Letter from Mumbai

Undergraduates at jawaharlal nehru institute of postgraduate medical education and research (JIPMER), Puducherry

I was privileged to interact with them on their home ground.

I found them enthusiastic, curious and eager to learn. They were kind and courteous to this ancient visiting neurosurgeon.

A committee of students, guided by their seniors and teachers, organizes Connaisance each year since 2017. The French heritage of the city is reflected in this very appropriate name for a conference of undergraduate students from all over the country and from abroad. It is held over three days. To the best of my knowledge, this is the only such meeting in India. I was a participant in the conference held in 2019.

Students attending Connaisance are offered a rich menu of 21 activities. These include presentation of papers and posters; participation in clinical case presentations, an intercollegiate medical quiz programme, debates on socially relevant medical topics, panel discussions and symposia. Students can also enrol for workshops on such subjects as basic life support, first-aid skills, surgical skills, interpretation of electrocardiograms, the basics of neurophysiology and tests for patients with neurological disorders; neonatal resuscitation. Sessions are also organized on creative and critical thinking; the principles of medical research; biostatistics and how to write papers and books.

In 2019, they had also added a ‘Model health assembly’. Topics pertaining to public health were discussed by delegates and at the assembly a cumulative draft was prepared defining problems and proposing solutions.

Almost all the tasks needed to organize and execute Connaisance are carried out by students—selection of invited speakers; their reception, housing and care; the individual sessions; production of programme sheets and other printed matter…

The students also produce an annual magazine—Montage. Started in 1967, the magazine features a subtitle on the cover. I provide some of these subtitles to give you a flavour of the thoughts and competence of their editorial boards. 2014: Andhaadhi; 2015: Rubato. 2016: Lorem Ipsum; 2017: Meraki; 2018: Equilibré. As in most college journals, Montage carries reminiscences, essays—serious and light-hearted, poems and cartoons. The paintings by students reproduced in the magazine are striking. Portraits and group photographs show prominent staff members and students. I was struck by the high quality of the photographs taken by the students of performances on the college stage during the year and subjects as varied as nature and wildlife. The website of this journal, www.facebook.com/jipmermontage/ is well worth a visit.

I reproduce two cover page illustrations by students with the explanations provided for them.

This was my first visit to the institute. I asked why the word ‘Postgraduate’ was included in its name when the institute is the successor to the Dhanvantari Medical College, which, in turn is said to be derived from Ecole de medicine de Pondicherry. The college appears to have been admitting undergraduates from the very start. I am afraid I have not yet learnt the answer.

Three hostels have been named after Lister, Osler and Aschoff. I saw the bust of Hippocrates on a pedestal at the junction of two roads in the campus. I was sad when students could tell me little on the great physicians of the past who have been honoured thus. I admit I was somewhat unfair when I asked whether the Aschoff hostel was named after the father, Ludwig, or the son, Jürgen. Alas! They did not know of the work of either.

My attempts at finding out more on the far-sighted pioneer who had attempted to instil respect for past masters of medicine also came to naught as he too has been consigned to history.

I must pay tribute to Dr V. Nallam. His father was a Professor at Ecole de medicine de Pondicherry and a renowned surgeon in Pondicherry. The son followed in his father’s footsteps and taught at JIPMER. After retirement he serves as a director of a medical centre in the city.

I remain indebted to him for his gift of a copy of his landmark book History of medicine of French India 1763-1962. Based on the official statements provided by JIPMER, I believed that Ecole de medicine de Pondicherry was established in 1823. Dr Nallam corrected my misapprehension. In his book he has documented that the school was actually set up on 13 April 1863 by Dr Beaujean, head of the department of public health in the French territory. Should doubt persist in any mind, a reference to the paper by Ramya Raman and Anantananarayanan Ramon (Indian Journal of History of Science 2017;52:287-96) will serve to dispel it.

Dr Nallam’s detailed account covers 324 pages and deserves study by everyone interested in the history of medicine in India and, certainly, by all those connected in any way with JIPMER at any time.

Figure 1: Chalk heart of a medico on the blackboard of JIPMER life. Depicted inside it are various objects that form a substantial slice of our everyday lives spent navigating through the mazes of the hospital and hostels, only to find solace in the quiet comforts of Pondicherry. The heart churns all these ingredients and more together to give rise to The Healer.

Figure 2: Medically accurate (almost) illustration of the ‘balance’ between the brain and the heart. The left part of the illustration is drawn in black and white and much like the left side of the brain is meant to represent logic, details, words and language. The strokes are much cleaner and softer showing a more controlled way of thinking. The right part of the illustration is the heart which is colourful and represents feelings, imagination, passion and creativity. Though drawn in black, the splashes of colour come off as impetuous and show a more reckless way of thinking.

The Retirement of Surgeons

I was almost 79 years old in January 2019. Neither I, my colleagues (neurosurgical and anaesthetic) nor our nursing staff noted any diminution in my surgical abilities.

I decided, then, to withdraw from the operation theatre and stop admitting patients under my care. There were three reasons.

1. I noticed increased anxiety before and after every major operation and a dread when the telephone rang in the middle of the night after such an operation. The difficulty in coping with the inevitable stress of such operations was certainly not good for me.
2. We had younger neurosurgeons on our team who had trained in specialized branches at internationally reputed centres and were thus far better than me. It was in the best interests of patients that these colleagues be in-charge and do the operations.
3. The references of patients to me had dwindled.

I handed over complete charge of any patient referred to me who needed surgery to my younger colleagues and did not take any part in further care of that patient. It was only fair that the person treating the patient had an unfettered opportunity to do what was best without interference from me. Requests from my patients that I stand by in the operation theatre were gently turned down. I explained that having a senior neurosurgeon watching every move would impose stress on the operating surgeon. This was not in the interest of the patient. So far, all patients and their relatives have found this explanation logical.

Word has got around and patients needing surgery are now increasingly referred directly to my younger colleagues. I am content with my once-a-week outpatient clinic where I do what I can to help those continuing to seek advice and guidance.

These thoughts came into focus at a gathering a few days ago when a reputed consultant in his late fifties, working in another hospital, brought up the topic of ageing surgeons. He had been introspecting and concluded that it was best to stop operating when you find yourself making errors of the kind never seen thus far. Since self-deception is always a possibility, he contemplated a pact with his anaesthetist, a much-respected surgical colleague and senior theatre nursing sisters whereby they would bring to his notice dangers to his patients from his actions and decisions.

What did I think of this approach?

I begged to differ. Awaiting errors could be catastrophic for both patient and surgeon.

The present atmosphere is vastly different from that in bygone times. Patients and families appreciated our concern then, viewed with understanding our explanation of what had gone wrong in the operation theatre and valued our sincere and unrelenting efforts at rectifying the consequences. If, despite all efforts, the patient failed to recover or died, at times, they would console us, saying, ‘Doctor, you did your best. Higher powers decreed against our relative.'

Today, we see mayhem at the hands of relatives and others after a medical catastrophe where the fault does not lie with the surgeon or clinic. Injury to medical personnel and damage to hospital property is unfortunately becoming commonplace. I know of an excellent, sincere, hardworking and eminently competent physician being shot dead by the patient’s relative as death was wrongly attributed to neglect by the doctor.

It is important that we withdraw from the scene BEFORE we do any damage to our patients.

The best judge of when to retire is the surgeon. It is always better to retire when everyone around has to ask, ‘Why are you retiring so soon?' than to face the ignominy of scrutiny of errors and veiled or overt criticism of one’s failing ability.

While age of the surgeon does matter, there have been excellent results from operations by some individuals well into their eighties. On the other hand, surgeons a decade or more younger manifest tremors of the hand and errors of judgement.

Much is to be learnt from the conduct of such neurosurgeons as Dr Wylie McKissock (1906-1994), famed in his days for his expertise in dealing with intracranial aneurysms, who decided in 1971 that it was time he turned to gardening and delight in the study of birds in Gairloch along, the northwest coast of his beloved Scotland. (Dr Dorothy Russell, the eminent British neuropathologist, also decided to tend to her garden after retirement.)

Part of the discussion at the gathering I refer to was on life after withdrawing from the surgical arena.

A surprising number of surgeons have no interests outside their specialty in medicine. This has been explained away by the rigors of study during undergraduate and postgraduate training (especially in India) and subsequent focus on patients. Such individuals are at a loss when they discard their operation theatre gloves and gown for the last time. The luckier ones have kept up with their extracurricular interests—social work, music, literature, philosophy, archaeology, the study of nature and of history, painting, photography, films, travel…

Unable to cater to those interests while in harness, they now turn joyfully to catch up with what they have missed thus far for lack of time and make opportunities for their pursuits.

And of course, there are, in most cases, grandchildren who can be spoiled with affection while their parents frown on the lavish attention that was never provided to themselves when young!

Some Musings on 90th Birthday Celebrations

I have had the good fortune of attending some of these and have gained much from these experiences and suggestions voiced by the person being felicitated. Almost all of them were welltravelled and counted among their friends gentlefolk in the best and widest sense of the term. Each of them had watched loved members of the family and life-long friends, some far younger than themselves, shuffle of their mortal coils and had grieved for them. Time had treated these individuals with respect. They had weathered the slings and arrows of ill-health from time to time and emerged the stronger for these experiences. Generally in good health, they expressed gratitude at the affection that had prompted the organization of the function and greeted each and every one present in person. One especially jovial individual was somewhat outspoken. He wondered why so much fuss was made of his 90th birthday. Paraphrasing Groucho Marx, he said, ‘I have done nothing extraordinary. You too can reach the age of 90 and more. Just live long enough.' Groucho, being who he was, had added: ‘I intend to live forever, or die trying.'

Since the individuals being felicitated had achieved success of high order in their respective fields (some in the medical arena), the accolades given to them by relatives, colleagues, students and others in their talks provided interesting information on various facets of the life and work of the individual. Almost uniformly, there was reference to grace and courtesy that formed the hallmarks of the person and her/his hard work, sincerity and outstanding intellect. Even more enlightening were the statements made by the ‘birthday baby’. I have been struck by the similarity of thoughts and expressions among differing personalities. I have gathered together statements made by several persons and present them as though they were uttered by one male individual.

While referring to those who had inspired him, he expressed gratitude for the discipline and the spirit of dedication that they had instilled. Parents, teachers and seniors came under this category. Tribute was paid to his better half for her affectionate and selfless care of household, children and, often of his own personal routines. Details were described with considerable emotion.

When asked for advice based on his long and varied experiences, there was some initial reluctance. Gathering together his thoughts, he conveyed his variation on the theme so well described by the likes of Louis Armstrong and David Attenborough—‘What a wonderful world!' Despite all the sordid politics and other human failings, the pale blue dot (Carl Sagan) remains full of fascination and astonishment. Certainly, during his long journey through life, he had been privileged to have drunk deeply of the Pierian spring (Alexander Pope) and had been the richer for the experience.

The distillate of his philosophy provided to us, the listeners, in the evening of his life, was thought-provoking.

Live for the day. One 90-year-old preferred to read the lines he had jotted down from the film Dead Poets Society. You may recall that Robin Williams, playing the role of maverick schoolteacher John Keating, exhorted his students. ‘Carpe diem. Seize the day. Make your life extraordinary. Medicine, law, business, engineering, these are noble pursuits and necessary to sustain life. But poetry, beauty, romance, love, these are what we stay alive for…' Another quoted his personal hero—Steve Jobs: ‘Your time is limited, don’t waste it living someone else’s life. Don’t be trapped by dogma, which is living the result of other people’s thinking. Don’t let the noise of other’s opinion drown your own inner voice. And most important, have the courage to follow your heart and intuition, they somehow already know what you truly want to become. Everything else is secondary.'

He continued to voice his thoughts. Cultivate an attitude of good cheer. Love and help others. Life is too short for recriminations. Filter out what is unimportant. The happiness you generate in others will, in turn, envelop you as well.

As you age, the truth voiced by every philosopher becomes increasingly evident. Each of us needs our basic creature comforts but once these have been provided, the quest for greater material wealth is counterproductive.

In summing up, a Parsi lady put it well: ‘I am well aware of being in the security lounge, awaiting my last and final call for departure. Till it comes, let me continue to live life to the full.'