My ROC Fellowship

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My ROC Fellowship at The Hospital for Special Surgery, New York

” Welcome to America Hope you will Enjoy your Visit” greeting by the Visa officer at the JFK Airport, ended all my fears of being sent back home.

“hi Ramya I am here at JFK terminal 4” I told my niece over the phone “OK just come out of the arrivals lounge and look to your left at the pick up and drop off area you will see me and Ram”

Life can never be so easy! You travel  13400 Kms and there is some one waiting for you with a smile to welcome you! And this gets repeated at every place You go  in America! Gods must be Sweet!

“Hi there!  may I help you?” asked a lovely young lady as I entered the education department

” Hi I have an appointment with Ms Amanda Irene at 9 am, I am here to report as the new Ranawat fellow”
” Oh great you must be Chikka …….. (chikkamuniyappa) Sorry I can’t get the name !”
” Please call me Chandra” I said
” Ok Chandra please follow me” said the lady
“but my appointment with Ms Amanda ” I wondered loudly.
” Sorry, my mistake I am Amanda!”
“Oh OK!” ( I was expecting, a 50 year lady sitting behind a huge desk who will interview me!)
“Please come with me Chandra” reminded Amanda
While on our way across the 70th street, Amanda gave me few items and explained ” This is your bag, this is your ID Badge, you have to wear your badge at all times while you are in the hospital premises. The east elevators are located at the entrance to main building, as we get out of the 2nd floor make 3 left turns and you will be in front of the Scrubex machine which dispenses the orange scrub suit meant for all visiting doctors” she continued ” please enter 4045, your ID number”  ” now you enter the pass code I gave you and select your size and press enter” a neatly  pressed scrub suit comes out of the machine. As I was about to  say “wow!”

” please remember your ID and pass code and do not forget to deposit your dress back while you go out” instructed Amanda ” please take the elevator again and go to 6 th floor and go past 3 doors on your left and you will be at Dr Ranawats  office, and you can always get back to me if there is anything I can help. All the best and Happy Learning new things at HSS”

I just realized my appointment with Ms Amanda was over!

It’s all well rehearsed at the Hospital for Special Surgery, daily there are several doctors from all over the world visiting HSS. Only for me it was all NEW!

As I reluctantly entered the 6th floor and opened the 3rd door I saw the Big man himself just coming out of his office ” Good Morning Dr Ranawat I’m ….”

“Do you know your Schedule?” he asked me before I could complete my sentence “no sir” ” You can call me Dr Ranawat”  he thundered!

“Sarah, could you please take this gentlemen to the research office and let them explain  the schedule” he told another beautiful blonde lady standing there with a white coat.

” Every Monday morning at 7 am CSR (Dr Ranawat) has a teaching session for all the fellows, Tuesday Morning is the Research meeting, Wednesday there may be Optional Undergraduate teaching, Thursday is Arthroplasty Grand Rounds and Friday is the General HSS Grand rounds at 7.15 am. Coming to clinical sessions Tuesday and Wednesday we have full day operating and the remaining days we have outpatient clinics (Mon, Thu &Fri), Monday and Tuesday the meeting is in Dr Ranawats Office and the remaining day at the 2nd floor conference room. This is your desk and your computer,  because of the patient confidentiality I can’t give you the user name and password but I will log you in whenever you need. By the way my name is Matin and I am from Mumbai, If you do not have any questions you can join back Dr Ranawat in his Clinic” Oh! I met a desi, I realized.

So within 30 mins of me reporting to Ms Amanda, I was in business – My fellowship had started!

Hospital For Special Surgery

With 150 years of history and as a home to many many innovators, Designers, great teachers, eminent researchers and super super specialists, Hospital for Special Surgery stands tall and spreads across 3 streets, with a beautiful east river view in the upper east side of the beautiful Manhattan. Probably the first Hospital to propagate Orthopaedics as a separate sub-specialty, initially had general surgeons as well but later shelved as orthopedic surgeons became dominant in the hospital. Today there are over 100 orthopedic surgeons from all super specialties practicing at HSS, there are 28 Arthroplasty surgeons in total, doing replacements alone.

Everyday they do, on an average 150 orthopedic surgeries (yes! one hundred and fifty cases) out of which usually there are about 50-60 joint replacements!. There are 20 major Operating rooms, 8 ambulatory surgery units (Day care surgeries like arthroscopies etc) And a couple of special procedure rooms. There is a in house cadaver workshop for training residents and fellows. There is a separate bio- engineering department doing basic research . HSS believes in being a front runner in cutting edge research. In addition many practices like the Ranawats’ have their own research wings.

HSS has been ranked #1 for Orthopedics for almost a decade in a row by the various news agencies. Everyone in the organization are very proud of this fact and HSS has never been shy of displaying this fact . One can see it in all their communications,  bill boards, signages, stationeries etc. Any visitor/patient will never miss hearing about two things from almost every one in the hospital that they are #1 and their infection rate is less than 0.5% the best in the nation!

Hospital for Special Surgery is not a charitable Trust but they do good amount of charity by raising lot of funds through fund raising events.

Ranawat Orthopedic Center (ROC) at HSS

ROC is a totally independent private practice at the HSS. This means that ROC rents space,equipment,theatres etc from HSS and has established a very successful practice. It has 3 surgeons the senior Dr Chitranjan Ranawat and the two junior Amar and Anil Ranawat.

Dr Ranawat has also established Ranawat Orthopedic Research Foundation (RORF) which is primarily responsible,  for all the research happening at ROC, for the Ranawat Orthopedic Conference happening every year in India and also for giving scholarship to 4 practicing arthroplasty surgeons in India for the Ranawat fellowship (I was one of them this year)

What did I Learn during My Fellowship?

Just before I completed my fellowship I wrote a letter to Dr Ranawat – I thought It is worth reproducing the way it is, as it retains the personal touch and sounds very dear.

Dear Dr Ranawat

The other day (in the uptown lounge) you wanted me to articulate, what I am learning here in my fellowship and how, it is going to affect my practice, when I go back. Some how, we did not get time to complete that conversation; hence I thought I will put it down so that you can read it when you are free. I am also adding a bit about, why I chose to come here for this fellowship. And what inspires me!
Let us consider these under the following headings;

  1. Total Hip Replacement
  2. Total Knee Replacement
  3. Out Patient Practice 
  4. Orthopaedic Research
  5. Teaching and Training &
  6. Beyond Orthopedics
  1. Total Hip Replacement

Probably, this is going to be the area of major change to my practice, blame it on my brief stint in England, I have been doing THRs through the antero-lateral (modified Hardinge) approach all these days, although I am quite comfortable and getting reasonable and reproducible results, some where I felt posterior approach may be a more versatile approach for all hip surgeries. And you have consistently echoed this, whenever, there was an opportunity. (I know people like me take refuge in quoting less dislocation rate for continuing to use antero-lateral approach).

Books, videos, pictures could not convince me enough to change my practice to change from antero-lateral to postero-lateral.

After assisting you here, I feel I have reason enough to change my practice. I am amazed at how consistently you can find the landmarks and make every surgery look so easy. Only few people can do that. I told you the story of a sculptor who, when asked about how he could produce such beautiful statues out of almost useless stones, he had answered “the beautiful statues are already hidden there in all these stones; I just remove the un-necessary parts”. When I see your surgeries, I feel it is the same way – It is as if the road is crystal clear – and every time you find the land marks in the same consistent manner.

I want to reach that stage, where, every time the surgery is as predictable.

Reproducing Leg Length and Offset has been a big problem for me – now that you have showed me a way, I just can’t wait to go back and start practicing this – I just do not know if I can find the infra cotyloid grove every time. Of course you have trained your eyes, hands and mind for so many years to perfect everything you are doing today. The least is I can start now!

Positioning the implants – trusting your own eyes and physical land marks rather than feelings is another learning point for me. For the femoral reaming – the starter reamer kept posterior and lateral in line with the medullary canal is probably more easy through the posterior approach – this also might help me to get the lateral alignment of the femoral component.

The importance of closing the wound is another re-inforced learning point for me (although I do not let the junior doctor to close the wound) but even after so many years you wouldn’t leave it for others- I do not think this is without a reason.

Capsular repair by making two drill holes in the trochanter is a fantastic way of making sure good closure – I had not seen this before but I want to practice this as well.

Injection of the ROC cocktail pain killer – which I have been resisting all these days, is probably another change. I see a pattern in your injection technique – and every time it is the same – every time you inject the same amount in the same area – unlike all others who do inject but around the joint. Probably you should describe that as well! (Sorry for asking ready-made answers for everything).

2.Total Knee Replacements

Mostly, I have been following your techniques – Including – tibial sizing – find the postero lateral corner match the lateral side dial the tibia    – for correct rotation – stop at the true antero medial border – remove the excess tibia (reduction osteotomy) Pie crusting of the medial collateral ligament for varus, – Inside out technique for valgus – Posterior release at the level of the tibial cut with cautery etc.

New things, I am learning now / made me thoughtful

Am I making my knees too tight? – 1-2 mm of play even in extension may be good (I was aiming for no-play but full extension especially medial side)


Using 8 mm poly insert is after all not a bad thing (I thought 8 mm was not enough thickness especially if the patient is obese/ moderately obese).

3 deg Fixed external rotation for every body – not good —  Flexion gap correction through bone cut only – parallel to tibial cut- ROC cocktail intra articular Injection for post op pain

– Will I start doing Patellar replacements for all Knees like you do? -I think I am not yet ready for this – may be for financial reasons rather than scientific reasons.

3.Out-patient Practice

I had no idea about your philosophy and practice prior to coming here – the first line I heard from you was – Eyes first and Most -Hands second and less – Tongue Last and Least!  I find this a fantastic philosophy – I was relying on my findings more than what the patient is saying or my assistant is feeling but this line summarizes the order of priority.

When the patient is not yet mentally ready for surgery but has findings enough to warrant a surgery — you just boldly ask them to go back and revisit her/his lifestyle and come back later after 6 – 12 months! (People in private practice like me are not bold enough to say it so boldly – because after 6 months they may not come back to you or some one else would have operated on them after a month!) But I feel for some one who is not prepared, this is great advice. Next time when they are back they will ‘buy’ the surgery from you.
Asking your assistant or your nurse to speak to the patient prior to you going and seeing the patient – is one of the best strategy for out patient practice – I see several advantages in this – it prepares the patient – gives them time and opportunity to rehearse their complaints – gives them a chance to express freely – often patients forget their lines when they go to see the ‘Big doctor’. For you, this gives an insight to the patients world – you already know the patient’s name, her complaints And her needs already before meeting her.

I have seen your patient examination techniques – every time it is thorough and intentional and of course well documented. I feel like taking a video and watching it over and over again. I know patient confidentiality comes in the way – I have made/making a mental note of everything – or probably there is a case for you to make video document of orthopedic examination of hip and knee (we can put it on YouTube so that people can see and learn). But what impresses me is the fact that its consistency and thoroughness every time – if you are so consistent you can’t miss a finding.

What I may not be able to reproduce is your charm – your ability to connect with the patient instantaneously and read their minds – understanding their needs and making a decision for them – preparing the patient for the worse but not denying them hope. I like your way of handling a difficult and unhappy patient – no confrontation be consistent in what you are saying if everything fails offer them a second opinion – do not lose a patient because he/she is difficult – keep the conversation open – I feel this way even this unhappy patient will come back after visiting few others. I think we have a philosophy here too.

Your ability to disconnect from one patient and reconnect with the next patient quickly is another quality I would want to reproduce.

  1. Orthopedic Research

I am amazed at how you have kept yourself ahead through research – what I see here is a parallel life – I see a structure which cannot fail! I want to understand this a bit more so that I can reproduce it (I know it’s not easy at all) – many of us get many bright ideas but almost all fail to execute it – we fail to put a structure to it so that it can reach a logical conclusion. Many projects die before they take off and equal many do not reach the conclusion stage.

5. Teaching & training

Your un-diluted enthusiasm for teaching is exemplary. As I see your tribe is becoming less and less. Probably the need has grown exponentially, distractions have multiplied and commercialization has taken over.

Getting up early in the morning and coming to your class will be an ethereal experience in itself for every fellow/resident who comes to HSS – lucky are those (many may not even realize this but, I am sure they will treasure these moments and keep them forever.

6. Beyond Orthopedics!
You have been exceptional as a Human being,  Doctor, Professor,  Educator/teacher, Academician/scientist, Designer, Entrepreneur, Mentor/guide, Father, Citizen (As I know) and also Husband, Grandfather (as I presume) and perhaps so many other responsibilities I may not even be able to comprehend.

You have handled all kinds of pressure and responsibility with ease and eloquence. You never lost your ground for the greatness achieved.

You have kept your standards very high and probably believed in what you keep saying “Everything in Life can be Improved” and went on improving – Today you have reached a place where no one will be able to dream. I know your mantra is very simple “whatever you do, do your best”. This is very powerful, because, you have proved this beyond doubt.

I was born in a small village with no connectivity of any sort. My parents never went to school but were small time agriculturists, By God’s grace,my parents & teachers blessings, my brother’s support and magical turn of events and scholorships, I happened to land up in a medical college, then in orthopedics (all in state run Hospitals) and later in England and now as a Ranawat fellow at Ranawat Orthopedic Center  HSS!

I could have stopped in any stage, but I was unable to – I am Unable to. I feel incomplete and feel so much restless after some time. After I learnt about you – I felt I have a role model to look up to. This was what made me chose this fellowship rather than any industry sponsored and so called training opportunities.

You have also proved what Narayana murthy of Infosys keeps saying “A plausible impossibility is better than a convincing possibility” – I would like to take this route. Of course life is not as simple as we wish – but like I said earlier, intention is important before execution. I want to Aim for the sky so that I might reach at least the tree top!

In this regard, I would say you inspire millions; I am one of them too. If you ever write an autobiography, I will be/want to be the first one to read it. And be inspired by it.

I guess I have articulated enough for this time! The letter has already become too long – Will wait for my next opportunity, to pick your brains.

Thanks a million for your time