Posted in bio ethics, Medical education, Medical ethics, medical satistics, tagged best medical quotes, bmj, dr venkatesan sangareddi, first do no harm primum nocere, hippocrates, Hippocratic oath, inappropriate medcial care, jamanetwrok, lancet, madras medical college, medcial ethics, medical science future, nejm, nobel prize in medicine, over treatment, principles of practice of medicine, william osler on September 8, 2023|
Postamble
This quote is being sent for the annual meet of “Right care movement” I know ,this can sound outrageous, permissble limits of abuse ? Up to 2% or 5% ? Let it be anything . Meanwhile try to enlighten yourself , the key differences between misuse & abuse.
Posted in Cardiology quotes, cardiology-ethics, Uncategorized, tagged bmj, future of medicine, google scholor, H index, hippocrates ethics, Hippocratic oath, i Index, Impact factor, jama network, kos island, lance, medical ethics, medical research issues, nejm, peer reviewed medical journal, principles of medical education, pubmed, SCIMAGO score, scopus, source normalised Impact factor on March 5, 2022|
“Publish or perish “
This sound bite is regularly uttered by all academic leads in any university or medical school. I don’t know, why this bothers me. Looking back, many of our mentors & professors never had any great publications. Still, they were extraordinary teachers and wonderful clinicians with great wisdom. They created generations of high-quality doctors who are present all over the globe now. Is scientific publication that important in a doctor’s life? After pondering for quite some time, got a hazy answer to that query in one of my sleepless early morning academic dreams.
Hippocrates was one of the applicants for the post of professor of medicine at Harvard medical school.His application was rejected for a dismally low H index. The reluctant father of medicine tried to impress the authorities, by telling them that his experience was vast and used to teach medicine 2000 years ago, well before their country USA was discovered. The father of medicine almost begged to reconsider their decision.The miffed Harvard academic office ridiculed the old man and insisted nothing will work, except a minimum H index of 50 or atleast 10 papers as first author in a peer reviewed high Impact factor journal. A dejected Hippocrates returned to Kos islands and asked his new generation fellows, what is this H index and Impact factor stuff ? His students were worried about their guru’s ignorance. They some how convinced the greatest ever medical teacher to urgently subscribe for a platinum membership of a premium medical authourship services located in the Boston suburb and fixed a 30 day deadline for his first manuscript.
(What is this H index ?) Why is it so popular?) Ref :
Off to Kos Islands
Now, let us travel back in time,2000 years ago to this picturesque nation, Kos islands in the Aegean sea,. This is where Hippocrates taught lessons under his favorite tree. No teaching apps, No 4k audiovisuals, The humble noise from within his lips became great wisdom thoughts. All that students had were set of ears to hear him. Hippocrates became the celebrated father of medicine for two reasons. He was the first to dispute the then-prevailing thoughts about human health and disease. He first proposed for every illness there is a hidden reason ie the beginning scientific basis. He insisted and negated the idea that diseases are bestowed upon by evil forces and spirits. The second one is more important. He realized knowledge, skill, and power are a deadly mix for the healing industry if they lack responsibility. He foresaw non-academic factors that will try to challenge the integrity of medical professionals and the health care delivery systems. It is astonishing to note how he could predict this 2000 years ago and wrote the behavior code for medical professionals which has become immortal.
How to grade the quality of medical professionals?
Scientific publication is just one of the indices of quality assessment for medical professionals. Grading them based on a few manufactured rating systems is beginning to look like an academic comical. There are many more visible and invisible, quantifiable and non-quantifiable quality assessment parameters that deserve attention.
Research & Innovations are indeed the pivotal pillars that take us to newer frontiers of medicine. But, It is explicitly clear now, the prime purpose of research is definitely not aimed at the growth of science. It is more of a survival tool, intertwined with commerce, status symbol, pride, peer pressure, self-esteem, rivalry, or just a filler for CV.
Final message
Blanket statements like Publish or perish at any cost could be a dangerous doctrine to adopt in medical education which is essentially about healing and caring (& whenever possible, curing). In one sense, medical teaching is little to do with research. Many of the great professors in our country never published a single paper. Unfortunately, research and teaching have been made to look inseparable. Beware, history has repeatedly taught us medical professionals need not be hyper-intelligent. They need to be just wise, men /women of integrity, enriched with sincerity, righteousness. Proper consumption of knowledge is much more important than the creation of it. Let us hope the future will be at least as perfect as the past.
Postamble
My H index stands at 15, I must confess I am confused a lot. Should I bother for more, or be just be happy to reach the H index of our mentor and father of medicine, which is numero Zero, and propagate his work.
Reference
2.Academic excellence does not always require publication Ernest L Boyer argued in his 1990 book, Scholarship Reconsidered: Priorities for the professoriate,(BoyerScholarshipReconsidered)
3.Too much academic research is being published https://www.universityworldnews.com/post.php?story=20180905095203579
Posted in Uncategorized, tagged bmj, ebm, ethics in science, evidence based medicine, lancet, medical education, nejm, new nejm journal on January 19, 2022|
The New England Journal of Medicine (NEJM) the premier journal in medicine originated two centuries ago, in 1811, when John Collins Warren, a Boston physician, along with James Jackson, submitted a formal prospectus to establish the New England Journal of Medicine and Surgery and Collateral Branches of Science as a medical and philosophical journal.
Subsequently, the Massachusetts Medical Society (MMS) purchased the Journal for US$1 and, in 1928, renamed it to The New England Journal of Medicine.
NEJM’s New Journey
It is 2022, after 200 years of providing explosive knowledge in medical science, MMS starts a new journal, fresh and bold. It is called NEJM Evidence. Can you guess, what is the need for such a journal now? I think the most battered word in science in current times is probably “ evidence”. It has a unique character of appearing most sacred as well as scandalous at the same time.
NEJM has remained the torchbearer of almost all advances in the medical field seen in the last two centuries. It is heartening to note the newborn is named as NEJM evidence. It has come at a critical juncture. I am sure, everyone will acknowledge that we are at difficult crossroads. Overwhelmed with unregulated scientific discoveries and publications, struggling to deal with self-inflicted knowledge pandemic. In the process, we have lost “not only” the ability to ignore trivial health issues “but also” failed to provide simple, cost-effective care to the real patients who desperately need it.
Let us hope, (& wish,) NEJM’s new prodigy will guide medical science towards a successful, meaningful, and ethically fulfilling journey for mankind. Meanwhile, let us pray for every medical scientist to be blessed with the required strength and courage to steer in the right direction, weeding off both academic and non-academic contaminants.
Posted in bio ethics, Cardiology - Clinical, tagged african children, bmj, cardiology, climate summit, evidence based medicine, green house effect, health outcome analysis, hunger, knowledge disease, lancet, logic in medicine, malnourished, nejm, obesity, poverty, rich vs poor, unequal world, unlearning in medicine on December 26, 2009| Leave a Comment »
When we get contaminated with excess knowledge , we lose our ability to think ! & Common sense is the casuality . . .
Human beings differ from other forms of life by their sixth sense . Our planet is few billion years old . Life came into existence over a million years ago .Our life has evolved over many thousands of years .The average life span of human race is 75 years . We need to realise , our life constitutes only a fraction of our planet’s life (<.0000001% ) . A may fly , which lives a life of less than a day , does it in style , looking for the light throughout the night , says good bye , to earth by morning leaving it unharmed . Actually , in terms of time , the life of the fly is just a fraction less than human life span , when compared to our planet’s life !
When these children are longing for food , some of earthly humans go to spend millions for obesity surgery ! That is the progress of knowledge driven society . . .
It is extremely common to experience the following scenario in any corporate hospitals of both developing and developed country .A uninsured or half insured ! person is refused entry into a hospital even for an emergency care while a wealthy person is lying comfortably watching TV in a five star suit of the same hospital after an inappropriate coronary angioplasty for an innocuous lesion of his heart !
The irony is , in this short span of earthly life , we want to prevail over the nature and conquer the planet . God is watching this human behavior silently . And he is smiling . . .
With all our knowledge base , modern science have done the maximum possible damage to our planet .We have made many lives extinct. If we tend to think , with the help of 6th sense we can become immortal , it would be the ultimate foolishness. When every one of us , is obsessed with our own health , we are deaf to the silent cries of our beloved planet earth .
Now , all of a sudden we realise all the accumulated knowledge & development has actually worked against us. We find our knowledge is dissociating our thoughts and now , we are fighting vigorously over acquiring the rights to damage our planet .
So it seems , the more we learn, less wisdom we have ! We may need to learn important lessons of living from all those species which do not boast to have the 6th sense !
Read a related article , excellent one published in British medical journal nearly 2 decades ago
Knowledge disease BMJ. 1993 December 18; 307(6919): 1578.
Posted in cardiology -Therapeutics, Cardiology -unresolved questions, cardiology-ethics, Uncategorized, tagged auditing health, bmj, cleansing medical literature, commerce in medicine, comparative effectiveness, cost effectiveness, drsvenkatesan, ethics in medicine, evidence based medicne, futile medicine, futility in medicine, health outcome analysis, hippocrates, inappropriate therapy, jama, medical greenhouse effectl, nejm, null hypothesis, optimisim, pessimissm, pessimissm vs optimissm, positive thinking, power of negative thinking, power of positive thinking, world climate summit on December 18, 2009| 1 Comment »
Pessimism, from the Latin pessimus (worst), is a state of mind which negatively colors the perception of life, especially with regard to future events.
Understanding pessimism is not that simple . Some people argue optimism represents a strong mind while a pessimism is the domain of the weak . But it is not necessarily true. Both pessimist and optimist are unreal , and playing the dangerous game of predicting the future. So realism is the answer .
In this era of information highways , commercial exploitation of science , our thought process is grossly determined by our perception of events.We hardly have an intention or time to analyse our thought process.
So how to identify good growth ? That is the million dollar question!
Actually the fundamental principle of scientific medicine lies in proving the null hypothesis null and void.Any treatment is useless until proved other wise . So pessimist can be argued to follow true science , while many of the hardcore optimists are blind believers ..
*It may be a harsh way of interpreting an optimist but uncontrolled optimism has played havoc in our patients like many of the failed treatments (Some of them released prematurely into patient domain has killed many lives . Power of positive thinking should be within the realms of scientific feasibility !
So in our journey to conquer human health , we may proceed with an optimistic mind and a pessimistic eyes !
This understanding is all the more important in this era of contaminated science .It is a well known fact , now last 50 years of planet earth has inflicted the maximum damage to ourselves than our ancestors did in 5000 years. That’s why we are compelled to meet at Copenhagen .(We never learn from our mistakes, that’s a different story !) .
There is definite and urgent need for world summit on cleansing the medical science from the clutches of commerce and ignorance . A medical green house effect, with dangerous holes in health care is imposing on us (Another pessimistic thought . . . of course in the interest of human kind !)
World health organization , a sleeping giant has to be awakened on this issue
Final message:
Mankind has evolved over many millenniums , probably with a sole purpose of living , that is reproduction and propagation of our genre without harming the environment and other species.
Unrestricted and unregulated growth of any kind is dangerous we call it as malignancy in pathology .In science , we tend to call it a” great future ”
Our sixth sense* has outgrown miserably out of reality , as have we decided to take on the nature and GOD .Now , many developing country men do not believe in death .They are fighting a losing battle against the God. And they suffer with escalating health costs of keeping the elderly , alive who are knocking at the doors of heaven or hell . The same countries, which deny funds for curable illnesses of the poor is a different story altogether !
The principle of modern medicine would ideally be
Read and learn for a complete guide on optimism and pessimism
* It is important to recognise , the same sixth sense has made it possible to share our views through a great tool of Internet . So we should not be against the growth of science but against the misuses and wrong interpretations of it .
The traditional characters of a pessimist
//
Posted in cardiac surgery, tagged bmj, clinicaltrials, doubleblinded, lancet, medicalresearch, nejm, observationalstudiesbetterthanrct, observationalstudyvsrct, plos, pubmed, Randomisedcontrolledtrial, rct, what is rct? on December 7, 2009| Leave a Comment »
What are the fundamental difference between randomised studies and observational studies ?
New discoveries come from shrewed observations made in bedside or labside while , randomised studies evaluate these discoveries for it’s effectiveness or futileness .
Let us realise , RCTs primarily never contribute to generation of original concepts or discoveries ! .It is a statistical tool to assess an observation .
Click below to reach the excellent knowledge source on above the issue .
PLoS Medicine: Observational Research, Randomised Trials, and Two Views of Medical Science
The fact that observational studies are done with open eyes & mind , it is obvious it demands intense conceptualization and thinking .
Blinded studies are mechanical studies . It is pure statistical research . It requires no thinking , medical mind , in fact one can do it with eyes closed as it is a strict protocol driven , even a non medical men can do a medical research , while it needs a alert mind to do a observational study .
Observational studies , especialy when done retrospectively has zero bias as the case selection and the potential intervention are completed even before the research question is raised. In fact many of the greatest medical breakthrough comes from retrospective analysis. Of course this has to be proved prospectively preferably in a randomised fashion.
So , we the medical professionals , shall do great observational research with open eyes and mind and let the the statisiticins do the outcome analysis blind folded .
If the core medical professionals are bothered more about randomised blinded studies ,which is meant only for evaluation purposes , the future of intellectual medical research is going to be in jeopardy!
Posted in Cardiology -unresolved questions, Cardiology hypertension, cardiology- coronary care, Cardiology-Arrhythmias, Cardiology-Coronary artery disese, Uncategorized, tagged ARBS, bmj, bnp, cardiology, chronic total occlusion, coronary care units, cost effectiveness, cpk mb, CRT, cto, ebm, ethics, ethics in cardiology, ethics in medicine, evidence based medicine, fondaparinux, heparin, hippocrates, hypertension, jacc, jama, jnc6, jnc7, lmwh, nejm, nstemi, pci, ptca, rescue pci, seminars in cardiology, stemi, troponin on August 19, 2009| Leave a Comment »
Coming soon : 10 more ways to increase cost of cardiology care . . .beyond common man’s reach
Posted in Uncategorized, tagged acc.aha, acs, angioplasty, bmj, circulation, cypher, des, drug abuse, ethics, europcr, evidence based cardiology, long stent, medical auditing, nejm, nstemi guidelines, pci, primary pci, ptca, rescue pci, scai, sirius, sirolimus, stemi guidelines, stents, sub acute stent thrombosis, taxus, tctmd, thrombolysis on January 18, 2009| Leave a Comment »
Drugs are poisons , whenever it is administered without valid purpose. it can enter human body in many ways (Oral, intravenous, percutaneous etc ) And now we have another route namely intracoronary !
In quest for prevention of restenosis, many of the anti cancer drugs are now delivered directly inside the coronary arteries .These drugs are secreted like a sustained release tablet from the drug coated stents.These drugs are expected to prevent restenosis within the stented segment.But, after years of intense debate and research , we realised that , drugs eluted from the stent could damage the distal coronary vascular bed and coronary microcirculation.( And thus came the epidemic of acute stent thrombosis ! )
The tender and sensitive coronary microvasculature is constantly exposed to these powerful anticancer and immmunosuppresive drugs .It is a great surprise , no body thought of this dangerous drug -coronary artery interaction ! It required the genius of Renu virmani and others to point out this.
But still , the cardiology community by and large , fails to consider this an important issue.This is proven by the fact, usage of DES is still increasing and used mainly as an off label indication.
A drug , to get a legal clearance it has to undergo hundreds of rigorous tests . Finally it is cleared for that specific indication for which it is tested .Just because a drug is cleared for one purpose ( Paclitaxel for malignancy ) it does not mean it is safe to use for any other purpose for which it is deemed to be useful . Exactly the opposite is happening in the the field of interventional cardiology . No body wondered to think what would be the effect of these drugs on the normal coronary endothelial cells and vasculature.Is it not a crime , without analysing this particular issue , dozens of drug eluting stents have been released in the market . And now, sounds of crying foul is heard world wide !
Let us thank , the so called negative forces in cardiology for making this an issue . In science , the watch dogs should bark at times of danger not wag the tail !
Posted in bio ethics, Cardiology -Interventional -PCI, cardiology- coronary care, tagged acc.aha, bmj, des, drug eluting stents, europcronline, evidence based cardiology, evidence based medicine, jacc, jama, lancet, tctmd on January 1, 2009| Leave a Comment »
Drug eluting stents : A slap on the face of Evidence based cardiology . . .
Click the BMJ link or read below
It is often said science is sacred and unfortunately we forget , science is not a heavenly creation and it is the creation of scientist of varying grades of integrity fueled by the vested interest of medical industry . It has been a almost a daily affair , some of the devices and drugs are recalled or found to be unsafe on patients.
Now the big cat has come out .The Drug eluting stent has fallen from Hero to Zero in a short span of 5 years. It was projected to have zero percent restenosis in 2002 . And now we realize it is Zero percent truth.
What has started as anecdotal reports of late stent thrombosis has indeed become an epidemic in all DES patients. The five studies that has been published in the NEJM this month (March 2007) has convincingly proved how unsafe these stents are in most of the coronary population .
Millions of patients in whom this stent was implanted will carry an impending stent thrombosis and possibly an SCD . Who is to take care of them ?
The DES story is a clear cut case of getting premature approval for a dangerous form of treatment inside human coronary arteries.
It is amazing how the scientist’s eyes are shut by the illusion of knowledge and lure of wealth. How foolish they were to think drug which was administered via the stent will selectively prevent vascularisation and leave the normal endothelium intact . Now they realized , one should not suppress the endothelial growth around the stent and got the fundamental point wrong. Which was the key reason for the astonishing episodes of late stent thrombosis. When we play with biology of nature we have to be little more careful .God has created man and his heart for over a million years . One can not alter it by a 6 month follow up study of DES .
When ICDs were exposed last year , of similar disastrous outcome they were recalled and explanted . How are we going to unstent the millions of coronary arteries ?
Somewhere along the line the medical professionals have lost the battle against the Wall street and NASDAQ . Or how else we can explain repetition of similar events.
The wages for the modern technology , the patients have to pay a heavy price.
Let us all hope common man with common sense will reign supreme over the sixth sense of the uncommon man . . .
“Ignorance is better than illusion of knowledge”
Dr Venkatesan Sangareddi MD , Assistant Professor of cardiology , Madras medical college Chennai, India
Posted in Cardiology - Clinical, Cardiology -Interventional -PCI, cardiology -Therapeutics, Cardiology -unresolved questions, cardiology- coronary care, Infrequently asked questions in cardiology (iFAQs), tagged anginal equivalent, bmj, cad, chronic stable angina, diabetes mellites, dyspnea, excercise stress testing, jacc, lancet, nejm, silen ischemia, silent angina, unstable angina, what is silent angina, what is silent ischemia on January 1, 2009| 1 Comment »
Anginal pain is a type of visceral pain.It is carried by type C unmylinated nerve fibres.The perception of angina is a complex process.It is a combination of visceral and cutaneous referral pain.
Presence of diabetes per se does not make an angina silent. In fact, if one takes 100 patients with diabetes , if angina occur in them , it is more often , manifest than silent. So , only few of the diabetic patients who develop diabetic autonomic neuropathy fail to have angina.The exact incidence is not known.It could be around 20%.
This again is not answered in literature. Among the anginal equivalents , the most common is dyspnea , which can occur in diabetics.But now , we know dyspnea also needs thoracic nerve signals from the intercostal muscle spindle and colgi organs.This can also be impaired in diabetics.
Yes.
Once silent does not mean always silent, and similarly once angina is felt it does not mean he is going to feel the next episode as well !
This strongly reminds us medical science is much a complex subject and what we know is very little in pain perception.
There is considerable overlap between silent ischemia and silent angina
The questions to be answered are
Which is silent ? Is it the angina or is it the ischemia or both ?
Silent ischemia can occur in any individual , this is also called as silent CAD . When ischemia occurs but fails to generate pain it is silent ischemia .Undiagnosed CAD in asymptomatic individuals is also called silent ischemia or CAD.In this population Exercise stress testing detects CAD which was otherwise silent and masked.These patients may develop angina during EST.
During exercise stress testing many times patient has significant ST depression more than 2mm but still chest pain may not occur.These episodes may either be silent ischemia or ngina. Many times the EST is terminated before angina is manifest .( Chest pain is the last to occur in the chain of events following ischemia- Concept of ischemic cascade )
When their ischemic colleagues , suffer a lot with chest pain it is tempting to think these diabetic patients are blessed!
Scientifically , this could be true in at least in some especially in a patients who’s coronary anatomy is known and devoid of any critical proximal lesions. For example a small PDA lesion can produce severe angina , but may be silent in diabetic and be comfortable .This lesion is insignificant other wise * !
It should also be recalled , pain relief has been an important goal for treatment of CAD .In olden days, thoracic sympathectomy was done for angina . In fact , even in CABG , one of the the mechanisms for angina relief is attributed to cardiac denervation.
Caution: Even a small episode of ischemia can trigger an electrical event .But it is rare.
How common is silent infarct (STEMI) in diabetic patients ?
In a simple questionnaire we asked the diabetic patients in our CCU how they felt their pain during MI.Most felt it normally as do other non diabetic . Diabetes does not make all anginal episodes silent. Severe episodes of ischemia may be painful while less severe episodes may be painless. Diabetic autonomic neuropathy is a least recognized and poorly understood complication of diabetes.Diabetes , involves the vasanervorum of the autonomic nerves.
The other mechanisms postulated in diabetic neuropathy are
Very difficult problem indeed.Controlling diabetes may partially correct the neural dysfunction.Many add on neuro vitamins and aminoacids are having a good market !
We don’t know.Logic would answer ” YES”
Cardiac denervation. The manifestations are
Silent Myocardial Infarction : A complete list
Dr.S.Venkatesan MD 