Heart of the Matter

Warning: This is an 864 words article! I am so cheong-hei** la.

I just got off a call from on of the consultant in our lofty Cardiac Centre in this country. He got me at a bad time. I was actually on the throne attending to some personal matters (relating to organic waste disposal). I think my voice, to him, must have been difficult to hear as it would be accompanied by the echoes from the walls within the confines of the small toilet cubicle.

Why he called was because he wanted to inquire about a certain patient who was referred to the centre for cardiac assessment. Apparently this patient has a malignant growth in his throat which needed major surgery. Unfortunately, just before the surgery, he suffered a heart attack which was treated and stabilized and hence the referral.

My involvement with the patient was minimal, mainly confined to the less than 15 minutes of ward round when the patient was briefly warded in my ward. So, it was not surprising that it took me some time to recall this patient.

The consultant was unhappy. “You mean you don’t remember the patients you refer to us?“, he said.

Well, the fact of the matter is, it’s true, I really don’t. It’s not like we refer one patient in 10 years. We refer patients to the centre almost on a daily basis. It would be quite impossible for me to remember every single one of them, would it? Furthermore, I did not personally refer this patient. He called me simply because he wanted to speak to the physician-in-charge of the ward, which happened to be me (partially anyway, since I am technically in charge of half the ward).

“Then I want to speak to the physician in charge”, he said. When informed that he was indeed speaking to the physician-in-charge, he softened his tone somewhat.

Next he asked, “I want to know what is your plan for this patient”. When pressed further on what he meant, he said. “I want to know if you plan to go ahead and operate on this patient. I mean, if you have no plans, then I don’t see why I want to do a cardiac assessment and stent him, after all, he will die from his cancer.”

I politely told him that I am not the surgeon-in-charge of the patient and therefore could not speak on their behalf as to their further plans (but in my heart, I was thinking, I am sure we referred the patient for a good reason, so obviously the referral was done with some future plans in mind ~ but I did not verbalize it).

“Never mind, I guess I will speak to the surgeons then”, he said.

Not happy, he turned to pursue another matter. “What about his COAD*?”, he said.

“What about it?”, I answered.

“Well, who diagnosed it? What have you been doing for him? Have you done a lung function test for him?”, he asked in quick succession.

I informed him that as far as I know, the diagnosis was not made by us as the patient was not under our follow-up; and no lung function test has been performed for him because the test is not available in our hospital. (Some one obviously must have diagnosed him with COAD and since he has been actually cleared for surgery, then obviously some one thought he was fit enough for surgery ~ I did not verbalize this as well).

“I want to speak to the MO in charge then”, he said. ( I should feel offended but I wasn’t)

I again politely informed him that the MOs have just been rotated to other wards and therefore the new MOs will not be of much help. Furthermore, I sincerely doubt the MO can remember the patient as well! I don’t even remember when the referral was made, much less my MO!!!

He was audibly pissed and he hung up after saying, “Looks like no one in your entire medical department knows what is going on. Never mind la, never mind la!!”

I’m not happy with the phone conversation.

I didn’t like his condescending tone of voice. I didn’t like the fact that he makes distinctions between specialists and MOs (if I had said I am an MO, he would have continued to berate me). I also didn’t like his accusations and insinuations. I didn’t like his attitude, just because he is some high-profile consultant in a high-profile cardiac centre. I didn’t like his “I am GOD and you are a stinking-lump-of-protoplasm” attempt at intimidation. I think he suffers from GOD-syndrome.

And most of all, I didn’t like the feeling that, to this man, the heart of the matter is, some patients are NOT WORTH the effort simply because the they have some terminal illnesses. I think if any of my HIV+ patients is referred for such an assessment, they wouldn’t be much cared for.

I think the motive of the phone call was mainly to tell us: “don’t blardy waste my time by referring such hopeless cases”.

Wed, 051207 @ 1103; post call and I didn’t need that kind of confrontation.

*COAD: Chronic Obstructive Airway Disease, a lung condition brought on by chronic smoking.

**cheong hei: long winded.

Foreign Medical Grads

Warning: This is one of those >1500 words article that I usually write when I am on call!

Recently some one voiced his concern over the perceived lack of quality amongst foreign medical grads, specifically graduates from Russian and Ukrainian medical universities. His article, in the MMR, caused a small stir with many people writing and commenting, some sharing his view while others spoke in defense of these grads.

While it is probably a thing to be proud of if one graduated from some famous or well-established overseas universities, not the same can be said of graduates from lesser known universities. Once in a while we hear or read in the media or similar concerns raised by common people and politicians alike, regarding the quality (or lack of) of the grads from the latter groups of medical school.

I remember when I first went to India more than a decade ago to study medicine in Manipal. Those days, people who go Manipal to study medicine are probably looked at in the same light as people going to Russia now to study medicine.

Tiger Circle in Manipal

I remember hearing comments like:

“So, you are going to Manipal. You managed to buy a seat is it?”

“I heard that you can never fail there, you just resit and resit the papers till you pass.”

“I hear you can pay (bribe) your way through medical school there.”

“You can’t get into local university is it?”

Let me just set the record straight and answer the questions above:

1. No, I did not buy a medical seat. Yes, I paid USD 10,000 as ‘Capitation Fees’ to secure a medical seat in Manipal then but the qualification entry still stand (minimum of B,B,C inclusive of Biology) and the capitation fee was part of the total medical school fees of USD 39,000 for the entire course. The fees also included 3 return flight tickets home to be utilised during the period of study. If one does not have the minimum qualification, then he just doesn’t get in.

In my college, the locals (meaning Indian citizens) pay a token fee for their medical studies (about Rs 4,000 per year) but to get into medical school, they have to take a nationwide entrance exam and those who are really qualified are admitted. Manipal then was (and still is) one of the top private medical school in India. The funding and running of the college comes mainly from foreign students like me who pay many times over what they pay.

A part of the tuition fee also went into funding the teaching hospital where free treatment was given to poor folks (there is also a private wing where the patients pay for everything; this wing was closed to medical students).

Two years after I entered Manipal, the practice of ‘capitation’ fees was abolished in India due to the negative light it was portrayed in and the cost absorbed into the total fees. (Call a rose by any name….)

2. This one is sadly quite true as, back then, there was no system of ‘3-strikes-&-u-r-out!!!’ implemented; so technically a medical student can continue to flunk his exams over and over again and still resit it, until he decides to call it quits. I actually have friends who have been there for more than 11 years and still have not graduated. I am not sure about the system now. But then again, you can see that they are not passed simply because they are so ’senior’.

3. Yes, I did pay my way through medical school, through hard work, toil and being far away in a totally foreign land speaking a totally foreign language. It took me 2 years to learn the local lingua franca through attending night classes after lectures. I almost flunked one of my surgical short case in the finals because I could not speak the patient’s language! But if you mean one can bribe his way through med school there, I will say “no”.

4. Another ‘Yes’. In fact, I applied to every single local medical school then (and even met the various Deans) clutching a 1st class honours degree in my hand as prove of my qualification before I eventually considered India. The answer was always the same: “We do not offer medical studies to a post graduate student; we do not have quota for your race; you are too old; you are the wrong race.” (note: I am not racist, but that was the scenario then).

When I was young-er. My room in Manipal which was the size of a toilet.

Life was tough in India. Very very tough in fact. I had to survive on RM200 per month allowance that my parents could send me (FAMA scholarship = Father-Mother sponsored). My dad sold the house to put me through medical school. I stayed in the hostel (it’s the cheapest accommodation), I ate vegetarian food for 5 years and 9 months, I refilled my pens, recycled the papers, save every paisa I could, I walked while others rode their bikes to classes, and once I didn’t go home for one and half years because I could not afford the flight tickets.

And why?

Because I felt the calling to pursue medicine. It was a passion and an obsession. It was something I had to do.

Why am I telling my story?

Because I can feel for those who are now studying in foreign lesser known medical universities. I can also feel the kind of ‘inferiority’ they must feel because their quality is being called into question.

There will always be black sheep in any profession. I am sure there are black sheep who are products of the most lofty and reknown universities in the world.

I believe no one will choose to endure these hardships, often in harsh and unwelcoming foreign countries, just for the fun of it. I know, I know some of them are pushed into it by their parents or are misguided, but I believe these are the minority. The rest go because, like me, they have a calling, a passion, and an obsession. If given a choice, I am sure most of them would choose to study locally but the reality is, there are simply no places for them to study locally.

You ask, “what about the quality then”?

Let me tell you this story:

I met Dr. S, a charming Malay lady, again last week at the National AIDS Conference in KL. She shyly came up to me during one of the tea breaks in between plenaries and greeted me. I was pleasantly surprised to see her! It has been more than 5 years since I last saw her. I still remember the day she reported for work as a house officer in the medical department. I was a medical MO then. She was a fresh graduate from Japan (a product of our previous Prime Minister’s Look-East Policy).

She was so bad!!! She could not speak English properly, she could hardly speak Malay (her native tongue!), she could only clerk patients in Japanese (and no one spoke Japanese then, not even now) and she could only write in Japanese (and so no one can understand what she wrote). Her clinical skills were zero. Less than zero. We were constantly on the look out at what she was up to, in case she kills some one.

But I have great admiration for her. She has a positive attitude and great fortitude. She knew she was bad. She knew she was in fact, hopeless. And so, she did what no one has ever asked to do (in my experience). She asked for an extension of ONE YEAR so that she can continue to train as a HO in medicine! The department granted her wish!

Last week, when I saw her, she was all smiles. In her eyes were a mixture of pride, gratefulness (according to her, I was one of her favourite MO!) and TRIUMPH! It’s like she was saying “Look Jimbo! I DID IT!!!!” For she now is a senior medical MO in a peripheral hospital, perfectly capable of treating patients well.

I was so proud of her and she knew I was proud of her!

Nowadays, grads from Manipal are looked up to. People no longer think Manipal is a pariah medical school. I am proud to be its product, a Manipalite.

See, what I am trying to say is, yes, the quality of some foreign medical students may be dubious but I also believe that in the end, it’s a very individual matter. When a person chooses to heed the calling, go into the wild, learn the skills needed and chooses to excel instead of staying mediocre, then there is really no limit at all to what one can achieve! Let me level the playing field by saying that I have also seen local medical grads who were quite hopeless as well.

I believe that some day Russian grads will also be looked up to. Mark my words.

Wed, 051207 @ 0700