Excerpt #12: Initiating A Formal Teaching Program

Excerpt #12:  

Chapter 4:  Initiating A Formal Teaching Program

M. Bakri Musa (www.bakrimusa.com)

What little informal teaching I did during our clinical rounds took the form of my peppering the trainees with questions and the “what ifs.” On the occasions when they or I did not know the answer, which were often, I would assign one of them to “look it up and tell us tomorrow.”

            I did that often enough such that everyone had an assignment at least once every week or so. It was an exercise to look up the literature and also to impress upon them that we do not always have the information at our finger tips.

            As for formal teaching, I replicated the programs of my residency days. I set up four sessions, one each on Tuesday and Thursday mornings, our non-operating days, and at the end of the day on Mondays and Wednesdays, which were our assigned operating days. The morning sessions were didactic, seminar-like, with one devoted to basic surgery, the other, clinical. Within two years with holidays accounted for, we would have covered over 90 topics, the entire field of both basic and clinical surgery, plus some general topics. Come the third year we would have repeated the whole sequence. I assigned the basic surgery topics to the interns as they were still fresh out of medical school, and the clinical to the medical officers as they had more patient experience. The schedule was such that every trainee would be presenting at least once per quarter.

            The afternoon sessions were less didactic. One was our weekly morbidity and mortality conference (M&M rounds) where we reviewed our deaths and complications. In the other, Clinical-Pathological Correlations (CPC), we went over our biopsies and other specimens with our pathologist.

            I assigned the first few seminars to the most capable trainees, both to set the standards and to give the others a longer time to prepare for theirs. At our first, I asked (demanded?) the three or four of my most diligent trainees to make sure that they would be present on time. I had also prepped the inaugural presenter, Dr. Zul, such that he could present his seminar almost verbatim. His topic? “The Old Lymphocyte,” which was a cute title to introduce immunology, the hot topic of the season. He read the preamble to my thesis and added some new materials from the literature on the then-rapidly developing field.

            At the scheduled time, sure enough only the presenter and me, plus the three or four interns I had specifically asked were there. We started right on time to a near-empty conference room. Five or ten minutes later the others began straggling in. By the time the last attendee had arrived, we were already in the discussion mode. Then this late character had the nerve to demand why we had not yet started. There was embarrassed silence all round. I told him that the formal presentation was over and we were now in the discussion phase. “Do you have anything to add?”

            He cowered like a rat that had broken into a closet hoping to find a stockpile of cheese, only to be greeted by the glare of cats ready to pounce on him. If there was a hole in the floor I was sure he would have crawled into it. From then on my seminars all started on time. I had busted the curse of the “Malaysian time!”

Our seminars soon acquired a reputation among the other interns and medical officers as well as the town practitioners. I also secured the commitment of a local pharmaceutical company to publish those presentations at the end of the two-year cycle.

            The hardest part was training my young doctors for their presentations. I had to devote considerable time with each individual on how to search the literature and write up their presentations. I also made them practice their oral portion. Quite a challenge as many of them had never done that sort of exercise before. It was also exhausting, and very trying, for both presenters and me.

            One young doctor was so paralyzed that he did not know where to begin. I worked with him for hours, going through step by step in the library and helping him with his essay. He finally had a decent piece and could present it to me in a private rehearsal with some coherence. On the morning of the seminar he confidently strutted to the front of the room like a tom turkey in the presence of a flock of hens. He began without even a hint of hesitation. I was thrilled. Midway he stopped, and was lost.

            I prodded him with generous prompts, like reading excerpts from his written presentation. Still without success! Then as a last resort I told him to just read what he had written. It was painful, for presenter and listeners alike. In the ensuing Q&A I departed from my usual practice and initiated it with gentle questions. He recovered, somewhat. He must have felt like the unsuspecting foreign tourist caught in a sudden tropical downpour. Suddenly drenched, and before he could be overwhelmed, the clouds parted and the skies became clear. That was the only time I had to rescue anybody.

            I thought he handled himself well, and I was pleased with myself at how I salvaged the situation. Speaking in front of an audience can be a daunting experience. I was very proud of what I had achieved with him. The following week however, he quit my program!

            My most enjoyable and rewarding teaching exercise was our CPC. The fact that we had an eminent pathologist who was also an enthusiastic teacher was a big factor. Prior to his appointment as a professor at UKM, Dr. Kanan Kutty was the hospital’s chief pathologist. As UKM then did not as yet have a functioning pathology unit, he availed himself to the hospital. When I approached him for the CPC, he was more than eager. “Help make my salary halal, doc!” he joked.

            Immaculately dressed in long-sleeve shirts and wide ties, shining leather shoes, and always well shaved and groomed, Professor Kutty was formal with my trainees but not with me even though I was much younger, casually dressed, without ties, and with long hair. Nonetheless the informality of my group soon infected him. Towards the end, he too was mellow and casual, loosening his ties often. My trainees enjoyed their sessions with him very much. We learned much in that solid hour.

            Our M&M rounds were less satisfying. As I was involved in most of the cases, it was difficult to get robust discussions going. Mahmud too was reticent in criticizing me. So I resorted to having the senior trainees do a literature search on current surgical practices pertaining to the cases discussed. Only when Dr. Meah joined us after obtaining her fellowship, and later also Dr. Bahari, did our CPC became worthy of its label.

            Once we had a senior professor from Indonesia visiting UKM. He was a liver expert and I had just the case for him, a massive liver injury from a road accident. It would be interesting to see how things were done across the Straits of Malacca. Alas at the last minute the visiting expert cancelled the rounds. He was busy being feted by the university.

            Later we had a visit by an Australian pediatric surgeon. We also had a special patient for him, a baby with primary biliary cirrhosis, right up his alley. Being the main referral hospital, GHKL had no shortage of “rare birds.” In contrast to the Indonesian surgeon, this Australian cancelled his social engagement to see our patient. We learned much from him, helpful little tricks for the delicate surgery we were contemplating on the poor child.

            I was not a pediatric surgeon but had done a stint at Montreal Children’s Hospital under the famed Dr. Harvey Beardmore. Earlier as a medical student I had spent a summer at Mayo Clinic under Dr. Hugh Lynn, also a well-known pediatric surgeon. As a senior resident I had a rotation with a pediatric surgeon, Dr. Sam Kling. When we compared notes, I had more cases under my belt than Mahmud. Together we performed many pediatric cases, including the first Duhamel procedure in the country for Hirschsprung’s Disease. That jaundiced baby would have been our first Kasai procedure, but the parents refused the surgery, and the child died.

            I have many fond memories of Sam Kling. One Christmas he gave me a bottle of scotch. I knew nothing about the stuff but when my fellow residents saw the label their eyes bulged with envy. It was rare, premium label. Imagine, a Jewish surgeon giving his Muslim resident a bottle of fine whiskey . . . at Christmas!

            That was Canada and Canadians. Those qualities are still very much reflected today; notice their intake of Syrian refugees in 2016 when many in the West, specifically America, shunned them.

Next:  Excerpt #13 - Teaching Future Doctors

From the author’s second memoir, The Son has Not Returned. A Surgeon In His Native Malaysia, 2018.