liver transplantation programme in Calcutta

Liver transplantation in Calcutta - a mirage?

Most people I meet ask me the same question- Calcutta is a metropolis with almost 20 million people- why dont you have a liver transplant program?
I fumble to give a proper reply.

Liver transplantation has established itself as a definitive treatment modality for a wide range of liver related diseases with 5 year survival rates reaching 80% worldwide.

It means that 80 people out of 100 receiving a liver transplantation will remain alive at the end of 5 years.

Without transplantation none or only a few of them would be living at the end of 5 years.
India was as usual late in picking up livers for transplantation, but its catching up pretty fast.
Two centers in Delhi collectively perform around 600 annually with other Indian centers catching up especially Hyderabad.
Calcutta features nowhere in the scene much like in everything else.
These are some musings on Calcutta's dismal performance in the field of liver transplantation.

Situation in Calcutta

A handful of transplants have been performed till date in Calcutta. Some at a Government Hospital, others at a private setup.
Most were live donors and a few bold attempts at cadaveric transplantation were made.
The results are not encouraging, which is acceptable ( every transplant programme in the world suffered setbacks in their early years)
Most of the transplants were performed by surgeons flying in from Delhi- the indigenous surgeons were restricted to a supportive role.
I don't have much information on the follow up- were the operating surgeons involved in immediate postoperative care?

Dismal performance (like in everything else in Bengal)

My lame explanations

Liver transplantation is not a one man activity. It is rather a part of a comprehensive hepatobiliary service that includes hepatology, surgery, radiology, pathology, anaesthesiology.
In the absence of a center that provides dedicated comprehensive hepatobiliary service, a  liver transplantation programme cannot work effectively.
This, in my not so humble opinion has got to do with the bengali mindset of 'ekla cholo re'.
Bengalis are poor team players by character and its hard to find a situation in clinical practice where hepatologist, surgeons, radiologists, anaesthetists(most important member of the team) have worked in a team.
The mindset among practitioners to focus their work in a particular institute is particularly lacking- the surgeons would rather have multiple attachments than work in a single institute- HPB and transplant cannot function effectively that way.

There is a critical shortage of liver transplant trained surgeons , hepatologists, radiologists and anaesthesiologists and other professionals.
A training framework has to be in place for 2/3 years to build up dedicated transplant professionals. The Government is too myopic to do so, and a private player too money oriented to invest in such training.
The few people whom we can call trained are those who have trained with individual,personal  effort.
A liver transplant programme  relies heavily on trained para clinical staff to be successful, not only in the immediate postoperative period but in the months and years that follow a succeful transplant. I cant see such training happening in the foreseeable future.
Follow up is an integral part of any successful program. A framework for followup has to be in place for effective care of the patients.
A transplant programme can't just afford to say- that a patient has been 'lost to follow up'

Is there a demand?

There certainly is. Patients are going to other parts of the country to get it done- spending considerably more money and human resources
A recent publication suggested that cadaveric organs (harvested from dead people- for the uninitiated) might be more useful in Calcutta because of peoples' pro donation mindset. In such a scenario the entire network of potential donor identification, organ retrieval , organ preservation, has to be built up.
This calls for painstaking effort involving an entire fleet of doctors from wide ranging specialities working in tandem with social organizations.

Things are changing - slowly but steadily. But are they changing fast enough to keep up with the times?

I would like to be in a situation where I dont have to explain to people from other parts of the world why we dont have a liver transplant program in a city with a population of 20 million.

continuing rants of a 'desi' surgeon

Continuing rants of a 'desi' surgeon

Hello friends,

back with more rants from a 'desi'surgeon

Speciality units in General Surgery Department

I wanted to share my views on the concept of speciality units in general surgery departments in 'desi'land.

The concept of speciality units is not new.

Many  teachers in surgery have tried to introduce it in different medical colleges, only to be turned down by the head of the department or booed down by their exalted colleagues.

The concept goes like this-

Generally, there are six units in each Surgery Department(one for each day of the week- if you had not guessed that before!)

The units  do similar General surgical work, that is everything that comes under the ambit of General Surgery.

The idea is to assign an organ based speciality to each unit;

like Breast and endocrine/ Thyroid and neck/Hepatobiliary pancreatic/Upper GI/ Lower GI/ units.
There should be separate speciality clinics as well.

Perceived advantage being that surgeons can work in a focused way in a particular speciality.

Organ based speciality is an accepted way of patient care and teaching worldwide.
Working on one particular organ system helps the surgeon in honing his skills over time, generating database for research and education, and more importantly gives recognition to the surgeon as a leader in that speciality.

Greatest opposition to this seemingly attractive concept comes from the surgeons themselves.
Some  excuses put forward by them are
1. I shall  forget how to operate on the breast if I do colorectal only- that's an example but you get the idea, right?
2. I have a reputation of being a great general surgeon. I can operate on anything under the sun. If I start doing only one organ system - I shall lose my reputation and my practice.
3. My job in desiland is transferable. I can be shunted out to any nondescript place a month later. What will happen to the skills I acquired by working in one particular organ system?
4. I think of the greater good , always! What if an innocent surgeon gets transferred into my department. That poor soul will be lost trying to focus in a particular speciality.
5.Everybody wants Hepato biliary( or so it seems) - I may not get the speciality of my choice.
6. What will happen to my trainees. Will they learn surgery of only one organ during their tenure?
If the trainees rotate between units- how will they build up rapport with their teachers?
7.Dr X gets Upper GI and gets all credit and recognition and I am stuck with thyroid. It is so unfair.
Why ,he doesnt even have a big flat!- (I think this should be reason number 1 for all those against speciality units)

The answers to these rants lie within us -the surgeons-
1. No one who is experienced enough ever forgets to do an operation.
Its like riding a bicycle- you can never unlearn it.
Of course- one may need more time to perform a procedure after some time, but the knowledge never completely disappears.
2. Being a master in colorectal surgery( for example) wont be detrimental to private practice- one can still continue to be a general surgeon with a speciality interest in colorectal surgery.
3. Once transferred out- one has the option of going back to general surgery or trying to introduce this concept in the new place. It's a lot of work I agree- and I would like to return home early doing my 3 days in North North desi land. why bother about speciality!
4. The new surgeon in the department can always start afresh in a speciality of his choice.
5. Of course- its a democracy( we have too much democracy in desiland! its injurious to health) the allotment of speciality should be on the basis of seniority.
6. The trainees rotate between different specialities. They get access to focused work and learn more over a period of time.
As for rapport building with trainees, if it can happen elsewhere in the world, why not in desiland.
7 Cant suggest anything to tackle this issue of EGO

The problem lies in our mindset. We are so accustomed to telling and hearing 'NO' to everything that we cant accept any proposal that is for our general good. 

General Surgery is already a threatened subject under the onslaught of superspecialities.
If the surgeons dont work together it will be more difficult in the coming days.

The patient's viewpoint

The patient gets better treatment in a dedicated unit.
If he has  a gall bladder  - he will be managed in a gall bladder unit- an unit that has the knowledge and experience gathered through focused work on gall bladder diseases.
The patient has more chances of being managed in a systematic manner adherent to acceptable guidelines- which produce better outcomes.


The Institution's viewpoint

Having speciality units is a boon for the Institute.
It can project itself as a center of excellence on a particular speciality.
The Institute can get funds for research on a particular topic more easily.
The Institute will ultimately be popular among the general public for providing quality care with better outcome.


Of course, all this is a bit Utopian- but my dream is to see my 'desi' college right at the top of the list of best hospital for teaching and care in 'desi'land

rants of a 'desi' surgeon

Hello friends,
For those of you who dont know me that well (that's most of you reading this !) - I am a surgeon.
Having worked for 6 years in Calcutta (excluding my days in training) , I am currently in 'firangi land'.
I wanted to get my thoughts and observations out in the open-hence this idea of writing a blog.

I would like to write on - healthcare and its different facets as I see it.
I am confident on ruffling quite a few feathers with the topics on which I write
I intend to write frquently- depending on my schedule.
Your feedback and observations will be much appreciated.

Attendance 

This is one thorny issue with doctors working in medical colleges(Medical Education Service) in 'desi'land.

Mention this to any doctor/teacher and you are sure to let open a can of wriggly squeashy worms.

I am keeping doctors working in Health Service out of this discussion as they have to work in extreme and grossly different circumstances.

Coming back to the topic- ATTENDANCE, hospital attendance to be more specific.

The rules tell that the doctor has to be by his office at 9.00 am, will be marked late if he's still 'not in' by 9.15 am, and will definitely be marked absent if he's still not present by 10.00am.

He has to sign out at 4pm.

Moreover, he has to mention his time of arrival and departure in the attendance register

Hope that's right- it keeps changing and I can never get a grip on Government rules.

(Everyone but me quotes the  Service Rules with great confidence and know all attitude)

What happens in 'desi'land

I choose the time-

 I am a doctor. Period.

 No one can question my integrity and commitment to work- because- I am a doctor.

 I can grace the department by paying a visit at 9.30/9.43 

 I can write 9.00 am/ 9.14 am or any fancy time I choose irrespective of the time I did actually arrived

 Any Head of the Department who questions this will be instantly unpopular and judged strict - despite the fact that he is only doing his duty.

 The HoD can himself or herself be late on occasions and do what I do. In such a situation it becomes a free for all, everyone's happy that no one has to report on time. Such an event brings much cheer and goodwill in the department.

 It often happens that I reach the department at 9.00am. - you guys know that I am sincere and hard working :P . What do I do next?- Obviously I go to the canteen and have my cuppa.

I would have done that anyway, even if I attended at 10.00am ;)

Proxy-

 Obviously! I cannot afford to lose a casual leave day by getting marked absent when I am late    (mind it! I am never late)

  It's easy to work this out- I ask someone else to sign for me.

 I can ask someone else to sign for me for days at a time- no questions asked.

 I take great pride in signing for someone else when that poor soul is late.

 Eyebrows raised- why??? i am only helping my colleague. 

Sign out

 Do I have to?

 I can do that on the next day. Just sign in the departure column of the previous day.

 It's easy.

 Certainly, you dont expect me to stay till 4pm everyday?!?

Bandh days

 Lets not go into this.

We take great pleasure in discussing attendance with our colleagues. 

 Infact, this thought of attending on time occupies most of our already overflowing brains.

In 'Firangi'land

 There's no attendance register ???- What on earth!!

 What if somebody decides to come late everyday of the week or for the month.

 Its so unfair- I reach the department at 8pm and someone else comes late everyday!!!

 Its an unfair land.

Well, my Professor in one hospital came in at 6.30am on most days and definitely by 8am.

Everyone's in by 8.15

If people are late- they have a good reason for it and they are apologetic about it.

I dont think these people have families, they dont have kids to drop off or do the necessary bazaar in the morning.

How on earth can they be in the hospital by 8am? 

These blokes stay on till their work is over.

Which may be at 2pm(rarely). Else, it's 5pm -for everyone, which means everyone.

May be an hour earlier somedays- but those days are exceptions rather than the rule.

And in some places I worked- if I am on call for 24 hours- I have to leave by 4pm the next day(that's an hour early-yeaa)

My blissfully ignorant opinion-

There shouldnt be an attendance register

 If I am responsible enough for my patients, I am certainly responsible for coming to the hospital on time.

 There's a schedule to attend to, work to be done in the hospital. If I can do it by attending at 10.00am- so be it.

 But regretfully, my work involves communicating with people, liaising with my colleagues from other departments- who may be waiting for me since 9am or beyond 3pm.

 And so, patient care and teaching gets delayed.

 But it's 'desi'land yaar!  What's life without delays!

 I dont have all the amenities of 'firangi'land.

 It's a struggle to reach the hospital on time- have you ever tried the mad hour rush in 'desiland'?

 At the end of the day, its about getting the work done in a proper way- its a 'desi'way- but it's our way.

Signing out- well, my work finishes by 3o'clock on half of the days.

What shall I do in the Department for 1 hour- chitchat and idle talk?

choosing a doctor

how does one choose a surgeon for an operation?

is it someone whom one knows personally( may be difficult to go against the wishes of such a surgeon)

one recommended by friends/relatives ( might not work )

one who practises in a 'big' corporate hospital ( 'big' corporate hospitals are infamous for overdoing/overcharging)

one who is famous and well known( might be the result of a great marketing campaign)