mean not like us bony hardly out of the teen boys and girls.

Mr. X will be in the hospital for hours and he will have all sorts rehabilitation measures. The patient also needed to be reminded constantly about what he was suppose to bedoing. So while making him walk he will stop and just look somewhere. So the Intern could start saying mr. X mr. x and after some time he could respond. It was a challenge and was astonished to see how delicately he was cared for. No! that's not the lesson. He was made to sit on the static cycle and made to ride it as part of his exercise program. once in a while he will stop and stare some where or lose his orientation. So the Intern will keep on reminding him to get back to cycling. 

On that eventful day the patient started looking down and the and the intern was cajoling the patient to start cycle again and why it is important for his rehab. The patient suddenly wiped his head up lifted his hand and gestured to stop. And said the most important lesson i learnt in the 4 years i was in college- He said "riding a cycle is important, but what is the value of riding a cycle which does not go anywhere"

Well you can infer whatever from that. I inferred a life changing lesson in regards to rehab. Hope you also find that a important lesson

epilogue: He did recover sufficiently (again adjective which is may not give clarity) and walked if i remember correctly.

 

Learning after graduation

 If you are in medical field, At the end of say every 2 years you should always ask yourself, "what did i learn in the past 2 years". The 2 years is arbitrary but it always feels good to have a number. I believe if we dont do that we will get stuck in the past and be assembly robots.  

The need for "learning" is embedded in medicine thats why we call it "practice". You never stop. But I hardly see people in medicine "practicing". After college, many people believe they have finished studying. And then there are "workshop" and CMEs which some people attend for the food, or your friend organized it, the lecturer who is a broker for the resource person encouraged you to, part of the college function or at last to study. The study crowd is becoming smaller and smaller.

The problems with CME and workshops have been highlighted by the great Sackett as early as late 80s. I also know from personal experience no one learns in a workshop. As J.K said there are 3 types of people.

1. they come sit and listen and go home 

2. they come sit, listen and feel as though they have learnt and change for 2 days to a week

3. the smallest minority, they come learn, contemplate and change

I, as usual also have a opinion this- if you go to learn something and you don't have any idea about it (i am talking about medicine here) or you were made dumb by your education from your school to college, you have no chance of learning. When the last time I gave a lecture I said, stretching does not change the length of the muscle". Now if you dont know anything about how a muscle length is maintained or what causes changes in the length, the neurology of muscle length and what does brain injury does to your muscles- you have no way of asking me any question. You have no way of debating to me about how i am wrong. If you dont know whats the evidence you have no right to practice medicine. So, you see learning cannot happen if you have no substrate knowledge or as they in zen if you cup is already full (with bull shit from school ).

Learning happens when we assume there is more to learn and i am a learner and 2 most of the knowledge is bull shit. We know to learn we need to read, listen and observe. After these reflect on it and test it. It is a laborious process. Sadly many of us have to run all day to make a living. I think it is hard to blame them. Already the college have made us into a dumb idiot and the money to live us makes us even dumber.

But that is not to excuse, we need to find a way to observe and reflect. In 2 years time you could have observed a lot and if you have reflected properly, you could no the crap we are doing and the some gold which are peeking out of the crap. We need to learn observe that and then search, read, learn and understand if what we see is gold or its fools gold. I think differentiating fools gold and gold breaks your heart and that makes us hurt. The hurt of I am wrong as we all know leads to becoming defensive.

You the defense our ego uses- well, i know what I saw (the most common i suppose) , Hmm what does this person know, research that is for a bunch of wussies, well he did it differently (the bobath and sensory integration defense) research will come later (modern defense among fascia, muscle imbalance in strength and length gurus and newer machine guys). The person who wants to practice lets his defenses down and try to move beyond and see the truth. Remember the truth has no power so it is not going to show to you clearly or is beautiful. So it is hard work to get the truth. But it is imperative as a person who looks after another person you try to come closer to the truth and use that. Not what you think is the truth.

So where do i start- well observe what you practice. are you doing it because it makes money, someone prescribed, some one told you this is the best or this is the latest. Are you patients happy or they are really improving. Patients happiness can be brought by 3 treatment for 500 rs or rubbing them for 20 minutes- but are they better off without those. Have we asked that? have we asked if they did not come to us- could anything changed? -read, learn and contemplate. 

Dont go to study the newest or the shiniest or the hottest topic. Start from your patients problem. What should i study to solve the problem. As i said if you dont have any problem- well you are stuck- you cant learn anything, they world has nothing to offer.  

You may think i am sitting in a arm chair and telling others to do the improbable. Well thats true. But think like this next time you or someone is the ICU what medicine do you want- the best which is near to the truth or the most expensive, the newest or the fanciest? If you say nearest to the truth-  dont your patient also need the same? 

For that to happen- ask yourself what have i learnt in the last 2 years. Do i need to change the practice in accordance with what i have learnt. What are the thing we still dont know? May be just maybe the health care may become better if we do it.

P.S- I do love to flaunt how much i read, I don't see that as anything wrong in it- I think flaunting the wealthy is what I find slightly repulsive  

Love

Hariohm

      

The Evil angel and woodcutter

Dear Varush 

One of the stories they teach as a child is- the wood cutter and the angel. Well, if you don't remember it- here is the gist of it is the wood cutter loses his axe. A angel comes and brings in different axe made out of gold, silver and he does not accept it saying it is not his and in the end accepts his iron axe. As a reward for his honesty the angel rewards him with all the axes.

Well, when I grew up, I understood the story teaches not only wrong morals and it is a evil story. The story teaches, you will be rewarded if you are honest, not greedy, don't covet for what is not yours. What a awful thing to say. The story should end with the wood cutter getting his axe and going home. There is no reward for being "good" or honest or not wanting what is not yours etc.

    In real word you need to be honest or ethical because it is the right thing to do. There is no punishment or reward for being dishonest. The universe does not keep score or the God, if he/she is keeping score should be a horrendous God. 

Look around ethical people do things which are ethical because it is the right thing to do. Not for the 72 virgins or the entry into a heaven or collecting good karma. Even this world does not worry weather you are ethical or not. You can be a complete ass hole and be the darling of the world- just look at the people we elect. history is also full of ethical people who are in the edge of history rather in the main stream.  Just read people like Bhaghat  Singh, the intelligent humanist is in the edge of history and the guy he thought were idiots in congress like Tilak (who was worried about his version of Hinduism where you and I will be still shudra) or  Lala rajabat rai (who thought Muslims were somehow lesser) are heroes. I think Bhaghat had the right idea -do the right thing because it is the right thing (even though i don't like the idea of dying or sacrificing for a idea)

Being ethical should be like the fundamental particles of morality not because it is good or bad- but because that's what a human should be. I know being ethical is tough so is crossing the road or driving in OMR road in Chennai or any road in Bangalore, but we do it. No one can be absolutely ethical every time but we can always try. We can stop when the stick hits the frontal brain. 

Remember not because it will lead to a better society or you will get in the good side of some infantile god or it is the law- but because that is our fundamental property.

As you can see from the arguments none of the evil religions can take you there other than using the brain. Have fun being ethical

Love

 Hariohm