Your offbeat voyage of self discovery began within the four walls of your college library. Can you look back in time to recount the magical experience of your formative years as a medical student?
I used to hang around the vintage racks of my college library, in the archival section wherein outdated books were stored, nay dumped. The disregarded corridors led me to a unique treasure trove of archaic books and journals. The primary fuel of my offbeat voyage was the long list of unanswered questions to which some of my professors like Prof. Humbarwadi would ask me to consult these secluded corners of the old sections from time to time.
The earliest editions of the books by another prolific surgeon Dr. Hamilton Bailey were thankfully part of my curriculum. The newer editions have unfortunately focused only on the technological and clinical advancements, leaving out many profound questions posed by the original edition. Presumably, some authority at some point had taken the liberty to overlook certain truisms as having been dealt with and spoken about at length, and hence omitted from the subsequent versions. Consequently, many beautiful aspects of art and intuition were disconnected from the science of it.
How does this disconnect happen?
As science evolves, there is a transition that happens, wherein many aspects of science are wrongly assumed to have lost their relevance for future generations. For instance, the first edition of the Harrison’s Book of Internal Medicine had a beautiful elaboration by Dr. Judah Folkman, Father of Angiogenesis, which was omitted in the subsequent editions. He alluded to the possibility of reaching a point in time when we can co-exist with our tumours. This would imply harmony, not conflict, between normal cells and cancer cells. The former would not be affected by the aftermath of the latter, and the latter would stop growing. In this first edition, Dr. Folkman also put forth the theory that if we cut off the blood supply to the tumour, it will be paralyzed, thereby losing the propensity to grow and spread further. Given the seminal significance of his words, the omission from subsequent versions was needless and heedless.
In the context of this loss in transition, I recall the amusing experiences of Stan Lee, creator of Spiderman, which he shared in a BBC Radio interview. His publisher had rejected the idea of a teenage Spiderman superhero calling it the ‘worst idea ever heard’. His hardcoded logic was simple: people hate spiders and teenagers can never be heroes, they can only play sidekicks. Lee was dejected and decided to give up on the idea with a fleeting tribute to Spiderman in the last issue of the loss making ‘Amazing fantasy’ comic series. The spider superhero went on to become an instant hit, and it made the fading comic series a resounding bestseller. Needless to say, the publisher came back to say how much he always liked Spiderman as an idea, and the rest of course is history. Stan’s superhero was simple and likeable due to the inherent contradictions – a superhero with spider skills but inflicted with glaring insecurities: a child raised by his grandparents, bullied at school, and hugely awkward in the presence of the opposite gender.
From Spiderman to Science, the same market forces are at play...
Undoubtedly. Coming back to science, it is not often dictated by the stalwarts; at times, the business of it takes precedence, led by the need for market creation. These forces let go of what they presume as foregone conclusions or arguments no longer valid. This popular view disregards the fact that people need to know certain slices of history which provide a deep connect to the future. The intuition of science can be found as much in history as on the way forward. The art and intuition are extremely intermingled as they both have creativity in them, and the science stands tall between them. We talk of science, and we talk of art, but we don’t often think about where they meet. Either our thoughts gravitate towards a ‘No’ or lean towards a ‘Yes’ when it comes to acknowledging the power of intuition, but we are never able to strike a balance. In the whole spectrum of science, intuition has been largely sidelined.
So, you were always drawn to the role of intuition in surgery...
Yes. Although extremely difficult to define in verbal terms, I always make a feeble attempt to put scientific intuition in perspective. We have always been taught about the importance of instruments and equipments, their designs, precision, and purpose; how they cut; how they retract a tissue; how a tumour is opened; how the surgical area is approached and accessed and the like. Of course, these are highly significant aspects beyond doubt integral to surgery. But in Milton’s book, the foreword began with a gratitude to his wife, for the time she allotted him in the kitchen to learn some sewing skills. Elaborating on the art of surgery, he writes, “A surgeon needs to know his ten important instruments – his own fingers.”
Today we talk of robots, machines and gadgets, but in the ultimate analysis, only these fingers are running the machines. Milton brings out the essence of science to underline the fact that fingers decide how the scalpel or retractor will be used. Milton’s words couldn’t have ring truer. These fingers, I feel, run a surgical symphony in the operating room. This aspect has to have an intuition to it, like how Mozart composed his music. Had Mozart followed a book and not his intuition, he would not have been Mozart today.
You often talk about unanswered questions. Could you elaborate?
Whenever I read about a surgical procedure, I always wonder what exactly drove the surgeon to adopt a particular technique on the operating table at a particular point in time. There are instances when the surgeon was reprimanded for the proposed choice of technique or approach, which must have perhaps been ahead of its times, and yet he backed his intuition. There would have been some strong reason for the surgeon’s conviction, which has to be something more than science.
For instance, it was historically believed in the earliest scientific literature that a surgeon attempting thyroid surgery was playing with fire, and the errors he would commit in the surgery were unpardonable given the risk of torrential bleeding and even life. Today, it has become a lifesaving surgery with several instances of successful operations across the globe. Now, if the slice of history related to this bit is omitted from the annals of medicine, the whole context to the surgical advancement is lost. What would have gone through the minds of the surgeons who dared to think different, risking their reputations in the event of adverse consequences, and how did they back themselves and their fingers – all of that would be lost in the missing notes. The very purpose driving the ambition would be lost.
Like for instance, we always say we keep checking the calcium in the blood. We say calcification can occur in the body, which can cause certain conditions of the parathyroid gland. When this gland creates a tumour, we have been taught to perform a parathyroidectomy surgery if the condition is accompanied by hypercalcemia or excess calcification in the blood. What is intriguing is that we were never taught why calcium doesn’t calcify in the blood under normal circumstances. None of the books would answer that question. But this was addressed in the old books in the library.
Again, the library! Every wonderment of yours can be traced to the library, I presume...
Yes, I vividly remember yet another instance. One late evening, the librarian, a kind-hearted, middle-aged lady, came to remind me that it was time to close the doors and put the lights off. I requested her to give me five more minutes as I was in the midst of poring over some invaluable information in the old racks. She conceded to my request but asked me a favour. She asked me to prescribe some medication for her chronic sinus headache. I asked her how she was so sure that it was a case of sinusitis. She told me she had been on medication for quite some time and knew her diagnosis well. Out of curiosity, I asked her how often she caught a common cold in a year, and when did she have it last? She promptly told me she had never had a common cold as far as she could remember.
Her answer left me puzzled, and the next question I asked her on an impulse was whether she had any issues. She again replied in the negative and told me that she was infertile. Now, this was my first accidental but intuitive diagnosis of a condition called Immotile Cilia syndrome, wherein the little cilia nerves in our sinuses and elsewhere do not move, and this disorder is accompanied by infertility. I advised her to meet the physician for appropriate treatment.
So, intution paves the way for discovery and direction?
You said it! You may have all the algorithms, but you need a peripheral intuition to set you on the right path. I remember a monk who once told me about the miracle of the healing touch or ‘kaiguna’ as we call it in kannada. He told me that a physician or faith healer who wholeheartedly treats his or her patients gets innumerable blessings from the patients and their near and dear ones, which manifest themselves in the physician’s hands. This positive healing energy can’t ever be used for self-benefit, it can only be transferred to other patients undergoing treatment. This is like distributing your dividends to those in need. Mother Teresa was the epitome of this healing touch. These healing hands, he said, are blessed with intuitive powers. I have no doubt in my mind that these powers guide the hands towards the right approaches and therapies. The universe helps you bring about a surgical symphony.
The monk insisted that I touch each patient, even those at a stage of no return or inflicted with a supposedly incurable disease, as things could possibly turn for good amid all adverse circumstances. I got a first-hand experience of this truism many a times. Once during my ICU rounds, I encountered a patient who was recovering well but suffered a psychiatric spell all of a sudden during the wee hours of the morning. He turned violent and tried to physically harm those around him before falling unconscious out of breathlessness. I made it a point to touch him and in that touch, there was as much science as was an earnest plea to help me pass on the dividend of the healing touch. At the same time, I shared my helplessness with his wife, openly telling her about the futility of the treatment being extended to her husband. Both contradictory acts – one to the patient and other to his wife - were guided by intuition, I did not initiate them, I was led to them.
Why do you call it a surgical symphony?
The symphony I talk of is the symphony of nature. During the 2004 Tsumani wave, elephants, dolphins, dogs, deers, foxes, and rabbits got intuitive signals of the impending danger beforehand. Many among them could plan evasive action well in advance. Similarly, we need to balance the art and science of any discipline using our intuition. This intuition can only be found with purpose and love. One can define and refine intuition only when a deep sense of intent and benevolence is developed within. I call intuition a fusion of passion and compassion; the former is not to be confused with pride, and the latter is not to be confused with pity.
You need both grace and gravity– the former is a spiritual, invisible force, and the latter is a scientific tangible force. No book can teach you intuition. This is an aspect you have to probe deep within you, at an elusive point where the surgeon’s ambition will meet his or her purpose. If passion is ambition, compassion is purpose. If passion is perseverance, then compassion is forbearance. If passion is power, compassion becomes a force. Passion may be self-centered, but compassion is always selfless. If passion become intense, compassion becomes inclusive. If passion leads to surrender of desires, compassion will lead to the acceptance of outcomes. Passion and compassion together build the fountainhead of intuition where only love and service remain.
I remember a patient of mine who was terminally ill, the tumour having come out of the face and neck, badly fungating and stinking. Slowly, it was eroding the main blood vessel that took blood to the brain. Every day, I had to put on a double mask for dressing the wounds. Clearly, the terminal end was expected to be a torrential bleed that would cause death. The patient’s family had given up on him as it was impossible for them to attend to the dressing of wounds at home, with maggots appearing from within. In fact, many of the adjoining patients requested me to shift this patient to another ward, as they could not bear the stench. But there was no isolation ward. I was totally helpless. Amid all this depressing environment, I was doing my duty as I had willfully assumed total responsibility of the patient. Just as I was dejectedly walking down the stairs, thinking about the gravity of the situation, a nurse walked up to me, volunteering to do the dressing several times during the day, so as to reduce the stench. It was as if some intuition had connected us together to resolve the predicament at hand.
As I thanked her, something inside me connected me with Mother Teresa. I immediately thought of how she used to serve so many similar patients without even putting on a mask. I couldn’t imagine the divinity that she possessed to perform these selfless acts with unconditional love. An act so pure is nothing but godly. As Mahatma Gandhi put it so beautifully, “The best way to find yourself is lose yourself in the service of others.” So, the nurse continued to nurse the patient like she had promised – till the last day of his life.
Intuition comes in moments of calmness, not during an agitated state of mind. It is the wisdom which dawns on us during a meditative trance. You need to lose yourself in your work to let possibilities find their way towards accomplishments. As the Chinese philosopher Lao Tsu says, “When I let go of what I am, I become what I might be.”
Can you share a few more instances to drive home the moot point for the benefit of casual readers?
I had a patient, an IT professional in his mid-thirties, with a complex cancer of the thyroid. The tumour was precariously close to the voice box, and the case was referred to me. I shared the facts and consequences with him, telling him that since a key nerve of the throat region was involved with the tumour, post the tracheostomy, he may not be able to talk again. He was reading Swami Paramhamsa Yogananda’s ‘Autobiography of A Yogi’ at that time. He told me with a smile, “Doc, you do your job, I will do mine; leave the rest to the almighty.”
Now in cases of peritoneal fibrosis, the general clinical practice is to remove the nerve if found grossly involved, else try and save it. During surgery, I was told by my team that there was no point in saving the nerve since it was badly involved. I still asked for an extra time of 20 minutes, much to their dismay. During those 20 minutes, I located the nerve and found that it was neatly covered by a sheath. Consequently, I could treat the tumour without involving the nerve. Today, the patient is leading a normal life and 12 years have passed since. What happened during those 20 minutes is beyond imagination, leave alone articulation. It was like I was being guided by my fingers towards a surgical symphony.
Every surgeon has at some point similar experiences, just that they don’t talk about it even if they may innately sense it. Swami Vivekananda has made a very apt observation on atheism. He says an atheist is not someone who does not go to temples, mosques and churches, he is one who does not listen to his inner voice. Now, this patient of peritoneal fibrosis told me years later that a hypnotherapist had told him at the time of surgery that his voice was destined for public speaking. Of course, I had no clue of this premonition then, but now I am inclined to believe there are dots which are connected in ways we are unable to comprehend. And it is best to marvel at them, not question them or draw conclusions out of them. Conclusion more often than not leads to confusion.
Let's end this thought piece with two cases you often talk about...of the monk and the governer...
Seems apt! A senior surgeon friend of mine once shared his predicament post the surgery he performed on a monk who was referred to him by a senior bureaucrat. During the operation, this surgeon happened to tell his team in a lighter vein, “I never imagined a monk could be that huge. Monks are supposed to be skinny and lean.” Just before discharge, when the monk came to thank the surgeon for the successful treatment, he said with a smile, “Yes, it is difficult to believe a monk could be as fat as I am.” When the puzzled surgeon asked if he was awake during surgery, the monk replied, “Your anaesthesia was deep enough, yet perhaps my consciousness ran deeper.”
Science is repeatedly driven by intuition in ways we can’t imagine. A governor of a global state once came to meet me in the most usual circumstances. He was flying to Delhi for a neck surgery at AIIMS. He had developed a tumour in the neck, but his master had advised him against surgery stating it was likely to turn fatal. For 20 years, the governor lived with the progressive disease until one day, the master said it was finally time for the surgery but only on India. So, the governor came to India in business class, complete with his battalion. He landed at Bangalore first as his physician here was to travel to Delhi with him.
This physician happened to be in my hospital at that time, so the governor showed up at my hospital. I was delivering a lecture at some institution, but my hospital people asked me if I would like to meet the governor to exchange pleasantries if he was around when I came back from the lecture. He was indeed around, and I had a good chat with him. He shared the prognosis and progression of the tumour. I reassured him that he was going to the right place. Just at that time, he asked whether I could operate on him. He told me that his master had told him 20 years back that he would be operated in India by a surgeon who will find him, not the other way round. He said his preference was Texas, but the master left him with no option but India. Then he told me that he felt from within that I was the surgeon. Would I be okay to talk to his master? I said yes, rather amused at the likely turn of events the governor was suggesting. I did speak to his master on phone who was thousands of miles away. He told me with a smile, “Yes you are indeed the surgeon. And don’t worry if he does not pull through the ordeal. Always remember you did your best.”
I was terribly puzzled by what he told me, unable to make coherent meaning of the seemingly contradictory messages. Nevertheless, I operated on the governor. During the surgery, my colleague passed out for a while, as he could not cope with the anxiety of this difficult surgery which involved a torrential bleed. This was strange as he is a seasoned professional who never had any such episode in the past. I completed the surgery, and as I sipped coffee during the break, the patient had a cardiac arrest in the ICU. They were trying to revive him, but it seemed a hopeless case. I went up to him, simply held his hand and went back to my work. Soon after, he was completely revived, and in fact we found him cracking jokes with the nursing staff, offering them jobs in his country.
I don’t know what happened and how it happened. I have simply placed the facts in chronological order, as they happened. How much of it was intuition, how much of it was intellect, how much of it was destiny, how much of it was free will, I have not the slightest idea. What I know for sure is that a surgical symphony had happened, with the scalpel and intuition working hand in hand.