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Dear fellow cardiovascular & thoracic surgeons of India. Ladies & gentlemen ! I thank you all for keeping your pledge and coming to the Valley of Kashmir to make the CTCON 2009 happen in Srinagar, despite its troubled times. I am sure that this meeting will spurt a higher growth of CVT surgery here and also snowball a trend for various societies to bring their bigger meetings here. Friends ! Like the squirrel who participated in building Rama’s Sethu, by carrying sand on its wet back, we too have done our tiny bit by holding this convention of national importance here in Kashmir, with a determination! I feel privileged to be born in India – a nation – despite all its paradoxes … is stubbornly and hopelessly democratic, and offers freedom to all and an unlimited opportunity to anyone who would brave it. I hail from a humble farming background in one of the most backward parts of the country … unable to converse either in English or Hindi until I entered the undergraduate college. And, today, I am overwhelmed with this honour of delivering this Presidential Address … Presidential Address of a specialty which is the pride of my country. I thank you all for this honour and thank the family of my fellow members of the Executive Committee of IACTS for their support and courtesies. The life of cardiovascular and thoracic surgery has been a distinct privilege. A career which is a perfect blend of “Swartha” and “Paramartha”. The “thunderbolt” (as the Sicilians call it) hit me in 1982 when I did my first independent open heart – courtesy Dr.GB Parulekar. Later that evening, while in the shower, the reckoning hit me along with the cold water … that I had fallen in love. That, come what may, any hardships, any humiliations … this is what I will do. … all my life ! And, so it was !! At the outset, I would like to thank my dear wife – Sadhana, who has put up with me for almost 30 years with understanding, grace and compassion, which I am not sure I always deserved. Sadhana has supported my professional growth unconditionally and never imposed any interfering demands. I thank Mr.Habil Khorakhiwala, the Chairman of Wockhardt Limited in believing and sharing our dreams and thank my associates for their support and faith in me. Among them my partners Dr.KN Srinivasan and Dr.Murali Manohar are in the audience. Dr.Murali Chakravarthy and Dr.Patil have been my anesthetists of 25 years. Murali is now the editor of Indian Journal of Cardiac Anesthesia. And, Vishal Bali who worked so closely with me for the past two decades, joining us as an MBA trainee, has reached the position of CEO. A couple of years ago, I was visiting a cardiac surgeon friend of mine in China. He introduced me to his old mother and when I bowed a “namaste” to her, she murmured a blessing, which my friend translated to me as…”may you live in interesting times”. It has remained in me since then like a sternal wire. The title for today’s talk is drawn from there. Friends, cardiothoracic surgery may be specialty that is small in numbers, but that has had a huge impact on medicine. Five decades ago cardiac surgery led medicine into an era of technology-based healthcare. The idea that a person’s circulation and oxygenation could be maintained by a machine, while complicated surgical operation is performed inside the heart was stunning in the late 1950s, and it broke down a lot of psychological barriers to the application of technology in all areas of medicine. As we look back over the past 20 years, we should recognize that a huge expansion of the medical infrastructure is occurring in India. In the metros and the two-tier cities, medical facilities are growing dramatically in size and economic importance. Often, cardiac surgery is the economic engine that is fueling that growth. Today however, we are at an inflection point. The diminishing number of bypass surgeries in the Western world and changing treatments of cardiovascular disease and rising technological and economic importance of PCIs is making us imagine a shrinkage of our speciality to insignificance. It is also leading to an alarming declining interest of the young medical graduates in our speciality. Let me discuss whether the cardiac surgery is really turning in to a slump career and then also discuss the new age issues that we face and how we can tackle them. Let us take a reality check in India. The situation here is completely different from the West. There is neither shrinkage nor stagnation of numbers. In 2001, we did 42,000 surgeries and in 2008 this number has risen to 87,996. That’s an impressive growth of 109.5%.And even after this impressive growth, this is equivalent to 87 heart surgeries per million of population, as compared to 1700 per million of population in the USA in the year 1999.The significance of this difference becomes even greater when one considers the World Health Organisation’s observation that the burden of cardiovascular diseases in India is much higher than that in USA. What’s the story last year ? We grew by 14% during the last one year. What is happening to bypass surgeries? Are the numbers stagnating or falling ?? In 2001, we performed 23,000 bypass surgeries and in 2008 it was 53,034. A growth of 130.5% in our bypass surgeries, in 8 years. 31,414 of them were on-pump and 21,620 were off-pump. A 60-40 situation. In 1999, India performed 6,607 valve replacements and a negligible numbers of repairs. In 2008 the total number of valve replacement and repairs has jumped to 19,658.A growth of 197.53%. In 1999, we performed 6750 operations for congenital heart diseases. Only 500 of them were for children below the age of one year. The number in 2008 has jumped to 12,996 .This does not include quite a few number of operations done without the use of CPB, as I have collected the data from companies that sell the CPB hardware. This growth, my dear friends, is only a tip and there is much more to come and sustain at least for the next quarter century. Let me explain…The first open heart surgery was done in India in the year 1962. Since then our population has more than doubled. We passed the one billion mark a decade ago and now we are many more. A falling birth rate of last two decades and an increasing life expectancy have however contributed to this population growth. A life expectancy of 41 years in 1961 has gone up to 63 years at present. This demographic shift to older population has given rise to an increase in the prevalence of coronary artery disease. There has also been a steady shift of the population from rural areas to urban cities during the past few decades. The 1991 Census shows that the urban population had increased to 26.1% of the total population. This has significance to the cardiovascular surgeon because the rural population which now forms more than two thirds of the total population has limited access to specialized medical facilities. Also of significance to us, is the high incidence of rheumatic heart disease in crowded urban slums and the higher incidence of coronary artery disease in the urban population as compared to the rural population. Even by a conservative estimate of rheumatic fever at least 50,000 new episodes occur every year and it runs a more rapid course than described in the West. India has a much higher incidence of diabetes than the West which is responsible for a much higher incidence of coronary artery disease which tends to have a more unfavourable natural history. Most of the diabetic patients have multi-vessel coronary artery disease or left main coronary artery disease which tends to be diffuse and the coronary arteries are smaller in size and hence majority of these patients are either unsuitable for angioplasties or ultimately come back for bypass surgeries. We have 16 million live births per year in India and we also know that 3 to 8 per thousand of these children will have congenital heart disease. We can thus assume that 48,000 to 1,28,000 children are born with congenital heart disease, every year. Notwithstanding all the impressive growth in the last decade, there are still a much, much larger number of patients who need to be operated upon. With the country’s growing affluence, rapidly increasing number of cardiac surgical centers, increasing health insurance coverage, increasing awareness for the need of the procedures among people and referring doctors…..there is a lot more growth ahead! We are going to need more number of cardiac surgeons at senior and junior levels. There are vacant positions for junior consultants or registrars in almost every center. But my dear friends, as we all have experienced, the cardiac surgical training is an arduous and long process. And, despite of all the sophistication, it is still very much individual skill-based and that demands long experience and sustained passion. It is a hard process without any short cuts. All of us have experienced it and gone through it. There is not only going to be an increase in the number of surgeries, but also an increase in the size of the difficult subset of surgeries demanding more from tomorrow’s cardiovascular surgeons. If the passion levels continue to go down, and the number of well trained surgeons dwindle, cardiac surgery may soon meet the fate of the folk arts which are dying for lack of youngsters who are willing to carry on the legacy. It is necessary to spread this word through media and campus meetings that by no means this is a slumping career. It will continue to supply both money and high levels of adrenaline for those who care and mind you there are plenty of them out there in the medical colleges. It might be a good idea to seriously look at a 5 or 6 years of direct M.Ch. or DNB course in cardiovascular & thoracic surgery after MBBS. I have already written to the National Board and MCI in this regard. Dr.KM Cherian, Dr.Devi Shetty and Dr.Raghuvamshi are following it up with the National Board and Dr.CP Srivatsava, Dr.Balaram Airan and Dr.Amit Banerjee are pursuing it for M.Ch. The need for spending such a long time in general surgery has long been recognized as redundant. We can create new syllabi on the model of the five years courses as they exist in NIMHANS at Bangalore. This might bring more passionate youngsters for training and there are many of them in the campuses. We are not going to be able to train sparrows to be eagles. What we have to do is to find eagles and there are eagles out there.
1. Competition with PCI’s : There is an urgent need for each of us to start educating the referring physicians in our respective local communities about the scope and limitations of PCI v/s Surgery. The cardiologists have been doing it aggressively and the community of referring physicians have a lop-sided view of the picture. As a united local group of surgeons of the city / state, we can conduct CME’s on these issues for the referring physicians. Brilliant writings by David Taggot, the recent press statements by the STS regarding the Syntax Trial and many other useful material can be used. The medical devices and pharma industry can and will be willing to support these meetings for physicians just as they do for the cardiologists. It wouldn’t be difficult. By balancing the views of the referring physicians, we will not only be able to compete but will be doing a favour to our communities. 2. Unhealthy competition with peers : United we stand and divided we fall. It is now quite clear that the future of a solid and scientific private surgical work lies in Group practice. The advantages are obvious : a) Advantages to the surgeon
revenue stream and / or pre-empt competition
b) Advantages for Institutions
c) Advantages for Community & Cardiologists
Planning and deal execution is the key and preparation should encompass assessment of objectives, business feasibility, review of legal risks and reimbursement analysis and organization of deal process. Choice of partners, alternative option, financial feasibility, capital building, work distribution and timeline for implementation will be the critical questions. One can choose from any models, a company that is proprietory or partnership or private limited. Choose to involve other specialities in the company, have a single boss or equal partners and have the junior employees paid by the company or the hospital directly. Structuring of incentives should consider not only baseline performance and contribution to business development, but also achievement of new quality goals and achievement of academic goals. The issue of corporate managers neglecting clinical priorities and surgical vision. 3. This is a peculiar time : the brokers, the money changers, the payers are in charge – not the providers or receiver of healthcare. This is an incredible phenomenon. There is no parallel in law, architecture, the arts or other professions or even in most industries. Commercialism in medicine is relentless and, if it persists will erode the trust between the surgeons and patient, and economics will drive ethics even more than it does today. Although profit in healthcare is essential to provide better service, running a strictly profit-maximizing corporation is different from a medical operation whose first priority is an obligation to the patient. Money is necessary for the success, but not the reason for the enterprise. A solid group practice which has matured can have interesting future perspectives. It could take business growth in more than one direction. The hospital managements are uniformly bogged down by the opportunity costs paid by the mistakes the business managers are making. If united, we can create surgeon-hospital joint ventures to take over the departments and run it by ourselves. I am sure we will do a better job of creating bigger business and achieving lateral goals. We can through the same mechanism even control medical tourism which has an exciting future only if handled decently. You will agree that we surgeons will do a better job of that. This mechanism can also think of owning the hospitals, but I wouldn’t go there. 4. Rapidly changing technology in face of personal complacency : We have to learn the difference between disruptive technology and sustaining technology. Disruptive technology is a breakthrough that has significantly changed or disrupted the way things have been previously done. Examples of disruptive technologies are all around us and significantly upset the applecart of the establishment norm. Let me give you some examples : Established Technology
Wireline Telephone
Silverfilm
Offset printing
Opensurgery
Conventional CABG
Disruptive Technology
Mobile Cellular communications
Digital photography
Digital printing
Endoscopic surgery
Angioplasty, beating heart surgery
However, disruptive technology in and of itself is not sufficient. The ultimate value of a breakthrough is determined largely by the refinements and the enhancements that occur after the breakthrough. The technology has its value and broad applicability because of the enhancing sustaining technology. Closer to home is the paradigm shift in the coronary revascularization by cathether-based therapy. The original introduction of coronary balloon angioplasty by Greuntzig in 1979 was clearly disruptive technology. But in the 30 years since the sustaining technology of guiding cathethers, steerable wires, exchange systems, closure devices, stents, IVUS, anti-platelet therapy, 2b3a agents, brachytherapy and drug eluting stents have significantly improved the original value of Greuntzig’s disruption. Once can view beating heart surgery as disruptive, but it is the sustaining technology that will ultimately create the value to beating heart surgery. Sustaining technology such as stabilizers, now in their second and third generation, CO2 blowers, shunts, pericardial stay sutures, suction exposure devises, anastamotic connectors, and possibly robotics. We are nearly five years into the evolution of beating heart surgery and sustaining technology and techniques will ultimately make the procedure more patient and surgeon-friendly and therefore of value. One should also realize that in the field of minimally invasive cardiac surgery, the “low hanging fruit” has already been picked up. However, there is a lot of other fruit ripe for picking, but “higher up” on the cardiac surgery tree. Those areas include new treatment for atrial fibrillation, gene therapy delivery, congestive heart failure management, percutaneous valve surgery, muscle and stem cell transplantation, tissue engineered valves and conduits, distal anastamotic connectors, artificial small vessel conduits and image guided surgery. When one contemplates the future of surgery in general, the following concepts should be kept in mind :
In our own lifetime we will be forced to combine the existing open skills with skills of endoscopic and other imaging technologies and cathether-based techniques under one roof of the same operating room to apply to the same patient in combination for superior and less morbid outcomes. It is going to be an interesting new beginning. Larger volumes, maturing sustaining technologies following the disruptive techniques beckon us. It is high time for the cardiothoracic surgeons in India to shed their complacency. We should start indulging in smaller meetings of sharper focus. We should realize that the next decades belong to us if we manage our databases meticulously and without lethargy and get accredited. Start writing and reporting. Only then, we shall be leaders. That is a win-win situation for the corporate authorities and we can harness their power and support. My dear fellow surgeons, all of us here have been smitten by the adrenaline and the bliss of cardiothoracic surgery . It almost took us nearer to God. A “Samadhi” All of us …. sleepless and worried about the patient, while returning to the hospital in the midnight can’t help feeling the importance of that faith. The dim corridors are silent, doors closed, nurses watching over the sleeping, lonely patients. None of us ….. entering the hospital in these quiet hours, fail to re-live the romance that made us feel elite and wanted. Let us not lose our faith in our old love. Ladies and gentlemen, may you live in interesting times ……………………!! Thank you for this honour.
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CTCOMCON 2010 Address by Dr. Rajan Santosham
CTCOMCON 2009 Address by Dr. Vivek Jawali
