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!
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!
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post graduate programme was discouraged and later withdrawn.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.
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
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.
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?
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.
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
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.
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!
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.
'Her Majesty's service' again
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
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.
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.
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.
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
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.
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
For now, I conclude with following suggestions to the
- Know your
goal and get organized before you start
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!