Quality where art thou?

Edison said,"“There's a way to do it better - find it.” He was a clever man, one I still admire, not just for his inventions, but his astute observations about various aspects of life. If he had walked into IVS Local here in Thupaai, I am pretty certain that he would have despaired!

This country thrives on its attestation, stamping, certification, endorsement, etc business. Understandable. After all there are no taxes, so there's got to be a way to make money. One such enterprise is IVS Local, an organisation that "attests" a lot of documents for the Indian citizenry here. The Embassy I guess couldn't handle it or just got someone who could monetise it better for them. What they call as outsourcing. When the primaries do a bad job, one can imagine how the outsourced secondaries perform. I exaggerate, of course! I am sure IVS Local do a grand job. My observation was that they could do better.

We are in the process of sponsoring a "maid" to stay with us (Khobragade Amman Thunai). Despite holding "phoren" passports, we were expected to swear (don't get excited) on an affidavit that this lady was not related to either of us (husband / wife), given that we are OCI card holders (Saturn never far away however far you run from it, eh!)

The Token

When you want your certificate - of some import for your sustenance here - attested, you go to their office in North Metha. It is located in the second floor of a commercial building. One has to get a token from the front desk before you can be served. A concept very commendable and close to my heart. Given that most of this country is occupied by Indians, I can only surmise that IVS is overwhelmed by the sheer volumes that cross their portals every day. So, in their infinite wisdom they have limited the service to 300 "general" tokens per day (not sure what "general" means; perhaps a special token allows you to be rejected with kid gloves?). 

The Queue

To get these tokens we have to queue up (the doors open at 8am). Of course, this serpentine queue starts from the elevator door, trailing through the corridors, with people jostling for space when they have to pass you in the narrow corridor. And clearly the builders of this complex did not foresee people like me with BMI's of 30 plus infesting these narrow lanes. Each "passing" of an individual resulted in various parts of my anatomy being introduced abrasively to other beings. 

The Vet

After a fashion you reach the front desk where two extremely patient and tolerant ladies "vet" your case (by the time you are done most of Thupaai knows why you are there and some souls nearby actually tut tut for your miserable existence). They then announce that you are eligible for a token (I was about to whoop out in joy but had the pre-emptive firm hand of my wife on my shoulder). 

The Halls

Having secured access into the hallowed halls of IVS, I beamed looking at the world around me, mouthing mentally, "My fellow men and women, I, too, have arrived!"). When I say halls, don't take it too literally. I was being facetious. It is one hall! About 30 x 30 feet in my expert reckoning. I could identify 6 different odours within the first 10 seconds after entering this hall. All from individuals standing nearby. None of them pleasant. I had to swat a wrist that was trying to feel my derriere. When you enter this building complex, be prepared to shed the concept of personal space near the security gate. Amidst the din of about a thousand people conversing or shouting, there was a voice calling out some numbers. I gathered that this was some random guy calling your token number to go get your "attested" stuff or whatever you came in for. Of course, one tiny corner in this hall had a desk with a plastic plate DELIVERY inscribed sitting on it's top. As expected this desk was not populated by anyone. Perhaps I couldn't see that far, so thick was the flow of traffic. There were chairs - those chain of steel chairs that seats five to six in one row jobbies - everywhere! And every single one occupied. The rest of us standing, some on other's feet too. 

A Counter Too Far

There was this red LED light thingy that informs you the token number and the counter you are supposed to go to, hanging on the far wall, below which were laid out 6-7 service desks. By the time we got in (our token no was 262) it was about 9 am. And we had to be at work by 11 and 12 respectively. The token being served was 72. Hope springs eternal! Whilst we were engaged in some nimble game of changing the squares we were standing in, the clock was ticking. It's during these times that you start grasping the concept of time dilation. The LED number showed up 90 after an hour (even with 7 desks, processing 18 per hour, given my poor mathematical skills = my wife tells me it will be too late for us to go to work if we waited for our turn). Tails tucked we retreated with heavy hearts only to girdle ourselves up for another day to face this drama again.

It doesn't take a rocket scientist or even a MBA graduate, for that matter(!), to realise that this entire thing can be choreographed in a much better and saner way.

1. People walk in. (no vetting; provide a separate information counter elsewhere - ground floor lobby or in a separate hall)

2. Take tokens.

3. Go to counter when called.

4. Present your case / documents. 

5. Arrange for "attested" documents to be picked up at specified time slot on a given date. Deliver it at home for extra charge.

6. Charge extra and provide a premium service. Open VIP counters.

7. Get a bigger "hall" or halls even. Clearly, it's a flourishing business!

8. Close late.

By continuing the way you are, you lay the foundations for failure. 

Enakku Thamizh la pidikkaadha rendey vaarthaigal - chalta hai!

3 Idiots - in 3 months!

Summer of 1983!

Yep, that's when it all happened. I had finished school and completed exams in April. Results were out by June (I think). The world around me thought I would get a state rank. Only I knew the depths (or heights?) of my intelligence! I did manage a school rank and got 96 odd % in the science tracks.

Of course, like all the other zillion science students graduating from higher secondary school, I wanted to be a doctor. Or engineer. Had to be a professional! Especially if you are an indigent TamBrahm in a tier 2 city (Salem had just become a corporation at that time! Just imagine!) Of course, given our habit of hedging bets and the immense confidence in our own abilities, I enrolled myself in the local college for B Sc in Physics.

First Idiot - BSc Physics, Arts College, Salem.

The Arts College in Salem, situated in a serene green area of the town, called Maravaneri, was certainly not renowned for its academic excellence. On the 2nd day in college, whilst the AP in Physics was just trying (he was very trying, indeed!) to evince interest in thermodynamics, or some such weighty topic, there was a lot of noise in the corridor outside the classroom. One very un-collegial guy sauntered into the class and just asked the assistant prof and the students to get out of class proclaiming that the college was going on strike for some silly reason - his brother may have sprained his left little toe or was constipated; can't remember exactly. He banged on the front desks of the class frightening us puppies out of our pants. It was the first of several "outages" we experienced in my one month in the prestigious institute. We were waiting for the results of the engineering and medical college applications to come through. I had even attended the REC exams and interview; in fact, got a placement in REC Rourkela (I think!).

Second Idiot - BE Production Engineering, PSG College of Technology, Coimbatore.

Going to Rourkela meant going more than the stipulated 100km away from home (Coimbatore was only walking distance and Chennai just spitting distance - for the family). I am just kidding. It meant going too far away and spending money in hostel. PSG Tech came through in the state entrance, as I had ticked it as my first preference. My maternal uncle, incidentally, happened to be in Coimbatore. Just mentioning. My interview with the Principal during course selection landed me in Production (and not Mechanical, which is what I wanted) not that I had any clue as to what engineers in these specific disciplines did at that time; all I knew was I liked tinkering with stuff, like a mechanic; so, mechanical, a word sounding close enough seemed fine. Incidentally one of my 2 brothers was doing his 4th year as mechanical engineer; he was always looking serious; he had that look of someone "munnerufying" in life; so mechanical engineering it had to be!

First day in a combined class with students of Applied Physics - whoah! I had not seen so many hot looking girls in one place in my 17 years of blissful existence. Er, forget the fact that there were only 10 or 15 girls, but that was 15 too many for me! About 4-5 of them actually looked like potential "sightu"s - TamBrahms too (but, of course!). That was the best thing about PSG Tech. What? You were waiting for me to tell me the other good things about the place? Sorry. I should have said best, and only, thing! For every 2nd day or so, we had to carry this ridiculous wooden triangular stuff in our shoulder - T square? Protractor? Detractor? I forget the name of this engineering implement which was the equivalent of a medic's "masal dosa" white coat - and pretend that we were serious draughtsmen at work copying, or for some of us lost souls, constructing new art forms on draught paper. And then came the Applied Maths classes - the only things I recognised during those tutorials were the arabic numerals neatly ensconced between various symbols. The numbers stood out like nuts in a large bar of chocolate. The saving grace during those miserable days were four things: 1) my longstanding school chums, Shankar & Senthil were in PSG with me - we used to do combined "sighting" 2) my eldest brother was medical rep in those days and evenings were spent with him productively in either restaurants or drinking beer in the local watering holes 3) my uncle's family - had a great time with my cousins - unforgettable days! 4) my eldest brother's closest pal, the late Natraj, who kept us fed and entertained, many a dreary night. May his soul rest in peace.

Peelamedu, RS Puram, Ram Nagar, Seetha Pudur, SaiBaba Colony, Railway Station, Gazebo Restaurant, Annapoorna, Gowri Shankar, Esso Bunk, Natraj's house, Brindavan Lodge, Nehru Stadium, Pazhamudhir Cholai, dhaba parotta kuruma on Avinashi Road.....the list is long.

I think, as fate or the medical fraternity would have it, I was destined for better things than getting hitched to the girl from Madurai doing Mechanical, whom I really liked a lot! I still remember the shenanigan surrounding my exit from Coimbatore.

The results for the medical college entrance had come late that year due to some lawsuits filed by entrants (I think). So, got a telegram from my parents in Salem that I had secured a place in Stanley Medical College (again, I had ticked SMC as my first pref) and commanding me (yes!) to take the Blue Mountain train that night to proceed to Madras and that my mom would join me in Salem in the train. My eldest brother had left to Ooty the night before on a sales tour. No mobile phones in those days, remember! I had no way of contacting him then, so after informing my uncle, proceeded to Madras per command from my mother. My eldest bro fumes to this day that I left CBE overnight without letting him know! He was more angry that I had left CBE than having left engineering.

Third Idiot - MBBS, Stanley Medical College, Madras.

After having gone to my chiththi's place in the morning - she & her family have withstood the onslaught of perennial armies of guests, with the greatest sense of humour and sanguinity (3 cheers to them!) - left for SMC, that temple of medical education, situated in the wonderfully named Monegar Choultry, in the picturesque area of Mint / Broadway, from whose womb, millions of great doctors have been delivered (okay, may not be all of them, but let's pretend, shall we). We were greeted by an elderly character by the name of Vidyasagar (he was my dad's English professor's son, so approx same vintage as my dad), wielding a large jolna pai near the admissions desk. I thought he was the assistant professor of some subject or may be even associate dean, only to be informed later that he was very "attached" to the college and was still getting to grips with transcending the 3rd year. Such was his love for the college.

Having completed the formalities, returned home (aunt's place in Mandaveli) to chill. I had 3 cousins - 3 boys at home - so there was no dearth of entertainment. Either ghali cricket or hand tennis as long as daylight allowed. Of course, great DD in the evenings. The grand sum of 1 channel, starting with "Vayalum Vazhvum" until the news at night, all programs were watched assiduously. Of course, Chitrahaar and Oliyum OLiyum days were the highlights followed by the movie on Sunday. Remarkable days those were!

Of course, there was this little matter of having to attend medical school amidst all this feverish pace of life. It so happened that it was the monsoon season (remember, because of the delay in admissions, medical college started only in September) and Madras was literally flooded and it was pouring non-stop for 3 days. On the fourth day, I was contemplating about life in general, and this particular problem of having to navigate through the small river that was running outside the house, when the door burst open and in came the serious figure of my engineer brother - monsoon rains couldn't stop him, such was his concern for his little brother. Having verified that college had opened 3 days ago and that my ass had not moved more than 10 metres from the centre of the house, he portrayed his concern forthwith by kicking my backside with his booted hindquarter. Having sent packing from the house with nothing but a frail little brolly to protect me from the cruel elements, I reached Mandaveli's bus terminus after a little while and boarded bus no 4E. Entertaining though it was, this route took about the same time to reach Mint as it would for a bus to reach Madras from Salem.

Having reached the college with dirty feet and soggy clothes, I entered the hallowed halls of the Anat (short for anatomy) block and was asked by a stern looking tutor to proceed straight to the dissection hall on the 2nd floor. When I reached the portals of that wonderful hall, was greeted by a smell that many will not forget for most of their life. The stench of dead bodies immersed in formalin and taken out for the express purpose of educating ignoramuses like me, combined with the smell of locomotives in the shunting yard behind the anat block - made for an aroma that will completely put anybody off food for a good few years. But, I was made of sterner stuff! The hall was already overflowing with white coated young chappies and chappesses - about 150 or so. And so MANY girls! Okay, the overcast clouds lifted, nay dispelled, and out came the fairies. I can put up with ANY smell to just be near and look at so MANY girls! It just required closing one's nostrils for about an hour or so each day - I could do that!

The dissection hour was followed by a class in anatomy - this wonderful man with a neatly barbered goatee proclaimed the origins and attachments of the muscles in the foot - words like adductor, abductor, hallucis, pollicis, pronator, supinator flew past past us thick and fast. Undeterred, we stood our ground and took all that in our stride. After all we were gonna be daawkktuuurrrsss!! By the end of the first week, I could actually pronounce a full anatomical term without messing it up - extensor digitorum longus - there you go! But, I was close to taking up another college soon. Hey, I had done 3 colleges - in & out of 2 in a jiffy - how difficult would it be to do one more. I even thought about running off somewhere north without telling anybody, such was my love for this new college. But, then came time to move out of my aunt's place and into the famous SMC Men's Hostel, another prime example of a fair accommodation with the highest standards of hygiene that each and every doctor exhorted and strove for! Yeah right!

This was the most sordid affair in my entire life. Okay, there were a few more, I admit, but this was the first big one. The hostel team couldn't find enough place to accommodate the entire lot of guys who had come from all the outlying districts of Tamilnadu. So 14 of us were packed into one room - a 15 x 15 feet affair - people talk about cattle class these days in aircrafts; we were like cattle on the ground! I could well imagine how it would have been for all those prisoners cattled into rail compartments during the holocaust (incidentally, I cried through the last 30-45 minutes of Schindler's List in the cinema hall and have not watched that movie on tape or DVD ever again!). We got to know each other pretty well in that one month we were shacked up in that one room; too well for some!

Then came the affair of eating in the mess - oh, what a mess it was! - I do not mean it in the culinary sense, of course. But, the human capability to take punishment repeatedly is so ingrained, that we marked the attendance register there for the three veLais without fail. we were 17 going on 18, with hormones pumping a million litres of testosterone everyday and nothing to do about it bar playing basketball or football or cricket for hours on end in the evenings (frying peanuts doesn't count!). Such exhaustions required a gynormous amount of calorie compensation. And that, one got in good measure in the mess, forget the taste. I am being harsh. The pongal, lumpy though it was came with medhu vadai - we ate the pongal as side dish. The pooris were not great but the kelangu was good - so poori became a side dish. Similarly, half a kg of potato chips went well with fried rice or biryani. After a few months we started loving it. We did not know at that time that it was one form of Stockholm Syndrome. We belonged to that naive age you see.

Contact with family was usually by means of inland letters - they cost 4 annas (25p) in those days and later became 35p. There was a single phone in the hostel for public use from where we could make calls home (if you were in the lucky strata of society with a phone in the house - thankfully I didn't have to worry about that problem). Calls from home were picked up by an attendant who was employed for this sole purpose. Of course, he was never there 99% of the time, given that it was a government job in India.

I missed my folks very badly, having spent the best part of 17 years at home, spoilt by availability of daily home cooked food. In some ways, my dad had prepared us kids in the house by sending us out on errands or expeditions outside town even, on our own at times. But, let me assure you, it certainly didn't prepare me for putting up with 13 other guys in a room! Nor for the wonderful facilities in the great Stanley Men's Hostel!

I used to feel really depressed at times, missing my mom, dad, sister and brothers. And my beloved Love'O Colony, Sankara Matam, Kanchi Matam, Sharadambal, RajaGanapthi Koil, Patta Patta Koil, VaOoCee Market, 2nd Agraharam, Kali Amman Koil, Krishna Coffee Bar, Hotel Ananda, Hotel Vilwadhri, Salem Cafe, Siva Vishnu Guha Kandha, Imperial, Central, Palace Theatre, Sangam, Alankar, Sangeetha, Kumara Malai, Kandashram....the list is long! I used to cry when I was alone in the early days - it was only for a very very short time though. Something then happened to me that took away all my ills and worries. That something was "friends". I was very fortunate to have some wonderful friends, who made life outside  the home that we were used to, tolerable, pleasant even. Thank you guys! And gals!!

My subsequent journey in medical college was made easy by having my focus divided equally between two important things in life - study and kadalai. Became doctors, after a fashion, eventually! Very likely ten years after exiting medical school. More for some like me. The rest, as they say, is geography!

This blog is dedicated to my puppy nephew Sai Prasad Ganesh who is feeling the mighty pressure of life weighing on him having just joined an engineering course in the US of A! Cheer up big guy, it gets better! Cheers!

India raped

On the threshold of 2013, a nation in its 66th year of existence as an independent state, India has to surely hang its head in shame in the pantheon of civilised democracies.

The expected happened. Precisely why she was moved to Singapore. You wanted to shift the focus of an uprising within the country and smoke it out. Objective achieved. Give yourself a pat on the back, clever politicians of India. The criminals in this entirely sad but telling tale are not the rapists, but the people who have allowed it to happen. A nation with a constitution but no will to question it, a country with a vast police force and extensive laws but without the will or courage to enforce the rule of it. We elect governments, we represent the country, we the individual citizens represent our culture. Therefore, we cannot blame just the government and the police alone. We are equally responsible for the decadence in our attitudes. 

I do not want Nirbhaya to rest in peace. I want her to haunt every single man who considers women as implements of sex and free labour. 

Believe me, Nirbhaya's death, and not the several multi-crore scams of the past few years, defines our country. Defines it in such a way that we cannot go out and cry to the outside world that we are Indians. A nation steeped in such chauvinism and misogynist depredation that the first family' son labels, with no compunction (see his response to Arnab's badgering - on YouTube), women protesters as 'dented and painted'. And, the top gun of the ruling party was mired in a gang rape case. The list of politicians charge sheeted with rape is endless. Several regional politicians advise women not to wear 'non-Indian' clothes and avoid going out 'unaccompanied' at night. Women going to 'clubs' are immoral, but men doing the same are just letting their hair down, no harm done.

All of which reflect this simple fact - this 'culturally rich' country systematically engenders male chauvinism. Fuelled by idiots of both sexes. In fact, the females of this society are as much, if not more, to blame as the vile males for this cultural deprivation - exemplified by domestic abuse of women by their mothers-in-law, for failing to bring enough dowry, for not slaving enough at the coal face, for not bringing up the children right, for dressing up, for wearing make-up, for chatting with male neighbours, for going to the movies, for having fun, for just living. 

We are a nation of hypocrites. The men want other women to be promiscuous, but want their girlfriends and wives to be faithful. They want their sisters to have arranged marriages, but want to marry the ones they love. The husbands want to be like bachelors after marriage / children - they need stress relief in the form of alcohol and gambling, but the wives have to toil taking care of family / children and this misogynist chauvinist of a husband as well. The men will wear kumkum on their forehead and pray to several female gods - Lakshmi, Saraswathi, Durga et al but will loot, rape and cheat with no fear; in fact, several, fuelled by the 'powers' vested to them by such gods, do worse. The list of hypocritical views of men in this country is endless. Worse, this is systematised. Just like caste and religion, it is congenitally transmitted. Until this, the root cause, changes, women will not be looked upon as human beings born equal in every way to men.

Shoba De in her recent piece in ToI said it well (http://blogs.timesofindia.indiatimes.com/politically-incorrect/entry/girls-don-t-run-scared-anymore). For women living in any modern democracy it should not be a question of restrictions and living defensively, but about the ability to move about just like any male in the society. It is a constitutional right. The onus of an individual's safety is not upon us but the guarantors of the constitution - our elected lot. When they rape, loot, scam and abuse power with no impunity, then we are not a nation at all. India has already proved itself to be a failed state - we, the citizens, are too apathetic to have noticed this. Such is the misery of daily life for the aam admi. 

Rape, in its original definition meant - to seize, take or carry off by force. And later, the connotations of violent plunder and abuse have come to the fore. In this latter sense, rape can also be used to denote the systematic abuse of an object or person. Thus, whenever we abuse a person - child labour, slave labour, forced sex on any human being - we are effectively 'raping'. Hence, any change to the status quo must start from within us as individuals. We need to change our attitudes, as individulas. 

On a mundane level though, the immediate need of the hour is for the government to act swiftly to demonstrate that it means business. Eradicating corruption, enforcing the rule of law, vigilance against all forms of male fide intent, protecting citizens just like it protects the netas would be a start. When even a simple Lok Pal Bill cannot be passed in parliament, can we expect any of this from the elected lot of this country?

India, when you have been raped irreparably by our politicians repeatedly, how are we going to defend the rapes of its citizens. Is there any hope? I know not. Rise, India. Before it is too late. Before anarchy pervades.

Satyameva Jayatae!

Truth alone triumphs.....stuff that is seen on our national emblems everywhere. From the humble rupee coin on. But, as one English barrister pointed out to the presiding judge, truth is a matter of opinion. And, in India, truth has many facets. The truth of the netas, the truth peddled by the babus, the truth of the aam log and so forth. It is one of these 'truths' that Amir Khan took on recently.

First off, kudos to Amir Khan for 'exposing' medical malpractice and related issues on a national TV program. My respect for him went up a notch when he did not back down or apologise when threatened by certain medical bodies.It is common knowledge about kickbacks, that start from referral of patients to other doctors or hospitals / nursing homes to getting a 'cover' back for sending patients for CT/MRI/ultrasound scans to getting bribed for ordering a long list of unwanted investigations. It is also true that many smaller labs end up doing 'sink' or 'basin' tests where, if the patient is 'normal', unnecessary investigations are ordered by the doctor but does not get carried out by the lab, with the samples being thrown into the sink/basin.

How did this come about?

To me, with my plain simplistic view of life, the answer is simple - AVARICE.

This may appear too simplistic an answer. But scratch a little and we can unravel a few strands that go into the heart of what makes this nation as it stands today - chaotic to the point of anarchy, total lack of morals and ethics, progress at any cost without conisderation of human, environmental or future costs, lack of the three C's of social cohabitation - common sense, civic sense and civility.

What has pushed this nation to this level? Is it due to the repeated betrayal of trust placed by a nation on it's governing members? Or is it mere selfishness? I guess the answer lies somewhere in between. Naivete / ignorance of the people,  an excuse often offered to me by some of my friends does not hold water. Recent elections in TN, UP and Bihar prove that.


Would I be right in thinking that this country's aam log have never been or inadequately educated on civic responsibilities and behaviour? This combined with lack of, rule of law, and enforcement has led to where we are today. 


My observations point to this - parents do not educate their children right from a young age about what is 'right'. When they go to any place where queuing would be the norm, whether it be a cinema hall or a sweet shop or an airport ticket counter, the adults just go to the front of the counter expecting to be served before somebody who has been waiting patiently for a while before them. The child observes this, and this wonderful social behaviour has been 'passed' on down generations until this has become the 'norm'.


This behaviour translates on to the road as well - I do not give a monkey's toss about others waiting in the left side of the road, I will use the right (opposite) side of the road to overtake every single vehicle waiting in line and get to the front of the queue, even if it means blocking the entire traffic on the opposite side of the road for hours. So everybody does the same, irrespective of their educational or social status. There is a phenomenon observed in birds and monkeys called mirroring. Indians exhibit the same phenomenon everywhere. A violation is considered a violation only if one or two people do it. If everybody does the same it becomes the rule; the person waiting in the queue is an exception and is a fool indeed. 


I digress.


Returning to the issue of unethical practice in medicine, I feel it is avarice that has taken the country spiralling down the dark path of degeneration. This, in a country that for eons has espoused quite religiously the tenets of contentment and satisfaction with one's available wealth and abhorrence of avarice. Lord Krishna resides by the bedside of fools, indeed, who feel their actions in all spheres of life are blessed. Like Kamalahaasan's Naicker delivers the classic and unforgettable line in the movie Nayagan, "Avangala nirutha sollu, naan nirutharaen (Ask them to stop, and I will stop)" - Indians expect the others to stop doing all the nasty stuff before they will shun it!


Is there any redemption for this nation? Unless there is a large scale revolution in social education and responsibility, I do not see anything significant happening. Mere enacting of laws that curb unethical practice, unless accompanied by powerful jaws of enforcement, will do little.Just like the red light is flouted in every traffic junction in this country...


At the end of the day, every citizen will have to realise that they are actually responsible as individuals for the downward spiral this nation is facing. Pritish Nandy has written a good piece about Aamir's show (http://blogs.timesofindia.indiatimes.com/extraordinaryissue/entry/does-satyamev-jayate-work). I think leaving aside all the other stuff it is important for us to dwell on the last paragraph of this write up. Somebody is telling that the emperor has no clothes. 


Aamir Khan is an intelligent person. He is not an intellectual. He's just using his star status to make certain social observations. Such social commentators need not necessarily be social engineers. It is not Aamir's job to correct the ills of society. More than a billion people have vested that responsibility on their elected government. Now it is up to the emperor and his ministers to do something about it. Will they?

How Goliaths are killing the Davids!

Dr David is a NRI doctor who completed his higher surgical training a few years ago in the UK. He then worked as a consultant orthopaedic surgeon in a large district general hospital in the south of England. He is married, with a wife who works in the IT sector and two kids - a girl, 14 and a boy, 10. He had some compelling reasons to return to India, most of them personal. But, he also harboured a desire to improve the quality of care and increase patient information /awareness. He did his homework prior to relocation, and targeted a few large corporate hospitals - Goliath-1, Goliath-2 and Goliath-3 were the most popular in the city. The reason for choosing to join a corporate hospital was that he was offered a reasonable retainer; something that will keep him & his family comfortably fed, clothed and the children schooled whilst he established his reputation and practice. Despite a lower salary, he chose Goliath-3 as he felt that it had the best infrastructure, a good set of colleagues in other departments as well as his own.

Dr David started getting disillusioned after a few months. He had been promised incentives - a percentage of earnings / revenue generated above his retainer level - after a 6 month period, depending on his turnover of patients and in turn, revenue. Within 4 months he had broken the retainer barrier and was generating sheer earnings in terms of surgeon's fees of at least twice that of what was being paid (as retainer). He discussed this a few times with management, who kind of promised him that it will be reviewed soon. 

Almost 18 months had passed when Dr David started realising that he was being taken for a solid ride. He started looking at options in Goliath-1 and Goliath-2 - the two other major players in the city. 

Goliath-1 was a well established brand that was notorious for it's unethical (mal)practices. Although, the revenue generated would be very good, Dr David was not comfortable with their practices; plus, the operating theatre availability was limited and there was a lot of internal politics. He didn't want to get mired in this. 

Goliath-3 was better in the latter aspects, but was run by a neurotic/psychotic. Dr David, again felt uncomfortable even thinking about moving there. There were, of course, certain other 2nd level corporate houses that did not have this retainer culture, but he found out that they lacked culture, period! Also, they did not have any of the equipments / instruments required for the kind of specialised work that he did; other consultants were bringing in their own instruments to work and were charging the hospital for it.

So, nearly two years following his relocation to India, Dr David was at a crossroad - he could either swallow things and maintain status quo, or start visiting several hospitals and collect a fee for service, or build / establish his own nursing home / hospital. With the fee for service model, he found that most hospitals levy a 15-20% service charge on the surgeon's fee (in addition to the tax deducted at source). Dr David was beginning to feel a sense of strangulation - the Goliaths had perfected the art of strangulation whilst he had been away from the country. It was their way or the highway.

Dr David is now seriously contemplating returning to the UK. He has looked at other options like the Middle East, Australia and New Zealand.

Dr David's case is just one example of many well trained NRI doctors who return to India with visions of making things better only to be completely disillusioned. Losing one's vision is easy if one is not lion hearted and perseverant. 

In recent years the government has  relaxed a few regulations to encourage more NRI doctors to return but clearly this has been a half-hearted stab - most NRI doctors tend to specialise in their respective fields, whereas the current regulations do not allow accreditation of the specialist qualifications (for example, whilst FRCS is recognised as a 'higher' qualification, FRCS (Urol) is not!!). My take on this is that this was probably done to protect the turf of the 'locals'. I mean, who is the loser? The poor Indian patient, of course.

There are several doctors who have trained exclusively in India doing a fantastic job - be it the quality of their service, their communication skills or maintenance of ethics. I do not say this in a patronising or condescending fashion; because, there are quite a few who practise medicine in the worst possible way - full of avarice, unethical, uncaring and extremely condescending to their patients.

The combination of economical disillusionment, lack of public infrastructure, power outages, lack of common courtesy and civility, the need to 'put up' with unethical practices (since this is almost systematised, just like corruption) is enough to make someone who is used to a different way of life to pack their bags and head back to sanity.

The hangers on are brave indeed!

First robot assisted cystectomy in TN - 18 Jan 2012

Wishing one & all a very Happy New Year!

New Year = new tidings. I am hoping this will be the year that will serve to influence my continued stay in India!!

Another memorable day in my life: 18th January 2012.

The day I performed robotic radical cystectomy in Apollo Hospital, Chennai. This is a first for Apollo Hospital, Chennai, as well as for Tamilnadu.

KS at console of Da Vinci Si - Apollo Hospital

Radical cystectomy - this term refers to complete removal of the urinary bladder for invasive cancer of the bladder. The patient was in her early 40s and an inveterate smoker. It was quite unfortunate that she presented with severe urinary symptoms as well as significant loss of weight over the preceding several months. Initial resection of the tumour (TURBT - transurethral resection of bladder tumour) had revealed a high grade cancer invading the muscle coat of the bladder. Clinically, it was also stuck to the adjacent structure. Staging investigations had shown some enlarged lymph nodes in the pelvis, but no evidence of spread to other organs.

Under these circumstances, suitable patients are usually advised radical cystectomy and given a few options about how the urine is diverted - either into a loop of bowel that is brought out through the abdominal wall (ileal conduit), creation of a new bladder (neo-bladder) using small bowel, which is then connected to the native water passage (urethra) or into the terminal part of the large bowel (where it admixes with stools). These options vary between individuals depending on their age, performance status, co-existing illnesses / health problems, nature / extent of the cancer, etc. This patient was advised an ileal conduit.

Ports placed prior to docking of the robot

Radical cystectomy can be done in one of three ways - open, laparoscopic or robot assisted laparoscopic cystectomy. I have described the difference between laparoscopic and robotic surgery in an earlier post about robotic prostatectomy (http://krish-sairam.blogspot.com/2011/11/my-first-robotic-radical-prostatectomy.html). Having done all three forms of radical cystectomy, it is my personal opinion that robotic cystectomy offers advantages for the patient as well as the surgeon.

Robot docked to the patient

Advantages for the patientThe entire procedure including the construction of the ileal conduit can be done through keyholes (although in this particular patient we did the reconstruction through a mere 5 cm cut in the tummy). Since there is no large cut in the patient's abdomen, recovery is faster. Also, with the precision and  magnified 3-D vision available with the Da Vinci Si system, dissection is precise that results in very little blood loss if any. With appropriate placement of the ports, removal of lymph nodes from the pelvis (which is an integral part of this procedure) as well is done with ease.

Also, since the bowel is not handled much (as in open surgery), it resumes activity over a shorter period of time.

Advantages for the surgeon

Surgeon fatigue is reduced, which translates to better technical execution. The patient is likely to benefit from this. The views of the pelvis obtained in robotic surgery is unmatched - this is my personal experience. Since there is no chopstick effect (as in laparoscopic surgery), dissection proceeds with precision, due mainly to motion scaling and tremor elimination - this, in my opinion, translates to enhanced patient safety and reduced liability for the surgeon.

Note the steep head down position of the patient

Estimated blood loss during the procedure was less than 100 ml. Patient was ambulant in 36 hours and had return of bowel activity in just over 48 hours. She was discharged on the 5th post-op day (which would be an unusual occurrence with open cystectomy).

With TG

As procedures go in urology, radical cystectomy is one of the most morbid and complex ones, and doing it especially with robotic assistance requires patience, dedication, and an excellent team of table side surgeons, anaesthetists and nurses. I am very lucky to have Dr Thirumalai Ganesan as my urology partner. As ever, thanks TG for everything! At the north end of the table, I am most grateful to the couple  - Dr Sumathi and Dr Aravind. And my thanks to the nursing and support staff in Apollo Hospital, Chennai for making this possible. I am certain that we are in for some exciting times ahead!

May I take this opportunity to mention that my personal website is now online although the patient info page is still not complete. Hope you will visit the site (http://www.krishsairam.com)

and send me your comments!

And folks, remember - SMOKING KILLS. So please give up the vile habit.

Orthopods cleverer than anaesthetists: it is now official!

http://www.bmj.com/content/343/bmj.d7506
Orthos and anesthetists: a prospective trial!


Kudos to the BMJ group for publishing this landmark paper. It IS actually quite well written and is hilarious.


What made me laugh was the irony of it - the fact that the ortho chaps had to prove that they were more clever on abbreviated IQ testing compared to anaesthetists. Thankfully, general surgeons and urologists do not suffer from this ignominy!