Pl read

1. Why o Why?

If you are visiting these writings for the first time, or have not read the entry "Why o Why",

may I suggest you read that first and then read the rest in numerical order?

Monday, 15 May 2017

20. Call your mother, even if it is not Mother's Day

One more Mother's Day is history.

The number of messages  sent  (to  mothers) would have been record-setting.

With whatsapp ruling the day, most messages would have been text messages with lots of esoteric attachments proclaiming a son or daughter's love for their mother. However attractive your message to your mother was, it may not have had same impact on your mother as hearing your voice and responding to your greetings with her loving verbal hugs.

Fortunately, you don't have to wait for the next Mother's Day to make amends. Mother's Day or not, mothers love the voice of their children.

So, even if you sent a text message to your mother,  call her. Like any mother, yours would love to hear your voice. I am sure your mother will not complain that  you had already written to her. And, you have many reasons to call her...

  • because she is always wondering how you have been -- during your last  call to her, weeks ago, you sounded as though you had a cold. She is worried whether  you are ok now. 
  • because you had to interrupt your last call to her -- your boss called to firm up the date for an important meeting. You had promised to call her soon after, but that is yet to happen.
  • because even though she has live-in help since she lives alone,  a call from you will perk her up like nothing else. At her age, hearing the voice of her children and grandchildren  can do wonders to her demeanor. 
  • because your mother's experience in managing a family can benefit you;  so far, even though you need her advice badly, you have been reluctant to ask.
  • because your mother  has done for you things like nobody else can or will. For all the hours she has  put in to nurture you, you can not compensate  her, but calling her  is the least you can do.
Whether or not you called or wrote to your mother on Mother's Day, call her today.

She deserves to hear from you everyday!

Wednesday, 10 May 2017

19. Self-financed medical care -- A case study

This posting is in the context of the ongoing furore about the overhaul of medical care in the US.  Much of what we have been hearing about have no faces attached to them, and so in some sense remain abstract. This blog entry -- which is an actual letter written to hospital authorities -- presents a real-life case study, elaborating on  the kinds of charges patients are highly likely to see in their hospital bills -- charges that they usually do not care about or take the time to decipher since they don't directly pay the bills. But, with more people expected to become uninsured, it is imperative that we get familiar with them.

The purpose behind the sharing of our case is to educate and inform.  The actual players in this case are not important, but the scenarios and their implications are. I hope others  will come forward and share their experiences, nay, nightmares.

Comments, as always, are welcome.


Dear Doctors:

Greetings !

At the outset allow me to introduce myself. I am Prof. Krithi Ramamritham, Former Dean of Research and Development, Indian Institute of Technology, Mumbai, India. I have lived in the US for over 20 years (during which time I was a tenured professor at UMASS). I am a US citizen and both my children are studying in the US. I am considered to be an accomplished computer scientist and returned to India to enhance its research potential in information technology and computer science, but I continue to travel back and forth.

In December 2009, I was diagnosed with Leukaemia in India. We had several options, but ... undoubtedly your hospital  was our first choice and we are glad to have made that choice. My medical record number is ... . At that time however, I had no medical insurance in the US but had to leave for medical care immediately, as the window of opportunity for treatment was small.

We were asked to pay a deposit of $40,250 which we did before we arrived here. Subsequent to seeing me in person and based on results of diagnostic tests, decision was made by Dr. ...  to proceed with a Bone Marrow transplant, at which point we were asked to pay another deposit based on a detailed estimate. So we paid up a total of $276,950 upfront. However, to our dismay my family discovered that even before the transplant, the balance in my account was just $12,000! And, this is on the 7th day after admission and without any complications. Of course this imposed a great amount of stress and anxiety for my family, as we had borrowed heavily to comply with the prepayment requirements of M.D. Anderson.  My family, out of concern for my health, shielded me from this news. If I had known then I would most certainly have reconsidered our previous decisions.

I have now seen all the letters and the discussions my family members had with you. I was very happy to know from my wife and brother in law, the consideration you have given to our case. I was also briefed by my brother in law that Dr ...  specially met him and assured him that he and Dr ... would do the needful and find a fair solution and help the family. He also reassured that the family should not worry about the financial aspects and should look after me very well and Dr ... and Dr .. will try and do their best on the financial aspects. Thereafter, I understand that my family members met Ms. .... While she conveyed that Mr ... has approved a special discount of 15% on the gross billings from the first dollar, we explained to her as to why we deserve a much higher discount than the 15 % specially approved by Mr ... We also followed up with a mail giving all the justification. I would like to present the justification once again here:

o       I am a US Citizen but unfortunately uninsured when I was admitted.

o       I file my tax returns in the US and has been paying taxes. My adjusted total income was about $xyz for the year 2008 and about $xyz for the year 2009.

o       Since the doctors that we consulted suggested that it is best for me to go ahead with the bone marrow transplant immediately without losing time we decided to go ahead with this decision even though the insurance through my visiting position at UMASS commenced from 1st July, 2010 and only the expenditure incurred after this date would get covered under such insurance.

o       We were asked to pay a deposit of $ 276,950 which we paid promptly in a matter of few days time. In order to meet this, we had to borrow and fund the treatment. You have to appreciate that it is extremely difficult for an ordinary person to promptly respond to a huge payment obligation of $ 276,950.

o       The deposit of $ 276,950 included about $ 150,000 for transplant which would cover hospitalisation for about 40 days (10 days prior to transplant and 30 days post transplant), all the labs, diagnostic investigations, doctors' visits, medicines and IV infusions, etc. It also included about $ 63,000 for 90 days visit to the hospital post discharge. My performance so far has been above average (as confirmed by the doctors) and I stayed in the hospital only for 23 days (instead of 40 days as estimated) and luckily I have had no complications and since I was self paid, most of the medicines by way of tablets were purchased by us outside of hospital pharmacy. Thus I would not have used at least $ 50,000 of the deposit for the transplant due to early recovery and purchase of medicines outside of the hospital. To summarize, based on the estimate which was given for an average case (whereas my recovery has been above average), our bill should not have been more than $ 225,000 until end of August 2010. Considering the insurance coverage from 1st July, 2010, the bill should not be more than $ 200,000 whereas the bills total $ 434,000 as of date.

o       There was no communication from anyone in the hospital until the last week of May 2010 post the transplant that I can apply directly to companies manufacturing drugs and seek assistance. Though late, we approached the companies through Mr ..., Patient Reimbursement Specialist and convinced some of the companies to provide assistance to us. Some companies agreed but some did not, saying that they don't cover treatment for past dates and would cover only for future consumption. One such replacement we could succeed was for Clofarabine for which we were debited $ 119,250; we have talked to the company directly several times and convinced them to support us before they agreed to the same. Ms. ... also confirmed that   the replacement medicines have arrived and she would reverse the amount by end of this month and that would reflect in the bill by the first week of July, 2010. To conclude, we have put in efforts to secure 100 % replacement for many of the costly medicines; the pharmacy has charged at least 5 times the prevailing market price in US, but has agreed to just 15% discount.

o       The estimate given by the hospital for entire transplant and post discharge of 90 days was exhausted even before the transplant had taken place giving my family unbearable shock and distress. No one has explained to us about the cost of the medicines or treatment for the plan chosen. We were repeatedly told that the estimate is based on the average and if there are no complications or above average, our spending will be much lower than the deposit paid.

o       The price charged by the hospital for us after the discount is much higher than price charged to insurance companies who were able to negotiate. Considering the fact that I started my employment on 1st May, 2010 we have requested a higher discount as you would have given to any large insurance company. This would help us financially to cope with the present situation.

o       We have also explained to Ms. ... that from all the information we have been able to gather, the prices we have been charged by the pharmacy for medicines and the prices charged by the hospital for room rent, doctors' visit, labs and diagnostic investigations are much higher than the price paid by insurance companies.  We were advised by one of the large insurance companies that a similar transplant from investigations, harvest, hospitalisation and transplant to post discharge activities would cost about $ 145 k as compared to $ 434 k which is billed as of date. Hence our request for a higher discount rate, trusting the words of Dr ... and Dr ... who agreed to find a fair solution. We are sure that you can verify these numbers as you have all the information with you. We are sure that our request for a higher discount is reasonable and would qualify very well in the definition of "fair solution" as committed by Dr ... and Dr .... When we are charged over 60% higher rates than that of market rates or insurance company rates, we deserve much higher discount than the 15% offered now.

I would have expected a bit more sensitivity and consideration towards a patient's situation, that too to a patient who is doing everything to follow the rules and who paid upfront the entire amount after having borrowed the funds. First of all, communication and information appears to be rather disjointed giving rise to unnecessary confusion and misinterpretation. Secondly, since we were forced to borrow funds at high interest rates, I have repeatedly requested for consideration for a slightly higher discount with your business service and the finance offices.

While I fully appreciate your kindness in agreeing to a discount of 15% on gross billings, I have given all the justification as to why it has to be more than what you have given. Also, we completely trusted the words of Dr ... and Dr ... that they would find a fair solution and we feel that what has been offered does not appear to be fair and hence our appeal. I sincerely request you to allow me the privilege of meeting with you in the hope that at least I can come across and convince you for a higher discount. Your kind consideration in this regard will be highly appreciated.


Krithi Ramamritham

Sunday, 7 May 2017

18. What does the future hold?

Today is the First birthday of our grandson. What an exciting year it has been!

With Facetime, Skype and other communication tools helping us to keep in constant touch , one would not expect any surprises when you see someone after a long gap. Does the lack of physical proximity and the missing sense of touch make a difference? Indeed, it appears that it does and it seems that the difference is more for the child than us, but it does exist for both. Be that as it may, even if you “see” the child almost everyday, nothing prepares you for the thrill of  tactile  as well as face-to-face experience.

One expects that since the child had been seeing you everyday, he would jump from his parent’s arms on to you without hesitation, and when that happens only after some delay, you ask, why? But, the exhilaration is to be felt to be believed. Neither is one prepared for the almost daily changes in the child’s cognitive and physical skills. Sometimes one wonders, how does a child learn? How is it that suddenly it seems he starts crawling or standing up and one fine day starts walking without support. What makes some toddlers do some of these things sooner than others? Do one year olds have worries like their parents? Do they think to themselves: OMG, that kid who was born 10 days after me has already started walking, whereas I  am barely able to crawl.

I am sure pediatrics science has answers such questions but won’t be surprised if each study designed to find answers to such questions raises more questions than it answers. For example, how does a baby learn to recognize its parents at an early age? But, that raises the question: How do we know that  the baby has indeed recognized its mom or dad?

Now, why do we ask such questions? Even more puzzling is: why do humans spend  the time and resources to answer such questions, which do not seem to have any material consequences?  (See) Why do we do what we do?From time immemorial, humans have been curious, sometimes just because of the joy and satisfaction one gets in solving a problem, sometimes because the answers lead to a better world. Once we have the  answers and they can be targeted at benefiting humanity, obviously it is important to capitalize on our new-found knowledge, for example, by converting the answers into the development of  useful interventions for combatting medical problems.

That brings us back to our ongoing struggle to make the benefits of developments in medical science reach those who are desperately in need of it, but just cannot afford it? Is it ethical to allow such a phenomenon to prevail? Consider the turmoil that is about to be unleashed by the end of  Obamacare. Most people seem to have reconciled themselves to the inevitability of its demise.  

How can we combat this palpable apathy and indifference?    

How can we make the world a better place for my grandson?

Friday, 5 May 2017

17. Overhaul of the US healthcare system -- speak up America

The  US Congress has taken the first step to  repeal of The Patient Protection and Affordable Care Act, often shortened as the Affordable Care Act (ACA) and nicknamed Obamacare. 

The nightmarish experiences of seven years ago appear in front of my eyes. Even deep inside me, I can feel the jitters. 

So can 10's of millions of Americans who have what is  referred to as a "preexisting condition". And, I have two!  So many "what if"s. Patients without insurance have more than their medical condition to worry about. "Control the spiralling nervousness", I tell myself. But, given what happened seven years ago, it seems like a hard ask. 

Subsequent to seeing me in person and based on the results of diagnostic tests, decision was made by my doctors  to proceed with a Bone Marrow transplant, at which point we were asked to pay a deposit (since we had no medical insurance in the US) based on a detailed cost estimate. So we paid up a total of $276,950 upfront. This included about $150,000 for transplant which would cover hospitalisation for about 40 days (10 days prior to transplant and 30 days post transplant), all the labs, diagnostic investigations, doctors' visits, medicines and IV infusions, etc. It also included about $ 63,000 for 90 days visit to the hospital post discharge. 

However, to our dismay my family discovered that even before the transplant, the balance in my account was just $12,000! So, the estimate given by the hospital for the entire transplant and post discharge of 90 days was exhausted even before the transplant had taken place giving my family unbearable shock and distress. And, this is on the 7th day after admission and without any complications.  We were repeatedly told that the estimate is based on averages and if there are no complications, our spending will be much lower than the deposit paid, and that is how it should have been. 

Since the doctors that we consulted suggested that i must go ahead with the bone marrow transplant immediately without losing time we decided to go ahead with this decision even though there were questions about the finances needed for further treatment. Fortunately my colleagues at UMass came to my rescue  and worked out an arrangement whereby I was able to carry out a collaborative project long distance, and benefit from the accompanying medical insurance.

After the transplant,  from all the information we were able to gather, we inferred that the prices we had been charged by the hospital's pharmacy for medicines and the prices charged by the hospital for room rent, doctors' visit, labs and diagnostic investigations were much higher than the price paid by insurance companies. This was truly unconscionable.  I was reminded of these and other aspects of the treatment  that happened  6 years ago. 

Clearly, many sleepless nights are in store. 

A patient undergoing treatment for deadly diseases such as LA is clearly worried about whether he or she will be lucky enough to see the next day.  For an uninsured patient, the worries are compounded by the question of where the next Dollar required to continue the treatment will come from; this worry will only help hasten the end of the patient's life!

Clearly, such an outcome will reduce the overall costs of medical care in the US. After all, there is no need for any further spending on a person who is no more. 

A very clever idea indeed!

Friday, 28 April 2017

16. When someone offers help, take it! When someone needs help, offer it!

Many of us, I believe are like me, when someone offers to assist us in some situation, we  don't like to take it.

There are a number of possible reasons why we may not accept help:
  • we feel embarrassed that we find ourselves in a situation where someone has to help us
  • we feel we will be beholden to them and we will at some time have to pay them back
  • we are not good at making conversation and accepting the offered help will mean  conversing with that person, etc., etc.
Whatever be the reason, I believe when we deny someone an opportunity to help, 
and conversely,  when we do not seize an opportunity that comes our way to help someone, we have missed a chance to increase the "happiness index" on earth.

First of all, most people feel happy when they help a fellow human being, because they are just good at heart, they want to reduce the pain of others, they are better positioned to perform the task; they want to repay some good deed that someone (not necessarily this person) had done to them earlier, they want to look good in front of others, etc. etc.

And to top it off, the person receiving help feels happy that his/her task has been accomplished without too much struggle on his/her part; embarrassment,  if any,  will be overshadowed by this. Also, from what I said above, when this person helps someone else later, happiness increases all around. 

So when help is offered and is taken, world becomes a better place. 

I have seen that even when help offered is monetary and is paid back later, the above applies. In fact,  in the case of monetary assistance, it might be good to ask the beneficiary to return the "loan" if and when they feel they are in a position to do so. There are many advantages to this. The returned funds can be used to help others. The person who benefited from the loan does not have to feel indebted for ever, in fact he/she feels better that they have reached a stature where they can return the loan. In all the cases we have encountered, the initial beneficiaries have become benefactors later in life, with the multiplication of the accompanying happiness.

In the entry titled 321Wow we saw how where we stayed in Houston changed as time for treatment elongated, until we found ourselves in a charity apartment. But "the next place we found ourselves in provided us a luxurious stay, thanks to my second PhD student from UMass, WZ, who has built a $2B beautiful University campus at Macau and has a home in Houston." This case study provides a nice example for the theme of the current blog entry. Also, it allows me to say thanks to WZ and his wife LC. Finally, it also relates to what I had said earlier in the context of students "who nurture the very institutions and people that nurtured them in the past."

Fortuitously, ZW contacted me just when we were desperately looking for a reasonably priced place to stay in, but without luck. We were thoroughly moved when he not only insisted that we use it for free, but that we also make full use of his Lexus. We felt overwhelmed but took up his offer with a lot of (mostly unsaid) thanks. WZ and LC's generosity will be long remembered and may it be an exemplar for others. Thanks a lot, my friends.

Happiness saw itself multiplied and spread enormously, thanks to ZW's timely offer of help and our taking it!

Tuesday, 25 April 2017

15. (Is there a need for) Saying "thanks"?

One of the most complicated and sensitive issues in human interactions, I believe, relates to something very simple: saying "thanks".

When you want to tell someone who has been there with you
when you needed them most, how grateful you are,
What do you say?
How do you say it?
Do you always (need to) say "thanks"?

It depends on one's culture, upbringing, relationship, etc., etc.

At least in a typical Indian home, if a person  is close to you, like a brother or a mother,  you usually do not say "thanks". In this case, presumably, the feeling is that, for them, they do it out of love, and this is their second nature. That is, they know that you are internally thankful to them, even though they do not hear the "thanks".

But, someone who does not know you may not understand if you truly appreciate what they have done for you, so you usually take the time to let them know that you are thankful for their help.

So, the irony is that the closer  you are to somebody, the more likely it is that they do not really  know if you are appreciative of what they have done for you.

Consider a mother. She usually does not  expect her children to say "thanks" when she prepares their dinner. But, just as she expresses her love for the kids through the care she takes in preparing what is good for them, the children may find a happier mother if they express their appreciation for what she has done for them; they can do this by eating the dinner with the attention that is commensurate with the affection with which she has prepared it for them (rather than eating while staring at the whatsapp message screen, as SK reminds me often☺). Here the best method to thank the mother is to consume the food in a way that expresses the love for the preparer of the food. Even a mother needs to know you are thankful, even if she does not expect or need  a verbal avatar of it!

This being the case, it is a given that  normally,  everyone expects to be appreciated for their good deeds. If nothing else, I believe this show of appreciation will bring out the best that is always inherent in each one of us.

I write about many of the people who were with me at one point or another during the LA journey,  in  two entries:

 No words or deeds can thank them

Above and beyond the call of duty

But, how does one thank the countless others  who came, offered their help and went without being noticed?  In fact this question is what led to these writings -- which is my way of giving thanks for what they did

Sunday, 23 April 2017

14. Why we do what we do -- our students are our (a)wards

Why we do what we do
   Our students are our (a)wards

When you examine the headings above, it may not be obvious that they are related enough to serve as a title for the following essay.

Consider the first question: Why do we do what we do?
We may have one or more possible answers.

n  We do what we do because we enjoy doing it, it gives us a sense of achievement, we get our own sense of satisfaction, like for example, when we finish a crossword puzzle within a self-imposed deadline, or when we reach a milestone in skiing.

n  We do it because if we don’t do it, we may be jeopardizing our future, for example, exercising regularly or eating in moderation, etc. As in the previous category, it is out of personal consideration.

n  We  do it for the benefit of someone else. For example, a teacher who imparts education or a chef who creates a gourmet meal. Of course, both get paid for their services, but their customers depend on them. Often, the payment could be intangible, for example, one gets an ego boost when others appreciate your work.

Come to think of it, teachers in  good universities today do what they do and obtain all of the above as a result. They enjoy what they do, have the flexibility to work on things which will create a better future for everyone – through the students they produce or as a consequence of their research, and in the process derive personal satisfaction.

Many educational institutions have awards for honoring their alumni, and in doing so, in a sense, they are honoring themselves – their own teachers and also the institution. For their part, by doing well in the real world – utilizing the education that they received  from these teachers –  these students nurture the very institutions and people that nurtured them in the past.  

The joy of seeing one of your “products” doing well, whether the product is a student or a useful artifact, can be profound.  One feels that nurturing such students and working hard to get the best out of them is  worth all the effort -- when you hear their success stories, or when they get recognized for their contributions a teacher proudly proclaims that he/she “was  my student”. When a student reciprocates and acknowledges the significant part a teacher has played in his/her success, there is nothing like it for the teacher. In my mind, graduation ceremonies (aka convocations, commencements) are solemn events because this recognition, by the teacher and the taught, of their mutual dependence, is brought out in a beautiful manner at these events.

Recently, some of us witnessed one such event when my colleague Prof. Sudarshan, received the Distinguished Alumnus Award from IIT Madras where he obtained his Bachelors degree years earlier. While he was on stage, listening to the citation and then receiving the award, among the audience members was his favourite Professor, Pandu Rangan, savouring and capturing the  moment on his camera. Within minutes, he posted the picture  on Facebook, with a note that paid tribute to his past student. Soon after, there was a beautifully crafted response from the taught. Their sentiments were sublime, the generosity of the teacher and the taught was touching and their mutual admiration quite apparent. I hope such relationships become the norm. Hats off to them.

Sunday, 16 April 2017

13. The importance of timely tests

"Testing can be used to show the presence of bugs, but never to show their absence!"

 Every computer scientist knows (or should know -- let me not presume what today's young computer scientists know) this quotation from the famous computer scientist Edsger W. Dijkstra. Of course he was talking about the testing of computer programs.

But the same is true for the testing of humans, to see if a person carries a "bug" which could lead to problems.   EWD also said that it is better to write bug-free programs to start with. Unfortunately, we don't yet seem to have the capability to do that with computer programs, or with humans, designer genes notwithstanding. May be some day, but how do we specify "correct human behaviour" so that we can be sure that the person being designed is not of the wrong kind.

For someone who has been diagnosed with an ailment, until the day comes when he or she has been "certified" to be ailment-free, each test, followed by the wait for the test results, is a "testing period". Is that why such things are called "tests"?

For an LA patient, the whole thing starts with  abnormal findings on a complete blood count (CBC) "blood test", one where the numbers related to blood parameters  don't fall within the expected range (see or  when a person feels  fatigued,  experiences weight loss, joint or bone pain, or enlarged spleen. This obviously underscores the importance of regular blood tests and being conscious of any major departure from normal health condition.

Usually, a follow up test, BCR-ABL,  is ordered  when the doctor suspects that a person has CML or Philadelphia chromosome (Ph)-positive ALL -- two of the numerous types of LA. 

(The different types of LA need to be introduced with some nontrivial background in hand. I am still unsure if I should venture into that topic here, but given the need to be informed in light of the improved LA treatment regimen  -- unfortunately countered by the increase in the number of diagnosed cases -- I might.)

Getting back to testing, for most of us, the tendency is to avoid the "testing period" by not going for the tests in the first place! This is clearly the wrong 

"prescription", but one that is often resorted to, with tragic consequences. Hopefully, the many messages that are broadcast these days through many media outlets, stressing the need for "cancer screening", will have the intended impact.