Plastic surgery for the poor
Shankar Man Rai carries out free surgeries in rural Nepal
Shankar Man Rai is a plastic surgeon working in Model Hospital in Kathmandu, Nepal. He graduated from Nepal’s first medical school, trained in general surgery in Bangladesh, and returned to Nepal to pursue a career in plastic surgery. His team now provides a free service to the people of Nepal, mainly operating on post-burn contractures, cleft lip, and cleft palate. They have provided more than 12 000 free surgeries across Nepal.
What made you choose plastic surgery? 1
Luck. One day I was in theatre where a group of US surgeons were operating. They were repairing a cleft palate. I watched the operation and was amazed by the transformation in the face of this child over half an hour. Then I looked around the operating theatre and saw that they only needed a few simple instruments to make such a difference. I thought to myself, if I could learn this surgery, I could take it to the poor villages of Nepal. I introduced myself to the surgeon and mentioned I would be interested in learning the procedure. The team happened to be looking for a local Nepalese surgeon to train. It was the turning point for me. Before that, I was thinking of a career in neurosurgery or cardiac surgery. That one operation changed everything.
What inspired you to provide free surgery around Nepal?
I was inspired to continue the work of the organisation ReSurge after they provided me with training. They provide reconstructive surgery to countries such as Africa, South America, and Vietnam. I was motivated by the kind of work they were doing. I learnt the surgery from them and wanted to continue their mission in Nepal. They now support me financially and professionally by sending us volunteers in speech therapy, audiology, and dentistry.
What is the most difficult thing about providing a plastic surgery service in Nepal?
The biggest challenge we face is reaching the poorest of the poor in the villages and providing them with a reasonable standard of care. It is difficult to bring reconstructive care to rural villages. We need motivated team members. Many plastic surgeons want to practise well paid cosmetic surgery in a large city, whereas our work is mostly reconstructive and does not offer the same financial incentive. So the most difficult thing is taking the surgeons to the people.
How do you follow up patients?
Unfortunately, our follow-up is not effective. When we visit the outlying villages we provide speech therapy, audiology, and dental services to everyone. At the same time, we arrange check ups for our cleft patients. By having regular camps, we can follow-up the cleft palate patients reasonably well. The reconstructive burn patients need physiotherapy, and by providing this service at rural camps we can assess their need for revision surgery at the same time. However, follow-up is not 100%; it’s difficult.
Is there a particular patient that you remember operating on?
There was one 18 year old Muslim woman who was married and had a small child. We could not find out how she had been burnt, but she had developed terrible contractures over both knees and could not walk. She had to practically crawl because the skin contractures were so bad. We never saw her husband. We performed surgery to release her skin contracture one knee at a time, separated by 4 months. After the first surgery she was able to walk with the aid of callipers. After the second surgery she was able to walk without any help.
In our follow-up, we visited her village and found she had re-married a supportive husband. She could still walk well and is expecting another child. A simple procedure had changed her life.
Your consultations, wound dressings, and team meetings all happen in the same small room. What is it like working in such a confined space?
It is good and bad. Having all the members of your team in the one room during consultations is helpful when providing multidisciplinary care for the patients. If I need to discuss a patient with the speech therapist, they are right there. I don’t need to pick up the phone. At the same time, because of the confined working space, there is less visible hierarchy. Consultants and juniors get to know each other well, and can begin to understand what motivates each member of the team. I think this is useful for getting the message of our work across. It is difficult to motivate your team if you maintain too much hierarchy. However, the juniors are still respectful to the seniors.
What do you think the future holds for your team in Nepal?
We would like to develop other specialities such as microsurgery and acute burns. Then we can provide these services in the villages rather than expecting patients to travel long distances to visit one of our centres in the main towns. This means we need to add more surgeons to our team. The challenge in the future is influencing younger surgeons to work with the poor. As a newly trained plastic surgeon, it is tempting to settle for a life of cosmetic surgery in a large city and few choose to work with the poor. We cannot attract them by paying them more or giving other incentives; it has to be a motivation of their own.
If you could give a medical student advice when considering a career in plastic surgery, what would it be?
Firstly, you should decide for yourself what motivated you to come to medicine. You should be true to your heart and not just follow someone else’s steps. Do not think of something that is glamorous or is something that everyone else is doing. You should listen to your heart—your brain is also important, but you should listen to your heart.
Secondly, whatever you do, do it to the best of your capacity. Many of us take it very easy and do not realise our true capabilities. You should try and be the best at whatever you decide to do.Timothy Buick, , fourth year medical student,
1Barts and the London School of Medicine and Dentistry
Correspondence to: firstname.lastname@example.org
Competing interests: None declared.
Provenance and peer review: Not commissioned; not externally peer reviewed.
Cite this as: Student BMJ 2013;21:f194