Volume 8 Issue 2 February, 2018
“Changes in source of learning”
A couple of months ago, one of my patients who suffer from Bipolar Disorder came to see me with his wife. That day I had a DNB and family medicine post graduate with me doing her psychiatry rotation. “Doctor, my uric acid level is raised and I have a couple of questions for you, he said. “One is about the association of uric acid and bipolar disorder and the other is whether my medication sodium valproate will raise my uric acid level?, he asked in a quick succession. I was surprised, for I did not have a clue to the answers. “I shall check these out and let you know when we meet again”, I said. In any case he was euthymic and I wanted to bide my time. I assured him that I would consider a dose reduction of his medication, the next time we meet.
Barely was the patient out of the room when the postgraduate doctor waved her smart phone at me displaying an article on the association between raised uric acid and BPAD. My jaw dropped in amazement. What dexterity in typing the search and to back it up there was 4G speed data access? Everything is at your finger tips these days, I thought.
By the way, the article stated that purinergic dysfunction is associated with BPAD in all phases of the illness. It may be a trait marker for higher vulnerability to BPAD and the uric acid may rise further during a manic episode. There is decreased adenosine activity and amplified purine metabolism. Valproic acid does not affect uric acid levels. Now I had my answers ready for the next encounter with the patient.
My memory went back to the time when I was resident, training at NIMHANS. One day during the ward rounds, I presented a patient who had chronic schizophrenia. The consultant gave me a patient listening and then asked me “what studies do you know regarding the course and outcome of schizophrenia, can you name some follow-up studies?” I did not have an answer to offer. No data existed in my head and there was no data at hand in those days. (Any G – 2G, 3G, or 4G). The only way we could access information was to go to the library and search through books and journals or to talk to colleagues.
When I was about to embark on the task of reviewing the literature for my MD thesis, one senior colleague suggested that I request somebody in the US to do a Medline or Medlar search. I remember that such of us who did so would get reams of paper with the references. Now doing such a search is a lot easier. During my child psychiatry rotation, we had the privilege of having a case discussion with Dr. Maria Kovacs who was visiting NIMHANS from the US. She was an authority on childhood depression and it was an enriching experiencing for us. At one of the recent ANCIPS, Dr. George Valliant from the US was an invited speaker. I did not attend that conference but happened to meet a colleague who had done so. With much excitement I asked him what he thought of that lecture. Listening to psychiatric luminaries always excited me. “Nothing much, you did not miss anything, you can watch him on YouTube” was the response. How true, a lot gets preserved on the YouTube for posterity. It’s all easily accessible and very convenient.
Sometimes, I ruefully recollect T.S. Elliot’s ‘The Rock’ wherein he wrote “All our knowledge brings us nearer to our ignorance. All our ignorance brings us nearer to death. But nearness to death no nearer to God. Where is the life we lost in living? Where is the wisdom we have lost in knowledge? Where is the knowledge we lost in information? The cycles of heaven in twenty centuries bring us farther from God and nearer to the dust.” I quote this because very often I find myself confused and perplexed when facing some patients with behavioral disorders. We had no biomarkers then nor do we have any now. Are we not struggling in unraveling the mysteries of behavioral disorders?
