Nobel laureate Marie Curie once said: “be less curious about people and more curious about ideas”. It’s a philosophy surgeon Professor Dhananjaya Sharma has very much taken to heart.
He took time out from the Center for Global Surgical Innovations and Low-Cost Solutions in Jabalpur, India, to talk to SURGERY about his work: from what drives him to ‘modify, simplify and apply’, to his thoughts on retiring in less than two year’s time.
Dhananjaya takes inspiration from Occam’s Razor, the hypothesis that if there are multiple explanations for any phenomena, the simplest is likely to be the correct one. “Similarly there are many ways of doing things in surgery, I want to find the simplest and the most economical way. It’s a good intellectual exercise,” he said.
Both his grandfather and father were physicians, and “from day one” Dhananjaya knew he would follow them into healthcare, choosing to become a surgeon because he wanted greater involvement with his patients.
He explained: “40 years ago, if you had a heart attack, you took out an ECG, prescribed aspirin and sent people home. There were no interventions. Now, physicians are doing so many therapeutic interventions, including endoscopies and heart catheterisation and stenting.”
Two decades ago, Dhananjaya started Central India’s first gastrointestinal surgery unit. Over the years, he gradually took a back seat. “I started thinking ‘what more can I offer?’ as I started approaching the evening of my career, before I hung up my gloves, so to speak.”
A passion and addiction.
He describes the “revelation” that he could find local solutions for patient’s requirements. “It became a passion, I became addicted to it. It’s all I think about now: how I can simplify a procedure, how I can make it more economical.”
Oddly, not everyone was enthusiastic about Dhananjaya’s efforts. “I used to call them low-cost or cheap innovations, but I realised these words are counter-productive,” he said. “Everyone has social aspirations, they don’t like the sound of the words ‘cheap’ or ‘low cost’ so I now call them affordable or cost-effective solutions.”
One of the best examples of the eye-opening work carried out at the Center is with patients who have stomas following abdominal surgery. “There is excoriation of skin around the stoma, so we apply medication to protect it,” he explained.
“Commercially available treatments are quite expensive, so we use linseed oil. It’s available in rural areas and even an uneducated patient knows about its medicinal qualities.
“When I really looked into it, I found it had been used by every civilisation in history. I didn’t know, I was taught about it by a patient. It is 10% of the cost and patients are happy: they know from their grandmothers that linseed oil has medicinal properties.”
He admitted that if resources and wealth were more evenly distributed, he probably wouldn’t have to apply the Center’s ‘modify, simplify and apply’ maxim.
“My Western counterparts don’t have to think or worry about it. Everything is laid out in front of them and they can pick and choose. I have to modify so I can make that surgery more affordable for my patients.”
He went on: “disparities are everywhere, not only in the field of medicine. The bottom line is: medicine is a social science. Patients are affected by the lack of money and support. When they go back nobody’s at home to look after them, and when they lose their jobs and salary, who’s going to compensate them? What we’re doing is social work.”
Inspiration in unusual places.
Dhanajaya and his team also devised an abdominal closure technique after reading about another Nobel laureate, French surgeon Alexis Carrel. He was awarded the prize for developing a suturing method based on his mother’s lace making and tatting (a technique for handcrafting durable lace) skills.
“When I found out about this, my mind immediately went to: ‘what more can we learn from this?’” Dhananjaya said. “If you keep your mind open, the ideas are raining down all the time. It is we who have closed our minds - you can learn from everyone. I learned how to give an intravenous drip from nursing staff, they taught me how to draw a blood sample.”
The exchange of knowledge is a fundamental part of how the Center operates. “Usually our ideas are the result of interactions among our consultants,” he explained. “We all sit together in between cases and talk about surgery and ideas.
“In my department, one of the things that is banned is ‘no cribbing’. Don’t cry on my shoulder, don’t come to me with a problem, I tell them to try to find a solution. Don’t tell me ‘I don’t have this, I can’t perform this operation’. I always tell them that we are all intellectuals and we need to find the solution to our patient’s needs.”
He went on: “If you portray yourself as an intellectual, you must do intellectual things. We try to find solutions. People come to us when they come across a new idea, they bounce it across us.
I’m always happy to assist my younger colleagues. I have so many students spread across the world, with visiting professorships in 29 countries. Now with videoconferencing, things have become so easy: I can demonstrate an operative technique or show my slides.
Dhananjaya revealed how, despite the complex relationships between India and Pakistan and Afghanistan, video conferencing technology has enabled him to teach there for the past several years. “They ask if I’m available and I say ‘why not?’. My time is running out, I have to share my ideas and philosophy.”
As eager as he is to share the wisdom he’s accrued during his career, Dhananjaya aims to provide a holistic learning environment. “There should be no pressure,” he said. “Education means I’m just creating an atmosphere for my students to learn. If they vibe with me, good, if they don’t vibe with me, I still have to teach them during those three years they spend in my department. I have to show them that this is how things are done, this is how you go along.”
He continued: “In a teaching hospital, everything is clear. The college part is for students, the hospital part is for patients. I’m nowhere - I have to leave my ego out.”
When asked if all surgeons have an ego, Dhananjaya laughed. “Come on! Surgeons are driven by ego! They used to have God syndrome, but they grew up and realised it’s not them doing things, there is a higher power.
“It’s only when my patients do well that I get credit, or when my students do well as a teacher I get credit. I’m the last one to get credit, so where is my ego? I have to focus on my patients and my students. That should be the philosophy.”
Although he admitted he is an agnostic - preferring to “worship at the altar of education” rather than a temple, mosque or church - he insists there is a place where faith and medicine meet. “Every thinking surgeon has to believe in God, because we’ve all seen so many miracles.
“People who we thought won’t survive do so against all odds, and sometimes patients who are not supposed to have any complications, we lose them. There are many things we can’t define.”
A ‘glocal’ way of working.
Things are a lot clearer-cut when it comes to innovation, and why Dhananjaya champions what he dubs a ‘glocal’ way of working, based on a combination of “wisdom from everyone and local technology”.
He explained: “I want to use technology that is locally available. I’m involved in its co-creation so I can maintain it and if some part is not available, I don’t have to wait for it to arrive from overseas after three months.”
That staunch independence means he isn’t beholden to technology companies who would force him to buy models by making previous versions obsolete. “Companies splurge on their advertising, they sponsor doctors and even their thinking: people become their mouthpieces.
“When a new technology comes in, it’s being driven by the commercial interest of the company. I could never be sponsored like that. My sponsor is right here in between my two ears, that is all.”
His team’s work has resulted in several affordable surgical solutions such as simplifying prognostic scores and simplifying various surgical procedures so they can be used even in small hospitals. A simple elegant example is restoring sensation in the feet of patients with leprosy and diabetes by a simple nerve transfer.
Not that he is opposed to technology. “It’s made everything safe for all of us,” Dhananjaya said. “I just want to add a word in front of technology and that is ‘affordable’. I don’t want to invent an operation that costs $1 million to perform.
“I’m not a surgeon for the elite, I’m a surgeon for the common man.”
And so he innovates, not only to help his patients, but also in a bid to reclaim the word from linguists who he said have “hijacked” it and “defined it in such a way that only very high tech innovation will be termed as such”.
“I innovate because my patients can’t afford it. They innovate because they have to justify buying that multi-billion dollar machine. We’re both doing the same thing but they are doing it more expensively, that is all.”
Dhananjaya is set to retire in 17 months, but admitted the notion fills him with a “mixed bag of emotions”. He wants to continue teaching and already has offers of work in Thailand, Bangladesh and even in Antigua. Primarily, his focus is on giving students the confidence to find their own solutions to situations.
From arrogance to pride.
Talking about the potential end of his career prompts Dhananjaya to recount a story from his early years which offers a profound insight into the man he is today.
“When I was a final-year student, one of the consultants in paediatrics offered to analyse my handwriting,” he recalled. “So I wrote something, and she said ‘you are very ambitious and you are very arrogant’. I said ‘what is wrong with being ambitious?’ She said ‘that is your arrogance’.
“I found out there is a very fine line between arrogance and confidence, and also between arrogance and pride. If I think I’m the only one doing a good job, that is arrogance. But if I think many people are doing their work and I’m doing my work to the best of my ability, I can say this with pride. So over time, I’ve changed from an arrogant young surgeon to a man who has pride in his work and the students who are doing well that I’ve assisted.”
He smiled and added: I have close to 100 of my students who have become professors in so many places. Now they want me to teach the same values to their kids! I say they’re not working under me, I can’t teach your children.
“But most of them are in touch with me and when I travel they all come to meet me, so maybe I’ll do something with the next generation as well.”
He added: “I don’t want to use the word mentoring, which is often used in the Western world. Being a mentor is an honour that has to be bestowed by the student. It’s only when they pass out and they say ‘Professor Sharma is our teacher and I like him, he mentored me and showed me the way,’ that I’m ready to accept that compliment.”
It will be very much deserved.
