N°015 - January / February 2022
Interview viewed 95 times
Could we have an insight into your education and the people who inspired you at the time?
My fundamental orthopaedic training, about 10 years, was in Mumbai. Then in 1990, after finishing my graduation and post-graduation, I went to England. I got my primary job in Kent, little south of London. There I quickly realised that I was doing general orthopaedics, which was not the purpose of my trip to UK. I was looking for something new. And that caused a little unrest in me. I asked some of my British colleagues: 'if I want to learn something new, what should I do?' They suggested that I must go and watch Dr. David Dandy at Cambridge. Dr. Dandy is a well-known pioneer of arthroscopy and he did a lot of knee arthroscopies. I wrote to Mr. Dandy, went to see him operate, had a few interactions with him and finally got a registrar job with him at Newmarket Hospital where all the elective work of Cambridgeshire was done. It was a mere coincidence that the Mr. Christopher Constant happened to be the upper limb surgeon at Newmarket hospital. So, I ended up with Dr. Constant by default. Inspite of having completed my training with all the possible medals, I was taken aback to assist some shoulder surgeries which I had not done or seen. Such as rotator cuff repair, shoulder arthroscopy, shoulder replacement etc. This was in 1992. So that really deflated my ego and at the same time inspired me, besides fulfilling my desire to learn something new. Dr. K. V. Chaubal (Mumbai, India) has been a role model for me. His clarity of thinking, ethical values and principles of medical practice are exemplary. Other specialist who I came across in my journey and who continue to inspire me are Stephen Burkart from San Antonio, Texas, Peter Habermeyer from Munich, Germany and Gilles Walch from Lyon, France.
Dr. Constant seems to have had a fair and positive influence on you. Could you corroborate this, and share the experiences of working with him?
Christopher Constant was a very hardworking, very pushy personality. At that time, he essentially did all open shoulder surgeries. He would put the arthroscope, see the rotator cuff tear and do open repair. Arthroscopic reconstruction was not well established in the early 1990's. But he was a very good open upper limb surgeon and I learned from him all open shoulder surgery. Open cuff, open Bankart, Shoulder replacements. On a personal level he was a funny guy and he loved food. I was involved in helping him with a paper to justify Constant score at the International Congress of Shoulder and Elbow Surgeon and in 1994 we both had gone together to ICSES in Paris. Overall, I spent year and a half with David Dandy and Chris Constant. And then I realised that I must take it further because I wanted to learn operative arthroscopic surgery not only diagnostic. I started exploring how to go further. I thought that there are two countries I should visit : France and Germany. In one of the conferences I met and I interacted with Peter Habermeyer at that time in Stuttgart. He was very kind. He hosted me for six weeks in Stuttgart in 1993 and I learned operative arthroscopy. At that time, he was doing the transglenoid pins for Bankart (Maki & Rose technique) like Caspari. Then I started attending all small meetings on shoulder surgery in Europe and eventually met the French surgeons like Gilles Walch, Pascal Boileau, who then visited India a few times. Once I was in Nancy not for orthopaedics but for some other reason. I had a spare day with not much to do! My unending desire for shoulders helped me find out that Daniel Molé does lot of shoulder surgery in Nancy. So, I visited him. He was very warm and gladly allowed me to join him for a day. We are good friends since then.
Your stint in UK probably shaped your career and outlook. Could you describe your stay and learnings there?
After my time at Cambridge/ Newmarket, I moved to Liverpool to do Masters in Orthopaedic Surgery. During that year I got a registrar job at the famous Charnley's Wrightington Hospital well known centre for joint replacement. I worked with John Murphy and Kevin Harding, the next generation after John Charnley. That is where I learned arthroplasty. They were doing 10 to 15 arthroplasty a day. Many hips and knees and a few shoulders as well.
To be precise, I stayed in UK for three years and 7 months. I was with my wife and we were married one year before I came to England. She's a nutritionist and when I was at Cambridge my wife took the opportunity to do her Masters. Once I completed the Masters in Orthopaedics and got the gold medal, I decided to return to India, as I had achieved what I had set out for! I could have stayed back in UK and made a name for myself there. Some of my colleagues did stay back. However, my whole purpose of coming to England was to learn something new, bring it back to India and establish it to my country. I am so happy that I could fulfil my dream of establishing shoulder surgery in India and hopefully benefit thousands of people. I am delighted that today shoulder surgery has boomed in India and continues to spread in the interiors of the country, benefitting millions.
Could you give us a brief glimpse of your current medical practice and consultancy, and an insight as to how you established it?
What helped a lot in my practice is that when I returned from England in 1994 I was the first formally trained shoulder surgeon in the country. All the modern hospitals were very keen to have this sub-speciality. So, I ended up here. But I had a very difficult initial 5 years. When I came, I put up a board outside: my name and shoulder and knee clinic. Some of my well-wisher doctors advised me that it will be difficult to survive. They would say: “Even if somebody falls just outside your clinic, he won't come to you”. Furthermore, nobody initially would refer a shoulder to me because they would think that in shoulders there is nothing to refer: exercise, physiotherapy and some pills, that's it! So, I started educating the population in problems affecting the shoulder joint. I gave lectures and did live demonstration surgery across the country. To generate work, initially, I practised in eight states of India. Every weekend I carried my equipment and would go to Gujarat, Rajasthan, Delhi, Calcutta, Madhya Pradesh.... I was working 26 out of 52 week-ends for the first 10 years. Half of these trips were academic; teaching, performing live surgeries to increase awareness in the medical fraternity about the possibility of treating several shoulder pathologies successfully. Several trips were for surgical operations, because as the knowledge spread the local orthopaedic surgeon would collect cases e.g of rotator cuff tears and instability. I would fly down to the town with an assistant and my equipment, do several cases on Saturday and return on Sunday. I procured a special bag with cushioning inside designed for carrying optics, in which I carried my arthroscope, camera and shaver. A commercial TV sourced locally, would function as a monitor. Usually, I was dealing with an orthopaedic surgeon of a small town in different parts of India. Typically, he would own a hospital of around 20 beds, with a busy general orthopaedic practice. However, he wouldn't be familiar with shoulder or knee arthroscopy. So, he would gather patients who are likely to need specialised procedures. Patients were given the option of travelling to Mumbai or wait for me to come down. Once sufficient numbers were collected to justify my travel, we would fix a date, usually a weekend. It was a perfect win-win situation. The host surgeon was happy because in his hospital theatre several cases (10 to 15) are being done. The patient is very happy because it is at his doorstep and I am happy because I get to do several cases in one day.
As an inspirational message to young surgeons aspiring to make a mark, could you share some of your struggles in the early days?
From the very beginning I was not willing to indulge in 'commercial form' of medical practice. That made my life even more difficult. So I decided to work harder, by going outside my locality to different states of India. Sometimes places where there is no airport, so I would take an overnight train journey. On reaching early morning, I would start my day at around 10 in the morning. The local surgeon would have gathered 20-30 patients who are likely to need arthroscopic intervention. The patients are well informed that the visiting expert will finally decide, whether surgery is needed. Those who did not need surgery were sent back with appropriate advice. Whereas those who need surgery were admitted. I would often operate 10 to 15 cases at a stretch. I did that for 15 years, it was a perfect model and it worked beautifully. Because there were no shoulder surgeons when I began, I formed the Shoulder Society of India in 1998. And then I started the Bombay Shoulder Course. Eventually in 2018, I'm very happy and proud, that I got the highest award in the medical field in the country called Doctor B.C. Roy award for introducing, spreading and pioneering shoulder surgery in India and placing it on the world map.
While surgery techniques have today come a long way, it was not the case back in the day. Do you have any memories of the same in your early days?
There was no pump like today so I would improvise with blood pressure-armband around a plastic bottle! Also, I would use a locally made electro-cautery which worked well in glycine used as irrigation solution. When I was in Germany I visited the Arthrex factory and I bought the Chinese finger trap for arm traction in lateral position. I bought also some instruments that time. In 1993, during my last few months in England I could do Shoulder arthroscopic decompression and Bankart repair using trans-glenoid pins. I would occasionally be called to do shoulder arthroscopic procedures in private hospitals by some of the consultants during my last phase in UK.
You have treated a number of high-profile patients ranging from film-stars to sportspersons to politicians. Could you describe the pressure, and the subsequent sense of achievement in such cases?
When I operated on (Bollywood superstar) SRK, I was asked a similar question by the media. Yes, initially there is a bit of anxiety when operating on a high-profile patient. However, once I enter the shoulder joint “I am relaxed & at home”, fortunately all shoulders look the same from inside…thank God!
What prompted you to found the Indian Shoulder Society?
It was to spread the awareness about shoulder surgery. When I started in 1998 we were ten people and out of ten, eight were general orthopaedics. Of course, I thought that not only shoulder surgery will spread but also provide a platform for international recognition. I was the president which I then passed on to the next generation. Today we have nearly 300 members.
What are your views on the penetration of good surgical practices and technology to the smallest parts and corners of India, allowing people there to have access to affordable and good recourse to orthopaedic treatment?
The current lack of facilities in villages is typical of any developing nation. I guess as the country develops the infrastructure and facilities will develop simultaneously in the interiors of India. Besides the government also needs to pump in more funds into health care, particularly in villages.
What do you think of the level of shoulder surgery in India compared to other countries?
At par, of course. However, the penetration in the interiors of India may not be as much. In my endeavour to expose the world to shoulder surgery in India, we conducted one of the biggest meetings of shoulder surgery with the Academic Congress of Asian Shoulder and Elbow Association (ACASEA) in 2017. So, all Asian countries came together: Japan, Korea, Taiwan, Hong Kong, Thailand, Singapore, Philippines, Pakistan, Bangladesh, India, Australia. It was a super-hit, from academic content, live surgical demonstration, to entertainment. I am honoured to be elected the president of Asian Shoulder Association for the next three years. One area we continue to lag behind is publications. This starts with poor maintenance of records. This void can be filled only with a change in our culture from day 1 of medical training. Publishing should become a part & parcel of medical journey and this has to come from the top of the hierarchy.
In your opinion, what are the major developments and achievements that we have seen in the field of Orthopaedics, in particular for knee and shoulder surgeries? What are the future unfulfilled needs that you think will drive the fraternity towards the next step of progress?
Arthroscopic Surgery and Joint replacement are perhaps the 2 biggest advances in orthopaedics in the last few decades. Particularly 'Shoulder replacement'. However, we still have a long way to go. We do not have answers to many common problems such as cartilage wear, rotator degeneration to name a few.
That was a very nice conclusion, thank you very much for this very rewarding interview.
Published in N°015 - January / February 2022