A SURGEON- ANATOMIST LOOKS BACK
A Long and Fruitful Association
THE PERADENIYA MEDICAL SCHOOL [PMS]
[This unpublished article was submitted, on request, to the editors of the 50th Anniversary Commemoration Volume, “THE PERADENIYA MEDICAL SCHOOL” . I am posting it on this blog, since it could interest past and present teachers and students alike of that school]
My ‘battle’ to establish myself in Kandy GH, to which I was appointed Orthopaedic Surgeon on the auspicious day of April 1st 1961, was greatly helped by the establishment of the Peradeniya Medical School (PMS) in 1962 with the opening of the Anatomy and Physiology departments endowed with the pioneering responsibility of guiding the first batch of students in the new medical school . Sometime that year, on a sunny Sunday morning, I had a most welcome visitor- Wazir Palli, the first Head of the department of anatomy in Peradeniya. During the period (1953 to ’56) when I cut my teaching milk teeth as demonstrator in anatomy in the only medical school in what was then Ceylon, Wazir Palli was one of the senior lecturers along with Joe Vaaz, Lester Jayawardena and R.Kanagasunderam.
I knew Palli well, because we used to have frequent discussions on the teaching of anatomy and WP naturally thought of me when it came to the Applied Anatomy lectures for the 2nd MB students. I gladly agreed to his request to give these lectures and thus started my long association with the Peradeniya Medical School –starting as Visiting Lecturer in Applied Anatomy, a ‘post’ which I held till I retired from the Dept of Health in 1983.
Palli was followed by Vaaz and Lester Jayawardena and in later years by Jayatilleka and Eugene Wickramanayake. In the latter’s time, at my request, I confined myself to the limbs, while other areas were handled by other surgeons in GHK. I enjoyed giving these lectures, in particular, on the limbs. Because, whenever possible, I made them lecture demonstrations, by presenting a patient to the students. I had the feeling that the students too enjoyed those sessions.
Kandy hospital, which till then had been just another Provincial hospital, suddenly became a centre of intense activity, since, in a very short time, it had to serve as Teaching Hospital to the Faculty, and this necessitated new buildings, new thinking and an administration mobilized to reacting fast. Chief of all ‘operations’ concerned with the Teaching Hospital was that redoubtable Iron Vice-Chancellor, Sir Nicholas Atygalle. He shook the ancient GHK buildings from foundation to roof.
Things changed fast. A new wing was built to house new theatres and additional wards and clinics. Arrangements were made to accommodate University Units in Paediatrics, O & G, General Surgery and General Medicine. The existing clinical units, including those of the specialities’, would all become teaching units, so that all clinical teaching in general surgery, medicine, paediatrics and 0 & G would be shared by University Staff and what was then referred to as DHS staff while the other specialities would be handled solely by GHK staff.
While this inevitably created certain tensions, the arrangement held quite successfully for the many years preceding the establishment of the Peradeniya Teaching Hospital and in fact continued even after that establishment, and prevails to this very day. The bulk of the clinical teaching was and still is done by Ministry of Health Consultants.
In addition to having the opportunity of teaching Clinical students in the clinics and the wards, (I always enjoyed discussion around a patient as opposed to didactic teaching), apart from merely delivering lectures (which delivery at 1 pm in the afternoon put me to sleep more than they did my students!) the Dept of Orthopaedics benefited directly by the extensions to Kandy Hospital and the reshuffling of clinics and wards.
When I started in 1961, the administration told me that they could not find me a clinic room, wards and OT time. There was only one OT which catered to two Genera Surgery units, one eye, ENT and O & G unit. With the extension to the hospital came, among other areas, new theatres. One theatre was set apart for eye and another for O&G and curiously, but to my advantage, one was (on the insistence of Prof CC de Silva) set apart for Paediatric Surgery. There was no paediatric surgeon in Kandy, because at that time, even Colombo did not have a special paediatric surgical appointment.
At a conference where Prof CC won his case for a special paediatric surgery OT, I pointed out that since there was no paediatric surgeon, and the chances of there being one in the near future in Kandy Hospital were very slim, and since a high proportion of my patients were children with deformities following untreated or badly treated polio and rickets, this theatre should by handed over to Orthopaedics. The charming Prof CC after putting up a fight with all his customary flowing gestures and liquid eloquence said, “All right Amerasinghe, you can have it”
That was how I ‘captured’ OTD! I use the word capture, because this theatre (once it had been set up, with my taking a personal interest in the matter) had to be ‘protected’ from invasion by the envious general surgeons. As was to be expected, particularly when construction work has to be rushed through without sufficient planning, there were many hiccups along the way. I shall deal with one, since it showed the ‘methodology’ adopted by the Big Chief in these matters...
The new OT’s had been built for air conditioning. So they were sealed units. When the Units were completed, it was found that there had been an error and there would be a considerable delay in installing the air cons. Sir Nick was furious. He wanted surgeons, who said they could not work in a sealed unit without air con, to start immediately. At a conference (where I was not present) Sir N had ‘barked’ at the O & G consultants saying ‘Open the damned windows and operate’. I never came across an obstetrician who did not fear that bark, which could easily be followed by quite a sharp, if not fatal, bite! So OTC started work with open windows and wind-swept leaves floating in from time to time.
I dug my feet in, saying I could not be picking out leaves from open hips, much to the VC’s annoyance and ire. But then, I was not an obstetrician! So I waited till OTD was ready, air con and all.
The early years of the medical school were exciting, productive and challenging. Fortunately, the Faculty was led by that energetic, charismatic and dynamic visionary – Seneka Bibile, Prof and Head of the department of Pharmacology in Colombo who was the only head, to move from Colombo to Peradeniya. He infected a young and determined staff in all departments, Uni and DHS alike, with his own brand of high quality, productive enthusiasm.
The staff of the fledgling school, were under the constant, disdainful, ‘looking-down-the-nose’ surveillance of Big Brother in Colombo, who thought we could never really match their own established, gold standard. One medical consultant, quite oblivious to the fact that I was by then actually teaching both pre and clinical students, said to me once. ‘How can you fellows n Peradeniya teach students?’ If not for the fact that I had a high regard for this, otherwise charming and highly competent clinician, who had many years previously been my demonstrator in pathology, I would have reached for my holster!
So, here was a real challenge. The gauntlet had been thrown down and we were determined to prove ourselves. Bibile led his troops from the front and before the first batch of students took their finals, the Peradeniya Medical School escaped from the heavy yoke of Big Brother in Colombo. We had gained our independence. A serious problem had now arisen. The question of uniformity of examination standards, in the two schools. This problem was got over by introducing what was referred to as a ‘Common MCQ’ paper at the Final MBBS. For five years (I think) the analysis of the results of this paper showed conclusively that batches of students in the two schools were comparable, and the common paper was scrapped. This was an acknowledgement of the fact that we had made the grade- a major victory indeed.
Bibile, from the outset, had his own vision of what the new medical school should be. He aimed for academic excellence with an emphasis on improved teaching methods and the inculcation of desirable attitudes of concern for the human being called the patient, with an emphasis on research, in not merely the pre and para-clinical disciplines, but very importantly ,in the clinical fields as well. He encouraged the keeping of good clinical records and the constant evaluation of treatment methods.
Bibile was responsible for establishing the Working Group of Medical Education (WGME) which, after we gained independence, was replaced by the statutory curriculum committee. I will not go into details of the working of the these two committees the first of which I was very closely associated with,(leaving that story to the medical educationalists – the new ‘elite’ of the Faculty) although I was a DHS and non-university man. There is one important acknowledgement I must make here. In the years during which I chaired the meetings of the WGME, the real heart of the group was the Evaluation Committee, headed successively by Valentine Basnayake, (and I believe) Hettiarachi, Jayasena and Bandaranaike. This committee made, in my opinion, the most solid and worthwhile contribution to the cause of medical education in this medical school.
Bibile took pains to rope the DHS staff into discussions on medical education and made them feel that they were all in fact ‘University men and women’. One vital aspect of Bibile’s mission I must emphasize. Although he had visited several medical schools abroad and seen the approach to teaching adopted by them, unlike many a subsequent ‘medical educationalist’ he was not mesmerized and seduced by what were described as ‘modern’ approaches, nor was he prepared to blindly follow any and every ‘imported’ teaching methodology from places where the socio-economic and pre-university educational reality differed vastly from our own. He emphasized that we must work out our own teaching methods, based on a clear idea of the relevance of our curriculum to the subsequent duties of the newly qualified doctor, whether it be in the pre, para or clinical fields.
One of the earliest medical education consultants Bibile invited to the ‘Faculty was charged with the task of drawing up a plan to study what the newly qualified doctor was actually doing after graduation, and match that reality with the relevance of the current curriculum. From this study would emerge a strategy for improving the teaching content, and the optimum methodology required to get that relevant content across effectively. Unfortunately, that particular consultant was hi-jacked by the Ministry of Health and Bibile’s highly rational approach to curricular change based on recognition of our own ground realities got buried, particularly, since he served as dean only for one term. I believe that in the absence of Bibile’s guiding, down-to-earth hand, medical education in the PMS lost its way! This is my strong personal conviction based on quite a long experience of guiding medical students long before the words ‘medical education’ started having an intoxicating effect on some teachers.
This criticism is not made with the purpose of hurling bricks at any individuals but springs from ideas nurtured organically without a heavy dose of imported fertilizer. During Bibile’s time a former Vice President of the Royal College of Physicians was on a WHO mission here to introduce us to the use of MCQ’s. Before his arrival, Valentine Basnayake held a workshop for a group of interested teachers (including this DHS man) and explained quite clearly to us and ‘drilled’ us in what then were the ‘mysteries’ of the MCQ. Dr John Stokes, a charming and brilliant clinician who had played a major role in the improvement of the evaluation methods used in the MRCP was pleasantly surprised that his ‘pupils’ were no neophytes.
I must make myself very clear. I am not saying that the PMS was one man’s offspring. Oh no! Bibile (who inevitably had his severe critics as well as his admirers) was the enthusiastic leader of a dedicated band of pioneers, both Campus and Non-campus or using the terminology of that period of development – Uni and DHS. Bibile would have been the first person to acknowledge the debt owed by this school to those pioneers. The close co-operation (fostered by Bible) between the two groups was evidenced by the fact that a DHS man (the Orthopedic Surgeon, GHK) was, for many years, chairperson of the important and highly active WGME, on 2 occasions chaired the NMU committee and was a member of the Faculty Board (as DHS representative) over a period spanning the deanship of Bible through that of those who followed, up to Malcolm Fernando. I took Faculty meetings very seriously and in spite of a heavy workload in GHK (being the only orthopaedic surgeon) hardly missed a meeting.
Faculty meetings particularly in the early days were most interesting. Many thorny questions arose. The medium of instruction, the explosive fear that with an overall decision that University education should be in both Sinhala and Tamil the Sinhala consultants in the General Hospital Kandy would be transferred out, the pressure exerted on the Faculty, from time to time, to take in a ‘favoured’ applicant who had completed part of the MBBS course in a foreign university, (the Faculty wisely decided that a pass in an examination held by a foreign university –however prestigious- would be recognized by Peradeniya only if that recognition were mutual; It was an expression of our confidence in the validity of our own testing methods), the guide lines for appointments to the Faculty, just to mention a few. The feature of the latter was that the then University Grants Commission had decided on those guidelines and then asked the Faculty for its views – a clear example of the dictatorial attitude of the Chairman UGC at that time.
The media of instruction problem was seemingly ‘solved’ by introduction of classes in English and Swabasha in the pre-clinical years and then, by sleight of hand, the policy being accepted on paper but not in fact! As at the present moment, the medium of instruction was English. This genuine problem of the medium of instruction has in my opinion, been the most vital problem that faced both staff and students in this Faculty.
The best efforts of the ELTU were negated by the fact that neither the Faculty nor the UGC has to this day really faced the problem squarely and being prepared to spend the required resources of time and money in launching an effective strategy. Particularly at a time when students came into campus not earlier than at least 6 months after selection to the Faculty, the only possibility of running an effective course in English learning was a form of “English language immersion course”. The students had to be ‘incarcerated’ in a ‘teaching village’, where they were compelled to obtain their needs of daily living by going to the ‘Kade’ manned by those who were fluent in English, making their demands only in English. Communication in any other language would be banned during this ‘commando’ course. There is no question that this calls for careful organization and the provision of buildings and other resources at a certain cost – but the method would produce the desired result. Successive governments have tried various experiments without determining the answer to a fundamental question. ‘How does a student In Sri Lanka, from a non-English speaking/reading background, to whom English is not a second language, but truly a foreign language, learn this language?’ The only exposure to English that the weak student received was during the English classes given by the ELTU. English was not needed for their day –to – day survival and no amount of preaching about the importance of English would motivate them to learn the language, unless their very survival (during a commando type course) depended on a knowledge of the language.
Marking essay type questions was often most depressing and I was driven to a form of schizophrenia, where I was unable to decide whether the poor answer was due to lack of knowledge of the subject being tested or a genuine difficulty of expressing oneself ,in what to many a student from a non-English utilizing environment, was a foreign language.
As the years glided on, I got the impression that the Faculty had slipped into an ‘idling engine’ mode and much of the initial enthusiasm and drive of the early years had been dissipated in attempting to import educational models from abroad and blindly follow the dictates of a fellowship bestowing WHO– a philosophy which seemed to dominate curricular matters where so-called ‘experts’ attempted to call the shots ,in some disciplines, even though they knew next to nothing about the discipline and in particular of the problem of helping students in our social milieu to master that discipline ; and most importantly, the importance of that discipline to the future medical practitioner.
I shall now jet propel myself over the years to the second phase of my association with this medical school, a phase which commenced two years after I had ceased to be a visiting lecturer in the Faculty. In 1985 I joined the Faculty ( a fully fledged University man) as Senior lecturer in the anatomy department, headed by Prof Eugene Wickramanake, whose views on the teaching of regional anatomy were akin to mine. I had happily gone through a full cycle –starting off as a demonstrator and then passing through a long period of clinical orthopaedics during which time I was a visiting lecturer in two disciplines, and was now rounding off my exciting teaching career as Senior Lecturer in the Depart of Anatomy – a post which I held from 1985 to 1999.
When I joined the department I thought I would retire into the obscurity of the anatomy block and help students to learn with understanding, and without tears, this very important discipline which, with physiology and pathology in its broadest sense, formed the very foundation of medical practice. It is interesting, actually unfortunate, that many a medical education ‘expert’, in an attempt to ‘decapitate’ anatomy, that favourite whipping boy of the medical educationalists in general, overlooked the simple fact that structure and function are just the two sides of the same coin, just as much as in the physical world one could not dissociate matter from energy. So, if physiology was important, so was anatomy.
Prof Wickramanayake requested me to take over the task of re-organizing the teaching of regional anatomy and gave me a free hand – a freedom to institute changes that I had long pondered over. As a result of this, an Introductory Course in regional anatomy was introduced; content was cut down with an attempt to concentrating on anatomy that would be of relevance to the student in his clinical years, living anatomy was emphasized and overall, an insistence on the importance of ‘body anatomy’ as opposed to ‘book anatomy. Body-side tutorials (like the ‘signatures’ of old) were brought in, in spite of the difficulties because of the large numbers of students.
I took up once again, my practice as a demonstrator in the fifties, of revising my anatomy by dissecting and re-dissecting the human body, as the soundest means of learning anatomy with understanding. These dissections were responsible for my being able to publish a 4 volume set of Practical Anatomy Manuals, which were used by several batches of our students from 1995 to 1999. Apart from having as my aim the main teaching points emphasized above, two further objectives aimed at in the manuals were the use of English which was as simple as I could possibly make it and the provision of a low cost manual, since the majority of our students were by no means affluent.
The pleasure of writing those manuals, based on a deeper insight into the, discipline cannot be measured. Neither t author nor departmentt gained financially by this publication, since the manuals were printed by the Faculty Printing Unit and the volumes were given to our students at a price taking into consideration only the covering of the costs of production. Unfortunately, although the manuals were used by several batches of students, without heavy bricks being hurled at them, I mean the manuals, the use of the manual, was discontinued the moment I left the department in 1999 and Cunningham Manuals which were discontinued by Prof Jayatilleke on the grounds that the English was too difficult for the students, were re-introduced.
At this point I must stress that with over 50 yrs of acquaintance with the discipline of anatomy and many years of experience of helping both undergrads and post-grads to learn the subject with understanding, I am of the unshakeable opinion that the best approach for the student to the study of anatomy – a method tested over the centuries and second only to study in the OT or post-mortem room- is the exposure and handling of structures, by the student himself, in the dissecting room. The time needed for putting this method into practice can be reduced by intelligent planning by those who know the subject and understand how it should be presented to the student.
The use of ‘prosected’ specimens, models and computer assisted teaching are just aids. I shall refrain from going into further detail but would like to caution this medical school, as it hopefully aims for a well-deserved century, that it should learn, in the interests of student learning, to render unto Caesar the things that are Caesar’s. Those who know little or no anatomy and less about teaching it, should not be allowed to experiment with students by foisting on them poorly tested methods which are thrust upon them, under the obscure cloak of ‘modern teaching methods’ and ‘curricular revision’.
Being new to the politics on campus, when I started work as a permanent member of the Faculty, I did not realize for some time that Peradeniya Campus was a key centre of JVP activity. During the years ’87 and ’88 the JVP star was in the ascendant. Student activists used to walk in unannounced into the Vice-Chancellor’s office and make various demands. Fortunately the Senior Student Counsellors managed to talk to the activists and explain to them that problems could be solved more easily if they were first discussed with us. We used to meet them as far as possible once a fortnight with profit to both sides. This was the period when staff, academic and non-academic, was threatened on pain of death, not to come to work. Some teachers were on occasion compelled to march the streets of Peradeniya and an Assistant Registrar was murdered, I believe, inside the senate building. The most gruesome incident was the ‘garland’ of heads arranged by counter terrorist death squads in a grisly circle around the Lotus Pond.
My dream of confining myself to the Anatomy Department was not realized, since I got involved in various committees, and though on reaching the retirement age of 65 I resigned from all official posts, I continued as Senior Lecturer, on extension (at the request of the Head Anatomy) till 1999, when I finally took leave of a very profitable association with this medical School, an association spread over nearly 34 years.
For a variety of reasons mainly that of relatively poor health, I progressively lost touch, with faculty affairs. I gather that in recent times, there has been deterioration in the relations between the University teachers and the Ministry teachers. This fratricidal situation will benefit no-one and would in particular be detrimental to the interests of our students. I urge a more rational, constructive and conciliatory approach on both sides of the unwarranted divide in the handling of questions of common interest, and a return to the harmonious relationship that existed in the early days of the Medical School, particularly under the guidance of the 1st dean Prof SW Bibile
Finally I must acknowledge my debt to a large body of students whom I had the privilege of hopefully helping, even in a small way, in the understanding of two disciplines. While I enjoyed my clinical work as an orthopaedic surgeon, when this Surgeon Anatomist (now relaxing in the ‘recovery room’ after ‘hanging up his gloves’) looks back, he can honestly conclude that he derived the greatest pleasure and satisfaction in trying to guide students in their learning.
What I miss most in retirement from my professional career is the constant contact with young minds, a contact which compels a teacher to be on his toes without passing into the complacency and somnolence of seniority.
One of the greatest pleasures for me is to see a former Peradeniya student climb to the top of the academic ladder and also to meet a former student responsible for looking after me ,when hospitalized, who comes up to me and asks ‘Sir, can you remember me.’ Yes, of course, I remember the face, but sorry, not the name! Most reassuringly, sometimes the boss of the Unit has been a former student during my first teaching phase in the faculty!
To all present and future teachers Uni and non-Uni I say: “Remember that the Student Body is the very heart and soul of a medical school and you are the custodians of the education and nurture of that body, and when you revise the curriculum do so with the interest of the student in mind and not for the satisfaction of some pet whim or fancy of yours’
To my young surgical colleagues who have grown up in an increasingly technology dominated surgical environment and are now guides and models to our students, I commend the words of that eminent, brilliant scholar-physician, the late Lord Henry Cohen of Birkenhead, (1900 -1977) former Professor of Medicine at the university of Liverpool, words which should be enshrined in neon lights at the entrance to every theatre complex:
THE FEASIBILITY OF AN OPERATION IS NO INDICATION FOR IT!
While hoping that the Peradeniya Medical School will, with skilful stroke-play and balanced judgement proceed to accomplish a century of sound achievement and scholarship, and will continue to produce caring, competent, confident (though not ‘cocky’) medical men and women who would learn to place the interest of the patient as priority, Number 1, let me say to The School (by which I mean the campus and the two associated Teaching Hospitals) from the depths of my heart:
MAY YOUR JOURNEY FORWARD BE A TRIUMPHANT MARCH!