(function() { (function(){function b(g){this.t={};this.tick=function(h,m,f){var n=f!=void 0?f:(new Date).getTime();this.t[h]=[n,m];if(f==void 0)try{window.console.timeStamp("CSI/"+h)}catch(q){}};this.getStartTickTime=function(){return this.t.start[0]};this.tick("start",null,g)}var a;if(window.performance)var e=(a=window.performance.timing)&&a.responseStart;var p=e>0?new b(e):new b;window.jstiming={Timer:b,load:p};if(a){var c=a.navigationStart;c>0&&e>=c&&(window.jstiming.srt=e-c)}if(a){var d=window.jstiming.load; c>0&&e>=c&&(d.tick("_wtsrt",void 0,c),d.tick("wtsrt_","_wtsrt",e),d.tick("tbsd_","wtsrt_"))}try{a=null,window.chrome&&window.chrome.csi&&(a=Math.floor(window.chrome.csi().pageT),d&&c>0&&(d.tick("_tbnd",void 0,window.chrome.csi().startE),d.tick("tbnd_","_tbnd",c))),a==null&&window.gtbExternal&&(a=window.gtbExternal.pageT()),a==null&&window.external&&(a=window.external.pageT,d&&c>0&&(d.tick("_tbnd",void 0,window.external.startE),d.tick("tbnd_","_tbnd",c))),a&&(window.jstiming.pt=a)}catch(g){}})();window.tickAboveFold=function(b){var a=0;if(b.offsetParent){do a+=b.offsetTop;while(b=b.offsetParent)}b=a;b<=750&&window.jstiming.load.tick("aft")};var k=!1;function l(){k||(k=!0,window.jstiming.load.tick("firstScrollTime"))}window.addEventListener?window.addEventListener("scroll",l,!1):window.attachEvent("onscroll",l); })();

M. Bakri Musa

Seeing Malaysia My Way

My Photo
Location: Morgan Hill, California, United States

Malaysian-born Bakri Musa writes frequently on issues affecting his native land. His essays have appeared in the Far Eastern Economic Review, Asiaweek, International Herald Tribune, Education Quarterly, SIngapore's Straits Times, and The New Straits Times. His commentary has aired on National Public Radio's Marketplace. His regular column Seeing It My Way appears in Malaysiakini. Bakri is also a regular contributor to th eSun (Malaysia). He has previously written "The Malay Dilemma Revisited: Race Dynamics in Modern Malaysia" as well as "Malaysia in the Era of Globalization," "An Education System Worthy of Malaysia," "Seeing Malaysia My Way," and "With Love, From Malaysia." Bakri's day job (and frequently night time too!) is as a surgeon in private practice in Silicon Valley, California. He and his wife Karen live on a ranch in Morgan Hill. This website is updated twice a week on Sundays and Wednesdays at 5 PM California time.

Sunday, April 28, 2019

Excerpt #13: Looking For A House To rent

Excerpt #15  Looking For A House To Rent
M. Bakri Musa (www.bakrimusa.com)

With my work routine now settled, my next mission was to find a house to rent, the Director-General’s promised lodging at Lake Gardens having fallen through. We decided to rent until we could find our bearings. The rental market was undeveloped, with rental agencies more the stepson of valuation companies. There were also minimal ads in the papers, so we had to drive around the various neighborhoods.

We were disappointed with the results. I began to feel that no one wanted to rent to us. We wondered whether it was because I was a Malay, someone with a foreign wife, or had young children.

            My sister-in-law Zainab disabused me of my paranoia. We would never get anyone to rent to us if we go around in my father’s old Ford Escort, she advised us. So, for the next few weekends we went with Zainab and Sharif in their Holden. We had better reception but still no hit.

            The Malaysian real estate market gave new meaning to the term “unfurnished.” We were stunned to see electrical wires dangling from wall sockets and ceilings, their fixtures having been removed by the owners or previous tenants. In one house, even the toilets were gone! Those owners were shortsighted or ignorant of marketing strategies. If they had spent some money to make their homes attractive with curb appeal and move-in ready, as with having landscape and nice furniture, they could command premium rents.

            One afternoon Sharif called about a house in Bungsar owned by his former secretary. Her husband, a diplomat, had just been transferred to Beijing to open the new embassy there. That very day after work I went to see the house, alone. It would have been too far to go back to Cheras, pick up Karen and the kids, and then trot back into the city and on to Bungsar.

            Again, the lukewarm welcome. The wife was less interested in showing me her house but more into small talk. My patience was again tried. I was hot, tired and had a long day. However, as soon as she found out that I was Sharif’s younger brother, the floodgate of welcome opened.

            “The surgeon who trained in Canada?” she beamed.

            Then we discovered that her cousin, Wan Aziz, now a naval architect, was my classmate at Malay College. The house was now mine, if I liked it, and I did! Seeing that she was now very keen on me, it was my turn to jual mahal(hard to get!). I used the excuse to show Karen the place first before making any commitment.

            I rushed back to pick up her and the kids. She too liked it; a modern, double-story terrace house with plenty of rooms. The yard, both front and back, was non-existent but that was fine. The house was ours within hours of Sharif phoning me, and I did not have to rent a BMW to see the place! In the West, I would have needed work and personal references; in Malaysia, as long as they could place you in their universe, that was it.

            The rent was RM500 per month, nearly half my salary. We still had to buy a washing machine, refrigerator, and air-conditioner. Karen also wanted a dryer but when I told her that the whole country was a dryer, she relented.

            We were shocked at the prices of home appliances. With Sharif’s help we drove a hard bargain as we paid cash. I also made sure that Karen was not with us when shopping otherwise the shopkeeper would jack up the price. I pity those who had to buy on “hire purchase.” They had to pay the full retail price and then be charged usurious interest rates.

            Notice the absence of any mention of a television set.We could not afford it. With two little kids, not having one was not an option. So we rented one, and soon discovered that we had to have an annual license fee for it, as well as for our radio. The government had inspectors checking on that.

            Used to such iconic television personalities as Walter Cronkite and Harry Reasoner delivering the news, listening to their Malaysian counterparts was a very trying experience. Why couldn’t they pick someone with a less grating voice? Those local newscasters whispered into their microphones, and stumbled often even at that! Why did they pick a non-Malay with a weird accent to read the news on national television baffled me!

            Those newscasters were not journalists; they did not write their materials. They were mere newsreaders. No wonder they stumbled often, and had as much passion reading their scripts as I do reading an old magazine in a doctor’s waiting room. The local professional journalists were no better, as judged by their articles. Nonetheless I forced myself to watch the news and read the papers as I was hungry for and eager to catch up on local affairs, making up for the deficit of the past thirteen years.

            One of those newscasts was a live coverage of the new Prime Minister Hussein Onn announcing his pick of a Deputy. It took him over two months after he had assumed office to do that, an inordinate delay, the consequence of much backroom dealings and maneuverings. The suspense was palpable right to the last minute.

            Then Hussein’s announcement; it was anticlimactic. His voice was flat, dull, and with no trace of any joy or excitement. Worse, his choice, Mahathir, was not by his side; he was on a political tour in Johor. He heard the news like everyone else in the country–at that very moment and through that news conference.

            Mahathir was interviewed on the same newscast, the man could only express his appreciation to Hussein. It was obvious that he too, like the rest of Malaysia, was caught by surprise. What a way for the new Prime Minister to make his first and most important appointment! I would have thought the two would have met privately earlier to discuss their respective views. At the very least Mahathir should have been beside Hussein during that press conference. I was unimpressed with the way Hussein handled it. He did not vet his choice; it was a blind pick.

            A few years later Mahathir took over because of Hussein’s poor health. A few years beyond that, following a major split in UMNO, Hussein admitted many times that picking Mahathir was his greatest regret!

Next:  Excerpt #16: Having A Maid
From the author’s second memoir, The Son Has Not Returned. A Surgeon in His Native Malaysia(2018.

Sunday, April 21, 2019

Training Future Doctors

Excerpt #13 - Teaching Future Doctors
M. Bakri Musa (www.bakrimusa.com)

One consequence to our lively rounds, seminars and conferences, as well as my own informality, was that my trainees acquired a reputation of being outspoken to the point of being biadab(disrespectful), or so I was told.

            One day we had a new lecturer fresh with his London University PhD. I suggested that he give a presentation in our usual format:  20 minutes of didactic session followed by Q&A around a couple of our difficult cases. On the appointed morning and after my brief introduction, I left the room to let him take charge.

            Later I asked my trainees how their session went. Not good! This young lecturer did not take kindly to their asking questions. He later dropped by my office to complain that my trainees were rude and impudent!

            Besides young doctors, I also had medical students from the Universiti Kebangsaan Malaysia (UKM) as well as the University of Malaya (UM). The latter were fine except that they expected certitudes and believed that the answer to every clinical question could be found at the back of their textbook, just like their math problems in high school. Once we were involved in an extended discussion on a patient with a complicated acute abdomen. We ended up with a series of differential diagnoses and I concluded by saying, “We’ll soon find out!” meaning, after the surgery.

            As I was accompanying the patient to the operating room, one of the students breathlessly caught up with me. “Sir! What’s the actual diagnosis?” I repeated that we would soon find out, as we had discussed earlier. He was disappointed; he thought I had the answer and that the earlier discussions were but an academic exercise!

            In 1976 the first batch of UKM medical students entered their clinical year. They presented a very different set of challenges for me. First, coming from the Malay stream, their English was not quite polished. Second, they were mostly Malays. The university was set up in response to the bloody 1969 race riots. The faculty, administration, and most of all the students were nationalistically-inclined. Third, they were entering a profession hitherto the traditional preserve of non-Malays.

            The discomfort and barely disguised envy if not resentment among the non-Malay staff to this new order was there but muted. They had yet to accept this new reality but acknowledged its inevitability. It reminded me of the early days of the Quiet Revolution in Quebec to the increasing presence of French-Canadians at such venerable and hitherto exclusively Anglo-Saxon institutions like McGill University and Royal Victoria Hospital.

            Much to my delight and contrary to all my expectations, the English fluency issue was the least problematic. As clinical notes and operative reports were all still in English (the King had exempted those as well as other professional communications from the strictures of the national language statutes), I made those students present their cases in English. I spun it in a positive way, to save them time and effort in translating.

            It was very trying for the first few weeks with the pace slowed to an intolerable crawl. However, by the end of their rotations, I could not tell them apart from the English-stream UM students. I was surprised and much gratified.

            Looking back, I should not have been surprised. They had English classes throughout their school years. It was just that they were not encouraged to use it. English-fluency was seen as being anti-Malay, or worse, a Mat Salleh (Anglo-Saxon) wannabe.

            Once I saw a group of students examining a Chinese patient. They were all wearing gloves and hesitant in touching my patient. Something else about their collective behaviors bothered me. Sensing that I was now on to something novel and potentially sensitive, I asked Mahmud what was going on. He told me of the rise of Islamic fundamentalism among the students. The faculty was very much aware of that. In fact they had scheduled a special senate meeting to address the very issue.

            That did it for me. I gathered the students, and with Sr. Fong beside me, told them that I wanted all my patients be treated the same whether they were in the Third-Class ward or the First-Class suites, from the estate in Ulu Pilah or the exclusive enclave of Bukit Tunku, illiterate or a graduate, and male or female. I skipped the race and religion part on purpose, but they did not miss my point. If they were uncomfortable with that, then they should ask their professors to post them elsewhere. No discussion!

            From then on there were no more problems on that issue. I was amazed at the ease with which I had solved a potentially explosive issue. While the university senate continued to grapple with the matter to no end, I nipped the noxious weed of religious extremism in its bud. That was not the case with the rest of the country. That poisonous weed today engulfs and blights Malaysia.

            God gives us the wisdom to solve a problem with ease to test us. Soon I became overconfident. One day we were making rounds on a challenging patient and I persisted in badgering the bewildered students on what we should do next. After yet another long quizzical silence on their part, I suggested in a thinly-disguised mocking tone, “Recite Surah Yaseen?” referring to the Koranic verse often read at funerals and on visiting the sick.

            The discomfit among my students was immediate and electric. Big blunder! I was ridiculing the holy text; the repercussions would be severe.

            Without missing a beat, I went on. If the family had wanted that, they would not be asking you or me, I told the students. The family would invite an imam or hafizwhose voice and tajweedwould be far more exquisite. The sick came to the hospital because we could offer them something else. Leave the Koran reading to those more pious, qualified, and with a soothing voice!

            With that, the relief on everyone was palpable, more so on my part. I felt like a member of the bomb squad who had successfully snipped the tripwire of his own making that would have caused a massive explosion.

            My other unpleasant encounter with religion, or at least its representative concerned a patient with cancer whom I had done a successful surgery. Her prognosis was excellent. To most, and not just village folks, cancer is a death sentence regardless how favorable the prognosis. She was a recent migrant to the city. Let loose from her comforting village anchor, she was lost. This was manifested in her endless somatic symptoms despite her successful surgery.

            I was about to embark on yet another series of tests when I decided to listen to her with extra diligence. She was obsessed not with death rather the associated funeral rites like ablution and praying for her soul. I assured her that we had an Imam in-house to take care of such matters.

            I contacted him about pastoral counselling and spiritual guidance for her. His reaction stupefied me.

            “When they have weddings, they don’t think of us. Near death, they call us!”

            This imam was paidby the government! I decided to spare my patient this charlatan. We found another imam, not government-issued. She was much relieved after the spiritual counselling.

            Like other faiths, Islam is not spared of pretenders, some very well compensated.

Next:  Excerpt #14 – Looking For A House

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

Sunday, April 14, 2019

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.

Saturday, April 13, 2019

Excerpt #11: A Much-Needed Break!

Excerpt # 11:  A Much-Needed Break!
M. Bakri Musa (www.bakrimusa.com)

My first extended weekend off was for Chinese New Year that February, only a few weeks after I had started work. Mahmud was kind enough to cover for me and I took my family back to Seremban for a much-needed break.

            That late Friday afternoon as soon as I reached my parents’ home, I crashed, waking up only for meals. I was exhausted. Karen was familiar with this pattern of my behavior during my residency days, especially after I had a busy weekend. My parents however, had never seen me like that before. They thought I was sick and Karen showed no concern!

            My new work flow may have become smooth but the transition, unbeknown to me, carried a heavy price, and borne entirely by me. I had been carrying the extra load by myself by being available 24/7. With the excitement of my new job, I had not realized the toll that it took on me.

            That long weekend break was just what I needed. It recharged my battery. Back to work that following Tuesday I was raring to go again. Some of my interns, especially the Chinese, were still sluggish, hungover from the weekend’s festivities. However, with my charging from behind, everything was back to its original fast pace in short order.

            With the clinical activities now under control, it was time to initiate a formal teaching program to befit a university unit. Up till then there were no seminars or lectures except for a weekly radiology conference. It was informal, with the radiologists going over the films and us clinicians listening in silence, with the occasional queries for clarifications.

            The head of the department was Dr. Hussain Ghani. At my first appearance for his conference he mistook me for a junior medical officer and began quizzing me like one. Zul interrupted and introduced me to him, as well as to Mr. Balasegaram, head of the second surgical unit.

            Bala was a Hunterian Professor, a high academic honor bestowed by the Royal College of Surgeons of England. I complimented him; he beamed. He smiled even more when I told him that I had read many of his excellent papers. He was an expert on liver resections and had invented the Bala clamp to control liver bleeding during surgery.

            I did not know Dr. Hussain. At the end of that first conference he cornered me and could not apologize enough. He told me how pleased he was to see me, another consultant who was a Malay. There was only one other at the hospital, Dr. Noor Maharakim, later honored as “Father of Malaysian Ophthalmology.”

            Dr. Noor used to live in Seremban only a few doors away from my parents in a modest neighborhood. He could have afforded a luxury bungalow in an exclusive part of town. He was also very charitable, contributing generously to his local surauthat both he and my father attended. My father would never fail to apprise him of my progress in Canada. When I introduced myself to him sometime during that first morning I was at GHKL, he already knew a lot about me from my parents.

            Back to Dr. Hussain; he was so eager to talk to me after the conference as if desperate to make amends to what he thought was his earlier slight. He began asking where I was from and who my parents were, all attempts to place me in the local social hierarchy. He took me to his private office and began reminiscing about his days as a medical student in Singapore and how he had very few Malay classmates. He did most of the talking. I felt that he was taking me under his wing, my self-appointed mentor. He sounded mellow and benign enough, like a faraway uncle who had been spared your daily juvenile tantrums and now desperate to make up for lost times.

            Then, in parting, “Bakri, don’t try to be a hero. Do your job well; don’t worry about being recognized.”

            I did not know what to make of his parting comment. Then I noticed the bare sign on his door, unlike Menon’s with a “Datuk” in front of his name and a series of non-academic initials following. I also noted the similar bareness with Dr. Noor Maharakim’s door. I thought that their being the first few Malays in medicine and having excelled, our society would have recognized their achievements if for nothing else so as to encourage others.[1]

            Today, two or three generations later, Malay leaders are still lamenting the lack of Malays in the sciences and the professions. Yet when we peruse the nation’s honor list, the one thing that stands out is that we continually honor the crooked and the corrupt amongst us. Former Prime Minister Najib Razak still trots around the country with no sense of shame touting his “Malu apa bossku?” (What’s there to be ashamed of with my boss?”), conveniently forgetting that he is enmeshed in the world’s most expensive financial scandal that is still winding its way through the country’s sluggish court system.

            My wise village folks have an apt observation to describe this major lapse of our culture, of valuing plastic trinkets over geniune gems. Or as my village elders used to put it, Pasir berkilau disangkakan intan(mistaking the glint of a pebble for the sparkle of a diamond).

Today, barely a generation or two later, Malay society is paying a severe price for having ignored the rare gems in our society, individuals like the late Drs. Hussain Ghani and Noor Maharakim.  [Note:  Both were later honored upon their retirement.]

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

Next: Excerpt #12:  Starting A Formal Teaching Program

[1]Both Drs. Hussain and Noor Maharakim were later honored with their Datukship; likewise, Mahmud.

Excerpt #10: Fixing The Out-Patient Clinic Circus

Excerpt #10:  Fixing The Out-Patient Clinic Circus
M. Bakri Musa (www.bakrimusa.com)

With my re-organized inpatient service now running smooth, it was time to focus on the pasar rabucircus that was our outpatient surgical clinic. Well, not just ours, the entire hospital’s. No one had paid any attention to those clinics. The elite, meaning the top civil-servant patients, were insulated; they bypassed the clinics with their direct access to the specialists.

            We had twice-weekly outpatient clinics from 2-4 PM, Mondays and Wednesdays, seeing in excess of 200 patients per session. They all came early with their assorted relatives tagging along and plugging up the waiting room and adjoining hallways. You get tired before you even start your clinic just by seeing the crowd.

            After the first few sessions, I could no longer tolerate the circus. I gathered all my doctors, nurses and ancillary staff to discuss on how best to handle the situation. One nurse suggested that I did not have to see those patients; they were the responsibilities of the trainees and junior doctors. She mistook my seeking a solution as making life easy for me. I also presumed that she did not want me to see all those patients as that would also increase her work load! The others did not even see the problem. Outpatient clinics everywhere in the country were crowded. Get used to that! They were free; what do you expect? Besides, we could not dictate to the other clinics what time to send their patients to ours.

            I had expected some suggestions from them seeing that they had been at it for years. Instead, they saw no problem. You cannot begin to solve a problem until you know that you have one.

            While it was true that we did not have any control over the other clinics (like the Casualty Department, Pediatrics, and Medicine) that referred to us, why not let only those patients come at   2 PM, our scheduled opening time. For those whom we had control, as with our follow-ups, have them come later at 3 PM. That would immediately reduce the crowd at opening time by half–substantial! As there was no opposition (at least no one voiced any) to my suggestion, that was the change I implemented right away.

            At our next outpatient clinic when the change became effective, it was a great relief! The throngs were gone or at least reduced substantially just as I had anticipated, to be replaced instead by a steady but manageable stream instead of the usual unruly mob that greeted us at 2 PM as with past sessions. Absent the mob, the associated mentality and behaviors–pushing, shoving and screaming–were also gone. The patients were now polite and well behaved. While it did not quite yet feel like my private clinic in Canada, the crowd was at least manageable.

            Like a well-manicured garden in the tropics, the beauty and orderliness did not last long. Soon, the overgrowth of unruly shoots and branches began appearing and took over. Within weeks the unruly crowds were back, at first a trickle and then as if nothing had changed.

            I could not figure out what had gone wrong. So one day I stationed myself in an unobtrusive corner of the waiting room. One of my follow-up patients came in at 3 PM, as per her appointment card. She had followed the instructions given to her.

            The receptionist however, berated her for being late. My patient protested and showed her the appointment card. The receptionist responded that while it was true the patient’s appointment was at 3 PM, it would be better for her to come early, as at 2 PM. The doctor was a busy man, she told her. As such it would be better for us to wait for the doctor and not the other way around.

            I had to control my laughter! My own staff had undermined my reform, and did it in a very soft and subtle manner–the Malay way. There was no way my patients could rebut her.

            That day after the clinic I gathered my staff again and asked why we were back to the bad old days of a mob at our clinic. No one volunteered an answer or offered suggestions as to why the changes that had worked so well for the first few weeks earlier had now failed us.

            I hinted that perhaps a few might not have understood the rationale for those changes and thus were not following them. We were undermining our own efforts. I sought out ideas on reducing or managing the crowd. Again, none was forthcoming. After much prompting on my part, the record keeper finally admitted that the old system made his work much easier. He had to go to the chartroom only once–at the beginning of the clinic–instead of back and forth with every arrival of a patient.

            I acknowledged his extra workload and then added that we should first think of our patients. We should lighten their work as they were the sick ones, not us. Seeing that my response had embarrassed him, I said that I would reconsider reverting to the old routine of making all patients come at 2 PM if that would make his work easier. Then with the spare time he could help in the clinic.

That solution did not enthrall him at all. What he had in mind was to have all the charts ready at the beginning of the clinic so he could retreat to the backroom to resume his siesta and not be disturbed until the clinic was over and he had to stack those charts away.

            Going back and forth for the records was a valid complaint. To alleviate the problem, I suggested we have a list of all our follow-ups beforehand and pick those charts up regardless whether those patients would show up or not.

            With that, my changes were back on track and the pasar rabucrowd outside our clinic was now gone again.

            However, this was Malaysia; what may look desirable may not be so. To me the lack of a crowd meant a smooth, well-organized operation; not so to locals. My nurse hinted that people were now avoiding our clinic because they thought the lack of a crowd reflected on the quality and reputation of our doctors. She suggested reverting to the old system with its unruly pasar miggumob, and with that, the façade of a “popular” clinic.

            I responded that I was less interested in how others view us rather more on how our patients regarded us. I was not into peraga(showy acts) like having a big crowd outside our clinic.
Our new routine remained, and with that our outpatient clinic continued to be orderly!

Next: Excerpt #11:  A Much-Needed Break!

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

When Clueless And desperate, Thump Your Chest For "Malay Unity"

When Clueless And Desperate, Thump Your Chest For “Malay Unity!”
M. Bakri Musa

The recent, much-ballyhooed love-fest between the two exclusively Malay political parties PAS and UMNO was nota major realignment of Malaysian politics, as many had interpreted, rather a pitiful demonstration of the despair, dumbness, and most of all the desperation of their respective leaders. They had failed to address the embarrassing backwardness of Malays while they were in power for the past 60 years.

            Now dislodged from their lofty perches as a consequence of the 14thGeneral Election, these leaders are left with thumping their collective chests calling for Malay unity. When pressed, as with unity towards what, their vacuous thinking is exposed. They are devoid of answers. What they are really scheming at is to be back in power so they could once again loot the nation with impunity.

The ugly reality and utter shame of continued Malay backwardness remains, made intolerable considering that all the major levers of powers–from the sultans, ministers, and the civil service–have been in almost exclusive Malay hands during those decades.

Instead of facing up to that failure and doing much-needed soul-searching, these leaders and their followers now resort to scapegoating and wallowing in their victimhood status. With the predominantly Chinese Democratic Action Party now in the ruling coalition, it becomes their favorite whipping-boy.

With Mahathir bringing in such sterling talents as new Attorney-General Thomas, those previously powerful and untouchable leaders now face criminal prosecutions that could put them behind bars for the rest of their lives. Instead of lauding this brave move, UMNO and PAS Malays would prefer instead that their favorite and clueless former AG Apandi remain in charge. Malays should be ashamed of him and others of his ilk, not proud of them.

            Malays must confront the reality that many of our leaders have been corrupt and incompetent. They have also betrayed the rakyats’ trust in them. Leaders like Najib had been in cahoots with foreign elements, both East and West, to rob Malaysia to satisfy their insatiable greed.

Why did we let them? How did these flawed characters rise so high? Does that reflect on our culture? Where is the Koranic wisdom that Allah would not allow His community be in error? Why have Malays been so wrong in choosing these leaders?

            Worst is their lack of shame, much less any sense of remorse or contrition despite the motherlode of foreign currencies stored in used-produce boxes (instead of in banks) found at their residences. Malays still consider these criminals fondly as their bossku(our boss). Look at the perversity of the recent by-elections at Semenyih and Cameron Highlands.

This new Malay alignment was purportedly to defend Islam and Malay interests. The first is laughable if not pathetic. This great faith does not need defenders, least of all from these slimy characters. Islam had withstood the hordes of Moghul invaders and survived powerful Western colonialism. It does notneed these lebaiswith their “Syariah-compliant lies!” What next? Syariah-compliant fornication? Such bida’a!

I would have far greater confidence – and respect – had these leaders articulated their vision beyond such hackneyed calls for Ketuanan Melayu or make Malaysia Tanah Melayu again. What do they have in mind? A pogrom against non-Malays? You would have the Chinese Navy landing on Malaysian shores in no time. The Japanese took only days to overrun Malaysia despite formidable British defenses.

No, you would not need the Chinese Navy. A few amoisfrom the Mainland would distract these corrupt leaders and achieve the same end. Look at what that moon-faced boy from Penang could get away with Najib!

Get real, folks! The sooner these Malay leaders in UMNO and PAS accept the present reality, the easier and faster they could make the adjustments and return to power to lead us forward.

If only these leaders had said they wanted Malay unity towards improving our schools and healthcare, so as to enhance the quality of our human capital, or strengthening our social structures to reduce rampant abandoned babies, underaged marriages, and drug addiction! Go beyond, as with freeing our people from the myopic and crippling interpretation of our faith. Then I and many others would be the first to join forces with them.

Consider Islam in Malaysia. Heavily supported by the state, it has reduced the ummah to the proverbial sheep, not the flock that could freely graze in the lush, green pastures and protected from predators, as gloriously expressed in J S Bach’s cantata “Where Sheep May Freely Graze,” but flocks being led to the slaughterhouse by their greedy, corrupt, and unscrupulous shepherds.

Tradition has it that the prophet was once asked for the signs of the end of time. “When the naked, destitute, and barefooted become your shepherd!” (Approximate rendition).

These are the new Malay leaders, our wira negara dan bangsa– naked of ideas, destitute of imaginative initiatives, and barefooted with their experience or competence.

            Jonathan Brown recalled in his book Misquoting Muhammad:  The Challenges and Choices Of Interpreting The Prophet’s Legacy, the advice given by one Mustafa Maraghi, the Grand Mufti of Al Azhar, to his country’s rulers, “Bring me anything that benefits the people, and I’ll show you a basis for it in the Syariah!”

            Malay leaders and ulama have it backward. They are busy looking into those ancient texts on how to develop the nation instead of studying the problems and then recruiting the best minds to solve them. These leaders are obsessed only with displaying their ostentatious piety when they should be focusing on formulating sound public policies.

            They will continue doing so until we, the rakyat, tell them in no uncertain terms that that is no longer acceptable.

My book excerpt will resume next week.

Excerpt #9: A Leaner, Flatter Organization

Excerpt #9:  A Leaner, Flatter Organization
M. Bakri Musa (www.bakrimusa.com)

I reorganized GHKL’s Surgical Unit III by dividing the large male ward into two, keeping the smaller female ward as one, and combining the first and second class wards as the fourth division. It turned out that each had about the same number of patients; that helped even out the load. I further divided each division into two and assigned an intern to each, with a medical officer over the two interns.

            I streamlined the organization and clarified the lines of authority. Whereas before there were the senior and junior house officers, the medical officers with their own myriad titles of registrars–ordinary, junior, and senior–and the consultant, now there would be only the interns, medical officers, and me.

            There was immediate dissatisfaction, not expressed openly but quietly as per the oriental style. I had two senior registrars and they did not take kindly to what they viewed as an apparent demotion to being mere medical officers. One was Freda Meah. A full-fledged surgeon before she left her native Myanmar, she was with the university so I could dispense with putting her into my scheme. I told her to find her own level, supervise the rest, and report directly to me. She had no problem with that.

            The other was also a lady trainee who by now had a reputation as a perpetual surgical test-taker. She had taken her FRCS examination umpteen times but never made it. As she was much older than me, she figured that she was just as qualified if not more experienced a surgeon than I was except for those silly string of alphabets behind my name.

            As she would need some time to study for her next examination, I put her in charge of the much lighter first and second class units. She was ecstatic not because of the reduced load, rather the chance to hobnob with the hospitalized senior civil servants and other elite of Malaysian society.

            I told Mahmud privately that he could take any case he wanted and then supervise the intern and medical officer assigned to that patient. I made it clear to everyone that he and I shared the clinical leadership. With his training in pediatric surgery, I had Mahmud take charge of that small unit with Zul who had shown an interest in that field as the designated medical officer.

            There was one other stipulation I introduced. No case should go into the operating room no matter what time of day unless Mahmud or I were present and scrubbed. Since Mahmud was busy on campus, that effectively meant me. “Even for a simple appendix?” one medical officer asked, less for clarification, more for sarcasm. “Yes!”

            As a surgical resident back in Canada, I used to chafe when the attending would not scrub with me and instead waste his time in the lounge discussing local politics or recounting his latest exotic vacation. I reckoned that the day I operated on my own would be the day I collect the full fees. Most residents felt otherwise however. They felt that the presence of the attending reflected on their competence, or lack thereof.

            My attitude was shaped by a “simple” appendectomy I was forced to do. Dr. Frank Turner was the attending. Such a case was not for the chief resident but all the other residents were busy. Sensing my displeasure at having to do the case with him, he went out of his way to show me that he still had a thing or two to teach me.

            As I inserted my index finger through the incision to retrieve the appendix, he stopped me. He asked me to describe the pathology just through the feeling of the tip of my finger. I did, and he then asked about the ovaries, liver and the rest of the bowels. Everything was normal I assured him except for the liver and the rest of the bowel. I could not reach them. Then he took over and inserted his finger and started rattling off. “Cirrhosis, gallstones….” I repeated my exploration but could not tell anything as those organs were beyond my finger’s reach. I wanted to enlarge the incision but he would not let me.

            Suitably humbled, I finished the case in silence. He had made his point. I should find out as much as possible through digital exploration. After the case, sensing my dejection, he said that he did not actually feel the gallstones rather those had been the incidental preoperative ultrasound findings.

            I wasn’t mad at him. Instead I took his lesson that day to heart. You could always learn something even from a simple routine case. I would often pull that old trick on my arrogant residents and medical officers just to humble them.

            Since that episode, I had picked up innumerable unexpected pathologies, like colon cancers during routine hernia repairs, ovarian abnormalities during appendectomies, and stomach cancers during simple umbilical hernia repairs, just by digital exploration through the incision, even in these days of exhaustive and expensive preoperative scans.

            As for my insistence on being in the operating room (OR) at every case, decades later the United States Medicare Agency would require surgeons to attest as to their presence in the OR, scrubbed, on allcases they billed.

            I implemented all those changes in Unit III the Thursday of my first week. That way they would get a two-day trial and have the weekend to recover. I apprised Mahmud of the changes, being careful to present them only as proposals. With Sister Fong reminding him of the problems with the current system, I had no trouble convincing him. He added that it was similar to what he had at the University of Malaya Hospital.

            I was surprised at the smoothness of the change. The nurses were pleased as they now knew exactly who to call and were spared the usual “call the other intern” response. With everybody knowing their responsibilities, things were smooth with little wasted motion. My earlier stipulation that I be scrubbed on every case was not as onerous as I had expected. I tried to restrain myself to be only the first assistant and let my trainees do the actual surgery. The junior doctors enjoyed my direct supervision. Up till then, the practice was for the more senior trainees mentoring their less-experienced juniors. This old “see one, do one, and teach one” was also the standard practice then at many major medical centers in North America. That was one reason I left McGill’s program to return to Edmonton where the tradition was for a resident, no matter how junior, to work directly with an attending.

            The new arrangement worked so well that everyone thought this had been the case all along forgetting the earlier chaotic system which we had abandoned only a few weeks earlier! As we were now efficient, we had ample time for coffee breaks after our rounds. The house officers in the other units were now envious that my staff were getting time off for coffee! The chaos in the other units reminded my staff how bad those not-so-long-ago days had been.

From the author’s second memoir, The Son has Not Returned.  A Surgeon In His Native Malaysia(2018).
Next: Excerpt #10:  Revamping The Out-Patient Clinic Mess