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4
R. Lati and A. Smiley
ization, improved dexterity, and tremor reduction for surgeons. The robotic arms mimic the
surgeon's movements while scaling them
down, providing precise control during complex operations. Surgeons have embraced
robotic assistance for procedures in every
clinical surgical discipline from neurosurgeries to like prostatectomies, hysterectomies,
and colorectal surgeries, hepatobiliary surgery, and endocrine surgery, resulting in
potentially decreased blood loss, shorter hospital stays, and improved patient outcomes.
3. Decision Support Systems (DSS):
Technological advancements and the advent
of electronic health records have paved the
way for digital decision support systems in
surgery. These systems leverage algorithms,
data analytics, and articial intelligence to
analyze patient-specic information and provide evidence- based recommendations. DSS
can assist surgeons in preoperative planning,
predicting surgical outcomes, selecting treatment options, and assessing risks. By integrating clinical data and evidence-based
guidelines, DSS programs help surgeons
make well- informed decisions tailored to
individual patients.
4. Personalized Medicine: Genomic research
and molecular proling have enabled personalized surgical approaches. Genetic testing
can identify specic genetic markers or mutations that inuence a patient's response to surgery, anesthesia, or drug therapies. This
knowledge can guide surgical decisionmaking by identifying patients who might
benet from particular procedures, predicting
the likelihood of complications, optimizing
drug selection, or identifying potential risks.
Personalized medicine allows surgeons to
customize treatment plans to individual
patients, improving outcomes and reducing
risks.
5. Enhanced Imaging Modalities: Advanced
imaging technologies have had a profound
impact on surgical decision-making. Magnetic
resonance imaging (MRI), computed tomography (CT), and intraoperative ultrasound
provide surgeons with detailed anatomical
information, facilitating precise surgical planning and execution. These modalities help
identify vital structures, vessels, and tumor
margins, reducing the risk of complications
and enabling more accurate and minimally
invasive procedures. Additionally, intraoperative imaging systems provide real- time feedback, enabling surgeons to adapt their
strategies during surgery.
6. Risk Stratication Models: Predictive mod-
els and risk stratication tools have emerged
to estimate surgical risks and outcomes. These
models use patient characteristics, clinical
data, comorbidities, and sometimes genetic
information to predict the probability of complications, length of hospital stay, or mortality
rates. Surgeons can utilize this information to
discuss risks and benets with patients, set
realistic expectations, and adapt surgical plans
or interventions accordingly. Risk stratication models aid in shared decision-making,
allowing patients to make informed choices
about their surgical options.
7. Multidisciplinary Approach: Collaboration
among multiple healthcare professionals has
become integral to surgical decision-making.
Surgeons now work closely with radiologists,
pathologists, anesthesiologists, and other specialists to ensure comprehensive patient evaluation and optimize treatment plans. This
multidisciplinary approach enables a holistic
assessment of patients, incorporating expertise from various domains to develop the most
appropriate surgical strategies. Collaborative
discussions and input from different perspectives enhance surgical decision-making and
contribute to improved patient outcomes.
These advancements collectively pave the
way for more precise, individualized, and optimal surgical decision-making, improving patient
outcomes and quality of care [1–4]. Ongoing
research, innovations in articial intelligence,
and further advancements in technology will
likely continue to shape and rene surgical decision-making approaches in the coming years.
But let’s get down to what really matters. Yet,
in the center of all the above advances is the sur-
1 Surgical Decision-Making andtheChanging World
5
geon and what constitutes decision-making, since
every surgical procedure potentially carries signicant risks and complications. Despite the
most conscientious preoperative preparations,
surprising events may still occur. If the operation
takes an unplanned turn, the surgeon has to make
difcult decisions. Depending on the procedure,
but an absolute must, continuous awareness of
the patient’s physiologic status—including uid
status, urine output, use of blood and blood products, bleeding, current medications (such as
vasopressors), and biochemical endpoints of
resuscitation, frailty index, and how the patients
look and feel, are the cornerstone of surgical
decision-making. Even when the operation is
going well, the biochemical prole of the patient
may not be optimal, or even satisfactory, which
may directly affect the outcome. In addition, the
surgeon must recognize his or her own physiologic status; if tired, for example, cutting corners
and making major errors are much more likely. In
my recent complex release of adhesion in a
patient with complete mechanical bowel obstruction from adhesions (grade 3 and 4), I noticed
oozing from the raw surfaces. When I asked the
anesthesia team, what was the patient’s temperature, I was told 35.50C. He became cold and
coagulopathic after three hours of intense lysis of
adhesions. I decided to stop the procedure, pack
his abdomen and performed a temporary abdominal closure. Next day, after resuscitation and
warming him up, I worked on him for three more
hours and now he is recovering ne. The decision
was a result of intense observation and
communication.
Most recently, in order to assist in surgical
decision-making and reduce errors and bias,
among others, it has been suggested [3] the use of
articial intelligence models that are continuously
fed real-time data from electronic health records
through mobile devices. By streamlining the data
collection process and leveraging AI algorithms,
the authors suggest that this approach may
improve the accuracy and efciency of surgical
decision-making. However, implementing this
approach successfully would require overcoming
certain obstacles. These include standardizing the
data, ensuring the interpretability of AI models,
implementing and monitoring the system carefully, addressing ethical concerns related to algorithm bias, being accountable for errors, and
maintaining the importance of bedside assessments and human intuition in the decision- making
process [1]. Irrespective of how helpful and crisp
and fast, can AI be helpful, or potentially be helpful, the missing link between AI and the patient
will be trust and bond between the patient and surgeon that needs to be established and maintained.
This bond and trust can only be established with a
handshake, looking straight in the eye of the
patient, with detailed explanations or even regrets
when we have, happiness when things go well,
and sadness on the surgeon’s face, when things do
not go as planned, or when there is not much that
he/she can do. These are the most difcult conversations that we surgeons have with patients and
their families. Articial intelligence cannot do
that. It can summarize the literature quickly, so it
will be useful, for some of us who are not up to
date on every clinical issue.
In this book, as in the rst edition, we address
these and other elements that are important for
the perioperative decision-making process. For
the majority of elective surgeries, the general
checklist for surgery that includes some common
steps and considerations include the preoperative
evaluation, anesthesia consultation, preoperative
instructions for the patient, surgical consent and
discussion, preoperative preparation, preoperative medications and precautions, and time-out
before the procedure starts, sufces, and it is
designed to reduce surgical errors.
The question that has not been answered yet,
is how do we as surgeons make intraoperative
decisions? When a patient is dying in our hands
from bleeding that we cannot control, when irreversible metabolic shock does not respond to
anything that we do, when new problems emerge
out of the blue, when things go alarmingly
wrong—in such dire moments during a carefully
planned operation, how do we decide what to do
next, and how should we overcome our own
fears? Many of us make decisions that later on we
cannot explain why we did things a certain way.
Usually these are decisions made on the basis of
a “gut feeling,” or “intuition,” or the “gray hair
6
R. Lati and A. Smiley
effect,” among other attributes. Yet, the anatomy
of such decisions is of great importance to all surgeons, patients, and those who work with surgeons. In this book, we will review theoretical as
well as any objective data that we as surgeons use
to make perioperative decisions. The decisions
we make, often with very limited information,
will decide between someone living or dying.
How do we make decisions in split seconds to
take someone to the operating room now, as
opposed to, let’s say “a bit later”? How do we
decide to operate on a dying patient, without a
CT scan, no laboratory data, just based on the
fact that he or she is in shock, just to nd liters of
blood in the abdomen, a torn vena cava, grade 4-5
liver injury, spleen, or some major blood vessel?
When the patient is dying in the operating
room from massive bleeding, everyone panics,
but the surgeon reaches in the open abdomen and
compresses the aorta between his or her ngers,
or puts a clamp on to let the anesthesia team catch
up. Personally, when things get “tight,” I lower
my voice and give deliberate commands. Is there
a molecular explanation for this? Our collective
rsthand experience as surgeons’ points to a
combination of factors contributing to our intraoperative decision-making process, including
education, clinical know-how, mentoring, and the
creativity and excellence that come with long
practice and with strict discipline.
Frankly, while the surgeon is the “captain of
the ship,” there are many aspects of the surgical
process that have recently received major public
interest, which are not in the hands of surgeons at
all. Involvement of other disciplines, mainly
administration, regulations, insurance and governmental involvement, has taken many of these
priorities, and even prevent surgeons from taking
potential decisions. The majority of private and
independent surgical groups, are no longer private, and no longer independent. They have been
swallowed by the corporate world.
Prof Haile Debas, on his presidential address [1]
titled “Surgery: A Noble Profession in a Changing
World” given to American Surgical Association
called surgery noble and quoted Webster’s Third
New International Dictionary that denes the word
noble as:” (1) possessing outstanding qualities
such as eminence, dignity; (2) having power of
transmitting by inheritance; (3) indicating superiority or commanding excellence of mind, character,
or high ideals or morals. Further, Prof Debas continues: “These three attributes bet the profession
of surgery. Over centuries, the surgical profession
has set the standards of ethical and humane practice. Surgeons have made magnicent contributions in education, clinical care, and science. Their
landmark accomplishments in surgical science and
innovations in operative technique have revolutionized surgical care, saved countless lives, and
signicantly improved longevity and the quality of
human life. Generations of surgeons have developed their craft and passed it on to succeeding generations, as they have to me and to each one of you,
to take into the future.”
Practice of surgery has changed signicantly
and dramatically; surgeons have become a
replaceable workforce for major corporations,
and worse we have become “shift doctors” managed by several VPs in expensive suits who often
have just come out of MBA school, and have no
clue how surgery or the department of surgery is
run. Furthermore, As Prof Debas writes in the
above cited paper: “Financial control and control
of access to healthcare were taken over by HMOs
and insurance companies. As for-prot medicine
proliferated, the health of our patients has come
to be treated as a commodity traded daily on Wall
Street. History will record that the medical profession was sidelined and watched haplessly as
MBAs and business executives dened the fate of
healthcare. He calls these effects of HMO
“deplorable”.”
While director and chairman of a major medical center and academic department, I witnessed
senior academic surgeons, deans, and others
major academicians being “walked out” of the
hospital or their ofces without any cause or
explanation. They wanted to “move in a new
direction.” The academic surgeons and surgery
itself once the “crème de la crème” of the hospital,
have come under major corporate attacks in the
last 2-3 decades. Unfortunately, this is not happening only in America. However, this hijacking
1 Surgical Decision-Making andtheChanging World
7
of the surgical world by the corporate world
should not cloud our thoughts, our surgical decisions, and we should make the best decision possible for every single patient that we evaluate and
care for, by being trained well, being ready to
care for every surgical disease. Surgeons should
act like true leaders, own the care of the patient,
lead the multidisciplinary and complex care with
passion, love, and respect for everyone and those
who directly affect people’s lives, save lives, and
prevent morbidity.
The consequences may be because the surgeon decided to operate, or when the surgeon
makes a decision not to operate, or not to operate
in a timely fashion. As my former Professor of
surgery, Gazmend Shaqiri, a true (general, vascular, cardiothoracic) surgeon used to tell us students at the University of Prishtina, Kosova,
“When a patient dies in a medical ward, he or she
dies from the disease; however, when the patient
dies in the surgical ward, the patient dies from the
surgery, or more importantly, of the decisions
made by the surgeon.”
Every surgical decision that we make as surgeons may have consequences, and regrets that
have been reported in about 1in 7 surgical patients
[2], both patient- and procedure-related. Yet,
despite this gloomy outlook, surgery was and
remains the best clinical discipline, and represents
both a science and an art, and surgeons are the conductors of a symphony that truly needs to run perfectly. There are other somewhat more silent
consequences of surgical decision-makings. How
articial intelligence will affect surgical decision
making in the future it is not clear [3].
In a study of almost seven million patients,
analyzed from the National Inpatient Sample
database, we found that delaying the operation
and not performing in the optimal time was the
most common cause of mortality [4]. While we
were unable to discern why the decision to operate was delayed, the decision to operate or not is
the surgeon’s and this decision not to operate had
major consequences. While surgical procedures
are far more complex than one individual’s decisions during surgery, there are elements to this
small surgical microcosm that add additional
pressure on the surgeon and how he or she copes
with this decision. Over the years, I have been
reminded often of the consequences of making a
decision, both wrong and right.
I am hoping this book will serve as a good reference or even inspiration for others to explore
the subject further and remind yourself what I
teach everyone who listens that “surgery is easy,
the decision is not.” I did not and do not envision
this as book of a bunch of algorithms both from
some great books on the subject, or created by
AI, whose computers are major polluter of our
environment, to create strict protocols, although
in a couple of chapters such suggestions have
been made. I wanted this book to go a bit
“beyond” the glory of being a surgeon and at the
soul of the surgical decision-making process, and
inside the surgeon being under his or her skin. I
wanted to explore what makes the surgeon’s
brain and heart “buzz,” and continue to work
nonstop for many hours. While at Yale University,
before the regulation of working hours for residents, one of my vascular attending and I operated basically non-stop from Friday morning
until Sunday afternoon, with few “power naps” in
the PACU or noisy operating room lounge
between cases. When we nished Sunday afternoon, I thought I was doing “ne” until I went to
start my car. Now that adrenaline was gone, I
could not even drive myself home. I was completely exhausted, and could not keep my eyes
open. I had to call my wife Drita to come pick me
up and take me home. How was I able to go on
for so long while we were operating and yet, I
could not drive myself home the ten miles to
Hamden?
The anatomy and the physiology of the surgeon are addressed in Chaps. 1 and 2. We cannot
forget that we are not super creatures, despite
what everyone may think of us; we are all just
humans, like all others except we are leaders who
really care.
Have you ever seen a surgeon emotionally
“naked,” helpless, lonely, exhausted, disillusioned and, simply tired of everything? Even
worse, most of us do not talk about the matter
until it becomes a real problem. Not a pretty
8
R. Lati and A. Smiley
picture by all means. At this point, you may be
thinking of friends and colleagues who committed suicide or were on the brink of doing so. Drug
and alcohol abuse, difculties with personal relations, multiple divorces, or simply becoming
obese and not caring for oneself are not uncommon among us surgeons. We are just humans, and
yet like many other professions, we still have to
get up and go to work, and make some incredible
decisions, that will affect our patients and their
families, and of course us, that we have to live
with those decisions. Hopefully, this book will
explain some of those decisions, and how we
make them, but most importantly how we live
with the decisions we make, and how we improve
constantly.
References
1. Debas HT.Surgery: a noble profession in a changing
world. Annals of Surgery. 236(3):263–9.
2. Wilson A, Ronnekleiv-Kelly SM, Pawlik TM.Regret
in surgical decision making: a systematic review
of patient and physician perspectives. World J
Surg. 2017;41(6):1454–65. https://doi.org/10.1007/
s00268- 017- 3895- 9.
3. Loftus TJ, Tighe PJ, Filiberto AC, Efron PA,
Brakenridge SC, Mohr AM, Rashidi P, Upchurch
GR Jr, Bihorac A.Articial intelligence and surgical
decision-making. JAMA Surg. 2020;155(2):148–58.
https://doi.org/10.1001/jamasurg.2019.4917. PMID:
31825465; PMCID: PMC7286802.
4. Smiley A., Lati R.. The role of delayed operation
in hospital mortality in emergency general surgery
admissions: a 10-year study of 6,805,380 Patients.
Unpublished data.
Professor Rao Ivatury: ALegacy
ofSurgical Decision-Making
inTrauma Surgery, Excellence,
Compassion, andHumility
RifatLati
2
Throughout his illustrious career, Dr. Rao
R.Ivatury
revolutionized penetrating trauma with his
groundbreaking advancements and unwavering
commitment to patient care.
R. Lati (*)
Department of Surgery, The University of Arizona,
Tucson, AZ, USA
Tucson Medical Center, Department of Surgery,
Tucson, AZ, USA
e-mail: Lati@surgery.arizona.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024
R. Lati (ed.), Surgical Decision-Making, https://doi.org/10.1007/978-3-031-67391-7_2
9
10
R. Lati
His Textbook of Penetrating Trauma has been
a bible of management of trauma surgery since it
came out in 1996. (Photo of the book that I have
on my desk and consult often to this day with his
autograph and dedication to me.) In addition, the
book Operative Techniques for Severe Liver
Injury (2014) became a new model of management of liver trauma.
His expertise and dedication were unmatched,
earning him immense respect and admiration
from colleagues, patients, and the medical community at large in all continents of the world. Dr.
Ivatury’s legacy extends far beyond his professional accomplishments; he was known for his
2 Professor Rao Ivatury: A Legacy of Surgical Decision-Making in Trauma Surgery, Excellence…
11
exceptional human character and humility, touching the lives of all who had the privilege of knowing him. His compassionate bedside manner,
genuine empathy, and tireless advocacy for
patient well-being set him apart as a truly remarkable individual. His surgical decision making
was impeccable, always calm and collected, and
always got ahead of death.
The loss of Dr. Ivatury is deeply felt by the
trauma community worldwide, as his contributions have had a lasting impact on the eld of
emergency medicine. His innovative approaches
to trauma care have saved countless lives and
inspired future generations of medical professionals. Dr. Ivatury’s absence leaves a void that
will be difcult to ll, and his memory will continue to be cherished by all of us who were fortunate enough to have crossed paths with this
exceptional healer and visionary in the world of
trauma medicine. He taught surgical decision
making without making noise about it. He simply
did it.
I met Dr. Ivatury or Iva as we fondly called
him in June 1996 as a third-year General Surgery
resident at Yale University Hospital, in New
Haven, CT. That day, my Chairman, Dr. Ronald
C Merrell, called me to his ofce to inform me
that I needed to vacate my spot as the incoming
fourth year resident to make room for another
resident, Dr. Robert Knox, from the closing
Bridgeport hospital residency program. Though
unexpected, for me and for Dr. Merrell, he had
arranged for me to join Professor Irvin Modlin’s
laboratory at the VA Hospital, West Haven, CT
few weeks later.
Coincidentally, on that Friday evening, one of
the surgical critical care fellows informed me that
Dr. Ivatury was giving a talk in New Haven and
asked me to join him and go to that program. That
evening, I met Dr. Ivatury, presented him with a
copy of my book, Surgical Nutrition: Strategies
in Critically Ill Patients, and told him that I am
interested in a surgical critical care fellowship
and sought his advice, since I have done 5 years
of research before joining the residency. He
invited me to an interview the following Monday
and to meet some of other faculty. Following an
interview with Dr. Ivatury and his partner Dr.
John Porter that Monday in June 1996, I was
offered a fellowship in Surgical Critical Care at
Lincoln Hospital in the Bronx, which due to Dr.
Rao Ivatury was known as the Mecca of trauma
surgery. And, thus, I entered the orbit of Rao
Ivatury.
This meeting with Dr. Ivatury was one of the
most important encounters, similar to the one
when I met Dr. Stanley Dudrick (see chapter 23)
in my life and career. I had been too busy operating and was enjoying being a third-year resident
and had not thought of a fellowship until then.
However, after this fateful meeting with Dr.
Merrell, I made the pivotal decision to pursue
surgical critical care fellowship, and eventually
become a trauma surgeon, a choice that would
shape my future professional trajectory for years
to come. This encounter with Dr. Ivatury was
truly transformative and set me on a path that I
am eternally grateful for. Daily trips by car or
train (most of the time) to southern Bronx were
memorable. I listen to books on tapes, or read
books on trauma and critical care.
Finishing a fellowship in Surgical Critical
Care was the best way to prepare for the next two
nal chief years of my residency. Gaining competency in trauma and critical care is the most
important way to really join the last few years of
surgical residency. Walking (or running) in a
trauma room without any hesitation or fear of
what you will nd is an amazing and liberating
feeling for a novice surgeon. Training in the
Lincoln Bronx, the country’s most premier
trauma center of those times, was a special treat
and real destiny.
Following graduation from residency in July
1999, I joined both Dr. Ivatury and Dr. Merrell at
Virginia Commonwealth University (VCU).
Both had taken on new roles, with Dr. Merrell as
the chairman of the department of surgery, and
Dr. Ivatury as the chief of trauma. I became a
close condant and partner of Dr. Ivatury during
my time at VCU, forming a strong bond with
him. Dr. Merrell, whom I had met during my time
with Dr. Dudrick in Houston, Texas, at the
Herman Hospital, the University of Texas, and
who had become chairman of the department of
Surgery at Yale University, invited me to leave
12
R. Lati
Cleveland Clinic in Cleveland Ohio on December
6, 1993, where I was a categorical resident, and
join Yale surgical residency program as a second
year.
The transition from Yale to VCU marked a signicant chapter in my career and solidied my
relationship with Dr. Ivatury, further shaping my
journey as a trauma and acute care surgeon. As
the title of this essay, Dr. Rao Ivatury was an
excellent and true master trauma and general surgeon, outstanding author, editor, and researcher,
all the while maintaining compassion and humility, under whose quiet mentorship, I and many
others who were lucky to work with him developed and grew as a trauma surgeon.
While working together or being friends with
Dr. Ivatury, after I moved to Arizona to work with
John Porter, I recall another signicant moment
that played a pivotal role in shaping further my
destiny and professional journey. Dr. Merrell, a
true pioneer in telemedicine, inuenced my interest in utilizing telemedicine and technology for
rebuilding post-war countries. This newfound
passion led me to delve into this eld further,
when Dr. Merrell sent me to Toulouse in early
2000 for a telemedicine meeting. Subsequently,
Dr. Merrell asked me to present him at the G8
Meeting in Berlin on May 4–5, 2000. My presentation titled The Anatomy of War and Destruction
of Kosovo: The Alumni’s View on Reconstruction
of Health in Kosovo, showcased the vision for
leveraging telemedicine to aid in the reconstruction and improvement of healthcare services in
Kosova. This presentation marked a signicant
milestone in my involvement with telemedicine
and the advancement of healthcare initiatives in
post-war regions like Kosova. It was in Berlin
that I presented the idea to create the Telemedicine
Project of Kosova and the International Virtual
e-Hospital Network concept. Despite Dr.
Merrell’s global leadership in telemedicine, there
were no opportunities to establish trauma telemedicine in Virginia at that time. I shared with
Dr. Ivatury my plans to relocate to Tucson,
Arizona, where Iva’s former partner John Porter
was working, in January 2003. However, due to
my commitment to oversee the building of the
telemedicine center and program in Prishtina
starting in September 2002, I needed to leave, but
still had to come back monthly to take calls at
VCU and to meet my nancial obligations. Dr.
Ivatury approved both decisions but expressed
his hope that I would prioritize assisting my
country, Kosova, before anything else.
Dr. Ivatury’s love and passion for helping
underserved individuals in the Bronx and developing countries around the world were truly
immense. His unwavering commitment to supporting those in need, whether inlocal communities or on a global scale, resonated deeply with all
of us who knew him. His approval for me to
travel the world, building telemedicine and
trauma programs in various countries, was the
best testament to his belief in the power of education, innovation, and compassion to make a positive impact on healthcare systems and those they
serve. Dr. Ivatury’s endorsement of my endeavors
underscored his legacy of generosity, mentorship, and dedication to improving healthcare
access for all. Our bond remained steadfast over
the years, and Dr. Ivatury graciously accepted to
become an Honorary Fellow of the Kosova
College of Surgeons in 2021. Unfortunately, due
to declining health, he was unable to travel to
Kosovo and witness the progress we had made
since the war. Our last conversation on the phone
took place after the passing of his wife, Laila. I
will deeply miss him, as will the world of trauma,
which will feel the absence of his expertise and
guidance, his compassion and humility. However,
his written works will continue to educate and
inspire generations to come. Dr. Ivatury’s legacy,
wisdom, and compassion will forever be cherished and remembered through his writings and
the lives he touched in profound ways.
Conclusion
Surgical decision-making is taught in a number
of ways. Much of what I have done over the years
and surgical decision that I made in trauma, I
learned from Professor Rao Ivatury. He was master surgeon, a renowned trauma and critical care
educator who has dedicated his career to improving patient outcomes in emergency and trauma
2 Professor Rao Ivatury: A Legacy of Surgical Decision-Making in Trauma Surgery, Excellence…
13
care. Dr. Ivatury has made signicant contributions to the eld through his research, teaching,
and clinical practice, particularly in the areas of
abdominal trauma, sepsis, and emergency medical response. He has held leadership positions at
multiple medical institutions and is considered a
leading expert in the eld of trauma surgery. Dr.
Ivatury’s work has had a lasting impact on the
eld of emergency medicine and he continues to
be a driving force in advancing the care of critically ill and injured patients.
In addition to his professional achievements,
Rao Ivatury, MD was known and will be remembered for his exceptional human character and
humble demeanor. He was and continues to be
highly regarded by colleagues, patients, and students for his compassion, integrity, and dedication to providing high-quality care. Despite his
signicant accomplishments in the eld of
trauma surgery, Dr. Ivatury remained approachable and down-to-earth, always putting the needs
of his patients rst. His humble nature and genuine concern for others have earned him the
respect and admiration of those who have had the
privilege of working with him. Dr. Ivatury’s combination of medical expertise and genuine kindness make him a truly exceptional physician and
mentor.