Dear Daryl,
Your aunt has asked that I share with you my thoughts
on medicine and medical education today.
Let me start by saying that I am most blessed to have
trained under your Aunt, Prof Florence Wang, and I recall my time in
ward 12A at University hospital under her as a most formative part of my
training. Thank you Prof!
It has been 3 decades since then and the world has
changed. The world of Medicine and medical education has changed beyond
even the most imaginative of us all had dared to dream. Some things are
good and much detrimental.
I will have to ask you very honestly why you wish to
pursue a career in Medicine for this is very important.
Most students simply have very little knowledge of
the world of medicine and some very quickly become disillusioned in
their clinical years. ALL my students come to me with FULL distinctions
or stand at >97 percentile of their cohort; that they are brilliant is
without a doubt but sadly many are NOT that motivated to serve humanity.
They come into medical school because their results qualify them too,
they sing the right well rehearsed song at the interview and because
they think it is prestigious, they want to be a medical student!
But the real world of sick humans with all the smell
and excrement and drains rapidly reverse all those good feelings, and
harsh reality sets in. Osler a great Physician whom your aunt and I both
greatly admire said that THE VERY FIRST QUALIFICATION is a Love for
Humanity. I believe that that quality is far more important than all the
'A's in your result slip.
AS a GOOD doctor, You will be very important. We have
plenty of doctors but not many GOOD ones. The future of many lives and
families depend on what doctors do and SAY; imagine all the Good or
Damage that can be done. But to be a good doctor is NOT easy. I just had
a tutorial with my students and told them that the VOLUME of information
that they need to read up is so MUCH that any serious student will
honestly spent ALL his time doing very little but STUDY. I hope this
realisation will help you understand the quality of life you will have
as a medical student, or rather the lack of it.
Modern medical education has moved far beyond lecture
based learning; here in the Clinical school the word 'LECTURE' is
OBSCENE and students learn through SDL - Self directed learning. Its
philosophy being that the advance of knowledge is so rapid that Students
MUST learn to teach themselves rather than being taught formally in a
Lecture Hall. This demands very matured and disciplined students for to
the lazy student, SDL means Sleeping DeepLy. Are you prepared for years
of being a nerd?
Please remember that Doctors are first and foremost
Diagnosticians… those training under me MUST not only be skillful in
diagnosis and management but also in social skills and leadership. When
I was under your aunt, she demanded History taking so detailed and
meticulous that 'War and Peace' looked like a short story in comparison.
Today students speak in SMS like language, and do "Focused History
Taking" instead of Detail History taking. Yes the Art of Clinical
diagnosis is dying, and High Touch Medicine being replaced by High Tech
Medicine.
In many Once Prestigious Universities which I will
not name, Final Year students now teach 3rd year students Clinical
Methods!!! Your aunt will tell you that 3 decades ago, only the senior
consultants in UM were allowed to teach Clinical Methods as it was
considered so very2 important. Osler is certainly turning in his urn!!
In your mind, do you envision yourself as a doctor
spending hours talking, feeling, touching, examining the patients.... or
a doctor ordering scans and more scans with nary a glance at the
nameless poor sick man lying on the bed? Ask yourself that question now.
Yes, the practise of Medicine is in trouble.
Blatant commercialisation, rampant blood tests done
without any doctors ordering or supervising, scans and probes of all
kinds, are being conducted by laboratories and some doctors misguilded
by wants rather than needs. When your aunt was holding the fort at Ward
12A, her ward rounds will start at 8am and the whole entourage of she
the Professor, Dr HC Ting the lecturer, the Med Officer, The Houseman
and the medical students will follow her from bed to bed. The Med
Student or the Hseman will present the LONG DETAIL history and she will
then TALK TO EVERY PATIENT WITHOUT EXCEPTION about aspects of the
history and personally examine every patient to confirm or correct the
juniors' findings. This of course was a Long tedious process and the
rounds will stretch till 1pm. But it was the Art of Clinical Diagnosis
at its finest. Today, I am sad to report that rounds are spent looking
at scans and reports and its a RARE occasion that the Consultant lays
his hands on the sick. Sadly I am not exaggerating. I wish I am.
Hope lies in every one of us doctors, present and you
the future, for the sensible management of patients; YOU remain the hope
for untold numbers of patients in the future. Sadly some doctors see
patients not as patients but as a disease that needs treatment which
provides our source of income. This is nothing new, physicians like
Osler had repeatedly cautioned against not forgetting the man behind the
disease, and medicine as a calling rather than a business.
“The practice of medicine is an art, not a trade; a
calling, not a business; a calling in which your heart will be exercised
equally with your head. Often the best part of your work will have
nothing to do with potions and powders, but with the exercise of an
influence of the strong upon the weak, of the righteous upon the wicked,
of the wise upon the foolish”.~ Sir William Osler
Many doctors are unhappy with their work or simply
too busy to talk, console or listen. Yes thats life in the 21st century
where we sms instead of talk. Many just treat the disease and completely
ignore the person who has it. We hear endless tales carried by patients
of doctors who grunt instead of talk, who are capable only of
monosylable conversation and who zip patients in and out of the
consultation room with a speed that will make Superman jealous. I try my
very best to teach my students the Art of Clinical Diagnosis but even I
fear that its a losing uphill battle. My colleagues and I here are led
by Prof Khalid who is a old school clinician, and we refuse to belittle
the Clinical Art despite the advancing machinery all around us. Students
are amazed and impressed by all the wizardry and sometimes to my
frustration fail to practise the Clinical Skills as much as I want them
to.
Ask yourself Daryl, what do you want? I do not want
you to come to medical school and be disillusioned by what you see in
the REAL MEDICAL WORLD as compared to the idealised world that we had
projected.
Doctors must never forget why we became doctors in
the first place, and the wonder of caring for fellow humans. Some may be
a bit burnt out. We had in our careers, seen and taken care of more pain
and misery than most people. We saw prostitutes, drug addicts, criminals
and the worst of humanity. Yes, this is another point that I must raise
to you. AIDS today is the TB of your aunt's era, its everywhere! Most of
my students come from very privileged families or they cannot afford the
fees! Hence it is a shock to many when confronted with Vagabonds,
homeless, addicts, pimps and Prostitutes. All the glamour flushes away
when you realise that such folks are among the many that you will
encounter daily unless you are in some Beverly Hills practise.
But of course we also treated decent human beings,
doting grandmothers and innocent children. No doubt, the demands on our
skills and the medical-legal complexities that accompany our practise
would have made even the greatest of our medical ancestors shudder. And
for this your training is NOT the 5 years of medical school BUT many2
years beyond. Are you prepared for such a LONG time spend in studies and
training?
You had read Dr Pagal's blog and written to him,
while he may be harsh and discouraging, much of what he wrote to you
with regards to THE SYSTEM has some truth to it. The system is basically
dictated by our political masters, a system undeniably sick, and Dr
Pagal has written frankly of much of our woes that only drastic
administrative tsunamis can repair.
Yes the system only makes it more painful. Long waits
for post graduate training positions is the norm now. Regulations as
thick as a medical text. Pharmacies selling controlled medicines like
sweets. To change that will require one of us to be the next Prof
Virchow, plunging head on into politics to make a difference.
In school we rose above the hoard, we were the cream
de la cream, and yes I can testify to that in my students. Some are so
brilliant they frighten me. We obtained results the envy of most and we
strove with pride to enter medical school. Could the same students have
done well in other fields? Of course they will shine too!!
In medical school you will work like ants on a long
march. You will stare at slides till you see mitochondria in your dreams
and memorised volumes of facts and figures. Some of my students are NOT
prepared for this; they thought that it will be a smooth passage and
when they hear this old Professor here telling them to read XYZ, they
simply turn off and zone away. Are you ready for a student life that has
NO LIFE??
I take them for tough postings in Internal Medicine,
I am among the strictest examiners, I expect the students to flourish in
the drudgery of crowded wards, to work till hypoglycaemic on medicine
rounds, to perform every procedure required in the book, and of course
to pass their exams reasonably well. I expect them to look at X-rays
until their eyes turned red. And do I have such students? Yes, I am
blessed that many such students have walked the wards with me. And I am
proud of them. And I know they will overcome every obstacle invented by
our political masters to excel in their fields because they have the
fundamental quality to be a good doctor; their love of Humanity and of
the Art of Medicine.
You will finally graduate and become a houseofficer.
Yes the field is as packed as sardines from Msia to UK to Australia, Dr
Pagal is NOT exaggerating when he says that jobs will be difficult to
come by soon. But if you are GOOD, you will be wanted! Its TOUGH I do
not deny and TOUGHER as the years pass by, BUT again I emphasize, if you
are good, you will be wanted for the good doctor is a rare specimen.
A few years later, you will pick a specialty, from
paediatrics to surgery, family medicine to cardiology, internal medicine
to radiology, and shuffled off to more clinics, rounds grand or
otherwise, work and studies. And MORE EXAMs. Girlfriend? Oh what
Girlfriend!!!
In the 80s, new diseases appeared. I still recall
with trepidation managing the very first patient admitted to our
hospital with AIDS. We knew very little but feared a lot. As registrar,
it was my duty to examine him. But again we survived. And learned. Now
at almost every bedside teaching, I see patients with HIV. In your
generation, you will see many2 more new ones, from Avian flu number
something2 to any new thing that crosses species as humanity ravish the
environment. Ready for that?
Your youthful enthusiasm and dedication will push you
through the initial years. As young doctors, weren’t we incredible then,
if only because we came back to the wards night after night, day after
day for emergencies, calls, rounds or simply a ’tissued’ drip. “Bengkak”
the nurse will phone and we leave our dinner to struggle with chemo
wrecked veins for IV access.
Did you know that your aunt will reprimand the ladies
for coming to the wards in pants? It is NOT acceptable then but now
almost all my female students come in pants! OOPs sorry Prof for leaking
such old tales!
We as doctors try to hold onto our commitment to
heal, that wonderful calling. Then we see another world – the realm of
the business of medicine, where every disease is a “case” to be
investigated.
A very senior Professor tells me she had seen doctors
ordering investigations before even taking a history! Here is also the
world of the grunting and monosylable doctor, the superman of 2 minute
consultations and management. True, the superb rare genius of a
diagnostitian may well have obtained all the data that he needed sub- 2
minutes, but the poor human called ‘the patient’ needed at least 6
minutes of compassionate conversation. (By the way, that is why the OSCE
exam is 6 minutes long, or SHORT from your examinee viewpoint.. now you
know how the patient will feel when the consultation is even shorter
than this!). Recall that the only reason the woman in labour remembered
the attending medical student is because they held her hand while she
screamed.
We are the descendents of Aescalapius, the inheritors
of all that is noble in the Hippocratic oath. We may fail to change the
ideas of many doctors however we may preach from some illusive high
moral ground. But as individuals can YOU NOT lose that ideal? If you
can, welcome to the world of medicine and modern medical education. You
will thrive no matter what! If not, seriously reconsider another
vocation.
If we tell our students that the learning of medicine
is through their apprenticeship to us their seniors, then we better be
sure that we are good role models. Your aunt was a superb clinician and
diagnostician and had inspired many of us.
As a future doctor, you can be the hope of the
febrile, the breathless and the pregnant.
Do not let what you see in the misadventures of some
doctors discourage you. Instead let them be teachers to you for you now
know what you do NOT want to be like.
When a doctor have taken medicine to be a business or
trade, he will ask what are his achievements — material success, cars,
wealth, etc..
When a doctor has taken medicine to be a calling, he
will ask what has he become — his character.
I hope we doctors can discern and reflect on what we
have become in the practice of medicine, and teach all our young
charges, delivering them safely through the long 5 years of protracted
labour into a reasonably sane medical world. Daryl, I hope I have helped
you somehow. Your aunt, Prof Florence has taught me much, this is my
little tribute in return, my Bunga Emas to her.
Thank you
Associate Professor Wong YO.
| 19 April 2012|
