“Historically Russians have had a lot of stress” – leading heart surgeon

Russia's Chief Heart Surgeon Leo Bokeria is considered one of the world's best. Performing up to six operations a day, he knows everything about having a healthy heart. RT meets a man to whom thousands owe their lives.

RT: You do four to six operations a day, the most complicated of them lasting for days. You complete them all without passing them on to other doctors, or to your assistants. Even younger doctors could find such moral and psychological strains unbearable. How do you cope?

LB: You know, there is nothing new about what I do, in fact. In America, surgeons start working very early in the morning, and complete several operations over one day. So do Dwight McGoon and John Kirklin, who trained me, and so do all other famous surgeons. When we started moving in here from our office in downtown Moscow, I insisted that operations begin at 6:00 AM, while previously, they would begin at 9:00 AM.

RT: You said you do very complicated operations on infants. But at the same time, you have successfully operated on a patient who was 92 years old. This is unique; nobody in the West does that.

LB: They do. Again, speaking of my friends, famous American surgeons, Dwight McGoon did it; Bob Wallace did it as well; John Kirklin operated on kids and adults with equal success. It’s just that, when you’re operating on a kid, everyone’s attention is drawn to you. When I was elected the President of the National Health League, someone said, 'It would be good to have a child surgeon chair the league.' When I asked what the difference was, I was told that a child surgeon would get more publicity, and draw more attention. Well, perhaps this does attract more attention, but still, I know many surgeons who operate on kids and adults equally well. First of all, a surgeon needs to have lots of experience and practice. Second, he or she needs to be an expert in heart bypass circulation methods, which protect the organism, and in cardioplegia, which protects the heart. In that case, given a correct diagnosis, a surgeon is going to be successful with both types of patients.

RT: Besides finely honed skills and lots of experience, in what else do you need to feel confident for the outcome of an operation?

LB: I do all of my operations myself, from start to end. Working along with me are two specialists: an anesthesiologist and a perfusionist. They are the key figures. Then there are assistants, who are usually highly-skilled professionals. Then there are surgical nurses, with whom I work in “automatic mode." We barely say a word to each other except for 'hello' in the morning, and 'thank you' before moving on to the next surgery.

Since sometimes I have to do five operations a day, the team may consist of four or five doctors. They are top-class specialists, and when we go on a road show, doing demonstration operations across the country, I take the entire team along. We also include an emergency physician in the team. I want people not just to see how Bokeria works – I want them to see my entire team at work.

RT: Speaking of your inner feelings, what mood do you need for a successful operation?

LB: First of all, I know the outcome of similar operations in global practice, and I know the results that my colleagues and I have achieved previously. As for the mood before an operation, it can be very different. For example, my third surgery today looked simple at first. It was an eight-months-old infant with a severe case of pulmonary artery stenosis. Technically, this is a very simple operation.

However, in the case of that specific kid, it was very difficult. I was more anxious before that operation than I was before the far more difficult large vessel transposition operation. Imagine that a child is born whose aorta goes out the right ventricle and pulmonary arterial goes out the left one, while it should be exactly the opposite. You must swap the two major vessels, relocate coronary vessels, and so on. While only two or three people in Russia can do such operations, it is very simple in that you can see everything: take this here, and put it there, and so on.

Therefore, my inner feeling is mostly determined by my skills and experience. However, there is another situation. A very close friend of mine has a grandson with a congenital heart disease. The night before the operation, the father of the kid (i.e. my friend’s son) called me at midnight, and demanded that I give a 100% guarantee that nothing wrong will happen to the kid.

Of course, I assured him that everything was going to be all right. In the end, he just pressed me into giving him a 100% guarantee. Naturally, I felt awkward preparing for the operation the next day. I always feel uncomfortable when forced to say what I have no right to say, because there is no way a doctor can give a 100% guarantee.

RT: Why is the rate of heart disease so high in Russia?

LB: Well, the reasons are obvious. Historically, our people have had to handle a lot of stress. During the whole 20th century, there have been wars, revolutions, repressions in Russia. It has been stressful this whole time. And we know that even rats die faster when they are stressed, as opposed to when they are not. That is the first reason.

Secondly, we neglect our health, and often think that this is something we should not be concerned about. People are not physically active. We eat whatever, buy the food wherever. Don’t have good sleeping habits – whereas, no matter what shift you work, you have to always have the same sleeping time. Everything that we call a normal balanced lifestyle is missing in our society. We don’t have a national health program, as they have in many countries. But the key issue is to encourage healthy eating habits in the country, and understanding the importance of physical activity. And we need to pay serious attention to fighting bad habits. We have a lot of smokers in the country, many drinkers, and the drug use rate is also very high.

RT: Let’s talk about your clinic. In 20 years, you have turned it into basically one of the best in the world…

LB: In 10 years – 1998-2008.

RT: You moved into this building when it was still under construction. Your clinic is now one of the very best in the world. How did you do it?

LB: Our center is 52 years old. We used to have to cram into small buildings. There was basically no infrastructure for cardio-vascular surgery, even though we had great surgeons, Vladimir Burakovsky for example. What changed after we moved here? I remember how I first started operating here. After my surgeries in the old building on Leninsky Prospekt, I would come out completely exhausted, sweating and so on. We had no air-conditioning. The lighting was not good. Whereas, here, after we moved… first of all, there was sterile air in the Operating Room, excellent lighting, a great frontal mirror, very good anesthesiology equipment, new bypass equipment, and the circulatory support that I have talked about so much.

So we were able to create the infrastructure for modern cardio-vascular surgery. When we launched in 1998, we were the best equipped clinic in the world. But for two years now, we have been feeling that this equipment is getting old and outdated. This year, the state gave us a significant sum of money, and just recently we bought totally new equipment, and I think that by the end of this year, we will again become a clinic that will be hard for anyone to compete with – because we have the equipment that not very many clinics do.

RT: What is the major difference between your clinic, and, let’s say, American clinics?

LB: Well, I am often asked this question. Russian cardio-surgery and
American cardio-surgery. Yes, that’s right, they do 600,000 and we do 30,000 open heart surgeries. But I always say – you can never compare the Bakulev Center and some clinic in a small American town. You should compare the Bakulev Center with the Boston Clinic, or the one in Cleveland, for example. If they come and look, actually many of them come regularly, I don’t think they will see much difference.

I just want to say that our clinic, wherever you put it on the globe today, will always be the center that does 4500 bypass surgeries a year, we do 3600 operations on children – out of this number, 1400 are children under the age of one. And together with our sister clinic in Perm last year, we did 7000 bypass surgeries. Even Chinese clinics don’t do this many, where there is a great need right now, and 150 million children there need at least some kind of surgery…

RT: Maybe this is a stupid question, but from the human point of view: if a patient is in critical condition, but he has no money, no insurance, would he get the surgery?

LB: So what? He will go into surgery. Right away. You mean this patient – they had a sudden condition? Some emergency? No questions, absolutely no questions. Any patient with an emergency will be admitted right away. The rumors about how hard it is to get treatment in a specialized clinic are really exaggerated. It is not so in reality, in reality we have the pattern of thinking that says – “Do I really need the surgery?” That is the first thing, and secondly – there are now opportunities for wider treatment. And we have these opportunities, because, I think, the Health Ministry gave quotas to 3 dozen federal institutions.

It turns out that the mindset in our country is that people with minor sicknesses do not go to see the doctor. They wait until they get to the point where they have to crawl into the doctor’s office, and these local organizations that just received new quotas do not admit patients with major problems. So some hospitals with quotas complain that patients are not sent to them, but in reality, they could not operate on these patients anyway. It will take some time before we figure out how it is that we have to do 142,000 bypass surgeries, while we only do 32,000; but where is the patient? Neither cardiologists, nor general practice doctors can provide that.

RT: You do many surgeries a day, travel to medical conferences, and also play football with your employees, and I know that every Sunday you write and read a lot. Do you ever rest?

LB: Of course, you exaggerated a little. I don’t play football anymore. I did, when we were still in the old building, we had a gym nearby, and I played with our interns. One of them gave me a little trauma, so I got mad at them and stopped playing after that. But I have an exercise bike, I have a treadmill, my favorite weights station – I can lie with my head down, hang and so forth. Also, I have a basketball hoop at home, a tennis wall, so I have my ways.

But my main physical activity is the static gymnastics which I do every day for many hours in the Operating Room. I don’t write much myself now, but I dictate a lot. The girls type up what I dictate, then I edit it, and that’s how my writing is done. I have not been on vacation this year, because everybody likes to vacation in the summer. I do too. But I noticed, if I take my vacation in the summer, the number of surgeries is reduced. For me this is a priority, because the salary of our employees directly depends on the number of bypass surgeries that we do. So this is a closed issue for me now. Maybe in the beginning of the year, I will hide for a few days somewhere outside Moscow. Even though, of course, I would really want to swim in the sea. Last time that happened was a year and a half ago.

RT: Are you a superstitious person?

LB: My superstitions are limited. For example, when my plane takes off or lands.