If it hadn’t been for his parents’ insistence he stayed in education, Mr Murali Bhat, consultant in hand and upper limb surgery, would have been a professional gymnast. But he is now hugely grateful for their guidance as he relishes leading innovation in hand surgery and encouraging his colleagues to think outside of the box when it comes to managing patient pathways more efficiently. He completed his orthopaedic training in India and did a fellowship in hand surgery at Nottingham University Hospitals, under the direction of the renowned Professor Timothy Davis. Mr Bhat is a consultant at Spire Gatwick Park Hospital in Surrey and for Surrey and Sussex Healthcare NHS Trust
OPN: What drove you to choose surgery as a career – and orthopaedic surgery in particular?
MB: From the age of seven to 18, I was a national gymnast in India and witnessed many a career ending because of injuries. However, many of the same injuries didn’t end careers for my western counterparts, since surgery was more advanced so I wanted to learn the art of healing sports injuries. Orthopaedics seemed the way to go.
During my orthopaedic training in India, I came across a patient with a nasty wrist injury from a motorcycle accident. It was the first time my boss had come across this injury. I asked if I could research it, which I did. He was so impressed that he let me operate. The result was spectacular. The desire to specialise in wrist and hand surgery was born right there.
OPN: It is clear that the healthcare industry has been greatly impacted by the Covid-19 pandemic, what has been the greatest impact within the orthopaedic industry?
MB: Virtual consultation is one of the biggest changes in the orthopaedic field, which saw rapid adoption during COVID and will be here to stay beyond the pandemic.
Even before Covid-19, I had started to triage patients virtually to manage their pathway more efficiently. It was clear from patient feedback that short and defective low value consultations with long wait times, occurred frequently. I began triaging my patients a week ahead, sending them care plans and custom-made videos about their injury. This enabled those patients who did not require a hospital visit to recover safely at home. Patient satisfaction was nearly 100%. With Covid-19, remote triage became highly relevant, and we expanded this approach across the whole department. I now lead on this service, helping to see nearly 300 patients a week at our “Virtual Fracture Clinic”. I also teach and train other healthcare professionals, including GPs and physiotherapists how to safely perform telemedicine consultations.
OPN: As a surgeon, how do you embrace new technologies to ensure the best patient experience, management strategies and surgical outcomes?
MB: In 2017, five hospitals across the country were chosen to train in the Toyota Production System (TPS) for healthcare – a technique first successfully adopted by Virginia Mason Hospital in Seattle – and I was lucky enough to be part of that. It has completely transformed my approach to everything I do. It teaches you to measure the current state with “value for patient” in mind, before implementing changes or increasing resources. I have also learnt to ‘mistake proof’ every part of the patient pathway. For example, I have a safety check-list which I go through with the team before I start an operation – just like a pilot does before he flies a plane. By going through the checks, everyone on the team relaxes and it leads to good outcomes for the patients. It’s a simple thing – takes just 30 seconds to do – but makes a huge difference.
In terms of new procedures, my ‘signature’ has been a variation of keyhole surgery for carpal tunnel syndrome using a 1cm cut in the palm as opposed to a longer 4cm cut. I have been performing this since 2014 and have recently taken it out of the theatre and into the outpatients’ clinic.
OPN: What’s the best part of your job?
MB: There is so much I enjoy in my job it is hard to pick the best. But what really makes me tick is seeing a happy patient who is pain-free thanks to surgery.
OPN: … and the worst?
MB: Change is often lonely. I am in a lead role for change in my hospital and sometimes there can be a knee-jerk reaction to change. It requires courage to relentlessly travel down this path. Thanks to TPS, I love change and don’t feel afraid to make the correct decisions, which may at first be unpopular.
OPN: What has been the highlight of your career so far?
MB: There are so many highlights, it is hard to choose one. However, a recent example must be the Virtual Fracture Clinic. I can see this approach being used worldwide and would love to use my experience to make that happen. For example, my mum rang me yesterday from a remote place in India with a wrist injury. I offered her a video consultation, safely diagnosed her injury, and gave her the appropriate written and video care plan and an electronic prescription for painkillers and splint. All she had to do was get an x-ray locally, which I also prescribed.
OPN: Tell us more about the hand surgery you undertake for conditions such as Dupuytren’s in outpatients using WALANT (wide awake, local anaesthetic, no tourniquet)?
MB: Conventionally, hand surgery under local anaesthetic required a tourniquet on the upper arm to stop blood flowing into the hand. The tourniquet becomes painful after 20 minutes and needs to be released. Therefore, any operation longer than that was not possible under local anaesthesia. However, the use of adrenaline within the local anaesthetic stops the bleeding, meaning a tourniquet is no longer required. Consequently, we can do bigger operations such as Dupuytren’s surgery, tendon repairs, arthritis surgery, etc. At present, some WALANT surgery is appropriate in outpatients. Others will need to be admitted as day cases.
OPN: How could this affect patient experience and outcomes?
MB: It has huge benefits for patients – it saves time, their recovery is quicker, and, if they are having the surgery done privately, is significantly less expensive.
And, in these current times, if they are not going into theatre, they don’t need to self-isolate for three days beforehand.
OPN: How did you manage to take this surgery out of theatre and into a clinic environment?
MB: Covid-19 is responsible for this innovative idea. Prior to Covid-19, I knew that skin specialists and plastic surgeons operated regularly in outpatients doing minor procedures in the minor operations room (MOPS). Access to MOPS was easier for patients and surgeons during Covid-19. I believed appropriately selected cases, like carpal tunnel release, tendon release surgery and minor Dupuytren’s surgery, could be safely carried out in MOPS under WALANT. I saw a clear opportunity to help my patients in distress and set up this service over a year ago.
OPN: If you weren’t an orthopaedic surgeon what would you be?
MB: I almost became a professional gymnast, but I think I was cut out to be a doctor. After under-graduation, I did consider being a general physician because I like the way every organ in the body works.
OPN: What would you tell your 21-year-old self?
MB: Live as if every day were the last day of your life! My advice to young people is choose a career that makes you jump out of bed every morning wanting to go to work, with a smile. I certainly do that.
OPN: If you were Health Minister for the day what changes would you implement?
MB: I would really love it. Healthcare doesn’t have to be complicated. I would empower pharmacists on basic health advice for the general population as with headaches and colds; I would educate and encourage the public to own their health and records; I would tell the truth about nutrition that too many meals and refined carbohydrates are our worst enemy (not fat or calories); help build proper bicycle lanes like Amsterdam and encourage cycle to work; and make it compulsory for hospital consultants to learn how to measure “current state” and “future state” before asking for more resources.
OPN: Are you attending any orthopaedic events this year?
MB: In July, I am attending a hand surgery virtual conference from the operating theatres of Ganga Hospital in India. They have the world’s biggest experience in putting together severed/amputated arms due to industrial accidents. Nearly 5,000 delegates from all around the world are expected.
OPN: Away from the clinic and operating theatre – what do you do to relax?
MB: I love competitive badminton and play thrice a week. Yoga, gym, cricket, and cycling are the other sports. I enjoy travelling around the world – my classmates from undergrad days are all around the world and in regular touch. My daughter is a cognitive neuroscientist, and my son is a mathematician, and chatting with them makes me happy, relaxed, and proud. I can binge watch Netflix on gloomy days.
OPN: How do you think the future looks in the field of orthopaedic surgery and what are your predictions for the decade ahead?
MB: There is increasing evidence that we are operating on far too many musculoskeletal ailments. Consequently, I expect us to consult and advise more than operate in the decades ahead. Where surgery is required, technology will keep improving. I remain concerned about fast tracking doctors to become consultants – we may have to make mentoring compulsory for new consultants during their first five years.