Sometimes, answers to our life’s questions come from unexpected quarters. Provided we keep our common and special senses receptive.

Within the ten years of getting an M.S. degree, I was enjoying success. 

I was one of the busiest surgeons. 

On some days, I used to operate 10 cases a day.

I was Operating at three different level facilities – primary, moderate, and advanced!

Coordinating Rotary Global free ear surgery project for the poor. Contributing time and money to many social organizations.

Teaching at a medical college.

Teaching as an invited faculty in many courses and conferences. 

Invited faculty at both the national and international levels. 

Work as a part-time agriculturist. 

A part-time job as a corporate trainer. 

Motivational speaker for students. 

Rejuvenating the ancient water management system in the district, built by my forefathers. 

Protecting ancient monuments in my city from real estate goons. 

Reading my favorite books. 

Watching favorite Hollywood flicks.

Enjoy a beautiful joint family.

Many more things.

I was always in a hurry. Or I was acting busy!

I was fast. I mimicked hectic.

I thought I was efficient.

But, a matter of factly, I was not effective. 

Overall, life was chaos!

Appears overwhelming! The truth was, I was busy being busy. 

I was trying to bite more than I can chew. I used to find it very difficult to manage time. As a result, my ambition to learn more surgeries suffered. I was performing 50% of the surgeries that I am performing now. Most of them were bread and butter surgeries. No creamy layer! 

It is challenging to motivate yourself when moving one task to another without a break! Twenty-four hours a day appeared to be too little! There was no sense of fulfillment. 

 To achieve anything significant, we have to do deep work. Deep work is working on a single task or activity with focus and without interruption. All successful people work in isolation and deep work mode. But, I was working in spurts or what Cal Newport calls “fractured time.” Cal Newport is the best-selling author of Deep Work, an excellent book. With a fractured schedule, I was performing basic level surgeries. I had no time to learn more. I did not know how to learn more in less time. It is at this juncture; I visited Gruppo Otologico, Piacenza, Italy. 

That Italy visit under Dr. K.P Morwani and Dr. Shan’s leadership was an incredible eye-opener for me. I made many new friends. Together we toured beautiful places like Milan, Venice and Como lake. For me, the center of attraction was Prof. Mario Sanna. He has a magnetic personality. He had four operation theaters. Almost every day, they operated major cases coming from all over the world. His colleagues and fellows performed most surgeries. He would join them only for the most critical step of the surgery. For example, tumor removal step of Paraganglioma or acoustic neuroma. Electrode insertion step of Cochlear Implantation. He was monitoring all surgeries through four video monitors, which relayed live from O.R.s. In-between, he would consult his patients. Teach fellows. Do many other businesses. 

He worked in spurts like me. Yet, efficiently and effectively. 

Gruppo Otologico is the most sought center for Lateral skull base surgery training. Even Americans come there. 

He is one of the most published. 

He is highly Respected. 

How did he do that? 

Answers to this question came from another Italian. An economist. Vilfredo Pareto who lived between 1848 – 1923. He discovered the 80/20 Principle. Now this concept is popular with many names. These are the Pareto Principle, the Pareto Law, the 80/20 Rule, the Principle of Least Effort, and the Principle of Imbalance. Pareto observed patterns of wealth and income in nineteenth-century England. He found that most “income and wealth went to a minority of the people.” It is obvious! But, he also discovered two other significant facts. 

First, there was a consistent mathematical relationship between the proportion of people and the amount of income or wealth that this group enjoyed. For example, 20 percent of the population enjoyed 80 percent of the wealth. This imbalance pattern is consistently repeated at different time periods or other countries, with mathematical precision.

In 1949, George K Zipf elaborated Pareto’s principle. He came up with the “Principle of Least Effort.” Zipf proposed that all resources tended to arrange themselves so on to minimize the work. The net result, approximately 20 percent of any resource, accounted for 80 percent of the activity related to that. Resources mean people, goods, time, skills, or anything else that is productive.

Prof. Mario Sanna was using 80:20 Rue or the Principle of Least Effort unknowingly! LOL, Smiley. Most businesses apply this formula to enhance their productivity. For example, Apple was selling more than 300 products with low profitability. When Steve Jobs returned as CEO, he ruthlessly sacrificed them all! See what Apple is now!

These two Italians helped me restructure my work. Besides, giving me an impetus to start lateral skull base surgery.

I started devoting 80% of my time to things that really mattered. That is for deep work. And the remaining 20% to all other issues, fractured-time-tasks. It started with planning my day. I started defining my spectacular day and how it should be. Days become months. Months become years.  

I love this quote from Spartan warriors, “Sweat more in training, and bleed less in battle.” I started planning my surgical list and each surgery. Twenty percent of the total surgical time went into planning the list or surgery. Planning started saving a significant amount of time for me.  

Surgical time: I copied Prof. Sanna. I started letting my fellows perform most surgical steps. I scrubbed only for essential steps. It served two purposes—training fellows and saving time for me.

Learning new surgeries: I realized that 80% of each new surgery’s steps had similar steps to surgeries I had already done. And I had to train or learn only the remaining 20% of the steps. For example, for anterior skull base surgery, I had to prepare only for drilling within the sphenoid. For cochlear implantation, train for cochleostomy and inserting the electrode. We can practice these steps on cadavers or simulators umpteen number of times. And upgrade our skillsets within a short time!   

When we want to change or learn something new, it may appear overwhelming. Once we understand this 80/20 principle, everything seems easy. There are many aspects to surgery. Once we overcome the initial inertia, the rest gets accelerated automatically. 

Delegation: Earlier, I was trying to micro-manage every aspect of our hospital, social work, family aspects, and others. I realized that I don’t have to do all the work myself. I can guide others and delegate 80% of my work and dedicate my precious time to the most critical issues. The principle of delegation helped me in three ways. My dreams became shared dreams. It enhanced team spirit among family members and staff of the hospital. I could use my spare time to build other businesses and my favorite hobbies. 

Out-patient: Earlier, I was devoting equal time to all patients, irrespective of their problem. I realized that only 20% of the patients required 80% of my time. The remaining 80% required only 20% of my time. Perfect diagnosis of almost every disease condition depended on 20% of our efforts. It may be a critical history point, one physical examination, or one diagnostic investigation. Only 20% of the condition required more effort to arrive at a diagnosis. This principle helped me to clinch perfect diagnoses ever for elusive problems such as vertigo and headache. (Disclaimer: Junior colleagues must examine patients thoroughly until they gain enough experience). 

Earning: It was inevitable to keep our surgical fee very low due to our population’s low socio-economic strata. I mastered a few key surgeries, which bought 80% of our income. A surprising turnaround was we even started getting international patients. It was an achievement for a small place like Chitradurga! We do have a standard operating fee. Yet, we do not turn back any patient on financial grounds. This simple social gesture enhanced the credibility of our hospital.

Training fellows: I asked my fellows to concentrate only on one step at a time. Master it. Then move to the next step. Each step comprised only 10 – 20% of the whole surgery.

Training O.T. staff: The same principle applied to the O.T. staff as fellows. I appraise the critical new steps of the surgery and equipment required for the same.

Arranging O.T. Trolley: We set the most commonly used instruments in a designated and easily reachable place. Eighty percent of our work depends on 20% of the instruments on the trolley! This simple change saved us a lot of surgical time.   

Hands-on training courses: I ask the participants to focus on the most crucial step and practice several times. For example, in temporal bone dissection courses, crimp the piston at least 100 times. Or until they are tired! They do not proceed further quickly. Hence, most participants of our courses are delighted. They come back again for more. Twenty percent of the participants in our training courses are those who have participated earlier.

I can go on writing about how I have used this principle in every aspect of my life and work to learn more in less time. Interested colleagues can read more about it in this fantastic book: The 80/20 Principle: The Secret of Achieving More with Less (1997) by Richard Koch. This book is one of the Top 25 Business Books of the 20th Century. 

With best regards, 

Dr. Prahlada N.B.

Pictures Courtesy:

  1. Mario 21
  2. Rockey 31
  3. LeoWolfert
  4. Pavlo Vakhrushev