Indian Journal of Thoracic and Cardiovascular Surgery, 1982; 1 : 5 - 9

Towards Self-Sufficiency and Progress N. GOPINATH"

It is a privilege for me to be invited to deliver the first Dr. C. S. Sadasivan Memorial Oration under the auspices of Association of Thoracic and Cardiovascular Surgeons of India and I thank the organisers for the honour. 1 first met late Dr. C. S. Sadasivan in 1957 when he had returned after completion of training in Cardio- thoracic Surgery in England and Europe. He was one of the tinest surgeons trained at Andhra Medical College, Visakhapatnam and he had the coveted honour of working with Major F .A.B. Sheppard, Professor of Surgery. Dr. Sheppard's stipulation that Dr. Sadasivan shot, ld accompany him to Madras on transfer. is a measure of confidence and respect he reposed in him. Dr. Sadasivan laid the fonda- tion stone for the development of Cardio- thoracic Surgery at Madras Medical College and Government General Hospital, Madras, and held the chair of Professor of Cardiotho- racic Surgery. Almost 12 years later, his department along with the Department of Cardiology under Dr. A. Srinivasan moved in to the spacious buildings of Institute of Cardiology, Madras.

Based on Dr. C. S. Sadasivan Oration delivered during Joint Annual Conference of Association of Thoracic and Cardiovascular Surgeons of India and Cardiolo- gical Society of India at New Delhi in October 1981.

* Professor & Head, Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences New Dclhi-110 029.

* Past Presidcnt, Association of Thoracic of Cardio- vascular Surgeons of India.

Dr. Sadasivan pursued the training of Cardio- vascular and Thoracic Surgeons with vigour and enthusiasm. One of the favourite fields of discussion he used to have with me was about making the country self-sufficient in all aspects of cardiovascular surgery. The training of a cardiovascular surgeon and other members of the team was one of the important aspects of this programme. He had started the Mas- ter's in Surgery Course in Thoracic & Cardio- vascular Surgery in 1959-1960. I had the honour of being admitted to the first batch of this course, which was established a year earlier at Christian Medical College, Vellore. The two-year training programme is the basis which continues to be the same even today. The content of the course and the pattern of exa- mination remains unchanged. While the course is being conducted by seven universities in eight institutions it is important to remind oneself that the programme had not undergone critical evaluation and has not kept pace with the astounding and far reaching advances made in the field of Thoracic and Cardiovascular Surgery for the last two decades. It may be partly due to tile different pace of development of the centres in various universities and auto- nomous institutions which reflect a conservative attitude. Also the standards are not the same in all the institutions and universities, where they face forces repugnant to academic develop- ment. The trainee, therefore, for no fault of his becomes a victim of the specified draw- backs by the end of the training. Coupled

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with this, he is not geared to develop another unit which he was to take over. In algebraic terms it can be summarized as hindrance to progress in his new venture. Unfortunately, tendency to critically evaluate a new entrant of the faculty and the unit he holds, comes in the way of development of the unit and the support it ought to receive, which then leaves him in a vicious circle. It is furth'er depressing to note the total malappreciation on the part of authori- ties to look into the member's requirements which vitally demand planned support.

But there is twilight in tile horizon. The surgeons are taking a second look into the training programme. Its duration and content need radical change. We have now adopted in our institution for training a three-year programme and also a straight five year pro- gramme. As regards the latter, the candidate is given admission after the completion of internship and has to spend first six months in the parent unit, i.e., Cardiovascular and thora- cic surgery department. After six months he is evaluated as to whether he is fit to pursue the course any further. The second year of the training is in General Surgery. At the end of the second year the candidate is required to appear for an examination in General Surgery which is mainly related to principles of general surgery. The next 4 years are spent in the field of cardiovascular surgery during which period he rotates through the departments of Cardiology, Cardiac Pathology and if possible, Physiology. The Final M.Ch. examination is held at the end of 5 years. The exposure which the trainee thus receives provides him with practical training and sufficient experience in all the necessary fields. The course is structured to meet the objectives related to the t,;aining and to help the assessment of the trai- ning programme effectively.

The concept of minimum level of competence rather than a uniform one is important and is assured. The minimal level of competence is that which a surgeon must possess to treat common form of cardiovascular and thoracic diseases satisfactorily. Thus the trainee, in

such a programme, is enabled to achieve neces- sary skills which is the standard viewed volun- tarily by us. This is different from,the stan- dards set by the outside forces of administration and universities who legislate the certification process. The concept of examination does not by itself evaluate the additional skills necessary to treat unusual and complex diseases. The log book maintained by the candidate is a measure of the trainee's competence but not necessarily so. It reflects better the standard of surgery and overall performance of the centre where the candidate is trained. The evaluation by the examiners and the certifi- cation best indicate the level of competence recognised by his peers and acceptable to ap- pointing authorities and public service commis- sion. It is important that the candidate's training should be excellent, considering the sub-opti- mal facilities available in the place or insti- tution where the trainee is absorbed. The surgeon must be emotionally mature and should possess intellectual capability. The former includes self-discipline and the capacity to function under stress. The intellectual capa- bility can be gauged as a sum of intellectual and factual knowledge needed for the tinal surgical judgement in the best interest of the patient.

It is very essential that there should be multiple areas of evaluation to determine the competency of a surgeon. In United States of America, there are four mechanisms deployed to define and measure competency in thoracic surgery and ensure quality control. These include approved residency programmes, certification by American Board of Thoracic Surgery, state and local hospital regulations. The process of recertitication at ten year inter- val is the key for contiv.uing evaluation which has been introduced two years ago. It is very essential to know that the Residency Review Committee and the American Board of Thoracic Surgery are completely independent organi- sations. The former evaluates the training programme, the latter assesses the trainee who completes such a programme. The princi- ples of residency training programme are laid

Self-Sufficiency and Progress 7

down by a board whose members are drawn from American Board of Thoracic Surgery. American College of Surgeons and American Medical Association. In our country at present there is no uniformity in the training programme. The skill acquired by the trainee is unsatis- factory. Progressive responsibility in the surgi- cal area under supervision falls short of the needs of the trainee, who has no privileged participation in decision making. It is un- fortunate but very true that the overall per- formance of the unit does not improve with such a residency training programme. There- fore, the resident who emerges at the end is one, who wears blinkers and in turn commits the same mistakes. He emerges with the same prejudices and deficiencies of the parent unit where he received his training.

In our country, the National Board of Examiners have taken steps to rectify some of the lacunae present hitherto. The board of examiners, has anaong the various committees, one for each surgical speciality which equally applies to medical specialities. The committee for cardiovascular and thoracic surgery has seven members with a convener. It is sugges- ted that 3 out of the 7 members are drawn from the Association of Cardiovascular Surgeons of India. ]'he committee has the power to lay down the contents of training programme and the examinalion pattern. The programme is of two types -one of three years, after the candidate had received a postgraduate degree in surgery and the other of 5 years duration after the basic degree in medicine, which is a residency programme. Hospitals approved by Accreditation Committee of National Board of Examiners can be even non-teaching hospitals provided they fulfil the criteria laid down. The candidate can even spend a part of the training in other approved hospitals if such ex- pertise and facilities are not available in the parent unit. Some of the objections levelled against the present programmes are tackled by the detailed measures taken by the National Board of Examiners which sends an inspector to monitor the programmes and the level of exami- nations as well. These examinations are recog-

nised by the Medical Council of India. We hope this would lead to re-evaluation of the present training programme. This should go a long way in having a uniform standard of both the training component and the level of compe- tency achieved, as the programme conductors and examiners of the present postgraduate examinations are members of the august body of the Association. It is time we discuss and set up uniform standards at all levels. This would activate the units which do not meet the criteria at present.

"In the busy schedule of a resident, there should be a positive and genuine concern for patients welfare'. The above statement holds great relevance in our society where a doctor is put on a pedestal. Extra time spent in explai- ning what we are capable of doing makes the patient and his family a partner in our daily gamble called medical practice. Listen to what Albert Starr has to say-- ' I knew before surgery that relatives are always very grateful but l never realised the extent of their gratitude. It is a kind of love relationship'. As one re- marked "there is yet a limit to technology. There is none to humanity beyond our own making'.

We have not yet touched the fi'inges of needs of patients in our country. The magnitude of their problems are overwhelming. It is a tra- vesty of truth, that all those that need aid do not reach the respective doctors. It is esti- mated that 600 persons need open heart surgery per 2.5-3.5 million population. Twenty nine infants per million population in United Kingdom need investigations for congenital heart disease; of these, 850 need cardiac catheteri- sation and of which 425 (8.5 per million) need operation under cardiopulmonary bypass. 4 0 ~ of patients with congenital heart disease, pre- senting beyond infancy, need open heart sur- gery. Of acquired heart disease, we have rheumatic heart disease which will keep us busy for the next few decades. Incidence of rheumatic fever and rheumatic heart disease in urban population is 1.23/1000 in males and 2.07/1000 in females. In school going children,

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it ranges fi'om 0.96-4.7/1000. Analysis of collaborative study of I.C.M.R. in school children in 5 centres revealed an incidence of 0 .52~ (691 in 132899). 60~o of these had mitral regurgitation. 2.27 ~ o had mitral steno- sis and 18.66~ had mixed lesion; this means nearly 80~ need open heart surgery. In an analysis of 500 cases attending our cardiac clinic, 43~ had mitral stenosis and another 53% had mitral regurgitation and/or aortic regurgitation. In our country roughly 6 million patients are affected with rheumatic heart disease. We do not see any sign of a prophy- lactic programme planned on a wide scale. We hope that the task force established by the Indian Council of Medical Research will lead the way. As for coronary artery disease, we have not yet met it squarely. In 1979 in U.S.A. 2240 thoracic surgeons did 200,000 operations-- 58X, of which were cardiac, 20~, peripheral vascular and rest others. Most of the cardiac surgery was for coronary artery disease. In 1976, income of cardiothoracic surgeons in U.S.A. was 88 crores for treatment of coronary artery disease. Study by l)r. Berry in Chandigarh revealed an incidence of 66 per 1000 of cases of coronary artery disease in males over 35 years of age. If this is taken as a true inci- dence, the number of patients with coronary artery disease would be about 6 million.

The magnitude of the problem immediately forces us to look into the present status of our major centres. The past decade has shown a change in emphasis in cardiac surgery. This decade will aim at further progress in the art of surgery. There has been no indepth study and evaluation regarding staffing, size and loca- tion of a cardiac centre. Each centre should be capable of conducting a minimum of 200 cases of open heart surgery per year. There should be 'round the clock" medical aid. A staff of three surgeons is needed to do 600 open heart surgery cases per year. Three cardiologists are essential as members of the team. For the Paediatric service, there should be two surgeons and it should have 2 to 3 paediatric cardiologists. The paediatric department should work in liaison with general paediatric department.

Centres are to be located in association with general hospitals for consu[tancy. Efficiency of a centre is related to surgical turnover, staff and efficiency. The question of area which a centre can serve has no relevance in our country. Of 25 centres where facilities are available for open heart surgery only 8 centres are capable of effective turnover. Even these centres stretch themselves to meet the needs of their patients. Upto now about 91 trainees have completed the training programme leading to M.Ch. degree; but of these only a few are able to head new centres. Many of them are either absorbed in the parent unit or doing thoracic and closed cardiac work due to factors beyond their con- trol. It must be clearly stated that in our country, there is a great need of surgeons to meet the prevailing situation. 1 want to empha- size that we must plan to have at least one unit in each medical college hospital and in other major hospitals. There are 36 units mainly doing closed cardiac, thoracic and peripheral vascular surgery in our country. 32 of them are functioning in medical colleges. Unfortu- nately, the mortality figures have a bearing on the number of operations conducted. This factor in initial stages creates a killer instinct among compatriols which in turn creates delusion and lowers the morale in the mind of a surgeon and his team which leads to premature death of the unit or leaves it in a gasping stage with hardly a chance to recover. Unfortunately, the centres are not fully built and developed as the administrators have no vision of the needs. The so called advisors add fuel to this situation. This leads to the next important aspect namely the financial one. The cost of conducting an operation is prohibitive. The cost of setting up a full fledged centre where all facilities for medical and surgical aid are awlilable comes to about Rs. 65 lakhs without taking into account the expenses of the personnel and building. Major amount of Rs. 35 lakhs is for cine-angiographic equipment. The cos~ of surgery and investigation comes to about Rs. 20 lakhs per year: personnel-pay etc. amounting to 12-15 lakhs per year. The patient-nurse ratio is to be according to Bohr committee which is still the main guide in the

Self-Sufficiency and Progress 9

health administration. For 4 bedded ICU accepted norm in U.S..~. is 64 personnel, including 16 nurses. There should be at least one nurse for two patients round the ck)ck in our country. In 1CU of a surgical unit the cost for 4 bedded unit is Rs. 7 lakhs. The cost of each open heart surgery would be Rs. 3500 to 4000. A valve would cost Rs. 4500-5000. Choice of valve is limited as only two prosthetic valves and two biological wllves hold the J. ~. I do suggest that we have to pool our resourc. to make an oxygenator, disposable items and biological heart valve in our own country. Except a good oxygenator, filter and valves rest are available in the country. Plans are underway to prepare biological valves. We have to remind ourselves of the saying "all excellence involves discipline and tenacity of purpose'.

We have a long way to go. The Association of both Surgeons and Cardiologists must head towards the path of progress. They must plan the training programme, develop the centres in the areas where there is potential for growth and meet the aspirations of the patients and the country. It is essential that the training of specialised nurses, technicians, and perfusionists shall be initiated as they are crucial to any centre, ttighly trained personnel in these areas is an aid to the success of a programme. We have initiated a course in cardiovascular surgical nursing. We propose to start another in perfusion technology. If optimum facilities

are to be made available, there should be at least one centre for four million population which would then mean 150 centres where facilities for all types of cardiovascular surgery including open heart surgery should be available. This would require at least 450 competent sur- geons to staff these centres. These would need about 300 paediatric cardiologists, 450 cardiologists specialised in adult cardiology and 300 anaesthetists. Besides these, there is an urgent need for 300 perfusion technologists, 450 well trained operating room-nurses, 600 postoperative intensive care area nursing personnel, 300 physiotherapists, and 600 medical specialised laboratory technologists.

There is an urgent need to associate the specialised anaesthetists in our association's activities besides those of the pathologists. We must take steps to have the para-medica[ personnel involved in our day to day activities and in the association. We should plan to set up a scientific programme in our meetings related to the para-medical activities at this stage. We must rededicate ourselves to achieve a measure of self-sufficiency and progress. These are the goals of late Dr. C. S. Sadasivan. 1 would like to echo the sentiments of Dr. Halsted by Dr. Rudolph Matas, 'what I shall have to say at this moment is largely prompted by very exuberance of my affection, by very joy of speaking of him and out of a fullness of my admiration'. Hence let us rededicate ourselves to foster science and practice of medicine.