Thursday, November 1, 2018

Earning child, parent trust is job number 1 for surgeon

Photos and interview By Louise Kinross

Dr. Unni Narayanan (above left) is a pediatric orthopedic surgeon at the Hospital for Sick Children who sees patients at Holland Bloorview while they do their rehab here. Dr. Narayanan went to Madras Medical College in India and trained as a resident at the University of Minnesota. This included a rotation, and then an extra fellowship year, at Gillette Children's Specialty Healthcare in
 St. Paul, which is a leader in care for children with cerebral palsy. Much of his time at SickKids is spent teaching fellows and residents. 

A number of parents suggested Dr. Narayanan would make a great interview. One of these, Samadhi Mora Severino, explains why Dr. Narayanan stands out: "What I adore about him is how humble he is and how attentive he has been with Kian (above right). Kian is partially verbal but he makes all the effort in the world to engage with him. I remember when we were doing serial casting, he was wrapping the cast around Kian's leg so they could count together. Not all physicians can bond with children with severe disabilities. Kian feels safe around him and loved by him. Kian has made it clear that he wants to be a doctor one day, and I know Dr. N is his role model."

BLOOM: How did you get into the field?

Dr. Unni Narayanan:
There are no medical people in my family, but I remember being interested in a career in medicine. I went to medical school in India from 1982 to 1987. At that time, people had blinders on, and a successful career meant being a doctor or an engineer.

Early on, I realized two things: I wanted to do surgery, and I wanted it to be a pediatric specialty. Some of the role models I saw were very caring individuals. It appealed to me—not just in terms of the surgical technical skills—but the complexities of working with children posed an extra set of challenges.

As a foreign medical graduate I was lucky to get a position at the University of Minnesota, and they had a very strong pediatric orthopedic program within the residency. It was their expertise and devotion to kids with cerebral palsy (CP) that greatly influenced what I did.

BLOOM: Of all the things you could do as a doctor, why surgery?

Dr. Unni Narayanan:
The ability to see changes—that you’re actually affecting change in a very real way by altering the anatomy. But I think to a great extent it’s who your teachers are.

BLOOM: What types of surgeries do you do now?

Dr. Unni Narayanan:
The major focus of my practice is cerebral palsy and broadly speaking there are two kinds of patients.

The first are kids who are able to walk, albeit with some difficulties. We do operations on them to help them walk better—walk further, faster and less inefficiently, so they have less pain, and can be more independent.

The second category is very different. These are kids who are more severely involved, who rely on a wheelchair for mobility and depend a great deal on a parent or carer to look after most activities of daily living.

The operations we do for these kids are focused on achieving one of the following goals: To prevent pain, if there’s a concern pain is likely in the future, or to relieve pain; to make it easier for parents to look after these kids; and to improve the kids’ health. All of these goals combine together to improve and preserve quality of life.

BLOOM: What is a typical day for you like?

Dr. Unni Narayanan:
The first category of operations is focused on gait-related goals. They tend to be everything from simple, short procedures isolated to one leg or just the foot or ankle, all the way to surgery at multiple levels at the hips, knees, thighs, lower legs and foot and ankle—so several operations done concurrently over the course of the entire day, and the child could be asleep for six to nine hours.

Our operations with our more involved patients are almost invariably long operations. They focus on the reconstruction of hips. Many of these kids have hips that tend to slide out of place and, in doing so, will create pain—if not now, then in the future. Or they may have contractures, where the muscles are too short around the hip, which make it very difficult to diaper and dress them and position them. These are complex operations to put legs back in place or to release and lengthen tight muscles. For different reasons they are big operations that can last seven to nine hours.

BLOOM: How do you stand for so long?

Dr. Unni Narayanan:
There are lots of occupations that require people to stand on their feet. If you’re serving coffee at Tim Horton’s, it's tiring at the end of the day. That’s where the training and repetition comes into these operations. And they are not done single-handedly. There’s a whole team involved.

First, there's the anesthesiologist, who is crucial not only to keeping the kids asleep, but instrumental in reducing the pain they’re likely to have after the operation by putting in epidurals and blocks. We have nurses who are really skilled at facilitating the procedure in terms of having equipment ready and helping with technical aspects. In the operating room I am fortunate to work at SickKids because I have the assistance of a fellow and a resident. The fellow is a qualified orthopedic surgeon—someone who is doing what I did 20 years ago.

The fellows need opportunities to do parts of the operation, but it has to be done under supervision, with me taking full and primary responsibility that the quality of what is done is as good as it can be. Usually at about mid-day I give my residents a break to get some lunch.

BLOOM: But you don’t take one?

Dr. Unni Narayanan:
No. But that’s only because I’m not a lunch person. Some operations may take a lot more than 12 hours. For those types of operations we have to take a break, and we let parents know that will happen. The children remain safely asleep in a sterile area.

BLOOM: What are the joys of the job?

Dr. Unni Narayanan:
It’s quite a privilege to work with kids. My research interest is in trying to understand whether what we and others are doing is making a meaningful difference to their lives. When you see evidence of that, reported in ways that are more than just the technical difference—the hip is in—that’s very gratifying.

It may be that the child had pain before and that’s gone away, or the parent couldn’t dress them before, and now it’s easier. Or in the case of a child we are trying to help to walk better—is that translating into less tripping and falling, less pain, walking longer distances, and participating more with friends and in recreation or sports?

We’re working with two patients: the child and the parent. I can only imagine, and even that would be difficult, to put myself in the position of a parent who’s giving up full control of a child to someone for an extended period of time where invasive things are happening. To allow that to happen to your child requires me to have empathy for parents, and to engender the kind of trust that I have to earn. The entire process where you get to know a family and the child, and earn that trust over time, till a day comes where an operation is imminent, makes my work life gratifying.

BLOOM: What are the challenges of the job?

Dr. Unni Narayanan:
In a condition like CP, understanding that one, we have no cure for CP, we can’t fix CP. A child with CP before the operation has CP after the operation. Recognizing that is important to me, but also how we communicate that to families over time, for them to understand, is not easy.

The primary problem is in the brain, not in the muscles and the bones, which is where I’m working. I’m working on the periphery, quite far away from the primary problem. I have to appreciate that the kind of changes we’re making, while they might be very helpful and go a long way to having a positive impact on children, may not entirely be at the level of what the parents’ hopes are.

That humility of understanding what the extent of our interventions can do, and communicating that, is a challenge, because, of course, parents have expectations that come from hopes, which are inevitable and understandable. It’s negotiating that.

BLOOM: Yes, I’m sure that parents have to grow into that kind of understanding of what the limits are.

Dr. Unni Narayanan:
It doesn’t happen in one conversation, no matter how receptive a parent might be. It’s my responsibility to do it in an empathetic way, and in a way that doesn’t dash a parent’s hope—hope is an incredibly powerful mechanism to help families cope.

It’s also important to understand the perspective of the child. We’ve found that parents ascribe a certain level of concern about functioning that is consistently greater than what the child ascribes. Parents tend to make comparisons with their other children who don’t have CP, or with the child’s peers. Parents don’t live with the condition in their bodies, so their sense is that it might be worse than what the child [reports].

We need to understand the perspective of the child and the parents, and align our goals to take them both into consideration. These are not 10-minute appointments. They can take the better part of an hour.

BLOOM: How do you find the time?

Dr. Unni Narayanan:
For new patients, we build that into the appointment, but the reality is I keep a lot of patients waiting in my clinic. I hope they realize, my apologies notwithstanding, that I’ve had to take longer than anticipated to have a difficult, complicated discussion and, having waited, they will also have that time when they need it.

Another challenge is that parents have access to all kinds of information from different sources—which is a good thing. They do their own homework and research, which allows them to ask questions.

However, sometimes they’re exposed to information that may not be well vetted and evidence-based. Yet it’s appealing, because large promises are made, which play to the vulnerability of their hope. They may ask how come we don’t offer certain procedures here. Is it because we don’t know what we’re doing?

These conversations can be difficult. There are unethical practices around the world, and south of the border, that take advantage of parents wanting to leave no stone unturned. And of course that is a completely appropriate sentiment. Why wouldn’t a parent want to explore everything possible? So how can I share information so that they trust what I’m saying, and I don’t leave them wondering could it be better somewhere else?

BLOOM: What emotions come with the job?

Dr. Unni Narayanan:
As a health-care professional, empathy is essential. I enjoy interacting with the kids. I take great pleasure in getting them to crack a smile. If I have to do big operations on them they have every reason not to be happy with me. But I try to establish a rapport with them and have them not be afraid of me. We try to make it a less anxiety-ridden experience: having a sense of humour, teasing them and finding a way to make them laugh.

Another challenge is the operation on its own is insufficient, without the kind of support and therapy and rehab required to make operations work at the end of the day. For that we are extremely lucky to be a publicly funded health-care system. That allows us to have kids spend up to three months at Holland Bloorview for free, where they can get therapy every day and not miss a day of school. Those kind of supports are just not available anywhere else in the world.

BLOOM: What about emotions you experience when an operation doesn’t go as you planned?

Dr. Unni Narayanan:
I’ve heard some surgeons say ‘Would you rather be a compassionate surgeon or a competent one?’ You should be both. If something goes wrong, I genuinely feel badly about it, and I need to communicate that to the family. If I think I have contributed to that, I have to say I’m sorry. I’m responsible, and with that responsibility comes a level of caring—not only to take joy from when things go right—but feeling everything from regret to feeling sad or bad that something hasn’t gone right. Fortunately, that happens infrequently.

BLOOM: How do you help your fellows cope when things don’t go as planned?

Dr. Unni Narayanan:
By being a role model. When something has gone wrong, they know it, and pretending it hasn’t gone wrong, or that it went wrong because of this and not that, causes you to lose credibility. Role modelling to the fellows to be honest. Saying ‘This is where we could have done better, where we made a decision, in retrospect, which was the wrong one.’

I need to walk the walk when I’m communicating with families, so that my fellows see that, and hopefully will incorporate it into their practice. By the way, there’s no one single way to be a good communicator, or to show empathy. Everyone has their own skill set, and their own personality, that they draw on.

BLOOM: You said earlier that humility is an important quality.

Dr. Unni Narayanan:
Yes. But at the same time, we can’t hide behind humility for failures to do things properly in order to prepare for a complex operation. If something goes wrong, or is unexpected, it is despite that planning, not because we didn’t do the thoughtful planning ahead of time.

It’s my job as a teacher to model to my fellows and residents ‘these are the things I’m thinking about in how we came to the decision to go ahead. Here are the different things I’ve done to ensure when we go to the operating room, we will not be surprised, because we have thought about all of the different steps we may have to take if we encounter an unusual situation.’

Nine out of 10 times there’s a particular sequence of steps you will follow. In one of every 10 children, you’ll encounter something different about the child’s anatomy, or the way the child is presenting. How do you recognize that, and how do you make decisions intraoperatively? The more thought you’ve put into it ahead of time, it won’t come as a surprise. If we know something may happen, we will have backup plans. We shouldn’t ever say that something didn’t work out because we didn’t think about it ahead of time, and do our due diligence.

BLOOM: How do you manage stress?

Dr. Unni Narayanan: I don't have any particular strategy to manage stress, but then I wouldn't describe stress as defining much of my work or personal life, beyond the average dose one expects. I play tennis for fun, and enjoy traveling and many other things with my wife, now that we are almost empty nesters. 

BLOOM: You direct a fellowship program in orthopedic surgery.

Dr. Unni Narayanan:
One of the privileges of working at SickKids and Bloorview is that the fellows keep us accountable and fresh. They’re constantly asking questions: 'Why, why, why?'

BLOOM: What do you look for in terms of applicants?

Dr. Unni Narayanan:
I have the privilege of going through 100-plus applications from around the world. I’m looking for clearly a track record supported by letters of recommendation and a CV and some sense from the personal statement about what his or her interests are in the future. We’d like to think we’re training the next generation of pediatric orthopedic surgeons and researchers who can be ambassadors.

Right now we have two fellows from the U.S., two from the U.K. and one from Portugal. Each year, we choose two from North America, and three from other parts of the world. Once I’ve created a short list, we do in-person and telephone interviews. When we do telephone interviews, five of my colleagues and I will have interviewed them, and we have a rating system.

BLOOM: But if two candidates look excellent on paper, is there something you look for in terms of their personality?

Dr. Unni Narayanan:
The question is, how do you find that out in a single meeting, or in a telephone interview? I think we all imagine we can, and we do our best.

All things being equal, we look for diversity. For example, we recognize that last year we had no women in the program. This year we have three.

Another aspect of diversity is where they come from. Candidates who may otherwise be very qualified, but who apply from Southeast Asia or Africa or parts of South America, are at a huge disadvantage.

It’s harder to vet their applications because their health-care systems may be different from ours. I’m very proud to be a member of a division where my colleagues accept that from time to time, we need to take a chance on someone who looks good. I grew up in India and trained there, and if someone in the states hadn’t given me a chance 26 or 27 years ago, I wouldn’t be here.

BLOOM: If you could change one thing about our children’s health system, what would it be?

Dr. Unni Narayanan:
Working with kids with CP is not merely surgical. We work very closely with our developmental pediatricians and physios and other therapists throughout their continuum of care.

The big black hole is when they graduate, when they get to this arbitrary age of 18 or 19. What then? We have in place less than perfect ways for them to continue to get some oversight with our physical medicine and rehab counterparts who look after adults. But there simply isn’t, within the system, a critical mass of adult providers who have the expertise, and/or the experience, or the interest in providing care for adults with CP.

BLOOM: I don’t see this being addressed systemically. What might be a solution?

Dr. Unni Narayanan:
There are different models and I don’t think any single model may work. We may have to have a multi-pronged way.

One is for us to get rid of this notion that SickKids and Holland Bloorview are pediatric institutions. For certain conditions that have their onset in childhood and are chronic, the system should continue to support the hospital to follow the patient across the lifespan.

At a higher level, the policy makers and Ministry of Health, in collaboration with us, should say that for certain childhood onset chronic conditions, we will make an exception to continue care. So rather than have Sunnybrook do a surgery for an adult, we will enable SickKids to do it.

Another idea is to have the system identify three or four providers who may have a niche interest in this population, and we would work with them. So perhaps I come to the adult institution because I know how to do this operation, and I need to get the privileges and time to do that. Or can we provide you with the operating room time at SickKids, because we are better equipped in taking care of the entire patient—we understand the other things that go alone with the condition.

BLOOM: What is it like working across two hospitals?

Dr. Unni Narayanan:
We have two institutions—SickKids and Holland Bloorview—that work to complement each other. Most rehab in other places is done at a children’s hospital. We’re very lucky that it’s separated.

I much prefer seeing patients with CP and other chronic conditions at Bloorview, because I have more time there, and it’s designed and built to accommodate children in wheelchairs. Hopefully the clinics in SickKids’ new building will be friendlier to wheelchair access. Right now, our examination tables don’t go up and down, and there are no lifts, so it really isn’t designed for kids with chronic conditions.

BLOOM: If you could give yourself advice on your first day, with the experience you have now, what would it be?

Dr. Unni Narayanan:
Stick with it, because you’re going to be very happy doing what you’re doing. I’ve been very lucky, either by accident or design. I stumbled onto a sub-specialty I love, and an environment that is so supportive, that allows me to do what I’m doing. I have to pinch myself doing what I’m doing. And the kind of colleagues I have at Bloorview—with Darcy and Golda and my physio colleagues—and at SickKids, they are hugely influential mentors. I would not change anything.