On this episode, Sanjay Swamy in conversation with acclaimed neurosurgeon Dr. Satish Rudrappa.

Dr. Satish Rudrappa is one of the most eminent and distinguished Senior Neurosurgeons in India. He has done his M.B.B.S from Karnataka Medical College, Hubli in the year 1990. He completed M.Ch (Neurosurgery) at the prestigious National Institute of Mental Health and Neurosciences (NIMHANS) in the year 1995 where he was awarded gold medal for “Best Outgoing Student”. This was followed by a Fellowship in Complex Spine Surgery from Detroit Medical Centre, Detroit, Michigan, USA, Thoracoscopic Spine training from Barrow Neurological Institute, Phoenix, USA and a Fellowship of Microvascular Anastomosis at Henry Ford Hospital, USA. At present he is the Director of Institute of Neurosciences, Senior Consultant Neurosurgery & Head - Department of Spine Surgery at SAKRA World Hospital, Bangalore.

Listen to the episode to learn about :

2:04- A day in the life of a neurosurgeon

5:44- “Neurosurgery is kind of a meditation”

16:15- Role of technology in medicine

18:35- Technology that would improve the medical field

21:00- Suggestion on technological advancements in the field

23:37- Dr. Satish Rudrappa on empathising with patients

27:40- Dr. Satish Rudrappa on ISR(Individual Social Responsibility)

32:34- Some closing thoughts

Sanjay Swamy 1:15

Hello, everybody, welcome to a new episode of Prime Ventures Podcast, where we bring you interesting stories by interviewing people for the startup world. Today we have a very special guest, a dear friend of mine and fellow Rotarian, and one of the world’s finest neurosurgeon, Dr. Satish Rudrappa, who is at Sakra World Hospital. Satish, welcome to our show.

Dr. Satish Rudrappa 1:41

They thanks, Sanjay, thanks for this programme,

Sanjay Swamy 1:44

Satish you are a known neurosurgeon. And we have very technology driven entrepreneurs as an audience. So I wanted to start by having you tell us what is a neurosurgeon? What all does it entail and what are some of the common conceptions and perceptions about what is a neurosurgeon?

Dr. Satish Rudrappa 2:05

That’s a big question. Thirty-five years of my experience, you want me to tell in a few minutes, that’s wonderful! Typically a neurosurgeon is the one who deals with the brain, spinal cord, peripheral nerves and spine. So anything in the nervous system from the brain down to your bottom and up to the leg. The nervous system is a wide system in the whole body and anything related to that a typical neurosurgeon deals with. But in the present day, as some of us have specifically chosen because neurosurgery itself is a vast subject.

A typical neurosurgeon can do everything but because the neurosurgery is a very precision oriented surgery, many of us have done specific work. For example, I do skull base surgery, which is the base of the skull, where the brain will sit. From the base many tumours arise and this requires a specialised skill. Along with that, I have done the spine and spinal cord surgery, once again, a highly precision surgery. So in that way, many people are sub specialising under the branch of neurosurgery. And all of them require highly skilled long hours surgery. That’s why we have made these divisions but I can operate anything in the brain and spinal cord, but specifically, I am sub specialised in skull base surgery and spine surgery.

Sanjay Swamy 3:31

Thank you. So you mentioned the other day that we need to count up the total surgeries you have done. It’s close to almost 15,000 surgeries over the course of 30-35 years, to do the math that works out to probably, two to three surgeries a day. And these are in almost all cases life threatening and at the minimum life changing for your patients. So a typical day for a neurosurgeon, if you’re having so many of these, how does the day look and how do you prepare and have a positive frame of mind and a peaceful frame of mind as you go from one surgery to another?

Dr. Satish Rudrappa 4:07

Yeah, once again, Sanjay, you have made me too old to look, no, I graduated in 95. Now it’s almost about 25 years. I am a neurosurgeon. And yes, I have done more than 15,000 surgeries to be frank with you. But the good thing about any surgeon is we keep the log of everything because that itself is a learning curve for us. Every patient which I have operated from the time I joined the residency, till today, I have every patient’s name, what disease, what surgeries I have done, and at least about 70% of those patients which are complex I have their videos of the surgery, volumes of work I have.

I’m one of the luckiest to be frank with you because with the grace of God, I could do this surgery continuously. From the time I graduated, not even a day I took off, and I was lucky enough to have every day surgery, very few people can do this. And at the same time, I’m also lucky because I do a lot of complex surgeries, which is also one of the ways I’m satisfied I was telling you other day, I have achieved the inner happiness because my dream was to become a good neurosurgeon, where every patient who comes to me can trust, it is good surgeon means not the number, not what I do. But every surgery I put in my hand, I had to be satisfied at the end of the day that I have done a great job.

And as you said, How I concentrate on this kind of thing, is neurosurgery is like meditation. And I must have explained so many times to you, and an average surgery of mine, a typical large surgery will be about closer to 7-8 hours. So in the beginning of when I graduated, I was definitely like anyone I was a junior and as we grow older and as I specialised, many people wouldn’t have specialised the way I have done it because I’ve done enormous work in neuroanatomy, that means sitting in front of the cadaver and dissecting every part of the brain, spinal cord, spine, at millimetre level watch through the microscope to understand how the anatomy is designed by the nature.

And another thing about neurosurgery is we don’t do everything when the patient is flat.

Sometimes I had to put them on the sides, sometimes I had to keep their neck and head in different angulations to approach the tumour area in a different angle. So I had to have three dimensional picturization of his tumour with respect to his position which is completely draped because once we keep the patient on the table, you must have seen in any of the movies we drape the patient means we cover all other areas except the operating area. So literally as though I’m blindfolded after positioning him like that so that requires a different kind of a dimension.

So by repeatedly doing these surgeries and anatomical dissection, even if you tell me the middle of the night, and if any of my residents call me for surgery, and they send the pictures nowadays on WhatsApp, and I can picturised three dimensionally on the next day morning, how I had to get in. And the other thing I always do is you must have heard of any best cricketing player even Sachin Tendulkar, everybody says that you have to rehearse in your mind before you enter the surgery. So similarly, when Sachin Tendulkar wants to play against a fast bowler, he must be imagining on the previous night, where the ball pitches and what stroke he has to do exactly same things goes through our brain means you give me 10 minutes before the surgery, but I would have done all the homework one day before when I’m driving, when I’m sitting in my car, when I’m listening to music, the next day procedure comes into my picture that the MRI picture comes to me and I rehearse every step from skin till the closure by myself two times, so that I can be as precise as possible so that I will never make a mistake.

So like any other job, it is dedication and meditation, which makes the difference. I don’t do extra meditation. I had the long surgery as I told you several times, when I am in the deep part of the brain and the crucial part sometimes without my knowledge, I sing especially those songs that I’ve heard in my childhood, I wouldn’t have remembered on the same day morning. So that shows that I’m deeply concentrating and my deeper brain is working rather than my superficial brain.

And running from one surgery to another also requires a kind of calmness in me because unless I finish the one properly I can’t go to the next. Like any other entrepreneur, I know you must be, we call you as a serial investor, I’m sure, you must have invested in a few things till you’re concrete that that is going to go well, you don’t go to the next one. Similarly, any patient I operate till he is completely, I’m happy that his blood pressure is normal, the anesthetic states that yes, he’ll wake up easily, and that no problem. I will be there every second and then go to the next surgery, whatever the time it is, it can be 11pm in the night, if I’d started at six o’clock, or in the midnight.

Sanjay Swamy 9:38

Fantastic. I think there are so many amazing lessons there. You need both what you said explicitly, as well as reading between the lines. They’re so fascinating. You mentioned a little bit about sharing the images on WhatsApp and so on. And you have seen over the last 25 years, not 35. This industry evolved and technology is starting to play a bigger and bigger role. What are some of the big things that you have seen? We talk about robotic surgery, we talk about so many other things as well. What are some of the things you have seen? And where do you see this going over the next say, in 5 to 10 years, in the form of telemedicine, home healthcare, remote monitoring, as well as of course, all surgery space itself.

Dr. Satish Rudrappa 10:26

This is a fascinating question you asked, the reason being when I joined neurosurgery, I should tell you this story. Neurosurgery was considered as a very tough field when I finished my medical school and I always wanted to be a neurosurgeon. In fact, I got into Nimhans. It is a nationwide examination and to my luck, it is situated in Bangalore, and thousands of people across the country will take the exam for four seats, at that time, it was designated for neurosurgery. And to get the four seats, people when they write the exam in different parts of this country, it was a humongous task.

So I too, went just like that thinking that I would write it and to my blessings. You know, I was the highest scorer I believe, then they called me for an interview. So when the interview came 95% of my classmates said, buddy, why are you choosing this field? Where the patient who goes walking, will come back either lying down or not able to walk or those who are lying down will never come back home. So why have you chosen that? It’s purely because at that time, there was no technology available, there was significant paradigm shift, from what I learned to what I’m practising today, that’s why I keep telling, I’m the one of the luckiest who went with a surgical skill, along with a technology. So when I joined neurosurgery We used to diagnose even the tumour to any clot in the brain by doing what is called angiography.

So, I had to put a needle directly into the blood vessel of the neck and inject some dye, see the position change of the blood vessel within the brain and think that it could be this part of the brain or that part of the brain is a vague kind of a thing. Mine was the last batch, then when I joined the first year at Nimhans, we had a CT scan meant only for the head, not the rest of the body, it was almost I think, it was six or 12 slice we used to call very vague pixel could see, then within three to four years, we started having 16 slices CT scan, and today we are having 124 slices that means so thin sections and I can reconstruct 2d and 3d.

So in addition to the CT scan, the next came in 1993-1994 India got his MRI. So MRI changed the complete perspective of brain surgery. So in addition to that we started having, those are for diagnostic purposes I’m talking about that is from CT scan and MRI. From the surgical perspective luckily, I studied at the best institution in the country. And at that time, we were the only people who had a few microscopes that were vague microscopes. You have to literally struggle hours together to focus yourself and do it and then picture.

By 1995 or 2000, we started having microscopes of different values but it is too expensive. So when I graduated, only one hospital in Bangalore had a microscope, besides Nimhans, and we were struggling where to learn much more. So at that time, I went to the US, then by the time I came back, a lot of development happened, the economy was open, the technology started coming to Bangalore. That is the beauty of it. That is a microscope change in which I can do the surgery in a microscopic way, look at every millimetre in the brain and the spinal spinal cord. And Indian surgeons are one of the best in neurosurgery. I can vouch and tell you anywhere, any part of the world because I teach everywhere. We are one of the world’s best neurosurgeons available purely because of technological advancement.

And at present, when I operate on any patient irrespective of what economy they come in, in and around me at least closer to about 20 to 25 crore rupees worth of technology will be there. For example, today I did one epilepsy surgery, I had a high end microscope where three people can visualise, which can be projected on a big screen so that other students can watch and I had a navigation system because I was doing a precision surgery at the deep part of the brain, I had to touch only the two millimetre part of the deep part of the brain.

So, unless the navigation is there, I had to open a bigger amount. Then the third thing I had was an ultrasound machine purely for the brain, so that whatever little abnormality I want to see, among the rest of the brain, the ultrasound can pick up that. So then I had monitoring of epileptic focus using the leads, and I monitored for about 20 minutes to 25 minutes, then I had another ultrasonic machine, which will remove only that area without touching the neighbouring area. So if we look at all these technologies, I’m one of those blessed for being in the best place at the right time, which made a lot of difference to me.

Sanjay Swamy 15:46

Fascinating. What do you see as some of the near term or medium term enhancements that are coming down the pipe, we see entrepreneurs working around with the new technologies, with AI and imaging and all of these areas, what would you like to see from the technology entrepreneurship world that could further improve or make it easier for doctors like you?

Dr. Satish Rudrappa 16:12

What I usually think is we had to refine our diagnostic technologies much more cost effectively. So I would love to see high end when we can find out where the oil will be available deep in the sea, using the ultrasound technology, I am just thinking aloud in next 10 to 12 years, with the my knowledge combining with the people like you to look at the ultrasound as the imaging technology as an outpatient basis, where I will not send them to the big gantry of MRI and CT and looking at their clinical symptom I just pass an ultrasound machine over their head and focus on what area it is.

And I can pick up like how we do for the pregnant woman to see the child inside the tummy because it is a transparent area where the ultrasound can go easily through the tummy. The skull is about 1.2 to 1.6 millimetre thickness, that deep, dense calcium material it has, I think if you bring out an ultrasound machine, which will pick up the right area, which I’m suspecting as a clinically suspect in some areas, I can do that tell that ultrasound and show the patient what it is and make it more cost effective. That is number one.

Number two, with an MRI technology, there are some of the tumours in the brain and everything. We cannot categorise the grade of the tumour where it can spread next and how it mobilises its energy to develop itself into malignancy. With the use of artificial intelligence and data analysis retrospectively looking at probably thousands of surgery patients. So you look at those MRIs, digitally look into these things and have a data analysis and create such a way that, I can come out with the beautiful algorithm to say that this is the area within the tumour which is turning malignant, unless I removed that rest of the tumour becomes much more aggressive, so which will give the lifespan of the patients much more better, and also to help us to treat new chemotherapy radiation in much more better way, especially for the malignant lesions.

And the other thing is from the patient data management, India has not grown to the level where we call EMR electronic management system, the electronic management system still requires a lot of time. So do a lot of my colleagues because I work in a Japanese hospital, they have an EMR system, but it’s so cumbersome. And then a typical day of mine, starts at 7- 7:30 in the morning and goes up to 11 o’clock. It is purely because of the number of patients I see. India is a volume base. When I was in the US when I was doing the fellowship programme the whole day, I used to see about 10 or 12 patients, here, in a typical outpatient day of mine, I see an average about 90 to 95 patients. So if the data, whatever I collect from them, if I’m able to dictate faster and it picks up easily, and also I feed my MRI X ray, everything happens in three to five minutes, we will have a huge amount of data available, but that has not been developed even now. It is so cumbersome.

The data management is very, very difficult to put in. And India, according to me, is a big mining area for the patients. We can be world leaders in research and development. I think the future is going to go in that direction and there are a lot of angel investors like you. If I tell you a few things I’m sure, with the knowledge we have and with a system I am working in, you yourself say, No, we’ll put some money, don’t worry about the end result. And one or the other day, it comes great not only to you even to the nation, and for the future research, that’s what my vision is about.

So actually, on that point, actually, it’s coincidental. We are recording this today, the government, the National Health Ministry today just announced a National Health Data Management sandbox environment for making the health records, both easily interoperable, machine readable, and with consent from the user to share when they go from, say one hospital to another. But it’s the start, as you say, and I think it’s a big problem area to solve to make it easy for you to also focus on treating the patient’s without any ambiguity in terms of the information that they’re sharing etc.

Dr. Satish Rudrappa 21:01

If you look at Bangalore as a city, about four to five years ago, some of the young entrepreneurs started one of the medical software kinds of things, where patients can take the appointment with us, and then they can have an appointment system, consultation system, and propagating the work. But what I find is the ethical principles in that because in the beginning, everybody starts with the bigger thing.

And once the investment comes, it becomes a kind of a society committed profession, where we have to look completely ethical, but with the business coming into place, the ethics will be diluted, and the data of the patients and also the data of the doctors has not been protected at all. And they push you to one corner and they continue and rather they don’t even keep the connection with you. I think India should grow ethically in this aspect. I’m a great believer of that otherwise, we might have innumerable amounts of data. But the technocrats, investors and healthcare professionals, if they don’t respect the patient’s rights, and the hospital and doctors rights, I think it’s not going to go the longer way.

Sanjay Swamy 22:20

Yeah. I think a lot of that has been taken into account in this national health stack that has been defined. So Dr. Satish, switching gears a little bit. On the personal side, although in your case that’s also very closely intertwined with your professional side. I’ve had the privilege of knowing you for 14 years now as a fellow Rotarian and this year the president of our Rotary Club, you’ve always been the first person ready to help in any situation. And several times of course, it might involve surgery that you may need to help perform or facilitate or any other form. So this extreme desire to help people regardless of their needs is certainly something extremely commendable and very humbling for people like us who watch you immediately jump to the occasion.

How has this become such a core part of your mindset and journey because you could keep yourself busy doing 24 hours a day for profit surgery. And related to that we talk about CSR and you have sort of talked about ISR, that I’ll let you define. Would love to hear your thoughts and if you could share with the audience some of your thoughts here.

Dr. Satish Rudrappa 23:43

Sometimes, my children ask me the same question. Forget about you asking, my children also ask the same questions to me. I’m really lucky to be a doctor one because I always wanted and my upbringing from the small town called Bhadravati where there are no differentiation of people. It is an industrial town. Fantastic town. Very well grown at that time when I was a child with good roads, good accommodation to everybody, everything was available but in spite of that, there is no disparity between poor, rich, middle class, low class, high class, I never heard of.

So at that time when I was a kid, I was exposed to all kinds of problems which I could see in and around me. You turn one side you will see the richness of the people, the other side you turn you’ll see poverty going on with labors and everything. I think my childhood shaped me what I am, and I’m really lucky that God has given me that opportunity to experience the difficulties, as well as see the difficulties of the people, which drove me to be what I am today. So at any given point in time, I find myself in another shoe, that is a great thing. What we call is empathy.

Luckily, even my mother was like that and my father was like that. Even my wife is like that. And my children are also going in that direction. I think it is a blessing in disguise for us. So understanding others from an empathic point of view is the key. And that’s what is, the medicine is about. That’s why I said I’m lucky to be a doctor, because it completely suited the way I think. I’m entered into the right profession. And that is the reason in if any patient, for example, if I see myself, they coming into my room, with their sunken eyes, with their helplessness, I find myself that if I were to be in their shoes, what I would have done irrespective of which day what suit I’m wearing, because now I love to wear suits, you must have seen me but suddenly I go into their dress and think from their angle, and I will try to do whatever best possible.

And at the same time, I have about 22 people in my team, everybody is converted into that. That’s another great thing I could do because I practice that they’ve followed me and now I never tell anybody what to do, but in every medical history, we take the nationality, address, at the same time we take economic history, economic history is so important in medicine because I have to treat every patient irrespective of their disease, with whatever available resources they have, that is called as feasibility after economics. So I might do the great surgery, it might cost a lot. So I should be able to waive off my fee or cut down whatever I pay or request the hospital saying that we will not send this patient back. It is my patient. It is sent somewhere with nature’s law. We have to do our best for them. I think that is a principle I adopted. And luckily, for the last 25 years it has worked. And I hope God will bless me to keep it throughout my life.

Sanjay Swamy 27:09

Wonderful. On that point, I just wanted to say, Yeah, pretty much everything you’re saying, even technology entrepreneurs. I think the most important thing is empathising with the customer, putting yourself in the customer’s shoes to understand their point of view. Once you do that, actually, solutions become a lot easier. And as you were relating this I was thinking about exactly how we try to solve problems in the tech world as well. But yes, do continue about ISR.

Dr. Satish Rudrappa 27:40

Yeah, I think from my perspective you’re talking about empathy, if you practice that itself becomes a meditation. Believe me, there are so many times you keep thinking from that aspect. It is not only you where you are giving solutions, solutions come in front of you. It just appears at that moment. You wouldn’t have thought about those solutions, but when you are repeatedly empathetic, there’s a cosmic energy that comes I think that the solutions come so easily that things work in your favour.

I’m a great believer in that. And it’s happened innumerable times to me, you must have heard it which I keep talking that is called as individual social responsibility. The individual social responsibility is nothing but what I am telling that is empathy and giving back to society. My whole graduation is done from a government perspective, because I’m a government student. From 10th standard, I started getting the National Merit Scholarship. And suddenly when I came to Nimhans and after finishing the highest degree available college MCh degree, one day suddenly flashed to me after going to the US, seeing the amount of the debts those students used to have, the fellow neurosurgeons when they’re done medical school entered into neurosurgery.

By then they would have had closer to about $250,000 US dollars as a debt, then suddenly it relates to me that I had zero debt and this zero debt, I wondered how it happened. Then I thought, the beauty of the democracy, the beauty of the democracy country selecting, there was an opportunity for me because I scored well, somebody recognised me that is a government recognise, I entered into the medicine through government, entered into the MCH when I did the fellowship and our residency programme, also government started paying me rather than me paying the fees is purely because the democratic country and several people paying their taxes, which I never knew.

Then, retrospective, I started thinking to make one person as a doctor in this country, how much it costs. I asked several of my own friends, colleagues, students, none of them know, to be frank with you, in the present day, to make one person as a doctor in a government institution, I’m talking about it called closer to about two crore to the government, including their free hostal, the professors’ salary who are teaching you, the patients who are coming free which you are seeing and learning out of them, medication given by the government in the government school to the patients. If you look at all those things, the five year medical course comes closer to two crore rupees.

This was not taught in the medical school, nor the government has every time proposed to anywhere else. Then I thought having taken so much if I don’t give back in every step, what I do, including the tax, which I file every year, I have to be completely transparent to the amount of money that is 10% of my salary, has to go to the people whom I learned there is nothing other than my patients. So that is the principle I started. That’s why suddenly I told one day my wife was asking, what do you think it is? I said, it’s my individual responsibility. The individual responsible when I came by then CSR was already in the Vogue. Then I thought enough when the corporates can do corporate is nothing but an individual. Multiple individuals form the corporation.

Similarly, in your own corporate world, you start telling everybody how lucky they are to be born in this country, get everything out of it without even monitored by anybody, nor the government is asking you to give back. That is my own individual responsibility. So then I thought, I should name it as individual social responsibility. The individual responsible for bringing up my children is also a responsibility. But to this society if I’m contributing, it is called as individual social responsibility away from my own kith and kin. When I do it’s become this society now than I thought and I should talk about it.

Sanjay Swamy 31:50

Fascinating. Dr. Satish I know we can go on and on. Coming to the end of this podcast. I wanted to really first thank you for spending your valuable time to share these insights with us. And I wanted to request you for some closing thoughts and advice for everybody actually these are very unusual difficult times with COVID. And all of a sudden living, trying to adapt to the new world, who knows how long this is going to last. And you always talk about, the frame of mind and things like that being also important parts of therapy. So I would appreciate it if you could share some closing thoughts for the audience. And thank you for being on the show.

Dr. Satish Rudrappa 32:34

So nice of you, considering this pandemic, I am sure many of us, you know, our life has turned upside down. Or even I was thinking forget about life, in how the perspective of life that we were thinking just a few months ago has completely changed to many. But luckily, mine has nothing changed purely because my perspective remained the same way because I always believe and keep telling everybody that happiness is the quotient and happiness comes only with the few things that are when you are now thinking from others’ angle, that is empathy and compassion. So when there is empathy and compassion, happiness becomes part of it, irrespective of ups and downs of your life, you will remain a ‘tathastha’ we call, you will be in one kind of a plane where it makes an enormous difference. No, I’m not a Satguru or a Swamiji. But it is my own personal experience. I keep telling and when even in the hospital, they said, you had to be careful and a lot of my students who are telling that, sir, you are above 50, you had to be careful and everything I told them yes, if not we in this kind of a war, who else can do and from the day one of COVID I never took off from work and I told them once you’re mentally, physically, you’re thinking very well, that is doing moderate exercise, you’re happy, your immunity will be always good. And more you think from others perspective.

Everything works in your favour. and India being the country, which always told the rest of the world about happiness, empathy, calmness and yoga. I think if we follow a few principles, I don’t think anything will affect us. And in this difficult time, we all should contribute more. We have to think about how to make this country much better. At our own level, we don’t have to think in a big way to change, small contribution from each one of us in whatever the work we do. If we do perfectly and systematically and ethically and honestly, I’m sure we’ll grow to be bigger countries, and we grow as bigger individuals.

Sanjay Swamy 34:53

Thank you very much, Dr. Satish and appreciate these wonderful words of advice. Thank you so much.

Dr. Satish Rudrappa 35:00

Thank you very much. Thank you for giving me the opportunity to be with you and sharing some of my thoughts. Thank you.

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