Research : a neccessity Research : a neccessity � D A il J i � Dr Anil Jain Professor of Orthopaedics University College of Medical U i it C ll f M di l Sciences, D lhi Delhi & Edit Editor Indian Journal of Orthopaedics
Practice of Medicine � It is an art � Transformed from an art based on “belief in supernatural force” to “ art based on science” l f ” “ b d ” � This art is learnt by “observations of talented physicians and by practice. h i i d b i � to documented evidence and than on validated evidence.
Art/ science ratio / � More and more knowledge based on scientific research � For diagnosis � For treatment and � For prevention of the disease � Will reduce guess work to achieve pt care. Will reduce guess work to achieve pt care.
Modern medicine Chinese medicine Ayurveda
Ayurveda y � Evolved from ongoing body of practical medical experience passed down orally through numerous generations until, h h i il eventually, it was written down. � Sushruta ‐ samhita ‐ 1st century BCE, � Charaka ‐ samhita ‐ 1st century A.D. y
Ayurveda y � Ayurveda ‐ far ahead of Western medicine in surgery � Based upon a combination of � empirical treatments . � erroneous religious and philosophical erroneous religious and philosophical assumptions
Modern medicine � like Ayurveda, � Evolved from a long pre ‐ scientific stage of E l d f l i ifi f development, � applied proper scientific principles � old ideas ‐‐‐‐ simply superstitious , with no genuine medical foundation. ‐‐‐‐‐ Discarded � kept the things that worked and � This is something that Ayurveda never did; g y
Ayurveda v/s modern medicine y / � Ayurveda remains in its original pre ‐ scientific stage, � Western scientific medicine � Western scientific medicine advanced
Medicine means Western medicine Rest of them are alternative medicine
� Medical science has to evolve � Medical science has to evolve � Because medicine is a biologic science d b l � Biology is not stationary Biology is not stationary
Asia pacific region p g � Unique � Region of contrasts R i f � Highly developed to poorest of poor � Excellent health infrastructure to no infrastructure
Low income group – GNI 995 US $ g p $ � Bangladesh, Myanmar, ‐ population 213 million � India, Pakistan, Vietnam, North Korea – just entered I di P ki Vi N h K j d in lower middle income countries � Total population ‐ 1773 million � 43.4 % of total 4086 million 43 4 � World population – 6900 million
Lower middle income countries � GNI ‐ US$996 and US$3,945 � Sri Lanka Philippines Indonesia 561 millions � Sri Lanka, Philippines, Indonesia ‐ 561 millions � Chi � China –GNI 4382 US $ GNI 8 US � Just entered in upper middle income countries � Population ‐ 1337 million � Total population – 1705 out of world 6900 million Total population 1705 out of world 6900 million � 43 % of 4086 million
Upper middle income countries pp � US$3,946 and US$12,195 � Malaysia , Thailand ,Turkey � Population 170 millions � 4% of 4086 millions � World population – 6900 million World population 6900 million
High income countries g � GNI above US$11,906. � Australia, Hong Kong, New Zealand , Taiwan , A li H K N Z l d T i Singapore, South Korea , Japan � Population ‐ 438 million Population 438 million � 10.7% of 4086 millions 7
Summary y � AP region ‐ 4086 millions ‐‐‐ World – 6900 million � LIC and Low middle income countries ( 87% or LIC and Low middle income countries ( 87% or APOA countries and 50% of world population
How science grows ? g � Should have problem � Identify the cause � Plan the strategy to solve � Plan the strategy to solve � Scientific appraisal of outcome � Longitudinal collection of evidence � D fi it � Definite evidence id � Evidence should be retrievable beyond y the human life
Why do we need research???? y
Modern Medicine ( Orthopaedics) � Practices are guided by the west . � Whatever advocated followed in principle and practice successfully f ll � Reason – there was not much disimilarity in di disease profile 60 yrs ago. fil 6 � NOW � Huge disparity
High income countries � Well organised health services W ll i d h lth i � Infective , nutritional disease ‐ Infective , nutritional disease eliminated � Systematic documentation � Effective insurance system � Effective insurance system � High doctor : pt ratio – 2.56 per 1000 g docto : pt at o .56 pe 000 � Bed : Pt ‐ 33 per 10000
Health services in LIC � Travel 50 ‐ 100 km for basic health services � Provide elementary services P id l i � No financial resource to reach bigger city hospital � Hence treated by osteopaths or non ‐ specialist � We get all complicated cases � Minimum standard of care not assured
Problems LIC ‐ poor Problems LIC poor infrastructure
Huge n/o patients g / p
Di Disease profile fil � Fresh fractures � Neglected fractures g � Complication of treatment treatment � All spectrum of � All t f clinical cases in plent plenty � Natural history of di disease
Pt’s load in india and developing countries � Health services – urban based � Population rural based � Population rural based Urban based health services R Rural poulation l l i
LIC and MIC – public sector p � Tremendous intellectual capacity � Lack “state of art” infrastructure ‐ � Heavy pt load l d � Poor record keeping � Poor follow up f ll � Migratory population � No hospital specific – clinical work
Pvt sector ‐ corporate hospitals t secto co po ate osp ta s � State of art technology � Limited clinical work – in volume and spectrum of Li i d li i l k i l d f disease � Not generalist but sub ‐ speciality experts N li b b i li
Best services ‐‐ Quantum of Best services Quantum of workload v/s work force / � We should know � Burden of musculoskeletal disease and trauma in � Burden of musculoskeletal disease and trauma in total and in specific geographic area.
We do not have data � Not even planning to have data. � No disaster plans
Scenario for training in Scenario for training in Orthopaedics p � Books written by western authors � on their needs � Campbell’s operative Orthopaedics – TB is just mentioned and PPRP removed TB is just mentioned and PPRP removed � Neglected trauma – just mentioned
Evidence based clinical treatment Generate evidence
High income countries g � They can generate evidence for ey ca ge e ate ev de ce o themselves
Low and middle income countries � Very little research input � Who will generate for most of our Wh ill f f clinical problems and of 2/3 world p /3
Clubfeet Th d The developing countries see the l i t i th Natural history of disease natural history of disease
MRC has done lots of work MRC has done lots of work
� NOW they have no reason to y work on TB spine – infection is almost eliminated l t li i t d
Can we generate evidence ? g � We have clinical problem at hand � We have intellectual capacity W h i ll l i � We have technical know how � What needs to be added ‐‐ will to do � Infrastructural support
Need of the pt different. SACH foot v/s jaipur foot N d f th t diff t SACH f t / j i f t
How much are we contributing to How much are we contributing to the literature?? � JBJS Br ‐ 2010 JBJS B
Publications � Total – 66 of over 300 � less than 20% of total world contributions � less than 20% of total world contributions � Over 75% population contributes less than 20 % � Low income ‐ 0 ( 15 ,India ‐ 9, North korea ‐ 6 ) – 30% � Lower middle – 0 ( 8 china) ‐ 12% � Upper middle ‐ 4 ‐ 6% � Upper middle ‐ 4 ‐ 6% � High – 39 – 60%
Research � Transform biological discovery to medical treatment Health research Government Industry d Research institutes Health care Health care
Requirements to conduct research q � Research temper � Research temper � Funding � I f � Infrastructure t t � Balance between Service and research
Is current clinical community Is current clinical community poised to do that? p � NO � How can we inculcate scientific temper and have a � How can we inculcate scientific temper and have a regular bench of clinician scientist
Barriers to research � Stimulate faculty for research � Improve research funding � Provide institutional support for research � Give extra credit for performers � Give extra credit for performers � Give extra credits for researchers over non researchers researchers
Infrastructure � Scarce funding – private ‐ Government � Private funding – clinical trials in development phase for market approval � For patient benefit research – a big no For patient benefit research a big no
Govt investment in research Govt. investment in research � UNESCO recommonds ‐ 2% of GDP for growth and d development l t � US and Japan – 2.8% � Canada ‐ 1.5% � India ‐ .8%
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