|Year : 2011 | Volume
| Issue : 2 | Page : 173-175
Issues in hand surgery
S Raja Sabapathy, H Venkatramani
Department of Plastic Surgery, Hand Surgery, Reconstructive Microsurgery and Burns, Ganga Hospital, 313 Mettupalayam Road, Coimbatore, India
|Date of Web Publication||24-Sep-2011|
S Raja Sabapathy
Department of Plastic Surgery, Hand Surgery, Reconstructive Microsurgery and Burns, Ganga Hospital, 313 Mettupalayam Road, Coimbatore 641 043
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Sabapathy S R, Venkatramani H. Issues in hand surgery. Indian J Plast Surg 2011;44:173-5
Plastic surgery calls for imagination, artistry, attention to detail, ability to hold on against odds, and at times even to think out of the box. Nowhere all these seemingly different attributes are in demand than when we try to put back a crushed hand to gain function, try to create a thumb for a child by pollicisation or redistribute the available forces to increase hand function after a nerve injury. The skills gained in practicing Hand Surgery will find its use in all aspects of practice. Reputed hand and micro-surgeons have become the successful aesthetic surgeons in the later part of their career. Although it is one of the oldest subspecialty of Plastic Surgery, it is at the crossroads at the moment. At a time when economic considerations drive choices, the young trainee in Plastic Surgery is not sure as to what the future could be if he or she should choose to be a hand surgeon.
| » Keeping Pace with Growth|| |
Hand Surgery developed as a subspecialty of both Plastic Surgery and Orthopaedics. Surgeons of both specialties have made significant contributions to its growth in our country. Prof. Venkataswami, who created one of the world's largest Hand injury centre at Chennai, is a Plastic Surgeon and Prof. BB Joshi, who by his innovative methods made hand surgery popular to the masses, was an Orthopaedic surgeon. Hand Surgery in India evolved with the management of deformities of leprosy patients by Paul Brand and his successors in Vellore and later in a bigger scale in the care of hand injuries.  This was partly due to the mushrooming of industries of a developing economy. Plastic surgeons made hand surgery their forte with their skills in gentle tissue handling and tissue replacement which these injuries demanded. The advent of microsurgery made replantation possible and extended the salvage of major injuries with free flaps. In the next few decades, both hand injuries and paralysis due to chronic infections like Hansens will diminish. Already we happily see this happen in Hansens, with many units designed for taking care of patients being reduced and some even being disbanded. With enforcements of rules and regulations for safety in the industries, industrial injuries will also go down. When we started our hand injury service in 1991, we regularly used to treat young workers with blow room or carding machine injuries from the textile industries every day. Now we hardly find a few cases in a month. The present epidemic is the injuries sustained in the road traffic accidents. In a decade, this too will pass. Secondary surgeries for functional improvement after trauma, obstetric and adult brachial plexus injuries and their sequelae, wrist problems, compression neuropathies, hand in cerebral palsy will gradually form a significant part of the future hand surgeon's work in India. If we do not gain competency to treat the changing spectrum of disease presentation, we will lose out.
| » Enhancing Our Skill Levels|| |
We will be able to hold the ground if only as a group we are able to show a perceivable difference in outcome when we deal with patients. That calls for enhancing our skill levels and undergoing special training programmes. Structured training programmes in Hand Surgery do exist in India. A two-year post-doctoral fellowship in Hand and Microsurgery was started by the National Board of Examinations in the year 2001. We select two trainees every year. Ever since we started the course, all the candidates have been orthopaedic surgeons. A one-year fellowship programme has been started by the Tamil Nadu Medical University this year and for the first time, we have one plastic surgeon joining the fellowship programme. Surgeons who take up these added qualification programmes will certainly be the future leaders in the field. Even in the United States, the situation is similar and they feel that immediate steps are needed to correct the downslide.  It is imperative that plastic surgeons do take up these programmes. A number of reasons starting with long years of training can be given for this lack of interest, but we cannot rest with explanations for the apathy. The 'ability to hold on for a little more time' is what is needed to reap higher rewards in the future.
| » Reaching Out and Extending the Boundaries of Care|| |
A specialty gets established when the surgeons who practice it reach out to more number of people. We are hardly 1300 plastic surgeons for a country of 1.1 billion people. Perhaps 250 of us will be having specific interest in hand and microsurgery. When we think of this fact we would guess that all these people will be tremendously in demand. Surprisingly, it is not the fact. Some younger surgeons even wonder if this subspecialty would be economically rewarding. At the same time, we have, in India, many great success stories in this specialty. Analysis of this will reveal that all successful units have some things in common. First, they had scaled up in volume and second they maintained quality. They reached out. Reaching out is in two planes. If we are satisfied only with numbers the units get fatigued out and do not get recognised as a centre of excellence [Figure 1]. If they concentrate only on quality but their services are available only for the creamy layer, then again they do not get recognised [Figure 2]. The trick is to do both [Figure 3] and that is the need of the day. Successful units do that with process innovation, analyzing every step of the process and cutting down on wasteful expenditure, looking for evidence in the existing practices, standardizing procedures thereby reducing complications and driving the whole system towards the patients' needs. They have found truth in the old saying that 'repetition is the mother of skill'.
| » Attracting Talent into the Field: The Need of the Day|| |
We cannot escape from the fact that we live in an era where economy drives choices. Even in that count, subspecialties like 'hand and microsurgery' are at a definite advantage. In a developing economy, people will pay for services, provided we make them feel that it is worth and cost effective. The senior surgeons must play the role of the inspirational role models. In the recently concluded IPRAS congress in Vancouver, there was a plenary session on 'Protecting the Specialty in the 21st Century'. In the interesting deliberations that took place on competition from sister specialties, there was consensus that competition and fear of losing out were in fields which do not involve much labour, time or long learning curve. There is no competition in fields that are skill intensive. Such fields serve as the rock foundation of the specialties. When people lose it, they easily fall prey to the market forces. This point was brought out with examples and case studies of various specialties. It is very essential that we hold on to reconstructive surgery base for the good and the growth of the specialty of Plastic Surgery. It's needs will never die out, and the skills will ever be in demand. They are immune to the economic melt downs. While it is good to explore new avenues and conquer territories, it is imperative that we maintain the base which brought the specialty into existence.
The decision of our editor Surajit Bhattacharya to bring out a special issue on Hand Surgery is both timely and appropriate.
| » References|| |
|1.||Sabapathy SR. History of Hand Surgery - India. In Hand Surgery Worldwide: International reconstruction of a 'Beautiful and Ready Instrument of the Mind'. Urbaniak JR, Levin SL, Baek GH, Soucacos PN, editors. Athens. Konstantaras Medical Publicataions; 2010. p. 93-8. |
|2.||Higgins JP. The Diminishing Presence of Plastic Surgeons in Hand Surgery: A Critical Analysis. Plast Reconstr Surg 2010;125:248-60. |
[Figure 1], [Figure 2], [Figure 3]