Navigating Neurosurgery into an Optimal Future
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0028-3886.266271
Source of Support: None, Conflict of Interest: None
First of all, let me congratulate Dr. Sanjay Behari, the erstwhile Editor of this journal to bring it to its present state of excellence and wish Dr. P. Sarat Chandra who is taking over this onerous responsibility to take it to greater heights.
I was introduced to neurosurgery a little over six decades ago as a trainee under Prof. Kristian Kristiansen at the Ulleval Hospital, Oslo, Norway. I started neurosurgery on my own 4 years later at my alma mater at Lucknow and a few years later at the All India Institute of Medical Sciences at New Delhi.
I had the privilege of seeing its evolution all over the world – the United States, Canada, Europe, Scandinavia, and a glimpse of it in Korea and China. I witnessed the old masters, including Penfield, Olivecrona, Norleen, Leksell, Donald Matson, Charlie Drake, and Hans Pia and also Dr. Chandy and Ramamurthi operate. I last operated upon a patient about 28 years ago. Ever since I did not enter a neurosurgery theater, but occasionally witnessed video-transmission of live surgeries performed by current “masters” during the annual workshops in our department.
It is not only the surgical armamentarium that has changed but also the diagnostic capabilities and support from allied disciplines. In a way, I was aware of the recent advances, but not the exact details. During my own professional life, I had used the developments over the years – the introduction of the bipolar cautery, the operating microscope, the lasers, the ultrasonic aspirator (CUSA), A-scan echoencephalography, positive contrast ventriculography, isotope ventriculography, cisternography, computed tomography (CT) scan, and magnetic resonance (MRI) imaging scans were used for the first time by us during this period. It is no surprise that the newer techniques and technologies have kept on being introduced to make neurosurgery less traumatic and safer and the same time applicable to lesions earlier considered inoperable.
I personally had the benefit of such advances nearly 3 months ago when I was operated upon for a pituitary adenoma. Thus, I entered a neurosurgical operation hopefully for the last time. Though I had only a few moments to look around before I was anesthetized, even during this short time, I could sense that it was a different world. During the whole exercise from the diagnosis to the operation and the postoperation period, the type of facilities that were used were mostly not available at the time I ended my neurosurgical career, and certainly not available to Cushing, Penfield, Dandy, or even to Jules Hardy, one of the later neuropioneers of neurosurgery. Thus, the ready availability of CT and MR scan, image-guided support, endoscopy, high magnification microscope, and an ultra-fine array of instruments no doubt helped make surgery safe. But the facilities of the intensive care unit on-call, laboratory tests (carried out several times in a day and night), support from allied specialties, ophthalmology, endocrinology, cardiology, nephrology and intensivist were certainly not available when I last operated upon a pituitary tumor and thank the Lord for all this, so that I am able to write this editorial so soon after surgery.
However, the reason to write all this is not a thankgiving exercise for modern neurosurgery, but to raise an important existential question.
While the ideal conditions mentioned above may be desirable, can these be made available to every practicing neurosurgeon in our country? I no doubt would wish it to be so. However, it may be worthwhile to precisely document the benefits that have accrued in comparison to the results without such facilities.
On the other hand, being aware of the existing situation, can one say that operating without such facilities is tantamount to taking undue risk and liable to be considered medical malpractice in a consumer court?
As a matter of fact, during the Institute Review Committee headed by Dr. S.J. Mehta, I was questioned whether it was justified in operating under the then prevailing conditions at the Institute.
This brings back memories of the beginning of our professional work. Following a visit to India in 1964, my mentor Professor Kristiansen commented, “If I not had seen his patients alive with my own eyes, I would not believe neurosurgery was possible with so little facilities.” As a matter of fact, we were not the exception; this was the fate of all our predecessors and contemporaries.
The autobiographies of our pioneers (Chandy, Ramamurthi) bear testimony to this fact. We all are aware that results of neurosurgeries by McKewan, Cushing, and Dandy, at least for some of the operations, are hard to match even today. This was achieved without most of the modern facilities.
For the young neurosurgeon, let me clarify, it is not to advocate that they should not be provided the state-of-art facilities. Nor should a neurosurgeon without such facilities deny his or her service to an unfortunate patient who cannot seek such service at an ideal place.
For the beginners, I am tempted to quote Theodore Roosevelt's advice (no doubt in some other context), “Do what you can with what you have, where you are.” I am sure much can be achieved!
For the leaders, I suggest that recognizing the problems, their trainees would face while beginning their careers, training should be modified accordingly. Attempts should be made to define the optimal conditions, which should be made available to their trainees when they embark upon an independent career.
This should be done on the basis of hard facts taking into consideration the socioeconomic circumstances, and to persuade the concerned administration to do the needful. A great deal can be achieved by creating additional facilities like the skill training laboratory (established at AIIMS with support of ICMR and Department of Science and Technology) and Center of Excellence for Epilepsy and Magnetoencephalography (MEG) established at AIIMS and National Brain Research Center (NBRC) with the support of Department of Biotechnology (DBT).
In addition, the better equipped and staffed institutions should have provision to provide opportunities for those from less endowed institutions for short-term training. The Neurological Society of India should play a proactive role in supporting such activities.