Scalpel has always been defined by science and never by intuition. If one broadly looks at the tenets and principles of surgery, the art and science of it have always been spoken about, but the role of intuition has not been emphasised much. In my formative student years, I used to hang around the vintage racks of my college library, in the archival section wherein outdated books were stored, nay dumped. The disregarded corridors led me to a unique treasure trove of archaic books and journals. The primary fuel of my offbeat voyage was the long list of unanswered questions to which some of my professors like Prof. Humbarwadi would ask me to consult these secluded corners of the old sections from time to time.
I knew the answers were there to be found in history, if one cared to dig them out, like how in the Egyptian mythology where some of the secrets are believed to have been mummified. One of my great discoveries in the library was this brilliant book by Dr Milton T Edgerton called the ‘The Art of Surgical Technique’. Dr Edgerton was a renowned plastic surgeon and one of the founding professors at John Hopkins University. His book was a wealth of great insights, adorned with beautiful hand sketches by the author himself. This book spoke about the art and science of surgery while hinting at the role of intuition.
The earliest editions of the books by another prolific surgeon Dr Hamilton Bailey were thankfully part of my curriculum. The newer editions have unfortunately focused only on the technological and clinical advancements, leaving out many profound questions posed by the original edition. Presumably, some authority at some point had taken the liberty to overlook certain truisms as having been dealt with and spoken about at length and hence omitted from the subsequent versions. Consequently, many beautiful aspects of art and intuition were disconnected from the science of it.
As science evolves, there is a transition that happens, wherein many aspects of science are wrongly assumed to have lost their relevance for future generations. For instance, the first edition of ‘Harrison’s Principles of Internal Medicine’ had a beautiful elaboration by Dr Judah Folkman, Father of Angiogenesis, which was omitted in the subsequent editions. He alluded to the possibility of reaching a point in time when we can co-exist with our tumours. This would imply harmony, not conflict, between normal cells and cancer cells. The former would not be affected by the aftermath of the latter, and the latter would stop growing. In this first edition, Dr Folkman also put forth the theory that if we cut off the blood supply to the tumour, it will be paralysed, thereby losing the propensity to grow and spread further. Given the seminal significance of his words, the omission from subsequent versions was needless and heedless.
In the context of this loss in transition, I recall the amusing experiences of Stan Lee, creator of ‘Spiderman’, which he shared in a BBC Radio interview. His publisher had rejected the idea of a teenage Spiderman superhero calling it the ‘worst idea ever heard’. His hardcoded logic was simple: people hate spiders and teenagers can never be heroes, they can only play sidekicks. Lee was dejected and decided to give up on the idea with a fleeting tribute to Spiderman in the last issue of the loss-making ‘Amazing fantasy’ comic series. The spider superhero went on to become an instant hit, and it made the fading comic series a resounding bestseller. Needless to say, the publisher came back to say how much he always liked Spiderman as an idea, and the rest of course is history. Stan’s superhero was simple and likeable due to the inherent contradictions— a superhero with spider skills but inflicted with glaring insecurities: a child raised by his grandparents, bullied at school, and hugely awkward in the presence of the opposite gender.
Coming back to science, it is not often dictated by the stalwarts; at times, the business of it takes precedence, led by the need for market creation. These forces let go of what they presume as foregone conclusions or arguments no longer valid. This popular view disregards the fact that people need to know certain slices of history which provide a deep connection to the future. The intuition of science can be found as much in history as on the way forward. Art and intuition are extremely intermingled as they both have creativity in them, and science stands tall between them. We talk of science, and we talk of art, but we don’t often think about where they meet. Either our thoughts gravitate towards a ‘no’ or lean towards a ‘yes’ when it comes to acknowledging the power of intuition, but we are never able to strike a balance. In the whole spectrum of science, intuition has been largely sidelined.
I was always drawn to the role of intuition in surgery. Although extremely difficult to define in verbal terms, I make a feeble attempt to put scientific intuition in perspective. We have always been taught about the importance of instruments and equipment, their designs, precision, and purpose; how they cut; how they retract a tissue; how a tumour is opened; how the surgical area is approached and accessed and the like. Of course, these are highly significant aspects beyond doubt integral to surgery. But in Milton’s book, the foreword began with gratitude to his wife, for the time she allotted him in the kitchen to learn some sewing skills. Elaborating on the art of surgery, he writes, “A surgeon needs to know his ten important instruments — his own fingers.”
Today we talk of robots, machines and gadgets, but in the ultimate analysis, only these fingers are running the machines. Milton brings out the essence of science to underline the fact that fingers decide how the scalpel or retractor will be used. Milton’s words couldn’t have rung truer. These fingers, I feel, run a surgical symphony in the operating room. This aspect has to have an intuition to it, like how Mozart composed his music. Had Mozart followed a book and not his intuition, he would not have been Mozart today.
All through my student and practice years, I have been instinctively driven towards unanswered questions like what exactly drives certain indications. Whenever I read about a surgical procedure, I always wonder what exactly drove the surgeon to adopt a particular technique on the operating table at a particular point in time. There are instances when the surgeon was reprimanded for the proposed choice of technique or approach, which must have perhaps been ahead of its times, and yet he backed his intuition. There would have been some strong reason for the surgeon’s conviction, which has to be something more than science.
For instance, it was historically believed in the earliest scientific literature that a surgeon attempting thyroid surgery was playing with fire, and the errors he would commit in the surgery were unpardonable given the risk of torrential bleeding and even life. Today, it has become a lifesaving surgery with several instances of successful operations across the globe. Now, if the slice of history related to this bit is omitted from the annals of medicine, the whole context of surgical advancement is lost. What would have gone through the minds of the surgeons who dared to think different, risking their reputations in the event of adverse consequences, and how did they back themselves and their fingers – all of that would be lost in the missing notes. The very purpose driving the ambition would be lost.
For example, we always say we keep checking the calcium in the blood. We say calcification can occur in the body, which can cause certain conditions in the parathyroid gland. When this gland creates a tumour, we have been taught to perform a parathyroidectomy surgery if the condition is accompanied by hypercalcemia or excess calcification in the blood. What is intriguing is that we were never taught why calcium doesn’t calcify in the blood under normal circumstances. None of the books would answer that question. But this was addressed in the old books in the library.
I remember one late evening at the library when the librarian, a kind-hearted, middle-aged lady, came to remind me that it was time to close the doors and put the lights off. I requested her to give me five more minutes as I was in the midst of poring over some invaluable information in the old racks. She conceded to my request but asked me a favour. She asked me to prescribe some medication for her chronic sinus headache. I asked her how she was so sure that it was a case of sinusitis. She told me she had been on medication for quite some time and knew her diagnosis well. Out of curiosity, I asked her how often she caught a common cold in a year, and when did she have it last? She promptly told me she had never had a common cold as far as she could remember.
Her answer left me puzzled, and the next question I asked her on an impulse was whether she had any issues. She again replied in the negative and told me that she was infertile. Now, this was my first accidental but intuitive diagnosis of a condition called Immotile Cilia syndrome, wherein the little cilia nerves in our sinuses and elsewhere do not move, and this disorder is accompanied by infertility. I advised her to meet the physician for appropriate treatment.
The moot point here was tapping into that particular aspect of intuition that paves the way for discovery and direction. You may have all the algorithms, but you need a peripheral intuition to set you on the right path. I remember a monk who once told me about the miracle of the healing touch or ‘kaiguna’ as we call it in Kannada. He told me that a physician or faith healer who wholeheartedly treats his or her patients gets innumerable blessings from the patients and their near and dear ones, which manifest themselves in the physician’s hands. This positive healing energy can’t ever be used for self-benefit, it can only be transferred to other patients undergoing treatment. This is like distributing your dividends to those in need. Mother Teresa was the epitome of this healing touch.
These healing hands, he said, are blessed with intuitive powers. I have no doubt in my mind that these powers guide the hands towards the right approaches and therapies. The universe helps you bring about a surgical symphony.
The monk insisted that I touch each patient, even those at a stage of no return or inflicted with a supposedly incurable disease, as things could possibly turn for good amid all adverse circumstances. I got a first-hand experience of this truism many a time. Once during my ICU rounds, I encountered a patient who was recovering well but suffered a psychiatric spell all of a sudden during the wee hours of the morning. He turned violent and tried to physically harm those around him before falling unconscious out of breathlessness. I made it a point to touch him and in that touch, there was as much science as was an earnest plea to help me pass on the dividend of the healing touch. At the same time, I shared my helplessness with his wife, openly telling her about the futility of the treatment being extended to her husband. Both contradictory acts—one to the patient and the other to his wife—were guided by intuition, I did not initiate them, I was led to them.
The symphony I talk of is the symphony of nature. During the 2004 Tsumani wave, elephants, dolphins, dogs, deer, foxes, and rabbits got intuitive signals of the impending danger beforehand. Many among them could plan evasive action well in advance. Similarly, we need to balance the art and science of any discipline using our intuition. This intuition can only be found with purpose and love. One can define and refine intuition only when a deep sense of intent and benevolence is developed within. I call intuition a fusion of passion and compassion; the former is not to be confused with pride, and the latter is not to be confused with pity.
The writer is on the advisory of the Prime Minister‘s scientific team and heads the Karnataka health Covid task force.
We need to balance the art and science of any discipline using our intuition. This intuition can only be found with purpose and love. One can define and refine intuition only when a deep sense of intent and benevolence is developed within.
