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Hello, I’m Domhnall MacAuley and welcome to this BMJ leader conversation. Today we’re in London and I’m talking to Ajit Abraham. You have reached the very pinnacle of your profession but I’d really like to take you to the start. What interested you in medicine to begin with?
Ajit Abraham: As a young boy in India, my aunt was my inspiration. She was the first female general surgeon in the southern state of Kerala in 1959. I had the privilege of joining her in theatre when I was doing my A-levels. I got to attend an operation, nearly made a fool of myself by reaching down to pick up something that had fallen off the sterile trolley, but was held back in time. The whole drama of witnessing a life-saving operation, seeing her fix someone and make them better, was something that excited me immensely. That was the trigger for wanting to become a surgeon. When I entered medical school, even when dissecting in the anatomy hall, I felt that was my calling. I was drawn to surgery. I just wanted to make a difference. I wanted to be helpful to people who were suffering. I love fixing things, and I thought I’d be good at it.
DMacA: That’s incredibly inspiring. She really was ahead of her time, a woman surgeon in 1959…
AA: Yes, indeed, and even today it’s something that we have to push actively and it’s why I’ve always been actively encouraging women in surgery. Interestingly, and it’s little known, half of the residents were female when I was training as a surgeon in India. That too is unusual even today in England. And I also think that its true to some extent in the United States and other places.
DMacA: Junior doctors are now almost obsessed by taking the correct direct career path. But I’m fascinated by your career because it was anything but direct. You had a fantastic international experience. Take us through that step by step.
AA: Yes. I’ve been very fortunate, as you say, to have had a very interesting career path. I was born in Africa, I grew up in the UK, went back to India, did my A-levels there, went to medical school, then did surgery in India. So I had broad exposure to general surgery in India in the 1980s and was prompted by a desire to learn more, to broaden my research capability, and acquire other skills. And that’s when I came to the UK to further my training because, in those days in India, you couldn’t really get a training in hepatobiliary surgery. I then went through the whole UK training scheme again. I got my Fellowship and then was fortunate to be selected into a national program for training in liver transplantation and hepatobiliary and pancreatic surgery, which was my chosen area of interest. Having spent several years doing research and clinical training in that area, I qualified as a consultant in 2005. I’ve since had an opportunity to go to the United States, around 2010-11, and then subsequently to set up a service in Singapore, where I re-established the liver and pancreatic surgical service at Khoo Teck Puat Hospital in Singapore.
I have been very fortunate to see the breadth of surgery in four countries on three continents in very different settings. And that’s what’s propelled some of my preoccupation with inclusion and equity over the last few years.
DMacA: Let me take you back to two things you mention. Not many people take a sabbatical. Tell me about that process.
AA: One of the things that’s driven me, and I’m reminded of the apocryphal story of Michelangelo on his deathbed at the age of 87, saying ‘Ancora Imparo’, which means ‘Still I am learning’. I feel that part of what gives fulfilment and purpose to our work comes from continuously learning and being stimulated to do that. And that’s what’s driven many of the different things I’ve done. And I think part of that ability to learn afresh is about consciously displacing yourself from a place of comfort, going somewhere new, being stimulated by new ideas, new people, new cultures, new opportunities to learn, new ways of doing that. That applies to both surgery and the context within which surgical delivery sits in terms of the healthcare systems and how they work. I think that’s critical. And in terms of training too, although increasingly the tendency is, as you were saying, to pursue a very direct path. I understand the motivations for that, but having had a very rich training and general surgical base on which I’ve subsequently developed my specialist training, I think that’s been immensely helpful because I’m very privileged to have dual accreditation. I’ve done trauma surgery for 20 years but I’m also unusual in that my specialism is liver and pancreatic and biliary cancer surgery and complex benign work. And I think all of that has now allowed me to take on robotic surgery. Because of the breadth of my exposure, there’s been an opportunity to participate and contribute in more than one field and to learn different skill sets.
I think the skill sets that you need as a trauma surgeon are very different from the ones that you need as a hepatobiliary surgeon. One requires long hours, intense concentration, precise repairs. The other is about damage control and the right kind of decision-making. Being privileged to sit in both those spaces has strengthened and reinforced my skill sets in both areas. I see that as a real blessing, and I hope that, in this direct pursuit of short, snappy and quick training, we don’t lose some of the richness that you inevitably need to develop surgical insight and wisdom.
DMacA: Part of that richness was your trip to the US where you worked with IHI which was another remarkable experience. Share that with us.
AA: That was a really privileged year, a blessed year. I had the opportunity, thanks to the, Health Foundation Fellowship, for which I’m always grateful, to visit the Institute for Healthcare Improvement and spend time with people like Don Berwick and Maureen Bisognano and others, but also to spend some time at the Harvard School of Public Health, and the Harvard School of Business, and the Kennedy School of Government, because even though I love what I do as a surgeon, I’ve always been conscious that surgeons have to contribute more in terms of strategic thinking around how that care is delivered and understand the context of the healthcare system, population health, and the populations within which that delivery sits. I’ve always been taken by Ron Heifeitz’s notion that somehow clinicians have to both be able to get on the dance floor and also get up on the balcony and hold both those two perspectives if they are to be truly able to contribute both in terms of clinical care to patients who need it, and also help shape the care that we deliver in the wider sense. That was what the year at the IHI really taught me, not only in terms of understanding quality improvement methodology and patient safety but also the clinical leadership that needs to sit around that to help and support that. And also to understand how cost and quality, population health, joy at work, the staff that deliver it, and increasingly the notions of inclusion and equity, all of these things interplay in such a way that you provide exceptional care.
So the time at the IHI was, as you say, transformational for me. I met some wonderful people, and learned some innovative things. It has informed the direction of my subsequent career journey.
DMacA: Now let’s bring you up to date and talk about something else, and you alluded to it a moment ago, that you are co-chair of the inclusion board. Tell us about that.
AA: I am, and since I took on that role, I’ve now been appointed as a group executive director on our Trust Board to drive both inclusion and equity within the organization and lead that agenda, and I think it’s particularly relevant where I work in East London which is a deeply underserved area. Socio economic deprivation is high and we have a very diverse population. There are, for example, over 140 languages spoken in East London. We also have very diverse staff and the purpose of connecting inclusion directly to equity is to make sure that we have an organization where all our staff feel included, treated fairly, and feel that they belong. And then to connect that sense of belonging directly to their sense of purpose in terms of ensuring that there is equity, in terms of the way we deliver healthcare for our patients, and to the communities that we serve and our wider population. This was brought home particularly during COVID and some of the challenges that our local communities faced in terms of accessing care.
I think that, increasingly, we don’t do enough when we talk about the quality of care if we fail to appreciate just how much issues around inclusion and issues around equity and the social determinants of health play into our ability as clinicians to deliver care in that richer sense of high-quality care. We don’t have to solve all of the problems as clinicians, but we certainly need to be aware of how some of these factors play into the way we can respond to people’s needs holistically.
DMacA: This whole area of fairness and diversity and equity is clouded in jargon. But I’ve heard you use simpler terms, which really brought it home to me. You emphasise that “fairness matters”. Tell us how we put that into practice.
AA: Absolutely. It does to me. And I think that resonates for most of us. It’s about fairness. It’s hard to tease that apart, the thinking of John Rawls has deeply influenced me, and I think we’re constantly trying to balance the tension between freedom and fairness.
And I think while there are legitimate criticisms we can make of Rawls’ Theory of justice. There is an attempt to balance that tension between respecting and recognising people’s freedoms, but also ensuring fairness in terms of his maximin or difference principle: of ensuring that when difference exists, we do our very best to ensure that those who are least supported or most underserved, if you like, by inequalities are also lifted up so that when one person progresses, we try to make sure that everyone else does. In that sense, institutions and organizations have a responsibility to look at their structures, their processes, the way they provide care, and where there is disparity that clearly impinges unfairly on the people that they serve. I think we have a responsibility to do everything we can to make sure that we address that unfairness and that we make sure that things work more fairly.
A lot of what we’re doing as an organization at Barts Health is an endeavour to look honestly at these issues. The reason I emphasize fairness is that I think sometimes when you look at things through the lens of identity, you can get caught up in identity and get distracted from the issues of fairness. And I think that while identity matters and must inform the discussion, it should not take over from our need to make sure that it’s fairness that sits at front and centre in everything we do. That’s been a big preoccupation of mine in my organization for some time now. And we’re very much at the foothills of what that means in terms of equity. But I think it’s an important principle to keep in mind that fairness matters.
DMacA: Now, let’s change tack a little bit, because you’re a surgeon and we have our image of what surgeons are like. Even worse, you’re a robotic surgeon, so that perception may even be exaggerated. But there’s another side to you that’s a little unexpected. And that’s your interest in mindfulness. Lets talk about that.
AA: Yes. This is my main preoccupation. I’ve meditated since I was about 21 and perhaps I’ve meditated because I’ve needed it more than most but I’m convinced increasingly, as I’ve gotten older and as I’ve learned to be more disciplined in the practice of just learning to ‘be present’. Mindfulness techniques vary; people can do it in various ways, and some are just naturally gifted at it. Others, like myself, perhaps not as much. But if you practice diligently and you persevere, mindfulness practices can increase your capacity to be present. As a practicing clinician, as a surgeon, anybody involved in healthcare, the capacity to be present in the moment, without judgment, is critical to your ability to respond in a way that’s kind and compassionate. I teach mindfulness techniques to some of the new consultants at their induction and they find it helpful. It’s just a collective way of anchoring ourselves in the present so that we can respond with kindness. The other thing that I think mindfulness practices can do, certainly based on my experience and what I understand of the emerging evidence, is that it softens our sense of self in a way that makes us naturally reach out and respond to others. It also makes us more conscious of our interdependence on one another. It offers an opportunity for us to recognize issues of fairness. I have this mantra that I think I’ve shared with you; “just be, be kind, be just”, and those three phrases are what keep me anchored amidst all of the challenges and constraints and difficulties that we are all facing. I try to say to myself- always try to just be, so that you can be kind, and then be just. Mindfulness has been very helpful in getting to a position where I’m able to, I hope, a little bit more consistently, to not only talk the talk, but to walk that walk in terms of my daily practice and in carrying out some of my other roles in the organization.
DMacA: Thank you very much for sharing so much of your life, your philosophy, and shaking up our understanding of what a surgeon really is. I love that mantra. ‘just be, be kind, be just. Thank you very much indeed.
Ajit Abraham MBBS, MS, MA (Medical Ethics & Law), FRCS, FRCS (General Surgery)
Consultant General, Trauma & HPB Surgeon
Ajit, whose family hails from Kerala, India, was born in Kumasi, Ghana, schooled in Manchester, and trained as a doctor and general surgeon in Pune, India. He returned to the UK in 1993 and trained further in hepato-pancreato-biliary (HPB) surgery and liver transplantation in London, mainly at the Royal Free Hospital and the Royal London Hospital.
He has been a Consultant General, Trauma & HPB Surgeon at the Royal London Hospital, Barts Health NHS since 2005 with related laparoscopic and robotic expertise. He is an Honorary Senior Clinical Lecturer at Queen Mary University London and the Barts Health Trust Undergraduate Dean. He has been the Barts Health Group Executive Director for Inclusion and Equity on the Trust Board since August 2022 and maintains a private general and HPB surgical practice at the London Clinic and Princess Grace Hospital, Harley Street.
He is an active clinical surgeon whose specialist HPB interests include surgical management of benign and malignant diseases of the liver, gall bladder and bile duct, and pancreas, complex gallstone disease, and acute and chronic pancreatitis; and related open, laparoscopic and robotic surgical approaches. He also has over two decades of expertise in elective and emergency general surgery and managing major chest, abdomen and pelvic trauma at the Royal London, the UK’s first dedicated major trauma center.
Ajit is the Honorary Principal and Trustee of The Staff College for Leadership in Healthcare, a UK charity, is on the International Editorial Board of BMJ Leader and has a long-standing yoga and meditation practice and is a Breathworks-qualified resilience and mindfulness trainer.
Professor Domhnall MacAuley
Domhnall MacAuley currently serves on the International Editorial Board for BMJ Leader.
Declaration of interests
We have read and understood the BMJ Group policy on declaration of interests and declare the following interests: none.