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Tuesday, July 23, 2013

Sri Lankans top in IMG exams

I just received this e-mail from a friend. An appropriate posting to follow Speedy's contribution.
This article by Paul Smith is from "6Minutes" of interesting stuff for doctors today.

Sri Lankans top in IMG exams

■ Paul Smith

IMG doctors trained in Sri Lanka have the highest pass rates in make-or-break exams that allow them to practise in Australia, new figures show.

In 2011, the pass rates for all IMGs in the Australian Medical Council (AMC) exams were 52% in the multiple choice questionnaire (MCQ) and 53% in the clinical examination.

Each year, more than 2000 non-specialist doctors sit the tests, where failure means they will be denied to right to practise in Australia. More than 70% of Sri Lankan trained doctors pass the MCQ, compared with 40% of doctors trained in Russia. However, not all IMG doctors have to sit the tests.

The biggest source of IMGs in Australia remains the UK, with over 1200 doctors brought into the country in 2011/12. Like those trained in the US, Canada, New Zealand and Ireland, they are generally not required to take the AMC exams because UK medical qualifications are deemed equivalent to Australian medical qualifications.

Sunday, July 21, 2013

Why are Sri Lankan junior doctors highly regarded in the UK?

Why are Sri Lankan junior doctors highly regarded in the UK? 
By Mahendra Gonsalkorale
It is a fact that doctors trained in Sri Lanka are well respected and welcomed in the UK. I cannot speak for more recent generations as I am now retired and out of touch but my younger colleagues inform me that this still applies. I can certainly speak for doctors of my generation and soon after. It is not just my experience but that of many of my friends and colleagues that interview committees sit up and take notice when they have a Sri Lankan doctor in front of them. There are numerous occasions when a Consultant with whom I have worked even as a locum asks me whether I have any friends looking for jobs. There is no doubt in my mind that Consultants in theUK, who have had Sri Lankan junior doctors working with them, develop a soft spot for them. I often wondered why, and these are some of my thoughts and I would welcome colleagues in the UK to comment and contribute.
What is a senior doctor looking for when they select a junior to work for them in their “Firm”?  Those were the good old days when clinicians worked in Teams with the Boss, a Senior Registrar orRegistrar, and Senior House Officers based in designated single or shared wards with responsibility for 24hour care for their patients. Sadly this concept has faded, thanks to working hour directives and other organisational changes. My view is that they look for a doctor with the following attributes.
1.       Clinical competence.
2.       Good command of the language and ability to communicate with patients and staff.

3.       Reliable and willing to work hard.

4.       Willingness to step in when there is a problem with staffing.
Sri Lankan doctors excelled in all above criteria. In addition, they endeared them to their ‘bosses’by displaying a healthy respect for them.  This at times went too far in their view and they found it a bit uncomfortable when these juniors used the word “Sir” every time they spoke to the Boss! It was of course our tradition In Sri Lanka to “sir” our bosses out of respect. Sri Lankans also have this habit of smiling even when they are criticised and we are very pleasant and friendly by nature. Those in my generation were also very familiar with typically “British” things such as English literature and history, the quirky British sense of humour (often lost in other Sub-continent Nationals) and of course that strong binding force, cricket. One thing we lacked in our early days was confidence in presenting a history and articulating a management plan with confidence. Our tendency to mutter words without coming out in a coherent statement was noticeable but our bosses empathised with us and helped us to gain these skills.
In short, we were regarded as competent, likeable, hardworking and respectful. No amount of desirable social behaviour would compensate for overall clinical competence and we had that in abundance, thanks to the excellent grounding we had in our Medical training in Sri Lanka.


Wednesday, July 17, 2013

Finding my feet as a doctor in London and other stories

Another article by ND. This was first published in the Sunday Island on 7th September, 2003.

Finding my feet as a doctor in London and other stories

Dr. Nihal D Amerasekera FRCR, FRCP
Consultant Radiologist

I qualified as a doctor from the Colombo Medical College in 1967. After my house jobs my career prospects became a part of the Health Department lottery. For 7 years I drifted from one job to another and finally decided to pack my bags to seek my fortune abroad.

The decision to leave my family, friends and country was not taken lightly. I still recall the sleepless nights, the agony and the anguish which almost tore me apart. I wanted a different life from that I saw around me and was attracted by the bright lights and the sophistication of a life in London.

The day of my departure came all too soon. The Katunayake Aerodrome as it was called then was fast becoming an International Airport. I remember vividly waving goodbye to board the Swissair DC10 bound to London. The flight was long and unpleasant. The plane vibrated violently and shook every bone in my body as my mind was in turmoil. I didn’t know then that the DC10 had the worst safety record in modern aviation history. I travelled with my friend and colleague, Asoka Wijeyekoon. We comforted each other until we disembarked at Heathrow airport on that cold and wet June afternoon in 1974.

I was met at the airport by Dr. Cyril Amerasinghe who most kindly gave me food lodging and lots of helpful advice to survive the rigours of an alien culture.

My first job was at Harefield Hospital near London. It was a clinical attachment in pathology to assess my work and suitability for a substantive post in the National Health Service. All I can remember of my fortnight there is the utter loneliness and the hollow emptiness I felt. For hours I gazed at the blue summer sky often regretting my decision to leave my country.

It is the help of a complete stranger which is most deeply etched in my memory. I was allowed `A350 by my government, half of which went for registration with the General Medical Council and the rest was the fee for Medical Defence. How I survived until my first pay was not their concern. A lady doctor from New Delhi who was completely unknown to me often paid for my meals and I borrowed the rest from friends to whom I am still grateful. Those were the darkest days of my time in the UK.

Roller Coaster Life

I started my ephemeral and roller coaster life at Harefield Hospital London. New people appearing and disappearing from my life in quick succession unnerved me. I stood there in awe in my white doctors’ overcoat in the most elegant and magnificent corridors of one of the world’s finest chest hospitals. My past with all its bouquets and brickbats were now forgotten. What mattered most was the present performance. I had a brand new identity now. The iconic position I held as a doctor in Sri Lanka had just melted into the distance. Outside the confines of the hospital I was a Mr. Nobody. This was a shock to my system but I soon overcame this without much heartache.

My first proper job came via the kind courtesy of Dr. Titus Perera who has since remained a lifelong friend. Chase Farm Hospital is situated at the north end of London in beautiful countryside. I lived in hospital accommodation in a single room which wasn’t lavish by any means. Although I had an English education and spoke with an Oxford accent taught to us at school, many in England spoke a strange mix of regional slang which was incomprehensible. It was the British doctors and the television news readers who spoke the English I was used to back home. It took me several months to overcome this hurdle.

Speaking on the phone without the help of body language and hand signs wasn’t easy. Working in pathology was peaceful and I cannot recall ever breaking into a sweat. My first pay was a godsend although a meagre `A3180. I managed to settle my debts and buy myself a few essentials. I had made a suit in a well known tailoring establishment in Colombo Fort which I had worn since my arrival in Britain. It clung to my body like a wet suit. The left sleeve of my jacket was longer than the right (Sunday is longer than Monday!!). I couldn’t raise my right arm above 90 degrees. The trouser flapped about in the breeze like a sarong. The shoes that I brought from home lasted the summer. In winter it shrank losing its shape awkwardly. Water seeped in from the cracks in the sole creating a sorry mess within. I had to purchase suitable clothing to restore some of my lost pride.

I was born with the sun on my face in a tropical paradise. I had now to endure the vagaries of the four seasons. The spring in England was most colourful. The lovely well kept gardens and beautifully manicured lawns looked very pretty indeed. The summer with its long days gave us plenty of time to enjoy the warmth of the sun. The autumn ushered in the short days of the winter when we never saw the sun. The prevailing south westerly wind brought the moisture laden clouds from the Gulf of Mexico and rain in Britain is never far away. The incessant thin drizzle is characteristic of the type of rain here which never seem to stop in the winter.

Despite this it amazes me how sometimes in the summer there are water shortages and hosepipe bans. The British are a very tolerant race accepting this with amazing grace. There are 50% more deaths amongst the elderly in the UK in winter and many suffer from the seasonal affective disorder (SAD), a psychiatric illness brought on by the lack of sunlight. I enjoyed the first snowfall of the winter immensely and looked up in awe as the fine sleet and snow fell from the sky. As it settled, it formed sheets of ice and became like a skating rink. Many slipped and broke their wrists clogging up the casualty rooms in hospital.


I had heard about racism in Britain and experienced it first hand very soon after my arrival. Wednesday was my half day off from work and I got onto the W8 bus to Enfield Town. I sat in the upper deck in a packed bus. Although there was an empty seat next to me no one was willing to sit beside me. Many passengers preferred to stand all the way to the bitter end. In those days there was institutional racism in the NHS where jobs were not given to the most deserving. I also had to accept the NHS has some obligation to employ their own graduates. Now Britain has come a long way to become a multi-cultural society with equal opportunities to all. In general the British are a tolerant and a caring race. Their generous welfare state and the social services depend on the heavy tax paid by the rich and middle classes. The free healthcare and education have been the envy of the world and is a heavy burden on the public.

The British are a reserved people. They tend not to speak to you unless they have been introduced. This is sometimes mistaken for racism. They hardly know or speak to their neighbours. It amazes me how silent they remain travelling in the buses and tubes reading books and newspapers. Once I was travelling in an underground train with my sandwiches (this had dried prawns and chillies). It started to smell a bit and the smell got worse. The travellers in that confined space found it intolerable but they couldn’t locate the culprit. I pretended it wasn’t me. A man seated opposite thought he had trampled something awful removed his shoes to look at the sole. Fortunately the train stopped at the station and I jumped and hurried out, like the rest.

The British love queues and seem to form them even when they are in their cars. In my memory Sri Lankans form queues only until the bus arrives. After that it’s the law of the jungle!! It took me awhile not to throw litter on the road and refrain from spitting. I believe I have turned the corner now after 30 years.

Jobs in the UK are for specified periods and my post finished in a year. Meanwhile I had found a suitable job in Prince of Wales Hospital, Tottenham. There was a large West Indian community in the area and ethnic food was freely available. I moved very soon to its sister hospital a mile away to a clinical post to sit for the MRCP examination. This was the busiest job I had ever done. On-call every other night and every other weekend. A hectic schedule by any standard. It is here that I appreciated the teaching I received at the Colombo Medical College.

I cannot praise my old teachers highly enough. The years of toil as a medical student in the Ragama section of the General Hospital Colombo came to my rescue at the examination. Sadly I never appreciated their efforts at the time having only 24 hours in a day to complete the endless tasks thrust upon me. I was fortunate to complete my MRCP within 2 years of my arrival in the UK.

It was not all work there was much happiness and camaraderie too. I made some good Sri Lankan friends. We stuck together through thick and thin over many years. On weekends we gathered together at ‘Daneland’ the home of Tissa Ranasinghe who was a lecturer at a local Polytechnic. We had numerous parties there with plenty of booze and baila. It was a refuge for many young Sri Lankan doctors and was the place for an authentic curry. I recall the many Christmases and birthday parties we celebrated in that house. It still amazes me how the neighbours tolerated our raucous evenings and sing songs.

Kalu dodol

Home cooked food sent from Sri Lanka was a luxury. Once I recall Dr. Agrabodhi Fonseka receiving a parcel of kalu dodol which arrived here with a consistency of concrete. Half an hour in an oven restored its softness and the flavour. We undertook daring projects to help friends back home. Cars were a luxury then in Sri Lanka and Titus decided to send an old car home to a friend. Colin De Silva who has never driven for 10 years took a vehicle without wipers to Tilbury docks on a rainy day driving on bald tyres. There were times when it wasn’t clear if the car was on the road or in the drain. I was a passenger in that car and wouldn’t dream of doing it now.

Colin was a Police Inspector at Gampaha in the late 1950’s. He came to London and qualified as a Solicitor. Colin was a "Human Rights Lawyer" helping foreigners to obtain permanent residency in the UK. He was a man with heart of gold often taking tremendous risks to help others. He sadly died in 1992.

The Ceylon Students Centre near Lancaster Gate Station was a magnet for all young Sri Lankans in London. It was run in grand style by its Warden, Mr. J. C. A. Corea, a former Principal of Royal College. The Centre went into decline when he retired. I often found long lost friends, old teachers and relatives there. Some wheeling and dealing, always ready to give me a bargain. You can also buy a Rolex watch for `A35 which will only work until you reach home. Once when I asked a friend how to get to the Centre, he asked me to follow the curry smell from the Lancaster Gate Station. He couldn’t have given me better directions. Its closure was a great loss to the Sri Lankan community in London. This was yet another short sighted penny pinching decision of our government at home.

I saw a change in many of my Sri Lankan friends. All Lankan cultural events were well attended. Those who never saw the inside of a temple whilst back home suddenly became religious visiting the Chiswick Buddhist Temple, taking part in meditation and almsgivings. This was indeed to be admired. I have always remained an agnostic. I disliked the repression of religion and remained rather superficial making the most of life. I refused to see why it is a sin to live it to the full. Meanwhile life was pleasant both physically and intellectually.

Some immersed themselves in politics of the kind practiced in Sri Lanka. They preferred to hover around our High Commission in London pandering to the politician when they came to London. Our community here is always ready for a party and a booze despite the various strictures and limitations imposed by the work ethic in Britain.

In London, we have the two most famous cricket grounds in the world. Lords and the Oval attract thousands of cricket mad Sri Lankans in the summer. I am yet to meet a Lankan who has no love for the game. In the late afternoon when the alcohol level has risen they even break into song although the jungle drums are prohibited. Our World Cup win in 1996 has given an extra zip to our love for cricket. Aravinda De Silva’s batting at a NatWest Trophy match several years ago must be the best innings I have ever seen.

Festival of Cricket

Old boys of the Sri Lankan schools organise interschool cricket playing limited over matches. This is an annual event now called the Festival of Cricket. It has a carnival atmosphere with food stalls and Lankan music. To have a big match — Royal-Thomian, Ananda-Nalanda or Josephian -Peterite in a foreign land is an achievement in itself. Some of the ageing cricketers show off their exceptional talents with the bat and ball. When fielding, although the spirit is willing the flesh seems weak. Nevertheless it is a fun day for all if the British weather plays fair.

All foreign doctors had great difficulty in reaching the top of the profession in the popular specialities like general surgery and medicine. Many moved laterally to take up posts in care of the elderly, psychiatry, pathology and radiology. I carefully weighed my chances and went into radiology. Luck was on my side as radiology came to the forefront of medicine with ultrasound, CT, MRI, nuclear medicine and computerisation. Now a job in radiology is like gold dust.

It is every doctor’s dream to work in a London Teaching Hospital for a good training and a valued entry in the CV. I needed a bigger pond in which to swim, more excitement, greater challenge and better prospects. It was Dr. John Laws, the Director of Radiology, who saw me first. He was charming and courteous and asked me to apply for the post. Perhaps it was the MRCP that helped me to get a job as registrar in Radiology at Kings College Hospital London. When I got the good news I went to see Tax Bygraves in concert at the London Palladium. London is the culture capital of Europe. The central square mile is a paradise for theatre goers. A wonderful place to relax and unwind.

Working with Dr. John Laws though trying was excellent experience. His technical skill was exceptional and his diagnostic accuracy was admired and respected by all. He later became the President of the Royal College of Radiologists. For me, learning the trade was hard work. There were 2 more exams to complete the first of which included radiation physics. I spent my time travelling by underground and buses attending courses. There was little time to relax, meet friends or keep in contact with folks at home. After each busy day at the hospital, I studied until one or two o’clock in the morning.

On looking back those were some of the most difficult times of my career in the UK. After the first examination I found a job as a Senior Registrar at University College Hospital in London. Life was less claustrophobic here and I was so pleased to complete my examination without undue delay. After almost five years training in radiology I was asked to apply for consultant posts. These interviews were an ordeal, but I was fortunate to find a job just 50 miles north of London and not too far away from my friends.

Hardwork rewarded

I started work in a District General Hospital 50 miles north of London. It was then a new hospital commissioned in the 1960s and completed in the early 1970s. The Radiology Department was being developed and my two older colleagues were to retire soon. The 675-bed hospital quickly grew and specialised to house many new departments including Cancer, Renal, Plastic, Urology and Cardiology services. I now have six colleagues in a most modern Imaging Unit fit for the 21st century. Like the perks, the responsibilities of the job were many. I had now reached the top of my profession in a foreign country that prides itself in an excellent health service. Eight years of hard work was finally fully rewarded.

Needless to say working as a boss is much easier than being a junior doctor. There were times when the weight of responsibility wore heavily on me. People management was a skill I had to learn on the job. When there was a problem in the department or complaints the buck stopped with me. Although the professional burden was heavy at times it was outweighed by the interesting clinic work and teaching commitment to medical students and doctors. It must be said I’ve had more rewards in my professional life than I deserve.

There are doctors who consistently perform below an acceptable level of competence and we must deal with them as a profession. We now live in a litigious climate. This at times is counter productive as fewer doctors will be prepared to take up the difficult cases. The bureaucracy of covering one’s back will indeed hamper clinical research. The day is not far away when this problem will reach Sri Lanka if it hasn’t touched it already.

I like the concept of the National Health Service (UK) that no individual should suffer ill health for the want of money. Private practice has been the bane of the health service since its inception in the UK. It is sad to see medicine becoming a business and lose its respected position as a noble profession. Despite its good intentions as the cost of hospital care, investigations and treatment reach staggering proportions, it is only a matter of time before charges are gradually introduced with a free service confined to the poor, elderly and terminally ill patients. It is an impossible task to fund an all singing, all dancing free health service in the 21st century. The rise of private medicine is the result and appears to be the only alternative.

Once a Sri Lankan is always a Sri Lankan. I miss my homeland dearly. While I was carving up a career a new generation has been born in Sri Lanka and many of my parents’ generation have gone to a world beyond. I am now a stranger to this new generation. Living in exile I have missed the births, marriages and the deaths of my close relatives. This I find hard to bear despite the material and career success abroad.

As a young man my career ambitions took precedence over all else. Alas it comes at a price. Having said this I have immense job satisfaction now, a steady income and a peaceful life. My life does not depend directly on politicians’ whims or that of their cronies. The British have given me their top job within eight years of my arrival here for which I am so grateful. When I recall the in-fighting and bickering at the General Hospital Colombo during my years of service I am thankful for my peaceful environment at work in the UK and the wonderfully supportive colleagues and staff.

I have had tremendous good fortune to work in two of the most famous Teaching Hospitals in London and also in several of the centres of excellence in the City. It was indeed a fine experience to work with the great and the good in Radiology.

I will be retiring from active work in a few years. The sleepless nights and the stress of work has indeed taken its toll. Although I feel full of energy and vitality as work piles on sometimes a sense of age and weariness steals over me. On looking back on my career in medicine what I would remember most of all would be the courage of the patients who had just a few days to live. The images of some of them will stay with me forever. We live such a brief and uncertain span of life.


I do have one regret that often comes to the surface of my mind. A regret I didn’t sufficiently return the love of my parents. Perhaps I never tried hard enough to understand them. I wish I had the words and the courage to explain the multitudinous slights and hurts I have given them. I owe my parents much. Living in Britain hasn’t helped to draw us closer. Sadly sometimes when a life’s path is chosen there is no turning back.

It amazes me how soon time has flown since that fateful day in June 1974. The journey through life has often been laborious. Yet it has been worth the effort and has brought its own joy and satisfaction. — TEMPUS FUGIT

I dedicate these memoirs to my friends Titus Perera, Cyril Amerasinghe, Tissa Ranasinghe and the late Colin De Silva. When I arrived in London virtually penniless and homeless they provided shelter, funds and friendship expecting nothing in return. I cannot praise them highly enough.

Saturday, July 13, 2013

Leaving Home

This article by ND was first published in the Sunday Island of 24th February, 2008.

Leaving home
By Dr. Nihal D Amerasekera

It is strange to look back and relive those heady days of idealism, bewilderment and youthful optimism. I was a final year medical student with the world at my feet!!
My father’s nomadic life of transfers as a government servant ended in Wattala in the late 1960’s. Those were difficult times. There were the stringent import restrictions imposed on us all. The roads were packed with ageing vehicles fit for the scrap heap. "Tighten your belts" was the favourite slogan of the Minister of Finance. It was austerity for the masses and prosperity for the politicians. We soon became accustomed to the vagaries and the intrigue of Sri Lankan politics far removed from the Westminster style Government prior to independence. During this chaotic period the country experienced a massive brain drain. Jobs were scarce and many left for greener pastures abroad. That was the scene when I embarked on my career in medicine.
We lived for a time on Station Road before moving to a house next door to the Urban Council at Wattala. It was a small but comfortable house. I was a medical student and travelled by train from Hunupitiya to Maradana with a happy band of medics. The train was always crowded and we never managed a seat. In our youth this was not a matter for complaint. Occasionally I travelled by bus to Pettah and changed to another to Borella. The red double decker busses were comfortable. I remember Mr.Jayasundera who sat next to me most days. He worked in Colombo and lived opposite our house. Mr. J was excellent company and in the 45 minute journey we put the world to right. I have often kept a lookout for his old house by the roadside during my many visits to Sri Lanka. The new highway has removed the old landmarks and I have never managed to find it. Mr. J if you are reading this note I recall those days most fondly and I wish you would contact me using my email address.
Final year examination
The final year examination hit us like a typhoon. As the dust settled I was making plans to move to the Kurunegala General Hospital for my internship. By now I had lived comfortably at home for 25 years. It wasn’t any hardship to live by the rules set out by my parents. Thus far I have lead a sheltered existence protected from the storms of life. I distinctly recall the day I left home to take up my new job. I feel deeply regretful for the lack of feeling and sensitivity I had shown for the occasion. It never occurred to me to reflect on the 25 years of care, love and generosity. Casually I said " I am going". There was a brief moment of stillness and a silence. I remember their glistening eyes when I waved my hand and stepped out of the house. They kept looking at me until I disappeared into the street. It may be the same in Sri Lanka now I do not know. My two sons were born and brought up in the UK. When it was time for them to leave the nest we had a last supper with plenty of light-hearted banter. We recalled the amusing moments we had shared together. Lavish amounts of wine helped to hide our emotions. They even had the good grace to give us a hug and say thank you. As parents we still cherish that moment. Watching them leave the home you've shared for all these years and the protection you've afforded them is painful.
As they spread their wings the best you can do is to implore them to keep in touch.
The house now seem so empty without their detritus and the constant mess. No loud music and no dirty cups scattered about the house. In those days it was thought there was no need to say thank you. The appreciation was implied by our body language. I regret very much not giving my parents that satisfaction of a proper farewell, a graceful thank you and a bear hug.
I left home totally unprepared to face the real world. My insecurities ran amok. Up until now all I have known was studies and examinations. I was now in control of my own destiny but was ill-equipped to handle its complexities. An intellectual background is sometimes a disadvantage. What I signed now became a legal document and what I said was taken seriously. I was too gullible and trusting and paid dearly for my errors of judgement. Those stories are best forgotten and buried deep. Good fortune was on my side and destiny played its part to turn my life around. It seems so unfair that decisions which affect our entire lives like choosing a career and a partner or deciding to leave our country of birth have to be made when we are still so young. In our youth it is the hormones and emotion that help tip the balance. The effects of our selections are as random as the throw of a dice. Sadly, before we leave the nest, no one can ever prepare us adequately for the storms that lie ahead.
Extraordinarily alien
I left home for the second time when I flew to the UK. In London everything then became staggeringly new and extraordinarily alien. I became yet another economic migrant in a vast country. They were more amused by my manner of speech than my accent. The personal freedom was refreshing and rejuvenating. Those were my days of wine and roses. I was young and took things in my stride. Soon I learnt my trade and acquired expensive tastes. Time passed swiftly when we raised a family and saw them grow up to be men. Although I am happy in my country home in the UK, the place where I was born has enveloped my heart to ensure it will always remain my real home. Despite the distance a complex and intricate knot seem to bind me to my parents. Being an only child the bond seems ceaseless.
My parents era was the time when responsibilities were more important than our personal rights. They gave their all to their children and took it upon themselves to look after their siblings and also their parents. We now live in an era when much is said about our rights and less about our responsibilities. I regret deeply not being with my parents in their time of need. We make important decisions in our youth which we cannot undo. We have to live with the consequences.. I was deluged with advice at the time which was lost in my quest for progress and personal glory. On looking back, we have disagreed on many occasions but in the fullness of time my parents have always been proved right. This admission is a little consolation after all these years. Writing about these events is a cathartic experience.
My father stayed on for a further two years at Wattala and retired. He lived for another 25 years before he was called to his final rest. My mother battles on enjoying the company of her grand and great grandchildren. There are the inevitable moments of loneliness boredom and despair. Visions of the past must haunt her sometimes, lying awake at night. We all hope old age does not erode our dignity and independence. At 86 she seem happy and contented and remarkably resilient. There is no worthwhile substitute to good health at any age.
It was only when I had my own children that I realised the sacrifice and the commitment shown by my parents. I will remember their love and affection always. Often, I do feel their presence by my side despite the distance and the passage of time. . Leaving the nest was the end of an era and the beginning of another. Sadly its significance struck home many years after the event.
Leaving home is a normal phenomenon and a part of growing up. There is no need for regret or remorse. It is for the parents and the children to celebrate this coming of age and make it a day to remember.

Sunday, July 7, 2013

First Faltering Steps of a Future Doctor

This article appeared in the Sunday Island of 7th July, 2013.

First Faltering Steps of a Future Doctor

By Dr. Lakshman Abeyagunawardene

Every student in the Advanced Level classes (University Entrance of a bygone era) in the Biological Sciences stream of every secondary school has to go through the routine of dissecting a variety of dead creatures like toads, rats, cockroaches, earthworms and even small sharks. A few of them who do well in the competitive examination get selected to enter a medical school of which there are many in government universities today. Yet another lot, whose parents can afford the "luxury", find their way into private medical schools either in Sri Lanka or abroad.

Having gone through the process more than half a century ago when private medical schools were unheard of, I thought of sharing my own experiences with readers at a time of significance to medical education in Sri Lanka. The 100th anniversary of the Anatomy Block of Sri Lanka’s oldest Medical Faculty falls on November 3 this year. It is in the Anatomy Block that young medical students take their first faltering steps. I must hasten to add that what I write here applies mainly to the situation that existed during my time as a medical student. But apart from a few changes that I have mentioned below, a medical student’s career basically remains the same.
The First Two years
Just as the name of the institution has changed, the undergraduate medical curriculum too has undergone changes since I was a raw freshman in the Faculty of Medicine, University of Ceylon. That was in June, 1962 when all Faculties were under the single banner of the University of Ceylon. Anatomy, Physiology and Biochemistry were the core subjects that we had to offer for the 2nd MBBS examination which was due to be held 18 months later. We had already cleared the first hurdle (called the 1st MB) when we qualified to enter the Medical Faculty. Being an Executive Committee member of the Colombo Medical School Alumni Association (CoMSAA), I have been able to keep track of some of the changes that have taken place since 1962. I am told that the 2nd MBBS examination of yesteryear, no longer exists. Unlike many of the recent changes in other spheres, I must say that the changes effected to the undergraduate medical curriculum have been for the better. As true medical educationists, those responsible for the changes have done so with genuine intentions and great foresight.

Although changes in the undergraduate medical curriculum do not fall within the purview of this article, it is pertinent to touch on that aspect albeit very briefly. Even as early as 1962, the existing curriculum being direct copies of those that existed in British colonies, curriculum reforms were in the air and talked about. It was felt that the replicated curriculum did not represent an indigenous identity and failed to meet local needs in keeping with the rapid social changes that were taking place around us. Moreover, medical schools in other countries too were changing the curriculum to suit their own needs. The establishment of a Medical Education Unit in the Peradeniya Medical Faculty under the auspices of the WHO and its Programme to Reorient Medical Education (ROME) was a direct result. The Colombo Medical Faculty soon followed with the establishment of the Medical Education Development and Research Centre (MEDARC) thus paving the way for the development of a new curriculum towards the end of the last century. My own professional biases as a Community Medicine and Health Education Specialist aside, I am particularly in favour of the introduction of a Behavioural Sciences Stream which covers personal development, ethics and communication skills. Basic sciences referred to earlier are now included in this stream with early clinical exposure.
Francis Road and Vicinity
The Colombo Medical Faculty occupies a fair portion of the quadrangle of land bounded by Maradana Road, Norris Canal Road, Kynsey Road and Regent Street (some of them have since been renamed). A little known narrow road called Francis Road which runs parallel to Maradana Road and Kynsey Road, bisects the quadrangle. While the Anatomy Block lies on one side, a majority of the Medical Faculty buildings are on the other side with the main entrance facing Kynsey Road near the Koch Memorial Clock Tower. The Office of the Judicial Medical Officer and the Medico Legal Morgue are next to the Anatomy Block as one proceeds towards Regent Street on Francis Road.
The Anatomy Block
The Anatomy Block is one of the oldest buildings of the Colombo Medical Faculty. Built in 1913, it had obviously been designed to ensure privacy – an essential element considering what goes on within! As freshmen, we spent most of our time during the first two years within the grey walls of the Anatomy Block. We crossed Francis Road only to get to the nearby Physiology Block. We were allowed to visit the Common Room and canteen only after being "accepted" by the honourable seniors following the traditional rag in the first two weeks. Dressed in a very special "kit" as stipulated by the Block Seniors, I remember vividly the day I walked into the Anatomy Block for the first time in June 1962. White coat with a shoe flower in the button hole, a brinjal round the neck, a canvas shoe on one foot to go with a black leather shoe on the other were part of our dress code during rag time that year. This unusual attire added to our discomfiture in unusual surroundings.

I was assigned to a cadaver (a dead human body or corpse intended for dissection) lying on a porcelain slab on my right as we entered the main dissecting room from the "T" shaped corridor leading from the main entrance. It was the still body of a dark skinned male whom I later learnt had been a homeless beggar. Although there was no one to claim his body when he died, there were eight young medical students to keep him company during the ensuing three months!

With Cunningham’s Dissecting Manual in hand, we sat down on stools placed around our "body" and awaited instructions from one of our teachers. We followed instructions and set about the task of identifying muscles, nerves, blood vessels and other structures through careful dissection. For dissection purposes, different parts of the cadaver were assigned to the eight students – head and neck, two upper limbs, thorax and abdomen and the two lower limbs. As the dissection process progressed, it was more convenient for the assigned students to detach the limbs from the main body and work on them separately at a quiet spot in the dissecting room. There was thus hardly anything left of the cadaver at the end of this period except for the skeletal remains. The budding doctors who were studying human anatomy had seen to that!

Life in the Block was not a walk in the park. We had to face bi-weekly oral tests referred to as "Signatures" in students’ jargon. They were conducted in small groups and based on the section of the body that had been dissected the previous fortnight. Successful students were signed up with comments such as "good", "fair" or "satisfactory", while the others had to repeat. Being new to the system, these "Sigs" were somewhat stressful. But they ensured that the students kept up with the study of human anatomy.
Familiar Smell of Formalin
An interesting book titled "The Colombo Medical Faculty: Evolution, Turbulence and Achievements" authored by Professor A.H. Sheriffdeen and Dr. Shalika Nagasinghe, was published in 2012 to coincide with the first Reunion of CoMSAA. In a section on the Department of Anatomy, it refers to the recent changes in the Anatomy Block which has been refurbished and modernised. The concluding remark is that "It has been air conditioned with hardly any smell of formalin in the premises which older alumni would recall with fond memories". As one of these "older alumni", on a recent visit to the Anatomy Block, I recalled with nostalgia the familiar smell of formalin but which was conspicuous by its absence that day. I am not sure what techniques are presently used for preservation of dead bodies that are meant for dissection. But at least during our time as block students, embalmed cadavers were immersed for about three months in a large tank filled with a formaldehyde based fluid that further preserved them.
Our Teachers
In concluding this article, I wish to pay tribute to our teachers who helped us to take our first faltering steps. As mentioned before, we spent a great deal of time in the Anatomy Block during the first two years and it was here that the first steps were taken.

The Professor of Anatomy during my time was M.J. Waas who had followed a succession of illustrious academics namely Professors A. Gordon Smith, W.C. Osman Hill and P.K. Chanmugam. Since my own graduation in 1967, Professors F.L.W. (Lester) Jayawardene, P.S.S. Panditharatne and Rohan Jayasekara had ascended to the Chair. The last named Professor Rohan Jayasekara is the incumbent Dean of the Colombo Medical Faculty, who incidentally is the first Professor of Anatomy to be elected Dean of the Faculty of Medicine, Colombo. Professor Jayasekara who has been a close personal friend of mine since the time we both stayed at the popular Petra Guest House in Jakarta, Indonesia in 1982, has been instrumental in giving a much needed face lift not only to the Anatomy Block, but also to the other Faculty buildings.

In the early sixties, Professor Waas was assisted by seniors such as Professor Chanmugam who continued to teach as Professor Emeritus even after retirement. Dr. Lester Jayawardene who was a Senior Lecturer spent a brief period in Colombo before accepting the Chair in Peradeniya. He had later returned to Colombo in the same capacity. Dr. Panditharatne who succeeded Prof. Jayawardene was a Senior Lecturer. Raja Bandaranayake (Professor and well known medical educationist in Australia) and Shanthi Goonewardene (later to be Associate Professor in Anatomy), I believe had just joined the academic staff. The junior staff designated as demonstrators provided further teaching assistance. Their main function was to supervise the dissections and to conduct the bi-weekly oral examinations. Most of them were themselves preparing for the Primary FRCS examination while others were well on the way to specialise in other fields. The demonstrators included P.A. Wirasinghe (now a Consultant Ophthalmologist), the late L.A.G. Jayasekara who was a Consultant Anaesthesiologist in UK, S. Dharmasekara (Medical Administrator) and Phyllis Costa Fernando (Consultant Surgeon).

Unlike today, with only two medical schools in operation at the time (the second Medical Faculty in Peradeniya had just got off the ground), we were fortunate to have the best medical talent available in the country to teach us. This applied not only to the non clinical subjects, but more so to the teaching in clinical fields which followed later in a student’s career. Medical specialists in the government sector attached to teaching hospitals engaged in private practice even at that time. But teaching medical students was one of their priorities.

Saturday, July 6, 2013

Lessons I Still Remember - 4

Sent in by Lakshman Abeyagunawardene

William Harvey and his discovery of blood circulation in the human body.

By the end of Term Two during our 2nd MB days, we had got quite used to the "Sigs" that we had to face ever so regularly in the Anatomy Block. It was about this time that the same system of continuous evaluation was introduced in Physiology as well. Whether we liked it or not, we had to prepare for these Physiology "Sigs" in addition to the regular "Sigs"in Anatomy.

Being the first few names in the batch in alphabetical order, Lakshman Abeyagunawardene (that's me), Sunil Abeysuriya, Surangani Abeysuriya, Rohini Abhayaratne and Lalantha Amarasinghe were in the same "Signature" group. One of the first "Sigs" in Physiology was taken by Dr. Carlo Fonseka who was then a Lecturer in Physiology. His first question to the group was "Who discovered blood circulation in the human body"? He added that whoever gave the correct answer will get a "Very Good" straightaway. Lalantha Amarasinghe lost no time in raising his hand and saying "William Harvey". True to his word, a highly impressed Dr. Fonseka took Lalantha's signature card and marked "Very Good". All of us went through the rest of the oral test, but as advised by Dr. Fonseka, I made it a point to read (or re-read) that relevant section in our Physiology text book. I have not forgotten William Harvey and his momentous discovery to this day. It's a lesson I still remember.

It was not by reading Samson Wright's "Text Book of Applied Physiology" that I learnt the above fact. It was through the "Phys Sig" that Dr. Fonseka conducted.

                                                         William Harvey (1578 – 1657)


Friday, July 5, 2013

Lessons I Still Remember - 3

Note from Speedy

I am really pleased to see early and hopeful evidence of others taking up my request to share what they learnt from our great teachers. Zita’scontribution is most welcome. Let us hope that more will follow. As promised, here are a few more recollections. 

From the best clinical teacher I ever had, Dr Wickrema Wijenaike. I was privileged to be his SHO and he laid down a few ground rules when I started which after 40 years are still relevant to sound medical practice.

(a)    If you request an investigation, you must justify them by telling me why you asked for them and how the results would help in the diagnosis and management of the patient.

(b)   You can prescribe a drug only if you can give me why it is indicated and show me that you are aware of  the side effects of the drug and how to manage them. To memorise the dose is not important, you can always refer the Formulary.

2. From Dr. George Ratnavale, Consultant Neurophysician (preferred term for Neurologist those days in Sri Lanka), probably one of the best dressed and polished clinicians in our time, tall and elegant with a graceful walk. In one of his Ward Classes, he asked us to take a history from a young patient with a severe headache which was relieved by the application of a wet cloth soaked in Eau-de-cologne on his forehead. The young man had a Pituitary Tumour and was dismissed by earlier clinicians on the basis that a headache which responds to such a “placebo” could not have a serious underlying cause. The lesson was not to be distracted by what seems a dismissive feature in a patient but to be thorough in your evaluation and take account of the whole clinical picture.



A Day in the Hospital Clinic

By Mahendra Gonsalkorale

Some sit on chairs very still
Others shift hither and dither at will
Thin ones, fat ones, tall ones, and short ones
Brave ones and the frightened ones

The New ones look lost and uncomfortable
The seasoned, resigned with magazine from table
Many occupy time with a Doodle
The Technos check Facebook with a Google

The Curious look around to see
Pretending not to be nosey
Somebody slumped with his eyes shut
Wakes up suddenly with a jerky start

Some sit erect giving that important look
while reading newspapers or a even a book
Some half asleep, but others more dense
The sound of loud snoring breaks the silence

As people enter they sit carefully and wait
leaving empty the chair between them and the next.
Some keep coat and bag on next chair, that's unfair
pretending not to see person looking for a chair.

A few in discomfort looking very glum
Scratching their heads and chewing gum
A restless child starts to annoy his mother
Her stern stare makes the poor child wither

Someone farts and pretends it's not him
Another starts looking for a waste bin
Some are laughing and some are groaning
Many talk loud and others are whispering

Nurses keep coming and nurses keep going
TV on the wall with nobody watching
Doors banging, telephones ringing
Receptionist looking busy phoning and talking

One picks nose, another stifles yawn gracefully
And the restless child gets even more lively
Mother shouts and waggles finger making him flinch
Child howls, they all stare and the mother turns pink

Quiet periods mixed with busy ones abound
Patter of shoes as clinic staff keep moving around
Doctors in a huddle, nurses in a muddle
Doctors and nurses, muddle and huddle

Suddenly the pale one vomits there
and another falls from his chair
Nurses rush and make oh such a fuss!
This dull place gets lively all at once

Name called repeatedly, an old lady wakes up.
Name called again and and the wrong one gets up
Another name called, and the previous name called
wants to know why she wasn't called

Name called repeatedly but nothing response-wise
Could it be the nurse's soft and rather delicate voice?
She calls a name, with struggle pronouncing
A man with a long name stands up grinning

Someone asks where the toilet is, can't wait
Another complains it is now 80 minutes late
Many getting angry by the minute, late to see doctor
Some get irate and demands to see a manager

Some look bored, resigned and listless, such a crime
Others check their watches for the umpteenth time
There are the staring ones with that unseeing expression
Resembling statues with a massive dose of depression

Someone walks in late, not well spoken
pauses at door, bemused with mouth half open
looks around hopefully, something wrong here
wrong clinic, wrong day or wrong time, oh dear

It's all in a days' work for the clinic staff,
conditioned and insensitive, always ready for a laugh
Patients will continue to trudge in and trudge out
It matters not a hoot if they are satisfied or nowt

Wednesday, July 3, 2013

Lessons I Still Remember - 2

(from my good old Batch ‘62 days)

 Sent in by Zita Perera Subasinghe

I am glad Mahendra (Speedy) started this feature. I think it is a great way to give tribute to our old teachers and share memories with our batch mates. I hope others continue this chain so our batch blog remains an active forum for discussion. 

Here are two of my examples of  “Lessons I still remember” 

1.      A precious line from Prof Carlo Fonseka’s lecture on Pain:

To try to define Pain is to render something that is simple in terms of something more complicated. (Those might not be the exact words).

I learned that definitions should not make the subject more complicated. 

2.     From Professor Rajasuriya: we all have anecdotes, one liners and lessons we shall never forget.

I remember him asking us to feel the pulse of a patient after we had had an extensive ward class on pulse and arrhythmias. 

Each one had to feel the pulse and give a diagnosis. Out came various weird and wonderful terms like bundle branch block, loud second sound, thrill and murmurs of all kinds. Finally, one girl felt the pulse for a few seconds and just said ‘Slow pulse’. Prof was delighted. And he asked ‘what would you say the rate is roughly?’ and she replied 60 which again was very close. 

We all learned: Look at basic physical signs and think of simple diagnoses first.  

By the way, the girl who got it right was Manel Rathnavibushana.

(Hi Manel!)