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“Live as if you were to die tomorrow. Learn as if you were to live forever” said Mahatma Gandhi.

Learning everyday is so essential to life.

In a profession like ours that is responsible for people’s lives and well-being, transferring the right information to the right people at the right time is even more vital.

Secondly, surgical technology and techniques advance rapidly. Unless the early adopters of a good technology diffuse it vigorously to the rest of the fraternity, majority of patients will always be deprived of better care and treatment.

Hence continuous learning is essential for surgeons all through their career span of 30 to 40 years.

I was an early adopter of Laparoscopic or Keyhole Surgery in 1990s with a handful of other Indian surgeons. My conviction that Keyhole Surgery has immense benefit over open surgery motivated me to embrace it, gain experience, develop techniques, and then train other surgeons interested in acquiring those skills.

Why should a private practitioner train others? Aren’t Medical Colleges and Universities supposed to do it?

Medical colleges and teaching hospitals stick to the prescribed syllabus to teach basics. Also they work under resource constraints, which makes it often difficult for them to allocate budgets for adopting latest technologies and skills.

Surgeons in private practice in India with pioneering mindset thus get a great opportunity to develop a leading edge practice ahead of others by early acquisition of new technologies and skills.

With opportunity comes responsibility.

Young surgeons graduating from universities have acute need for mentors who keep abreast of new developments, latest practices and advanced skills.

Senior surgeons too have limited avenues to constantly upgrade their skills unless the experts in private practice open doors to share their knowledge with their peers.

Hence the early adopters in Indian private practice have a bigger undertaking to train others compared to developed countries whose universities have resources and well oiled processes in place to lead as well as diffuse innovations.

Is it financially rewarding for Indian trainers to train their peers and juniors?

Its not. Its an honorary work where large part of expenses are borne out of pocket by trainers.

For instance, I was at Mysuru recently for five days with my team as an invited Faculty at the prestigious annual conference of Association of Surgeons of India, ASICON 2016. It was a great honor and privilege to demonstrate a surgery to an audience of 4000 people, make a presentation two days later, and be a panelist on the last day of the conference.

I did not gain financially if you calculated the travel costs of mine and my surgical team borne by me, and the opportunity cost of lost practice at Trivandrum for five days.

Next time, would I accept such invitation?

Absolutely yes!

But why?

A recent study from University of Alberta Canada, states five main factors that motivate the surgeons who want to teach:

(1) a sense of responsibility towards other surgeons

(2) an intrinsic enjoyment of teaching

(3) the need to maintain and expand one’s own knowledge base (teaching is the best way to learn)

(4) watching trainees develop into competent practitioners and playing a role in their success

(5) fostering positive lifelong professional relationships with learners.

The satisfaction from the above listed reasons far exceed the needs to feel exclusive, make huge money out of training, or nurse pride that I am superior to others by keeping my tips and tricks secret.

Apart from my regular travel to various conferences as faculty, we have been running short term and long term fellowships in Minimally Invasive Surgery at our center for many years.

So far, we have just been training the fellows who would approach us.

With the encouraging results and feedback from them, we plan to launch a formal fellowship program in the first quarter of 2017.

Our main aim is to fill confidence in talented surgeons that come to us.

We follow a three step process to do so, which has never failed in creating confident Keyhole Surgeons at the end of each fellowship.

First, we share all our tips and tricks wholeheartedly with our fellows. No withholding. You would have seen me do so in my live surgery demonstrations too. The tips could be on patient positioning, port placement, minor but vital trick in suture placing, needle holding, which hand or finger to use, where to look etc. etc. No trick is small to a learner. Besides, transparency makes a tremendous difference to the trainees’ morale and their trust in us. Its a vital foundation to build before we move forward.

Second, we provide them with first hand exposure when they are ready for it. This is a golden moment for a trainee to try newly learnt techniques slowly and safely under our guidance. Confidence starts galloping with practical exposure and now is the time to nurture it. How do we nurture the new-found confidence? Trainees need to be confident all the time; not just while operating. Their opinions must be valued. Good suggestions accepted. Training should extend to adjunct procedures- ERCP, EUS, Colonoscopy, and what not. Their good work must be showcased with opportunities to present in National and International conferences. That’s when a well rounded Laparoscopic Surgeon will emerge out of the program.

Third element of our fellowship is to develop a critical non-technical competency. Why do some surgeons outperform their peers even when technical skills are equal? Studies in healthcare show that Emotional Intelligence (EI) is the differentiation. A recent article from Dr Daniel Chiu, a gastrointestinal surgeon from the University of Alabama speaks at length about relevance of EI to surgeons and how it improves Doctor-Patient relationship amongst host of other benefits. Developing EI in our fellows is a subtle process. Many a times they may not know they are being trained. Recording all complaints, organized history taking, thorough examination, how to convey prognosis to patients, how to speak to their relatives, conveying pros and cons of available treatment options, excellent bed side manners, and auditing one’s own work for continuous excellence are some of the soft skills what we offer to our fellows to learn in this element. The idea is to start developing them as effective leaders of their future teams and empathetic care givers.

Our above three step approach over the years has been evolved into a well structured fellowship model. We call it TIDDMAS Training Model:

In essence, building trust, confidence and leadership in our fellows is the real substance we intend to develop through our model, by relying upon the forms of tips and tricks, hands-on exposure and emotional intelligence.

Hope we will be able to train hundreds of more fellows with the upcoming launch of our formal fellowship program so that we can make a difference to thousands of more patients through them.

That in itself is a handsome reward.

Would you agree?

Take Care

Mahatma Gandhi once said “It is unwise to be too sure of one’s own wisdom. It is healthy to be reminded that the strongest might weaken and the wisest might err”

To me humility as a virtue is the most understated. Because from humility comes my desire to stay true to the people who matter most to me: my patients, my staff, my peers, my students, my friends and of course my family.

When my well wishers acknowledge me for my accomplishments, I believe it’s something each of us can achieve by staying determined, grounded, and by realizing that learning is a never-ending joyful process.

Looking back, I cherish being raised by my parents on a foundation of humility and perseverance. It was such a great blessing.

While growing up in an island surrounded by Ashtamudi Lake, I would drop my ailing father on a wheel chair to a Primary Healthcare Center near our house and walk to the market to sell home grown vegetables and coconuts to make ends meet for the family.

These are my treasured moments where I learned many of life’s lessons from my father. Staying humble was of paramount importance to our family. It kept us happy every day in spite of limited resources, especially after my father passed away shortly there after.

My first tryst with perseverance was right after my high school. The nearest Pre-Degree College was a 12 km walk one way, followed by a ferry boat ride.

Perseverance became my great ally during this phase and made those walks part of a larger purpose- to be successful in life. This mindset immensely helped me complete Plus Two exams with high grades and secure admission in medical college.

When I started off as a rookie surgeon with just a degree in hand, I had not much clue on what direction my career could take. Timely guidance from my would be mother-in-law inspired me to pioneer Keyhole Surgery in spite of worthy obstacles along the way.

If I were too full of myself at young age, I don’t think I would be receptive to anyone’s advice including my mother-in-law’s.

Focusing on acquiring skills in Keyhole Surgery was tough in early 1990s. A preliminary training in Coimbatore and an endo-training box bought with a bank loan were the only two resources I had access to.

Although it seemed a bit daunting to venture into an uncharted territory, the wonderful aspect of Keyhole Surgery that it would dramatically improve patients’ experience of surgery kept me going. I am thankful to this day for a timely sense of purpose that kept me focused on a worthy vision.

During my training, I realized that ability to suture with both hands would significantly improve surgical outcome. I there upon embarked on attempts to acquire ambidexterity as I was a naturally right handed person. I would deliberately write, shave and play tennis with my weaker left hand. I would practice suturing using both my hands on sheep intestines bought from slaughter houses for a really long time. It was great fun although I occasionally doubted myself. Eventually, I could use my both hands equally well for suturing which helps me achieve excellent surgical results for my patients.

Today, our Keyhole Surgery work is considered as one of the best in India. I also get frequently invited abroad to teach other surgeons of Asia Pacific. If thousands of patients, team members, peers, friends and family did not repose their faith in what we do, none of this would be possible.

Tomorrow, science will evolve further. More and better ways of treating diseases will emerge. Its our responsibility to keep abreast of change and be able to offer the best treatment to our patients all the time.

If you asked me what do I consider most important to succeed, I would say humility as one of the top three things needed. Because when humility is the driving force, the desire to succeed doesn’t remain focused only on yourself, but it helps you care for all the people you can make life better for.

In light of that, power of all the obstacles and criticism will melt away. For as Gordon Hinkley, a noted western philosopher said “We are not on earth to see how important we are, but to see how much difference we can make to the lives of others”.

Take Care.

  
The fear of Surgery is real and often overwhelming.

The desire to avoid Pain is central to that fear.

Surgeons in the middle ages amputated limbs and stitched up wounds with nothing but opium to numb the patient. Often, it had little or no effect in overcoming pain.
But modern surgery makes the surgery completely painless.

This is largely due to two monumental strides of medical science. Anaesthesia and Keyhole (Laparoscopic) surgery. The elimination of pain is a key objective of both these fascinating developments.

In every civilization and era, medical practitioners have experimented to alleviate the suffering of their patients. Thus the story of Anaesthesia is very interesting.

Sushruta used cannabis vapours to sedate patients before surgery as far back as c 6 BC in ancient India. The ancient Greeks used deliriant herbs in a brew. The Chinese used a mixture of herbs and wine while the Romans used mandrake boiled in wine.

Chloroform became popular in the 19th century after an anaesthetist named John Snow performed obstetric anaesthesia by chloroforming Queen Victoria for the birth of her son in 1853. But Snow later conducted careful studies to discover the dangers of chloroform which had led to a number of deaths.

Today, the science of Anaesthesia has made tremendous progress.

Three types of Anaesthesia are used in surgeries today.

General Anaesthesia which makes a patient go to deep sleep when surgery is taking place and thus making the patient unable to sense pain. Almost all open (conventional) surgeries deploy General Anaetheisa because of big size incision made on abdomen- almost the size of your palm (6-9 inches).

Spinal Anaesthesia is where patient is fully concious when surgery is going on but feels no sensation at the location of the surgery. Spinal anaesthesia has become the first choice for many keyhole surgeries.

Local anaesthesia is given on a localised section of the body. It blocks the nerves that transmit pain signals to the brain. As more and more laparoscopic surgeries are becoming daycare surgeries, local anaesthesia’s role getting bigger and bigger.

Administering anaesthesia is a job requiring special skill. Determining whether the patient requires general or local anaesthesia, the dosage required, the type of drug used etc. are crucial decisions an Anaesthetist is required to make. The patient is also required to be kept under close and constant observation after being administered anaesthesia. Thus Anaesthetists are priceless partners of surgeons in not just giving good anesthesia but also in improving the outcome of the surgery.

Having said that it is important to choose Centers that have long experience and published results of their laparoscopic procedures. Keyhole (laparoscopic) surgery introduces certain other elements such as inflation of the abdomen with carbon dioxide, which need special attention by the Anaesthetist-Surgeon duo. This is where experience matters.

Our Center at Trivandrum has very high capabilities of an expert team of Anaesthetists headed by Dr Gopakumar. Be it high risk obese patients or surgeries needing extreme tilt positions; this team always produces excellent results.

Another huge contribution by this team is nothing less than a blessing to patients. I am talking about their skills and focus on reducing post operative pain during recovery period. Most hospitals neglect this important area but our team assigns high priority to it. As a result our patients recover painlessly after surgeries.

Our experience of one of the largest Indian numbers of advanced laparoscopic surgery coupled with world class anaesthesia team makes our Centre one of the best Keyhole Surgery Centers in Kerala and India.

As we recognise the many facets of the history of medicine and surgery in this fascinating series, it will not be an exaggeration to say that modern surgery would have been impossible without the advent of Science of Anaesthesia.

Take Care