Saturday, May 30, 2026

UDLCO CRH: Why I didn't take up a career in surgery

 Summary



  • Introduction: Selecting a medical specialty is a pivotal milestone in a clinician's professional identity. This analysis evaluates conversational and narrative transcripts from two medical practitioners to understand how undergraduate experiences, evolving technological paradigms, and early clinical exposures guide medical students toward or away from specific fields.


  • Methods: The text applies qualitative narrative analysis to first-person reflective accounts from two alumni of Indian medical training programs. The analysis focuses on their shifts in perspective regarding Internal Medicine and General Surgery during their clinical terms and internships.


  • Results: Career choices are shaped by three distinct factors. First, historical context matters: the lack of advanced imaging and interventional therapies in the 1970s made internal medicine feel like an exercise in "control without cure," driving one practitioner toward the immediate, definitive interventions of surgery. Second, a physician's autonomy plays a role: surgery appeals to students who want direct control over the outcome, bypassing the unpredictable nature of patient compliance with long-term medications. Third, early clinical exposure can alter expectations: when a student witnesses a premature surgical recommendation or recognizes the repetitive nature of routine procedures, their interest can shift away from surgery toward more complex medical diagnostics.


  • Discussion: Student life acts as a testing ground where clinical experiences interact with a student's personal goals and temperament. For one student, the desire for immediate, definitive cures outweighed the intellectual satisfaction of bedside diagnostics. For the other, witnessing defensive or routine surgical practices pushed them away from the operating room and toward the broader, less repetitive field of medical cognition. This shows that specialty selection is rarely just an objective choice; it is heavily shaped by how early clinical encounters match a student's emerging professional values.





2. Thematic Analysis

The narrative content highlights three core themes that influence how medical students choose their specialties:

┌────────────────────────────────────────────────────────┐
│             SPECIALTY SELECTION IN MED SCHOOL          │
└───────────────────────────┬────────────────────────────┘
                            │
         ┌──────────────────┼──────────────────┐
         ▼                  ▼                  ▼
┌─────────────────┐ ┌────────────────┐ ┌─────────────────┐
│ Curative vs.    │ │ Patient        │ │ Procedural      │
│ Management Bias │ │ Compliance &   │ │ Repetition vs.  │
│ ("Cure vs.      │ │ Locus of       │ │ Cognitive       │
│  Control")      │ │ Control        │ │ Strategy        │
└─────────────────┘ └────────────────┘ └─────────────────┘

1. Curative Intent vs. Long-Term Management ("Cure vs. Control")

A major factor in choosing a specialty is how a student views the final goal of patient care. In the 1970s and 1980s, internal medicine relied heavily on supportive care rather than definitive interventions. As a result, students who prioritized immediate, tangible results often felt unfulfilled by simply managing chronic conditions.

"The realization seeped into me gradually that I wanted to CURE my patients, not merely CONTROL their diseases with drugs..."

Surgery, by contrast, offered clear and decisive resolutions—such as removing an appendix or fixing a fracture—which strongly attracted students who valued definitive outcomes.


2. Patient Compliance and the Doctor's Locus of Control

The transcripts reveal an interesting link between a student's preferred way of working and the specialty they select. Internal medicine requires sharing responsibility with the patient, meaning the success of a treatment plan depends heavily on long-term compliance and regular follow-ups. For some students, this reliance on factors outside their control feels frustrating. Surgery provides a much more direct line of accountability. The surgeon plans the procedure, executes it in a controlled environment, and sees the outcome directly reflect their own technical skill, providing a clearer sense of personal impact.


3. Procedural Repetition vs. Cognitive Novelty

While the direct nature of surgery attracts many students, it can also push others away if they feel it becomes too routine. Witnessing standard procedures performed over and over can make the field feel finite and predictable. Furthermore, seeing a senior physician recommend surgery too quickly or inappropriately can damage a student's enthusiasm for the discipline. Students who lose interest in the repetitive physical aspects of surgery often find themselves drawn back to internal medicine, choosing to focus on diagnostic strategies and medical cognition rather than manual procedures.


3. Socratic Steelman Analysis


Topic A: Surgery as the Ultimate Expression of Definitive Clinical Action

  • The Pro-Steelman Argument (Direct and Accountable Intervention):

    Choosing surgery is a logical path for clinicians who believe medicine should deliver direct, definitive results. The surgical model removes the uncertainty of long-term patient compliance by treating the disease as a structural problem that can be physically corrected. When a surgeon removes an obstruction or repairs a damaged organ, the benefit to the patient is immediate and measurable. This approach centers the responsibility on the clinician's technical skill and judgment, making it highly appealing to students who want their training to translate directly into clear, observable cures.

  • The Con-Steelman Argument (The Overtreatment and Mechanical Bias Risk):

    An overemphasis on surgical intervention can create a narrow viewpoint where every clinical problem looks like an indication for operation. This "mechanical" approach can lead to reflex choices, such as recommending an appendicectomy for abdominal pain before exploring other possibilities. Focusing too much on anatomical fixes can cause a clinician to overlook the complex, systemic nature of many diseases. It can also turn highly trained professionals into routine technicians, limiting their long-term intellectual growth and missing the subtle variations that a more analytical, medical approach would uncover.

Topic B: Internal Medicine as the True Foundation of Medical Cognition

  • The Pro-Steelman Argument (Intellectual Depth and Systemic Care):

    Internal medicine represents the intellectual core of clinical practice, emphasizing deep history-taking and thorough physical examinations over procedural routines. It treats the patient as a complex, interconnected system rather than a collection of isolated surgical targets. The field requires advanced cognitive strategies to solve diagnostic puzzles without relying solely on imaging. Managing chronic diseases through careful adjustment of therapies provides its own deep fulfillment, supporting long-term health and addressing the root lifestyle and metabolic factors that surgery often bypasses.


  • The Con-Steelman Argument (The Therapeutic Nihilism and Dependency Trap):

    An exclusive focus on diagnostic reasoning can sometimes lead to an unhelpful pattern of making precise diagnoses without being able to offer effective solutions. Identifying the exact location of an injury or illness loses its value if the only available options are basic palliative measures or lifelong medication. This dynamic can turn medicine into an exercise in management rather than resolution, leaving patients dependent on prescriptions and exposed to the risks of poor compliance. For a student driven by the desire to clearly fix a problem, a career spent managing chronic symptoms can feel more like an admission of therapeutic limits than a true cure.



Provide an imrad summary, keywords and thematic analysis of the content below focusing on how medical student's choice of future specialties are driven by their experiences during student life.

[28/05, 20:34] hu1: A story from my book:

[28/05, 20:41] hu1: CURE VERSUS CONTROL: WHY I CHOSE SURGERY OVER MEDICINE

I joined the Armed Forces Medical College (AFMC) on the 15th of July 1973, shortly after my 18th birthday, full of enthusiasm, brimming with energy, and raring to start my medical education. 

Young medical students pass the first 15 months of medical college in the Anatomy dissections halls, cutting up dead bodies soaked in Formalin (known as cadavers), and also in the Physiology and Biochemistry labs. After that, we entered what we called the 4th term, and started visiting the hospital wards to examine patients. One student in the clinical batch of 6-8 students would have to “present” the patient: what he/she had heard and seen, to our teachers, who were all senior doctors of the Armed Forces. The rest of us were free to question the presenter about any important questions that she had missed out on. Such questions were highly encouraged by our teachers. 

I found the whole process of taking a “history” and eliciting physical findings to come to a provisional diagnosis, an extremely fascinating one. The diagnosis had to be arrived at without a single investigation, not even a blood report or an X-ray. These would be done, but to arrive at a correct diagnosis without these was obviously an immensely satisfying experience! 

How did we do it? Can it still be done? Is it possible without a bunch of tests? 

It is possible, and it is being done by senior clinicians, but sadly the emphasis on investigations like Ultrasonography, CT scan and MRI scans has become so common that it has completely displaced the classical routine of a “detailed history and a thorough clinical examination”, which served us so well in the 1970s. We used to listen to the heart sounds and heart “murmurs” very carefully. Murmurs are sounds of turbulence of blood flowing through the four cardiac valves. Each valve could either be narrowed (stenosed) or could be allowing blood to flow back (regurgitation). One could diagnose cardiac valvular diseases by carefully listening to the heart. These days Echocardiography records these sounds, and technicians interpret the sounds. It is also true that investigations like Ultrasonography, CT and MRI scans took a decade or more to reach our shores. In the Armed Forces hospitals where I worked for over 22 years, these investigations were mostly not available. 

While it was undoubtedly satisfying to make a correct diagnosis, I soon realized that there was nothing much we could offer by way of medications or “procedures”. Heart attacks (myocardial infarctions) were treated with Aspirin, injections of Morphine and tablets of Sorbitrate! There was no coronary angiography, so no angioplasty and no stents. All that came decades later! Many patients who had blockage of major vessels simply died! Similarly bleeding stomach ulcers were treated with blood transfusions, antacid gels, and even milk drips given into the stomach by a naso-gastric tube. Obviously, these measures didn’t suceed very often in stopping the bleeding! Treatment of clots in the brain causing a stroke (brain attacks causing loss of movement of a part of the body, loss of speech etc) were treated with anti-coagulants given by mouth or by injection. Today’s technology of “stroke protocols” where it is possible to bust the clot with great accuracy and precision….  were decades away. 

Hence after making an accurate diagnosis which even included the part of the heart or brain that was dying, we could do very little about it in the 1970s an early 1980s!! To put it simply, the patient would survive if the attack was relatively mild, and if he/she had a body constitution which permitted survival. 

I got so interested in Internal Medicine that I started consulting multiple books, above and beyond our standard textbook, and I prepared notes on diseases of the different systems in the body, like Liver Diseases, Neurological diseases etc. I read a lot about how the waves get created in Electrocardiography (ECG) and I taught many of my fellow students about ECGs. I realized that the best way to learn was to teach and be asked questions. So I used to look for interesting cases in Command Hospital, Pune (which was our teaching hospital), and I would read up extensively on that disease. Then I would invite a few of my classmates for an “evening clinic” to that ward, and one of them would “present the case”, and I would be the teacher asking them questions, and they were also free to quiz me. This proved to be a great learning experience for me and them.   

But what has all this to do with surgery? The realization seeped into me gradually that I wanted to CURE my patients, not merely CONTROL their diseases with drugs like anti-hypertensives, oral hypoglycemic agents, Insulin injections, drugs to treat bronchial asthma etc. Patients with such diseases never get cured, the medicines they are prescribed merely keep their diseases under control, that too only if they take their medicines regularly and come for checkups as advised. 

A surgeon could remove an inflamed appendix, fix a fracture with plates and screws, reduce a dislocated joint, excise (take out) cancerous tissues, remove stones from the kidneys or ureters which are causing pain, bleeding etc. Many serious conditions of the intestines and stomach like a perforated ulcer, twisting of the intestines, intestinal obstruction and many more could ONLY be treated with surgery. No medical management existed except to “optimize” the patient’s condition prior to surgery. Management of serious trauma was almost entirely surgical. Badly diseased heart valves could be removed and replaced with artificial valves. The list is endless, and with every day that passes, the scope of surgery only gets wider and wider.
Apart from the curative aspect of surgery, the whole idea of tackling the surgical issue, planning the surgery, and finally DOING it, was very fascinating for me. The idea that what the surgeon did, or didn’t do, and HOW well he did it, would make all the difference, was a novel one. 

In the field of Internal Medicine, the physician made the diagnosis, and advised the medications. However, the efficacy of the treatment depended on various factors like availability of medicines, compliance with treatment, willingness and ability to come for reviews. Thus a “lack of control of the disease” could be due to a variety of reasons beyond the physician’s control, as patient compliance was completely out of control. 

All these factors gently nudged me towards surgery, and not medicine, as my specialty of choice. I was fortunate to score 65% in general surgery in my MBBS exams, and this helped me to get a seat in General Surgery at my alma mater AFMC. The rest, as they, is history, and I did thousands of surgeries in my career, venturing into fields like Obstetrics, Plastic Surgery, Pediatric Surgery, Urology and Orthopedics.


[29/05, 17:59]hu1: Did you read my piece?


[29/05, 17:59]hu2: Reading it!


[29/05, 17:59] hu2 : Very inspiring 🙂👏


[29/05, 17:59]hu1: My book

[29/05, 18:00]hu2: Great 👏

[29/05, 18:09]hu2: I had some interesting stories about why I didn't take surgery after internship although throughout my MBBS I was sure I would be a surgeon!🙂🙏


[29/05, 18:21]hu1: Oh!!
Great
Please share 😁


[29/05, 21:47]hu2: During third year I would see an appendicectomy being done by our house surgeons every day in the casualty OT for months until I was sure I could do it blind folded and couldn't wait to begin internship where we were often given a chance to do it ourselves during those days.

However in my final year of MBBS when my sister suffered from a long term intermittently recurrent pain abdomen and I took her to our professor of surgery he immediately asked for her to get operated for an appendicectomy the very next day even when I was sure that wasn't the diagnosis! 

That's when I felt the discipline of surgery demands that one keeps operating to stay relevant and I also realised that I would get bored of doing the same repetitive activity again and again as surgeries were finite and scope for developing new techniques were limited.

Hence my internship went without my realising that much cherished dream of holding the scalpel cutting open the abdomen and catching bleeders.

I did get to do umpteen cut downs and venesections during general medicine residency but it was something I never particularly enjoyed inspite of reasonably being efficient with it.

Hence my books are all about Medical cognition strategies!

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UDLCO CRH: What ails today's iodine deficiency driven goitrous hypothyroidism research outcomes in India and perhaps research in general globally?

Summary



  • Introduction: The universal salt iodization program stands as one of the most sweeping public health interventions in modern medicine, catalyzed in India by pioneering efforts like Dr. Vulimiri Ramalingaswami’s Kangra Valley experiment. However, a growing body of post-iodization research reveals that thyroid abnormalities, such as colloid goitres and hypothyroidism, persist unabated in areas with documented iodine repletion. This raises a critical question: how did a single-nutrient intervention become a global mandate despite a complex, multi-factorial disease etiology and highly regional epidemiological data?


  • Methods: This analysis reviews historical milestones, clinical case observations (e.g., euthyroid colloid goitre presentations in iodine-sufficient regions like Telangana), and multi-centric epidemiological studies tracking thyroid autoantibodies, dietary goitrogens, and xenobiotic exposures (such as lithium or amiodarone). It contrasts traditional binary statistical significance markers ($p < 0.05$) against clinical effect sizes to evaluate public health policy decisions.


  • Results: Universal salt iodization dramatically reduced classic endemic goitre rates in targeted high-risk belts (e.g., from 35% down to 5%). Paradoxically, contemporary data shows a high prevalence of non-autoimmune goitre despite iodine sufficiency. Operational factors such as the consumption of uniodized local salt varieties ("doddu uppu"), dietary goitrogens (e.g., frequent cruciferous vegetable intake), genetic variations in TSH receptors, and drug-induced mechanisms continue to drive goitrogenesis independently of iodine status.


  • Discussion: The persistence of thyroid disease in the post-iodization era indicates that iodine deficiency was an incomplete explanation for global goitre patterns. Public health frameworks chose a broad, single-variable intervention to bypass the logistical difficulties of treating complex, multi-factorial diseases in low-resource settings. While this approach effectively mitigated severe conditions like neonatal hypothyroidism and cretinism on a large scale, it also created a clinical blind spot. As a result, non-iodine-deficient thyroid disorders are frequently mismanaged or overlooked under the current public health paradigm.







Keywords

  • Universal Salt Iodization (USI)

  • Endemic colloid goitre

  • Public health policy

  • Goitrogens

  • Thyroid autoimmunity

  • Socratic steelman

  • Epidemiologic paradigms



2. Thematic Analysis

The provided transcripts focus on three central themes:

┌────────────────────────────────────────────────────────┐
│             THE IODINE ETIOLOGIC PARADOX               │
└───────────────────────────┬────────────────────────────┘
                            │
         ┌──────────────────┼──────────────────┐
         ▼                  ▼                  ▼
┌─────────────────┐ ┌────────────────┐ ┌─────────────────┐
│ Reductive Public│ │ Post-Iodization│ │ Statistical     │
│ Health Mandates │ │ Persistence    │ │ Epistemology    │
│ (Broad stroke   │ │ (Goitrogens,   │ │ (P-hacking vs   │
│ single nutrient)│ │  autoimmunity) │ │  effect sizes)  │
└─────────────────┘ └────────────────┘ └─────────────────┘

  1. The Reductive Triumph of Public Health: Landmark experiments successfully proved that iodine supplementation could rapidly reduce severe endemic goitre. This success led policymakers to treat a complex, multi-causal endocrine issue as a simple, single-nutrient deficiency, transforming a localized solution into a universal mandate.


  1. The Multi-Factorial Reality of Goitrogenesis: Clinical evidence in iodine-replete zones shows that goitre is not caused by a single factor. It is driven by an intersection of genetics (TSH receptor mutations), dietary goitrogens (cabbage/cruciferous vegetables), environmental pollutants, and medications (lithium, amiodarone) that persist regardless of iodized salt usage.


  1. The Epistemological Shift in Research Data: The historic reliance on simple $p$-value cutoffs allowed broad public health policies to oversimplify complex data. Modern scientific consensus is shifting toward analyzing actual effect sizes and broader clinical context, revealing that universal interventions often overlook important regional and structural variations.


3. Socratic Steelman Analysis



Topic A: Universal Iodization as a Necessary and Documented Public Health Triumph

  • The Pro-Steelman Argument (The Preventive Architecture):

    The decision to implement Universal Salt Iodization (USI) was a highly effective choice driven by urgent clinical necessity, rather than a premature move based on weak data. Before USI, severe iodine deficiency caused widespread, preventable neurological damage, neonatal hypothyroidism, and overt cretinism across entire geographic regions. Dr. Ramalingaswami’s large-scale field studies proved that introducing iodized salt reduced goitre rates from 35% to 5%.

    From a public health perspective, waiting for a perfect, multi-variable map of every non-iodine cause of goitre would have delayed an affordable and highly effective intervention. Salt was selected as the ideal delivery vehicle because it is universally consumed, cheap to process, and bypasses the logistical challenges of a weak healthcare infrastructure. The policy succeeded because it focused on preventing severe intellectual and developmental disabilities at a population level, accepting that a small number of sporadic or non-iodine-related goitres would remain.



  • The Con-Steelman Argument (The Monoculture Blindspot):

    By treating all goitres as an iodine deficiency problem, public health policy created an oversimplified clinical framework. Forcing universal iodization across diverse populations ignores regional realities where goitre is endemic due to environmental goitrogens, unique water quality issues, or specific genetic traits rather than a lack of iodine.

    Furthermore, pushing excessive iodine into populations with long-standing nodular changes can trigger thyroid dysfunction, such as the Jöd-Basedow hyperthyroid phenomenon. This absolute focus on a single nutrient has led researchers and clinicians to overlook other critical causes of thyroid disease, leaving millions of patients in iodine-sufficient areas without proper answers or targeted treatments for their conditions.


Topic B: Persisting Goitre and Hypothyroidism as Evidence of an Incomplete Etiologic Model

                    ┌───────────────────────────┐
                    │  POST-IODIZATION GOITRE   │
                    └─────────────┬─────────────┘
                                  │
         ┌────────────────────────┴────────────────────────┐
         ▼                                                 ▼
┌─────────────────────────────────┐               ┌─────────────────────────────────┐
│     THE ARTIFACT/COMPLIANCE     │               │       THE PATHOGENIC REALITY    │
│            HYPOTHESIS           │               │             HYPOTHESIS          │
├─────────────────────────────────┤               ├─────────────────────────────────┤
│ • Pockets of uniodized salt use │               │ • Non-autoimmune, iodine-       │
│ • Natural background variations │               │   replete colloid goitre        │
│ • Shift to "organic" salts      │               │ • Chronic goitrogen exposure    │
│ • Minor statistical noise       │               │ • Xenobiotics and drug-induced  │
└─────────────────────────────────┘               └─────────────────────────────────┘

  • The Pro-Steelman Argument (The Artifact & Compliance Hypothesis):

    The ongoing presence of goitre and hypothyroidism in the post-iodization era does not invalidate the iodine-deficiency model. Instead, it highlights gaps in public health execution and natural baseline variations. First, universal compliance is an illusion; substantial pockets of rural and remote populations continue to consume non-iodized, locally sourced rock salts ("doddu uppu") or marketing-driven alternatives like uniodized "organic" salt.

    Second, as classic endemic goitre fades, the remaining cases naturally reflect the background rate of sporadic thyroid disease present in any population. These include autoimmune conditions like Hashimoto’s thyroiditis, drug-induced side effects (from medications like lithium or amiodarone), and rare genetic mutations in the TSH receptor. Therefore, persistent thyroid disease is not proof that the iodine model is broken, but rather that localized compliance issues and typical background illnesses are now more visible.


  • The Con-Steelman Argument (The Pathogenic Reality of Non-Iodine Drivers):

    Blaming persistent thyroid disease purely on poor compliance or random background noise ignores a clear medical reality: multi-centric studies in completely iodine-replete zones consistently find a high prevalence of goitre alongside low thyroid autoimmunity. This proves that large numbers of patients are developing structural colloid goitres despite having optimal iodine levels and no autoimmune disease.

    The persistence of these conditions highlights the significant, unaddressed role of environmental and dietary goitrogens, such as dimethyldisulfide from cruciferous vegetables, cyanogenic glucosides, and widespread industrial pollutants that disrupt thyroid function even when iodine levels are perfect. By attributing every thyroid issue to an iodine imbalance, the current public health strategy fails to address the real, non-iodine chemical and environmental factors that continue to damage population-wide endocrine health.



Provide an imrad summary, keywords thematic analysis of the content below focusing on how iodine deficiency became an important public health strategy even though the global epidemiologic data is not yet robust to have mandated a global public health intervention strategy considering that there are very many unknowns in this space and both goitre and hypothyroidism continues unabated in the post iodinisation era. Make your arguments using a Socratic steelman approach with significant points supporting both sides of the iodine etiologic divide.

Conversational learning Transcripts:

[29/05, 14:05]hu1: The man behind iodosed salt Dr. Vulimiri Ramalingaswami from Srikakulam, AP. Kangra Valley experiment he took up when he was AIIMS, Delhi director.
Jade basedow phenomenon : when patients from hilly regions of Himalayas like Kashmir, their Thyroid receptors are upregulated while they consume low iodine, when they move to Delhi, while they get adequate iodine  their Thyroid Gland secret excess Thyroid hormone to cause Hyperthyroidism.



[29/05, 14:06]hu1: Iodised salt


[29/05, 14:15]hu1: Wolf-chaikoff effect opposite to Jade basedow phenomenon : When Chernobyl atomic reactor blast during early 1980s? local people were supplied Potassium Iodide tablets.
When people consume Potassium Iodide, Thyroid Gland would be amazed, from where i am getting so much Iodine........... Stop uptaking iodine, which was contaminated by Radio active material from environment, food, water.
Thyroid cancers were prevented after Chernobyl blast.


[29/05, 15:18]hu2: Currently seeing this patient of Goitre in OPD which has been FNACed already by Dr ... and @Dr...and their pathology team.

A question for everyone here in this context:

What could be the etiology in this patient? Is it related to iodine?


[29/05, 15:19]hu2: Signed informed consent has been collected from this patient before sharing her data, which has been meticulously deidentified


[29/05, 15:21]hu1: Graves? Hyperthyroidism if it is painless.


[29/05, 15:21]hu2: No clinical features of Graves


[29/05, 15:21]hu1: Ok


[29/05, 15:22]hu1: No nodules even


[29/05, 15:22]hu1: Painful


[29/05, 15:23]hu2: No nodules, painless


[29/05, 15:23]hu1: Ok

[29/05, 15:23]hu1: Thyroid Ultrasound?

[29/05, 15:24]hu2: Slowly progressive since 10-20 years

Typical of a colloid goitre

The intriguing question here is what causes colloid goitre here in Telangana in a relatively well iodised area?


[29/05, 15:24]hu2: The report is attached above along with fnac


[29/05, 15:24]hu1: But people here don't use iodised salt


[29/05, 15:25]hu1: They use what we call doddu uppu.


[29/05, 15:26] hu2 : Is Telangana deficient in iodine similar to sub Himalayan goitre belts such as Kangra valley as in your example?

[29/05, 15:27] hu1: How is T3, T4, TSH


[29/05, 15:29]hu1: TPO Antibody?


[29/05, 15:32]hu2: I'm assuming it's normal although the patient just left

Because it's clinically more of a simple colloid goitre the pre test probability for TPO coming positive was low and hence not tested


[29/05, 15:32]hu3: Diffuse hyperplastic goiter  smooth surface with regular margins involving the entire gland  endemic  ( iodine def)  goiter?


[29/05, 15:32]hu2: Thanks

Yes but the moot question here is:

Sub himalayan goitre belt are well known with most colloid goitre attributed to iodine deficiency but what's the reason for many other colloid goitres in other parts of India other than sub Himalayan region?


[29/05, 15:35]hu2 : One of the studies undertaken from an institution of national importance to answer this question found:

"There was a high prevalence of goitre despite iodine repletion and low thyroid autoimmunity.



[29/05, 15:37]hu2: 👆So while Dr Ramalingaswami's discovery is a great landmark current research leaves us with more questions around colloid goitre than what can be explained by iodine deficiency alone

[29/05, 15:39]hu3: She needs surgery if COMPRESSIVE SYMPTOMS R PRESENT  AFTER THE PT IS BROUGHT TO NEAR EU THYROID LEVEL


[29/05, 15:40]hu2: Yes we have asked her to meet the surgery team although her current issues are related to referred temporal pain due to  caries teeth


[29/05, 15:40]hu2: Patient is absolutely euthyroid


[29/05, 15:41]hu2: She's currently ready for surgery although her mild metabolic syn phenotype puts her at moderate cardiac risk


[29/05, 15:43]hu3: 7 percent of long standing colloid goiters though they r benign may have risk of developing  papillery/ follicular carcinoma


[29/05, 18:05] hu1 : There would be sporadic cases. He did work up in 1 L patients.

That sample size is very large and robust.

[29/05, 18:07] hu1: With iodised salt cases have come down from 35% to 5%. 
Thats great reduction.
He did survey in the year 1955.

[29/05, 18:11] hu1 : Structural functional Thyroid receptor malformation is the cause??


[29/05, 19:11] hu4: Iodine deficiency is only one of the causes for a goitre, though the numbers have come down these days.
The other large group of etiological factors are
Autoimmune ( an important cause), genetic due to mutations in TSH receptor/ hereditary ,drug induced and sometimes it is part of certain syndromes such as plummer vinson syndrome ( rare condition)...

[29/05, 19:13] hu1: TPO antibodies
TSH receptor autoantibodies

[29/05, 19:16] hu1: Normally one autoimmune disorder overlap with others.


[29/05, 19:19] hu1 : Still in our villages people use noniodised salt.
Recently i went to Flipcart one lady gave me salt saying organic. Its noniodised.


[29/05, 19:20] hu4: Frequent Consumption of goitrogens,such as cabbage etc, another reason in sensitive individuals


[29/05, 19:21] hu1: Yes


Even drugs.

[29/05, 19:36] hu3 : Psychiatric drug LITHIUM   ANTI TB DRUGS  PAS  CERTAIN ANTI ARRYTHEMIC ( CARDIAC) DRUGS  CAN INDUCE GOITER FORMATION THEY CAUSE MILD TO MODERATE ENLARGEMENT OF THYROID GLAND UNLIKE ENDEMIC GOITER WHICH ATTAINS HUGE SIZE WITH COMPLICATIONS


[29/05, 20:11] hu2: Amiodarone


[29/05, 20:13] hu1 : In the year 2002 i have seen 3 cases of Lung fibrosis while working in ... hospital those days which was opposite to secretariat. 
... Sir use to be there.
He is good teacher. Very friendly. Later became very busy.


[29/05, 20:14]hu1: Amiodarone was the cause

[29/05, 20:15]hu1: I did one duty with Dr. ... Sir.


Now they are not reachable


[30/05, 07:47] hu1: The most common cause of Hypothyroidism world wide is iodine defeciency.

The common cases what physicians observe Primary Hypothyroidism.
Hasimotos thyroiditis what physicians observe in Primary Hypothyroidism.
Anti thyroid peroxidase antibodies, Anti Thyroglobulin antibodies damage the gland.

[30/05, 08:56] hu2: Thanks for sharing.

To summarise from yesterday's discussion:

The link between endemic goiter and iodine deficiency has been researched in India by several eminent researchers, and this has led to the publication of several important reports.

Critical research has resulted in endemic goiter being reported from all over the country and not just from the Himalayan and Sub-Himalayan regions. 

Researchers from New Delhi had shown that this was linked to iodine deficiency and that this resulted in decompensated hypothyroidism in many cases.This led to landmark studies which showed that iodine deficiency was associated with hypothyroidism in neonates, setting the scene for the now legendary salt iodization program supported by the Government of India.




In the postiodization phase, what happens to the prevalence of goiter? This very important question was answered in a study linked below. The researchers noted that thyroid autoimmunity could only partly explain the goiter and concluded that the role of goitrogens is an area that deserves further study.👇



[30/05, 09:02]hu1: This sample size is not enough to get P value of 0.05.
Minimum 3500 pts are required in each arm.
It means sample size should be more than 7500.


[30/05, 09:03]hu1: Still journals accept these studies.



[30/05, 09:15]hu2: Why journals don't go by p values was also brought out around our recent discussion on resmetirom as discussed globally after it was inspired by @⁨hu1 and the local institutional discussion here.

More around that journal club, which continues even today as archived here:

Again the above discussion around the original drug that inspired it has now become pretty dense to follow especially because of the TLDR content and hence it's better avoided for now.

The content below is useful and recommended to understand why p values are no longer considered by journal editors 👇

Many scientific journals are shifting away from relying solely on p-values (often the p < 0.05 threshold) because of widespread misinterpretation, data manipulation, and a "reproducibility crisis" in scientific research. [1, 2, 3]  

Journals are updating their policies to fix these issues in a few key ways: 

1. Misleading Results 

A p-value only tells you the probability of getting your data by pure random chance if there is actually no real effect. It does not measure the size, importance, or clinical relevance of an effect. For instance, a drug might have a statistically "significant" effect on reducing cholesterol by a microscopic $0.5\%$, but it is practically useless to a patient. [2, 4, 5, 6, 7]  

2. p-hacking 

Relying on a strict p-value cutoff creates perverse incentives. Some researchers engage in "p-hacking"—manipulating, tweaking, or selectively analyzing data until they cross the magic 0.05 threshold. This leads to published findings that are often false or impossible for other scientists to replicate. [1, 2, 3, 8]  

3. Publication Bias 

Journals historically preferred "positive" results (showing an effect) while ignoring "negative" or "null" results that didn't yield a significant p-value. This skewed the scientific record, so many journals now explicitly welcome all rigorous studies regardless of their p-value. [3, 9, 10, 11, 12]  

What Journals Use Instead 

Instead of binary "yes/no" significance, leading journals (like the New England Journal of Medicine, Epidemiology, and the International Journal of Epidemiology) now require or strongly encourage: 

• Effect Sizes: Measuring exactly how large or meaningful an observed difference is. 

• Confidence Intervals (CIs): Giving a range of plausible values to show the precision and uncertainty of the data. 

• Study Preregistration: Requiring scientists to lock in their methods and analysis plans before looking at the data to prevent p-hacking. [3, 5, 6, 13, 14]  


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