It has been a busy few weeks – I have moved to my own house now, and I would definitely say all the hassle was worth it! Good time to put pen to paper !!

All throughout my career as a surgeon, I have been pretty lucky not to have had a major complication until very recently. I must emphasize the word ” have had”. But as one of my mentors put it, rather bluntly, ” If you have not broken a plate, you have not washed enough” !!

Complications are an inevitable part of surgery or for that matter any invasive procedure. There is no way out of it. However we as surgeons like to avoid complications they are indeed part and parcel of the business, and there is no way around it.

We as surgeons take utmost care to avoid complications. We take all the precautions before and during the surgery. The training and accreditation process is long and arduous. The stakes are high …..things do not often go wrong they do go wrong!

Once again most complications do not need further surgery or procedures and can be managed conservatively. Unfortunately, this is not true for some, and sometimes despite the best intentions, surgery does cause a significant amount of harm, rarely causing even permanent disability and/or death.

Understandably the first victims the patients get angry and frustrated. ” Why me ” is the first question that most patients have – after all there are complications that happen one in a million and patients naturally want to know ” Why me”. It is difficult to give a straightforward answer …often there is none. The only way forward is to accept it and acknowledge it and Move on.

A significant source of anxiety and stress for the ” first victims” is “what happens next”. Most do not know what will happen next and what the future holds for them. Most feel that they have been ditched and abandoned. Therefore it is important to involve the patients in the discussion about their future care and plans. At the very least it will give them a sense of security and will allay a significant source of anxiety.

Now we come to the Gist of this story……Who is a ” second victim”?

For every story there are 2 sides, Simillarly every coin has 2 sides. In literature it is well described about the ” First Victim” but very little about the ” Second Victim”.

In every major complication that happens as a direct or an indirect result of surgery ,there is always a man or a woman behind the scalpel, who is usually suffering silently despite his or her best intentions. This entity was ignored till quite recently. Thanks to a few surgeons from the US who had brought this to light, the term ” Second victim” has appeared in the medical literature.

Second victims are often unseen and unheard. They are invisible but let me tell you that the suffering is real. As surgeons, it is incredibly hard when one of your own patients suffer a complication as a result of our actions. More so if this is a major complication which are often life-changing for the patients.

The matter is even more complicated in that there is always the additional worry of litigation . inquiries in the background for the second victim after a complication. These add on to the stress during an incredibly difficult period following a major complication. Atleast the first victims have a good support network provided for them but unfortunately the second victims often have none !!

So it is important to recognize the “second victim” of surgical complications and adequately support them. It may be useful to refer the second victim to more experienced mentor who can discuss and debrief the case with them. It is also important to help them get back on track and often there is an incredible feeling helplessness following a major complication. As with most things in life, first step is to acknowledge and recognise the issue , rest will follow !!

So next time you read the news or hear from one of your colleagues , it is important to realize that there are two victims – One is visible and obvious , the other is invisible and hidden in the shrouds………We should support both of them, as no surgeon ever takes a scalpel to intentionally harm his or her patients!!

Have a great week ahead and I wish you safe surgery as always !!

LBS

It has indeed been some time……Work kept me busy 😦 However sundays are always a good time to put pen to paper!!

I always had this question lingering in the back of my mind. I consider myself quite fortunate…i have had the previledge of working in south asia , east asia and the west….totally different worlds and totally different cultures!! Having being exposed to many different cultures puts me in a unique perspective to answer this question!!

Although it is a very difficult question to answer , in my experience, there is certainly an inheritable component. To avoid being labelled as a racist i will use A B C to denote various geographical areas….it should be very obvious to you what i mean 😉

People in A are usually poor , uneducated and somewhat easy going. They are generally very collegial and understanding.However they do tend to loose their temper very easily and that can often escalate situations badly….i never understood reasons for this….may be they are continously stressed from various life issues, hence naturally predisposed to this behaviour!!

People in C are usually very mild , polite and well mannered. They tend to be understanding and accomadating. However they tend not to be very hard working.

People in B are easily the worst….rude as hell and materialistic. They worship “money” as their religion. Work is their life and there is absolutely no enjoyment……It is not surprising that these nations top the list of ” unhappiest” nations in the world….though the per capita income is high!! They also get very annoyed at the slightest hint that someone else is doing things better 🙂 “island mentality ” -google it out. It is an actual entity 🙂

So in essence what experience do I have to justify my conclusions ?

Well….I moved from A, worked in B and moved to C.Part of the reasoning i moved to C was my kids. I could see how even myself was picking up dirty habits from B. I certainly did not want to , and definitey did not want my kids to pick them…No way !!

The fact that they may be partly inherted comes from the fact that even in C , i occasionally come across people originating from B with Absolute same mould as their counterparts from B. Same arrogance , rudeness and superiority complex!! They say you cant change the spots of a leopard…..true!!

I once worked for US based educational firm….my manager was a vety polite gentleman from C. I had many directors from C also….they were not easy customers to please, strict but above all polite and understanding……then came along a newly minted director from B living in C …he was the most junior of all directors i worked for ….but was an absolute bastard….rude, arrogant topped with a superioirty complex which was in my opinion pathological….his ego was beyond my comprehension…..pretty common trait for people from B!! Needless to say I left 🙂

So why do people from B always need to feel the urge to prove ” I am better than you” where as A and C do not?……I really dont know. But the fact that they persist when people from B move to A or C tells me that they may be partly inherited!!

Dont take this rant too seriously 🙂 …..it is no way scientific but it may be your experience too that certain people are “always” rude arrogant and so ” full of themselves “…..”centre of the universe”

That is me signing off for today!

Guess A B and C!!!!

Tc and safe surgery

LBS

It is indeed quite some time I last put pen to paper !! Exceedingly busy week followed by another did not leave me any breathing space….Since it is the weekend and I have caught up with what is happening around me a bit, it is a good time as ever to get back to blogging!!

The most intersting news that I came across was from a certain East Asian country I used to work some time back. “Island mentality” and boasting about how “meritocratic” their society was indeed the highlight if any conversation, formal or otherwise, among the “natives” of this particular island. If you have not heard of ” Island Mentality” I suggest you google it…I always suspected it existed during my stay in this particular island but very recently realised that this was indeed described in psychology 🙂

So to come back to the story , the gist is ” natives” of this island thought [ and I belive still think despite all that has happened”] they and their systems were infaliable….they were the most pure, most incorruptible, most reputable….and many other ……Any argument to the contrary were met with strong disdain and contempt, what ever the facts were…..in essence they were like ” toads trapped in a deep well” – their whole world was a tiny island and ” ofcourse” they were the best ” in their tiny world”. Needless to say I left this place at the earliest opportunity as I had seen the world and knew better 🙂

So imagine my surprise when I read the news…..one scandal after another….followed by another….by another 🙂 Well so much for the ” incorruptible ” aryan ” nation……most meritocratic society ” in the world “!! How intersting….

I had not taken my eye off the “hot news” when one of my good friends forwarded me a new appiontment of a certain individual into a certain healthcare institution……I knew this individual for a long time, he was much junior to me…..arrogant , know all, who could not even do a simple ” sebaceous cyst” properly :).Every time he did an oncall , we had few pts dropping dead on the post take Ward rounds…..I remember the times where we would just do all the cases ourselves and defer the rest rather than let this guy “put a knife ” on our patients. Morbidity Mortality meetings were quite memorable 🙂 Needless to say i would not let him within 1 mile of myself or anyone i know let alone do surgery….he was so “good” 🙂 So I asked my friend ” how is this possible ? How can any sane man employ him? ” My friend replied in a single word “Meritocracy” !! Needless to say more …..

So in essence ,can a truly ” incorruptible” or ” Meritocratic” society exist ? The truthful answer is No……so please think twice [or even more], before you say ” our society is ” incorruptible ” or ours is the most “meritocratic”and look down upon others[ Island mentality] …….chances are it is not!

Whether people have insight to acknowledge this is a different story ……My experience is most dont and continue to live trapped in a delusion!! As they say ” Ignorance can indeed be a bliss”

Intersting to know what you think too! Have you come across people in such delusional fantasy worlds also ?

LBS

Busy week it has been so far ! What better way to relax with family than to take the kids to a good old fashioned French circus complete with a big top! Cant beat that !!

While I was watching and thoroughly enjoying the breath taking performances, I could not help by observing the similarities between what we do.

Both are high stakes industries, there is little margin for error. An seemingly inconsequential mistake can prove fatal. Both involve long and ardous training, dedication to achieving excellence. Both rely heavily on team work.

Ultimate end point of both is to achieve client satisfaction….you may argue that surgeons job is to “cure diseases”, but i would argue along the lines of the old quote “Relieve pain, Allay anxiety and Cure if possible”!

Ever wondered why operating rooms are called ” theatres” ? In the operating room Surgeons ” perform” operations. A well performed surgery is a smooth well planned just like a well choriographed act on a stage performance….Every step falls beautifully and effotlessly into its place to create a ” surgical masterpiece!”

Now is a good time to reflect on a certain trait I often see in trainees… I often come across the notion that ” theatre” is the place to ” learn”. I am opposed to this……theatre is the place to “perform”. Learning has to take place before coming to theatre! One should know exactly ” what to do” and “how to do” before coming to theatre …..Theatre is the place to “do” under supervision, not to ” learn what to do”

For example “juggler” does not come on stage to practice…..” sword swallower” knows exactly what to do BEFORE coming on stage. Similarly “Tight rope walking performer” is not learning how to do it on stage…..they ” Perform” on demand!!

Ofcourse , you can ” just appear on stage” with the intention of ” learning on the job” …..but you will end up making a ” clown” of yourself:) On a serious note – even ” clowns” practice before hand and ” perform” on stage:)

Same goes on for ” Surgery”

For all trainees, Remember , next time you walk into that ” theatre” , You are a “Performer” and you are there to “Perform” !!

Have a great weekend and safe surgery for week ahead!! Tc

LBS

Recent events surrounding the Titan sub has got the world thinking…..While wishing all involved in this tragic acicident RIP I think this is a good time as ever to revisi It the concept of “Risk”

Risk is inevitable, however well prepared you are , however intelligent or however wealthy you are. As motorists , pedestrians, surgeons, Endoscopists patients, we take risks each minute we are alive….there is no way around it….if you are totaly risk averse you should not get out of bed 🙂 …but then again that predisposes to DVT due to immobility and sudden death by pulmonary embolism !!!

So if Risk taking is an inevitable part of of life , what can one we do to mitigate the risks ? One important caveat is , eventhough we cannot remove ourselves totaly from exposure to risk, we can often set limits on what is an acceptable risk for us! In otherwords you would be able to set an arbitrary limit on what is an acceptable risk level for you!

How do we do that ? Risk assement tools are useful in many situations. As a surgeon I use a lot of risk assesmsnt tools in day to day practice – NELA score , Childs score are a few examples. But these are validated riak a outside professional life

One important risk assesment tool I picked up is from a book I read from the pioneering neurosurgeon Ben Carson. Benjamin Carson was the first black american neurosurgeon and pioneered the field of neurosurgery with many ground breaking operations. In his books he talks about a simple way to risk stratify any decision.I use this decision making tool every day and it has worked well for me…so far!

In any decision in life consider the following four scenarios

1. What is the best possible outcome If I take the proposed action ?

2. What is the worst possible out come if I take the proposed action ?

3. What is the best possible outcome if I do not take propsed action?

4. What is the worst possible outcome if i do not take proposed action ?

These 4 scenarios add clarity and greatly help with decision making. I have often used these to aid me in many difficult decision making sitiations i face as a surgeon…..I think they are equally applicable to many other professions , or for that matter , real life also!

With that I am going to wind up! Catch you soon! TC and stay safe!

LBS

It was a busy week and I could not put pen down to paper for few days 😦 Got few minutes before I start my endoscopy list…so i thought why not write something!!

I often come across this notion of ” Worlds best hospitals”. I think as a practicing surgeon and a doctor who has been in this business for decades i feel its time i put my thoughts down too:)

Often these claims are made by ” lay media” , not by professional medical journals. And that itself is a red flag for me…..healthcare nowadays is a complex metric to measure , even for professionals specialising in this field….how can lay journlists get it right ? I feel it is a tall ask of them.

Secondly, more often than not , these lay journals do not give any specific criteria that they used to arrive at the conclusions …there is no objective evaluations that they used to judge various institutions……they arrive at their conclusions by some “vodoo magic” and they expect us to believe their “conclusions” as “Gospel truth”!!

In any reputed medical journal any article is accompanied by a decleration of conflict of interest and financial disclosure…..it does not come as a huge surprise to me that almost all of these ” worlds best hospital” guides conveniently ignore this bit 😉

Oddly enough I often see that these ” world best hospital” guides are heavily biased towards west or east asia…..some of the fantastic hospitals in south asia are specifically ignored 🙂 No surprises there i would say !!!

I, for one , have worked in some of the east asian ” worlds Nth best hospitals” prior and work currently in the west, I have worked in some very high volume centres in south asia too ….I can safetly say that my experience in some of the ” words Nth best hospitals” advertised is far far from ground reality!! There are regional hospitals in the far east even , that , in my opinion, perform far better than the , so called ” worlds Nth best hospital” advertised in these bogus media pages!! Perhaps they dont pay enough 😉

I often notice that trainees from so called ” Worlds Nth best hospital ” often come to the west to complete felloswships! Sometimes to ” lesser” hospitals than their ” perstigeous institutions”….if the assesments are correct it should be Vice versa is it not ?

So in conclusion….Do not go by these bogus media articles on ” Worlds Nth best hospital”

If in doubt , ask an expert , or look at the statistics yourself……You cannot have the world best colorectal surgeons in a hospital that does not even do 100 colectomies per year or worlds best liver transplant surgeon in a place where you would be lucky to get 1 transplant a month 🙂 Afterall if you need a mechanic to fix your car you will go to the highest volume most experienced mechanic wont you ? Not who advertises he is the best but doesnot do one car per month 🙂

Tc and catch you soon!

LBS

With the advent of technology people as a whole have moved away from reading …unfortunately :(. I see this every day when I see my daughter and compare her childhood with my childhood. I understand that people grow older and times change …but still… is it for the better? – I honestly don’t know!

I was born in Sri Lanka – A beautiful tropical island in the middle of the Indian Ocean. Surrounded by the greenery and the natural beauty of the countryside, we received wholesome education – where we had time to play and enjoy nature despite fairly hectic school schedules. Netflix and computer games were unheard of 🙂 We had television and radio…and We had Books to read…Good books too.

Once we finished school and came home and mopped up our schoolwork, there was always time to sit down to a good book and enjoy it. We always had a book or two in our school bags ” just to kill time”. We were lucky in that sense that we did not have anything else to “kill time “. I still remember that I brought my first laptop computer after finishing medical school. I had my first smartphone as a third-year medical student…..

It is a habit I kept even when I completed my education and moved to the developed world to train as a surgeon ……Even when commuting on a train, I always carried a book with me. When technology advanced I invested in a Kindle – Which was amazing – It opened an amazing array of books with knowledge and wisdom beyond my wildest expectations !!

A good book summarises the experiences of an individual lifetime and lessons learned into a few hundred pages which you can read and learn from a few hours…..Rather than blindly staring at a screen on Netflix, a good book will stimulate your mind to ask questions, discuss things in your head and look at things differently. It is not a passive exercise but a very active training session for your mind to gather information, process, and incorporate them into your day-to-day life…..It is unfortunate that the world of smartphones and cheap technology is ridding the human race of an incredibly valuable habit of reading!

Being a general surgeon, Over the years I have kept a lookout for some excellent autobiographies by Surgeons. I am gonna summarise my best picks down below – They are by no means the best i am sure….but they left a lasting mark on me, and I hope you will enjoy them too

1.”Gifted Hands: The Ben Carson Story” by Ben Carson: In this autobiography, Dr. Ben Carson shares his inspiring story of rising from a disadvantaged background to become a prominent pediatric neurosurgeon, detailing the challenges he faced along the way. This is an incredible book about overcoming your circumstances and thriving, despite racism and favoritism. Suffice it to say an all-time favorite of mine !!

2. “Complications: A Surgeon’s Notes on an Imperfect Science” by Atul Gawande: Dr. Gawande, a renowned surgeon, shares his experiences and reflections on the complexities of surgical practice, including successes, failures, and the broader issues within healthcare. This book really resonated with me once i started practicing as a surgeon….A must-read for any aspiring surgeon !!

3. “When Breath Becomes Air” by Paul Kalanithi: While not solely focused on surgery, this memoir by a neurosurgeon reflects on life and mortality after the author’s diagnosis of terminal lung cancer. It offers a different perspective on the intersection of medicine and humanity. This is a beautifully written book with deep meaning and questions all the materialistic teachings that our brains have been overloaded with! It puts life in a better perspective and clarifies what is truly important in life from what is not important…if you are a young surgeon, this book is a must-read for you…

Keep reading and Keep enriching your mind!!

TC and see you soon!!