Reminiscences of Neurosurgery training at AIIMS, New Delhi
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0028-3886.227296
Source of Support: None, Conflict of Interest: None
Training in surgery, and in particular Neurosurgery, at a leading institute like All India Institute of Medical Sciences (AIIMS), New Delhi, in the early seventies was full of challenges, and also a trial for the teachers, students, and patients alike, for achieving the best possible results. It was highly interesting to work under outstanding teachers like Dr. PN Tandon and Dr. AK Banerji who inspired their students and helped them in overcoming challenges, thus playing a major role in shaping their future.
Early Days as a House Officer
I joined as a house officer in the Department of Neurosurgery, AIIMS, New Delhi in May 1965. This was soon after completion of my internship at SCB Medical College, Cuttack. During my MBBS course, I had developed a special interest in the functioning of the nervous system. However, I was absolutely fresh as far as exposure to Neurosurgery was concerned. My job at AIIMS was basically the clinical work-up of indoor patients of a 10-bedded department, dressing of postoperative cases, attending to night calls, presenting history and clinical findings of patients during the ward rounds, writing progress notes, making discharges and death certificates, contributing towards maintenance of artificial ventilation of patients (as there was no intensive care unit!), motivating the relatives, of patients who succumbed, to agree to conducting an autopsy on their deceased relative, consulting Dr. PN Tandon and Dr. AK Banerji for advice on managing complications, joining them the next day for the 8 AM rounds, and in preparing cases for emergency surgery. Thus, the work schedule kept me busy round the clock and gave me a lot of confidence in dealing with serious patients. Additionally, morning rounds with the Neurology team headed by Dr. Baldev Singh along with Senior Residents (Dr. Gauri Devi, Dr. Sahni), and the Neurosurgery team headed by Dr.PN Tandon along with Senior Resident, (Dr. Brahm Prakash) were highly interesting and stimulating. I had to often present on the rounds, the clinical features of the newly admitted cases admitted to the ward. Generally, operation theatres were not easily available and anesthetists were quite reluctant to conduct neurosurgical procedures. My colleague, Dr. Raina, left soon after I joined, and this situation intensified my responsibilities, and considerably increased my work schedule to a round-the-clock one without any breaks. Even visiting my room in the hostel to freshen up became impossible for days. My friends visiting me from other hospitals in Delhi once left a note on my hostel room door, “Not able to meet you in this life, hoping to meet you in our next life.” Despite the high rate of complications and mortality prevalent at that time, I enjoyed the hard work, spending more time in the ward and loving the challenge. Dr. GR Gode, of the Anesthesia department, observing my situation, predicted in the recovery room, “This hard work will pay you after 10 years.” Several new building were being constructed in the AIIMS hospital campus, and in-patients were scattered around multiple wards, depending on the availability of beds for them., I had to, therefore, walk for miles every day and night inside the campus. Dr. Banerji used to say “Hard work does not kill!” When I read that the father of modern Neurosurgery, Dr. Harvey Cushing, was a hard task master and a perfectionist himself, it became a matter of great consolation to me. One interesting story of training under Dr. Cushing was particularly dear to me. The story was that of Dr. Sir Hugh William Bell Cairns (the neurosurgeon who trained at the London Hospital and with Dr. Harvey Cushing at Harvard before setting up the Nuffield Department of Surgery in Oxford, United Kingdom, who is famed for advocating crash helmets for motor cycle riders after treating Lawrence of Arabia's head injuries due to a motor cycle accident), when he went for training under Dr. Cushing. As soon as he met Dr. Cushing, the latter said, “Mr. Cairns, you are two days late, now get into the operating theatre.” It was six weeks before Dr. Cairns could manage to get off service long enough to pick up his luggage at the dock side. Dr. Cairns once told Dr. Charles Sherrington (the English neurophysiologist and Nobel laureate) that he had once contemplated bringing a pistol to either to shoot Dr. Cushing or himself!
In AIIMS, during my tenure, once a very important person, a lady, with a parasagittal meningioma, was operated. She had a stormy postoperative period. Surprisingly, the 24-hour duty was divided between Dr. PN Tandon, Dr. Banerji, and myself. We used to place our bed next to her and manage frequent seizures and fever throughout the 24 hours. She survived with our committed efforts but had some personality changes. Thus, in those early days, I learnt a lot from the dedicated commitment, team work, and teaching by personal example, of these outstanding neurosurgeons. Subsequent to Dr. Brahm Prakash's joining as a senior resident, my responsibility become a little lighter. I joined MS (General Surgery), a 3-year course at AIIMS, New Delhi, under Dr. BNB Rao. When he asked me what I would like to specialize in, my answer was Neurosurgery. I passed the Educational Commission for Foreign Medical Graduates (ECFMG) test and wanted to settle in the USA. But I was advised by Dr. A. Earl Walker, (the erstwhile Chairman of Neurosurgery at the Johns Hopkins Medical Institutions in Baltimore and an eminent epileptologist), to complete Neurosurgical training at AIIMS, India before coming to him! I visited USA several times after that, yet I have had no occasion to feel that my neurosurgical training at AIIMS was in any way inferior to the one that I would have obtained in the USA!
Later period (as a Senior Resident)
After obtaining my MS (Surgery) degree at AIIMS, New Delhi, I became a Senior Resident under Dr. DS Mehta at GB Pant Hospital, New Delhi. Dr. Mehta, was a British trained surgeon under Dr. Peter Henderson who was a member of Faculty of Biological Sciences at the University of Leeds, United Kingdom. Dr. Henderson was Dr. Cushing's last resident. Being Dr. Mehta's only resident and assistant, I had a great deal of exposure to cranial and spinal surgery, in addition to head trauma. AIIMS was mostly admitting elective cases like the practice being carried out in Christian Medical College, Vellore for a long time. From GB Pant
Hospital, New Delhi, I moved to Institute of Medical Sciences, Banaras Hindu University, Varanasi, for over a year as a Lecturer in Surgery (Neurosurgery). For the first time, I realized the importance of research and teaching (as an academic neurosurgeon), which I had missed at the previous institutes. After over a year at Varanasi, I come back to AIIMS, New Delhi as a senior resident, enrolled in the M. Ch (Neurosurgery) course.
I had one colleague, Dr. HN Agarwal, who was soon going to appear in the M. Ch. (Neurosurgery) examination, so I had to handle a major share of the clinical responsibilities during my MCh training program. I loved to attend all emergency surgery, that is, those conducted for tumors, abscesses, hydrocephalus, and head trauma. By this time, I was tuned for all this hard work and no longer had any complaint regarding it!
By the early seventies, training had become more organized at AIIMS,, with the support of separate operation theatres, an intensive care unit, and a dedicated anesthetist (Dr. Surinder Saini) in handling neurosurgical cases. Dr. Saini was always willing to help and was readily available, thus, considerably easing our work.
Rounds used to start at 8 AM in the Radiology department. All Neurosurgery, Neurology, and Radiology (Dr. Sneh Bhargava and her team) departmental members were present at that time. Angiograms and ventriculographic images were interpreted and discussed after the presentation of a short history and the clinical findings by me. The concerned surgeon and assistants would move to the operation theatre and rest of the doctors would either go for ward rounds or to the Radiology department to conduct emergency angiograms, pneumoencephalography, and ventriculography., Thus, the two senior residents at that time, Dr. AK Reddy and myself, hardly any free time. On a given emergency day, I could operate on a brain tumor in the morning, another in the afternoon, and a brain abscess in the night.
Assisting Dr. Tandon and Dr. Banerji was a pleasure. Both were outstanding surgeons belonging to the Montreal Neurological Institute (MNI) legacy. Dr. Tandon also had Scandinavian (the Oslo) influence. Dr. Banerji had trained at Christian Medical College, Vellore, under the master surgeon, Dr. Jacob Chandy, who had, in turn, been trained at the Montreal Neurological Institute.,,,
Training was highly exciting and also entertaining at times, never to be forgotten. Dr. Banerji had the intuitive feeling that some of us were getting to be the “cutters” without learning to be be the 'thinking' neurosurgeons. He persuaded us to 'think and cut' and coined the word “thoughter,” constructed by the amalgamation of two words, “thought (ful)” and “cutter”. Thus, we were also exposed to neurosurgical decision making at a very early stage of our career, which is rarely the case in the training program of a present-day neurosurgical trainee.
Both my teachers knew how to impart responsibility in stages. Initially, we were exposed to conducting a craniotomy exposure and closure. Obviously, things were difficult in those days since computed tomography, magnetic resonance imaging, operating microscopic, neuroendoscope, or a electrical or pneumatic drill were not available. However, it was always a pleasure to see the results of surgery when the patients survived and recovered well. During one of my visits to a famous neurosurgical clinic in the USA, the chief there asked me, “Do you have a structured training program at your place?” I replied in the affirmative. “Oh, then you train your own competitors!,” he exclaimed. The situation was the same at Queen Square, London. Dr. Lindsay Symon, the Professor of Neurosurgery at the Institute of Neurology, University College of London, said that, in the past, at several places in the United Kingdom, the operation table on which surgery was being conducted was maintained at a height almost touching the ceiling, with the main surgeon perched on a very high stool so that the assistants could not see the surgery and could not not learn from the procedure! In contrast, when I look at the training at AIIMS, I feel proud of the contributions of our selfless, and dedicated teachers. One day, while we were taking ward rounds, Dr. Tandon, said, “I would like to see my students going far ahead of me!” I don't know if any of his students have actually gone beyond him in terms of their professional competence, but I think it is a prophetic statement of a great teacher.
One day, I was supposed to expose a craniopharyngioma by a subfrontal approach. Dr. Tandon was busy in a meeting. When he came to the theater in an hour's time, the operation was over. It was a cystic tumor. He carefully inspected the area and asked me to check the hemostasis and then close the craniotomy wound. It was indeed a blessing to have a teacher like him.
After days of busy schedule from the morning 8 AM to 2 PM, 2 days in a week, we had a journal club and a seminar in the afternoon, which we could never miss. One day, I was supposed to present a seminar. Due to the busy clinical schedule, I had not prepared the presentation. I got a real strong firing for the lapse, but by now I was quite used to it. In the afternoon, Dr. Banerji used to visit the ward and the intensive care unit to check case records, progress notes, operation theatre notes, intensive care notes (as the intensive care unit was under the Neurosurgery department), and clinical findings in particular. Thus, he taught me to be careful in the documentation of cases, which is essential for clinical research as well as for avoiding litigation in the present era. As exams were approaching, Dr. Tandon spent an hour in the evening teaching me angiography, ventriculography, and pneumoencephalography. When I look back, it is unbelievable how close Dr. Tandon and Dr. Banerji were to their students, how sincere and genuine were their interest in imparting and sharing knowledge, how much they believed in inculcating the spirit to withstand failures and not get depressed and disappointed when things went wrong, and how much they emphasized on dividing time for clinical work, learning, and research. Dr. Tandon had a knack for finding something novel and unrecorded among the clinical cases admitted to the Neurosurgical service. He gave me the topic of 'Hemorrhage in pituitary tumors' as my M. Ch dissertation. About 80 cases of pituitary tumors done until that date were analyzed. Cases having hemorrhages (old, silent, recent, and apoplectic), were classified. I did the same study in 400 cases of pituitary tumors at the Department of Surgical Neurology of National Hospital of Neurology and Neurosurgery, Queen Square, London and published the results with Dr. Lindsay Symon in Acta Neurochirurgica. It was highly quoted. This publication served as the source of great satisfaction that I derived from clinical research, and its foundations were laid long ago during my training at my alma mater at AIIMS. I believe that research is infectious, and the source of infection is the teacher!
My teachers were hard task masters and perfectionists. They never accepted excuses for something which was immediately required for the benefit of the patients. They would not accept delays and excuses regarding things that were immediately needed for the patients. The firm foundation of the Department of Neurosurgery of AIIMS, laid by these great teachers, is ultimately responsible for it becoming one of the leading neurosurgical training centers in India. Needless to say, technology has come in a big way to achieve precision in Neurosurgery and in contributing to improved results. Surgical skill is now of primary importance. However, whatever training I was imparted in those days at AIIMS, New Delhi, was essential for my neurosurgical carrier as a surgeon, teacher, and researcher. Technological progress has now taken over every aspect of surgery and its specialties quite rapidly. For example, robots may soon take over the art and craft of surgery since they are capable of being programmed to work more precisely in pinpointing and extirpating the lesion. Dr. Cushing once predicted that surgery would one day be conducted without a drop of blood being lost. Who knows whether or not robots will replace surgeons in the future as the preferred technicians conducting the actual surgery. Surgeons would certainly demonstrate less skill and precision as compared to robots; yet robots cannot replace the values and work ethics that I learnt working under outstanding medical teachers in the Department of Neurosurgery at AIIMS, New Delhi. I quote at the end, “Successful education is not achieved by adopting the latest fashionable fads but in establishing a faculty of competent teachers who can inspire and motivate the students by personal example. When we reflect on the key events of our own educational system, seldom are the merits of a particular video recording of a surgery or of its mere technical nuances that come to mind; rather, it is the contributions of a certain teacher who has played a key influence in shaping our career.”