Author: Dr ANDREW C S KOH

by Dr. Andrew C S Koh

Houseman ship in the Ivory Tower

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I have sometimes sat alone here of an evening, listening, until I have made the echoes out to be the echoes of all the footsteps that are coming by and by into our lives

,Charles Dickens, a Tale of Two Cities

Where the love of man is, there also is love of the art

Hippocrates

In July 1977, I found myself working in the ivory tower called the University Hospital Kuala Lumpur, presently known as the University of Malaya Medical Centre, as an intern, or houseman. This is a one-year compulsory training for all new medical graduates before being granted full registration as a medical practitioner under the Malaysian Medical Council. I spent the first 6 months of internship in Internal Medicine and the second 6 months in Obstetric and Gynaecology.

I was given provided accommodation in the houseman’s quarters located on the top 14th floor of the University Hospital block.

I will start my story in Internal Medicine first. Each house officer was assigned to one medical ward. I was assigned to ward 13, located on the 13th floor. I took care of 28 patients in ward 13. This ward was under the care of a medical officer, a lecturer, and a Professor. I worked from 8 am until late in the evening but I had to be back at midnight to look after the cases in ward 13. We called this Cinderella call and we did not particularly like this system because we can’t go anywhere after midnight. There was a restriction of freedom but this was good training. It drove home the point that life as a doctor was not going to be easy. You need to have the calling, the passion, the commitment, and the willingness to sacrifice your time wholeheartedly. Half-hearted commitment will not do.

Houseman ship in Medicine was extremely demanding. My day starts with an early breakfast in the hospital canteen. Then off to the ward to do a fast ward round, making sure that I know each patient by name, provisional diagnosis, latest blood tests and imaging results, management plans, and so forth. There would be new admissions that came in the night before which I was not familiar and others were the older ones that were admitted earlier. By 10 am, the medical officer will come with the lecturer to do the daily ward rounds. Going from one patient to the next until the last one may take a couple of hours, depending on the complexities of each patient. After that, I would have to clerk all the new cases admitted via the outpatient department or the accident and emergency department. My job was to take a full history, do a physical examination, and document these on to the case notes. The medical officer would come by later to check on each case and order the appropriate investigations and recommend the plan of management. Then it was back to clerking new cases, doing ward procedures, and reviewing tests reports, until late into the evening before passing over to the houseman on call.

The highlight of my stint in Medicine was the weekly Professorial grand ward round. My Professor will come in at 9 am with the medical officer, and my job was to present every case to her from head to toe. The ward round usually took a long time to complete because the Professor was very long-winded with her teaching and frequently sidetracked by telling long stories and no one dares to interrupt her! By lunchtime, we would have covered possibly 8 or 10 patients at the most and there were so many more to cover! The team adjourned for a lunch break and resume the grand rounds until 3 or 4 pm. After this, I was back to clerking new cases and reviewing reports. By this time there would be a backlog of cases to clerk and my day would end very late!

The houseman ship provided me with hands-on experience, learning through apprenticeship, and supervision. The medical officer was my mentor and I tagged along with him as close as I can without encroaching too much onto his personal space. Now was the time to put into practice all that I have learned in the last 5 years of medical school. I could learn as much as I wanted to or I could be slip shot and just do the bare minimum. It was entirely up to me and I chose the former route. I got on very well with the nursing sisters building up a relationship with them over time. I learned a lot from them as some of them had been in their profession for decades.

The stint in Obstetrics and Gynaecology was an entirely different ball game altogether. There was no more Cinderella call. If I was not on call, I would be free after doing all the duties for the day and passing the cases over to the on-call houseman. History taking was short and sweet and straight to the point. Lecturers and Professors did not breathe down my neck and were not interested in a detailed history of every case.

Here I learned how to deliver babies, observed forceps and vacuum deliveries by the lecturers, assisted in Caesarean Sections, tubal ligation, vasectomy, and minor surgeries. There were some dramatic incidents as well. A pleasant lady who was a long standing staff of the department of Obstetrics and Gynecology came in for a Caesarean Section and died suddenly on the following day. The lecturer said she had a fat embolism, a rare but fatal clinical syndrome.

One day, when I was on-called, a lady who came in for an emergency hysterectomy had a postoperative intractable massive hemorrhage. The Professor on call was called into the operation theatre. To stop the bleeding he performed bilateral internal iliac artery ligation and saved the day. So many pints of blood were transfused but she was survived! The Professor was praised for his prompt and life-saving decision. This was the first they had to resort to this measure to arrest post-hysterectomy hemorrhage in the Hospital.

Of course, the most unforgettable, most painful, and most unfortunate incident was the MH 653 fatal air-crash in Johore on 6th December 1977. It took the lives of all 7 aircrew members and all 93 passengers on board including the late Professor I S Puvan, Professor of Obstetrics and Gynaecology of University Hospital. He was such a well-loved and well-admired Professor with such a big heart, powerful persona, and everyone including his patients missed him so dearly. His impeccable bedside manners and pleasant personality were second to none and hard to match. A real life Dr Kildare. Even until today, I could not forget about him.

Working in the labour ward was equally exciting and dramatic. We would not know when a patient would come. They usually come in at the most God-forsaken hours of the night but seldom during office hours. Patients came in with variable degrees of pain. Some came in screaming and shouting in pain while others came in with more respectable and tolerable pain. It has to do with the pain thresh hold. Generally, Indian women seemed to have a much lower pain threshold. They tend to scream and shout with each contraction and demanded more and more pethidine for pain relief which was not good for the fetus. I learned from the midwives. Some of them had been in the profession for decades and were very experienced. The Indian word for breathing in and out is ”muchu” and the Indian word for pushing with all of your life is ”muku”. When you want her to breathe in and out, you would say ”muchu” and when you want her to push with all of her life you would say ”muku”. The problem was when the houseman mixed up these two commands and said push with all your life when he wanted her to breathe in and out and to breathe in and our when he wanted her to push with all her life! I was told that this had happened to some houseman before my stint but whether this was true or not I could not confirm. They said that truth is stranger than fiction.

I remembered one day I reported for duty in the labour ward, after taking over from the previous houseman. The labour ward seemed to be too quiet because there was no patient in labour. All the midwives were relaxing, having a jolly good time, and you could have heard a pin drop. Being a newbie to the trade, I blurted out, why is there no patients in labour? The mid-wives rebuked me and said do not be a jinx. Not long after this, patients started to come one after another none stop until my shift was over! Now I understand why Paul Simon and Art Garfunkel said in their song, silence is golden!

To be continued….

by Dr. Andrew C S Koh

Medical Undergraduate and houseman-ship

University of Malaya, Kuala Lumpur

A dream, all a dream, that ends in nothing, and leaves the sleeper where he lay down, but I wish you to know that you inspired it

Charles Dickens, a tale of two cities

The next 6 years of my life was spent in Kuala Lumpur, the big capital city of Malaysia, 5 years as a medical student in the University of Malaya Medical Faculty, and 1 year as a houseman in the University Hospital, now known as University of Malaya Medical Centre.

I started my career in medicine in July 1977 as an undergraduate student. It was a 5-year course followed by a 1 year as a houseman-ship. The childhood ambition of my life finally came true like a dream! As far as I could remember, I had always wanted to be a medical doctor. I thought this would give me a stable career, a better quality of life, and hopefully a stable source of income. I would be able to help people who are sick, to render assistance, relieve pain, relieve suffering, relieve anxieties, and so on. My opportunity to do all these had finally arrived, thanks be to God, who always had my interest at heart and always had me covered.

For the first two years, I stayed in a residential college called the 1st College as this was the nearest college to the Faculty of Medicine. It was just a matter of 30 minutes walk up a long and winding road, but traveling by motorbike would only take 10 minutes. After 1 week of orientation, we were ready to attend classes. On the first day, the Dean of Medicine, Emeritus Professor TJ Danaraj addressed the class of 72-77 in the grand clinical auditorium. The first words he said were, “Medicine is a life long course, it is never 5 years in a medical school”. He went on to say that what we learn would be obsolete the moment we graduated. He was right and this turned out to be true.

He said a doctor should never stop learning because medical knowledge progressed rapidly and doctors had to keep up with new knowledge and new skills to keep up to date to practice safely. A doctor is like a pilot. If a pilot stops flying and did not clock in the required number of flying hours he would be grounded.

I remembered he also said, “If you want to make plenty of money please go and do another course right now’’. Medicine is both a calling and a passion. Without this two ingredients, it would be very difficult to pursue this career.

Professor Danaraj was very knowledgeable but also very strict. He was a very respectable clinician and academician not only in Malaysia but was also worldwide. We were very blessed to be taught by him.

The medical school curriculum was divided into 2 modules. The first 2 years was the preclinical module where we were taught the basic sciences, anatomy, physiology, biochemistry, parasitology, pathology, clinical pharmacology, public health, statistics and so. The subsequent 3 years was the clinical module when we started to clerk patients in the wards and learned the art and science of medical practice under the guidance and teachings from the lecturers and professors.

The preclinical years were quite boring as we had to study a lot of basic sciences and were not allowed to interact with patients in the hospital. It seemed irrelevant at the time but this was not true. Without the basic prerequisite knowledge to us back up, interacting with patients would be dangerous. The pre-clinical years builds up a strong basic foundation needed to understand and practice the art and science of medicine. After surviving the first 2 years, I moved on to the next 3 years of the clinical module.

Our batch was very fortunate to have world-class eminent clinicians like Prof. TJ Danaraj and others of his caliber to teach us the art and skill of medicine. Prof. TJ D told us not to refer to any patient as case 1, case 2, and so forth. Behind every case is a person, a human being with a name, and a soul. They were not to be referred to as case number such and such. Empathy, compassion, kindness, the right attitude, and good bedside manners go a long way.

I remembered those clinical case conferences taught by Prof. TJ D in the clinical auditorium. One student will be selected to present a case to the class in front of him. There would be tension in the room as the poor student at centre stage presents the case, terrified, expecting to be scolded and torn apart by the barrage of questions that followed. Even those who did not present the case would be equally terrified, especially those sitting in the front rows, expecting to be hauled by Prof. TJD anytime. Even those who kept quiet would be hauled up for not asking intelligent questions.

Then there were the teaching rounds with Prof TJ D in the wards. Ever so often, he made a spot diagnosis just by looking at the patient without even taking a history or doing a physical examination. He made spot diagnoses of patients with hyperthyroidism, hypothyroidism, end-stage renal failure, and so forth. He taught us the importance of observation before palpation. He taught us to use all our 5 senses of observing, hearing, smelling, touching, and feeling to make a diagnosis. A good history and a good physical examination is also the key to making a diagnosis.

On one particular teaching ward-round, a patient with Chronic Rheumatic Heart Disease (CRHD) was presented. Palpating the character of the pulse, observing the JVP waveform, locating the position of the apex beat, palpating the precordium for thrills, and palpating the liver size would be sufficient for him to arrive at the diagnosis. Auscultation using the stethoscope was only required for him to confirm the diagnosis. The clinical acumen of Prof. TJD was hard to match. Besides cardiology, he also was a neurologist par excellence. I was also amazed by his ability to elicit clinical signs in neurology.

Medicine is both an art and a science. They say you can train a monkey to be an engineer but you cannot train a monkey to be a doctor.

My life as a medical student was not very dramatic or colourful by any stretch of the imagination. The preclinical years were very demanding. There were lectures to attend, practical work to do in the biochemistry laboratory, and practical work at the anatomy dissection room. The class was divided into small groups for anatomy classes and each group was assigned one cadaver. Seeing a cadaver for the first time was not so frightening after all. The cadaver had been preserved with some kind of embalming fluids to prevent decomposition. The smell of embalming fluids in the anatomy room very strong and irritating to the eyes. The professor of anatomy told us to respect the cadavers because they were there for us to learn anatomy. After every dissection, the cadaver gets smaller and smaller until there would be nothing left. Each group became closely knitted and built up a relationship over the year.

There was a Christian fellowship group in my class. These are my Christian classmates about 10 or 12 of them. Although I was a free thinker, they invited me to join them in their weekly fellowship and other activities. They shared the gospel with me, gave me a Christian book to take home, and even prayed for me. In my last spring cleaning, I found this book with autographs and a message. My Christian friends were very helpful, reliable, honest, respectful, and good role models. Through their influences, I came to know about the Christian faith. I also got to join the activities of the Varsity Christian Fellowship, (VCF) and made friends with some of my seniors who are Christians and members of VCF. In the 4th year of my study, I became a Christian through the sharing of one VCF member who visited me in my room when I was in the middle of a situational life crisis.

I have one classmate whom I am particularly fond of. He was a top scholar from Sarawak and had long beards. We called him “janggut’, which means beard in Bahasa Malaysia. He was a good role model too and we spent quality time and did many things together through the years.

For the last 3 clinical years, I moved to the clinical student hostel, CSH, which was within walking distance from the medical school and the University Hospital. This was very much nearer than the first residential college. Life in the CSH was interesting. Students played volleyball, tennis, and sepak takraw in the evening. Some of my classmates played mahjong until late into the night even during the examinations but still end up with distinction and top of the class. Some of my classmates were very rich and drove brand new BMWs while most of the Professors were driving very old Volvos or Peugeots.

I was not a very good student. I found the medical course challenging. There were plenty of things to read, remember, memorise, and understand. By the grace of God, I managed to pass all my examinations and graduated with MBBS (Malaya) in 1977. In those days, due to a shortage of doctors, medical graduates were required to start houseman-ship immediately passing the final year examination. But to negotiate for a pay increase, our class refused to start houseman-ship immediately. This initiative forced the government to increase the houseman-ship salary from RM 850 to RM 1150. After 12 months of houseman-ship in the University Hospital, Kuala Lumpur before I was finally registered with the Malaysian Medical Council with a license to practice medicine in Malaysia. Some people called this a license to kill. Don’t ever believe this! Life is sacred. The Hippocratic oath says, “Above all, do no harm”.

After graduation, the MU Class of 72-77 still kept in touch and met regularly through WhatsApp and Reunions. Initially, we had reunions once every 5 years but for the last 5 years, this had become a yearly affair. The last annual reunion was held successfully in Singapore, hosted by our Singapore classmates. A reunion was planned to be held in Ipoh in 2020 but unfortunately, this event had to be canceled due to the COVID 19 pandemic. We hope that with the availability of the vaccine, this will pandemic be over sooner rather than later.

To be continued…..