Vision 2020—“Creative Leadership and Accountable Governance”

Introduction

With blessings of Lord almighty, and equally good wishes from members of the Association of Surgeons of India (ASI), I have embarked upon an exciting journey and challenging leadership path of Hope, Action and Trust. The year 2019 was a year of preparation, keen observation and undertaking a number of responsibilities as Vice President (President elect) at various ASI events and representing the Association at overseas meetings. Travelling extensively and interacting with members across India over the past couple of years has well and truly been a valuable learning experience. Academics, Education and Training shall be my top priorities this year. As the President representing Asia Pacific’s largest and world’s second largest surgical association, I reiterate my promise to ensure creative leadership and accountable governance.

MISSION ASI (2019–2021), which encompasses a wide spectrum of initiatives and projects that were conceived, designed and championed by the National Executive Committee of ASI since the beginning of 2019, are being actively pursued during my term. The National Skills Enhancement Programme (NSEP), which is one of the flagship arms of “Mission ASI”, aims to enhance the surgical and endoscopic skills of practicing surgeons at identified centres of excellence. I am very confident that this innovative initiative would pave the path to standardize the delivery of surgical care in our country.

Currently, there are 479 medical colleges in India, out of which 227 are in government sector and 252 in the private sector. There is an annual admission capacity of 67,352 MBBS students each year [1]. Currently, there are 2877 postgraduate seats for MS (General Surgery) and 391 National Board of Examinations–accredited DNB seats (General Surgery) [2, 3].

At any given time in India, there are over 3000 surgical trainees in the system, who are indeed the future of ASI. And therefore, enhancing their knowledge base and improving their skills is of paramount importance. Over the past six months, I have been working on giving shape to an implementable Vision for 2020, with particular focus upon reaching out to our budding surgeons.

Vision 1: ASI Courses for Trainees (2020 and 2021)

• ASI Basic Surgical Skills Course—ASI Surgical Skills Training–ASISST (three days)

• ASI Critical Care Course in collaboration with Acute Critical Care Course India (ACCC India) and the University of Manchester (two days)

• ASI Basic Laparoscopic Skills Course (two days)

• ASI Anastomosis Skills Course (one day)

• ASI Communication Skills Course (one day)

All the above mentioned five courses are being delivered across the country since January 2020. Dr. Abhay Dalvi, Vice President and incoming President ASI for 2021, has very kindly agreed for these Courses to be continued in 2021 as well. Details and course schedule are prominently displayed on ASI website (www.asiindia.org)

• ASI Basic Surgical Skills Course—ASISST (three days)

The Course aims to impart basic surgical skills to year 1 surgical trainees over a three-day period. The basics of theatre etiquette, handling of instruments, knot tying, suturing, bowel anastomosis, bladder repair, vascular/tendon repair, fracture fixation, principles of diathermy and Minimal Access Surgery will be taught by surgeons who have undergone a standardized “Training the Trainer” Course held under the auspices of ASI. Some 135 trainers from all over India have already been trained, and they are all set to conduct the Course in their respective places for surgical trainees.

• ASI Critical Care Course in Collaboration with Acute Critical Care Course India (ACCC India) & the University of Manchester (two days)

Identifying and managing critically ill surgical patients presenting with unexpected adverse events, which have enormous impact on outcome, should be a vitally important component of training. A surgeon in training should be able to identify those at risk and be able to pre-empt for a safe and effective management of life-threatening conditions. The Course aims to empower and equip surgical trainees to effectively deal with a number of unexpected critical care scenarios beyond the “golden hour”, which go a long way in saving lives. Limited to 24 trainees, the Course provides an opportunity to practice these critical care scenarios and associated challenges, and equally, hone technical and non-technical skills in a simulated environment over two days.

Trainees are expected to have read the ASI Critical Care Manual, which would be sent to trainees well in advance before the course. Teaching would be interactive with feedback. Each participant will have a mentor who will address flaws. Real-life virtual patients form the basis of case discussions. The course includes lectures, skills stations, case discussions, small group interactive discussions and moulage. Moulage significantly improves training outcomes by adding realism to critical care scenarios, thus exposing course participants to face real-life situations in a controlled learning environment. About 20% of the time during the course would be spent on formal and informal assessment. Participants would be assessed all through the duration of the course for their contribution and team approach. That will form a part of formative assessment in a mutually respectful environment. In order to successfully complete the course, a pass in theory and practical moulage is a must.

In the UK, it is mandatory for trainees (specialist training years 1–3) to have successfully completed Care of the Critically ill Surgical Patient Course (CCrISP), which is run along similar format to ASI’s Critical Care Course. In the fullness of time, I am very hopeful that this would become a mandatory course during basic surgical training all across the country.

• ASI Basic Laparoscopic Skills Course (two days)

The aim of this course is to introduce participants to Minimal Access Surgery (MAS). Didactic lectures would be given on various aspects of MAS and equipment will be demonstrated. Participants will be practicing various tasks on endo trainers to improve the hand-eye coordination. This course is suitable for 2nd and 3rd year MS/DNB trainees in General Surgery. At the end of the course, participants would have sound theoretical knowledge of “Minimal Access Surgery” and an opportunity to develop hand-eye coordination.

• ASI Anastomosis Skills Course (one day)

The aim of this course is to give “hands on” experience in doing intestinal anastomosis using animal intestine. Participants are mentored to perform anastomosis using different techniques. Various types of stapling devises would be demonstrated and instructions to use them shall be highlighted. This course is suitable for 2nd and 3rd year MS/DNB trainees in General Surgery. At the end of the course, participants would have sound theoretical knowledge of various types of intestinal anastomosis and will gain confidence in performing anastomosis.

• ASI Communication Skills Course (one day)

Clinical competence and effective communication are the two essential skills for every practicing doctor. Up until August 2019, communication skills module was not even part of the Indian Medical Curriculum, nor was it formally assessed. Communication skills need to be at its best all the way through—from the time the patient enters the consulting room right the way through seeking informed consent, pre- and postoperative ward rounds and most importantly, breaking bad news. To precisely address this issue, ASI has introduced a one-day Communication Skills Course for trainees, where Calgary model of Communication skills would be taught by an accomplished Dale Carnegie-trained leadership trainer. The focus would be upon history taking, information gathering, informed consent, handling tense situations with angry relatives and breaking bad news—all of these in an interactive role play format.

Vision 2: National Skills Enhancement Programme for surgical trainees (NSEP–PGs)

This is a one of its kind two-day Resident-led ASI Programme that aims to sharpen the presentation skills of our surgical trainees, and equally, ensure that they learn the ABC’s of certain basic procedures, which are often not formally taught neither in the regular teaching sessions nor at major conferences. Starting from this year, one such meeting would be held in North, South, East, West and Central zones.

Moving away from the routine tradition, the main speakers would be surgical trainees with Assistant Professors chairing/moderating the sessions. The target audience includes trainees themselves and final year undergraduate students who have expressed an interest to take up surgery as their career choice.

Short crisp videos relating to basic ward procedures such as insertion of Ryles tube/urinary catheter/chest tube, excision of skin lesion, incision and drainage of abscess, handling of surgical instruments, primary stabilization and management of trauma patients, abdominal closure and equally, ten-minute crisp presentations about patient preparation prior to theatre, importance of proper documentation, breaking bad news and several other relevant issues would be addressed. “How I do it” videos from experts would also be included to make the meeting even more meaningful.

Vision 3: Surgical Trainees on International Platform

It is vitally important for trainees to present their work at international meetings whilst pursuing their MS/DNB Course. This not only broadens their horizon but also connects them with their peers overseas and provides a platform for them to understand the surgical care delivery in another country. With these thoughts on my mind, I have been successful in convincing key opinion makers and leaders in overseas surgical associations to create a time slot for trainees from India to present at their meetings and assured them that the same would be reciprocated for overseas trainees at ASI annual conferences (ASICON). Starting from this year, trainees, who are associate members of ASI, would be presenting their work at the 120th annual Congress of Japan Surgical Society in Tokyo (April 2020), 54th annual Scientific Congress of College of Surgeons of Malaysia in Penang (August 2020), 49th Annual Scientific Congress of College of Surgeons of Sri Lanka in Colombo (August 2020) and at the 106th Annual Clinical Congress of The American College of Surgeons in Chicago (October 2020). Selection would be transparent, based upon robust criteria. Funding for trainees to attend these international meetings has been secured along with complimentary conference registration.

This is indeed a landmark development, and I can assure you that no stone would be left unturned in further strengthening our bonds with many other surgical associations world over.

Vision 4: Reaching Out to the Community at Large

India is predominantly a rural country with close to 70% of population and workforce residing in villages. It is therefore my wish and desire that every state chapter/city branch of ASI adopts a village and undertakes initiatives for the welfare of our community that are “village specific”.

With personal experience of having adopted Ibrahimpur, a remote village in the State of Telangana and championing life-transforming initiatives over the past five years, which attracted national and international appreciation, I wish to share that as a first step, it is important to have several rounds of discussions with the adopted village residents to identify projects that would benefit them the most. Subsequently, after zeroing down on identified projects, funds must be raised locally and time-bound execution can be achieved by working closely with the Village Sarpanch. This is precisely what was done in Ibrahimpur, which could very well be replicated in any village across the country.

Nothing gives me more pleasure than to state that all the projects conceived in Ibrahimpur over the past five years have now been completed. There is so much more to do… My family has joined me in this noble lifetime mission. One must not forget on a daily basis that we come into this world with nothing and also leave this world with nothing. In adopting Ibrahimpur, the Lord showed me the path to a world of immense satisfaction working for the welfare of people who I had never known prior to 2015. The joy on their faces is immensely satisfying.

Conclusion

I am hopeful that ASI would enthuse our younger generation of surgeons and make them even more inspired, inclusive and insightful. “Hands that serve are holier than the lips that pray”. In addition to striving for excellence in surgery, I look forward to a “golden era” when members of our esteemed Association would also substantially contribute to the welfare of our community, particularly in rural India.

“Vision without action is merely a dream. Action without vision is merely passing time. But vision and action together can change the world”

Sudha Murthy, Chairperson, Infosys Foundation

Community Outreach Work done by President, Dr. Raghu Ram Pillarisetti in the state of Telangana

“The Ibrahimpur Model”

Projects completed in Ibrahimpur - a remote hamlet in the southern Indian state of Telangana (2015–2020)

•‘Vaikunta Dhamam’ (Crematorium)

Sadly, many villages in our country do not have the very basic facility to perform last rights for their loved ones. They travel many miles to the nearest district headquarters to fulfill this vitally important activity at the most difficult time in their lives. To precisely address this issue, a modern crematorium has been built on a spacious land in the outskirts of Ibrahimpur. Great care has been taken to ensure that this place looks like a spacious home providing every possible facility and lots of open spaces with greenery providing the much needed solace and peace.

•Sheep sheds

It is a normal practice in villages for 50–100 sheep to be crammed inside small homes leading to airborne and waterborne infections to both sheep and the residents. To address this issue, 46 sheep sheds (for all the 46 families in Ibrahimpur with sheep), with solar electrification, have been built in a space spread over three acres of land in the village outskirts. As they are housed outside the village, sheep do not come into the village, thus preventing animal-borne diseases within the village community. This is the first of its kind initiative undertaken in the southern Indian States of Telangana and Andhra Pradesh.

•Home solar system

Reliable sources of 100% free electricity through solar panels for 26 homes have been provided to the poorest of the poor in village so as to ensure zero electricity bills for lifetime, which also contributes towards eco-friendly homes and neighborhood.

•Initiatives in the village school

Some 150 children study in this elementary school. Lunch used to be served in an open compound, which was causing great inconvenience and health hazards, particularly in summer. A dining room has been built, and students now have access to a closed convenient and aesthetically done up place for dining, which also ensures hygiene.

•Digital study room has been built in the village school. Children now have access to state of the art audiovisual facilities, which provide a serene environment for study during school breaks and during school holidays.

•Funding for after school private tuitions: With growing demands on children to perform well, many a times, the Government school students lag behind because they cannot afford tuitions after school hours to clear their doubts and better their performance. One teacher has been allocated for 50 students, and three teachers have been handpicked to conduct the extra classes for 150 students from 4:30 to 6 pm in the school premises. This initiative has reached out to the poorest of the poor studying in the School, which also takes care of engaging these students with some worthwhile activity until their parents (most of whom are farmers) return home.

•Village gym/yoga classes

Having addressed certain basic needs in the village, initiatives were undertaken towards healthy living that impacts the body, mind and soul! An open-air gym has been made, which aims are to ensure village residents are in shape, and equally, to promote the concept of exercise as a way of minimizing lifestyle diseases. The gym is housed in the Village Community hall premises. Also, yoga classes are held every morning in the community hall and residents are actively encouraged to attend these yoga classes through a public address system.

Adopted village—Ibrahimpur: dining room and digital classroom for the school, solar panels and Vaikunta Dhamam (Crematorium)