Wednesday, September 18, 2013

From the Bottom of Heart

Another heart day is here to celebrate, evaluate, comprehend, apprehend, explore and innovate. On the occasion, Color Doppler talks to Dr. Murali P Vettath, who has created many firsts in the world of cardiology, in a bid to explore new horizons of cardiac inventions




 Dr. Murali P Vettath
Director, International Centre of Excellence in OPCAB Surgery,
Malabar Institute of Medical Sciences
 

Ria Lakshman. V, cd news

For many, he is God, who redeems their life. For the people, whose lives are exacerbated with severe pains of cardiovascular diseases, this man prophesies as savior and masters his art of recreating the realms of human heart on them. For many others, he is a mentor, philosopher and friend, who explores roads that are less taken. It is the story of Dr. Murali P. Vettath, the Director of International Centre of Excellence in OPCAB Surgery, Malabar Institute of Medical Sciences, Kozhikode, who has created many ‘firsts’ in the field of cardiac surgery.

The evidence of Dr. Vettath’s quest for innovation and his unwavering dedication to medical field is seen everywhere. In the journey that has taken him across the length and breadth of cardiovascular segment, he has performed more than 6000 open heart surgeries, with more than 3500 bypass surgeries performed on beating heart. His voyage began from Coimbatore Medical College in 1983 and carried on to take a DNB in General Surgery in 1987, followed by an MCh in Cardiothoracic and vascular surgery in 1991 from Government Medical College, Trivandrum.

With his specialized training from Australia in coronary bypass surgery for five years, Dr. Murali P Vettath established two cardiac centers under the Z H Sikder Cardiac Care & Research Centre, at the Z H Sikder Women’s Medical College and Hospital Pvt. Ltd., in Dhaka, Bangladesh. Besides giving training to numerous cardiac surgeons in Bangladesh, he performed the first beating heart surgery in the country in 1999. In 2002, with an intention to serve the people of his home town, Dr. Vettath relocated to Calicut and became the fortitude of Malabar Institute of Medical Sciences (MIMS).

Today, Dr. Murali P Vettath is one of the few surgeons worldwide performing 100 percent of all the Coronary Artery Bypass Grafting (CABG) on beating heart. He has authored numerous publications and research studies and invented surgical devices. His works are the bibles of cardiac surgery that he is now the mentor of many surgeons from all over the world. On the occasion of another World Heart Day, here, Dr. Vettath talks to Color Doppler.

You are the person who performed the first beating heart surgery in Bangladesh and you are still one of a few who continue to perform it. What was your motivation to begin?

Off Pump Coronary Artery Bypass (OPCAB) was a technique started by Buffalo and Bennetti in 1985. There was an enthusiasm among the surgeons in 1990s to begin OPCAB, which slowly reduced towards 2000, as many surgeons failed to find their comfort zone in OPCAB. The success of OPCAB lies in minor modifications in the techniques of anesthesia, surgery, viz; stabilizing and positioning of heart. This has to be mastered and in an experienced hand, the results obtained are worth the effort. In fact, we analyzed our 3000 patients who underwent off-pump over the past ten years, and found that results were worth the struggle.

It was probably the idea of mini-invasive direct coronary artery bypass graft (MIDCABG) introduced by Benetti in 1990s that explored the possibilities of not using CPB (cardiopulmonary bypass). The introduction of LIMA stitch was the next revolutionary step in development of OPCAB. This stitch allowed the grafting of posterior branches of the coronary arteries. Stabilizers further enhanced the process. But circumflex territory was still a danger zone. It was that time that the role of positioners became more important. So the process became even more seamless.

When you perform CABG on-pump with the help of heart lung machine, the heart is motionless or practically dead for the time. Instead, the heart lung machine performs the function of the heart. Beyond a time period, this is bad and it has a 2 percent inherent mortality in it. There is also a 2 percent stroke risk. This thought provoked me to change the technique to off-pump or performing surgery on beating heart.

In 10 years of OPCAB experience, where more than 3000 OPCABs were performed, we noticed that in the last 2000 OPCABs, we had only one conversion to the heart lung machine. The mortality rate has been drastically reduced CABG (Coronary Artery Bypass Grafting) surgery has come a long way - from Off pump in the 50s, CABG moved to On-pump after the heart lung machine was invented, and it is now back to Off-pump. It has come a long way. We had to re-engineer the OPCAB, because this procedure was not reproducible by lesser mortals like us.

Whatsoever, the ultimate aim of a surgeon is to deliver good results. The mindset of the team and their consistency is important to deliver this. Very few cardiac surgeons in the world actually do 100 percent off-pump surgeries. Surgeons try and perform OPCAB to a certain extent, but when it becomes risky then they change it to on-pump.

You are a researcher. There are innumerable inventions and publications in your name. Can you give an insight into your inventions that revolutionized cardiology?

When we sight a problem during surgery, they we try to find a solution to it. That is how inventions happen. To take the case of Vettath’s Anastamotic Obturator (VAO), I found a problem with the side clamp on the aorta, especially when a surgeons need to avoid it when a no-touch technique is required in case of diseased aorta. In patients with plaquey aortas, a saphenous vein top end needs to be connected. VAO can be used to make an anastomosis on a non plaque zone in aorta. The technique is to identify a soft spot on the aorta, and make two purse string sutures around the intended zone of anastamosis. A stab wound is made and an aortic punch is used to make a punch hole on the aorta. The VAO is then inserted into the hole and one of the purse strings is used to snare the bleeding around the VAO, if bleeding persists. The advantage is that this allows the surgeon to perform a hand sewn anastomosis on the vein graft. The instrument can be reused and could help in avoiding stroke in elderly patients. It is also a good tool to be used in redo CABG.

Similar is the technique of long mammary patch. This technique was devised to perform OPCAB for patients with diffusely diseased coronary arteries. In this technique, the distal perfusion tips of aortocoronary shunts are cut and inserted into the coronary artery. The bulb is inserted into the end from where the blood flows. The advantage of this technique is that the intima is left intact and no injury is made on it. We do not add any other medications than those used for the normal CABG patients. Also, the patient will remain stable during the surgery.

We also re-engineered the use of Intraaortic Balloon Pump (IABP) in OPCAB. Every patient undergoing OPCAB gets a femoral arterial line and this is used for monitoring, along with the radial arterial line. In this technique, the femoral arterial line is removed and a shealthless IABP is inserted. The IABP is maintained till the end and is removed only when the patient remains stable. It is very useful in avoiding conversions. With this, the conversion rates to heart lung machines have sharply declined. Then, once the grafting is complete, the IABP could be removed in the theatre itself. These are few of the modifications we did over years. By re-engineering the techniques, we are now able to perform OPCAB in any patient who needs CABG.

What do you predict are the future developments in cardiology?

Over the years, I have noticed that the life span of an Indian male or female has increased. And, the incidences of cardiovascular diseases too have gone up despite all the medicines, innovations and awareness that have increased. Especially, in Kerala, rate of awareness is high. If anything is announced in radio, television or internet, they immediately come to us. Coronary artery disease is mostly a sign of aging. We cannot stop aging. By performing CABG, all we do is, connect another pipe to bypass the block in the artery. But the disease process still goes on, we can only try and postpone the inevitable. It can be stopped only to an extent. I always say, what I do is a glorified plumping job. But, still we try to keep a man alive by doing this plumbing job on a beating heart.

What happens is over time, people develop diseases of the blood vessels, like diabetes, which affects kidneys, heart, eyes and every other organ. Nowadays, patients come with a lot of co-morbidities like renal problems, where they are on renal dialysis and also who need renal transplantation. In early days, people with all these never survive. Now they get dialysis, get a bypass surgery, and then they go and get transplant done. I have seen lot of patients who come here from Cochin to Kannur and different parts of the country, who are planning for a renal transplant. They come here, get the grafting done and go back for their renal transplants.

When I went to Tokyo, I visited a hospital where there was a floor of patients over 90 to 100 years of age. These are the patients, whose aortas are replaced. Aortic surgeries are done on the patients at 90 and 100 years of age. And, most of them are walking freely around. They have gone beyond what we are even thinking about. Here, over 80, we don’t want to do aortic surgery because we think that this fellow won’t survive. Do we really need that? It is very interesting. So with all these developments of heart disease surgery, renal surgery everything, what we are now looking at is Aortic surgeries.

Cardiac Transplantation will now remain the next procedure, Cardiac surgeons in our state are going to focus on, as the left ventricular assist devices in the market are prohibitively expensive and there are a huge number of heart failure patients waiting. Next would be the increase in number of Aortic stents that has come up. This is a procedure done in the catheterization lab. Its performed like an angioplasty, by make an opening in the femoral artery in the groin, through which he puts the stent into the aorta, opens the blocks or even narrows a section of the dilated aorta, in case of aortic aneurysm. These are done without doing surgery and I think there is a lot of future in that.

Over the last 10 years, which I noticed that, the most important thing that has happened in cardiac science is the treatment for acute MI or Acute Myocardial Infarction. This is called a Primary Angioplasty. That is, when one has severe chest pain or a heart attack, and if you reach the cath lab within the three hours. Then you can open up the block. These three hours is a golden period. You open up the block; perfusion of the artery is so good, that there is not much of damage happened to the heart. One could reach a cath lab within three hours (Golden hour) then the chances of recovery of that damaged myocardium or heart muscle is very high. That is the best thing that has happened.

Coronary artery or its branch gets blocked completely by a blood clot, then that area of muscle supplied by that artery suffers from loss of blood supply. But, since there are blood circulations coming from the other side, the area of damage gets smaller. If that block remains there for a long time, then he might succumb to it. The block happens when there is a sudden rupture from an inner layer of coronary artery (endothelium). Then, like volcano, some secretions come out. The blood will suddenly clot inside in that region. This formation is called a heart attack and this is called a Myocardial Infarction. Like the stroke in the brain, heart attack is the block in the coronary artery. So, there is no blood circulation in the area. So with Primary Angioplasty Interventional Cardiologist open the blocked artery and stent it, thereby saving the myocardial damage and saving precious lives.

Earlier what we do is to give injection that thins the blood. This does work in 75 percent of block and the 25 percent it does not. So still the block is there. So if you open it up, the block goes. We have performed more than 1500 Primary Angioplasties over the last 10 years. But for this we need a big cardiology team. Everyday there are more number of people coming up with this problem.

You were telling, Australia is still doing 99 percent surgeries on pump. So as of now, how do you evaluate the cardiovascular treatments in India?

We are in par with the best coronary surgery center in the world, in terms of quantity and quality performed by a single surgeon. In India, there are only a few Cardiac surgeons who perform OPCAB on all their CABGs. When I came from Australia, I found that equipment wise and manpower wise, we are better than or in par with the Australian centers in terms of Coronary surgery.

What are the new researches coming up in cardiology?

In stents, there are new biodegradable stents. In the usual drug eluting stents, the metal bit will remain and a covering comes over it. In this, after six months, the stent melts. It is already there in the market and there are companies that promote it. That will be the future of cardiology. In cardiac surgery, newer surgeries are coming up. One is Coronary bypass surgeries with robotics. The only thing is that it is time consuming and is costly. It is already there, in Delhi they do, and all over the world, like US, Germany, they have robotic surgeries. In India, surgery developments are low because the treatments are not insurance based. People need to spend their own money to do surgery. Only 25 percent of the patients in the country are insured. So, if the insurance becomes mandatory, more and more surgical developments would come to our place as well.

In India, do you see an increase in the number of people who come with cardiovascular diseases or is the number decreasing?

Oh. Yes! It is increasing. The awareness is high. But, the number is also going up. So the number of centers has also gone up. In fact, when we started here in MIMS, 10 years ago, there were only three or four, less than 10 cath labs in Kerala. Today, there are 70 odd cath labs in Kerala. There are 100 cardiac surgeons and 300 cardiologists in the State, which is a very big number. Japan has the highest number of cardiac surgeons — 3000 cardiac surgeons and 500 cardiac centers in such a small country. On an average, there a surgeon does only about 30 or 40 cases a year, whereas surgeons like us, do 400 surgeries a year.

You have made many inventions. How does it benefit the cardiac treatment in the country?

All my inventions are to supplement the surgeries. It is not made for commercial value. It is for the surgeons to have these devices as lifesaving equipment in their surgical set. I have patented many of these techniques. I patented because I feel good about it. You don’t make money out of it. The device what I have made will costs Rs. 500, whereas the device that comes from US and all costs 500 US dollars for one shot, which we can’t afford. That is why I made this. And, this is for life time. I have showed the device and anyone can make it. Most of the things what I have done is to help a surgeon to improve the technique of surgery and hence, to make the surgery successful.

CABG (Coronary Artery Bypass Grafting) surgery has come a long way from Off pump in the 50s, CABG moved to On-pump after the heart lung machine was invented and it is now back to Off-pump. It has come a long way. We had to re-engineer the OPCAB, because this procedure was not reproducible by lesser mortals like us.

What is your message for your colleagues or the other doctors in India?

Off Pump is a very good technique to do, but until you master it, there is a steep learning curve. Also, you have to do only what you can do. Don’t try to mimic something because somebody has done this. That is what I always say. I have videos and other things on net. But, unless you come and see me doing it, you can’t do it. Some come here, see it and go back. But they are not able to do it. Recently, a surgeon from Singapore came here. He was here for three months. He was assisting, he was so observant. He went back and after six weeks, he did his first Off pump. He mailed me only after he successfully did it. He was a professor in National University Hospital, Singapore. Beating heart surgery was not very successful there. His Boss was telling me that “This man will drive it forward.” I think there are still few more modifications to do. I am learning and I am changing. Change is the constant in Cardiac surgery too. I cannot say this is the ultimate thing. I don’t do things what I did 10 years ago.

In science, this change is very important. We have to move and change according to how it goes. And, prove on whatever we do. I am not even happy with this 0.4 percent mortality rate in OPCAB. Unless the physicians have an aim in life, he cannot grow. Otherwise, it is like a bank job. You sit there and do same things systematically forever.

This interview was taken for Color Doppler magazine, September 2013 issue - http://colordoppleronline.com/heart-day-special.html

Thursday, September 12, 2013

Touch Therapy for Stroke Treatment

Extol the smartphones! They are capable to introduce cost-effective and timely care in stroke evaluation, thus enabling physicians to save the lives of millions, say studies from America and Japan

Ria Lakshman V | cd news

Recent clinical trials have demonstrated the effectiveness of telecommunication in the treatment of diseases. It enables the sophisticated satellite technology to broadcast consultations between a healthcare professional and patient through videoconferencing equipment. Although the technology fastens the treatments, several studies highlight its defects such as the lack of reliable connections, high cost factor and the fear of malpractices. However, for diseases like stroke where time plays a significant role in treatment, telecommunication outweighs its demerits.

Stroke is a disease that kills six million people worldwide, according to the World Heart Foundation. It disables another five million every year. Therefore, a rapid, available-at-any-time consultation between the patient and the stroke specialist is of great importance in deciding optimal treatment. The more neurons die, the chances of death is higher. 

 Recently, the usage of telemedicine in treatment of stroke, dubbed as ‘telestroke’ is gaining popularity among the physicians, especially in Europe and United States. American Heart Association (AHA)/American Stroke Association guidelines already permit the usage of high-quality video conferencing for telestroke consultation by a remote stroke specialist when the in-person stroke specialist is not available in the hospital. The method is efficient, but several barriers hinder the treatment. Firstly, it is time-consuming to set up and establish a video conferencing device. Secondly, hospitals require heavy cost for acquiring, installing and maintaining telemedicine communication systems. Finally, the neurologist or the stroke care specialist who is oceans apart require a desktop or laptop computer to access the images, which further delays the treatment.

Smartphone for stroke evaluation

Dr. Bart Demaerschalk MD, the director of Mayo Clinic and Telestroke program and his team of doctors have now cropped up a more feasible solution to the troubles – the usage of smartphones for the telestroke evaluation. The smartphones are the most widely carried portable communication device of the day and most of the physicians use them too. They offer a wide range of possibilities in employing for treatments, especially when coupled with prevalent healthcare applications. The app stores have a plethora of video conferencing and teleradiology applications available to facilitate telestroke consultation. The use of videophones cut the costs for establishing video conferencing devices of telestroke evaluation by an order of magnitude. It also expedites the time taken to set up and consult the patient.

In the study 'Smartphone teleradiology application is successfully incorporated into a Telestroke network environment' conducted by Dr. Demaerschalk explored the possibilities of the smartphones (specifically Apple iPhone 4) by developing a Resolution MD (ResMD) mobile application. This application provides a complete telemedicine solution to the mobile devices, providing instant access to 2D and 3D image visualization of scans on smartphones. The neurologists found that the CT brain scans of the patients on iOS device were accurate to 100 percent in detecting intraparenchymal hemorrhage and it also showed 98-99 percent accuracy in detecting early acute parenchymal ischemic change.

The study, which was published in Circulation: Cardiovascular Quality and Outcomes, the AHA journal evaluated 53 patients presented at Yuma Regional Medical Centre with acute stroke. The scan results were simultaneously reviewed by radiologists and telestroke specialists with smartphones, followed by an independent adjudication panel of stroke neurologists. The results were remarkably good that it showed smartphones can be used anytime and anywhere, particularly in rural hospitals where there is no immediate access to neurological care.As a progression, Dr. Demaerschalk and his team also analyzed the satisfaction of physicians on high quality video conferencing using FaceTime application of Apple iPhone 4 in another study titled 'Reliability of Real-Time Video Smartphone for Assessing National Institutes of Health Stroke Scale Scores in Acute Stroke Patients'. The results demonstrated iPhone 4 as a reliable tool for stroke telemedicine, rating higher acceptance and satisfaction among the physicians. Being a first-of-its-kind study in the sector, both the studies are revolutionary and explored an untapped segment in the medical device sector.

First-class Image App
In addition to Mr. Demaerschalk’s researches, there are studies from Japan that developed systems to exchange diagnostic images and clinical management information. The study “A New Support System Using a Mobile Device (Smartphone) for Diagnostic Image Display and Treatment of Stroke” by Hiroyuki Takao, MD, an instructor of Jikei University School of Medicine in Tokyo and his colleagues developed a system to efficiently manage stroke diagnosis and the subsequent treatment, thereby reducing extra work hours, making physicians efficient even when away from hospitals. Designated as iStroke, the system comprises of a transmitting server and a receiver phone. iStroke comes with several useful functions in stroke management system.

The system facilitates stroke call function or the facility to alert the medical staffs about an expected admission of an acute stroke case. Incorporated with a time-bar function for monitoring patient, the system allows physicians to view both static and video images in real-time. Tweeting facility to fellow specialists to exchange opinions further enhances the system. On the whole, i-Stroke offers a complete solution to acute stroke management by encouraging swift reaction in treatment of stroke.

Limitations of the system

Perhaps, the system of videophones may limit the autonomy of the vascular neurologists. Under the system, it is the medical assistant who captures the images and sometimes, it could be challenging for the assistant to simultaneously conduct and record an examination. Also, the procedure demands a photographic talent for the assistant who captures the images, the knowledge of the angles, lighting, acoustics and background. Another possible disadvantage is psychological, the deterioration of the physician-patient relationship and rapport, especially because the patient interacts only with the medical aide and not with the neurologist directly.

However, on comparison with the parameters such as accuracy, specificity, sensitivity, cost-effectiveness, installation cost, accurate decision-making, time efficiency, rate of technical complications, patient privacy and security features, the above said limitations can be ruled out to certain extent.

Conclusion

When the studies in the field of telestroke evaluation are coupled together, the real-time smartphone neurological examinations and teleradiology assessments appear to be promising for the vascular neurologists. A single mobile health tool will enable them to actively conduct full telestroke and teleradiology assessments necessary for a complete virtual stroke consultation in a remote environment. Besides offering a real-time treatment for the patients, the introduction of smartphone and tablets to telemedicine may significantly overcome the cost barrier that prevents the hospitals from expansion of telestroke network.

This article was written for Color Doppler magazine, September 2013 issue - http://colordoppleronline.com/touch-therapy-for-stroke-treatment.html

Tuesday, September 10, 2013

When strikes cause strokes…

Kerala has doomed to a state when one day in a week is a strike. Are the organizers conduct strikes to safeguard the citizens’ rights or to deny them? Aren’t the leftists and rightists of this land equally deny the rights of people? A thought on the issue

Rather than calling my land as God’s own country, I would call it as a Land of strikes. Each day in Kerala dawns with a news of strike or with a possibility of a strike in the nearby days. The method of organizing strikes to get ones state-defined, judicial rights is definitely good and appreciative, as this attracts attention from the authorities and forces them to take a course of action at the earliest. But, Kerala degrades its value by calling for strikes every now and then. Currently, Kerala organizes strikes for things we cannot call rightful.

Today, private bus association had called for an indefinite strike, which means nobody knows when it will end. This was to protest against Motor Vehicle Department’s (MVD) direction to install speed governors on heavy vehicles (especially on private buses). When there are frequent accidents (two days before, an accident in Malappuram district in Kerala claimed the lives of 13 children) and complaints of over speeding, there is no harm or injustice in MVD’s direction to install speed governors. This is one possible solution to bring safety to the lives of citizens in Kerala, which include the lives of private bus employees too. MVD has launched extensive checking of buses and have cancelled the permits of 300 vehicles, which were illegally on road. Nobody can blame MVD for taking action against vehicles which did not oblige law.

The purpose of law is to bring stability in the society, by punishing the wrong doers and guiding them to the right path. Laws are meant for the well-being of human beings. Why do the people in Kerala or more precisely, the strike organizers in Kerala refuse to understand this simple fact? Perhaps, through organizing strikes, people think that they are executing their ‘right’. It is true, but your rights should not restrict or create hindrance to the lives of others. What is being forgotten here is that every person in this land has an equal right.

As a citizen, a person has the right to travel and voice his opinion on issues. He may not support the strike because that goes against his social policy. The strike organisers have no rights to hurt him by pelting stones or by stopping him from going to work. To say, the strike against MVDs on the issue of speed governor installation is a matter that was hardly supported by any person in Kerala. The people do not wanted to sit at home to support the strike and this was evident when the roads were busier than the usual days. A strike can be only called successful when it receives the support of the masses. It is a method of protest to raise the voice of all, not of one or two.

In fact, the matter what Kerala witness now is a form of ‘left approach’ that projects a rights-based approach. Rights-based approach is one of the best moves to the development. It can stop the bourgeois attitude of power and dominance, as well as stop the means-based approach. But, when this left approach becomes extreme, it harms the society by slowly stooping down to the power and dominance.

To elaborate, Kerala believes in the fad of union formations. This unions or associations are believed to give unlimited power to the people. It is true that the unions prevent the weak in the society from getting exploited. But, what if the strengths of unions are ever increasing? It definitely creates another hierarchy and affects the stability. Kerala is an example of this scenario. ‘Unity gives strength’, but too much of strength creates a greed of power. This greed generates the attitude of dominance over the weak. This dominance are regularly seen when a group of small people called “strike organisers” stops the vehicles from passing by or prevents the shops from opening on a strike day.

Hence, Kerala depicts an interesting picture where the leftists and rightists get narrowed to the same path at one point. The latter already supports a means based approach, by forgetting the rights of people. In turn, the former opposes the latter through union formation and various protests to safeguard the rights. Slowly and steadily, leftists too gain power and they began regulating people, denying the rights of the people. Overall, be it the rightists or the leftists, both deny the rights of the people living peacefully.

Kerala is an exemplification to every land who wishes they had a left approach of development. The land not just shows the benefits of the left approach, but it also shows what happens when the left approach crosses the extreme.

Sunday, September 1, 2013

We are educated, but useless as well!!!

This was a blog post I wrote towards the end of my post graduation. I re-post this now because I feel the matter is still relevant to ponder (Perhaps this reflects me!!!).

I am nearing the finishing point to acquire another educational degree. By all means, the post graduation is considered to be well-educated in Indian context. So I am well-educated, but ain't I  ignorant when it comes to basic skills of life? I began thinking this, only when my beloved mother started screaming at me for being stupid when it comes to households like ironing clothes or keeping room clean. Look back to your life during college, I am sure you too must have survived few minor burns when boiling water for tea or burned your clothes while trying to iron (many of us avoid this by drinking tea from canteen and giving clothes for laundry!).

The matter sounds trivial, yet it is something to ponder. We earned gold medals and distinctions in our academic records, but when it comes to simple things like fixing a button on a shirt or drilling a hole on the wall, we run to call help from professionals. Our savior, the internet is there to teach us everything, yet it hasn’t seems to be of much use when it comes to these silly, yet necessary matters.

Unable to create anything by ourselves, we adhere to the practice of buying things. We mastered ‘consumption’ and literally wait for things to happen for us. You can raise the question “So what?” to me for writing this. It may not prove harmful as long as there are things to ‘consume’ and people to ‘help’. Yet, we forget one thing that we are being dependent on one thing or the other that truly make us slaves.

The educational system should be blamed for this. Instead of numbing children down with mathematics, science and history, the educational system can think of making an interactive learning environment, where craftsmanship and problem-solving abilities are valued. The motto of learning should not be restricted ‘to think’ for oneself, it should also include ‘to act’ for oneself.