A SURGEON- ANATOMIST LOOKS BACK
0n
A Long and Fruitful
Association
With
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[This unpublished article was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!
Mark Amerasinghe
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