Vo l . 1 5 / N o. 3 / AU G U S T 2 0 0 8
Professionalism – The Antidote
For Over-Regulation
Speech given by Dr Lum Siew Kheong, President,
College of Surgeons, Academy of Medicine of Malaysia at
the joint Annual Scientific Meeting of the CSAMM with the
11th Congress of the Asian Association of Endocrine Surgeons
in Kota Kinabalu, Sabah on 19th March 2008.
I bid you a warm welcome to this Congress and I hope that you will advance your knowledge
on the science of endocrine surgery over the next three days. Since you will be given an
adequate diet of the science of surgery, I thought it appropriate in my speech to focus on the human side of Surgery –
referred to by a variety of labels ranging from the art of medicine, professionalism, communication skills, empathy,
collegiality and so forth. Unlike the science of surgery, there are no frontiers in the human aspects of surgery. It centres
around the mastery of the seven deadly sins of a human being – anger, envy, pride, lust, greed, laziness and gluttony. All the
great religions address it in one form or another.
Two weeks ago when I was in Australia, there was intense publicity in the papers and television on a certain Dr Graham
Reeves, an obstetrician and gynaecologist in Sydney, who was dubbed as Doctor Death. In 1996 he was disciplined by Med
Board of NSW for endangering the lives of nine patients of whom two died. The Medical Board suspended him from doing
Obstetrics but allowed him to continue Gynaecology. He was also advised psychiatric treatment. One of his patients blew the
whistle on him on this occasion and on further investigation he was alleged to have circumcised women, did botched
Caesarean sections and in one case he removed a patient's uterus during Caesarean section and did not tell the patient. The
patient discovered her uterus was missing when she underwent tests for infertility.
These were some of the comments from the public I heard over television.
1. The OT nurses and the doctors in the OT knew but they kept silent.
2. Other doctors who did the reconstructive work arising from Dr Reeves' practice kept silent.
3. The Health Care Commission is a disgrace
4. The Medical Board of NSW should be closed down. It is biased towards doctors.
5. There is no transparency in the hospital system. The conduct of the hospital in covering up deaths is indefensible.
In short, these comments mean that the buzz words of today – integrity, transparency and accountability have no meaning
in the medical world.
The people interviewed suggested the following:
1. They felt that patient safety was paramount.
2. They advised anyone who was “assaulted” to go to the police rather than the Medical Board or Health Commission.
3. They felt that there must be system changes to make doctors' work transparent and accountable.
4. There must be mandatory reporting for misconduct.
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Office Bearers 2008 / 2009
The Annual Scientific Meeting of the College of Surgeons, Academy of Medicine of Malaysia
and The 11th Congress of The Asian Association of Endocrine Surgeons (AAES)
International Conference on Surgicial Education and Training
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If we think that these militant positions happen only in the European Societies and do not happen in Asia, just consider this
article.
The STAR newspaper on 12th March 2008 quoted a report from Reuters that according to a survey done in China, thousands
of Chinese doctors are beaten up every year and the profession is commanding less respect as rising medical cost and
inequality of access fuels mounting discontent.
The distrust of the medical profession is not something new as we can infer from what the playwright, George Bernard Shaw
said, “All professions are a conspiracy against the laity.” However, there was no major public outcry against doctors all these
years.
After the Bristol cardiac surgery deaths enquiry and the Dr Harold Shipman scandal in the UK, public pressure forced the
Government to act. The General Medical Council in the UK today has laymen in it because of public distrust in the ability of
doctors to police themselves. The training and practice of Medicine in the UK has never been the same again. Dr Hickey, the
Medical Protection Society Chief Executive of the UK, commented recently that the pendulum of regulation had now swung
too far and doctors are now over-regulated. Travelling to 15 countries over the last 18 months, he found a profession that
was demoralised – with doctors facing multiple jeopardy for a single mistake. This led to incredible stress on the doctor and
his family. He commented that he had seen marriage breakdowns, nervous breakdown and suicides amongst those who were
not even guilty.
The writing is on the wall in our country. Hardly a month passes without some adverse publicity in the press about the
medical profession. There will be increasing public pressure on our politicians to regulate us with more and more laws if we
do not change from within. Changes from within will tend to emphasise on remediation and rehabilitation rather than
punitive sanction but that coming from legislation is likely to follow the reverse order. The jailing of a doctor about two
months ago for failing to register his clinic under the Private Healthcare Facilities and Services Act serves as a warning of the
dangers of legislation once it is passed. The main areas we need to address are in the area of Surgical Training, Continuing
Professional Development and encouraging professionalism. I will not comment on Surgical training and CPD here as they
are large issues on their own right but I will comment a bit about professionalism.
Medicine is a profession. Most of us exit medical school without knowing what being a professional entails. We think that
we deserve to be called a professional because ours is a noble profession and we have special knowledge after years of study.
If that is the case, what about the oldest profession in the world? They are also professionals but they did not do much
studying. What about professional soldiers and our policemen who acted very professionally after our recent elections?
We also have teachers, secretaries and even car mechanics whom we label as very professional. What then are the
ingredients of professionalism? Professionalism is defined in the Oxford Dictionary as “qualities associated with a profession
especially competence, skill etc”. This traditional concept of professionalism does not capture what professionalism really
means. In his book “True Professionalism”, David H Maister, a former Professor from Harvard Business School, emphasised
that professionalism implies four important attributes:
1.
2.
3.
4.
Pride and passion in your work
A commitment to quality by never compromising your standards and values
A dedication to the interest of the client
A sincere desire to help your client, your colleagues and your own career
These four points capture the essence of professionalism demanded by modern day society. Real professionalism has little
to do with the business you are in or how many degrees you have. The opposite of professional is not unprofessional but
rather a technician. A true professional is a technician who cares. There is a saying, “People do not care how much you know
until they know how much you care!”
Professionalism is not a label you give yourself but a description you hope others will apply to you. Do not wait until you are
paid before being helpful. You are a professional – prove it from the beginning by being helpful. If your patients are not
actively telling their friends about you, maybe your work and service isn't as great as you think it is. Money, professional
fulfillment, prestige, etc. does not come with a profession but are consequences of unqualified dedication to excellence in
serving clients and their needs. The noble path does win, but only if you are prepared to make the investment to act
professionally, over a long period of time.
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Professionalism is predominantly an attitude and not a set of competencies. Attitudes and character are inherent. They can
be suppressed or encouraged to develop. To get people to be professional, you must treat them as professionals and be
tolerant of nothing else. No one can develop right attitudes if he has not seen them in his mentors and employers. If there
are no good mentors and the doctors are not treated fairly by the hospitals, it takes a miracle to produce a caring doctor.
Doctors must be open to learning from non medical human resource personnel about the need to serve a client, how to work
with people whether they be your juniors, seniors or colleagues.
Ladies and gentlemen, I will share with you the way I remind myself to be professional under difficult circumstances all these
years. I commit to my memory these 2 phrases, “you are the salt and the light of the world. Let your light shine before all
men so that those who see your good works will glorify God”. When you are the “salt” you are to add flavour to the life of
another person. But, do not be too salty to others making you self righteous, intolerant and prejudiced. When your light
shines before all men, you give your patients excellent service, compassion, kindness and hope in the midst of their
darkness. Remember always that the good works that are seen are not meant to boost your ego but to help the patient see
the love, grace and mercy of God. This mental attitude suppresses your selfish nature, your pride and your ego and brings
out the best of altruism from you. “You are the salt and the light of the world. Let your light shine before all men so that
those who see your good works will glorify God.” These two phrases capture the entire essence of professionalism.
I have outlined some of the human elements in the practice of surgery and the dangers of over-regulation if we are not seen
to be taking steps to change for the better. I have also outlined what true professionalism entails. Practise and preach the
message wherever and whenever you can to your colleagues and juniors and I am sure it will help reduce the number of
complaints against the profession. If I may now end by encouraging our local delegates to practice good collegiality and
human relationships in the next three days by mixing beyond your group of friends in between lectures and whenever you
dine. Extend a hand of friendship and make our friends from all over the world welcomed. On that note, I thank you for your
attention. E
Office Bearers 2008 / 2009
PRESIDENT
SENIOR VICE PRESIDENT
Dr Lum Siew Kheong
Datuk Dr Noor Hisham Abdullah
VICE PRESIDENT
Prof Dato' Lian Chin Boon
H O N S E C R E TA R Y
Dr Prof Yip Cheng Har
HON TREASURER
Prof David Choon Siew Kit
CPD DIRECTOR
COUNCIL MEMBERS
Dr Chew Loon Guan
Dr Isa Omar
Assoc Prof Kwan Mun Keong
Prof Dato' Lokman Saim
Dr Rohan Malek
Dr Pall Singh
Dr Andrew Tan
Dr Peter Wong Toh Lee
bhbhbhbhbhbhbhbhbhbhbhbhbhbhbhbhbh
The President and Council of the College of Surgeons, Academy of Medicine of Malaysia
would like to record a vote of thanks to the following Council members (2007 / 2008) who had retired.
1.
2.
3.
Dr Andrew Gunn
Dr Lim Lay Hooi
Dr Ashim Kumar Nandy
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By Dr Lum Siew Kheong
The Annual Scientific Meeting of the College of
Surgeons, Academy of Medicine of Malaysia was held
together with the 11th Congress of the Asian Association
of Endocrine Surgeons in the Sutera Harbour Resort,
Kota Kinabalu, Sabah from 19th to 22nd March 2008. The
theme of the meeting was “New Frontiers in Endocrine
Surgery“. We were extremely happy that five Presidents
(or their representatives) of overseas Colleges of
Surgeons joined us for our meeting. They were Prof
Armando C Crisostomo (Philippines), Mr Richard E C
Collins (RCSEng), Prof Ian Gough (RACS), Dr Naronk
Rodwarna (RCSThailand) and Dr Chan Heng Thye
(Singapore). The 448 participants of the meeting
included 124 overseas delegates and 324 Malaysian
delegates.
dances added to the excitement of the evening. This was
followed by lucky draws for the evening.
The success of the meeting is reflected by the large
number of letters I received, from all parts of the world,
congratulating the CSAMM for the splendid meeting and
wonderful experiences the participants had at the Kota
Kinabalu meeting.
For those who missed the Kota Kinabalu meeting, the
CSAMM welcome you to join us at the next ASM in
Langkawi from 28th to 31st May 2009 which will prove to
be just as good!
The Organising Chairman was Datuk Dr Noor Hisham
Abdullah and Prof Dato' Khalid Abdul Kadir, Master of
the Academy of Medicine of Malaysia, was the guest of
honour at the opening ceremony. The 35th AM Ismail
Oration was delivered by Prof Freda Andrea Meah at the
Opening Ceremony on the topic “Endocrine Surgery in
Malaysia.”
There were two Pre-Congress Workshops, six Plenary
lectures, six symposia and concurrent free paper and
video sessions. The pre-congress workshop was on
“The art of writing a good paper” and “Training the
trainers: Assessment and examination techniques.”
The AAES Norman Thompson lecture was delivered by
none other than Norman Thompson himself on the topic
“Evolution of Endocrine surgery: Past, present and
future “Numerous speakers from Australia, Egypt,
Germany, Hong Kong, Hungary, India, Japan, Korea,
Malaysia, Singapore, Sri Lanka, Sweden, Taiwan,
Thailand, UK and the USA participated in the meeting as
speakers and it was no wonder that the quality of the
meeting was very high indeed. An afternoon was devoted
for leisurely pursuits and these included island hopping,
para-gliding, visits to the Monsopiad Cultural village,
Manukan island, Kota Kinabalu City tour and lessons on
batik and pottery making.
The highlight of the meeting was the Congress Banquet.
The new Council members of the College of Surgeons
were introduced in a simple ceremony. The audience were
then treated to a splendid performance of Sabah cultural
dances. The participation of the foreign guests in the
Overseas Presidents & Representatives: Dr Jamal Azmi Mohamad
(President, MOA), Prof Armando C Crisostomo (Philippines),
Mr Richard E C Collins (RCSEng), Prof Ian Gough (RACS),
Dr Lum Siew Kheong (Malaysia), Dr Naronk Rodwarna (RCSThailand),
Dr Chan Heng Thye (Singapore)
The Outgoing Council of the College of Surgeons 2007/2008
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Introduction of the new council 2008/2009 at the congress banquet
Australian guests having a fine time at the congress banquet
The lovely dancers at the congress banquet
Overseas speakers and guests from Japan, Hong Kong, Egypt and
Singapore at seafood restaurant
Cultural performance at congress banquet
The beautiful sunset at Kota Kinabalu, Sabah
E
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Royal Australasian College of Surgeons, Melbourne
4th to 5th March 2008
By Dr Lum Siew Kheong
PRINCIPLES OF SELECTION
1.
Dr Andrew Sutherland, President RACS; Dr Harjit Singh Head of Gen
Surgery, KKM; Dr Lum Siew Kheong, President, College of Surgeons, AMM
This International Conference was organised by the Royal
Australasian College of Surgeons and held in Melbourne
from 4th to 5th March 2008. It was very well attended and
delegates came from all over the world. Malaysia was
represented by Dr Lum Siew Kheong (President, CSAMM),
Dr Harjit Singh (Head of Gen Surgery, KKM), Dr Zainal Ariffin
Azizi (Head of Gen Surgery, HKL) and Prof Azad Hassan
(Head of Dept of Surgery, University of Malaya).
Selection of candidates for surgical training was the main
topic of discussion. Selection of candidates for surgical
training is a complex process. Those responsible for selection
carry the burden to ensure that only the able are admitted
and the inappropriate ones are not admitted.
The meeting began with a major review of the selection
methodologies used by surgical and other medical
educational bodies in the published literature. Thereafter, a
draft was distributed for discussion and consensus building.
The final consensus at the conclusion of the meeting
encompasses the points as stated below.
Eligibility criteria should include generic and specialty
specific components.
2.
Those responsible for selection should include those
responsible for delivery of education and training
(Universities, in our case), the employers (Ministry of
Health, in our case) and the profession (College of
Surgeons, in our case).
3.
Selection must aim to identify those doctors with the
values, attitude and aptitude required to become a
surgeon.
4.
Selection methodology must be predetermined,
transparent, involve multiple assessors using a broad
range of tools to maximise validity and reliability. The
tools must have clear criteria for marking and given a
weighting for each tool so as to permit ranking of
applicants.
5.
Potential for successful training is the basis for selection
and not the extent of prior knowledge, experience and
skills in that speciality.
6.
Early selection into a surgical training program must be
accompanied by clearly established assessment tools to
identify underperforming trainees to ensure they do not
progress unless the competency (or competencies)
deficiency is rectified.
7.
Knowledge is an essential base for clinical reasoning
and judgment. A national exam as in the USA and
Canada is helpful.
8.
Structured referees' reports can provide credible
information from surgeons, colleagues, other
healthcare professionals and employers based on first
hand experience of the applicant's performance in the
working and learning environment.
9.
Structured curriculum vitae provide important verifiable
biographical information on clinical experience,
academic and other accomplishments.
10. Structured interviews use questions which target
specific competencies identified through job analysis,
yield important information not possible with other
selection tools.
11. Correlation between selection methods and subsequent
professional performance should be undertaken to
establish their validity.
continued on page 7
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SELECTION METHODOLOGY
1.
Selection must take place through open competition
using an explicit merit based process which identifies
and rewards excellence and individual achievement.
6.
Weighting allocated to each selection tool as a
percentage of the overall mark must include a range for
flexibility.
7.
Marking Forms for each selecting tool must contain
headings which reflect the core competencies identified
through analysis of a surgeon's job and recognise that
tools vary in their ability to measure the different
competencies.
2.
Application forms must have a standardised structure
and include the opportunity to ask specialty specific
questions.
3.
Short listing for interview must be based on individual
scores from other selecting tools eg referees report, CVs
etc
8.
Marking of Structured Curriculum Vitae: This must be
marked independently by a number of persons and a
consensus mark allocated.
4.
Selection methods may include the following:
a. Structured Referee reports
b. Structured Curriculum vitae
c. Portfolio assessments
d. Structured Interviews
e. Written tests, including aptitude tests
f. Dexterity tests
g. Presentations
9.
Marking of Structured Interviews: Errors and biases are
reduced by including behavioural questions (about the
past), situational questions (responses to hypothetical
situations) and multiple trained interviewers.
Performance in the interview must be marked
independently, following which a consensus mark is
assigned.
5.
The marking system and the marks available for each
heading must be agreed and published in advance.
10. Ranking of candidates must be based on the combined
standardised marks from each selection tool. E
(with the participation of the Royal College of Physicians
and Surgeons of Glasgow)
D AT E
VENUE
THEME
28 th to 31 st May 2009 (Thursday – Sunday)
Awana Porto Malai, Langkawi
“Teamwork in Surgery”
H I G H L I G H T S
• 36 th AM Ismail Oration: Prof John Cameron
Alfred Blalock Distinguished Service Professor of Surgery, Johns Hopkins Medical Institutions (JHMI), USA
President, American College of Surgeons 2008 / 2009.
• RACS Travelling Fellow: Prof David Watson, Flinders Medical Centre, Adelaide
• Johns Hopkins Travelling Fellow: Prof John Cameron, JHMI, USA
• RCPG Davies Memorial Lecture
• Ethicon Prize
S E C R E TA R I AT
C SAM M AG M / AS M 200 9
19 Jalan Folly Barat, 50480 Kuala Lumpur, Malaysia
Tel: (603) 2093 0100, 2093 0200
Fax: (603) 2093 0900
E-mail: [email protected]
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L AT E S T
N E W S
F R O M
T H E
J O U R N A L S
21-gene assay predicts breast cancer relapse
better than “Adjuvant”
Patients were evaluated using the 21-gene assay (Oncotype DX, Genomic Health, Inc, Redwood City, CA)
compared with “Adjuvant” – a standardized validated instrument that projects patient outcomes based on classical
clinicopathologic features.
In the present study, the researchers assessed 465 patients with hormone receptor-positive breast cancer with zero
to three positive axillary nodes and followed them up for recurrence. After 5 years of followup, 99 women
experienced a recurrence of disease. The researchers found that risk scores generated by the 21-gene assay
significantly predicted recurrence for both the node-negative and node-positive patients better than “Adjuvant”
criteria.
Plotting risk scores as a linear, continuous variable, they found that a higher score predicted recurrence with a
hazard ratio of 2.64 compared with 1.34 for those with the “Adjuvant” criteria.
For patients with a risk score of less than 18, approximately 3.3% of patients experienced recurrence within 5 years
if there were zero to one positive nodes, and 7.9% experienced recurrence if there were two to three positive nodes.
Based on their finding, Joseph Sparano, (Albert Einstein Cancer Center, New York, USA) and colleagues say that
the tool could be used to "select low-risk patients for abbreviated chemotherapy regimens and high-risk patients
for more aggressive regimens or clinical trials evaluating novel treatments."
J Clin Oncol 2008; Advance online publication
Kuching Forum
6th March 2008
Diabetic Foot & Vascular Surgeon by Dr Chew Loon Guan (centre) and local surgeons
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