Leading with Passion

Presidential Address: Vascular Society of India. Delivered on Thursday, October 17, 2024, during the 31st Annual Conference of Vascular Society of India held at Jaipur (VSICON2024). Dear Colleagues and Friends, It has been a proud privilege to serve as your President over the last 2 years. There are many who I met in my professional career, whom you could blame for me standing here today. Prof. S. K. Khanna [Figure 1] who got me into vascular surgery, Prof. Shigehiko Shiyonoya (of Shionoya criteria for Buerger’s disease fame) [Figure 2] who arranged formal training for me in Nagoya, Dr. Sakurai [Figure 3] who taught me that surgery need not be stressful, Dr. Nishikimi [Figure 4] who taught me to be a thinking surgeon, and Dr. Matsushita [Figure 4] who taught me to experiment. I have been fortunate to walk the halls of reputed organizations during my training that include Armed Forces Medical College, Pune, PGIMER, Chandigarh, and Nagoya University School of Medicine. Short stints at AIIMS, New Delhi, with Prof. SN Mehta, University of North Carolina at Chapel Hill with Prof. Blair Keagy and Methodist Hospital, Houston with Joseph Coselli, certainly added to my skills, knowledge, and confidence. There are others who played a major role in molding me as a surgeon and a vascular surgeon and some of them are Prof. S. M. Bose, Dr. Gurpreet Singh, Dr. M. Prakash, Dr. Aseem Bhardwaj, and Dr. Wasif Ali. Dr. Wasif incidentally gave me my first vascular procedure when I joined General Surgery at PGIMER: an above knee amputation for irreversible acute limb ischemia.Figure 1: Prof. S. K. Khanna, formerly Head of the Department of Surgery at PGIMER, ChandigarhFigure 2: Prof. Shigehiko Shionoya, formerly Head of the First Department of Surgery at Nagoya University School of Medicine, Nagoya, JapanFigure 3: With Dr. Tsunehisa Sakurai, Chief of Vascular Surgery at Nagoya University School of medicine. Now runs a Vascular Center in NagoyaFigure 4: With Dr. Naomichi Nishikimi and Dr. Masahiro Matsushita, Consultant Vascular Surgeons at Nagoya UniversityMy team [Figure 5] has stood with me through thick and thin and enabled me to spend time working for Vascular Society of India (VSI). While family [Figure 6] is often taken for granted, it plays a major role in our professional development and also provides the emotional support that we need when dealing with tough situations at work.Figure 5: Our vascular team in Hyderabad: Vascular surgeons, interventional radiologists, and podiatric surgeonFigure 6: The family is an important part of life: My wife Laxmi and daughter CharuThe Presidential talk had been abandoned few years back and I decided to revive it. What is the purpose of such a talk? Should it be an academic one: the conference is taking care of that and all academic information is so easily available nowadays. Perhaps a message would be worth passing on: my thoughts, my views on how we should function as professionals. One thing is sure, it is not easy to prepare a Presidential talk: I have had no experience. I wondered whether I should speak extempore or read a written talk or make a presentation using slides: I decided to combine all three. I will speak to you about Leadership with Passion. Both are subjects close to my heart and since the duration of the Presidential talk has been dented by a demanding scientific program and organizing secretary, I will not speak for very long. We have seen numerous passionate leaders. Some examples [Figure 7] that stand out include our former President, Shri APJ Abdul Kalam, Steve Jobs, Mother Teresa, Michael DeBakey, Nelson Mandela, and Martin Luther King Jr.. What made them stand apart was their belief in their cause and the zeal and energy to pursue that cause relentlessly: they were all passionate leaders. Passion provides unlimited and unending enthusiasm and energy.Figure 7: World renowned passionate leadersWe have a few examples in our society too [Figure 8]. I am sure you recognize all of them and I need not name them. I have found passion in all these people and in many others in our society. They have done or are doing extremely well in their chosen field of vascular surgery, are an inspiration for others, and I am sure that their passion has been a major driving force.Figure 8: Some passionate leaders in Vascular Society of IndiaIn life, some are fortunate to be able to choose a profession or career that they are passionate about and will undoubtedly do well. Compared to marriage in India, it would be like a love marriage. On the other hand, many of us came into this profession and specialty either by parental or peer pressure or by chance. This is like an arranged marriage. Here, the profession has chosen you. You need to develop love and passion to make it work and believe me, it is so doable. Passionate leaders have a cause to follow. Why they do something is far more important than how they do it. This has been the essence of Inspirational talks of Simon Sinek, an English-American author. “WHY” gives you a reason to do something. If you are passionate enough to believe in the cause, you will find WHAT you need to do and HOW you need to do it. As vascular surgeons, are we passionate about providing the best care for our patients? If yes, we will undoubtedly do well and always be ahead of other specialties. This is a very interesting video uploaded by Derek Sivers on how leaders are made and about the importance of followers. Please see the link: it will be worth a watch (https://youtu.be/fW8amMCVAJQ?si=KjVFgcLxXTqyMpdk). In a very simple way, it conveys how leaders and movements are made. A leader needs the guts to stand alone, even at the cost of looking ridiculous. What the leader does is fairly simple and easy to follow dance moves. When the first follower joins him, he publicly displays the courage to follow. The leader embraces him. Now, it is no longer about the leader, it is about them. The follower calls in his friends. It takes a lot of courage to be the first follower, stand out, and look ridiculous with the leader. Being a first follower is often an underappreciated form of leadership. It is the first follower who transforms a lone nut into a leader. While the leader is the flint, the first follower is the spark. The second follower joins them and three is now a crowd, and a crowd is noticed. The movement must be public since new followers see and emulate the followers, not the leader. As momentum picks up, more join in. This is the tipping point and now we have a movement. More people are now willing to join in. They won’t stand out, won’t be ridiculed, and will be part of the in-crowd. Everyone now joins in because they will be ridiculed for standing out. And ladies and gentlemen, this is how a movement is made. A passionate leader must do what he or she believes in, at the risk of appearing ridiculous or even unpopular. Remember, a leader must embrace the followers since it is they who make a lone nut into a leader. We say everyone should be a leader. No. Leadership is overglorified and overrated. If you find a lone nut, trying to do something good, have the guts to be the first follower at the cost of being ridiculed and convert the vision into reality. Leadership in Surgery All surgeons are by default in a leadership position. Surgery is often the face of a hospital. Operating rooms and Cath labs are high stress and high performance zones and the hospitals work around them. These areas have expensive and sophisticated equipment to use and maintain, have multiple groups working together, they are densely staffed, require quick on the spot decisions, and all this in a changing professional landscape. Surgeons need to take charge and carry everyone together for smooth functioning of these areas and of the hospital. Qualities of a leader: A leader has many positive traits, the foremost being integrity and ethics. Integrity: While all humans should have it, it is vital for a surgeon and a leader. It is the supreme quality for a leader. It is based on values. It is doing the right thing even when no one is watching. It is a notch above honesty Being ethical is a very important component of our lives as human beings and as vascular surgeons. Integrity and ethics add up to one’s character. It is very different from reputation. One’s reputation is what one is perceived to be. Your character is what you truly are. As surgeons and leaders, we are in a very unique and privileged position in the society. No profession has such privilege and respect where another human surrenders his or her body to you, to cut and poke and set it right, as you see appropriate. It is true faith and trust. Abusing such privilege and trust by performing unnecessary or wrong investigations and/or procedures would be the most heinous of crimes against humanity. There is a very simple and easy benchmark to follow: would you offer the same investigation or treatment or intervention to a close family member or to yourself? The decision becomes so easy to make. Every patient deserves the right diagnosis and the right to choose treatment and we have no business to push them into something for our gains. Every leg walking into the clinic does not merit vein ablation. We have no business scaring patients into procedures and should offer appropriate choices. Every painful or numb foot does not require computed tomography angiography and angioplasty or atherectomy. Most such diabetic patients with neuropathy only need advice regarding footcare, something that, unfortunately, is not even discussed with them. Most patients with claudication will not end up with gangrene and should not be coerced into getting revascularization. They require medication, risk factor modification, and exercise. Open surgery with vein bypass is better in so many situations. We should not pander to the interests of the industry or our egos or to FOMO by performing endovascular procedures in such situations. I am passionate against direct sponsorship from industry. We need support of industry for education and awareness, for our midterm meeting, annual conference, and various endovascular and cadaver training programs, and all such support should come through the VSI or regional vascular societies. There is evidence[1] that direct favors from the industry to individuals will affect the decision-making, consciously or subconsciously, when treating patients [Figure 9]: certainly not something that we as good professionals would desire. The interests of the industry should not supersede the interests of our patients. William J. Mayo stated: “The best interest of the patient is the only interest to be considered.”Figure 9: Unholy nexus between Pharma and Physicians: From the presentation of Alik Farber during VSICON 2023 at Mumbai (with permission)In a comic strip by Walt Kelly on Earth Day in 1971, Pogo and Porkypine come upon a once beautiful forest, that is now littered and what should have gotten to the heart, now gets to the feet [Figure 10]. Tall and aggressive advertisements, unrealistic promises, poor follow-up of patients, unindicated investigations and procedures, kickbacks, and many such activities have become the bane of our beautiful profession, and the enemy is really us.Figure 10: Pogo and Porkypine in a littered forest that should have been so beautifulBesides integrity and ethics, there are some other vital elements to leading with passion. A passionate leader has these traits built into his or her thought process: Moral responsibility: Set the standards and be a personal example Valuing others: Treat all members as partners and enable them to grow Commitment to excellence: Our society needs to be better than the best and self-sustainable Visionary perspective: Understand what is needed for the society to grow Recognition of opportunity: Identify/create situations that benefit VSI and involve members to contribute to growth Optimistic enthusiasm: Encourage, build morale, and build a positive perspective Perseverance: Follow through with determination despite obstacles and show a firm resolve and sustained effort Bias toward action: Focus on what needs to be done and convert ideas and intentions into action. My tips for the youth who are the upcoming leaders in our society: Be a good surgeon and a good human being. Be fair to your patient, maintain good clinical records and follow-up your patients. Update your knowledge and skills regularly and publish your work. Develop an innovative mind, think outside the box. Do not perform a procedure that you are not trained to. A single mistake by you can ruin an entire family. Manage your time well and do not ignore your family. Be future ready: It is necessary to learn good endovascular techniques but equally important to nurture our open surgical skills. We are looking at better medical therapy for atherosclerosis, better devices, translational medicine, individualized medicines, and an aging population. All of us need to develop skills in robotic surgery. Also, dream big. The only certain way to failure is to never try. Albert Einstein said, “A ship is always safe at the shore, but that is not what it’s built for.” Finally, take care of yourself, physically, mentally, emotionally, and spiritually (I don’t mean the liquid variety). You cannot pour from an empty cup [Figure 11].Figure 11: Take care of yourself: Do not burn outChange is inevitable and the only constant. Science may change, evidence may change, therapies may change, your position may change, and your colleagues may change; however, what must never change is the desire to do the right thing. We have initiated the process of writing VSI guidelines on deep vein thrombosis (DVT), varicose veins, aorta, peripheral arterial disease, and vascular access, for publication in our journal. This process helps us to understand the published literature, methodology of writing, and collaborating and perhaps also makes us realize how little Indian data we have. This brings us to the next step: how do we get Indian data – we are starting registries for major vascular diseases (DVT, varicose veins, peripheral arterial disease, carotid disease, and aortic aneurysm), and we hope that all our members will subscribe to them. Data confidentially is assured. Registries will not only generate good data but also help us in creating publications and also strengthen our position as a society in performing vascular and endovascular procedures. These processes require a lot of passion and a lot of hard work. We have seen improved international collaboration, especially through the World Federation of Vascular Societies (WFVS), and many of our members have taken the opportunity to participate and present at prestigious international meetings including Society for Vascular Surgery (SVS), European Society for Vascular Surgery (ESVS), Veith Symposium, and the Charing Cross Symposium besides others. As our registries get populated, we will be in a much better position for international collaboration and for being part of international guidelines. Vascular awareness programs have been started with renewed vigor, thanks to our secretary, Dr. Tapish Sahu. We have regular CMEs across the country. Vascular day is being celebrated in multiple cities across the length and breadth of India and even abroad. I congratulate the Vascular Society of Kerala for coming up with the idea of “Amputation Free Kerala” that then moved to “Amputation Free Uttarakhand” under the leadership of Dr. Parveen Jindal and then as a Society, VSI took it forward to “Amputation Free India,” and this year, we gathered further momentum and international support to make it an “Amputation Free World.” This received support from SVS, ESVS, Vascular Society for Southern Africa, and Japanese Society for Vascular Surgery, and many thought leaders in the field of vascular surgery. We discussed this in the SVS Audible Bleeding Program: https://www.audiblebleeding.com/2024/09/19/svs-step-challenge/. We have created a young surgeons’ group and a women surgeons’ group with the aim of empowering them and preparing them for leadership roles in our society and internationally. The process will help in building self-esteem and confidence and motivate them to contribute more to VSI and the specialty. It will provide a greater sense of belonging and diversity in leadership will throw up brighter, better, and more innovative ideas. My suggestion to women surgeons: Be yourself and don’t try to be a man. Step up, take initiative, and take responsibility. Do not expect favors and do not tolerate discrimination. A lot remains to be done for the future and some of these include having centers for basic research, better data collection and clinical research, a lot more publishing, improved endovascular training, and improved open surgical training. We need to understand and accept that we are not the only specialists performing vascular procedures but that WE ARE AND NEED TO REMAIN THE BEST AT TREATING PATIENTS WITH VASCULAR DISEASES. Is the leader the best at the job amongst his or her peers? Quite often not. The leader should have the ability to get the best people together and get them to work together toward a common goal. The leader must be the most passionate to get this done and a classic example is Captain Kirk, Captain of Starfleet, and Commander of USS Enterprise shown in the TV serial, Star Trek. At the end, “Do not follow where the path may lead, instead, go where there is no path and leave a trail”. Ladies and gentlemen, I hope I have been able to leave a small trail for the VSI. I will finish my term in 2 and I will to do what I can for the of the and the I am to the VSI and to the members of VSI for their you, ladies and gentlemen, for me out. support and sponsorship of interest There are no of