'There are moments in a man's life when purpose comes to him suddenly.'

- Wilder Graves Penfield (1891 - 1976).

 

It is just a brief note in response to many young Neurosurgeons who wanted to know about my rather unconventional road in Neurosurgery. I hope this will be of help them in their career.

This is not an autobiography! Autobiographies are written by winners!!

After all, one can learn from other's mistakes as well!

 

 

 

...Why Neurosurgery

 

Following my graduation from Bangalore Medical College, I returned to Chennai (it was Madras at that time.) Getting a job was difficult. Employment exchange had a long waiting list. There were no corporate hospitals then. I was not cut out for a GP with a clinic.

 

As many young graduates would do, I dreamt of becoming a Surgeon. I knew, my M.B.B.S grades were not good enough for the much sought after orthopedics or general surgery post graduate courses. Although my only exposure to Neurosurgery was my mother’s surgery for facial tics by the pioneer Neurosurgeon, Prof. B. Ramamurthi (BRM), and an impressive talk by well-known Neurosurgeon, Prof. S. Kalyanaraman during my house-surgency, prompted me to think of ‘Brain surgery’ as an exciting option. I am still to find a more impressive speaker!

 

Christian Medical College, Vellore and Madras Medical College were the only centers in the country that offered a direct admission to Neurosurgical post graduate programme without a general surgical post graduate qualification in those days. I thought a junior residency would help. In addition, they offered Rs.200/mth, which was incentive enough for me!

 

...Resident Internee

 

My first day in Neurosurgery was the 3rd of August, 1977 as a Resident internee at Madras Medical College. For the first time, I got exposed to a well-organized department. Weekly Wednesday meetings and Friday grand rounds were very educative. Monthly mortality meetings were ‘cross fire’ sessions. Being the most junior in the department, my role was to maintain the case files and be an observer, wasn't even allowed to do L.P! Observe, I did; observed the hierarchy, working of some internationally known surgeons and silent politics within the profession.

 

Prof. BRM was the towering head of the department, although he was elusive for me. He retired on the 31st of January, 1978. Along with him, the most junior in the department, yours truly, too had to retire from the government service, as the then government stopped paying the Rs. 200/mth and instead wanted me to pay the hospital to be a trainee. Needless to say, I was the only resident internee the Neurosurgery at Madras Medical College ever had. I was the first and the last.

 

To my bad luck, following Prof. BRM's retirement, the direct admission to Neurosurgical post graduate programme was discouraged and later withdrawn. I was back to square one, jobless and unsure of the future.

 

...With the legend @ VHS

 

Prof. BRM, on his retirement, started a Neurosurgical unit at VHS hospital, a community primary care hospital in the suburbs of Madras (now, the heart of ‘New Chennai’) and was looking for an assistant. The only available one with some exposure in Neurosurgery was me. Everyone else was either in the government service or in a postgraduate programme. I joined him on the 24th April, 1978 solely because I could not manage a job and he could not get an assistant.

 

My routine began at 7A.M with rounds in a city cancer centre where our patients underwent radiotherapy, followed by rounds at a local posh nursing home where ‘well to do’ patients got admitted. Then off to VHS, some 10 kms away. The doctors at VHS used to call me for each and everything as the Prof was unapproachable. Only I was allowed to contact ‘the big man’ day or night. So, it was nonstop 24X7 for the most senior and the most junior Neurosurgeons in the country with no buffers in between. There was some help with diabetes and hypertension from Dr. M. C. Vasudevan who was a research assistant and pure ‘vegetarian physician’ in those days. He is currently a renowned Neurosurgeon himself. In addition, I used to help the Prof in his private clinic in the evenings. and end the with my night rounds at VHS.

 

It wasn’t just writing case sheets and cutting the stitches at surgery. Those were the days of clinical medicine with no CT/MRI scans. In fact, neuroradiology, as a specialty, was nonexistent. Cerebral angiograms, Ventriculograms, Pneumo-encephalograms, and Myelograms were the imaging modes and were done by the neurosurgeons. It was all too much for me to start with. Myodil was a luxury in those days. No image intensifier was available. My air myelograms, where x-rays were taken with a tilted table at the clinical level unlike the currently popular whole spine MRI, and also percutaneous vertebral angiograms became popular.

'Great teachers don't teach; they inspire'. Prof. BRM did. My job became my obsession.

 

I literally lived with my patients at VHS, much to the amusement of my master at times! I was thrilled with the confidence shown by the city doctors when they chose me, instead of the ‘Institute of Neurology’ to refer patients in acute stage in my Prof’s absence. Whenever the Prof was away, I used to go to various neurosurgeons in the city with all the investigations for advice. There were occasions when I used to ambu-bag the patients for days together. Ventilators were not easily available in those days, you may know. I have often reopened the craniotomised areas in those unfortunate patients in ICU to find out the cause of their death.

Over the years, our department became popular; we started getting patients from all over the country and also from neighboring countries. VIP patients preferred our center to more well established centers in the country. Microneurosurgery in India started with our trans-ethmoid-sphenoidal pituitary surgery in our center. What started as couple of beds in the general surgical ward became a separate independent ‘Neurosurgical ward’ in a new building. There have been many greats who have established Neurosurgical centers in their life time. The greatest achievement of Prof. BRM’s is to have created not one, but two neurosurgical centers of excellence in his life time, many would say. The most I liked in him was his appreciation and respect for a good worker, be it a ward boy or a professor. I was allowed to argue with him regarding patients without any inhibitions. A patient with a recurrent temporal glioma deteriorated the night before his surgery. Prof was away and I did the emergency surgery myself. That was my first independent tumor excision. The next morning he appreciated my bold decision.

 

Years rolled on. I never thought of my post graduation or future, it was work, work all the way. General surgical qualification was a prerequisite for D.N.B (Neurosurgery) in those days. Over the years, many other universities started direct post M.B.B.S neurosurgical postgraduate programmes in the country and were not finding students!! They all wanted me to keep the course alive since they could not manage enough students. I couldn’t contemplate going away from Madras due to personal reasons or was it my bonding with my master?

 

In early 1983, the direct post M.B.B.S neurosurgical postgraduate programme was restarted in Madras Medical College. I was excited that I would get a P.G seat in Madras at last and that I would be able to continue my association with the Prof. After all, I was the most eligible with over 5 years experience with the father of Indian neurosurgery. I thought my getting a seat was just a formality. It was not to be. Although Prof. BRM was the most admired, some senior neurosurgeons despised his authoritative attitude (well earned, I must add), and took it on me. I must admit I might have antagonized some senior surgeons on occasions for my master’s sake. They preferred to keep the seats vacant rather than giving it to me. Perhaps, I should have asked the Prof to put in a word; nobody would have dared to say no to him. I even contemplated legal action against the Madras Medical College for refusing me.

 

Many of my well wishers felt that I am wasting my youth in VHS. I began to realize it is time for me to look out for something. Prof’s son, Dr. Ravi Ramamurthi, my contemporary in M.B.B.S, completed his M.S (Neuro) and was due to return home in 1983 from his UK training and direct F.R.C.S (Neuro). I responded to an advertisement in the BMJ, hoping that that job will facilitate me to get direct F.R.C.S (Neuro), as Ravi did. To my utter surprise, I was asked to join St. Lawrence’s hospital, Dublin at the earliest. Mention of Prof. BRM in my C.V must have done it, I guess.

 

I left VHS on the 31st July 1983 to Dublin, Ireland. Saddened to leave VHS and my exclusive 'one to one' clinical association of 5 years with the Prof, the face of Indian Neurosurgery; something nobody else can ever claim to have had. Perhaps, those 5 years are the best years of my profession; but my association with the legend continued, as you will see.

 

...Irish experience

 

I joined as an assistant to Mr. Patrick Carey (surgeons are usually referred to as Mr in U.K and Ireland), senior Neurosurgeon at St. Lawrence’s (Richmond) hospital, Dublin, Ireland on the 2nd of August, 1983. It was the premier neurosurgical center in Ireland. Presently, it is called Beaumont Hospital and is a large academic teaching hospital. The post was an equivalent to that of senior registrar, with a registrar with F.R.C.S in neurosurgical training programme and two senior house officers, preparing for F.R.C.S under me. I did not expect this. It took some time to get used to the new set up. Mr. Carey reassured me and made me comfortable.

 

Dublin was one of the few centers in the world who were persisting with  epilepsy surgery in 1983. It was a specialty on the way out in those days (only to resurrect 15 years later with MRI and computers). Nevertheless it was new to me. Weekly Aneurismal surgery and monthly epilepsy surgery were a routine. Pituitary surgeries were through a sub-labial trans-sphenoidal route. Anterior approaches to the spine were quite common. I used to go to the railway station every Friday morning to collect rats for my microsurgery training and soon I became proficient with microneurosurgery

Gradually the juniors started to accept me. Soon I was allowed to operate independently and Mr. Carey stopped coming to operating room. In fact, he left everything to me and made ward rounds only twice a week.

 

I introduced ICP monitoring in Ireland with the good old Richmond screw. There was an interesting case of frontal depressed fracture; on elevation there was persistent bleeding, presumably from anterior ethmoidal artery. The only way I could control was with gauze packing and removing the pack the next day. Another unconscious patient with fractured temporal bone and a lucid interval. I removed a huge EDH with out a prior CT. Those days CT scan took time with waiting for the radiologist and warming up the machine. Everybody criticized me for such procedures in a western country. I felt good when Mr. Carey defended me and appreciated me in our weekly clinical meeting. A patient with C2 metastasis was transferred from a local hospital on a ventilator. I carried out a transoral – pharyngeal decompression with our ENT colleague; it was the first transoral neurosurgery in this part of the world, though, as expected, the patient didn’t show any improvement; that was the beginning of my interest CV junction anomalies. Interestingly, I was the Neurosurgeon on call for U.S President Reagan during his visit to Dublin in 1984!!

 

All along, I maintained my association with Prof. BRM with a monthly operative log book!. He used to reply promptly with encouraging words. Neuro F.R.C.S was always in my mind. The Royal College of Edinburgh insisted on general F.R.C.S as a prerequisite, despite my repeated requests. I began to wonder where I was going and frustration started creeping in, for the first time in my career. Mr. Carey offered to get me into McGill university, Canada. But, I was keen to get back to VHS with F.R.C.S.

 

Mr. R. P. Sengupta, an internationally acclaimed Neurosurgeon of Newcastle upon Tyne, U.K came to know of me and wanted me to come to Newcastle, instead getting struck in Ireland, which he felt would take me nowhere. Opportunity of working with an iconic surgeon rejuvenated me.

 

I left Dublin with fond memories to Newcastle upon Tyne on the 31st of July, 1985.

 

...@ Newcastle upon Tyne

 

I took few days to go thru’ the General Medical Council, U.K, since I was exempted from PLAB (Professional and Linguistic Assessments Board) test, thanks to Mr. R.P. Sengupta. I joined the Regional Neurological center, Newcastle upon Tyne as a neurosurgical registrar on the 4th of August, 1985. To my disappointment, I was posted with a young English surgeon, who wasn’t that busy and could work with Mr. R.P. Sengupta only in my free time. Obviously that spoiled my relationship with English surgeon. He started treating me like a novice in Neurosurgery, which I couldn’t accept. That was my mistake; I should have waited instead of sitting on my ego.

I didn’t enjoy my work and I was getting nowhere with neuro F.R.C.S, although the Royal college of Edinburgh came down and offered to could consider my neurosurgical experience if I did part 1 F.R.C.S. I thought doing part 1, with all basic sciences 8 years after M.B.B.S, was beyond me. As you may know part 1 F.R.C.S of those days, unlike the present part 1, was the most difficult examination in medicine. I became restless and it was all getting too much for me; I resigned my post on the 31st December, 1985, although Mr. R.P. Sengupta offered to take me into his unit. He also told me that I should make it easier for others to help me. But, I thought enough was enough and left Newcastle.

 

...Back @ VHS

 

A month later I rejoined VHS. By then, the department had expanded into a recognized teaching center with the first batch of fresh graduates for the direct D.N.B (without a general surgery qualification) course. Soon I felt redundant. Prof. BRM advised me to concentrate on a qualification and that direct D.N.B was a good option. But my mind was fixed on the more glamorous F.R.C.S without which my overseas experience would not get its due, I thought, especially when it didn’t happen at VHS where I grew up. Moreover, my ego didn’t allow my going through D.N.B along with the fresh graduates. I decided to get back to my mission F.R.C.S!

 

...Mission FRCS

Dublin has always been my second home. I left for Dublin in August 1986. My friends at Dublin arranged an accommodation and admission to a 4 mth full time preparatory course for part 1 F.R.C.S with the Royal College of Surgeons of Ireland. I went thru the course with all sincerity and the examination went on well until the last orals in pathology, where I couldn’t define an abscess, abrasion, sinus, or fistula (try it for yourself). I failed.

My money was running out and into my last 1000 £s. I needed a job to keep me going until the next part 1 examination which was 4 mths away. I didn’t feel like going back to the department of Neurosurgery at Dublin which had undergone lot of changes with new consultants.

 

...On 'Her Majesty's service' again

 

Thanks to Mr. R. P. Sengupta, I rejoined the Regional Neurological center, Newcastle upon Tyne in a locum vacancy for couple of months. I did not mind going back to Newcastle as I needed to survive my second innings for F.R.C.S. Poverty decides the personality, perhaps!

 

To work in the U.K without PLAB test, I needed a sponsor and to change my hospital I needed a new sponsor. I took a chance and responded to an advertisement in the BMJ. I lost all my hope when I met two young, enthusiastic candidates with F.R.C.S at the interview, my first job interview ever; after all, nobody likes an old, unqualified critic with them! At the interview, Mr. Gordon Brocklehurst, Neurosurgeon at Hull Royal infirmary, wondered why I, with all my experience, needed a job in UK. I told him all about my FRCS aspiration and that I needed the money to survive. To my surprise, I was offered the registrar post.

 

I joined Hull Royal infirmary UK, as a registrar in August, 1987. Mr. Gordon Brocklehurst was a laser neurosurgeon with lot of research work in CSF, hydrocephalus and in photodynamic therapy for gliomas. More than anything else, he was really a true Englishman. He respected my neurosurgical experience, gave me full freedom and was also supportive of my F.R.C.S attempts. At the same time he made sure I got trained in laser surgery, photodynamic therapy and in rehabilitatory procedures for pain and spasticity relief as well. ICP monitoring was a routine. I also learnt carotid endarterectomy in association a local vascular surgeon.

My monthly operative log book to Prof. BRM was revived and so were his encouraging letters.

All along, I was failing in my part 1 F.R.C.S examination every 4 mths, although I passed my part 1 D.N.B examination in the process. My active clinical work did not allow me to prepare for the examination, or so I thought. After a long discussion with Mr. Brocklehurst, I stopped working in September 1988, rented a flat locally and was settling down with full time preparation for part 1 F.R.C.S. As luck would have it, I passed my part 1 F.R.C.S examination the very next month! I cursed myself for giving up a job and a sponsor.

 

...Final FRCS

 

I was back at Royal College of Surgeons, Edinburgh. They told me that lot of things have changed and that the college was being criticized for not following strict guidelines. They insisted that I should do my final F.R.C.S before I go for neuro F.R.C.S. I was dejected and felt all my efforts at part 1 F.R.C.S were for nothing.

Australian and Canadian Royal colleges were the only other colleges offering F.R.C.S in Neurosurgery those days. They were ready to accept my experience and part 1 F.R.C.S; but they wanted me to take their PLAB like entrance test first. They discouraged back door entry into their countries with F.R.C.S. As such, I had to choose between general F.R.C.S or final DNB (neurosurgery). As you may know, DNB is still to get it’s due, even today. After all that I had gone thru’, I felt I must get the F.R.C.S. But how? The last time I worked in general surgery was in 1977.

 

Anyway, the impossible is often the untried; I decided to give a try.

 

Prof. R. Narayanan, one of my teachers who is still close to me , suggested I should take his son in law, Dr. J.S. Rajkumar’s help. He is a gold medalist from Madras Medical College and has already done his M.S and F.R.C.S (Edin) without going to U.K. I joined him at Maidstone hospital, Kent, U.K as he was going to U.K for training. I attended his out patients, ward rounds and surgeries at Maidstone hospital, Kent, U.K for three months.

To everybody’s surprise I passed my final F.R.C.S at the first attempt in 1990! I couldn’t believe myself, especially when I took about 10 attempts for my part 1, so much for these exams. I was probably the only one with F.R.C.S without ever having done a laparotomy. I couldn’t sleep in my excitement and took the earliest flight to VHS to share my happiness.

 

Back from my celebrations, I knocked at the Royal College of Surgeons, Edinburgh again for neuro F.R.C.S. My bad luck, the College had withdrawn the neuro F.R.C.S, as there were no takers other than the Asians. The General Medical council did not recognize this neuro F.R.C.S and it was not a mandatory requirement to become a Neurosurgeon in U.K. As you may know, there were only F.R.C.S and M.R.C.P and no specialist examinations in the UK during those days.

 

Anyway, I wasn’t too disappointed; after all, I got my F.R.C.S and the world has accepted me as a Neurosurgeon at last.

 

...Final DNB

 

I started packing up to return to VHS. It wasn’t to be.

Prof. BRM wrote to me that I should do Indian examination since VHS was a recognized post graduate center for D.N.B examination. I decided to stay back, continue my study holiday for another 3 mths for my final D.N.B, although the General Medical council gave me permanent registration with my F.R.C.S and there was no need for a sponsor. The whole Asian community was laughing at me for wasting time and money by prolonging my study holiday; after all I was the first to go for an Indian examination following a western qualification. I took my theory in London and was disappointed to see the quality of examiners at my clinicals in Bombay. I expressed my feelings to one of the examiners at the airport and later to Prof. BRM. Six mths later I got thru’ my clinicals at Delhi in 1991, thanks to the examiners! I knew I passed as I was coming out. I phoned up Prof. BRM and asked him to thank Dr. M.C.Vasudevan, my good old friend and colleague, who did all the pre–exam paper works for me.

 

...Final Stint

 

Just when I thought I found all the answers, the questions were changed!

Prof. BRM wrote to me that it wouldn’t be possible for me to work in VHS as it was already crowded and that I should go to Dubai or Saudi to make money. I was forty years old then with all the qualifications, but too old for a government job. There were no corporate hospitals to give a fat salary those days. I realized that I needed money to tide over the initial period of my private practice in India. All my money had exhausted with my examinations and stay in the UK. There was no time to sit around for the right job. I took up all kinds of locum jobs so that I get paid double for every hour of my stay in the UK; literally lived in and out of suitcase in my race against time. Fortunately, I managed to get a 6 mth locum registrar job at Brooke’s Hospital, London, which gave me a good introduction to the revival of stereotactic surgery with MRI and computer.

 

...Back to the future

 

As VHS was not on the list for me, I started looking for options;it wasn't easy. I wanted a full pledged teaching unit. I joined Sri Ramachandra medical college, only to leave because MCI did not accept me as a teaching faculty without M.Ch. Another institution could not accommodate a non-Brahmin.  Fortunately, Apollo hospital, a premier teaching hospital, recognized by the National board of Examinations, India and intercollegiate specialty fellowship boards of the Royal colleges, U.K for postgraduate teaching purposes, welcomed me and I gladly accepted and continue till date.

 

...@ Apollo

 

On my return in 1993, I joined Apollo hospitals, Chennai and continue till date. I had to wait for nearly a year to get my first patient. My association with Prof. BRM continued as ever. But for his morale boosting letters, I could not have survived thru my years in England. I used to take blessings from him before my difficult cases, and report back to him regularly. I introduced ICP, monitoring, Aneurysmal surgery, Anterior spinal instrumentations, and Trans – oral procedures, probably for the first time in Tamilnadu; I was certainly the first to present series of such cases in clinical meetings with pre and post op pictures during 1995-97. Following a month's training in Washington D.C, I started multidisciplinary approach to skull base  in 1998. It was a good feeling to get invited by the Madras Institute of Neurology to perform trans-oral and trans-naso-sphenoidal procedures.

 

For now, I conclude with following suggestions to the young

  • Know your goal and get organized before you start
  • Stay focused on the goals, and flexible in your approach
  • Get your qualification first; everything else can wait
  • Do not develop an attitude or ego; but live your values at work
  • Everybody has flaws; don’t miss the good because of the bad

 

Let me see what is in store in 21st century

 

all the very best to you!

 

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