Ram Gokal (b. 1945 – )

Consultant Nephrologist, Manchester Royal Infirmary & Hon Professor of Medicine, University of Manchester

Ram Gokal’s story  – as told to John Feehally in a conversation in May 2023

Rhodesia  (now Zimbabwe)

I was born in Southern Rhodesia in 1945. My parents had emigrated from India. My father was a tailor, and no one in my family had ever received a college education. But I did well in O levels and A levels, and my father wanted me to go into the civil service which was regarded as a reputable career for a well educated Asian man. But ever since I can remember, I wanted to be a doctor. My father relented and I was accepted to study medicine at the University College of Rhodesia & Nyasaland (UCRN – subsequently UCR) under a Rhodesian Government scholarship. The medical faculty was affiliated to the University of Birmingham (UK) and students qualified with their MBChB degrees from that institute.

UCRN was then the only institution in Rhodesia (indeed in all southern Africa) where White, Black & Asian students studied together on one campus. Rhodesia was an apartheid state in all but name. I was very unsure that I would cope intellectually when I was mixing with other students in this way, but I got the top marks at the end of my first year. In 1966, my final year at UCR, Ian Smith (Prime Minister of Southern Rhodesia) declared UDI (Unilateral Declaration of Independence). There were riots on campus, the military came into control the situation, and it was a very insecure and tense time. I was president of the students’ council and was much involved in the discussions which led to the University being shut down for several months, with no certainty as to when it would re-open.

So I returned home to work in my father’s tailors shop, and I was bored!  What should I do next? I wanted to be a GP but could now see no certain path in Rhodesia to become a doctor.

Then I saw a small advertisement in the Rhodesia Herald asking for applications for Rhodes Scholarships to study in Oxford. I applied and to my surprise was short listed, and after a few interviews was short-listed for the final one (3 scholarships to Oxford – 7 candidates). But my father did not want to me to go to Oxford UK, 10,000km from home, and told me to withdraw. David Lewis, who  was from the  Rhodes Scholarship organisation (he had previously been the Rhodesia cricket captain) came to my father’s shop with the Dean of the medical faculty to persuade my father that I had nothing to lose and he should let me go to the interview.

My father relented; I was successful at the interview and I arrived in Oxford in 1967 to start my clinical studies. I continue to be registered with the University of Birmingham and graduated with my degrees of MBChB from there .I assumed that when the political situation improved I would return to Zimbabwe, but it was 1980 before the politics had settled, but by then my career path was set in the UK,  I was applying for consultant posts in the UK, and it was too late to consider a return to Africa.

Oxford

In Oxford, Paul Beeson was professor of medicine,  he examined me in finals in Birmingham, and he then offered me the house physician post in the Nuffield Department of Medicine (NDM) in Oxford.  After house jobs I went to London to do the high profile SHO rotation, which include Hammersmith and Queen Square, and I got my MRCP. When I finished the rotation I went to visit India to deal with some family matters, and to my surprise Paul Beeson tracked me down there and offered me the NDM registrar job, which I of course accepted.  Paul Beeson soon retired, and was succeeded by David Weatherall (both were iconic figures for me personally and also for Oxford medicine). Another major influence in the NDM was John Ledingham who admitted nephrology and hypertension cases to the NDM wards. I still wanted to be a GP, but Weatherall started encouraging me to become a clinical haematologist. I really did not want to do this and  told him that ‘when I looked down a microscope at a blood film or a marrow, all the cells looked the same to me’! He laughed and took the hint. John Ledingham then asked me to apply for the registrar job on the Oxford Renal Unit at the Churchill Hospital. The renal ward at the Churchill was in buildings put up in World  War 2, but regardless of the environment I immediately loved the work, and fell under the spell of Des Oliver (the single handed nephrologist who then ran the unit), a gentle and compassionate giant (he had played rugby for the All Blacks). We all had to build Kiil dialysers and I sneezed and coughed as I was exposed to the formalin. ‘Don’t worry’, said Des, ‘you’ll get used to it!’

I needed to do some research when I finished my clinical registrar job, and I was interested in the bronzed skin colour of some of our long-term dialysis patients which indicated they had severe iron overload. David Weatherall helped me write an application for an MRC Training Fellowship; I was successful and the work led to my MD thesis.

Newcastle

With my MD completed the next step was a senior registrar job. John Ledingham and Des Oliver pointed me to a post in Newcastle (Terry Feest had just moved to a consultant post in Exeter), and I was appointed.  I arrived in Newcastle in 1978, and wondered what I had come to.  It was cold, grey, windy, and I could not understand a word of the Geordie accent!

But I quickly felt at home, because of the kindness and warmth of David Kerr and his team. Kerr was a lovely man, he generated the unit’s  caring atmosphere. He taught us compassionate clinical care, and intuitive clinical skills. Dialysis space was still at a premium and many people could not be  offered treatment, and I learnt much from the gentle and compassionate way David came alongside them as difficult decisions were being made.   David was based at the RVI, next to the university, and was able to combine superb clinical and teaching skills with a very strong research environment. I was content to be there, all I wanted was to complete higher medical training in Nephrology and General Medicine, to be ready for a consultant job.

CAPD

David Kerr and Mary McHugh (senior registrar in nephrology based at Freeman Hospital) went to Canada in 1978 for the International Congress of Nephrology in Montreal and  visited Dimitri Oreopoulos in Toronto where they saw CAPD in action. They came back enthusiastic to start CAPD in Newcastle. After some discussion it was clear that it would not work to start this new treatment at both Freeman and RVI, so David decided it should all be at RVI, and asked me to lead it. I was not enthusiastic, not least because I had bad memories of intermittent PD (using the ‘stab’ technique with rigid catheters) which we had used in Oxford for those awaiting an HD space.

But we set off, established the first CAPD programme in the UK, and published our results. The international leaders of PD at that time were in the USA: Jack Moncrieff and Robert Popovich, who had first reported its use, and Karl Nolph who had become its main clinical proponent in the US. This trio (the ‘CAPD mafia’) came to Newcastle and shared their experience. It was a telling moment when we realised that we had more patients on CAPD than they did! It was not too much later that I in turn joined the ‘CAPD mafia’ and began to travel the world talking and teaching.

Manchester

I was appointed as a consultant in renal and general medicine at Manchester Royal Infirmary (MRI) and began there in 1981. Netar Mallick with Bob Johnson (transplant surgeon) had established an excellent collaborative set up for treatment of renal failure. They had a large transplant programme supported by HD, although they were hampered by lack of HD space.  As the second consultant I took the lead in developing a substantial  CAPD programme, the largest in the UK, built on a  very strong multidisciplinary team, particularly the group of senior nurses (notably Linda Uttley, Linda Whitworth, and Judy Moon) who led so much of the clinical work and taught the junior medical staff.  We placed strong emphasis on the work of our CAPD home care nurses; I regularly made home visits with them, and was humbled by the limited circumstances of many of our patients, and their gratitude.

When I first arrived at MRI there was a weekly meeting at which decisions had to be made not to offer dialysis to obviously suitable people. Soon it  was a meeting to discuss  the ongoing dialysis and transplant care of such people who were now being treated because we were using CAPD so effectively alongside our limited HD resources.

I was always aware that CAPD would have limitations as long term therapy compared to HD, not least because of peritoneal membrane changes, but it had a major role as  a bridge to transplantation and also for those not transplantable who could dialyse at home for a good number of years before a change to HD might be needed.

From the beginning we also created a strong research environment. Over my time in Manchester, I supervised nine successful MD or PhD students who worked on PD topics, renal standards, renal bone disease and cardiovascular outcomes. The first was Chandra Mistry who did the crucial work which demonstrated the value of icodextrin as a non-glycaemic colloid osmotic agent to promote ultrafiltration in PD (link).

Career

My national and international reputation grew. I taught, wrote standards, wrote books,  gave lectures, chaired committees, and travelled endlessly.  I would sometime go to Japan or the US for only a day or two of work. My secretary hated me travelling because she knew when I got back I would present her with a handful of dictaphone tapes to process – I worked  all the time on planes –  the one time I could get peace and quiet to dictate research papers, book chapters and the like. All in all I amassed over 250 peered reviewed publications, 30 chapters in renal textbooks and edited 3 textbooks on PD

What might I have done differently in my career?

My strong focus was always on treatment. And it was deeply rewarding to be able to treat people with ESRD, who we knew were previously left untreated for lack of resources.

But I wish I had also had more time and space to focus on prevention  of progression of CKD. I could see that conventional measures – diet, BP control, ACE inhibition – were having some effect, but it was incomplete. People still progressed. Before my retirement I made contact  with an institution in India, and we did some joint work showing that Ayurvedic treatment with diet, yoga and meditation could stabilise CKD (unfortunately unpublished as I lost contact with them around the time of my retirement).

Racism

Early in my career I was aware of bias against my  progress based on my Indian heritage. A specific example relates to my attempts to get a consultant job. I was short listed multiple times – also on the short  list would be Ramesh Naik (another African Indian) and Jo Adu (of Ghanaian origin). As well as the three of us there would be one White candidate at the interview. It was the White doctor who was appointed time and again, although eventually all three of us got UK consultant posts. I could always sense individuals who had racial bias but this was rarely overt. But over a drink at a Renal Association meeting I did hear a group of consultants from the south of England talk disparagingly of Manchester with its leaders Mallick and Gokal as ‘wogga wogga land’ . We were able to dismiss this as driven by jealousy;  we knew we had built an excellent unit at MRI, one of the best in the country, and we were confident our results and achievements would speak for themselves. Beyond this, there were no overt personal racial issues I faced – and it is  reassuring for me  that the world of nephrology has moved on so much in this regard, especially in the UK!

Ambition & Ego

 At most stages of my career I was ambitious – ambitious to make progress, ambitious to do more for my patients, ambitious for recognition. But I have been always aware that it is all too easy for ego to take over and lead to the unhelpful urge for recognition – for example  ‘why was he asked to give that lecture and not me?’  Such thinking does no

good and should be kept in check.  I continually asked myself ‘for what am I ambitious?’ and ‘is that the right goal?’.

Retirement

I retired in 2005 when I was sixty years old. By any conventional assessment I was still at the height of my career – with an international reputation, and many opportunities to lead and develop the CAPD community, But I knew instinctively it was the right time to stop. I was tired of the endless international travelling.  At my retirement event, Norbert Lameire chided me gently and entertained the audience. What is different between God and Gokal? God is everywhere, Gokal is everywhere… except Manchester!  I looked ahead and to some extent saw only ‘more of the same’. My family circumstances were an additional factor, I had been a single parent for quite a time. I wanted time and space to reflect on the deeper meaning of my life and  increase my spiritual awareness. And I wanted to explore broader aspects of health and healing through traditional methods, including diet, yoga and meditation, especially in my own Hindu-Ayervedic tradition. So I left MRI, left nephrology, married again, and moved to Toronto where I still live and work on those issues at the age of 78.

Finally….

I am indeed grateful for having had the opportunity to follow a career which I loved and enjoyed, care for patients (a humbling experience – they taught me a lot about life!), teach, lecture  (and see the world), and do research (to further knowledge and treatment approaches – I am grateful for the wonderful research fellows). I was also fortunate to have had iconic mentors throughout my training career (Paul Beeson, David Weatherall, John Ledingham, Des Oliver, David Kerr). I also had wonderful and helpful colleagues in Manchester – Netar Mallick, Bob Johnson, the nursing staff, and Andrew Boulton in the joint Diabetic Renal Clinic we established); and international colleagues around the world. It was a good ride and now its a different journey!

 

 

Last Updated on May 31, 2023 by John Feehally