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Posts Tagged ‘ethics in cardiology’

It is  often  quoted  “Practice makes  every one  perfect”  . . .  Doctors continue to practice for ever  . . .If practice is only  a rehearsal  , when do they perform  for real ?

And , we know  a doctor spends his entire life time practicing  . . . In other words  doctors are only experimenting .

So , do not get fooled by his errors . Errors are bound to  happen  during their  practicing sessions !

The problem  with general public  is , they never understand this basic fact – medical  science  is nothing but  a , on going research on human body .If only  we understand this  we can accept  the millions of medical  mistakes*  that occur  every day in  the global  medical  profession . The major  aim of modern medical science  is to reduce that .

* Of course, negligence is a punishable offense . But,  we should also realise , non- negligent medical  mistakes are many fold higher than negligent ones .

While  a careful doctor will avoid negligent mistakes a thinking doctor will avoid   non -negligent mistakes also.

This puts onus back on doctors. We need to critically analyse , every

treatment modality we follow .

If you are a strong believer of   “Medicine is indeed  a  science and doctors are scientists ” , please read this article from British medical  journal and conclude  yourself.

http://www.bmj.com/cgi/content/full/328/7454/0-h

Further reading

The bestseller  How doctors think

Picture courtesy : Jupeter stock Images

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There are thousands of forums for medical science.

Most are aimed at research.  Few are available  to scrutinize  research.

Cardiac safety research consortium

This one from Duke university ,  is a great beginning in collaboration with FDA .

Let us welcome , this whole heartedly and wish all success in it’s motto !

Namely , exposing all safety issues in the modern cardiac therapeutics .

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Many believe  modern science is pure and uncontaminated.

I wish it to be true ,  But reality mirror tells a different story !

The following  “spheres of knowledge”  collectively  form the  cardiology literature .

How much ?  each sphere , contribute is any body’s guess !

The same  rule might  apply  in all  medical  specialties.

Readers are argued to add more spheres of  knowledge.

The seventh sphere may be Eg :  “Commerce based cardiology “

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Cardiology  is  among the top medical  specialty  in the current era. It deserves this  special status as it is probably  the  a specialty  which  is based on maximum  scientific evidence and  involves ,   the  most advanced diagnostic and treatment  modalities.

As on today ,  a cardiologist  can deliver a stent  anywhere along the coronary tree and even  implant  a valve percutaneously . A surgeon can put multiple grafts in a beating heart  with a patient totally awake !

A  person can live with an  artificial heart for months and a cadaver  heart can give  fresh lease of   life to a terminal heart failure patient .

Why such a glorious filed of cardiology  should often   evoke a pessimistic reaction  in the minds of  public and media ?

This is because  for a   simple reason , in the name of technology , we tend to  indulge in scientific excesses.

This article in Circulation is not a  surprise then . . . Click on the link, Thanks to AHA this  comes free of cost !

For pdf article click on  the image

Note : Non adherence , inappropriate therapy,  Class 2b  indications ,  are  simply semantics in stage  play !

Actually these terminologies are synonymous with

  • Guideline violations,
  • Unscientific ,
  • Empirical.
  • Unethical or  even quackery

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We generally  believe  drugs  and devices are prescribed  by  physicians with strong scientific basis .Unfortunately  it is  not  true  in many instances.  A drug which is approved for one disease is assumed to be useful in a similar disease  (But not tested in  clinical trials ) and it becomes  an unapproved  indication .This is often termed as off label use (A decent terminology for unscientific usage !) .But ,there are pros and cons to this type of physician behavior .

Pros

The best example  is  the role of sildanafil in pulmonary arterial  hypertension(PAH)  . A drug which was introduced for erectile dysfunction , was found to very useful in regressing pulmonary arteriolar pressure  (Mistaking pulmonary arteriole for penile vasculature  !?) .  A new therapeutic concept was born  for a  hither to difficult problem of PAH. This  successful  discovery  was  attributed   to off label  usage  of a drug .

Cons

But this is a rare  success story of off label therapy.  In real world , we  tend  to  overuse this in many situations and harm is anticipated.

Drug eluting  stents was used extensively in off  label situation ( Acute MI in a thrombotic milieu, very small vessels , in close proximity  to bare metal etc all these are non label or off label  use of coronary stents   which  resulted in many deaths )

Who gave the freedom and liberty for the physicians to use a drug or device off label ?

No body gave  it , we assumed ,  we have it .

When somebody uses a drug for an unapproved indication is it not unscientific  and guideline violation ?

It is a violation , but we can afford to do it because every body does so !

Is there any scientific  body to sanction and desanction off label  usage ?

Unfortunately  not !

So what  is the solution ?

Self regulation  . . . Can it  be  a  fool-proof method  ?

or  Is it foolish  to expect it so  in this   era of commerce  ?

Related video in youtube hosted by me.

http://www.youtube.com/watch?v=d2WfLrTiUks

Related article

Guideline violation in cardiology practice

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Common sense would  indicate  medical care is  meant for the sick and ill  . Relieving  the mankind  from all those  suffering  with a healing hand has made the  medical profession noble and sacred .Medical science   grew with this sole aim  many centuries ago  .Some  times  we succeeded   and many times we failed  and the journey is  continuing .

In those days ,scientists were dedicated , inventions were genuine and were driven by a need to conquer a diseases .Some where along the line, (May be in the last 2-3 decades?)   our quest for money power exceeded commonsense  . Commerce entered   every  walk of life and  medical science became the biggest causality.

The purpose of noble   profession was forgotten . Simultaneously   public awareness and quality if life vastly improved in many of the developed countries . So the traditional illnesses  either disappeared  or reduced   to a great extent . Then came the life style diseases.The cost of treating  an illness spiraled too much especially   in the scientifically advanced countries . What was perceived  as great health care system  became  the  most ridiculed  health system in the planet  ?

Why ?  The simplest answer to this q  is

In the name of science  and  modernity , medical treatment  was glorified beyond the level it deserves ,  and hence  the  cost of treatment is  kept at artificially  & foolishly high  (This often involves  diagnostic   exploration of human body with modern gadgets without any meaningful   purpose )  .

ie , In  a  nutshell  of modern medicine is   often a medical mirage than a miracle . We know ,  the chances of success  as we  try  to chase it. If we think the  world is   waking  on this issue .

We are in for a surprise ! Even as  every one  is asking for outcome analysis in modern health care

more and more countries just imitate the failed ( Scientific and moral failure ) western models of health care .

When major illness are reducing in a society what will the health care providers do ?

Feel happy ?  Yes that’s what   a  sane   mind  would   do .  In a capital  rich ,   health conscious ,   knowledge  driven  society the opposite happens .

When  the patient  input  into a top hospital  reduces , the MBAs   in  them plan strategies  to bring  increase the bed occupancy rate and  maintain  patient  parity.

If sufficient  patients  are not there in a community what shall we do ?

Create  more  patients

Creating  new patients is a too dangerous game ,  what shall we do ?

In the  name  of preventive screening   let  us  label   normal  persons as patients .

How to do it ?

The following examples  are personal observation made in  huge city of educated elite  in a developing country . Excuse me if it offends a few  . . .

Define, redefine all criteria that define the disease (There are

  • Make, 130/85mmhg of blood pressure as pre hypertension and make them visit our HT clinic every month.
  • In the  name of risk stratification do CRP, Micro HDL , Apo a   etc and  catch them  for primary risk reduction for a non existing illness
  • Let us  label  all the   age related  bone loss as  deadly osteoporosis and do bone graft.
  • Let us  call  the occasional post dinner stiff stomach as non ulcer dyspepsia   and  insert a  endoscope  into the patient tummy .
  • Do a 64slice CT  in a master health check and convert many  of the healthy  normals into carriers   soft  coronary plaques.
  • Do a ultra sound scan  in every one who takes alcohol and  give our brains a temptation to label  the normal  fatty streaks  as infiltrative  fat disorder .
  • Do routine pelvic scan and detect  sub clinical fibroid uterus as potentially  malignant and  post them for hysterectomy on the next operation day.
  • Convert all healthy women as a  potential cervical cancer  and administer  herpes vaccine and help  the vaccine company share  move up in wall street !
  • Finally , screen  all  our  playful   kids for   learning disability and   label them as slow attention deficit disorder  and  make their  life permanently   miserable .

The list is endless  . . .

Final message

We  are in a  era ,  where  even   a  simple  illness  ( common cold ? )  can be converted into a billion dollar industry . ( Are you aware of H1N1 fiasco ,  The role of   WHO  and  mystery labeling of pandemic !)

While the above  misadventure  with scientific excesses   goes  on merrily  , lest we forget , millions of children  and adults  suffer in misery for want of  live saving  investigations and drugs  in any country .

When a person with a head injury dies due a  missed   subdural  hematoma for want of CT scan in one hospital  ,  ” in the adjacent hospital”  a wealthy and healthy man  ( who got admitted for master health check up ) undergoes  a series of scans  all over the body   even as he is  watching   the  satellite TV in  the comfort of a  five star suite   !

God will never  forgive  the  noble professionals   if they are part of this  negative health care  forces

Finally  ending with a very positive note !

The new   initiative by  Obama   , ” Health care  for  the uninsured ” is to be welcomed as great move  and will do a world of good .

But , our  only  request  to WHO ( or related   bodies )  is to create a forum or authority  to  impeach all fancy diseases from the medical   literature  !

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Modern medicine promises   healthy new lives  to millions. We all , enjoy  the   fruits of  great scientific discoveries.  But do we  realise , medical science is nothing but experiments done on live  human beings . All  treatment modalities   are under constant scrutiny.  A great drug becomes the most harmful drug over a short time.

A drug or a device which is banned in one country is freely used in other country , marketed by the same parent company . How on earth this can happen ?  A device  ( Eg : A stent )  which is found  inferior  can  still can  be used legally elsewhere ,  hiding the information .

  • Do we divulge all vital information to our patients ?
  • Do we reveal all our conflicts of interest to our faithful patients ?

Informed consent is  the  “greatest  invention” in medicine . That is democracy in medicine . Doctor  patient conversation is   supposed to be  most noble of all communication !

But . . . this is under  genuine threat .  In this ” New medical AVATAR ” truths  remain only as thoughts , they  rarely  come out as words or action !

One such  situation a  physician  often  faces  in his office ,   as he is compelled  to act against his  conscience

If only we  have an ability to  read  his silence it will go something like this  . . .

For the sake of  Science &  Commerce , I have to implant this device  in your heart , and  my gut feeling says  ,  you will do much better without this device as well !   But ,  I am sorry . . .  I can’t avoid it .

Doctors are not be blamed  . . . rather  , we can’t blame  any body

Patients believe in doctors , and doctors believe in science  And the irony is ,  doctors have no other option as they are  coerced to  believe ,  in whatever is published  as science even if it is  half baked , unproved,  unapproved or  even dangerous science .

Let us prey for the genuine science to prevail  at least in human health  and the mankind  reap the maximum  benefits !

Let us  recall  Mahatma Gandhi’s    “Seven Social sins”   That included one  advice for the scientific world  nearly a century ago when it  was at it’s infancy !

Seven Social Sins By Mahatma Gandhi


  • Politics without Principle
  • Wealth Without Work
  • Pleasure Without Conscience
  • Knowledge without Character
  • Commerce without Morality
  • Science without Humanity
  • Worship without Sacrifice

– Young India, 22-10-1925

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Medical profession has  evolved over centuries with humble discoveries by genuine researchers in the past . As we  pursued  science vigorously  , we  looked  for innovations , when innovation  work ( or many times shown to work !) we jump to sky , even as  some of these  innovations fail and crash down  to earth , many times  we continue to be in the clouds . This is the fundamental problem of modern medical science . When  our expectations reached  unrealistic proportions ,   we tend to lose the common sense . Prolonging life and reducing human suffering may be the ultimate aim of the medical  profession , but  If we try to fight the death with science and money without application of mind , our current  life may become  miserable ! Thats what is happening for the majority of the population of this planet . After all ,  death is an essential and final  component of life !

Coming to the issue of CAD ,  in our country , a  rich gets a 4th generation drug eluting stent for a insignificant  asymptomatic PDA lesion , and poor fellow with left main dies without any intervention .This is  fairly acceptable   to this uneven world  , where a rich westerner  dies due to obesity related disease and a  poor African dies to malnutrition .

This article is in   response to  my  recent  experience  when  . . . I advised

Simple life style modification &   few drugs   for a patient with chronic multivessel   CAD  , I was  made to look   ordinary , inferior  and funny   by  many of the current generation cardiologists .

Further , the term optimal medical therapy(OMT)  for chronic stable angina has evoked laughter in one of the interventional cardiology  conferences  I  attended !

It is a sorry state of affairs  for the whole cardiology community , a  genuine scientific  fact , proven by  real life experience  as well,   is  being  ridiculed.

Richard  Conti tells in this excellent editorial in his journal   Clinical cardiology about the issue of medical management of CAD

“Respect in clinical trials”

Chronic stable angina pci vs cabg vs medical courage trial oat trial ethics in cardiology

Click here to reach the article  http://www3.interscience.wiley.com/cgi-bin/fulltext/122512853/PDFSTART

A similar study which  suggested  exercise  could be  better than PCI in the recent 2009 ESC is suffering the same fate !

What if regular exercise were as good as a stent for stable angina?

http://www.theheart.org/article/1000047.do

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  1. Do 64slice MDCT  in all patients who has  a coronary event and follow it up with catheter based CAG.
  2. Use liberally the new biochemical marker ,  serum  B-naturetic peptide (BNP) to diagnose cardiac failure in lieu of basal auscultation.
  3. Advice  cardiac resynchronisation therapy in all patients  who are in class 4 cardiac failure with a wide qrs complex .
  4. As it is may be considered a  crime to administer empirical  heparin, do ventilation perfusion scan in all cases with suspected pulmonary embolism.
  5. Do serial CPK MB and troponin levels in all patients with well  established  STEMI .
  6. Open up all occluded coronary arteries irrespective  of symptoms and muscle viability.
  7. Consider  ablation of pulmonary veins as an  initial strategy in  patients with recurrent idiopathic AF. If it is not feasible  atleast occlude their left atrial appendage with watch man  device.
  8. Never tell  your patients   the  truths  about the  diet , exercise &  lifestyle modification (That can  cure most of the early hypertension) . Instead encourage the  use of  newest ARBs  or even  try direct renin antoagonists   to treat all those patients in  stage 1 hypertension.
  9. Avoid regular heparin in acute coronary syndromes   as  it  is a disgrace to use it  in today’s world. Replace all prescription of heparin with  enoxaparine  or  still better ,  fondaparinux  whenever  possible.
  10. Finally never discharge  a  heftily  insured patient   until  he completes all the  cardiology investigations  that are available in your hospital  .

Coming soon :  10 more ways to  increase cost of cardiology care . . .beyond common man’s reach

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cardiologist Is he a person who puts  a   metal coil  coated with a synthetic fungus   in  a   incidentally  detected  block  inside a  small coronary artery and sends the bill to the Insurance company ?

Is he a person in a  cosmopolitan  hospital  who opens up a    chronically   closed  coronary artery , in an asymptomatic patient  and  live telecasts  his achievement trans continentally ?

Is he a person who   checks in by  the early morning flight and  puts multiple wires in  an  aged   patient   with  class 3 heart failure and  make  him walk  20 meters extra at a cost of  1000$ / Meter ?

Is he a person living in   Wall   street  ,   who   looks  for variety of holes In  the heart and trying to occlude  it  with   exotic   devicespci ptca stent

Is he the unknown   physician   who Intervenes in the natural history of Rheumatic heart disease   and arrests   immune mediated   valve damage by giving the  monthly injections  penicillin in remote parts of our country ?

Is he the person   who   Intervenes to prevent young   persons   from  smoking and help maintain  their  coronary endothelium  enriched with nitric oxide  & arrest  the coronary epidemic ?

cardiologist 2

Is he the small town doctor  who  Intervenes  to treat a breathless cardiac failure patient  with  digoxin and frusemide  and  dramatically alleviate the  symptoms and  prolong the  life of our poor country men?

Is she the village health nurse from an inaccessible health  centre  located in a  hilly terrain ,  Intervening  successfully, by   pulling out  live babies  from  severely anemic pregnant  mothers with failing hearts ?

pci ptca cardiologist coronary angiograms

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