Padmashri Dr. K. M. Cherian: An outlier and maverick surgeon ahead of his time: A tribute by his students

“Chief,” as his trainees commonly addressed him, Dr. KM Cherian (Dr. KMC) has always been an outlier. One such act that defined him was his decision to return home despite having had an opportunity to settle in developed nations. That heralded the era of development of pediatric and congenital heart surgery in this part of the world. He took this plunge when everyone else did the opposite! His other acts of defiance of the status quo are far-sighted, such as working in a public hospital soon after his return to India, and all his well-known attempts to start pediatric heart surgery and thoracic organ transplantation. He wore so many hats in his professional career. A surgeon, entrepreneur, teacher, mentor, academician, and all of them with aplomb, most of the time. His dexterity and elegance in the technical performance of surgery, regardless of the type, are well known and legendary. He was probably one of the last Titans who graced the world of cardiac surgery who believed in surgery as an art first and science later. His mentorship was also unique. Never the typical teacher who holds one’s hands and trains each step. Not him. He always believed in encouraging everyone to develop their own style of technical performances. Yet, he was hostile and expressed his deep displeasure at the bloody, messy surgical fields, confusion, and the presence of too many hands all over the surgical field. Questioning the norm, or taking up cases when others had given up, or innovating procedures to make it simpler, distinguished him as a last court of appeal as far as corrective cardiac surgery was concerned in South Asia. DR. KM CHERIAN, AS A SURGICAL COLLEAGUE TO A CARDIOLOGIST It was a privilege to work as a young pediatric cardiologist with a demanding surgeon and his equally capable surgical team. Due to nonavailability of other imaging techniques in that era, echocardiography and cardiac catheterization/angiography were the only diagnostic tools for evaluation. While his expectation was always that the evaluation had to be precise, prompt, and flawless, he also understood the limitations, in which we worked. He always believed in people more than the machines they used to work with. It was not so infrequent to err in precise diagnosis and evaluation those days. It was the beginning of an era of echocardiography being the mainstay. I never recall a single incident when he made a big issue out of it. Most of the time, he shouldered the responsibility for those shortcomings. He performed surgery in numerous surgical workshops across India and worldwide, despite extremely limited resources, and despite the aforementioned constraints, he never complained about it. Even during the intervention procedures, having him around boosted our confidence levels as we felt secure and protected in case of any complications. Of course, we used to have big dressing down after the procedures in those times, but he always bailed us out regardless of the time. Many colleagues perceived him to be dictatorial and authoritative. But as senior cardiologists working with him, we found him the easiest surgeon to work with, a surgeon who openly accepted his errors of omission and commission. Another notable attribute was that he always encouraged interventional workshops in cath labs as another means to stretch the frontiers of medical science. This stood us in good stead during the formative period of the specialty of pediatric cardiology in India. Patients poured in from all corners of the world for his care as a last resort of hope. He always felt a moral obligation beyond the call of his duty. His candor and disarming opinions, often being self-critical during the mortality and morbidity meetings, enriched all of us, and we also found it deeply inspiring. Never one to hide, he always brought out the flaws in the system that we created and attempted to find solutions to improve the system. I wish modern-day surgeons would continue to have these traits. Many of us who finished our advanced training overseas did not have many options for joining a center of excellence when we returned. We should admit that there were no other centers that had a separate division of pediatric cardiac sciences, and we considered ourselves privileged to be appointed as his colleagues. It was an exciting era of learning from him, through him, and thanks to him. He always got the best out of us. The center has always been a hub of academic activity, in addition to being an exceptional clinical platform. At any given period, there used to be either renowned surgical/cardiology guests, often esteemed members of editorial bodies of prestigious journals, renowned surgeons, ongoing surgical/interventional and morphological workshops. The entire process of preparing patients for these workshops gave us a tremendous opportunity of learning.We had the privilege of being part of several research projects, including animal trials, bovine jugular vein conduits, biomedical sciences, and even applied mechanics with the Indian Institute of Technology Chennai. During a trial of breathing exercises after a Fontan operation, a yoga teacher was appointed in the hospital to study and evaluate traditional techniques for modern-day challenges. This was a quarter of a century ago. During many of our journeys together for workshops and conferences, he always remained an energetic and enthusiastic colleague and friend. Besides, he always tried to improvise anything and everything during our stay. Be it the sense of dressing from a medical and social point of view, etiquette in meetings, dealing with patients, especially during complications, Dr. KMC remained a role model and an inspiration. All in all, his greatest qualities were perfection, professionalism, punctuality, empathy, accountability, and most importantly, responsibility. I don’t recall anyone who in his lifetime has given so much to everyone, including those who worked with him even for a shorter time, with his all-around contributions to the development of medical science.DR. KM CHERIAN, AS A DOCTOR The chief had empathy toward his patients in truckloads. More importantly, he always felt that surgeons are the custodians of their patients and their interests. He felt committed to them regardless of the challenges. He displayed humility, empathy, and compassion for poor patients. Any infraction regarding patient care or other undesirable workplace activities was dealt with an iron hand. For most of his patients and the parents of the children he treated, he was almost like a messiah, and he always carried that sense of responsibility in mind while delivering care. DR. KM CHERIAN, AS A TEACHER Corporate medical worlds in current India emphasize optics and one-upmanship. Dr. KMC, being both an employer and employee in his organizations, never focused exclusively on these ancillary or supportive issues and rather rightfully focused more on medical excellence, and with him at the helm of affairs, it was pure medical science that triumphed over glossy optics. In that context, for puritans of medical excellence, he was master par excellence. We sincerely wish that many of us were like him. Alas, changing times and circumstances, and probably our own destinies, prevent us from reaching the pinnacle of excellence in medical leadership. His mentoring was also unique, with minimal interference in our technical performance, and a comment here and there with a breezy visit behind our work and advice. Holding himself accountable for our errors and the necessary verbal whiplashes so that imperfections are perfected during our next surgical performance. Sometimes, all he said was, “Mr. X is getting better,” and our days were made, and we would be charged to aim at the pinnacle of art. Chief was an unconventional teacher and mentor, emphasizing practical and common-Sense thinking. Operative and other responsibilities were assigned, observed, and assessed. If they were successfully discharged according to his expectations, additional responsibilities were assigned. His clinical executions of surgeries, keen interest in each and every detail of each patient in the intensive care unit (ICU) whom he had operated, succinct yet effective communication with bystanders, devotion to his work while celebrating fine moments life throwing at him, passion to achieve excellence in his leadership and sense of ownership he had toward his program have been highly inspiring to those of us who had the privilege to spend decades with him. As a teacher, he encouraged healthy, although fiery discussions and arguments among cardiologists and surgeons during the decision-making processes such as cath meetings, journal clubs, and seminars. Not even those accustomed to silence were exempt from discussing an issue if there was merit in doing so. He had the ability to pull anyone and everyone into the heat of the discussions. He always believed in the idea that discussions and debates bring clarity and depth to making clinical decisions and improve the quality of care. He nurtured and supported all efforts to the best extent possible. If necessary, he arranged the artists as well for the drawings, and one can see those illustrations in most of his publications. As a painter and artist himself, he was well aware of the strengths of illustrations in articles. Many of us still feel that we underutilize ourselves and our own potential once we leave him and that speaks so much about his ability to harness so much from others. But for him, many of our published works would not have seen the light of day. Many might argue that he was authoritarian, autocratic, unforgiving, undemocratic, brash, and some of his attempts at scientific breakthroughs were attempts that defied the existing ethical and moral guidelines. But that would be grossly unfair to measure an icon’s attempt at bettering medical science during his time with the present-day yardsticks. If at all, those attempts have made cardiac science in South Asia a shade better. DR. KM CHERIAN, AS A LEADER As a leader, he always led from the front, being accountable and truthful for his actions. Some of the rules he established, including dress codes and attendance punching systems, and his sincere efforts to rectify the incomplete medical records, have been exemplary and extraordinary, considering that he was the one conceptualizing, implementing, and auditing them. I still get goosebumps narrating an incident as I (Dr. Shiva) issued a notice to him for incomplete medical records, and he complied with the directive and had the greatness to inform me about it. He always believed in authorizing and then empowering the systems that he initiated, and did not hesitate to become a willing player for that, regardless of the position and aura he carried around him. He had great leadership qualities. Once he gave the responsibility and it was accepted by us, He expected completion of the assignment regardless of the challenges and he always succeeded in getting the job done! He had this unique quality of making people work to their talent potential and bring out the best in them. He was always one of the first to arrive at the hospital and probably the last to leave. He attended to the inpatients of the entire hospital, as all of them were his patients, in daily rounds and had a mercurial memory of the preoperative status and demographic details of each one of them. We, the attending consultants seeing our respective floors, were exhausted just to see a few children under our care, let alone seeing all the patients every 24 h. There has not been a single day when we have not marveled at his devotion, panache for clinical excellence. The present generations would find it hard to believe that he still found time to celebrate his life and his times, as well as some of the fine moments of his life, despite those work schedules, a damning indictment on our current concept of work–life balance. His work ethic was most inspiring, and this has indeed rubbed off on all his trainees in various shades, as can be witnessed by the way their services are run today. For me, the chief, as all of us fondly referred to him, was everything that we were not and what we wanted to be. It has been an absolute pleasure and our privilege to work under him, be mentored by him, and work with him. Some of us have been fortunate enough to spend decades with him. There have been moments of great anguish, sadness, frustration, and anger when he was critical of our actions/inactions. Looking back, we’re glad those moments were worth the time, considering the positive impact they had on us in the long run, both personally and professionally. THE CHIEF AS AN ADMINISTRATOR Dr. KMC had been an administrative leader for almost 2 decades before we started to work with him. He knew that doctors require professional progress as a primary prerequisite for success. He also knew that patients and their feedback were the most important criterion for success in the healthcare industry. He kept the financial sustenance of the programs as a top priority and never rested on any laurels. He always saw an opportunity in any challenge that the program threw at him. His concept of starting and encouraging separate adult and pediatric cardiac programs, homograft banks, inhaled nitric oxide therapy, Ross operations, thoracic organ transplantations, and trans-myocardial revascularizations aimed to achieve success from all angles, focusing on patients, doctors, and the institutions themselves. His commitment and tenacity to accomplish the desired objectives were incredible. Backing the right personnel, right initiatives, and sustaining them for their logical fruition are the traits of great commanders. The chief had loads of them. Closer to our own work as pediatric cardiac doctors, Dr. KMC had understood the importance of creating a center of excellence in pediatric cardiac sciences. He also had the great and vital insight into its requirements – resources, manpower, and infrastructure – and the visibility it gives to the hospital. He knew that the enormous goodwill it would generate from society would offset the modest financial returns from the program, thereby ensuring handsome and comprehensive returns to the institution. It is remarkable and to his credit that the program for pediatric cardiac sciences had exclusive 3 consultants each in pediatric cardiology and pediatric cardiac surgery in 1997, with a separate pediatric cardiac ICU! An initiative that took another 10 years to realize and implement for other centers in the country. DR. KM CHERIAN, AS A COLLEAGUE Each one of us has had the pleasure and privilege of being his dear colleague. Known for his good sense of humor and desire to celebrate his beautiful life, he always had time to discuss both professional and personal issues with us, and he did his best to facilitate better lives for all of us. As his colleagues, we had the opportunity to travel with him to numerous national and international conferences. His informal sessions with us and his attempts to make us comfortable as his associates have always been exemplary. Most of us, as current leaders, have made attempts to integrate those qualities into ourselves. He made it his responsibility to project all of us at international meets as his prodigies and as men/women with great potential and promise. We say with pride that all of us, his mentees, have benefited immensely from his benevolence in this aspect. Some of us used to exchange our books of general reading, fiction, and other aspects outside the medical field with him, and we admired him for his ability to find time and inclination to read them despite his schedule. An avid reader of diverse topics, the Chief was a great company to socialize and unwind after a grueling meeting or workday. Notwithstanding, as an employer, Taskmaster, and Leader, Dr. KMC was a close colleague and confidante to many of us. It took time to get close to him, which had to be preceded by a demonstration of excellence in your work and knowledge of medical or even in practical life sciences. He was always available to us for good counsel or help in any sphere of activity, profession, or personal matter. The learning, academic, social, and camaraderie workplace environment created by him was the reason he could hold on to most of his staff despite modest remunerations offered in those times. DR. KM CHERIAN, AS A SURGEON AND AS A RESEARCHER It is part of folklore that he was an exceptional surgeon. A surgeon par excellence! A surgeon with a remarkable connection between brain and hands, which is so essential, particularly for a congenital heart surgeon! This made him stand out as an outlier of his time! What set him apart from others was his minimalist movements with his fingers, unhurried, dexterous, diligent, and precise. The sutures were always spaced apart equally, and most of the steps were simple. He expected, of course, a symphony of movements from other team field. He to the of surgeons and the era of the time started the was The entire of pediatric cardiac surgery, most of had to be under a set by it was of or the had to be before the time he had finished the and the was a a to the It was to see him a with a or a of For art among surgeons, the Chief the of the of art with science. A at work when he was There puritans who found Chief in his to surgical But his while doing them always all of us. the times and Dr. KMC his work in India with a to his work and from the His passion to and from India was extraordinary, and his attempts to our work from India to the better world were incredible. he wore his up his with his own of of right or for that the up of the or on the of it was that passion for research that him to these He was, like any one of us, not a but a who wanted to he of and them to their logical All in all, it is better to Dr. KMC as a idea that during our times than him in separate as a surgeon, leader, and so An idea that is to be not just but to be and carried We are all and being pediatric heart It is an that we him for what he was, a when we ourselves taking additional responsibilities outside our field. But that is it great and can and in all He was one of those Once it was a privilege to be among the few fortunate to have been mentored by to have worked under your and to be your colleagues. for all those moments that made us feel of ourselves. We have tried to be and in We also that would have made another to this had been it is what for excellence and it has been said in times all of us. and of interest There are no of