The Hindu Business Line : Winning hearts

"If I am convinced that the risk is far higher than the benefit the patient might get from the surgery, I do not operate. But often patients are quite foolish. They go shopping around and find a doctor to say: Okay, Apollo has refused you, but I will do it." Dr M.R. Girinath Chief Cardio-thoracic Surgeon, Apollo Hospitals, Chennai.

You hardly expect a great sense of humour - often of the dark variety - in a cardiac surgeon of repute, who has completed 25,000 open-heart surgeries in 20 years. But when you seek Dr M.R. Girinath's response to the Apollo Hospital Managing Director Preetha Reddy's comment that he has another 25,000 surgeries to go, he quips, "If, like you, journalists have ghost writers, we surgeons had ghost operators, sure, I could achieve that milestone too."

Chief cardio-thoracic surgeon at the Apollo Hospital in Chennai, he is reluctant to talk about his own work, and comes out with 17 suggestions on what you should be writing on.

Senior cardiac surgeon Dr Felix Sridhar, who has known Girinath from his internee days 20 years ago, looks upon him as a role model and says, "What I admire most is his dedication and commitment to patients. Even in those days he would never cancel an operation, even if he had to work till midnight. He is extremely publicity shy. If the hospital had not insisted on celebrating this landmark, he wouldn't have bothered. There were so many instances when he could have gone to the press, but he never did." His staff talks about his humaneness, and Sridhar about the many patients he has operated on without charging anything.

To which Girinath says, "We often get paid in unexpected ways. We once had a tribal from Madhya Pradesh, who came complete with a bow and arrow in his hand and feathers in his hair, and a child who needed a simple heart surgery. He didn't have money, so I wrote a note to Preetha (Apollo's Managing Director) and she is, of course, very generous and we did the surgery free of charge. Three months later, when he brought the child for a check-up, he opened a dirty piece of cloth and offered what looked like a betel nut to me. Obviously I didn't look very enthusiastically at it."

But then the grateful man said, "Sir, I can't give you money, but this is kasturi (musk). It had blood on it and he said it is the perianal gland of a musk deer. We cleaned it and put it in our wardrobe and it smelled good for many years."

So how did he hear of Apollo?

"I don't know. But I do know that he wasn't brought to us by our marketing department!"

It is as much his surgical skill, his sense of humour and his magic one-minute dialogue with his patients during hospital rounds that have contributed to what the Apollo chairman Dr Pratap Reddy calls an "outstanding achievement". He is probably the only man in this part of the world who has done 25,000 open-heart surgeries. But it is not just the numbers but also the outstanding results; in the last three years the success rate of the coronary bypass surgeries is an astounding 99 per cent. How many surgeons in the world boast of such a record? His patients have included babies just a couple of days old to 87-year-old men".

He adds, "More important is the team that he has built around him... the doctors, the nurses and the whole unit. He has demonstrated to the world what India can achieve in providing hi-tech and quality health care."

But success sits lightly on the cardiac surgeon who feels he could have done better. "We get inundated in a lot of routine work because there are not enough centres in the country. But more important than the 25,000 cases is the fact that we've been able to train close to 30 young surgeons. Many have left and set up their own units, so the multiplier effect of the work done here is the biggest reward."

He proudly and affectionately reels off names. "Vijay Dixit was easily one of the best I've trained. He was required at Apollo, Hyderabad, 10 years ago. It felt like cutting off my right hand, but the group needed him. He has done excellent work. Practically all the leading cardiac surgeons in Gujarat have been trained by us, as also Dr Prasad Krishnan at Colombo Apollo, who is doing 500 cases a year and is very popular in Colombo. Then there is Dr Janardhan Reddy at Vijaya... ."

So, at the end of the day, that must be a very satisfying feeling?

"Oh yes, many of them are doing better surgery than me, so I sometimes think I should quit!"

You note he's not serious about that one, but he promises that "the day I find that my physical skills, very important for a surgeon, are not as good as they should be, I will be fair to my patients and quit".

Girinath says that stamina is not as important as other skills "because as a senior you do only the intricate and important parts of the operation. But as most of the surgery we do is really micro surgery, you need very skilled and steady hands and very good eyesight". So, how would he rate himself today?

"Today, my surgical skills are much better than 10 years ago and I find I'm doing all the difficult cases in the unit because I'm able to do an exemplary job."

To remain physically fit, it's a five-day per week routine of about 20-25 minutes on the treadmill, and only one proper meal a day. "In the morning it is just some toast, during the day it is from one case to another. By the time I get home, I'm hungry for an early dinner."

Lunch, which he volunteers to share with you, is an unappetising two phulkas with some boiled beans and radish. You hastily decline, but not without a pang of guilt at your normal intake.

Over the years, there have been a lot of poignant and stressful moments. Like the poor sardarji who placed his pugdi at the surgeon's feet when he was asked to return for his sister's surgery after two months. "He thought we said that because he didn't have the money, but at that time we were really packed. We doctors enjoy playing god, but I certainly don't like being treated like God, so we took her case immediately," he says.

The most stressful is the moment when he loses a patient. "Despite best efforts, certain patients start slipping away. You feel both frustrated and angry and wonder if you could have done things differently. But we do try all the time to bring down mortality rates."

He does not turn away or refuse even complicated cases, "unless I am convinced that the risk is far higher than the benefit from surgery. Then we advise against the operation. But often patients are quite foolish. They go shopping around and find a doctor to say: Okay, Apollo has refused you, but I will do it".

Despite best effort when a patient dies, "the only way you can cope with this is to do better next time. And I don't spare my staff at all".

When you point out that his staff finds him "impatient", he snaps, "Yes, I do give a tough time to those around me because I will not tolerate any slackness. I want them to put all that they have into patient care. But these days the youngsters are able to handle emergencies in the middle of the night without calling me."

He denies that cardiac units in India are doing unnecessary surgery. "No, we don't do that. We place great emphasis on ethics and honesty. I avoid promising the moon to any patient and tell them precisely what they can expect. Despite brilliant surgery, you can achieve only so much when the arteries are really bad."

Of the 25,000 cases, 19,000 have been coronary by-pass operations and 400 patients have had to be re-operated. "There are two problems with re-operation; it is a much more difficult operation because everything is adherent and we have to free the heart and be very careful about the old grafts which might be diseased and you can push the cholesterol deposits into the arteries. Two, many patients in India can't afford a second operation."

Over the years angioplasty has replaced some amount of coronary bypass, for reasons such as shorter hospitalisation, no incisions and faster return to normal life. But though he prefers to send patients with one or two vessel disease for angioplasty, "the major problems is the prohibitive cost when drug coated stents are used (to keep the vessel open). Each one costs about Rs 1.5 lakh, so if a patient requires two or three stents, the procedure will cost Rs 5 to Rs 7 lakh and will have a 10-20 per cent re-blockage rate. A bypass in a private room costs less than Rs 2 lakh."

When you point out that even this is a prohibitive sum for the majority of Indians, Girinath says that health insurance is the only answer. On why he never thought of starting his own hospital, he says, "I have enough headaches as it is. Do you know how terrible it is to run a hospital? Hospitals are not only capital and labour intensive but also headache intensive!" But, over the years, he has never hesitated in putting in his personal money to upgrade the equipment in his unit. He dismisses this with a vague, "If it helps me sleep better in the knowledge that my patients are safe, why not?"

One secret behind Girinath's success is his willingness to bring in or adapt to the latest technology in surgery. Says Sridhar, "He is always eager to go along with changing trends or technology. The beating heart surgery came so late in his career. After all, he was not in his 40s. So when I wanted to take it up, he encouraged me. It was a very strenuous and technically more demanding process. But I started in 1999 and later he took it up too and we've crossed 2,500 cases. Nearly 90 per cent of our bypass cases are currently being done by this technique."

But technology and surgical skills apart, it is the way he interacts with patients that wins their hearts. "He is so busy and while making rounds there might be 50 to 60 patients. He can't spend too much time with them. But he is always cheerful and jovial and invariably cracks a joke. They just need to see him... and one tap on the back does wonders," adds Sridhar.

Picture by Bijoy Ghosh

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