This is the first in a series of CTY interviews with individuals who have distinguished themselves in the area of humanitarian activities related to the care of children with congenital and acquired heart disease.
Introduction
SR: Good morning ladies and gentlemen. It is my pleasure this morning to introduce Dr K.M. Cherian to you all, not that he really requires introduction. But there are some facets of his life that you may not know that I would like to cover in a brief introduction.
Dr Kotturathu Mammen Cherian, some of you may know him as K.M., or K.M.C., or Dr Cherian, and all of his trainees will know him as Sir. He was born on 8 March, 1942 to Mr Mammen K. Cherian and Mrs (Meriam) Cherian and he was one of four siblings. If this does ring a bell, can I ask you to put your hands together and wish him a happy birthday (clapping).
Dr Cherian had his initial schooling in the state of Kerala, in a place called Chengannur. He went on to earn his MBBS and MS from the Kasturba Medical College, Mangalore. After completion, he was a lecturer in the Christian Medical College, Vellore. Dr Cherian was one of the first Indian cardiac surgeons to go overseas to Australia, as a senior registrar in Sydney and Auckland. He went on to complete his FRACS in 1973 at St Vincent's Hospital, Sydney. Subsequently, he went to the University of Alabama, which at that time was the Mecca of cardiac surgery. He returned to India and then went as a visiting professor to Portland Oregon in 1984–1985. Once he returned from Portland, he established himself as a cardiovascular surgeon at Railway Hospital at Perambur, where there were many firsts done in this country. After that he founded and directed the Madras Medical Mission, and subsequently became the director and CEO of Frontier Lifeline Hospital.
Dr Cherian was given the prestigious Padma Shri Award in 1991, and the Indo-Australian Award in 1997. He is a past president of the Paediatric Cardiac Society of India and the Indian Society of Cardiothoracic Surgeons, both of which have bestowed upon him their lifetime achievement awards. He was the first Indian to be elected the President of the World Society of Cardiothoracic Surgeons and he is one of only a few Indians to be awarded membership in the American Association for Thoracic Surgery. He is the only Indian whose name was engraved in stone in Greece, when the World Society meeting took place there. He also has many other firsts in India to his credit: the first successful coronary bypass, the first bilateral mammary artery grafts, Senning operation, paediatric heart transplant, and bilateral lung transplant.
Dr Cherian is married and blessed with two children. The elder one, Sandhya Cherian, works with him. The second, Sanjay Cherian, is a budding cardiac surgeon. Dr Cherian has been in the company of the greats of cardiac surgery. You can see him in photos with Albert Starr, Donald Ross, Christian Barnard, Miguel Barbero-Marcial, C. Walton Lilliehei, and Francis Fontan. You can also see Denton A. Cooley and Sir Brian Barratt Boyes, who had been his mentor during his training. One of the most treasured photographs is with Mother Teresa when she visited the Madras Medical Mission. I was fortunate to be present when she came to visit that place.
Dr Cherian enjoyed a special place and relationship with one of the luminaries of cardiac surgery, John Kirklin. He has been his blue-eyed boy in the University of Alabama. The whole UAB team has been a source of inspiration and support for him all along. Dr Cherian himself has trained and been a mentor to a galaxy of surgeons. Many of Dr Cherian's former trainees are now heads of units, running the show in various parts of the country today. One of Dr Cherian's best statements is: “You guys should have common sense and think practically”. I think this holds true even today. This perhaps is the statement that has inspired a lot of his trainees to excel in their specialty. He does best what he knows best.
He has a huge legacy, including the Madras Medical Mission, the Pondicherry Institute of Medical Sciences, the latest project Mediville and the Frontier Lifeline where he works at the moment. His passion for children has also translated into support for an international school. No wonder he is among the big fishes of this country.
So before I end, let me share with you the statement Dr Cherian made in his presidential address to the Indian Association of Cardiothoracic Surgeons, which demonstrates the character of the man. He said, “Let me end by sharing with you what I strongly believe are the missions of a cardiothoracic surgeon: quality versus quantity of care, care first cost second, commitment to passionate cardiac care, dedication to future training of cardiothoracic surgeons, research and development, cost effectiveness, transparency and accountability”.
So ladies and gentleman, I present to you Dr K.M. Cherian, a skilful cardiac surgeon, a humanitarian, a medical trendsetter and entrepreneur in India, a fierce nationalist, a visionary, a tough task master to all his trainees, and as far as all his trainees are concerned, an astute surgical mentor. Thank you very much Dr Cherian.
Interview
KMC: Yes, today is my birthday. I am completing 72 years and going on to 73!
TRK: Happy birthday Dr Cherian! Who are the surgeons who have had the most influence on your career, and in what ways did this come about?
KMC: Dr S. Ullal, my first mentor, gave me the confidence to realise that self-confidence is the most important thing to achieve, and of course it should be backed up with theoretical knowledge. Theory not in terms of subject alone, but including history also. He made me read the history of cardiothoracic surgery. The second person was Mr Mark Shanahan. He was a perfectionist. He took 5 minutes to park his car parallel to the kerb! He is one who would go after an RBC and try to put it back into the arteriole. He was very patient, helpful, and showered me with brotherly affection. Sir Brain (Barrett-Boyes) influenced me with his technical ability and intelligence. Dr Al Pacifico was been one of the finest and fastest technical surgeons I have ever met. Dr John Kirklin was a master teacher who did not allow anybody to deviate from the University of Alabama protocol bluebook. He was a great thinker and hard worker. More importantly, he made everybody think and write. Thus, I got the opportunity to write in the Textbook of Cardiac Surgery. Dr Albert Starr has a sharp mind. Most of the things that he does he may not explain, contrary to Dr Kirklin. But when you ask he would always say, “I am glad that you have been following each and every step”. Thus, all five had distinctive qualities and it was my constant effort to imbibe them.
TRK: You have had many opportunities to work in high-profile units around the world, yet to the great benefit of the region, you chose India. What was your thinking over the years about this issue?
KMC: This question reminds me of the book by Robin Sharma, The Monk Who Sold his Ferrari.Reference Sharma 1 I chose to come back to India in spite of having a green card and a permanent residence in Australia, because I wanted to see whether I could do in India what I had learnt overseas. I also started realising that what is important in life is contentment. I would have been able to achieve it monetarily or materially in other rich countries. I also knew that there would be great disappointment even before starting the struggle to get into the system, as well as in achieving recognition by the society, in spite of huge personal sacrifice. In this country, we have a “crab syndrome” and usually the big crabs are the ones which pull down the small crabs that try to climb out of the container. I selected Railways Hospital over All India Institute of Medical Sciences or Christian Medical College Hospital in Vellore because I don't belong in these great established set-ups. I knew my limitations, and that I would never be able to compete with my contemporaries, who had many other strengths than I did. Coming from a background of a farmer's family, with no medical man even as a distant relative, I knew that I was totally different and inferior to many of these giants. The only thing I had was enthusiasm and willingness to work hard, and a motivation to achieve contentment in my field. As you all know, enthusiasm is the precursor for success. Nobody succeeds without hard work!
TRK: Along the same line, I have met extremely talented Indian surgeons working all over the world. Yet you have managed to build a stable cardiac unit which actually attracts surgeons (as well as patients) from around the world. What are the elements that were important in creating this working milieu for your team?
KMC: There are many talented surgeons of Indian origin all over the world. They are not only talented, they have rich backgrounds and high connections. I think that I have been able to attract young surgeons mainly because of my selfless hard work, motivating other young surgeons to work with me. I have been very blunt, candid, and open in my criticism during their development stages. At the same time, I spent lot of time scrubbing with junior colleagues to show them how to do whatever I learnt. Many of my junior surgeons as well as other colleagues who are now occupying very important positions in different parts of the country (as well as abroad) may not like my personality. But, I have always tried to help them and I never tried to damage their futures. I have never expected anything in return, not even a word of thanks from them. Some might recognise that I helped them, some may not. Some might acknowledge that they have worked with me, some may refuse. I don't think anybody will say that I have been a dubious character. I have realised that god had endowed me with two hands which could coordinate with my brain, even from my younger days. This helped me to mould myself, with the experience that I gained from great teachers, to become a cardiac surgeon. I had my own drawbacks, especially not being able to express myself in a foreign language, as my basic education was in my own mother tongue. It is necessary (as you all know) for a good surgeon to be able to operate, to look after the patients. A surgeon must consider the physiology and anatomical correction as well as support the patient mentally and psychologically. Most importantly, the surgeon should support the patient's relatives, as though he is one among them. I feel this is the success of the patient population coming to us from all over, irrespective of the country. It is not gold, a Rolex watch, or a diamond necklace for the referrals, whether it is a company or individual involved in corporatisation.
TRK: A surgical education is not usually the best background for solving complex business/financial problems, and it has been the downfall of some talented clinicians. You on the other hand have had extraordinary success in both realms. How did you manage this?
KMC: A surgical education itself is not sufficient to become a successful surgeon. As I have said, there are many factors which make you a successful surgeon, but the business aspects of surgical practice can be difficult. I started the Madras Medical Mission instead of going alone in private practice, which would have made me a rich man. But, controlling a hospital as an institution needs, initially at least, like-minded people. But the moral, ethical, and financial background cannot remain the same for everybody, as the non-professionals can get carried away with the money somebody else generates! It is very difficult to accept or practice to pay your junior colleagues more than you earn, especially when you start an organisation. That itself will prove your commitment to both health care and society. I always used to think about it, and my answer always will be if it is for money, pleasure, good cars, the house, all the other frills, I could have stayed back in one of those countries where I had legal resident status. I will never accept the fact that I had extraordinary success. Yes, for my limited ability I was successful. It doesn't mean I am overambitious.
TRK: You have mentioned “social and corporate responsibility” as an important issue, and have been quoted as saying “Healthcare is an industry, but care of the sick is not an industry”. I like this statement very much. Can you expand on what it means to you? These concepts may be obscure in some parts of the world.
KMC: Yes. “Health care is an industry but care of the sick is not an industry”. This is not my statement. I copied it from Florence Nightingale. The full statement is “Care of the sick is not an industry – it is a calling”. It has no religious connotation. That concept (industry) is mainly for non-medical people, businessmen, and non-practicing doctors. Because we have been so classified, it has been necessary for us to accept it (health care) as an industry. You have to behave like an industry, but an industrialist or a businessman never considers that it is your own brother or sister or other relative that you are treating. So caring for the sick cannot be just an industry. If that were so, one should not have gone for this profession. I would have been a very successful farmer, and I still enjoy farming. But once you consider all your patients to be close to your heart, as individuals important to you, then this indifferent attitude does not come. My room is always open for anybody to come and talk to me regarding all their problems. I don't shut myself away from others as a CEO. I do not like that terminology for myself and I would prefer myself to be called a cardiac surgeon. I would emphasise: a full cardiac surgeon. In 2009, I was given the lifetime achievement award by this Society. In 2010, a lifetime achievement award was given to me by the Indian Association of Cardiac Surgeons. In my reply speech, I thanked both societies for making me a complete cardiac surgeon, and I would like to remain a complete cardiac surgeon dealing in both adults and paediatric patients, whether their problems are straightforward or complex.
TRK: Your later career has been characterised by a move into basic scientific research, molecular biology, gene therapy, and finally construction of a dedicated research park associated with Frontier Lifeline. How did these interests come about, and what obstacles did you face in establishing your current research programme?
KMC: Today, you see, the corporate world, the banks, the financial institutions encourage you to build another hospital. They are not interested in technology or research. Anybody to whom you talk, they would say that medicine would become very expensive, especially specialties such as our own cardiac surgery. Hence, they all want to make medical cities to generate more money. Nobody thinks of ways of reducing the cost, by employing our own indigenous technology, for which we need our own research rather than research imported from other countries. Nobody wants to grow old, everybody talks about regeneration and rejuvenation. We have the best opportunity to combine all these concepts, our own research, our own technology, utilisation of our own ancient medicines, combined scientifically for evolution of a new concept, for example, a Biohospital. Being a cardiac surgeon doesn't prevent you from protecting the environment or trying to imply carbon credit policy, or saving the ozone layer of the earth, or replenishing the ground water level, or creating jobs for rural women in medical technology. This is my aim, which is new. And since I have done many new things, I have decided why not try this also. It is not easy as I said. It is a nerve-wracking, tough experience in one's life. But without repeated trials and a few failures there is no ultimate success.
TRK: You have travelled from humble beginnings in Kayamkulam to an undisputedly iconic status in the medical world. Do you have a guiding philosophy that you can share with us?
KMC: My humble beginnings studying in a small school which did not even have complete thatch proofing, slowly graduating to studies under a mango tree with the same class of students has been an experience. I have seen the difficulties of life in different strata of people, whether they are rich or poor. Please do not think that all rich men are comfortable. My childhood experience helped me in building a school with a mango tree in the centre, where I have more satisfaction at present in seeing 60 girls from the slums, cared for by single mothers, who are in no way inferior or distinguishable from the “creamy” layer. I take pride in saying that the educations of these 60 children are entirely supported by me. That is a great satisfaction, more than being professor of cardiac surgery. We are in a different country, where I believe empowering the women is the way to build the society and the nation.
TRK: How can a surgeon and humanitarian such as yourself, who does the work of 10 single handedly, find the correct point of balance in life? Do you have interests (outside of your main life's work) that you find fulfilling or exciting?
KMC: I do not do anything single handedly. I have very competent colleagues, many of whom have been much better than me, and I give them a free hand. When I was building Madras Medical Mission, MM or Frontier Lifeline, half of the time I would be at the construction site and my colleagues would be doing all my clinical duties. It has been a pleasure to see that I achieved what I wanted to my satisfaction, since even in those non-clinical areas also I was looking for perfection. My colleagues have been managing the patients to my satisfaction, which means they also became perfectionists in their own way. In 1937, there was a big famine in Travancore, part of present-day Kerala, and my great grandfather had kept 40 cents of his paddy fields to be used for feeding the poor, with two to three harvests in a year. This poor feeding continues even to the present time, but of course nobody comes to drink porridge nowadays and hence whatever is the income from that particular field is given for feeding the poor in the destitute homes. I feel this has influenced my outward look towards charity. It may be a little bit of genes that I have acquired!
TRK: I think that you have now performed over 36,000 cardiac operations. What would you consider to be the most important changes or advances that you have seen during your career span?
KMC: The most important change I have seen during my career days? I had the opportunity to interact with almost all of the pioneers of cardiac surgery, from C. Walton Lillehei, Juro Wada, Chris Barnard, Norman Shumway, Dwight McGoon, etc. I had the opportunity to use the disc oxygenator for the first 2 years of my professional career. It was like from the disc oxygenator, to the Rygg Bag, bubble oxygenator, membrane oxygenator, ECMO, etc. Personally I have not done anything. The biggest advantage for me has been being in the right place at the right time, and knowing the right people.
TRK: Along the same line, what are the major surgical and health-care delivery challenges that face us in 2014?
KMC: Cost of treatment. In western countries everything depends on insurance schemes. The situation is catching up in India also. In a country like ours, how much people can afford as a premium? And this is a country with 1.2 billion population. We create our own challenges by unethical and unhealthy competition among ourselves, because we are being controlled by corporate industry. A uniform delivery of health care will be a great challenge.
TRK: If you had it to do over again, what if anything would you change about your work and career path?
KMC: If I had to do it all over again, I would do most of what I have done before, but I would be very careful in choosing friends and colleagues if mutual trust were not there. As Gandhi said, “If the trustee of a trust behaves like the owner, the trustee is doomed”. I have been asked many times what I would have been if I were not a cardiac surgeon. My answer is, as I said, that I come from a farmer's family and I would have been a very successful farmer.
TRK: What are the individual qualities that you consider to be most important for a successful career in paediatric cardiac surgery?
KMC: You have to be obsessively involved in getting perfection, thereby getting good results irrespective of caste and class, etc. In paediatric cardiac surgery, you should consider that every child you operate is your own child or your own younger brother or sister.
TRK: Is there any other comment that you would like to make to the audience?
KMC: Lastly, what I would like to say is the measure of success doesn't depend on what you have achieved or how famous you have become. You should think of the obstacles, the difficulties, the tribulations, and the sacrifice one has undergone for achieving the success. I would also like to say the harder you work, the luckier you become. Lastly, recognition by your own professional colleagues is the biggest achievement you can get. I am grateful and humbled by your gesture.
