“High time we moved from eminence-based medicine to evidence-based medicine”

The transformative influence of his teachers, both at home and work, as also his inherent passion and dedication to the larger cause of science, has helped him unleash a riveting continuum of disruptive innovation with the archetypal equanimity of a Yogi in Jagrut Samadhi. World-renowned oncologist, prolific inventor, selfless entrepreneur, and committed activist Dr. Vishal Rao recounts the timeless charm of his student years and envisions a luminous future of fusion medicine in an earnest conversation with Sudhir Raikar.

Every interaction with him unfolds a new, invigorating aspect of his character and credence, for his inherently matter-of-fact demeanour does not subscribe to self-proclamation of any kind. It’s only when the discussion (with the right audience) seeks to probe deep into the cocoon of the given context that he gets into the flow with child-like fervour, sharing the minutest detail of every experience or insight – whether clinical or lyrical - without the slightest reserve.

Most important, in every conversation, he refrains from being prescriptive about his ways. Instead, he encourages you to drive your own vehicles of inquiry aimed at touching the depths, not allowing you to be swayed by lengths and widths in settling for convenient conclusions.             

Whether his trademark ‘namskara’, wholesome and endearing laughter, uncanny knack of meticulously attending to phone calls during hassle-packed transit times, or the simple and scrupulous (as opposed to simplistic) demystification of highly intricate clinical procedures, the magnetic appeal of this towering man of science sets him apart, so does his intrinsic inclination to connect with comrades across different disciplines, unlike many medical maestros of equally remarkable acumen but outlandishly reticent mannerisms, and at times even radioactive influence, conscious or otherwise.       

 

Before we move to the tete-a-tete, here’s a customary fact file of a man who hardly needs an introduction:

Born and brought up in Mangalore, Karnataka, Dr. Vishal Rao completed his schooling from St. Aloysius high school, Mangalore; MBBS and MS from KLE College, Belgaum; PG in Otorhinolaryngology from Rajiv Gandhi University of Health Sciences, Bangalore; and Fellowship in Head & Neck Surgical Oncology from Tata Memorial Cancer Centre, Mumbai.

As the chief of Head & Neck Surgical Oncology & Robotic surgery at HCG Cancer Centre, Bangalore, he specializes in surgeries for benign and malignant tumours of the thyroid, parotid and salivary gland surgeries, complex neck surgeries like radical and modified neck dissections, carotid body, other vascular tumours, and parapharyngeal space tumours. He has been conferred the Honorary FRCS from Royal College of Surgeons in Glasgow. The author of many an insightful paper in breakthrough techniques and procedures, he also serves as the editor of the Journal of Precision Oncology.

Dr. Rao is an international advisor to World Health Organisation Tobacco Free Initiatives for the implementation of the WHO FCTC- Framework convention for Tobacco Control through the National Tobacco control program. In 2017, he was conferred the Judy Wilkenfeld Award for International Tobacco Control Excellence. He has more than 18 patents filed for his innovations on medical devices, drugs, techniques and theories. He is well known across the globe as the inventor of ‘Aum Voice Prosthesis’, a $1 speaking device for throat cancer patients. Rated among the 100 global social innovations across the globe, AUM has found glowing mention in leading media conglomerates including the BBC, Harvard Business Review, and Forbes.

Excerpts from the conversation….


Let’s begin with your formative years of school and college life. Any fond memories that come to mind ahead of other reminiscences?

I hardly enjoyed my early schooling years as they were only about book learning, not about the experiential leaning that I craved for. I was the inquisitive type, ever loaded with a flurry of fundamental questions, but we were invariably encouraged to accept facts, never to question them. As was the general format the world over, superficial and surface-level learning was the norm. ‘This is the way it is, you can’t go beyond’ was the implied warning accompanying each lesson. Consequently, I struggled to stay put, somehow balancing my tryst with books with a little bit of play. Thankfully, I was blessed with an outstanding physics teacher Mr. Ganesh Prabhu during my transition to high school. This maverick virtually drilled a hole in my soul. Today I realise he actually taught me design thinking besides introducing me to the fascinating depths of astrophysics. I was so immersed in the subject that I even decided to pursue astrophysics as a career. To multiply my delight, I was also introduced to a couple of gems: Mr. Vag Shenoy who showed me the marvels of mathematics and Mr. Subramaniam who taught me the art and science of the English language. Under the tutelage of this dynamic trio, I was undergoing the most transformative years of my life, the foundation stone of my life. 

Was this the turning point in your academic voyage?

Absolutely. It was a game changer. These Gurus scared the living daylights out of me in a very positive way. Today, I can say with great pride that my role models of the time were not the usual known greats like Mahatma Gandhi. They were Prabhu sir, Vag sir and Subramaniam sir. I still remember Vag sir’s trigonometry class. He enters the class, walks up to the blackboard, draws a right angled triangle, and writes a/b. He only says, ‘this is tan theta’ and leaves the class, with us staring at the blackboard in absolute wonderment. The next day, he proceeds to the next step in similar fashion. Years later, I realised this was the best way to approach any problem. The more you ponder over the ‘chakarvyuh’ of any challenge, the more you are likely to find the way in and out of it. 

It soon dawned on me that my new-found fascination with learning was more to do with the teacher, rather than the subject. It was about the way the subject was taught, which had reasoning embedded into the learning. I could not see anything beyond physics and mathematics. I loved trigonometry and calculus and gradually dabbled into the intricacies of quantum physics. Locking horns with complex IIT problems of astrophysics and mathematics ignited a different spark in my brain. It may seem odd, given my chosen profession, but biology did not interest me one bit. This subject was a bible of facts, and you were not supposed to question facts; you were instructed to accept them. And I was inherently programmed to defy this diktat.  


 So, you dived deeper into Physics and Mathematics?

Yes, it was not love, it was an obsession. Thanks to both subjects, I was brought face to face with two great philosophies in science: one was the Einsteinian theory that urged you to imagine without an hypothesis, and the other was the Newtonian doctrine, which instructed you to experiment towards building a hypothesis. I learnt both with an open mind. Thanks to the unique methods of Vag sir, we learnt that problem solving becomes most enjoyable when it seems impossible. He stimulated our thinking by offering minimal help. He never gave the solution on a platter. He made us think through the problem in solitude. He showed us any given step only when we had given up, not earlier. This method of teaching and learning became ingrained in my life.  

Any fond memories of the time?

Plenty, but I will share one particular instance from the fag end of my high school learning, when we were almost ready to take the plunge into higher education. Vag sir used to take a tutorial class for a small group of students which we fondly called the Vag ashram. He always admonished us for our laid-back approach to life and work, which he believed rendered us completely useless. So, one fine day, after drawing on the board a complex engineering problem that he had plucked from the weirdest corners of IIT questionnaires, he threw a challenge at us in inimitable style: ‘The solution to this problem has 10 steps, I want you to get the first step right, you have one hour,  and your time starts now.’

In less than an hour, I and one of my classmates Shailesh solved the entire complex algorithm. When Vag sir had a look at our copies, he immediately asked us to leave the class and continued addressing the rest of the class. Now, we both were not at all the serious students you would normally expect in a math class. We sat under a tree wondering whether we did the right thing in attempting the problem. However, being the crazy types ourselves, we knew we were right and Vag sir had only granted us a special place in his heart by shooing us out. He was a minimalist, a man who rarely ever smiled, leave alone attempting a casual conversation with anyone. Vag sir had asked us to leave as he believed we didn’t belong to that group anymore. The others might have thought we both had committed a blunder they were very lucky to escape.


Did this turning point improve your grades in school and college?

During the early years, I was statistically an outlier, an average student, but under the wings of these masters, things seemed to accommodate and fall in place around me. All of a sudden, scoring cent percent marks became a cakewalk although I was never target-driven, nor did I ever aspire to top the class or anything like that. Thanks to my mother’s efforts, I was able to balance spiritualism and purpose, never linking effort with a goal or target. I have always believed the pursuit for perfection should be effortless. Results should only be a by-product of your wilful deep dive into the chosen subject. There’s hardly any point in subjecting yourself to textbook learning ordeals with no love for the subject.

When and how did medicine creep into your scheme of things?

Like I said before, biology didn’t interest me, so medicine was nowhere on my priority list of aspirations which had only four tick marks: astrophysics, mathematics, hotel management and bike racing. The first two were obvious; the last two were based on my perception of preoccupations linked with contentment. So many around me were pursuing hotel management and they seemed really happy, so I presumed this was something fun and fulfilling. Biking was one of my hobbies so I had decided that if nothing else worked, I would make it my career.    

But as things would have it, I accidentally did very well in the biology exam and my mom was thoroughly convinced that I should pursue medicine. She strongly felt only medicine would offer me the god sent opportunity to heal people and touch lives, and the magic of science that I was sold on will work wonders in biology. I was not convinced, but she told me I will meet someone soon who will show me the way. Reluctantly, I decided to give in to her insistence.

Now, when it came to studying medicine, both me and my mom unanimously agreed that I should study in Manipal. However, when my marks fetched me a merit seat in a Belgaum college, I was thoroughly disappointed. I had not even heard of the place before. Mom told me not to worry. An ardent devotee of Shirdi Sai baba, she believed the written parayana of Sai Charitra would fetch me an immediate transfer within a week’s time. But in the rush to return to Mangalore, she forgot the Sai Charitra on the admission counter of the Belgaum college, the last few pages left unfilled. So, this time round, she told me to begin my studies in Belgaum and wait for the first opportunity to secure a transfer.         


Can you share a few pages of your Belgaum diaries?

Throughout my tenure at Belgaum, I was known to be an exceptionally unruly student.  Invariably found lurking in the unlikeliest of corners, I regularly bunked classes and partied with friends on untimely vacations and getaways. Much to the dismay of my professors and classmates, I cleared all my exams, managing to study for a week or two during which time I was nowhere to be found. In a nutshell, I was in my own world, living by my own rules. 

And yet, certain influences came to stay with me for life. Prof. Humbarwadi was my first mentor and guide in Belgaum. I spent hours with him on his pet preoccupation of dissecting the voice box, marveling at its enigma and exceptionalism. It then seemed a wayward exploration, unaware that I was of the ‘grand plan’ that was to unfold in due course. I call it the premonition of destiny. Today, when I connect the dots, my ongoing work on voice prosthesis innovation is automatically put into perspective. You connect the dots when you turn back, not when you look forward. You simply need to keep creating the dots as you move forward. At some point, it all begins to make sense. 


The architect of the other turning point, the proverbial U-turn of my medical vocation, was Dr. Arvind Desai. He was known to be a rather vintage maverick, a hard nut to crack. I proactively secured posting under him, trading mine with a friend who had to attend a wedding, who was more than happy to escape the Desai ‘trial’.  My logic was simple, who could be worse than me?

Dr. Desai was the best thing that happened to me in Belgaum. He had an outstanding clinical acumen, and he treated patients like family. Rather than applying textbook principles on a patient, he created a textbook out of the patient, such was his mastery as a visionary practitioner. I used to get up at 3 a.m. only to observe him at work. He would open the Harrison’s Principles of Internal Medicine and literally pre-empt the patient symptoms, ensuing interventions and likely outcomes – right from the point of admission to the point of discharge, like how an astrologer reveals what stars foretell. My admiration for him turned into worship within no time.


I still recollect a difficult case of an ICU patient, a pregnant lady who had attempted suicide. Dr. Desai narrated the entire regimen in inimitable style – ‘These are the parameters, this is the ventilator setting, this would be the intervention, she would be out of the ICU on the 5th day, she would be discharged on the 7th day’. It was like a true story unfolding before my eyes. Everything happened just as he had predicted. On the day of discharge, I came to know that he had even settled the bill on the poor lady’s behalf, sacrificing half of his salary. I was speechless, witnessing humanism in all its glory, after having suffered a truckload of regular experiences rooted in nepotism and fascism. When I went to pay my compliments on an impulse, he shooed me away, urging me to get back to work rather than wasting time in thanksgiving, which he reckoned was a useless endeavour.

On the last day of my posting, I touched his feet. It was only then that he told me, “Vishal, 20 years back, I worked at your hospital in Mangalore. I didn’t tell you before as I wished to protect you from bias of any sort.” Dr. Desai, during his student days, had interned at a Mangalore hospital owned by my family. I now fathomed why I instinctively felt a deep connect with him. I could sense the preordained flavour of the association. The world is indeed a small place and we are all connected in ways not known to us.   

  

What was the trajectory post Belgaum?

When I was ready to leave Belgaum, I aspired to become a neuro physician, not a surgeon. However, I almost instinctively chose oncology for my post-graduation, without any known trigger whatsoever to explain the choice. In the library, my eyes invariably fixated on a chapter on throat cancer every time I opened my book, almost as if this chapter held a series of decisive conversations with me, not the other way round.

I made Head and Neck cancer surgery my choice for specialization, and even ‘decided’ on the institution to pursue it: the Tata Memorial Hospital in Bombay (although I had an assured seat in a Bangalore institution). All of this happened without any rational explanation to ‘justify’ my choice. I went to Tata Memorial Hospital to secure my internship even before my results were announced.

Meanwhile, I was awarded a gold medal in my PG. One other gentleman who had also won the gold medal mockingly complained to me: “Vishal, you have devalued Gold. Almost everyone to whom I convey the good news says: no big deal, if someone like Vishal with his relaxed lifestyle can get it, anyone can fetch it”   I relished this situation as it took away the awe linked with such feats. The hype around academic achievements needlessly creates a fear psychosis among most learners which is not how it should be. Education should trigger jubilation, not trepidation.  


I relished the three-year Tata experience end to end. 13 hours of daily duty left me no room for personal life, but I had no reason to complain. Time flew like never before under the guiding light of selfless veterans like Dr. Pankaj Chaturvedi. His pioneering efforts aimed at cancer prevention (as also some celestial direction from up above) put me on an offbeat track: of striving to reduce the need for a hospital by working towards disease prevention, not to build another hospital for disease management.  

Sadly, in the medical sphere of today, we are only innovating illnesses, not therapies. No wonder, most medical students feel a compelling need to build a hospital to cherish what they assume is the crowning glory of a successful career.

 Medical care is only a part of the holistic term health care, and it comes into play only when there is a deviation from health. A healthy society thrives on as less ailments and hospitals as possible. High time we broke the conformal barriers that disallow health care innovations to serve the larger cause of humanity.


Given your spiritual bent of mind, did you face any workplace conflict or quandary in a typical healthcare setting? 

There is no conflict, there is only resolution.

Spirituality, as I see it, is an unexplored science, and God surely follows the principles of Quantum Physics. I read the Bhagwad Geeta out of sheer curiosity, an endeavour which strengthened my belief that spirituality lends you grace and gravity: the grace that lifts you upwards and the gravity that keeps you grounded.  You need both to ensure progression.       

Spirituality helps us see through and work around problems, not attack them in mindless fashion. Take the case of cancer. How come a patient at an early stage of cancer does not make it, while another manages a miraculous recovery, even at the point of no return! There is a strong, inexplicable force with a mind of its own which can help us embark on the spiritually therapeutic path of healing provided we don’t crush it under the debris of abject negativity and fear of the unknown. 

How right was Werner Heisenberg, the founding father of Quantum Mechanics, when he said, "The first gulp from the glass of natural sciences will turn you into an atheist, but at the bottom of the glass God is waiting for you.”

 The ascetic spirit of India was best envisioned by Swami Vivekananda. He and Jamsetji Tata met en route a Japan to Chicago voyage when Swamiji shared his aspiration with the visionary industrialist, “What a wonderful feat it would be, if the philosophy of the east met the science of the west”. Years later, Jamsetji incepted the Indian Institute of Science (IIS), donating almost half of his personal wealth for this noble cause. Jamsetji’s letter addressed to Swami Vivekananda, which has been embossed on the IISc walls, is a towering inspiration to millions who harbour similar ambitions rooted in selflessness.

The turning points in my medical career have given me a renewed sense of purpose, and the ensuing objectivity has helped me appreciate the play of life and death in a reassuringly spiritual light.

Your strides in AI and robotic surgery are exceptional in every sense. How did the tryst with your machine friends begin? 

 As medical students, we tend to equate deep learning with a state of being perpetually under the water, studying and poring over intricate concepts all the time. This perception essentially spells the disconnect between med tech and medicine. Bridging this gap is an acute need, it is no longer an option.

Every specialty today is moving away from organ ablation towards organ preservation. In fact, within this fundamental departure is housed another paradigm shift: of achieving organ preservation even through surgical means, not just through non-surgical means like radiation. But unless organ preservation reinstates organ functionality, any restoration will be rendered deficient if not fruitless, given that the patient will be ruthlessly deprived of quality of life. My belief in the power of med tech stems from this acute need to ensure quality of life for my patients, which is as much about restoring their capabilities to earn livelihood and social respect as about saving their lives and vital organs.


Today, I do a lot of robotic surgeries but ten years back, I had not even imagined this big leap forward. Back then, robots were not in my scheme of things as I was happy with my results and dreaded the possibility of any disruption affecting my efficiency and consistency. However, my perspective changed the moment I visited the Robotic Innovation Center in Korea as part of a training program. I got a great glimpse of what was to unfold in the next ten years.

After I came back, I set about unlearning a lot that I had learnt in the last decade. Unlearning is the key differentiator for innovation and insight. This unlearning has helped me fathom the essence and credence of our robot friends.

I always say a surgeon has ten most important instruments at his or her disposal; these are not any fancy devices of plastic or metal, but a surgeon’s ten fingers, each blessed with unique clinical capabilities. Now, surgeons have small eyes and big hands, while the robot has small hands and big eyes. That’s the game changer any surgeon would relish: to probe deep into areas with enhanced vision and precision. Technology has made the representation of reality way more interesting than the reality itself. No wonder, robots take site location and visualization and human error mitigation to a whole new level. 


You have gainfully used interventional radiology in conjunction with robotic surgery. 

 I would cite one classic example of a tongue cancer patient of mine. He had completed chemotherapy and the tumour had recurred in a span of four months. In conventional surgery, when you remove the base tongue, you may have to remove the entire tongue and even the voice box, which massively impacts the patient’s quality of life. I was intent on helping my patient escape this unpleasant eventuality.

 Interventional radiology helped me block the posterior branch of the lingual artery (principal artery supplying blood to the oral floor and tongue), thereby blocking the base tongue. This way, we could achieve tongue resurrection in a manner akin to removing the entire ground floor without removing the first floor. This was unthinkable without interventional radiology and robotic surgery.

 This potent combination helps the surgeon breathe easy in every respect, given the submillimetre precision in mapping, analysing, and holding on to the tumour at the exact point in the given surgical step, thereby even allowing the surgeon to take a break midway, without losing precision as also eliminating the torrential bleeding that otherwise accompanies organ resurrection in such surgeries.

 This is what I call the era of fusion medicine where the radiologist enters into the OT and perform a cardiac surgery, and he is rechristened as the interventional radiologist. On the other hand, a surgeon has the CT scanner inside the OT, and he becomes the navigational surgeon. The med tech possibilities are immense, the merger between radiology and robotic surgery is only a part of fusion medicine. Going forward, machines won’t replace doctors as is being furiously speculated; instead, they will assist doctors to augment and accelerate human healing. The medical fraternity is at a juncture today where acceptance of this fourth wave is not an option anymore.

 

How will this buy-in come about?

The fundamentals of this buy-in lie in purposeful medical education, which will happen only through a systematic and consistent collaboration between academia and the industry to create powerful synergies. We need to develop a consortium to challenge status quos; we need to move from eminence-based medicine to evidence-based medicine.

We need collaborations beyond conventional spheres, not competition between warring cartels. The ultimate truth about ideas defies popular perception: “Ideas never come from you, they come to you”. If we copyleft (not copyright) our work, it will help us evolve as also serve others in the true spirit of innovation. I have known from personal experience that the copyleft principle unleashes an idea’s true potential, from conceptualization to implementation, to ensure that the world gets the absolute best. We must always ‘Pay it Forward' to society, breaking free of fear, insecurity, and conformity to convention only to see the world anew each passing day.

Industry today is at 4.2 while health is still moving from 1.2 to 2.2, lagging almost two generations behind. In the next decade, health will be able to keep pace with industry only if it embraces AI, robotics and a host of other technologies including digital therapies, IoTs, ultrafast scanners, wearable devices, big data, blockchain and nano health. The real charm of these technologies is their cross-talk; they form a potent and purposeful ecosystem; they don’t work in isolation.  The coming generation of robotic surgery will be driven by retractors, nano bots, fusion of drones with robots, extended reality devices, and super conscious robots.

Consequently, health will become wellness-driven, not disease-driven. The myopic view that healthcare is only about disease management will disappear into thin air. To put it in simpler terms, Paracetamol 650 mg will no longer be universally administered.


And how soon do you see the transformation happening?

Very soon. Earlier, we used to define changes as generation gaps, today we define them as version gaps. That explains the shrinkage of bench to bedside cycles: from several years to a matter of few months and days. And it is such a good thing, given the need for accuracy and consistency in medical interventions.

Our greatest competitors are in fact our strongest collaborators. What better time than now to harness the power of collaboration to its fullest, thereby expanding our outreach to masses for achieving far-reaching, measurable, cost-effective, and sustainable social outcomes.

 

 

Is a cancer moonshoot initiative possible in India?

The groundshot initiative has already begun in India, and no better place than India to launch a moon shot initiative as well. Aided by technology, focused studies like cancer genomics will provide us with even richer and actionable insights for precision medicine. We only need to move away from our pet preoccupation of singing glories of our rich heritage without fostering and experimenting with original ideas. How long are we going to remain constrained copycats of the West?

 It is only when we dive deep into the living waters of disruptive innovation, powering ambition with purpose, that wealth and value creation will happen at the intersection of socialism and capitalism, giving birth to conscious capitalism which will ensure economies of scale.  If we are proud to achieve a Formula One pit stop in 1.82 seconds, shouldn’t we aspire to save a life in lesser time and with better speed. I think we should, and we can, provided we create the doors of possibilities, not merely open the doors of opportunities. 


 Note:

 Dr. Rao’s spirituality and mystical experiences comprise an epic subject that merits comprehensive chronicles. Even the preface to it has been excluded from the purview of this thought piece as it is only for a readership attuned to grasping the depth and gravity of the subject matter; individuals who are blessed with the ability to suspend judgment without harming the cocoon of scientific temper; those who can protect the fabric of intuitive discoveries from the brute force of perfunctory intellect; those select few, to quote Dr. Rao, who “strive to be spiritually intellectual, not intellectually spiritual.”