Study, Research, Publish

Heart, Guts & Steel - The Making of an Indian Surgeon

(This is an unpublished chapter from the manuscript of my new book, “Heart, Guts & Steel: The Making of an Indian Surgeon“)

One summer, I took a few days off to surprise my parents on their twenty-fifth wedding anniversary.

To keep me engaged on the 24 hour journey, I picked up a popular bestseller from the library. For good measure, I also carried along a medical journal. I hopped into an upper berth shortly after the train left Dadar station, opened the book, and fell asleep within minutes!

I slept through the night – and all next day… waking up briefly only to gobble down the sandwiches our cafeteria manager had thoughtfully packed for me!

As our train crawled into Basin Bridge station, a few minutes from the terminus at Madras Central, I finally got down from my berth.

A thin, dark gentleman who had also made the journey gave me a broad grin, and remarked in Hindi laced with a thick Tamil accent: “Araam se soyaa saab!” (You slept well, sir.)

I simply nodded.

Every surgeon is sleep deprived. All the time.

And a train journey following two busy operation days and a hectic emergency weekend gave me the rare chance to catch up.

– – –

On the break, I dropped by my old medical college to meet a few friends. But they weren’t in the wards.

“It’s their Part 1 exams next week,” a junior resident explained. “You’ll find them in the library.”

And so I did.

We chatted for a while. They asked about my work in Bombay. And when I told them, one asked: “But if you’re so busy, when do you study?”

Great question. When indeed?

I tried to squeeze in an hour of reading before going to bed. Often, though, it was late at night, I was bone-tired and only stared blankly at the pages until I couldn’t keep my eyes open any longer.

And when there was some time to spare, I grabbed the opportunity to catch up on sleep rather than read textbooks or browse the latest journals.

“But what about your exams?”

“Well, we don’t have any! Not until the very end.”

The system of evaluation in Bombay was different. My friends in Madras had to take an examination after the first year. It tested them on the basic sciences that were foundational to the practice of medicine or surgery. In Bombay, we were formally evaluated only at the end of three years.

Does that mean we hardly studied throughout our residency training?

Well, a few residents did put off heavy reading for later. But it’s tough to take responsibility for the treatment of so many patients without learning continuously. Even as residents, we made executive decisions about operations and post-surgery patient care. If things went wrong, we took the blame.

So we had to study continuously, even if it wasn’t based on a structured curriculum like my classmates followed in Madras.

Was ours a better system?

Maybe not. My friends are just as competent surgeons today as I am.

The difference was how soon I became confident. As Senior and Chief Resident, I gained the tough skills of decision-making under pressure, taking risky calls in a critical situation, and facing up to their consequences. Others only acquired it years after they graduated.

– – –

The freedom from a rigid curriculum also let me publish papers in academic journals. I had always been eager to publish scientific papers, and now I had access to a wealth of clinical material – with no leash on my desire to compile it into articles.

My earliest publications were case reports about interesting surgical problems.

The fascinating Rapunzel Syndrome – named after a fairytale princess who lived in a tower where she had been imprisoned by her wicked stepmother, and let down her long hair so that Prince Charming could climb up to her room – referred, in surgical parlance, to a hair ball that extended from the stomach, down into the small intestine.

A 27 year-old lady we operated for the condition came to hospital with incessant vomiting caused by bowel obstruction.

At surgery, through an incision in the stomach, we delivered a hair ball 25 centimeters across – and then teased out a ‘tail’ that was nearly two feet long! It made for a dramatic clinical photograph, and my submission was published in a British journal called ‘Tropical Doctor‘.

In quick succession, two more of my case reports were accepted for publication by the same journal. One described a rare tuberculous infection of the stomach. The other reported an unusual complication of TB in the kidney.

My next paper was a case series of patients with a rare stomach condition.

A twenty year-old man was in our ward for stomach ache that had persisted for a year. All his routine tests were normal. Even an endoscopy revealed little. One morning, on ward rounds, my colleague asked: “Could this be another gastric volvulus?”

A volvulus is a strange and unusual condition where the stomach flips over on its axis, twists, and blocks the passage. The main symptom is stomach ache which is relieved with belching or a change in position.

I was disinclined to accept the diagnosis. After all, common things are commoner. And rare conditions don’t often cluster. We had just operated on a gastric volvulus three months earlier.

“Let’s get a barium meal done anyway, just in case,” he insisted.

A few hours later, we got the films developed.

Surprise, surprise! The stomach had flipped up, with all the characteristic features of this unusual problem. We had our second gastric volvulus!

The next week, we operated. I shot many intra-operative photographs of unique anatomical features that caused the stomach to twist. We reviewed the medical literature for similar cases. Then we submitted our small series for publication. It was eagerly accepted!

There’s nothing special about publishing scientific papers. Any surgical resident could have done it. But my peers back home who had more oversight while training didn’t bother doing it – unless they were instructed to

I believe this independent streak, instilled early in my training, had a subtle but significant effect on the kind of surgeon I eventually grew into.

– – –

Whenever I came back home, I regaled my friends with stories about life in Bombay. Contrasted against the quiet Madras lifestyle, the strumming, vibrant metropolis that was known as India’s New York was rocket-fast. I had only read about such a societal structure before, in Mario Puzo’s classic book, “The Godfather“.

But in the Bombay I trained in, I saw a very near approximation of it.

And although the street culture had its seamier side, even as drug dealers and sex workers plied their trade, and friction between organized crime factions led to shoot outs and gang wars, the city was quite safe for the regular citizen.

In his book “Dongri to Dubai: Six Decades of the Mumbai Mafia“, Hussain Zaidi traces the roots of the city’s criminal underworld and its genesis into what it has become today. At the time I trained as a resident in surgery, the boundaries between rival factions were being redefined after an upheaval in the aftermath of riots and terrorist attacks.

Our hospital lay in the hotly contested border between the central and southern zones. Gunshot wounds and stab injuries were a frequent sight in our emergency wards during this period.

Even more fascinating was the revelation of how some doctors were drawn into the struggle. One of my interns was always accompanied by a mobster who served as his bodyguard, even as he carried out his medical duties on the ward.

“Why does he need protection?” I innocently asked one of his colleagues.

“Because rival gang members may attack him, sir.”

To a young twenty three year-old surgeon-in-training, there was something thrilling, even romantic about the scenario. Like it was out of a novel.

But there’s nothing romantic about young men being fatally shot through vital organs, or brutally stabbed and needing emergency operations, or innocent bystanders admitted with accidental injuries.

(This is an unpublished chapter from the manuscript of my new book, “Heart, Guts & Steel: The Making of an Indian Surgeon“. Set out your reading strategies and get started.)

You can read another section of it in this post, ‘Crisis’.)

Heart, Guts & Steel - The Making of an Indian Surgeon

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