Scalpel - the last chance in heart disease? Episode 6

Monika Rachtan
I invite you to listen to the podcast. Patient first.

Monika Rachtan
Good afternoon, I would like to welcome you very warmly to another episode of the programme. First of all, the patient. And today my guest, but above all your guest, is Michał Zembala. Good morning, and a very warm welcome to you, Michał.

Michał Zembala
Welcome. Thank you very much for inviting me to the podcast of the programme.

Monika Rachtan
I am very happy that you have accepted my invitation and I would like to remind you right away that today we are speaking to patients, so there are no stupid questions here, no questions that should not be asked. I am going to try to speak to you today in the language of my audience, that is, the patients, and ask the questions that they ask, for example, on internet forums. Is that OK with you?

Michał Zembala
Very much so. I am very happy about it because. Because the more knowledge we can pass on in a way that is accessible and, I don't want to say simple, but that is understandable to the patient. For the patient, the better.

Monika Rachtan
So, Michale, let me start by saying that you are an amazing figure in Polish cardiac surgery and I think that many patients consider people like you, performing such a specialisation, to be doctors who are, in a way, gods. You had the opportunity to meet very prominent cardiac surgeons in your life, because you knew your dad privately and professionally. You probably also knew Professor Religa privately and professionally. That's right. And was it always in the hands of such eminent cardiothoracic surgeons? That scalpel is the thing that saves lives absolutely. But do these patient behaviours and what this patient does in his or her life also have a big impact on how this work of yours looks afterwards?

Michał Zembala
I think these are too big words, because those who are outstanding are actually very, very few in the world of cardiology, cardiac surgery, but also in the world of medicine as a whole. And this eminence is difficult to define. Because who is an outstanding person? Who is an outstanding doctor? The one who has written a lot of scientific articles, or the one who operates very well, or the one who treats very well, or the one who finally has a very good approach to the patient? It is difficult to define, but those outstanding ones, understood as a scientist, but above all as a clinician, who also has an excellent approach to the patient, are really few, and I speak here in all responsibility. However, God forbid, I would not count myself among them. In Poland, however, we have a very special, nice, good situation, because there are many such very, very good and very well-working people. I am an ordinary doctor who has achieved something in life. However, really communicating with people who have achieved gigantic successes teaches you a lot, and also the way, or maybe above all the way, of interacting with the doctor-patient relationship.

Michał Zembala
And that is, I think the key thing, because you can learn to operate. Of course, some, some people have less talent, maybe a little more square hands, but let's agree you can learn to operate. But you have to develop a relationship with the patient, you need time with it. I don't want to say born, but it has to be nurtured, because it is an extremely delicate relationship, but also one that many people seem to deny is completely unnecessary and redundant.

Monika Rachtan
That is, you think that doctors miss the point that this right relationship with the patient. The question is what does that even mean?

Michał Zembala
Well, what does appropriate mean? I would be a lifelong advocate of such a relationship, a very non-hierarchical one, because in many cases the doctor is either considered by himself, God forbid, or by others to be someone really special. It is good that this is the case, because respect for the doctor, for the profession is there, but without exaggeration. A doctor is a person who simply has a slightly different set of skills, a different set of knowledge. It's important that he can share and serve with this knowledge.

Monika Rachtan
That's how I think about this patient-doctor relationship and I think that this relationship is also a bit disturbed by the attitude of patients, unfortunately, because today it's a bit like that, I have the impression that some patients treat a visit to the doctor as such a service. Is it? That is, I come in, I open the door, I pay, I open the door first, then I say what I want, I demand, I tell the doctor what tests I am to be prescribed? The medicines he is supposed to prescribe for me. I leave, I close the door. In fact, I have this beautiful catalogue on the internet where I can choose dermatologists, technologists. People rate it, I either like them or I don't. And so it's actually kind of all changed a lot and gone the wrong way and that I've had to re-write the script somehow.

Michał Zembala
To redo it is not possible. A complex predicament because, on the one hand, let's ask ourselves as if we were patients, what would we expect. We would expect quality. Will someone help us? They will indeed help, they will make our health, which is shaky at the moment, improve. So it would be worthwhile for us to look for a doctor who is able to guarantee such quality, and if we were to reach him or her, read this queue of ours, we would expect that after visiting such a doctor we would receive a certain set of answers that would make our health somehow better. So ok - the patient demands, the patient expects. And that is good. The important thing is that these expectations are realistic, not hurtful to the other party or to the doctor. Because in addition to these expectations on the internet and these stars, pluses, reviews, there is also hejt. Right? And if a particular website, portal or provider itself starts to manipulate these ratings, reviews, then all of a sudden it's accepted.

Monika Rachtan
They are manipulating these days.

Michał Zembala
In the sense of manipulation, in the sense of cutting out data, descriptions, comments. This suddenly gives rise to a picture that is not true. So it's important that the patient has access to. A certain transparency of results with a certain transparency of quality - this is where we enter a discussion which is taking place in the Polish, Polish media, Polish public space, which concerns quality in medicine. How should this quality be rewarded? How? First and foremost, it is quality that should be assessed.

Monika Rachtan
When I listen to doctors talk about assessing this quality, I get the impression that some are unfortunately afraid of this assessment and that is why they negate it so much and why they try to push it away. Maybe I shouldn't say this here, but.

Michał Zembala
Just so gently. But fuck.

Monika Rachtan
Yes, I have that impression too. Michale, but let's go back to cardiology. To cardiac surgery. Could you explain to our viewers, the patients, what a cardiac surgeon does and how it differs from a cardiologist?

Michał Zembala
This is me thanking you very much for this question. Because it is extremely important. I have to say that I receive in the counselling centres rarely, because rarely. Once a month, in one, once a month. But it's not uncommon for me to encounter that patients confuse the concepts and come to the cardiac surgeon, to me with problems that relate to the cardiac area, that the cardiologist can solve more than the cardiac surgeon.

Monika Rachtan
What are the problems?

Michał Zembala
And these are problems concerning hypertension, cardiac arrhythmias or such general cardiovascular diagnostics. But the most common three are hyper cholesterol, chemo, hypertension and cardiac arrhythmias. And these three problems, these three huge groups of conditions are absolutely not the domain of the cardiac surgeon. And although a cardiac surgeon, understanding cardiology in part, can try to solve them or direct that patient to a specialist who does. But that's not my remit. So it's important that the patient understands, That you understand that the cardiac surgeon is the kind of specialist who surgically treats heart disease. So we have a diagnosed disease either a disease of the structure of the heart, which is the valves, or coronary artery disease, which is clogged not veins but arteries or an aortic aneurysm, right? And that disease requires the proverbial knife, scalpel, it requires correction. That's the surgeon.

Monika Rachtan
And who detects the disease?

Michał Zembala
Cardiologist approx.

Michał Zembala
And the cardiologist is a diagnostician, but these days he is also a therapist. Because let's not forget that some cardiovascular conditions, such as coronary heart disease, can be treated. Or diseases can also be treated in part by anyone.

Monika Rachtan
So that's what I'll ask the way.

Michał Zembala
It's blurring that line. Let's remember that for diagnostics, for basic fundamental things from my point of view and the cardiologist's point of view, which is I get really sore in my chest or every time I wake up, I've got cardiac arrhythmia, my heart is pounding. And when I go up to the fifth floor, I'm already breathless. These are all things that should be diagnosed by a cardiologist. Only when this cardiologist evaluates and says that you have a heart disease that requires surgery, then with such a problem you can go to a cardiologist, so that, excuse me, to a cardiac surgeon, so that this cardiac surgeon can advise on how, when and where heart diseases can be treated.

Monika Rachtan
And tell me more, because I also think that we abuse a little bit, however, as patients, the competence of the cardiologist when, for example, we are diagnosed with hypertension. The cardiologist diagnoses us, but then transfers us to primary care. And does this family's primary care physician have the competence to continue to manage this patient? Is there a need for the patient to go to the cardiologist all the time and spend their money often? Because we tell it like it is?

Michał Zembala
Beautiful is the question. Beautiful. And it is my joy that it falls. Because the family doctor, the doctor even has the competence to try to treat this hypertension himself, without the opinion of a cardiologist, a specialist, a cardiologist, because the family doctor's role. And I think this is changing strongly. The role of the family doctor is not just a kind of hub, where the patient comes in and the family doctor, and this referral here, and that referral there, and that referral, It's the family doctor who is the first contact, with whom they can treat some of the diseases themselves in order to relieve the specialists, so that the specialist is there for those cases that really need more attention. So the primary care physician should focus on providing this basis for the patient.

Monika Rachtan
That is, when he refers me to a cardiologist and I come in with hypertension, it's not as if he begrudges me the referral and says oh lady, he supposedly writes.

Michał Zembala
But you know what it is? Mentality, so terribly ingrained, so terribly ingrained that I think it's going to take two generations before it changes. Because it's not uncommon for me to encounter that a patient comes in, says I have hypertension. What medication are you taking? Please show me what medication you are on. I don't know, here's a box. But I don't actually know either. The doctor gave it to me, but I actually wanted to see a cardiologist privately tomorrow. Not enough.

Monika Rachtan
That he went to a cardiac surgeon, that.

Michał Zembala
Still privately, it's still completely mixed up. Somehow there is this in us. This kind of belief that if a person pays and goes private, they'll be better off than going to an outpatient clinic, a GP, a fantastic doctor who will help them ten times more than I will.

Monika Rachtan
This is true. I think that this role of doctors, PCPs, family doctors, because I think that's the better way to talk about family doctors, has unfortunately been very much degraded somewhere, and I think wrongly. Great doctors who can look after the whole family, they actually know the family best. And if I have this research I've read that if we have one GP for most of our lives, the chance of us living longer is much higher and that's years later. If that person just goes to one GP, they live on average 5 10 years longer, they are able, by knowing that patient, by looking at them, they are able to detect diseases and see those changes that occur in the patient. Now I would like to ask some more about this cardiac surgeon, because they said that patients come to the cardiac surgeon privately, so why do they come? Good direction. They embrace That's what you can come to the cardiac surgeon privately for? Because it seems to me that you get to you hot, in an emergency often

Michał Zembala
On the cardiac surgery ward yes, but the more surgical outpatient clinic is to prepare the patient for surgery. It is not required, it is not absolutely mandatory, so it can be bypassed completely. That is, a patient can, who has a referral for surgical treatment, can even should approach the hospital outpatient clinic and get all the information there. But I have to tell you the reasons, because I ask the patient why you came or why you came from a town three hundred kilometres away from me. If you passed by on the way, which falls most often, there are two things. The first is that he was in such an outpatient clinic. But the doctor there had no time for him.

Monika Rachtan
And that is sad.

Michał Zembala
And the second is that he wanted to get a second opinion. So those are the two reasons that dominate such visits. The first is that he was somewhere, he was waiting in a hospital outpatient clinic. And I understand, because I also worked in an outpatient clinic in a hospital in Silesia, that there are a lot of patients there, Time is limited, there is a lot, a lot of traffic and a lot of other activities. And that patient there. Maybe he should be pulled more in the sense there should be more time spent on him.

Michał Zembala
But patients say he doesn't have, the doctor didn't have time or he only said 5 sentences. Or he still wants a second opinion.

Monika Rachtan
This is what I am wondering about. What do you mean by the notion that the doctor had no time for the patient? That is to say, what should the patient give during that time so that the patient feels better cared for?

Michał Zembala
Here I'll tell you that it's very individual, because being in an outpatient clinic sometimes one patient requires 15 minutes of conversation to explain the condition, to explain the direction of further diagnosis or further treatment. But there are patients who require an hour or more to talk to them. And such is the convenience of the surgical clinic at Szpitalna Street. I don't remember there ever being one. So if the patient is a very complex patient and you can sit down with them and actually get the whole family together and talk as a group, and that conversation takes a lot of minutes, because we have to discuss how to prepare for the surgery, what the alternatives are, where to do this surgery, when and how to plan this further treatment and answer all the questions of the patient, who not infrequently comes with a whole sheet of paper and the family has another question, it takes a lot of time.

Monika Rachtan
I can't imagine such advice under the National Health Fund. If they are implemented, these doctors are truly wonderful.

Michał Zembala
But in the outpatient clinic at Szpitalna Street I remember that there were always very many patients, very many, that is about 15 20 patients for the time from 8 o'clock to 2 or 3 o'clock and at the same time. Maybe it was a matter of organising the outpatient clinic at the same time the wound was being looked after. The same doctor was supposed to look after the patient, who came in parallel to one room, to the third room and there he was supposed to look at, take care of the wound, remove the stitches. It is impossible to reconcile all this, so over many problems, troubles and patients you just have to sit for a while and a while, i.e. sometimes many minutes.

Monika Rachtan
I think that we in Poland have such a mentality that if the heart beats harder, everyone is already very afraid of these heart problems. Oh God, it's probably from the heart, even though we don't care too much about the heart in Poland. And does every faster heartbeat or every pain in the chest mean a heart attack and that something terrible is happening?

Michał Zembala
No, absolutely not. But you can't underestimate it either. Because if we are dealing with a patient who is in his 50s, has smoked cigarettes all his life and is hypercholesterolaemic, his risk of having a heart attack will be much higher AND for him this chest pain may mean just that than a 20-year-old. That's how they happen too. The fact that they come, that he woke up after three days of partying and his heart was beating harder. And so I sit and look at this boy and think to myself clear. I was also beating harder yesterday after Christmas when I woke up after three days. So I think at the root is also our education and our awareness, our knowledge.

Monika Rachtan
Well, that is the problem in Poland. You said the word that someone has a higher risk of having a heart attack. There is still this notion of cardiovascular risk and it often appears in various articles that patients, for example, may read in some daily press or in weekly magazines that they buy. What does high cardiovascular risk mean?

Michał Zembala
Yes, we are talking about patients who are 50 years old plus in women who are postmenopausal, so there is a gender difference also women higher risk in menopause and people who have a genetic background of higher cholesterol, hypertension, not infrequently smokers. So these risk factors already mean that our chance of being a cardiac or cardiac surgery patient in the future is high, because in our body the disease can develop faster and run worse.

Monika Rachtan
You said gender, you said age, but you also said that patient behaviour is very important. So my understanding is that we can divide these factors into those that are influenced by the patient. Of course, and those that are not influenced.

Michał Zembala
Absolutely no influence. But in addition to those we can under this list of I have no influence write gender, write genetic factors, genetic conditioning. But if we were to give it those bullets it would come out more on the side of I do have an influence though and here at the top of that list would be stimulants, including nicotinism. However, we still smoke a lot as a society 29% Poles.

Monika Rachtan
The most recent research so was 23.

Michał Zembala
There was, so there was less, yes, two on that cholesterol after all we can't just blame it on genes, on grandmothers, great-grandmothers, we can also look at what's in our plate and what's in our snacks and crisps, right? So let's look at that too, that we don't always dump everything on these genes and hypertension the same way, because after all, diet affects that and. As I'm explaining to the lady who says husband is taking these drugs, he's taking these drugs, and there's already a horse dose in there. I ask, but the blood pressure goes down, but I ask and you, when you eat dinner, do you salt those potatoes? Of course I salt them. And the husband says But I like it that way. Salt it the state. Let's start with those factors that we can modify, that we can totally modify. Simple little things that will make it suddenly this risk, which of course is related to things or factors that we can't modify or change, but. I think more is on our side and more we can change than we feel sometimes.

Monika Rachtan
I'm glad you're talking about the little things. I have just written an article aimed at pharmacists and it was about what to do with a senior citizen who comes in with osteoarthritis, to motivate them to start moving around a bit, to break the vicious circle that is this disease. My advice to pharmacists would be to advise seniors that it might be worth taking care of their granddaughter's dog for a few days, going for walks, getting used to the rhythm, or finding something terribly simple to join a seniors' club and going for walks in the city or town where we live. It doesn't seem like much, but so much. Or that one stop in front of the house to get out and walk around.

Michał Zembala
Exactly such a cool measure of a patient's fitness is what I always ask my patients, especially those with circulatory failure or valvular defects. This is usually the way to church, because many older e persons still walk. And it's significant that a patient will say that up until five years ago I used to walk without any trouble, now I'm no longer able to. I see it more and more on television. Or such a measure of distance is the Żabka. There are so many of these frogs in Poland that it's hard to walk to that frog, so that's the kind of distraction. To say that such a way to increase the physical capacity of this physical effort is for the patient to buy in instalments, i.e. to specifically forget something. So go to that frog and instead of buying two rolls, buy one, go back under the gate and then go and get the other one. And that's kind of the way to make that known distance, because it's a nice measure for the patient to remember. Oh, I walked that distance yesterday without any trouble, and today I'm already halfway there. I'm breathless or as a result of the treatment.

Michał Zembala
I can already go the frog further, I can already jump it to the next frog. This distance is so quite cool. The frogs are so spaced out. Gee, that's the way it worked out for us. It absolutely didn't. But, but it is with such a dense network.

Monika Rachtan
In good faith.

Michał Zembala
They are deployed and they are sympathetic enough that it's so much fun to put together so pro patient.

Monika Rachtan
Patient. Today I'm reading the comments in the teaser for this episode, when I wrote shyly to our viewers that I would love for them to ask questions. And you know, there I was telling you about it, There were just hearts, flowers for you and they asked, but they wrote Very cool professor. And I think to myself, when I listen to you, I understand why they wrote like that, and that every doctor should have at least half as much enthusiasm for the patient as they wanted to, that they should be able to explain so that the patient understands what they can do for themselves. With simple, straightforward actions.

Michał Zembala
Because in all of this we are not gods, as you said or professors. We are first and foremost human beings. This title is just a title, titles and actually a title only. We are first and foremost doctors, physicians, human beings. And it's good how a doctor is also sometimes a patient. And I think that among us doctors, there are probably not enough of these patients, because when I went to hospital for asthma, I was also in a regular room of 3 people and I functioned just like any other patient. And then you see the shortcomings, you see the shortcomings of the system, you see the things that you could improve in yourself, in the facility that you work in, but you also see the pluses that are there. And here I'll tell you an example of a deficiency in the system and a thing that needs to be changed. The simple thing at five o'clock in the morning everyone is still asleep, the appointment is seven o'clock, and here the room attendant rushes in, knocks down the bin, throws it away, everyone on their feet is up. It's that kind of experience, that kind of patient experience, which maybe doesn't necessarily exist in this hospital, but on the other hand, when lunch was served, maybe it's that kind of, sorry, that kind of Polish, then when lunch was served and there was, for example, a

Michał Zembala
a leg of chicken, 5 potatoes, a salad of some kind, and I think, well, that's great, that's just great. And I bring back this empty plate, and there's a pile of these uneaten and one patient. Well, the cuisine here is always terrible, it's always terrible. This Poland will never change.

Monika Rachtan
And you enjoyed it.

Michał Zembala
And I liked it. And I also think that we have such an innate talent for complaining, not to see that it's, it's not, it's cool, it's okay.

Monika Rachtan
That's right. I came to this hospital not to eat well, but to be treated, diagnosed. And that should be the point I'm focusing on, so that. It has a nice doctor to get a competent one. And about this kitchen, it's possible to get 3 days tired. I think no one will be hurt. Let's go back to what Poles are afraid of. A heart attack is something like that. What are Poles afraid of?

Michał Zembala
I think it is everyone who is afraid of it, because it is a disease though. A disease that is, above all, chronic, sometimes fatal, crippling what and which in our society, however. So this is something to be feared. One should defend oneself with one's arms and legs, so as not to get a heart attack.

Monika Rachtan
Well, that's because it's cardiovascular disease. This is the most common cause of death in our country. And most people die precisely because of heart disease. And I would like to ask what a patient who has already had a heart attack can do to avoid having another heart attack. Because there are figures that say that within 12 months it is significant. Patients who experience for the second time, yes.

Michał Zembala
This secondary prevention, because we are talking about it, is extremely important. It is indeed the case that, depending on how this first infarction went, the risk of reinfarction is from 20 to even 50% per year, so it varies depending on our risk factors, on how this infarction, the course, what the disease is, but nevertheless it is high. So still the world of cardiology is watching these patients very closely and secondary prevention is one of those priorities of cardiac societies today, because we have coped with the treatment of myocardial infarction. We have also coped very well in Poland with the creation of haemodynamic laboratories that can competently, effectively and safely perform coronary artery plastic surgery, i.e. this ballooning or occurrence of lesions responsible for infarction. And this works very well. As a result, the mortality rate of myocardial infarction in Polish society has fallen significantly, but the mortality rate in complicated myocardial infarction, i.e. cardiogenic shock, is still very high. And this is the goal that Polish cardiology is setting itself today, to reduce this mortality rate, this value, but this requires very specialised care.

Michał Zembala
On the other hand, it is important that after a heart attack. Undergo cardiac rehabilitation.

Monika Rachtan
Well, what is it?

Michał Zembala
Because cardiac rehabilitation, which should take 3 to 5 weeks like this, is a way of exercising appropriately either in the outpatient system, which is such an outpatient clinic to midday, or in such a hospital system. That is, I am in the rehabilitation ward all day and night. And in the action of a cardiologist, rehabilitation specialist. There is such a selection of resistance exercises. One that is a bike, that is a treadmill, that make this heart muscle suddenly. It activates areas that were previously less used.

Monika Rachtan
Can this be seen?

Michał Zembala
This can be seen in the Echo of Cartography. This can be seen. scintigraphy it can be seen slightly in the electrocardiogram, but please see that the effectiveness of such rehabilitation is very high. Let this be an example. I am sure you have heard the cardiac care coordination programme KOS myocardial infarction, KOS. Maybe it's a name like Bird, but it's coordinated specialised care and the idea was that every patient in the area covered by this programme went directly to cardiac rehabilitation after a myocardial infarction and, depending on how extensive the infarction was, what risk group the patient was in, was either put on outpatient rehabilitation or day rehabilitation. On the other hand, it was observed. A huge difference in the survival of patients after the introduction of this programme. This is a huge success of Polish cardiac medicine. And today we know that every patient after a myocardial infarction should go to such a specialist rehabilitation programme, because thanks to it they are able to improve their efficiency, lower the risk of a repeat myocardial infarction and lower the risk of death from a repeat myocardial infarction. So this is a very, very big gain.

Monika Rachtan
And this patient should then continue these exercises, this physical activity at home

Michał Zembala
As much as possible.

Michał Zembala
This outpatient or hospital facility is only there to firstly teach, secondly to supervise and thirdly to give a tool that this patient should continue at home. It is then up to us what we do with it. It would be good if this programme extended for more visits and more visits. But let's also remember that there is some capacity in the system, because you can't suddenly follow the whole population like that and hold their hand for another five years. It would certainly result in reducing mortality even more. But I think we can continue some of these exercise tasks ourselves.

Monika Rachtan
So again, it comes out that it is not the gods who exercise for us, it is we who have to.

Michał Zembala
We won't.

Monika Rachtan
So mobilise and continue these exercises. This is very important information today. Is it standard nowadays that in these recommendations in the card that the patient gets after a heart attack from the hospital, he always gets a referral for this rehabilitation? Do you have to make a reminder?

Michał Zembala
Yes, yes, the patient himself gets, he gets a referral for rehabilitation straight away. And I have to tell you that here such a great authority for me is Adam Staroń, a doctor who came back many years working in Saudi Arabia. There he created a phenomenal system of cardiac rehabilitation. Today, he works in Gliwice and he is such a visionary of this way of managing cardiac rehabilitation. He even talks about such an exercise prescription, i.e. a document that the doctor should issue to the patient. What exercises, at what pace, at what intervals to do? I think this is in front of us and I encourage you very much to contact him as well. Adam Staroń an outstanding person, very humble, but with very, very deep thoughts and a big vision of how to change this to make it work.

Monika Rachtan
I have made a note, I have noted it down. I will try to invite him. If he is willing to talk, I think this is a good place to educate patients here as well. I would also like to ask about these recommendations on the hospital discharge card. What else can be found there, a healthy diet, are there any medications?

Michał Zembala
And the question is who reads it I'm afraid not many people so from my counselling experience. I have to tell you that it is probably the reading of this document that ends up for the patient just what medication to take. Many patients don't know what's in there. I ask Let's see what was written there and what they actually wrote there. Let's read the document. That is the first thing. Let's read this document, this document is for you, dear patients. It is your kind of mini guide. I was in hospital, this was done to me, and now I have these recommendations. And there, among these recommendations, of course, should be dietary recommendations, but also if we write the Mediterranean diet.

Monika Rachtan
That's right.

Michał Zembala
It's sudden. However, we'll be coming home to these noodles and roulade of ours. This is nowhere near that Mediterranean. And not either. Let's not kid ourselves, we live in an area where these noodles and potatoes will dominate, it's impossible to suddenly turn life upside down. I will only eat seafood. Well glory, but it won't work like that. Let's be realistic about how it works.

Monika Rachtan
I, for one, think that in this kind of misunderstanding of this recommendation card, again a very helpful hand will be extended to us by our primary care physician. And I really say to everyone, to all patients who are in hospital for whatever reason, Listen, and have you been to the doctor with your signature? There's no reason for me to go to him? Well what do you mean why? He is the one who will explain to you. He will tell you everything. He will take the time to tell you what a healthy diet is.

Michał Zembala
Also remember that today our health care system, our medical education system trains a lot of nutritionists. And I think it is. A phenomenal thing and very unfortunately underestimated, because in hospitals, including where I worked, this dietitian was many times seen as a person who distributes food. Nothing could be further from the truth, because clinical dietitians today have the knowledge to treat food like medicine. Protein requirements are higher in such a patient with cachexia. The dietitian will then compose this diet in such a way as to compensate for this protein requirement. Is it a nitrogen balance, is it a fat diet, is it a diabetic diet? So let's use the services of clinical nutritionists, because they are. They are available. They are the very educated people today who have not only a passion for what they do, but also a huge amount of experience. Here is an address that I would encourage you, dear patients, to take advantage of the help of a dietician, because it is possible to make this Mediterranean diet out of our potatoes and roulades. I am not saying that this roulade should be cut in the shape of a fish, but everything is good that is within limits.

Michał Zembala
As a patient asks me, after a heart attack, the patient comes and says can I have a beer?

Monika Rachtan
Or perhaps.

Michał Zembala
And why not? If it's one beer a week, I tell him brightly. Mr John, make it a holiday. Well let Friday be one beer a week. But not every day, right? Let's remember that apart from the fact that we should treat these sick people, we should make their heart function well. That apart from the heart, there is also the head And the quality of life is also important. Because all of a sudden, if we tell a patient that they should turn their life upside down and not eat this, then we will have a huge complex. That patient will simply say that he won't live like that.

Monika Rachtan
Well, yes. Well, that's what you said? Since when did you list the things that this nutritionist, that he can take care of? There were so many concepts in there that I didn't understand. The patients probably didn't either. So here I am reiterating and talking about the fact that precisely if such problems and such difficult tasks are in front of us, it is worth using a person who has trained for this. And importantly, my guest also in one of the episodes was Professor Agnieszka Mastalerz, national consultant in family medicine, and she also spoke about the fact that primary care doctors have been given new powers and can now refer certain patients to dieticians. Also there every single pathway is a cardiology pathway, that is your patients.

Michał Zembala
That's the way it is, that's the way it is. And it's very good, because the group of dietitians who are educated, they are educated very well.

Monika Rachtan
It grows 5 years of study, usually at a medical university, so it's not some course, but it's also important. And I think it's worth reminding people about that every time we go to a dietician, to make sure that it's a clinical dietician, because there's a problem in Poland.

Michał Zembala
As far as that is concerned. Yes.

Monika Rachtan
Well, they are.

Michał Zembala
There are dieticians who can, who have their own, who are not dedicated to medical problems. The distinction is the clinical dietitian and what is important is that we have to say so. Have the patient take their medical records with them. This will definitely help the dietitian to determine what treatment with this diet he should implement.

Monika Rachtan
And I have another question, and this too may seem trivial, but my experience shows that, unfortunately, all the time this problem exists somewhere, that when we get this discharge, even we make an appointment with a professor doctor, we get a recommendation, a prescription, the same prescription will not cure us. These recommendations have to be followed and these medicines have to be taken. And patients, including the elderly, sometimes reduce the amount of medicine on their own. Why should I take so many of these tablets?

Michał Zembala
But it is also our fault. I have to say it is our doctors' fault, because let us respect, I say this to my group, let us sometimes respect those recommendations and those medicines that the patient has already taken before. Because let's also remember that many of these patients are poorer, they are only living on a pension or a retirement pension. And all of a sudden, when you come and say from your real life situation that I had this kind of medication, and I was in hospital and they changed me to this kind of medication. And when a person compares what are in total similar preparations, well then what is she talking about? I have bought these medicines for two more months, and now I have to throw them all away, because I have these medicines And what am I supposed to do? And hence it is very important to look at the patient as a whole. Not just that we now necessarily have to change his medication, because such only appreciate what someone before us has done, what someone before us has recommended, if of course it is justified, and take these medications into account. I am also in favour of the patient, in many cases, modifying certain doses of medicines himself through his own observation, because if he observes his health condition, observes his blood pressure, he can himself make small modifications to the doses of medicines, half a tablet less, half a tablet more.

Michał Zembala
If we are talking about controlling hypertension so that he can come to this doctor in a month's time with a notebook where he has his blood pressure in the morning, his blood pressure in the evening, his weight in the evening. And here I was taking this medication, here I had a higher pressure, and this I increased by half a tablet and here it dropped, and this I observed. The patient also has to participate in this treatment. This is his health.

Monika Rachtan
This is very important information for patients that, firstly, they can do this and, secondly, that they have to inform the doctor about it, in the diary, of course, because this is then a very, very important indication for the doctor. So we appeal again to you to allow yourselves to make such modifications. Of course, if you feel able

Michał Zembala
Come with your cardiologist or GP. If I have a spike in my blood pressure, and it's Saturday Sunday, so that I don't have to go to the doctor every other day. Can I increase it? Can I increase it? And what does this tablet work for? And if I take more of this tablet, it will have what? What effect? That's how aware we are becoming. We should know this.

Monika Rachtan
And I'll also ask about whether it's worth inviting your son's daughter or someone simply kind to visit a cardiologist, cardiac surgeon or primary care physician?

Michał Zembala
It is always worth it. It is always worth coming with someone close to you, because first of all, for many patients, you know this well, because for many of you this visit is associated with some stress. Because you are coming to someone you don't know, because you have to open up to the other person and tell them about your problems. This is stressful. Also, a person doesn't always remember everything. And if there are two people or even three, each can remember something, each can correct certain. Notes. And in this way, this care of the patient is more complete. Particularly if the case involves an older person, an elderly person. And I have to say that in such a practice the time of day is very, very good. And it looks good, because a lot of times an elderly person comes, a grandmother with her grandchild.

Michał Zembala
Not with a daughter or a son, but with a grandchild and I see that this is our generation, ours. Such 40 30 year olds looking after, looking after this older generation, these seniors. And it is our generation that looks after these seniors very much. It's true. It happens a lot of times that a grandmother says that the watch his grandson bought him is one that measures the ECG and shows atrial fibrillation. Very often it's the granddaughter who has found the address and said she wants to come here because she's read here, she's read there, she's read there and she actually wants to get another opinion. So it's our generation. It's fantastic. And it's the grandchildren who are very much on the lookout for these recommendations in seniors.

Monika Rachtan
Like this. I think it's worthwhile for us to think about it too, to get a little bit into that health of our mothers, grandmothers, because they just need it. Also on the internet. Even though you can find this valuable information, it's our generation I think that can pick out better.

Michał Zembala
Better than that, better, better.

Monika Rachtan
Yes, often my mother says to me that she has read. It wasn't long ago, either, that no one knew whether this butter was healthy or unhealthy, that she had read something on the internet and that it definitely was. 'Mum, but what website did you read it on? Well on the internet I read it, Mum. That's right. So I think it's worth paying attention to that and also educating these seniors a little bit. And I've noticed too, although it's also specific to my job, so it's probably a bit different. I try to talk to these older people and encourage them to take care of some part of their health. I think these topics are worth raising.

Michał Zembala
Absolutely yes, because. this too.

Michał Zembala
It shapes our sense of family, of community. Because today grandma is ill, but in 30 years I will be ill And how do our children see us, how will they care for us?

Monika Rachtan
That's right. And one more thing. When you were talking about these pills and this comparison of what the patient had written before, I thought that there was one very important thing that should also be passed on to patients, that they should not be ashamed of this doctor. That is to say, if there is a situation where we have these tablets, it is important to say, tell this doctor he won't do anything bad to us, he won't shout at us.

Michał Zembala
I hope at least that such behaviour happens. But you really have to show. You have to say hello, you have to not be afraid, you have to say that I've got it redeemed. I've really spent a lot of money to get these tablets purchased. Can we use some of these preparations that are here?

Monika Rachtan
So I think it's worth it and we should pay attention to it during such a visit. If it's not us, it's our children, so that I do that kind of drug review. And with this card in general I think it's always worth having this book with the doctor. What medicines do we take? That's right. And now I wanted to ask you a little bit about your work, because apart from being a cardiac surgeon, well there are also these transplants, heart transplants. And it's also a very interesting topic for me at least, because I wonder what it's like to be in that place when you actually have a life in your hands. You remember that first operation.

Michał Zembala
That first operation? You always remember the first ones and then, apart from the first one, you only remember the less successful ones. Maybe it's just the nature of the profession, but I remember the first one very well. A heart transplant is such a magical operation, maybe not technically very complicated, but one that gives a lot of satisfaction. But it is a difficult piece of bread, because many of these patients are very, very seriously ill. And here it is important to remember that this surgery is just such a part of the treatment. Very many of these patients that my team and I have had the privilege of treating in these years 2018 2022. These were patients who were on the brink of life and death, these were patients who, who were dependent on medication, who depended a great deal on cardiac medication to sustain their lives, vanity machines, who, who, for many weeks or months before the procedure. They wouldn't get out of bed because of that kind of cachexia. It was a very, very difficult patient population.

Monika Rachtan
But there are also probably young people who need reading at a young age.

Michał Zembala
It's a very, very such a diverse cross-section of ages, genders.

Monika Rachtan
What kind of feeling accompanies you at these surgeries. It is such excitement, it is joy, emotion.

Michał Zembala
The emotion is always there when the patient takes their first steps again, when they start walking and when they come out. And yes, you have to hold back your emotions a little during this procedure, because, well. In part, this man's life depended on my work. But it's not just one person's responsibility or one person's job. It is the work of a whole team of people.

Monika Rachtan
In preparing for this interview I was watching one outing with you in which you spoke beautifully about the team you've created and so I think that team is very, very important and it's important that every element works together and interacts.

Michał Zembala
And yes, and it is important that there is a lot of diversity in this team. I'm talking about the kind of team we had, which was a group of people who took care of heart transplant patients and post-transplant patients before, where there were a number of anaesthetists, a physiotherapist, there was a dietician, there was a physician assistant. So people who come from different from different medical fields and disciplines, who some are in the degree of a student, the other is a master's degree, the third is a professor, the third is a doctor. It doesn't really matter. We are all per you and competence counts, the competence of these people.

Monika Rachtan
I would now like to ask what patients most often ask in the comments where can you find now, how can you make an appointment to see the doctor?

Michał Zembala
Now I very often discuss with patients online. That is, a lot of people write to me on social media, in emails, and I very often give this information by email, usually in the evening or sometimes in the cities I visit. Nowadays I'm in Warsaw more and more, so I actually meet patients here or in the clinic or outside the clinic. Yes. Today, after this meeting of ours, I have one meeting with a patient in Mokotow, so very, very loosely I would say.

Monika Rachtan
That is, you can write.

Michał Zembala
You can write, my address is generally available, please just be a little patient, because I am abroad a lot and when I do, I reply with a delay of 2 or 3 days.

Monika Rachtan
I know that in the reality of our Polish healthcare very quickly anyway, because I sometimes call some clinic for example a week and I need treatment Michale, I told you at the beginning that I collect questions from patient groups and that I collect questions on Facebook in different places on the internet. And this gives the kind of questions that the patient has a little lack of time for in the doctor's office.I would like to ask. I'm absolutely not asking you to make a diagnosis, because I know we're not allowed to do that here. But I am asking for answers, because this first question is quite interesting. Tell me if it is a different approach to operate on a patient who has, for example, a congenital defect and needs a heart transplant, and a different approach to operate on a patient who goes to a cardiac surgeon because he has simply neglected it.

Michał Zembala
I've never grown children either, so it's difficult for me to comment on the birth defect as well as the child with a birth defect. But I have to tell you that I have always recognised the principle of everyone equal. So in many cases, even in this transplantation of parts that we were running patients. It may sound so stupidly wrong, but also don't understand you, the state, well, we numbered. I mean the patient was named after the number of the room they were in, so patient number two for example, patient number 2, patient number 3, patient number 5 also so that. As if to separate who he is, who he was professionally as a person functioning in society from who he is now. Now he is a patient just as important. His material status or social status doesn't matter. It's just that everyone is the same. And I think that partly answers the question. That the same emotions accompany the treatment, which is, it affects a young person as well as an elderly person. And the same effort, and the same level of commitment, At least in my case.

Michał Zembala
And whether I'm operating today on a person who is of the Catholic faith, or like I'm going to be operating on Monday on people in the Philippines who are Buddhist or in the Middle East who, who are of the Mahommatean faith. So it doesn't matter, absolutely doesn't matter. Because the patient comes first, the patient is the same.

Monika Rachtan
Thank you very much for your answer to this question. This is the answer I expected, but I wish such an answer would come from the mouth of every doctor. Or perhaps more so, that the testimony of that answer would be the behaviour, the demeanour of the doctor. I hope that will be the case soon. The second question is this thesis. I read on one of the groups. A patient who is treated in a private clinic gets a lot of information at discharge. Everything is explained to him. If he goes to the National Health Service, everything is explained to him. You have to ask, ask questions, and still the doctor does not always want to answer.

Michał Zembala
It is sad because it should not be like this. I believe this is not the case in many places. Maybe. Maybe this one asked this question, asked by someone who has had this experience. I know I will be corrected by the state that it is like that everywhere, but I wish it was different. I would like it to be different. I would like this quality of care in private facilities, public facilities, facilities to be the same. It is only and always up to the people. But maybe let the excuse be that the public one maybe there is such a glut of patients that someone didn't have time. But that doesn't explain it either, does it? So.

Monika Rachtan
Maybe it's just sometimes worth asking this doctor, saying Doctor, could you please give me a little bit more time? Because I didn't quite understand, can I come in at some point where it would be a better time for the doctor?

Michał Zembala
As much as possible.

Monika Rachtan
Here is a request for advice. I need advice. I've been feeling palpitations coming on for about a week now, which he simply underestimated. Today I felt worse, so I measured. My blood pressure was normal. Pulse 116. I've been feeling unwell all day, having fits of cold sweats, general waking up. Pulse after rest 111, after exertion again 116. I need advice on where to go and where to start. TSH cardiologist I will add that I have been breastfeeding for 7 months. Could this be happening due to deficiencies?

Michał Zembala
And this is such a classic question for a cardiologist. It's not a question for a cardiac surgeon, it's the very mistake we were talking about at the beginning. One. Two, the woman writes that she is freshly postpartum, so her goiter compensation may be different and her exercise tolerance may be different. We don't know how much weight she gained during her pregnancy. Maybe she weighs 120 kilos today and she weighed 80 before and the differences in the Pulse she says are within the error limit of the device with which she measures it 120 and then it's 116, so sort of. There is no concrete answer to that question.

Monika Rachtan
OK, so you need to see a doctor.

Michał Zembala
To the GP. This is what we were talking about in the first place.

Monika Rachtan
And just by collecting these questions at the group too, I would like to emphasise that this group is a place where you can get support. At least I think so, and I have the impression that a lot of people are expecting a diagnosis and that it is great, however, that you take this time. You write on the group ok, but those 5 minutes spent on the phone to your GP will be a much better spent 5 minutes, because there you will probably already get some guidance on which way to go. I think it's worth thinking about that. You also just mentioned those watches that grandchildren buy their grandmothers. I had a heart attack a week ago. I thought I could use an ECG watch. Do you have one and is there any point in buying one?

Michał Zembala
A good idea it is and it is very, very valuable. Especially for people with arrhythmia, with a known or not known or suspected rhythm. I have to tell you that I myself have been a sceptic about whether these watches work well or not. Of course Apple has a certified watch, but many manufacturers are already getting medical certification. But my experience with it was changed by one patient, because he came to me with a printout of the watch and that printout was sensationally accurate. Because the quality was very, very high and including the interpretation of that data, So I'm as much in favour of using this as possible, because at least there's a human being in the state. This patient was suffering from atrial fibrillation, a common arrhythmia in our population, and this watch was able to detect when this arrhythmia was occurring. Extremely important, because in many patients the arrhythmia, there atrial fibrillation goes on without symptoms. They don't feel it. And yet when the arrhythmia occurs, the risk of stroke is definitely higher. So this patient on the basis of this device showed that he does have this arrhythmia. He doesn't feel it at all.

Michał Zembala
There were indications for treatment, so it is as much as possible that I would encourage this technology to be used.

Monika Rachtan
So what if I bought a watch like that? I didn't even have a heart attack.

Michał Zembala
But I have a suspected arrhythmia or I have uneven palpitations. I want to know what it is. Obviously this kind of gold standard would be a Holter, a Holter test, but that's either a 24-hour test and it happens that this test won't pick up those 20 in those 24 hours or 7 days. Maybe it will pick up something. And the watch is such a tool, which the patient also looks after himself? I have it, it happens to me more and more often. And now when I come to the doctor in a month's time, it will show the whole history, that I had it here, here, here, here, here and here and then. The more information a doctor has, especially a specialist doctor, the better, more accurate diagnosis he can make. Because the worst patient is, I'm sorry ladies and gentlemen, is the one who will come in and say well I've got palpitations, well, when do you not remember it? Maybe a week or four ago. And do you measure your blood pressure? Yes, yes, I have a blood pressure. What kind of pressure is it? I can't remember. Have you ever written it down? Never. So.

Michał Zembala
We are older, we are getting sick more often. We examine ourselves, we take notes. We keep a kind of document that shows the history of our illness.

Monika Rachtan
I think this is a very important tip.

Michał Zembala
Those like. It may not have to be a diary that's printed a regular notebook.

Monika Rachtan
Line.

Michał Zembala
And there are patients who are so disciplined, they have everything written down. treating such a patient is really a great pleasure, because not only can they be diagnosed, they can be well directed to further treatment, to this specialist, because this one deals with this one, and this one will really be a good address here. Either here, or make it even more so that this patient is satisfied with the visit, but also the doctor is satisfied with the visit, because after all, our intention is to help.

Monika Rachtan
That's one more thing I'm going to ask you, which came to my mind now that you said that the doctor is able to point out another doctor to go to. And I, again, would like to speak to the patients a little bit, because when I heard such opinions o. He referred me to his colleague to still go. This is not in bad faith.

Michał Zembala
When No, it's not, it's not, it's not, because none of us is an omnibus and in very many cases someone else specialises in something else and someone else is better at something else than I will ever be. And that is absolutely nothing wrong. It is very common in the UK, for example, where doctors even write letters to each other and I also use this, I write to the patient, I hand this qualification card, I read the card with a consultation, and on the second page I write a letter to the doctor, I say show this to the doctor, because there is a request to him Dear colleague, Dear friend, please kindly do it again. I am the one who suspects such a disease, but please still this communication of the doctor to the doctor is as important as the doctor to the patient.

Monika Rachtan
But the patient is that bridge and must. This letter must pigeonhole.

Michał Zembala
However, it happens very often that a patient, that a patient comes in and says I was still here, but. And only after half an hour does he pull out this card, well he still pulls out this card. So let's not be ashamed of that. This is normal. This is our health, our documentation and our communication between patient, doctor, doctor, doctor.

Monika Rachtan
That's another question of how many heart attacks can you survive? It's also a question about whether that's the end of the story, or can three?

Michał Zembala
You may not survive one, you may not survive one. It all depends on how extensive this infarction is. If it is a widespread infarction, coming out of the trunk of the left coronary artery, for example, it can be so severe that the person will die immediately. But if the infarction is about or necrosis, because an infarction is necrosis that affects such a small part of the muscle, there could be 6 and 7 of them, if they are tiny micro infarcts. So it's difficult to answer that question unequivocally, but I wouldn't want the reader to go on the record here now.

Monika Rachtan
OK. Yes, that kind of advice I think is also very important. The questions from the forum were all there. Now lastly, a question that has been a constant on my agenda, which is the humanisation of medicine, because as I mentioned to you, the Institute for Patients' Rights and Health Education is a partner of this, of this podcast, and I'd like to ask you what the concept of humanising medicine means to you. You've said a lot about that today.

Michał Zembala
Well that is what I think we have said. A lot, a lot, a lot. It's a concept that I don't think we touch enough, because medicine should be just so human, so accessible, so for everyone, so not secret knowledge, because it's our health, our life. We doctors are there to take care of this life and health of our society.

Monika Rachtan
I think that's also very important. Well, just for doctors to get involved in that human side of being a doctor. This is what we wish for all patients. On the other hand, I usually do the summarising of the episode, but today I would like to hand that task over to you. If you could tell us what patients should take away from our conversation today, three important things.

Michał Zembala
I think, first of all, prevention. We have not talked about it much today, but prevention is extremely important. We have touched on this subject. We don't smoke, we eat healthy. Let's not give up that pork chop and those noodles, but salt certainly does. Let's cut down on butter and pastries, which are common, because as I tell patients. You need to change your diet. What are you eating? That pastry? Yeast cakes. Well I tell you, So let's limit it. Let's take care of movement and exercise, because we've talked about prevention of a second heart attack. But prevention of a first heart attack is movement, it's exercise outdoors. We are not talking about running a marathon, but 30 minutes a day, at least to walk around the block, around the block or to that frog we forgot to go to. So first prevention, second a visit to the doctor. The GP's first contact, which we have talked about, is. The key one, is very, very important here. Many of you I'm sure probably don't even know, don't know your doctor.

Monika Rachtan
He does not know his name.

Michał Zembala
Let's go, let's get to know each other, let's at least introduce ourselves, and let's head over there, because that doctor really can sometimes be more knowledgeable than the professor you go to and pay a pile of money to. So that's 2 and 3 Let's remember that cardiology punitively. Surgery today is a very rapidly evolving field and many elements of therapy that were not available yesterday will be available tomorrow. So this picture of medicine is changing very rapidly and what was impossible yesterday. There is a great chance that it will be possible tomorrow.

Monika Rachtan
Thank you very much for this summary. Thank you very much for our conversation. I guess we wish you a lot of health above all and we wish that you come across those nice, good doctors with whom.

Michał Zembala
I think there are more and more of them, and the very fact that we are training more and more doctors, I believe that there will be more and more of those who adhere to these elements, the principals of humanistic, medicine.

Monika Rachtan
Thank you very much.

Michał Zembala
Thank you very, very much. Thank you.

Monika Rachtan
Thank you.