Letters to the Editor
32 YEARS OF CLINICAL PRACTICE - FROM TRAINEE TO TRAINER -
A PHILOSOPHICAL REVIEW
This is a retrospective review of my experience from 1965 to the present, a period spanning just over 30 years, from housemanship in Penang, to being a medical officer in Kota Bahru, Kelantan, surgical trainee in University Hospital in Kuala Lumpur, registrar in the various hospitals in the United Kingdom, a surgical lecturer at the University here and finally Associate Professor and Head of the Department of Urology, Singapore General Hospital. From trainee to trainer, there was no perceptible time when I evolved from one to the other.
In clinical practice, one is seldom 100% sure of our diagnoses, and the outcome of treatment. Usually 80% is my favourite cut off point.
We did not realise this when we first graduated from medical school full of confidence, with the new knowledge just recently acquired. In those days, there was a shortage of medical officers in Penang and we had to run the Accident and Emergency Unit as well . We were too confident of our diagnoses and used to discharge patients home even though some of them begged for admission. We mellowed subsequently when we realised the many mistakes we made, patients with abdominal colic being readmitted as appendicitis, and children with gastro-enteritis being readmitted with dehydration and shock.
My first surgical posting was with Mr Peter Vanniasingham in Penang. He was a disciplinarian and a very good surgeon. He encouraged me to take up surgery. I learned how to do circumcision from him . We were allowed only one cat gut suture and no more. This simple operation, I found out later, has so many variations that no two surgeons at the Institute of Urology did it the same way. As the saying goes, there are more ways to skin a cat than you think. I am still doing circumcision the way I learned it and have not changed because the outcome is satisfactory.
One advice to our young registrars is that as they mature and travel, they will see many new ways of doing things, but they must be discriminative, and remember that what is more important is the outcome. “New” does not necessarily mean “Better”. So, do not be in too much hurry to adopt something new. Study the rationale and the outcome before you change. There are more new ways and technologies which are rejected eventually than the ones which subsequently prove to be truly progressive.
Medical Officer in Kota Bahru
In general the patients in the East Coast then were very reluctant to have surgery except in an emergency. Even then, they sometimes refused and were prepared to accept their fate. I remember the night I was called to see a young boy with air-way obstruction due to diphtheria. He was already suffocating and we were pleading with his father to allow us to bring him to the theatre to do a tracheotomy. The father refused. When the boy started to gasp, we had no choice but to push the father aside, rushed for the instrument, and performed the tracheotomy in the ward, without his consent. Luckily, he survived and we were not sued for assault!
There are many rules and regulations in life, and in our clinical practice, the many guidelines. But there is always the exception, and one should not follow strictly or blindly. However, at the junior level, you are strongly advised to follow the guidelines. Only when you are more mature can you afford to bend the rules. For the senior staff, it is important for them to remember that they are there not just to ensure that the juniors follow the guidelines, but also to waive the guidelines or bend the rules when the need arises.
Surgical Trainee in Kuala Lumpur
Registrar in U.K.
Peel Hospital was a small General Hospital with about 200 beds. I worked for two general surgeons with special interests. One, Mr Frank was interested in thyroid and breast surgery, and during his free time, he would go up to the hills, up and down the valley, to hunt. The other, Mr Thompson, was interested in Urology and he would go down to the nearby river Tweed to fish! I learnt transvesical prostatectomy from Mr Thompson and saw him perform the occasional transurethral surgery using the cold punch. There was no resectoscope like what we have nowadays, and the view was poor. I had only occasional glimpses of what was happening. I did not foresee then that with the invention of the Hopkin’s lens and the improvement in the diathermy machine in the next few years, transurethral surgery would rapidly replace open surgery for the lower urinary tract. The pace at the hospital was not very busy and I took the opportunity to study for the Final FRCS Examination and passed.
Lectureship at the University of Singapore
For our young members, this is good advice. Always think ahead and take action. To help us to decide when to take action at the right time, I learnt another important lesson from Professor W C Foong who took over the Headship of the Department after Prof Ong, that was to be familiar with the pathophysiology and natural history of the diseases we are treating. That was his favourite theme for students in the written and the oral examinations.
As students, you may not appreciate this basic truth, but as you become more experienced, you will realise that you cannot practise good, rational clinical medicine without a good understanding of the pathophysiology and natural history of diseases. One good example is our understanding of urinary tract infections.
We used to think that the introduction of organisms into the urinary tract was more important than host resistance as the cause of urinary infection. Now, we understand that it is host resistance which is more important, and not the other way around. Introduction of a few organisms really do not matter and it is more important to keep the bladder empty to avoid infections. Therefore, patients are now relieved of their agony as soon as they arrive at the Accident and Emergency Department.
Specialising in Urology
I learnt a lot of theory at the Institute of Urology, London. However, after 3 months, I was unable to obtain hands on experience. Fortunately, I managed to transfer myself to New Adddenbrooke Hospital in Cambridge to learn transurethral surgery from Mr Robert Whitaker. Cambridge was ideal for me and I achieved my objective of learning how to do a proper transurethral resection of the prostate under his guidance.
Complementing and not competing with each other was an important lesson I learnt. When I returned to the University Department of Surgery, Dr Jimmy Beng and I complemented each other in trying to establish transurethral surgery in the treatment of our patients with lower urinary tract problems. In his landmark paper, Dr Beng proved that TURP was far superior(1). This new procedure took time to get established and we needed to collect data to support it. I helped to further the cause of transurethral surgery by publishing my first 169 cases, looking mainly at the complications(2).
We showed that TURP was safe even in our hands, and at that time we were juniors in the Department! Blood transfusion rate was 44% instead of 96% for open surgery and patients could go home in 5 days instead of 10. The mortality rate was about 1% and the permanent incontinence rate was less than 1%. By the 1980’s, TURP was well established as the procedure of choice for treating obstructing prostates.
The University Department of Surgery in the Singapore General Hospital was also called the “A” unit for short. All the members would work together as A team. Dr Jimmy Beng left the Department for private practice in 1978. Fortunately he was soon replaced by Dr K H Tung and Dr E C Tan. With Tung and EC we worked as a team and helped to establish Urology as a specialty in Singapore(3).
Qualities of a Clinical Teacher
We need to constantly remind ourselves that in clinical practice, we are in “tiger country” and have to be vigilant. As the Chinese saying goes, if you go up the mountain often enough, you will eventually meet the tiger. It is appropriate to warn our younger colleagues about the tiger in our daily practice, and it is important for them to know what to do when they see one!
Over the years, it is gratifying to see young Registrars slowly developing and maturing into Consultants in their own right, and becoming eventually better in some aspects of clinical work than you, the trainer. This is the way it should be; if not, there is no progress. I was told by my teacher that if your students are not better than you eventually, then you are not a good teacher! The challenge to you now, my younger colleagues, is to make your trainees better than you are!
I would like to end by sharing with you a saying by Lao Zi, the founder
of Taoist philosophy:
May peace and tranquillity be with you.
A/PROF FOO KEONG TATT
Editorial Note: This article is based on the Inaugural Singapore Urological Association Lecture given by the author on 25 January 1997.