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Careers in Retina

Jul 28 | 2:00 PM

At a certain point in your ophthalmology residency, there comes a point where you need to decide whether or not you'll pursue a subspecialty- and if so, which one. If you decide to go for the most popular ophthal specialty- Retina fellowship which offers an atmosphere of camaraderie - what are the other perks? How do you go about it and which are the best institutes in India and abroad? Let's dive in with Dr. S. Natarajan who is the leading VR surgeon in the country!

[Music] so hi everyone welcome to today's session it's good to have you all here and we are looking forward to a wonderful discussion today uh today's session is the first session of uh nuts about retina it is a metfix club formed by dr nitrajan sir and those who are interested in ophthalmology especially retina they can join the club and there are going to be lot of uh discussions uh live surgeries talks uh which you can enjoy so you can join the club right away and you'll get the notifications uh now starting with the today's session i'll introduce myself first i'm dr shachi desai i am practicing in ahmedabad i completed my fellowship in 2013 under doctor nitrogen sir at aditya chotaya hospital now before uh introducing uh sir i'll i would like to introduce dr divakan he is going to be my co-moderator for today's session he is a young dynamic highly qualified vitriolic surgeon ocular oncologist and rop consultant he is working with iq india and he is also general secretary of yossi which is young ophthalmologist society of india so welcome dr divakand it's good to have you and would you like to share some more detail about your journey thank you so much and warm welcome to everyone it's so wonderful to share this platform has so it's been a past couple of years most of that has been through the pandemic uh so i finished my fellowship uh and from 2019 i've been practicing in lucknow i cover almost six to seven centers in on and look forward to session this session and i'm sure it will be a great learning experience for me as well now i'll introduce sir sir is everybody who is in ophthalmology must be knowing dr nitrogen sir uh he is an excellent vr surgeon his career in retina started in 1985 and he was the youngest experienced vr surgeon at the age of 27 years and he has done more than 60 000 retinal surgeries so far he started his private practice with a small clinic and now aditya chota hospital is considered one of the biggest and top 5 institutes in mumbai so that's a big achievement uh sir has been recipient of lot of awards and padmashree which is one of the highest civilian award is one of them sir is also a charter was also a charter member of retina hall of fame uh like very few people or very few sergeants from india have their name in that list so it's i mean uh so cv is like 60 pages it just keeps on going so i'll uh stop here and so i welcome you here and thank you so much for taking time out for this session and i am i mean we all are blessed to have him as our guru because he is always available for us and i whenever i talk to him i always learn some of the other things so today also i'm looking forward to learn lot more tips from him how i built my career and practice in the commercial city of mumbai and my inspiration is which was there in my father's car i remember from 1960 that means about three years old you may wonder how when my father taught me how to read so i know this arise awake and stop not till the goal is reached and later i met swami chinmayananda who mentioned you keep pushing the coal so that you keep achieving a peek at how it all began so i was born in madurai the historic temple town in southern india which was a i mean it's a very old temple there but i was born in the government asking hospital which is now called rajaji hospital i'm glad mothra is known for the hospital and my grandfather and my father we were all from there and i started this journey with blessings of my mother my father my guru dr madina and i knew him as a school kid because my father and grandfather were osteomorphism because when i came to mumbai i didn't have friends i didn't have mentors i knew people i had acquaintance i had doctors referring me patients from all over india including bombay and maharashtra but i didn't know anybody personally would support me and then finally or rather all the time god and my father apprentice and grandfather progress were government employees and my father dr anderson support for my success and she was a great support i am very proud of my parents for holding me into this position when i was in there i was a kid everybody used to wonder it was like a child labor when i was done with the clinic patients at home i would like i looked deep into my dog's eyes and actually used thermoscope at the age of 10 to check the dog's retina and i saw something glittering i still cannot forget what i saw it was glittery and i stuff so my love for ophthalmology began then and i actually decided to be an ophthalmologist at the age of eight when my family friend though who's the founder of vg paneer golden beach mentioned to me convert your dream into your prayer and pray that tell that everyday night get up in the morning and work for it and you won't believe it even thinking back my prayer was i should become an internationally renowned very good eye surgeon i just become but nothing is automatic and thanks to my guru doctor senior medicine chairman emulators and one step must start each journey and a constant inspiration for me all the time is from awakening i quote him stand up be bold and this is all for you be strong take the whole responsibility on your own shoulder and know that you are the creator of your own destiny and that's what i did when i did my fellowship i thought shankaranetha was mine and sm stands for shankarnath and sn also stood for s rajan and life is a series of experiences with which one should follow intelligently and that's i'm using the word intelligently because if you see that al pacino sunday speech which is a four minute speech which he gives to a losing soccer team you will tell that opportunities in the front of you in the side of you and behind you it's only one or six inches this way or that way you win the game or lose the game so people who are ready to be a part of the team will win and people who are ready to sacrifice and ready to die also will win and that's what i did in 1988 i was offered the position of head literature surgery at the tapar institute of thermodynamic hospital and continued the work till 1990 but in that time before that the previous surgeons were dr usakar and dr who are only doing one or two surgeries a month and i think i asked for accommodation they gave me a five percent interest loan and i took a house i said i without help they will not come i performed about thousand five hundred rental surgeries from october 1989 to 88 to 1990 july and it was a wonderful learning experience because it was like a stage which was created in bombay for everybody to see what was with natural surgery and every time i still remember i gave my card between actual surgeon to a gp and i don't know why he asked me are you anything related to any rectal surgeon he asked me i said why he said it's rhyming i said then i it it actually said i said the word which is there in every toilet in the flesh and in the wash basin but i don't know why you don't understand what is but anyway i put eye specialist and material surgeon because it was terrible but i think i said who if i am not proud of my speciality who will be me proud of my specialty having come from a disciplined and traditional practice that is shattered mumbai is energetic bus and the city's work collect attitude was perfect for my setup one day a chairman from bank of india who's known to me dr sini wasan was imprinted with his voice treatment casually told me why are you not working for yourself and you're working for a bombay hospital so then i said who will give me loan i have i don't have anything on my name he says no you talk to the technical department and then we will help you and this was a thought that kept running over and over in my head and since instruments were not given to me in time i they had the series 10 000 that time without me unit light pipes were only few it was break breaking i had to buy then if a cutter was not that i had to buy and i said what sort of hospital i'm working and every sunday i had to do a cme to teach what is which is retina to the whole mumbai i had almost talks in all the club the mumbai particularly word c word d word and uh medical brotherhood the other uh medical association medicine so i think i had to popularize my specialty because nobody knew what was material surgery in bombay in 1990 and then finally i i think i started the arith that time and everybody said and i have this child psychology when anybody says you cannot do it i will do it so they told me that you cannot start with natural surgery in private practice but i decided and i still remember dr nick paul always appreciated me because i think even though i didn't train under him but he told me even i had to do cataract and some 10 of his friend who was oculoplastic surgeon who worked with him in the retina eye care center in the microcontroller's place later now manish network is doing exclusive but in the beginning he also had to have uh other parts of the but i exclusively started with retro surgery mumbai is an expensive city after all being the financial and economy capital of the country and mumbai alone contribute to more than five percent of the total gdp and 25 percent of the industrial output mumbai is the financial commercial and entertainment capital of india and in the hub of bollywood and attracting thousands of immigrants all over the world india the largest port of india new airports textile bills mobile is considered now as the central hub for trade industries and business but in 1989 88 when i went there was no exclusive surgeon and real estate in mumbai is very expensive so i started my private practice as ayat hospital when i needed money to take this drastic step i did so the loan from a bank i borrowed even the 25 percent from the beginning so i used to tell you the quote i wear was i was playing compound interest and i almost paid 30 interest in 1990 for the 25 percent of the initial load which i have to take a private loan to get that i took only a 60 lakh loan but i know that i went through i won't call it hardship because i loved every part of my journey slow and steady for a while it was but soon things took off my mantra during tough times creativity is just not going to the moon but living effectively on the earth and this is the building when i in 1990 when this is the sheriff of mumbai that and i told him you can be the chief guest but will inaugurate he said how can it be i found the chief that i said no but i knew him and he was a tamilian but i it's still july 15th he said it will be raining and i cannot take a helicopter from pune because the monsoon season the governor was living in pune not in mumbai so i said no problem yeah i will not change the date because i have fixed the date and after you can see here he inaugurated the hospital and dr jian rao the founder of ali prasad was there as a guest of honor and nana who was a sheriff of mumbai and dr you can see dr kuresh musketi in the background dr sujal shah he inaugurated the elastic center in 2001. all this in the other when everybody thought that the other is the laborers area and i still remember the chairman told me that chairman of mumbai is like going to the other is going to uh the laborers area and gradually perseverance better financial planning and share hard work i would say work with passion gave me the means to open a bigger and better idea in the presence of jian rao dr winget and many others all the best institutes and i follow this patient is the most important customer in the hospital and not a customer the patient is the most important in this thing so i think we all work with the patient centering and setting up a private practice is great for the economy but i felt it was equally important to give back to the society which got me wondering how can i help mumbai so dr abdul kalam gave me the new foundation called the rather idea foundation for tweaking that little life which i am now covering all the slums of mumbai and we have touched about eight million people and we do i donation program and you can see that's the old building and 2004 to now is this new building in wadala and we had a i had that first mover advantage i was the head of champion italy i was having a holiday institute of medical sciences and also the head of the heli prasad in installing wide-angle observation system many things i mean i think it's all history now and then there was a article all that that that matthew the doctor attracted and i think yeah and then we have i wanted to when i left championing they asked me what is my address in mumbai and the letter comes even today without anything and we also made the first project of carrying remedial camera on the motorbike which is the first of its kind in the world we have interior research institute vision sciences uh and then also we have now got a 10.5 crore loan with six institutes that i think having the iraq clinical trial network which is one of its kind thanks to government of india so friends and to all the post graduates and the people who are assembled here the seven secrets of success i found the answers in my room the roof said aim high the fan said be cool clock said every minute is precious mirror said reflect before you act windows said see the world calendar set be up to date doors said push hard to achieve your goals and this is paul coyle who says when you want something all the universe conspires in helping you to achieve it you are the block because you will decide oh how can i be the best surgeon or how can i have the big eye hospital you are having doubt so don't have doubt and five peace which i follow perseverance perfection patience prayer these four i borrowed from shamachaw's dance group and procession as the veterinarian surgeon have added and this is law of attraction by ronda band which is there in sanskrit yet whatever is going on in your mind is what you're attracting we are like magnets and you become and attract what you think so my dream is to now look at nobel prize for working something where the millions will be benefiting by doing research in genetics genetic engineering artificial retina or sexual stem cell think big let that one idea be your everything so i thank my fellow driver here and shubha for preparing this and thank you very much for a patient listening um so you are all you can ask questions and that was a great presentation sir a very long and happening journey and i always i mean uh there is one thought that it's like uh it was back then there were no retro retinal surgeons so some i mean there is one side of the story that there are there was no competition so maybe it was easier to start but then i if i think for today if i am planning to start exclusive armd clinic uh it is like that so limited number of patients and even today people are not thinking of starting only exclusive retina uh it's difficult to uh like practice so only retina it's always good to have cataract surgeries with you so that um but it's really great so i think we will start with our uh question answer session i mean dr divakant if you can you all get energized when we listen to you uh so uh a lot of key points from your presentation but we'll go one by one and we'll start right from the basic thinking about a resident a first year resident or a final year who is thinking about taking up retina so the first question would be like is if somebody has is about to complete his post graduation so how he should go about if he wants to take up retina how to approach his residency uh so that he is uh ready to take that fellowship i i think the i recommend everybody to read surgical self-education last chapter in my material micro surgery by steve jobs even though you are not going to do literature surgery you are just doing your post graduate but the last chapter is very important because you have the steve charles is explained that everybody should have a temperament for doing natural surgery one it's a long surgery second your back has to be strong and then you have the mind also has to be there and i always it's not that catastrophe you don't need your mind but unfortunately all our ophthalmologists everywhere in the world say oh cataract surgery is few minutes but nobody has told the patient that you use your skill development using like for even to learn fake or you use both hands both legs high hand coordination i when using the microphone now we are using 3d so i think one year aptitude you have to check yourself are you fit for doing with natural surgery and then are your neck and lumbar spines are strong because you would use indirect a lot you have to use a sit by a central ambient microscopy a lot using a 3d and holding the lens like this you can have a shoulder pain are you doing really some weight some stretching some gym and everybody says i don't have time if you talk to steve charles he'll say between surgery you run in between the ot and in between opd also he does that and he doesn't sit and same thing i do i think you have to be one are you when you see when i did fellowship some surgeries have lasted for eight hours and i still wonder what did we do inside that with this cavity for eight hours i really don't know and by the time that iris is gone the lens is gone the cornea is gone and then sometimes i wonder what do we do because by the time the end of the surgery corner will be adamantly so i think now we have come to a technology where we are doing as transcendental transconjunctival and i think the finally is the acumen what do you have which is a self-surgical education so i also written in a recent book along with drastic surgical self-education because i believe that well you should have a checklist and i also recommend atul governor's checklist manifesto you have to have a checklist for yourself one is you have do you have binocular vision do you have a good vision serious second is are you having that panoramic vision you know you're going to you see inside the eye and can you observe when you're working on sometimes people see where see the fundus they don't have any uh methodology like you're seeing the optic this and then the periphery they will see detachment did not look at the optic now or while operating first question i ask every fellow after buckling what do you see first they fumble because they don't know what is going on in the surgeon's mind but they only look at the side mirror or the side tube so i think the post graduates should assess and they should not design for example they are working in a medical college where no retinal surgery is done stirling is aspiring you should go and do a visiting fellow in any of the institute and check whether he'll be able to cope up with it when i was doing my post graduate when i wanted to do micro surgery i went i went to dog and then when i came back after the interview and i'm saying i'm joining a lot of assistant professors in the call hey come on man retina strategy means or not so everybody was discouraging but now i think every city every town has a veteran surgeon and i'm proud of that and i'm glad every witness of surgeon in mumbai is happy because i have kept a fee so high so that fortunately any surgeon below me will be all right any junior so they can always say that say we are half of documentaries so that whenever they cannot afford me they go to them because i think everybody has to survive and i think that is important it's no point in only you are becoming richer you are becoming good i think all around you people have to be good so i'm happy i think there are about 200 electron surgeons in mumbai but i think about three thousand surgeons so i think one is your aptitude and the second is half the people say oh alright how can we invest so much even i i thought i had that i should confess here when i left shankaranita i thought vegetarian surgery is not possible in private practice so sir is it that do you think that they should uh before a resident selects any fellowship should they invest more time in improving their skill in general often before choosing any speciality i always say that one you should be a excellent clinician that means oneness clinical achievement cells that means that the bedside manners of the patient so right from this gate i still remember once i was in a drama hall one one old man with a stick and then i was sitting in the wheelchair caught my hand and asked me dr natalian do you remember me i actually didn't remember because he was looking thin he lost weight and he was actually a tall man when i when he told me you know what he had he had a cerebellar tuber and i think just by his gait i told him you have some neurological problem so when i examined him i saw some then i asked for the field of vision and then sent him to the neurologist after he never came back because he was i went to a neurosurgeon and operated but he was surviving he told me because of you i'm surviving so i think i forgot what was the diagnosis some aneurysms somewhere the neural surgery so what i'm saying you have to be a good clinician that means overall you should not be only written i mean you'll see only retina and not see the optic nerve not see the cornea i think you have to be a good clinician right from taking history even today i think you will remember i think i'm very particular of history you should know to ask a pertinent question automatically you get the right answer so i think you that you develop by clinical so you have to be a good ophthalmologist you should know everything about what is happening yeah no right or whatever the latest happening in cataract whatever say i used to tell the patient to lie i don't know what's happening because i don't want them to ask me questions on cataract laughing even in the party i tell them i'll i said actually i'm not i lost the patience of answering them what is the last thing what is cataract and everything i think you go to the we have a big team so i think when you're doing you should be thorough particularly when you're doing ms you should make sure you know everything enough on your own somebody also because it's not that old now separate everything is together then i think you can branch off in the meantime i when i did i was doing like a extra capsule cataract and i also done inter inter-capsule cataract with the forceps so i and then cryo and then like when i came to rockville everything was micro surgery before that was not even loop it's a naked eye surgery and no glove so later now i have a double glove because i started the first protect me for hiv patients in 91 i think when even hesitating so i think you have to be a good clinician good clinical equipment and you should learn to look away i have a methodology of examination so i think you should be a good eye surgeon then become a good microscopy anyone right now everything is a micro surgery so i'll be a good micro surgeon and i and then uh i become a witness and now i think people are i don't know if they are when he's trained whether he's doing combined surgery i'm adamant i don't want to do but i like talking gopal doctor i think they promote bender and told me they have later got trained in feko and then they're being combined and i use the time for going to the next 40. so i think it's up to student that if they feel confident then then only they should go ahead with the future fellowship programs here exactly because material surgery is time consuming and the patients also have so many questions and then you should not give up and you should see how your surgeon is dealing other than other mental then you take him so that relevant question whether it is important to a specific number of cataract surgeries before one plans to pursue a vr fellowship i think you have partially answered that but somebody recently asked me is a thorough knowledge of cataract surgery required to pursue a retina no finally it's a high hand coordination so main thing is the number i don't know why every i i remember answering this in the uc also everybody is concentrating on number of surgery but i think nobody is asking how to be master of every step so for example if you do a 10 cataract and do every step at the 10th case perfectly i think you are achieved and then after that every case will be automatic but if you make a mistake and same thing continuing and then you are not improved whether you do 100 surgery or a thousand surgery you will do the same mistake and then the same thing will happen so i think the number is a myth i think because somehow the medical college i would i don't know whether it's government medical college or private medical college they say i want to i mean even this fake training which has become a business of getting doctors from medical colleges and they have not done cataracts or fake they come and they say i want to do 20 i don't want to do 50 but i don't know nobody so i recommend the book called concise mastery by richard cream which says that also there's a thing called clinical mirror neurons where when you see people doing you can register in the brain and you can do it even though you're not trained but i think for that you need that capacity to observe continuously and practice that so i think number is not important quality of every step is very important if you have seen your own recording even for a cataract surgery you can in the beginning you will see how many times you are using the forceps and catching the conjunctiva for no reason because you are thinking something and doing something so thinking and doing has to be same that means you have to concentrate focus so the power of concentration swami yogananda has mentioned he says then automatically everything will be perfect it is like a capture excess they say i had a bad day so my capsule is not gone well how is it correct it's not it's not correct because your mind is not good so you should not operate them so for me i get angry but nothing will be seen in the patient there's no connection totally disconnected and it's what surgery will be the spinal level so i think the number is not important but i think the quality of tray each step is important when we did fellowship every patient we can't open that fully swollen because we are handling the eye for six hours so you can imagine whether you say put a speculum and stand under the specular under the shower can you open your eyes for so many minutes not possible but we put so much of a ringer lactate and bss vss plus and once i remember uh the sister gave me distilled water and i was putting this water on the cornea and by the time dr was doing the cryo it was white kanye was totally white and it was terrible so i think mistakes can happen but it cannot happen again so that is why checklist is important that surgical self-education is important and then we i use ask every time what is the injection you are giving mistakes are happening all over the world gentamicin wrong dosage optic nerve is gone and then giving lignocoin into the eye so i think everything will be because you're not careful and usually you're not mentally trained so i think i have a checklist for so many things we have a fellows manual i think it's almost 100 100 pages i think yes sir it's like more uh of the students right now they are more confused uh between choosing medical uh fellow retina fellowship or surgical retina fellowship so what's your advice on that so so i think a medical retina is in a way i've seen when the specialist was happening in the in the u.s i was wondering how come they are separating medical and surgical but now i see medical retina isn't again an art because you have to study oct octa in depth and a surgeon has a really a fast look okay michael roll will operate we'll do this but i think the various layers of retina when we were doing a pg we are studying 10 layers of retina and only for example we never thought we can examine i'm happy i introduced the first row city in india and alvarez what are you going to do with it i said you know whatever others cannot see i will be able to see those cities now everybody wants to have oct to practice so i think medical itself is becoming vast so no so many new drugs coming and then there are a lot of refractive problems in amd and diabetic metal edema so i think definitely a person who is not inclined to do prolonged surgeries i think for him if he's interested in retina it's an again it's a science and art of doing medical economy i think so many things are and particularly the new challenge which i'm planning to write a book is inherited natural degeneration it'll come under medical letter right now but one day it's going to become surgical retina and inject the gene in the vector in the subactive space so it will come to between the surgeon but as of now a phenotype and genotype is in the medical retina at least to evaluate the patient erg then eog and then you have the fundus photo autofluorescence and also red free so i think you have to learn to see my my new things so that you can look at more and more of smaller thing and become a master of only the math lab i think those who don't want to leave for doing fecal surgeries i think medical retina is perfect choice for them because when i was choosing doing a fellowship i was also confused that after doing my fellowship i won't be able to do faculty surgeries and i was so much in love with fecal surgeries so that was the confusion but i think medical doing medical retina a fellowship will give you that choice uh that option that you can continue doing your cataract practice and along with that you can have your retina practice as well so i'm better but there are also medical specialists in the us they only do medical responsibility so i don't know i think i i know dr class said he was doing plastic surgery oculoplasty he was doing an amazing wonderful contribution in retail surgery instrumentation and he'll look at right either he was doing screen so he'll say what is the problem i said there's no problem but i said where is the time what he was doing he was doing from morning seven to evening six and we both started our career together and anyway i mean he's going to retire i think but still he's doing amazing and same thing with stanislaw reserve and he did the one of the maximum number of rtbc italy but he said he's a self-styled libertarian surgeon amazing what a contribution is doing in the floor right now which is now happening so i i think that's another thing where a medical record also is a really advanced doctor he also is very interesting if somebody is interested in all layers of vector yeah and i think ocd and you still a lot of things have to be answered in a diabetic and amd where people will they can be the experts because they can see better than what the others who are uh doing a custody thing so i think exclusive medical also is possible for example somebody uh as a like a man sachi you are a daring literature sergeant kirobi is a direct natural surgeon as a female i'm saying and even the uh my friend in puerto rico forgot her name um miracle so i mean all of them do well but i think there are so many doctors i know they want to do nine to five that means they want to go hour nine to one and they go back uh the first five years of life of the child they don't they want to look after the child because they may not have the support like you have even success feeding her child in the hospital and then in between surgery she'll come feed the child and they asked she asked me permission a lot of doctors were jealous how can you allow that what is the problem i gave her a room and she did it so i i think for me the patients also were benefiting because she was an excellent surgeon so i think career and private practice you can choose so if you want to choose a fixed time because medical right now you want whatever emergency you can for example night you have a sudden loss of vision with the you can definitely see the patient next day morning nine o'clock you don't have to do anything in the night unless a trauma but is a we are surgeon doing trauma i first ten years i was on call day and night when i was in city of course i was traveling also yeah so it has good work-life balance also yeah that's right yes and also excellent science so many people may think i think i remember when the uae is fellows fellowship was not there and dr jb did a ufo one of the first to do uh his finish and come back in 1889 i think he came back in 88 i don't know 87 until he came back i think and i think that time i used to wonder what is there anyway it is it's only steroids but i know now so much yeah i wanted to document history investigation and ask for the right investigation so nasty now used to be you know i know him very well so you should tell me you ask you you are standing investigation some report will come and if it is positive how do you correlate so don't ask for investigation when it is not relevant yeah yes so what the mind does not know i do not see yes the discussion dr priyanka has asked in the chat box whether it is feasible for a female to start a set up a private retina practice in 1898 he was talking about the women in india and i think he said every woman is a mother and it was for some in some part of the time so he says if you respect your women in india india will become great and we call it a maratha so i think there's no question of female male but i am i welcome i think and if the females do well i think we should compete again healthily and we should not be the indian crab with one crab going up ten traps pulling you down no you encourage so wherever you are you can do it and that's what is my talk i started this in 2004 that barack obama i started saying you can do it and barack obama in 2007 when he did the election he said yes we can and then i tell that uh also followed me yes definitely we can i think i can do it and then i want to say now sachi has got three clinics and she is doing three with a private practice so she is more than two i have only one practicing we are only at once uh centers or not all in all the three centers yeah so i i wanted to add that it's like a better option to do a private practice for a female in a way that it offers you more control over your work should you the headache was to control convince some hod some chairman some purchase officer some department bed everything was a problem so when you start your practice and that's what everybody asked me what is the difference i said earlier the headache was because of the others here the very very index finger of yourself you know you will decide what headache you want to take for example whether to take a one quarter load or tweak a two crore load or a four cruise or whatever so depending on that if you say we say tamil whatever is the size of thumb you should have the swelling or a pain uh like any inflammation the size of the thumb but if you have like an elephant what will happen you can't manage your thumb no so that is why i think no i think there's no problem in there i only will say be ethical be strong and be bold and plant well see i think now we have a help with the people with finance people for uh planning strategy and when we started i remember even chat accounted i was not willing to meet you'll ask me how many ultrasound you will do how many this will do and you will tell me you have to daily do two others when you say this much is the cost of b scan you have to loot so many cases and i will remember the just like hospital asked me the size of the room is this much eggless is this much and the cost of this room is so high in just look hospital so we will charge some 10 000 i said who will come to you everybody will come to me i told them so i think the problem is even charging even though you're spending so much you can't take it from one patient i think that's where the numbers have to be more so you have to do scientific marketing and i i think that is very important and be truthful never put anybody down and i think you may be the best you can tell you are the best don't tell that i'm better than him so sir as you said that uh i mean in us they have this practice of being i mean reading a specialist coming together and starting a group practice i think here also people who have recently finished followership or who are thinking of starting at the beginning they can start a group practice so that financial burden is uh shared and uh yeah everyone has their own group and they have a lot of patience and that way it becomes little easier i think correct i think joining hands is important but the only thing we see difference between india and the uss in india somebody becomes greedy and that's why i i used to give a talk when it is like a pilot and a co-pilot luckily they are trained well to work together and so here it's like a plane taking off and two people are fighting then you can imagine what will happen it happened i think in history pilots fighting but it's very very rare maybe one out of 100 000 anything but here in the practice if when you start together and you have then something have different opinion so we should have exit class also clear okay we will practice for five years and i will not practice in the same area no something like that and the american has non-competence agreement it's like preview pre-jupiter agreement it doesn't work in india so i think we have to find our own yes yes so i am practicing exclusive vr as of now but one thing that i've seen what has happened is that that awareness amongst the public has increased in terms of recognizing the speciality so now people know that there's something called a retina specialist and i have this problem and i need to go to a retina specialist so if one is able to establish himself another brand that you are the vr surgeon in that region so it might be possible to establish an exclusive vr practice and developing proper referral channels so that can definitely work but as sir is rightly mentioned it will require a lot of dedication and conviction to establish that kind of practice so sir after fellowship how many years are required to before starting your private practice i mean what do you think i'm should we should they spend some more time practicing their specialty and then enter into a private practice or they can directly go ahead no again again you see as a fellow in 84 in the first month itself for some reason i had to start protecting me even though i didn't know when i said you don't know how to start a case and he said you start i started and after that i started doing with your strategy from 84 itself which is never heard of because nobody was not sharing with your surgery at all with anybody so what i'm saying again how confident you are that's why the surgical self-education you should ask your own question how many techniques are done on that situation and see whether for example you start private practice in the first case is giant title tear and in case you are not well acute mentally and surgery clinical acumen and surgical expertise and you take it up you're going to screw up there and what's the point you know so i think yes and then you can tell that you should be you can tell see i've just started practice i'll prefer you you can have an agreement with the either your mother institute or which is in the same city or where or a senior surgeon saying that i am now doing this i like to do the cases which i am confident now i i prefer you go to him but follow-ups i can do for you and the problem here is ego they don't want to send a patient which is another problem i see so i don't have ego in this age also even though i've done so many thousand surgery sometimes when the patient says i want to go to second place i only tell them there's no senior to me unfortunately in india now but i said you go anywhere i'll give a letter i'll call them and tell yeah i'll send you then they'll say well by the time they call or whatever they say any i mean war seniors available in india everybody knows me and they they if you have to take opinion even abroad they'll tell me why are you coming here if not operating either serious experience what do you want to come here so i think that gives them confidence okay but what i'm trying to do i don't know ego and asking what should i do this pain like you asked a question and yesterday i have not answered i saw the answers by others so i think it's important i think uh it's after doing a fellowship if you spend two three years uh working on it then uh like in fellowship what happens is like you are always there in back of mind you always know that your sir or your guide is always there and if you uh make any complication or make any mistake then he's there to take care of so i personally believe that you should do uh some surgery some years of experience on your own without any uh like help or guide behind you and see your complications answer their questions counseling lot of other things you should practice little more one to two years uh and then you should start your private practice because that will help that will help in increasing your confidence and in the practice as well correct the answer yeah because it's like if you have given already answers to the patients when you when there are complications then you know how to deal with such situations right because it's like in a private you are alone to tackle such conditions so that's the thing so there was also one question of like people were confused that the whether they should go with uh senior residency after uh before the fellowship or after the fellowship so i think in that also i think uh-huh now what does senior residents you are telling that is i thought only names no sorry it's now every institute is having a senior residency and uh if you are applying for any government post then one of the requirement is that if you you should have done the sr ship for one year six months or one year i'm not sure but they asked this requirement so uh like uh those who want to join a government uh set up then yeah no no seriousness you can do it anytime like after residency also even after fellowship also okay so do i want to say something yeah it's usually after residency that people join uh but i think uh can you hear me yes yes yes am i audible yeah yes yes so uh in terms of senior residency i think uh that is more required for if somebody is looking for a faculty position and a good fellowship is a wholesome experience and you can probably follow it up with a senior residency to hone your skills if you want to join exactly some place i think both are not a substitute to each other because in a lot of places we have seen that uh the senior residency is a bit diluted apart from rpc i think the other places they rotate you amongst different specialities and you're not really sure that you'll be pursuing one single speciality so i think if you after a fellowship you can find a senior residency where you can pursue withdrawal then that how much roughly how much investment required if somebody is planning to start a basic uh search i i think when i started i wanted everything i want to compete with america i didn't want to compete with anybody else less than that so i had everything what they had and i had one thing about america did not have biome and europe also switzerland introduced biome but nobody was using in germany also and same thing happened in japan and i think only a few centers ahead and nobody was believing bio so i thought i should have one up and i did it so again what is that you want to concentrate for example you can now have a good indian machines available so depending on the budget and depending on the place you are practicing but how you can take the return on investment the financial guys talk so all that i didn't calculate i think i had that idea i will do and i will get and it happened but yeah i think that is because my conviction was very strong and as here i think now with the competition with the now so many people taking giving loans and you can extend so again depending even taking a loan i think a lot of instruction forces were there in all india by telling how to take the loan and plus also whether to take so much so i think you are it's exactly like how much you can manage for example like if you take one crore loan but can you manage your title so i think the number will depend on type of instruments what type of instruments you see and type of practice also you want to do and the type of patients also for example you know i am the most expensive surgeon same time we are having a charitable clinic we do free also so i tell them you want free you don't ask for nutrition anybody will do i may do on my own but i will not ask somebody cannot ask for me because i'm an exclusive surgeon so what i'm trying to say is depending on how you can do and i think there are patients even paid me 10 lakhs for a surgery because same patient wants to get operated in the us and then when they come back and they tell me like us they told me it's tough so i operate fine i think these people in bombay they can pay the doctor to come to what you call us and come back and they insult that they pay me and i think so again where you are practicing and how's your clientele and for example i remember in 90s when i started at that time the feco was just coming i did [Music] and he got a beautiful hospital so he had that uh legacy machine that time and everybody involved was charging 21 000 or something that time in 1990 then he was charging only seven thousand i asked him how is it you're able to manage he says i do more number of surgery and i remember a hundred kilometers from rajcode somebody had a lastic uh my friends only and i i think they could manage because i think the conviction and and then nothing was available around and they could do more numbers at less cost so again this pricing competitive pricing then uh i i knew this will money who sold this company to further so he always told me he was a disrupter he says the blood sugar or a hb1 ac if others charge a 400 he was charging 200 and he said this cost price 20 rupees only so i think uh while starting the practice it's like what instruments you choose is the main thing and i think uh if you like what i did was that uh ocds must and it's required so you choose a machine where they have a lot of features with a lower cost and ffa is unfortunately in a way it's not that mandatory sometimes so i uh bought a machine where it's a smart scope handheld so that way i was able to control and keep my budget uh in rain and also i thought that again biome was one thing that you need a proper visibility is extremely important during the surgery but machine is something that if you know how to do a surgery or if you know the machine then you can uh do well so uh i went for uh reticular rather than constellation because that will like make a huge difference between your budget so when you want to start a practice you can always choose machines which are like you can always juggle and like select the machines which you want and then later on in future you can invest more and then uh upgrade your machines i think that way we can start but always i think medical retina setup or surgical retina usually 50 to 50 lakhs to one crore it takes i think right now and also there is option of refurbished instruments also that people they go for to start with they can start with refurbished machines and then later on they can buy their own so that should not be the limiting factor if you are really keen on starting your private practice now that is because i think the fellows are trained in institutes with their high-end machines and then they are feeling bad to go down but i think then they should actually ask for that trial and then practice in the if the institution allows to use that machine and become expert so i think finally you have to be the master of the technology and not when i did my first uh vitrectomy in private it was first time on the reticule machine i haven't never operated it before but at the same time i mean because of like fellowship and after four years of experience so i was like able to do it and i mean it's good enough machine so you can i would say that if someone is thinking of a budget and problem is there then they should go for lower end machines also they are fine they work fine so how's the professional satisfaction in retina practice well as i said i started from 84 and i have seen as 82 i went as a volunteer when i was doing my pg and even before that when i used saturn the early morning classes so it was actually everybody was wondering adrenal surgery means the patient will not see but i think for me like i have a lot of one night patients who come as a with a detachment or which is hemorrhage or any when they get a vision we are the only hospital in the world who are doing a thing called celebrate vision that means the patient gets vision i i buy a cake and cut in front of everybody in the uh with a patient custody and we have a interview if the patient wants to do and we put it as a happy smile on youtube so i think the my satisfaction is amazing because so many no pli's i operate in a trauma particularly in kashmir and then also when everybody said nothing can be done i have done so i think and i tell the patient i operate if the eye becomes nice here what will you do if you are going to cry or if you are going to fight why operate i don't want the only professional fee i want to know what you will get so i i'm telling you so i think the professional satisfaction is really good and i think in the first 90 to 2000 i always used to tell the patient for me i went through is fine the patient will say i'm not able to see it doesn't matter i tell them when i convince them and i tell them no problem everything is fine i said if you are not operating what do you do and then i tell them you want to go for a second will go but what i'm saying but still it is uh very very satisfying yes because uh i really i think patients understand after a long time i have a challenge one patient is reading so much now and i forgot suddenly i remembered i have not answered in the morning i mean so many questions and she has asked me a question i think i should ask you she written something like victoria's skirt i didn't know what were following attracted me which is skirt i don't know what is that meaning so what i'm saying people ask so i encourage malcolm gladwell said if you spend 15 minutes with the patient and then you think everything is fine but if you spend three minutes extra the medical legal case comes down drastically so i think the last question should the patient like you should ask is do you have any more question and the patient should say no more questions and then i think it is satisfying because the yo they bring their expectation to reality and i have another big problem because patients think that i am god and that everything also patient told me i am gordon retina the patient vision is only pl and if the total cataract ac is flat and then the surgeon i don't know why from indoor told even 70 which will come back when you get there when you do these oil removal and through the total cataract some gap i could see there some fibrous issues i told you only one percent chance he was very upset then we needed a carotid doppler he's got a what i'm saying is you have to bring down the expectation to a reality but even sometimes in spite of that patients tell you you told me you're 100 guaranteed even though i have not told so i think we have a video recording now video consent but i think finally it is really gratifying for me i think because i wanted to do micro surgery and 84 so many people told me you have taken with neutral surgery you are doomed but i think i am grew up with surgery and i have seen all the pioneers in meteorological surgery ever from femi taco [Music] he used to tell everything about history about dr aruga jules road and all these views i met every a person who has found something in retina so i'm glad the whale would have to be meeting again only 100 br surgeons are invited and i'm there from 96 so i'm going 20 20 to also hope so with the travel so i think the that i'm enjoying so internal strategy i'm really enjoying because the name same money i got only through it yesterday so it's really very gratifying with newer instruments and uh with gas and everything even after doing retinal detachment surgeries we now in today's time we still get six twelve six nine six six division sometimes correct is really gratifying yeah yes yes yes it is yeah so what about the international fellowships i mean what's what do you think about international fellowships no i think you should have fellowships like where alibecker went and where you have the uh or even dr the ashish from uh south africa but if you don't get a chance and only assist you'll be frustrated so there's like observation so i think you have to go to the fellowship where they allow you to be a that means local license they have to give you and allow you to operate see once you're experienced surgeon you can pick up from international centers which i recommend if you have the time money an opportunity you should visit centers go to the ot observe you'll learn a lot dr dewakan can add more points i think you have done fellowship in bayer's institute so as sir had pointed out so i have a little different opinion on that see in india we get a lot of surgical opportunities so i think it might be a good idea to explore that opportunity in terms of research and exposing yourself to more cutting-edge technology attaching yourself to a great international mentor so all these things the time i i spend really little time at stanford but it was a great learning experience for me so i knew that the kind of surgery that they were doing we are doing that on a regular basis but the way they do things the way they approach the cases the way they are able to uh involve the financial aspects and all of them are involved with some uh some initiatives some these kind of things so these are the things that we can learn from them so spending a short time maybe three four months there add a lot of value to our practice sure so how to get into those fellowships i mean is it a is there a short answer to that no there is a international what do you call a fellowship ico internet which i am a trustee where you have 5000 they give for a fellowship so you and even our hospital we have fellows from abroad coming so three months they are low so they give you 5000 dollars to manage so again the host institute has to agree and it's possible so i think what yeah i'm saying that observer ships are easy to come by so at least you can start with that ico is a wonderful option yeah i think for that we have to clear those ico exams for the fellowship is it required is different but they fellowship i think they got to apply and then they were evaluate and then they give to the host institute okay you can choose your score in the ico exam matters but it's not uh there are a lot of people who have done an ico fellowship without actually qualifying all the exams so it adds to your score you can also pursue one without actually completing all the steps yes okay i think any more questions to ask doctor i i think the only point which is very good if you have an international mentor you like for example ashish sharma is now co-author working with them with all the top medical people in amd so like that i mean also will have that rapport and it helps you to be otherwise as an indian alone very difficult for you to be known all over the world if you're really internationally you want to be famous but i think if you want publication you want to be known i think better to have international exposure as he said you have to go with an idea that you are going to learn something daily then you should go i remember in 87 when dr told me to go to johan which i refused i told him i am i want to be experienced here and plus i said if i go abroad i will be probably flabbergasted with the europe and other things and not the real surgery so when dr jivanov came and told me that he i have a golden hands i didn't even feel like wait but 91 onwards i went because i was again one of the guest faculty there for three years three terms which is a great thing to be a part of teaching in europe so i think uh international definitely helps and you should use it yes and as you said sir that in between after uh working for some time if you go in between then that also helps in brushing up your knowledge and you can add actually when you are already practicing then you can actually learn a lot of things and you have that eye on looking those things that we should learn these and we should adapt this for this technology so and also you will be more more confident seeing similar complication happens in diagrams also yes and how to manage it when it happens so there are two three questions regarding which books are good for to learn i mean during we have fellowship to read before starting so i think one is a witness micro surgery by steve charles and i always recommend stellar the basic ophthalmic surgery book you should read and then the regular standard textbooks for uh whatever is the postgraduate reading you should do yeah another good resource is the american society of retina surgeons website and their membership they offer around two years membership to free membership to fellows so they have a wonderful website and a lot of resources are there all the latest general articles that one should be well versed with are also listed there so that is one resource that all of us can expect yes okay there are a lot of questions regarding private practice only after uh vr so i think that uh people but how to start a private practice and how is it sustainable and is it really difficult to start a year practice all those questions are there no it is exactly like starting any practice whether it's a vr or cataract so i think the question is you have to create opportunity look for opportunity i only say be honest be good and be bold you will be able to do what you want only thing is there is one thing called achiever another thing called all the time like it's like seeing the half class full and half class empty so i think we should have a positive thinking and also for example one bank does not give a loan for the other bank no point in getting depressed no yeah and or even a interest so i think if there is a problem i mean you find a solution that's why if you are going to start practice and you have a question how to start then better go and see whoever is started already see every i did that i went and saw all the operation theaters in india by including singh and many places i went then i made my ot and i think a similar thing i'm sure you have done that whatever you want so i think how to start is again your uh resources and mentally how strong you are are you are you a man who will take that decision and stand by or a man or a woman stand by that or can you take the stress of loan or will can you join somewhere and work for some time or do you like to work like a consultant nine to five then you're not supposed to on the first day of the my opening clinic in the early morning he said dr nitrajan i'm glad your standard prostitution he said i said how can you call that he's saying private practice you have to satisfy people if you're an institute it's different because as a fellow or a consultant you say something many times patients also take it but in a private practice even at this age at this time of my career with the highest number of surgery i have to be humble because my young halfway age person can also do better with general surgery than me and the patient will go to him and i think i it's not that doctor i remember talking you nowadays patient wants red carpet welcome right from his car so you have to do that but if you are not mentally ready for that i think better because i don't understand in the government hospital line that means you want the personalized special care and i tell them what are the if you can't give it then why do you want to do it so i always say high-tech high-tech high hospital that means high touch means human touch high tech is whatever technology are using and human touch is required in private practice and i think people are very smooth talkers but i want to say you have to inject like in a banana the truth like a vegetarian you can't be beating around the bush so i always tell them three things happen and i made a special concern you have either improvement no improvement or deterioration you will be in only one of them you cannot be in all the three see if the patient is not coming with me he'll go to you and all my competitors are happy because i already told them no guarantee chances are very bad and then when some other surgeon says if i say 60 and somebody says 70 they go and get operated and when they reckon they'll come back and ask her 70 political skills 70 people can do well or in another 60 people either way 30 or 40 are getting recurrence and who's that in which group is the one you want to know you nobody can predict and i always tell them the american constant form says that medicine is not a calculating science you can keep on telling probability but you cannot tell you will get attached right now don't worry it's a lie yes so if i tell them out of 180 can do well and you pray for it with 80 why are you to be asking for how are you asking for guarantee if you ask for guarantee i said so i think those who don't want to have a headache of private practice they have other options as well i think uh today nowadays corporate setups are there government institutes are there so what do you think i mean uh which one is the best part apart from private practice uh which one are the best pins what uh what are the questions like like government setups or corporate setups again it's in your mind no see everybody wants to work one is for salary that means money and the other is job satisfaction so in government if you are getting a job site is very nothing like it and i think there are people that some institutes have seen amazing so some you don't have an instrument at all and i remember in my time there with little surgeon they got a fellowship and came and they posted them in spin cleaning so how will you get job satisfaction so again depending on as he talked about senior residency same thing is about uh the job satisfaction in government or private there's no comparison so i mean jj hospital and of course has taken every instrument after i came and you know all instruments what we have jj has yeah i think sir they have advantages of like a better platform they to start with if you are starting with an institute then you get a better platform to start with in government setups that they have more they can do a lot number of patients so research work is good if you want you if you're interested in doing research then because in private uh it takes time to build up your practice and then research and everything is not possible in early days so i think that way government setups and even corporates i think they offer such advantages correct even in government here jj is well equipped and ire is well acute now and uh km is also well acute only now the cyan is having a problem so i think even in common the setups are excellent now so again depending on how do you get it yeah so i think sir uh almost we have covered all the questions even uh from audience also and i think ultimately it depends on you your interest what to do in i mean whether to start a private or join a corporate

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dr. S. Natarajan

Dr. S. Natarajan

Prof. Dr. S. Natarajan, Padmashree Awardee (one of the highest civilian Award by the President of India), is a luminary surgeon in the field of ophthalmology in India and the world. The Founder of the...

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dr. Diva Kant Misra

Dr. Diva Kant Misra

General Secretary at YOSI | Ophthalmic Hero of India 2020 | Vitreo-Retina & ROP consultant at Eye Q Super-specialty Hospital | Completed his training in advanced retina surgery from reputed institutes...

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dr. S. Natarajan

Dr. S. Natarajan

Prof. Dr. S. Natarajan, Padmashree Awardee (o...

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dr. Diva Kant Misra

Dr. Diva Kant Misra

General Secretary at YOSI | Ophthalmic Hero o...

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