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It takes an odd gumption and a total mastery over the medium to make a film like ‘Dunkirk’. You can’t think of anyone better than Christopher Nolan to do this.

Provided with the barest minimum of background, the viewer is hurled into the terse action of a World War II incident. It’s all around you, all the time. The scenes over the skies, in the sea and the beach are breathtaking. Background score is brilliant, drums pounding out the inevitable doom unless when they accelerate tempo to signify visceral action. The staccato of the machine guns, the pounding of the cannons and the empty sound of the sea engulf your heart not the ear.

The way Nolan converges three parallel plot timelines with different tempos (a few days of a soldier, a few hours of a civilian rescuer and an hour or so of a fighter pilot) inexorably into the very climax is superb and must be a cinematic highpoint. What a master storyteller!

There’s hardly a skeleton of a story. No strategy rooms, no lonely soldier pining for his beloved from the trenches, no martyrs wrapped in flags to gun salutes. There is no invincible hero fighting behind enemy lines or evil enemy commanders. Indeed there is no filmy heroism or villainy.

But there’s emotion, raw and nearly all of it understated: fear, despair, desperation and glimpses of grit. There is very little drama not when men do good under duress, but when they crack. There’s no celebration at crisis resolution: only acceptance, tired faces, hung heads and relief.

And above all there’s character: in the father, who lost his first son three weeks into the war, who sails into ground zero in his private boat to rescue stranded soldiers with his second teenage son; in the British admiral who stays back to evacuate every man in his watch and then waits to help the French soldiers; in the RAF fighter pilot who saves the day going after a Luftwaffe bomber though he has run out of fuel and in the boy who forgives a war-stricken soldier who accidentally killed the boy’s mate.

This is pure war. And pure cinema. Whoever thought that you could say so less yet tell so much!
Just don’t miss this beauty!

A dear friend and colleague, Dr Vivek Baliga has written this very informative article about heart attack on his blog.

Here’s the link:

http://heartsense.in/chest-pain-and-heart-attacks-what-to-do/

Coronary Stents
Coronary stents have been around for a few decades. They are used to treat narrowed arteries of the heart to alleviate cardiac chest pain, termed angina, and during a heart attack while performing life saving coronary angioplasties. Nearly all of the coronary stents are made of metal and crudely resemble a spring inside your ballpoint pen. The best long-term results are seen with drug eluting stents (DES) that are essentially the metallic stents coated with special medicines to improve performance.
Downside of metallic stents
Metallic stents including DES, have a few perceived drawbacks. The main ones are:
1. A metal is left behind after an angioplasty. Some patients are conscious that they are carrying a foreign object. This is perhaps the least of the concerns.
2. Very late stent failure (>1 year after implantation) and Very very late stent failure (>5 years after implantation) are known to occur. These are related to presence of the metal or the adhesive that binds the metal to the drug.
3. Coronary arteries have dynamic physical properties. For example, expansion of calibre when more flow of blood is needed termed vasodilation. They also possess biochemical properties such as secretion of local hormones that are beneficial. The metal from the DES cages the artery from inside this preventing it from demonstrating these properties.
4. If long segments of coronary arteries are treated with metallic DES, in the event of a subsequent Bypass surgery, the cardiac surgeon has difficulty finding a place to stick the grafts.
Case for Stents that dissolve after their job is over!
 A stent that would stay for 3-6 months after implantation and disappear after that would be an ideal foil to address these problems. This was the premise with which scientists invented Absorbable Stents. The basic material used to build absorbable stents could be either metal (magnesium, zinc) or polymer (Poly-L-lactic acid, PLLA) that has appropriate degradation characteristics.
Absorb™ BVS
The absorbable stent that has shown the best performance is the Abbott’s Bioresorbable Vascular Scaffold (BVS), Absorb™. Absorb is the only fully dissolvable stent system approved for clinical use (also received FDA approval in July 2016). The clinical evidence for its efficiency and safety comes from a series of clinical research trials called as the ABSORB trials.
In ABSORB trial 29 of the 30 patients who underwent implantation of the BVS, first reported in 2011), continued to​ do well at 5 years. The comparative study of the BVS with Abbott’s own best performing metallic DES, Xience™ called ABSORB II showed that as late as 2 years on, the two stents were more or less similar in efficacy and safety. The patients with the BVS had similar relief from symptoms and somewhat similar, low failure rates. But it was really the results of the ABSORB III a large enough study for doctors to generalise conclusions from that really proved that the BVS performed as well as the DES. The abrupt and gradual failures​ of the BVS were seen in a few patients more than with the DES but the statistical analysis suggested that it was due to chance rather than a true difference between the stents. With these results, and the USFDA approval, the BVS was ready to go places. In India and some European countries the Absorb BVS was already popular even before the USFDA approval.
Is there an issue now?
While superficially the promise seems to hold, of late some mixed signals are emerging with the use of Absorb BVS. The 3-year results from ABSORB II trial showed a higher rate of heart attack and stent failure with the BVS compared to the metallic DES. The difference was so striking that the trial’s lead investigator, Dr Patrick Serruys termed these results as unexpected and disappointing. The setback seemed more alarming because it happened in patients who were not expected to have these complications. In fact, these were the patients who were being regularly followed up and had shown no warning signs of problems!
Are there signals from ABSORB lll?
The ongoing trial ABSORB III has also shown some issues when the BVS is implanted in coronary arteries of smaller calibre. The lead investigator of that trial, Dr Stephen Ellis has cautioned against the use of BVS in smaller vessels. The manufacturer Abbott Vascular seems to endorse this view, at least partially.
What happens now?
Experts acknowledge that there are some niggling issues with the current iteration of the absorbable stent. Clearly, they cannot be used in all types of arteries from all types of patients. So over enthusiastic implantation regardless of patient type just because of patient’s request or affordability is a definite no!
Secondly, Absorbable Stent technology is a definite breakthrough. Further research from scientists will certainly iron out the issues faced by the first generation of dissolvable stent systems. Until then, bioabsorbable stents are meant for very select individuals in carefully monitored environments such as research trials and registries.
Cardiac doctors have been very perceptive and careful in examining and reporting even minor failures. It is this culture of scientific temperament that has lead to tremendous advances in cardiology. We look forward to great times ahead.
SanthoshSanthosh Padmanabhan, Runner, ‘monk’, teacher to the underprivileged at the Ananya & Thulir schools and the chief coach from the running club, Runners’ High of which I was once a part, wrote a mail to me asking me about the appropriateness of routine health checks for runners who were newly joining him. This was my reply.
Dear Santhosh,

In this mail let me address the issue of preventive health checks.

I am aware that there is a large debate in the realm of public health whether preventive health checks are effective/useful or not.

What do people who are opposed to health checks say?

The detractors of health checks seem to point out that
a. Preventive health checks do not truly prevent diseases or their complications
b. On the contrary, they actually increase the number of diagnostic tests, medicine use & even increased number of surgical procedures.

I’ll give two examples to support the above concern:
1. There is a condition known as sub-clinical hypothyroidism, where the thyroid is mildly dysfunctional but not enough to cause biological abnormalities. Some and not all patients of sub-clinical hypothyroidism progress to develop actual thyroid disease and its complications. Routine health checks targeting thyroid disease can detect sub-clinical hypothyroidism. This in turn triggers additional hormonal and antibody testing by the doctors reading the test results. Also a number of physicians prefer to prescribe medications on detection of this sub-clinical hypothyroidism.

Yet, there is no clinical evidence that any of these testing or prescription of hormonal replacement benefits the patient!

2. Mammography is a routine health check test as many of us know. It is said to detect breast cancers very early and thus prevent breast cancer related deaths. Typically, very early cancers detected by mammography necessitates a counseling session and in most instances such counseling leads to the patient opting for limited surgery i.e.,removal of the affected breast.

Recent evidence, however has shown that about 50% of very early cancers detected by mammography disappear over a period of time, indicating that body’s own immune mechanisms are able to weed out many of the cancerous cells.

Logical projections have allowed public health scientists to conclude that:

If we do not detect these very early cancers, i.e., not perform routine mammography, but employ clinical methods of breast cancer surveillance, like self examination or periodic physical examination of the breasts by experienced physicians, that itself would lead to detection of cancer early enough to offer limited surgery. Technically this means that avoiding mammography in routine health checks would avoid unnecessary breast removals in 50% women without putting the other 50% to any disadvantage.

In both these above instances, imagine the psychological trauma, additional testing/ treatment and above all the huge healthcare cost burden to the society.

Does this mean that all health check is bunk?

No.

Complete health check or full body health check is not a panacea to all ill health. However, in specific disease entities early detection has been shown to change the course of disease. I’ll again give two examples:

1. Hypertension: Early detection of severe hypertension and its treatment has been clearly shown to be a very important and cost effective public health initiative. Such detection and proper treatment reduces complications like kidney failure, heart failure and strokes. This has been proven beyond doubt.

2. Screening for cervical cancer in women by Pap smear detects such cancer pretty early. It has been adequately proven by public health research that such screening allows very early treatment, surgical and otherwise, of women with cervical cancer. And such early treatment not only saves lives, but also saves a lot of money which would have been otherwise spent in treating, in futility, advanced cervical cancer.

So what do these examples tell us?

That there is no generalization possible on usefulness or otherwise of preventive health checks. In high end private clinics esp in western countries, tests such as whole body CT or MRI scans and other high cost tests are included in such health checks and are obviously useless and may even be harmful.

On the other hand in a country like India, where basic health awareness is poor health checks (which include testing of blood pressure, examination of the heart for possible valve disease and holes, testing for blood sugar, blood cholesterol, screening for cervical cancer) are not just useful, they should be made compulsory. In fact, with years of experience, I have realized that a large number of patients who come to us for ‘preventive health checks’ mandated by their insurance company or their employers etc have never undergone even basic screening earlier. Indeed, but for this compulsion, many of these individual would not have got their blood pressure, cholesterol or sugar checked. In India, where nearly 14% have diabetes, 10% have hypertension and about 8% have some form of cholesterol abnormality, such neglect would be a massive public health blunder.

The topic of preventive health check is very complex. Indeed, there is almost nothing preventive about such health checks. Such checks actually, give an accurate view of the problems that the patient already has.

Let me clarify: preventive health check will not prevent diabetes or hypertension. On the other hand, it will diagnose a hitherto undiagnosed diabetes etc and help prevent the complications.

So in my opinion, we need preventive health checks as long as they are designed to detect health issues for which early prevention is beneficial. We certainly do not need fancy tests like whole body scanning.

Towards the end of this mail, I should still address the issue of your runners needing health check. I do not know, if RH knows this: there were 4 patients who had heart attacks and one who actually died during our last annual long run of the city. And this wasn’t even a half marathon. We (Fortis is a medical partner for a large number of running events) realized that, often our runners are fueled by zeal rather than meticulous training. A reasonable number of runners believe that running absolves them of all sins: many smoke, a lot have poor eating habits, some sleep badly and most have work stress.

Testing our fitness for the events at hand is imperative under three circumstances:

a. If you are embarking upon a new endurance activity like long distance running, especially after a certain age (I would peg it at 30 years in India, as against 40 in the Caucasians, due to our inherent genetic risks) you must ensure that you have no medical issues.

b. People with risk factors like high BP, sugar, cholesterol, smoking, family history etc should certainly test themselves before starting ANY exercise program

c. There are unsuspecting conditions such as valve diseases, hypertrophic cardiomyopathy etc which will not be detected even on a routine health check. Special tests like echocardiography are required to exclude these conditions, which are often fatal. A 1500 rupee test once in a life time to make sure you are not going to collapse on the race? Far cheaper than the travel insurance which you keep buying for 110 rupees every time you fly domestic!!

Lastly, as an organization, Santhosh, there will be a question of liability, if one of the runners should develop a problem during a training run. While it is easy to absolve yourself with a declaration from the runners that you are not liable for any issues they have or develop during training (like how how the running events take a declaration from the participants during mega events), I believe that people like you, who have been responsible for making running popular among public, are justified in taking precautions to ensure that running does not get adverse publicity by untoward events on the track.

So as a cardiologist practicing in a country which is now declared the capital of heart diseases in the world, I’m entirely with you if you (autocratically) mandate that your runners have health checks before long distance running. In fact, I believe, you are doing them a favor by insisting on such testing!

The sweeping allegation of corruption against doctors in Aamir Khan’s talk show was something that was waiting to happen. Too many people believe that a good number of doctors are out to get their money, by hook or crook! Clearly the show itself was one-sided: there are a large number of doctors that are not corrupt; even where individual cases of alleged wrong practice was projected on the show, the accused were given no chance to defend themselves. Aamir was judge, jury and the executioner. Despite this, the criticism of the manner of the show is not to say that all doctors are honest.

This piece is not about whether or not doctors are corrupt. This is not even about why they are forced to be corrupt. A chain email is already doing that job of condemning ‘Satyameva Jayate’, and extolling the greatness of doctors toiling under adverse educational, vocational and financial circumstances. I am just examining how some doctors end up indulging in malpractices and dishonesty in their professional lives.

Most of the doctors I know are personally fine people. There is far less lying, adultery, cheating, scandals and financial scams involving doctors than say, film actors! Yet, like any government clerks, private IT managers and bankers, some doctors are unscrupulous in their work.

Root cause analyses will lead us to two factors: Comparatively poorer remunerations across the nation and across private or government sectors are given to doctors when you consider their age, qualification and training. A 30 year old MD who puts in six and a half years in graduation and another three years in post graduation is offered thirty thousand rupees (less that $600) a month in private hospitals. Government service provides even less! A ‘software engineer’ even without a post graduation, a CA who is much younger earns at least twice this amount in Metros at start up. A professor in the prestigious AIIMS who teaches life-saving skills to younger doctors while actually treating Governors and Supreme Court Judges would barely receive a 6 figure salary at retirement. Compare this with the professors at IIMs and you will realize, similar skills do not yield similar remunerations.

In smaller towns and villages the situation is worse. If an MBBS doctor charges Rs five for a consultation (very frequent in rural Karnataka), imagine the number of patients he has to see just to bring home groceries worth Rs 4000 a month! The examples can actually go on, but the fundamental issue is doctors feel, and often justifiably so, that they are underpaid, while the world around them seems to have a great time!

Of course, that you have less money is no excuse for turning to burglary or kickbacks. But, on the other hand, when has affluence prevented greed & gluttony? All around us, we see people who are illegally wealthy, yet continuing to indulge profiteering. The mining scam in Karnataka or the 2G controversy are huge examples. This brings us to the other fundamental point:

Some doctors are corrupt, not just because they are underpaid, but corruptibility is in the grain of our society. I would really like to go back in time and see if during the time of Lord Rama, people in India were honest and just. But at least, during my own lifetime – I’m 45 now – I haven’t seen many Indians around me that are honest or transparent! Our society seems to be full of people whose only aim is climbing up the social and financial ladders at any cost. Morality and honesty are sacrificed at the altar of selfish personal gain. How, then, do you expect the doctors alone to be clad in pure white? Have you ever waited at midnight for the traffic lights to turn green, when all around you, others are driving through the red light, just because there are no cops? How long can you hold on to your principles there, without looking like a moron who is not ‘smart’?

After all, when a doctor finishes medical school, he doesn’t come out trained in malpractice. It is the community around him that urges him to issue a bogus medical certificate, offer kickbacks for referring tests to a laboratory and even abort a female foetus! So the society reaps as it sows. In fact, it is a testimony to the doctor community’s integrity that only a few among them succumb to these temptations!

It is very fine for people like Aamir Khan to want doctors to put patients before themselves, others before their own families and to feel that doctors must serve and not think of money! But doctors too live in the same society which demands bribes and kickbacks. No registrar gives a discount to the doctor on the bribe amount for registering a property! Shows like Satyameva Jayate appeal to the viewer by ‘sensational’ expose’s but fail to address more fundamental issues. If you look close enough, you realize that when it comes to the moral fabric of the society, it is only Mithyameva Jayate! Given the size of that problem, it is well nigh impossible for medical practice to totally rid of dishonesty and corruption. So, don’t expect this problem to go away. It will only change with society. Or Armageddon! Also be thankful that despite so much pressure to be otherwise, a large majority of doctors are actually honest and incorrupt!

bcpRecently, Hema my niece sent me this chain mail and asked my opinion about it

“PASS THIS ON EVEN IF YOU DO NOT USE IT

Recently this past week, my cousin Nicole Dishuk (age 31…newly graduated student with a doctoral degree about to start her new career as a Doctor…) was flown into a nearby hospital, because she passed out.

They found a blood clot in her neck, and immediately took her by helicopter to the ER to operate. By the time they removed the right half of her skull to relieve the pressure on her brain; the clot had spread to her brain causing severe damage.

Since last Wednesday night, she was battling… they induced her into a coma to stop the blood flow, they operated 3 times… Finally, they said there was nothing left that they could do… they found multiple clots in the left side of her brain… the swelling wouldn’t stop, and she was on life support…

She died at 4:30 yesterday. She leaves behind a husband, a 2yr old Brandon and a 4yr old Justin… The CAUSE of DEATH – they found was a birth control she was taking that allows you to only have your period 3 times a year… They said it interrupts life’s menstrual cycle, and although it is FDA approved… shouldn’t be – So to the women in my address book – I ask you to boycott this product & deal with your period once a month – so you can live the rest of the months that your life has in store for you….”

The mail goes on to name the products by trade name and asks people to boycott them. Hem wanted me to opine on this. Here is my reply to her:

Every drug has side effects. But in general, modern drugs will undergo many checks and tests in order to be extremely safe. So it is unlikely that hundreds and hundreds of women who take birth control pill drugs are dying such horrible deaths regularly.

Let me illustrate safety of important drugs with an example. A patient of mine, who has a serious heart disease,  is on aspirin for many years. We know that aspirin prevents death due to heart attacks and strokes. So, it is possible that this guy lives on thanks to aspirin.

Now, the other day this patient started vomiting blood and was rushed to the hospital almost in an unconscious state. Fortunately we were all there and despite the fact that he had vomited over one and a half litres of blood we managed to transfuse blood to him and take him up for a test called as endoscopy. This test showed that he had a huge ulcer in the stomach which was continuously bleeding. That bleeding was controlled by endoscopic treatment and the patient went home after 3 days of recovery time.

I can easily make a huge story about this and send a chain email which says: Aspirin causes big bleeding ulcers and you can die of a horrible death, so all you heart patients please stop taking aspirin! And also I could request ‘everyone who cares about your near and dear ones to forward this mail to as many people as possible and prevent hundreds of deaths!’ Yet I prescribe aspirin to literally hundreds every month because it saves too many lives

If you ban birth control pills based on such sensational stories then you will have a billion people in each state of India and we will all die because there will not be enough food to eat for all of us!

It is possible that this story is true. But whoever wrote it up made it look so  gruesome to you tend to vilify the drug. And when you read this, you are not reading the positive side of this drug. Worse, people maybe forwarding such mails to their contacts without even verifying if it was true thus causing panic and misinformation about drugs.

As I said at the beginning, every drug has side effects. Thanks to research and regulations modern drugs are very safe and serious side effects are extremely rare. Rather, far more lives are saved by the good effects of drugs than are lost due to their adverse effects. Patients who take medicines should consult doctors and learn about the positive and negative effects of drugs, balance the possible risks with possible benefits and then take the decision to use the drug or not, rather than being tricked by such mails!

If you have more chain mails on medical stuff, send them to me. Let’s look at them objectively.

Simple problems need simple & straightforward solutions. On the face that’s how the honorable health minister’s prescription for the ailing health of Indian rural Medical system. So, all medical students of India shall serve a one-year rural term before getting into any postgraduate specialist training. Lo and behold, all our villagers will brim with good health.

 

If the solution to this massive rural-urban healthcare disparity was so simple, why did it take so long to be thought of!

 

In all fairness to the medicos let’s examine the issue closely.

 

Unlike in the US, the average medical student enters medical school after class 12, meaning he (also could be a she, but forget about being politically correct, that’s not the issue here) is 16-17 years of age. MBBS is 5 years plus a year’s internship. Having gone through the mill, let me assure you that a majority of doctors who come out of medical school after MBBS are clueless about clinical practice. Our system teaches them how to examine patients, how to assist consultants in their surgeries and clinics, but fails to teach them how to prescribe medicines and worst of all, there is absolutely no training in interpersonal communication. A fairly large number of MBBS doctors would never have experienced how to discuss the pros and cons of let’s say undergoing HIV testing. Or how to declare to a family that a beloved one is dead.

 

Equipped with this kind of ability to practice, to deal with the illnesses of our rural kindred, look at what he is armed with. A large number primary health centers in the country function without adequate medicines, lab facilities, x-rays, nurses & technicians. In the absence of all these, how does our man diagnose the diseases? And in cases where he can, does the paper on which the prescription is written cure the patient. Remember, utter poverty prevents a great majority of patients in the villages from buying medicines.

 

If indeed shortage of doctors in rural areas is the reason for making rural tenure compulsory, why not make it universal. Why only sent PGs-in-training to the villages? This is where our honorable health minister has taken the easy way out: unlike the MBBS students, interns or practicing doctors, PGs are almost at the mercy of the authorities. If they are sent they better go, or else they won’t get the degree. Come on doctor, why don’t you send your in-service doctors to the villages? It is no secret that a large number of doctors in government service posted in rural areas are actually sitting in urban or semi-urban areas by hook or crook. Governments have realized that it is impossible to take corrective action against serving employees. Whereas PG students will have neither choice nor voice against this decision.

 

Is there an educational advantage for the PGs to be posted in villages? True, they get a closer look at the medical problems of rural India. The exposure to some of the third world problems such as rheumatic heart disease is so great in rural India that I know of doctors in US coming to India to study tropical medicine in this population. However, learning cannot happen in the absence of diagnostic aids. If clinical suspicion of disease cannot be confirmed by laboratory or imaging techniques, do you really learn something out of that case? Learning how to treat diseases merely on basis of clinical suspicion is not scientific medicine. Our rural doctors have no choice, but to allow PGs to learn this kind of medicine is certainly not on.

 

What about comparative economics? In a good number of cases, medicine is chosen as a career by the top students in the class. Having been brilliant throughout and for the six year toil, the salaries offered by most governments in the country are at best pathetic. Contrast a student who after 3 year BSc or 4 year BE earning 5-figure monthly salaries. And if there is a 2 year MBA thrown in, earnings could cross a lakh a month.

 

It is nobody’s case that a non-medical man should not earn comparatively larger amounts of money. But then, after any sort of education, most people are given the freedom to work where they want. In places where labor of any kind is difficult to obtain, financial incentives are given so as to compensate for the inconvenience caused. A PG cannot claim any of this and will become a hapless scapegoat of one more governmental scam.

 

Improvement of rural medical facilities is truly an important requirement. Invest in hospitals and well-equipped clinics in villages and towns, pay the doctors well enough and then rural medical service may improve. If building hospitals in non-urban areas is made a profitable business, private players will also come in. Strategies for these have to be thought of. But all these ideas need men of steel to think and execute. In the absence of such steel, people like the hapless PGs will suffer.

  

 

Playing God comes easy for doctors. It is all too common for a cardiologist to think that the life saved was due to his/her own effort. In any case such a happy ending to a sick patient’s sojourn in the ICCU always gives a great feeling. But today my dilemma was a different one.

 

A seventy year old man is in my hospital as we speak. He has a hole in his heart from birth & that’s troubling him now. He’s better after receiving some medicines but my problem is whether to go the whole hog & send him up for surgery. The basic pro-con question is, whether to take a five or six percent risk of death during surgery on a seventy year old gentleman who has seen it all, or let him live on medications for an indeterminate time period without putting him into an immediate man-made risk. Remember, average lifespan in India is 65 years for men & this man has seen his great-grand child.

 

The family looks up to me to take a decision. “We trust you. Do whatever is best for him. But please make sure that he’s alright”. The last line is a killer!

 

I took this problem to a very senior colleague of mine. He asked me to perform some more tests & see if the old man merits surgery. My problem is not that. Intuitively I know that the man will qualify for surgery after the tests. But before running those expensive tests (he has no insurance – has to pay from his pocket), what I need to know is, if he does merit surgery, should I send him to the surgeon?

 

I think the question is not of mathematics: Five or 6% risk is small so should we try to beat the odds?

 

The real question is: If I send him for surgery, and if he dies, can I shrug my shoulders & walk off from the family?

 

The real question is: What are the true odds that he will do as well without surgery?

 

Who will ever know the real answers?