[HSF] Re: Leipzig photopanorama (OT)

Thu Dec 20 22:11:09 EST 2007

Perhaps now in this vigorous discussion of medical propriety, it would make sense for me to make a very brief description of a "new" model for the practice of medicine. Each one can then push their ideas through this model and see what sense, if any, that their ideas (or my model) makes.

The patient doctor relationship, that is, the act of medical practice, is analogous to inter species play, eg play of a dog and cat, or a man and a dolphin. The special characteristics of this play are: it is mutually consensual or it is not play, the play is neither species it is only both, neither species becomes the other or can be the other, neither species can understand the other it can only observe the other in specific instances, there is no third party or even one of the species to judge what is legitimate play. I got this from Bateson who called this type of learning "practice". Naturally I thought that medicine might be well described by this analogy.

There are lots of other perspectives of this model that give special answers to questions of propriety in medicine as opposed to the usual "feelings", legalism, or customs.

Chew on this for a while and get back to me. I have been thinking about it for months.

tea

----- Original Message ----
From: Ani Anyanwu <anianyanwu at hotmail.com>
To: openheart-l at lists.hsforum.com
Sent: Thursday, December 20, 2007 11:00:46 PM
Subject: RE: [HSF] Re: Leipzig photopanorama (OT)

Prasanna

That patients give informed consent does not mean all is okay. People can consent to the most bizarre of experiments which is why we have Nuremberg, IRBs and ethics committees. For example it is hard to see how a rationale 50 yr old man will agree to have his LIMA attached to his LAD via *median sternotomy* using a stapling device when the alternative, hand suture with prolene has up to 95% patency at 20 years. What conceivably could he hope to gain with the new technique? What did the investigators tell him he could gain? A 5 minutes quicker operation? Surely not a more effective one.  That is why we have ethics committees to protect patients for they do not know better and can consent to anything. Up until the surgeon spoke to him about a stapling device the patient likely did not even know how the LIMA was attached to the LAD so how can such consent be informed.

We all hate IRBs and ethics committee but their existence is necessary to help protect patients. The example you give of the total artificial heart and other such heroic experiments does not apply here because there was no alternative effective therapy. However for various reasons as outlined by Dr Novick even the greatest of surgeons and academics may perform unethical experiments on patients. I listened to a talk earlier this year at a meeting from a French group on use of donors aged 60 or above for heart transplantation - I stood up and asked the presenter if the patients were aware they were involved in such an experiment of older donor hearts and the presenter said no - its like the patients were lucky to be transplanted so they should accept what they are given.  

Surgical innovation such as described by Don for example is a different thing. We will modify our ways of doing things which is why we visited Leipzig and other such life meetings. Looking for solutions for existing problems requires innovation. However seeking alternatives to what are considered *effective* treatments requires ethically approved experimentation. As it stands now you could design a mitral ring shaped like a star and get it approved by FDA and implant it in humans without formal testing. I think the rule in innovation should be only do to the patient what you would not mind being done on you (for example if i had a diseased aorta i would not mind Don's technique used on me, or if i had mesothelioma i would not mind a drug tried on me that had never be tried on a human, on the other hand if i was having a LIMA, I would want it sewn with prolene...).

Ani

> Date: Thu, 20 Dec 2007 20:05:51 +0530> From: prasannasimha at gmail.com> To: OpenHeart-L at lists.hsforum.com> Subject: Re: [HSF] Re: Leipzig photopanorama (OT)> CC: > > They do not just chop up patients and they do have informed consent> ,disclosure etc and patients can agree to or withdraw from their> protocols.They have their local protocols and IRB etc. Remember that every> country has its own ethical guidelines and approaches to social problems.> The American view of things may not necessarily be the German or UK view or> that of the rest of the world from even the patients point of view.> I saw quite a lot of old people being operated there and when I said that> in my country they would just plain refuse surgery they said that if that> they wish it happened in Germany and if it happened their health budget> requirements would have halved. Patients expect , demand and get treatment.> Even in their 90's. My take on things may be very different from what
 I saw> but what is to be taken is their open mindedness and openness to> innovations and suggestions etc . For eg I was asked to give a talk on the> modifications that I have made etc and it was received well from a centre> which uses cutting edge technology. Dr Falk immediately fashioned a Goretex> steel ring to see how it was done etc. I was watching a patient with a> dysfunctional ventricle undergoing a David + Mitral repair + CABG by Dr Mohr> and I happened to ask him if he would consider an LV lead in view of his> preop dysfunction. He immediately did a trial pacing with a temporary lead> and seeing the improved function implanted the LV lead. I doubt many> surgeons with a lesser stature would have even bothered to hear or consider> my comment being a small unknown surgeon from some corner of the world and I> was impressed by his open minded approach to all suggestions and ideas. I> reiterate I would like to work in such an environment where
 thinking ,> discussion and ideas are given thoughtful address.> If you think that some companies in some countries ethically behave as a> realit check you should see how they try to "evaluate" their products in> third world countries under all sort of guises.> > Prasanna> > On Dec 20, 2007 7:41 PM, Ani Anyanwu <anianyanwu at hotmail.com> wrote:> > > Prasanna> >> > And where does the patient fit in all this?> >> > Would you also like to be the patient having one of those distal> > connectors in his LAD, or adjustable mitral rings for simple degenerative> > disease, or a Bentall at 82 yrs old for a 4cm aorta, or a mitrofast (Leipzig> > 2005) for ischemic MR?> >> > I think it was Westaby who once responded to a question on whether he had> > used a new device yet and replied that it had not yet been tested on the> > Germans... Ethics and IRB committees are a pain but they exist for a reason.> >> > Ani> >> >> >> > > Date: Thu, 20 Dec 2007 18:58:58 +0530> From:
 prasannasimha at gmail.com>> > To: OpenHeart-L at lists.hsforum.com> Subject: Re: [HSF] Re: Leipzig> > photopanorama (OT)> CC: > > I was talking with Falk and actually he thinks> > it may be better for actually> upsizing if you get SAM. He was also trying> > it out and trying to define> indications.> I wish I could work in an> > environment like the one Falk operates in.> Prasanna> > On Dec 20, 2007 6:12> > PM, <Hgrmd at aol.com> wrote:> > > Prasanna,> > Volkmar Falk's adjustable> > ring is ingenious, but I truthfully doubt I> > would have much need for it,> > since I usually get the correct size using> > the usual> > methods. The cool> > thing is that Volkmar operates in an environment> > (unlike> > the U.S.)> > where new methods like this can be tried without too much> > apparent> >> > hassle.> >> > Hal> >> >> >> > **************************************See> > AOL's top rated recipes> > (> >
 http://food.aol.com/top-rated-recipes?NCID=aoltop00030000000004)<http://food.aol.com/top-rated-recipes?NCID=aoltop00030000000004%29>>> > > _______________________________________________> > OpenHeart-L mailing> > list> >> > Send postings to:> > OpenHeart-L at lists.hsforum.com> >> > To> > UNSUBSCRIBE, to CHANGE email address, or to view archives:> >> > http://mmp.cjp.com/mailman/listinfo/openheart-l> >> > All messages> > transmitted by the OpenHeart-L are subject to the policies> > and> >> > disclaimers posted at:> > http://www.hsforum.com/listdisclaim> >> > -----------------------------------------> >> > > > -- > Prasanna Simha M>> > _______________________________________________> OpenHeart-L mailing list> >> > Send postings to:> OpenHeart-L at lists.hsforum.com> > To UNSUBSCRIBE, to> > CHANGE email address, or to view archives:>> > http://mmp.cjp.com/mailman/listinfo/openheart-l> > All messages> > transmitted by the OpenHeart-L are subject to the policies
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