The unsung heroes of healthcare: Part I

Medical Tribune August 2009 SFXII

David Brill

Born in 2004 from the legacy of SARS, the annual Healthcare Humanity Awards are given to those who go above and beyond the call of duty to improve the care and wellbeing of patients. David Brill spoke to two of this year’s recipients about their achievements, challenges and hopes for the future.

The children’s champion: Ensuring a bright future for Singapore

Some doctors continue their medical education by reading journals and taking exams. Others brush up by attending conferences or participating in workshops.

Dr. Ong Say How is different. He keeps up to date by watching cartoons and listening to pop music. Unlikely sources of information for most specialists, but an important part of the routine for this dedicated child and adolescent psychiatrist. Following popular culture helps him better relate to his patients, he says. And few would question his approach: in 2005, Ong received the Best Psychiatrist Award from the prestigious Columbia University in New York, US, for his volunteer work in Caring@Columbia – a program for underprivileged and at-risk children. Other accolades have followed since returning to Singapore, culminating in his recent Healthcare Humanity Award.

Engaging troubled children would be a daunting task for most, but Ong is completely relaxed around youngsters. This, he says, is his strength – allowing him to break down the formality of a clinic setting using humor, anecdotes and roleplays. “I think like a kid sometimes, so we can talk on the same page and be on the same wavelength. Most of the time when kids come to me they have already seen their teachers, seen their school counselors, talked at length with their parents, and nothing has helped. So I have to take a different approach to get them to confide in me,” he says.

As a consultant and deputy head of child and adolescent psychiatry at the Institute of Mental Health, Ong has spent much of his career engaging with the youth of Singapore. He also runs an outpatient clinic at the Child Guidance Clinic and is involved with various workgroups and committees, including the national Pediatrics Services Review Committee. His caseload is wide and varied, but most commonly involves anxiety, depression, stress-related conditions and attention deficit hyperactivity disorder.

Progress has been made but child psychiatry remains a “high-need medical area” for Singapore, he says. Surveys point to a fairly high number of undiagnosed psychiatric disorders among schoolchildren, suggesting that screening is one of the areas in need of strengthening. Improving step-down facilities and access to treatment in the community are also amongst the most pressing challenges, he says.

“Some kids fall through the gaps because they are not very aware of the services available to them, or sometimes still face a stigma about seeking psychiatric help. And parents alike … a lot of families are still stricken with fear when it comes to seeking help for their mental health. Rather they will bring the kids to see a non-professional, or a temple medium or a traditional healer, and in the end they suffer.

“Recently I lost a kid because the parents were not keen to bring the child forward and refused to seek help in the community setting. Someone so young and intelligent and with so many good things going for him – it’s just sad that the parents or the child himself refused to seek proper help.”

Despite the tragic stories such as this, Ong remains upbeat about the future of Singapore’s youth. New outreach programs are underway in schools, bringing psychiatrists closer to counselors and teachers, and opening up new avenues for screening and prevention. Mental wellbeing, Ong hopes, will one day be entrenched in the national curriculum. In the meantime he will continue to champion for the children through his tireless work in the clinics and community.

“Seeing them open up and let you into their thoughts and feelings is the first step to building that rapport and to making the first change. It’s very rewarding when they start to trust me that I will help see them through and see them smile again. The children are our future, and in order to secure a future for Singapore we must make sure that they are well taken care of,” he says.

The Unsung Heroes of Healthcare: Part II

Medical Tribune August 2009 SFXII
David Brill

Born in 2004 from the legacy of SARS, the annual Healthcare Humanity Awards are given to those who go above and beyond the call of duty to improve the care and wellbeing of patients. David Brill spoke to two of this year’s recipients about their achievements, challenges and hopes for the future.

A picture of health: Putting patients at the center

Associate Professor Chia Sing Joo is designing a hospital. It’s his biggest project to date, yet he works on it alone. There are no meetings, no paperwork and no phone calls – he’s been doing it for years and no one even knows about it.

The blueprints, for now at least, are in Chia’s mind. He refines them constantly, hoping one day for the opportunity to put them to use. “I would like to build a hospital which is totally patient-focused,” he explains. “Patients don’t have to wait for a long time, and they don’t have to worry about unforeseen outcomes because the process is so transparent. The doctors all share the same values and are not for profit. Every patient would want to come here, and every doctor would want to train here.”

This vision may sound ambitious, but Chia is already striding toward it. As chairman of the division of surgery at Tan Tock Seng Hospital (TTSH), Singapore, he has worked hard to improve processes of care and ensure that the welfare of patients remains the primary focus. Day surgery is up; unnecessary inpatient stays are down. Increased collaboration with GPs has freed up hospital beds and reduced waiting times, and the establishment of a multidisciplinary surgical oncology group has improved quality of care and outcomes for cancer patients. The list goes on, and many more projects lurk in the pipeline.

Communication is a theme that surfaces repeatedly in conversation with Chia, and would form a central pillar in the ethos of his patient-centric hospital. As a member of TTSH’s mediator team he is often on the front line against complaints, and has come to believe that the majority could be avoided simply by spending more time talking to patients and their relatives. Misinformation can lead to misunderstandings, and anxiety and stress typically follow, he says. And nowhere is this need for openness greater than when advising patients on surgery.

“First I explain the options to the patient and the complications of each,” says Chia, who is also a senior consultant urologist. “Second, I tell them what I would choose if they were my uncle or auntie. Finally, I let them know that there is no guaranteed surgery in this world. Expectations are important – patients have to understand that we are only human and a lot of things are beyond our control. If you do these things, there are very few patients who will not trust you. If complications arise, 99 percent will understand that you have done your best and this was something unavoidable and unpredictable.”

Chia’s quest to improve patient-doctor communication, however, does not end in the clinic or the operating theatre. He speaks in public forums, has recently published a book entitled Male Urological Problems: The Essential Guide for Every Man & Couple, and is now working on another layman-orientated book about “how to spice up your sex life”. He also gives out his home and hand phone numbers to patients, and encourages them to call if they have any concerns or questions. And, it seems, they don’t hesitate: he estimates that his phone rings every 5 or 6 minutes on a typical working day.

Even by doctors’ standards, Chia is a busy man. In between the phone calls, books and surgery, he also spends one day a week as a visiting consultant at KK Women’s and Children’s Hospital, works on several research papers, oversees the development of a new training center at TTSH, raises three sons – none of whom want to be doctors – and still finds the time to run for an hour before dinner. Citing “every day” as his career highlight, however, it is clear that he wouldn’t change a thing. Except, of course, for the long-awaited chance to roll out those imaginary blueprints. “If I really had the opportunity to build my own hospital, that would be a great challenge for me,” he says.

Staring disaster in the face

Medical Tribune October 2008 P11
David Brill SFXV

Dr. Arif Tyebally is a veteran of disaster relief missions in South East Asia. He spoke to Medical Tribune’s David Brill about dealing with tsunamis, earthquakes and cyclones.

December 26 2004 was a day that
changed the lives of countless people.
As a 9.3-Richter earthquake
shook the ocean floor off the coast of Sumatra,
the tsunami that resulted at the surface
killed more than 200,000 and left some half a
million homeless.
Dr. Arif Tyebally witnessed the devastation
first hand. Arriving in Aceh, Indonesia,
as part of the emergency relief effort, he saw
homes destroyed, families separated and
people living through hardships he had never
imagined possible.
“To this day I can’t think of anything that
could be worse than the tsunami,” he says.
“It was unbelievable. Thousands of homes
just flattened. Nothing can recreate it, and
nobody can describe how bad it really was.
I don’t think anyone could be prepared for
what we saw.”
On a regular day, Tyebally, 33, is a pediatrician
at KK Women’s and Children’s Hospital
in Singapore. He decided to volunteer
for the mission to Aceh when he saw the extent
of the destruction on television. While
millions donated their money, he felt that offering
his medical expertise was a better way
to help.
On arrival in Aceh, the Singapore team
lived in a camp for internally displaced
people, where they set up and ran a general
clinic. Being part of the second wave of relief
teams, there were few acute injuries from the
tsunami itself, and they treated mainly postdisaster
complications such as gastroenteritis
and respiratory and skin infections. With
local pediatric facilities severely stretched –
one local hospital with facilities having been
completely destroyed and another badly
flooded – Tyebally helped to run a makeshift
pediatric department in a nearby military
hospital.
In spite of the devastation all around
them, the residents of the camp showed a resilience
which inspired Tyebally.
“People would go back to where their
homes used to be to search amongst the
rubble, and if they could find something like
a sewing machine they’d take that back and
start to work from the camp. And the children
still went to school, even if they’d lost
their parents. I’m sure they must have been
going through really hard times, but it was
good to see that despite the situation that
they were in they were all trying to get back
to their daily lives,” he says.
Tyebally spent 10 operational days in
Aceh, treating some 70 patients each day. For
many, however, the tsunami had left wounds
that he was powerless to heal. He recalls the
thousands of photos of missing children that
lined the walls, and the haunting memory of
one lady who spent weeks going from hospital
to hospital looking for her child, long
after the waters had subsided.
“You can’t really help someone like that,”
he says. “You just have to talk to them. They
probably know that there isn’t much hope,
but for a mother any hope is still hope. It’s
very sad to see things like that happening.”
With some of these memories still troubling
him to this day, you could have forgiven
Tyebally for shying away the next time a
natural disaster struck in Asia. Yet in October
2005 he found himself among the first official
medical teams to arrive in Muzaffarabad,
Pakistan, following a 7.6-Richter earthquake
which left some 80,000 people dead.
The Singapore team set up a hospital –
again within a tented camp – comprising an
emergency room, wards and an operating
theater. Unlike in Aceh, however, the team
was treating mostly acute cases such as fractures
and open wounds. Some patients, he
says, had walked for 5 days with fractured
hips in order to receive treatment.
The conditions encountered in Pakistan
were also a challenge for the relief teams.
Aftershocks from the earthquake were common,
while sleeping in tents in an inaccessible
mountainous region with winter approaching
ensured that living conditions
were far from luxury.
For Tyebally, who speaks Bahasa Indonesia,
the language barrier in Pakistan was another
new problem which he had not faced
in Aceh. He soon realized the need to work
closely alongside local volunteers, many of
whom had given up paid jobs to come and
help out at the disaster zone. He was touched
by how helpful the people were – both in assisting
with the logistics of the team’s medical
operations and acting as interpreters for
the patients and local medical staff.
With two disaster relief missions under
his belt, Tyebally was elevated to Singapore’s
team leader when Cyclone Nargis struck
Myanmar at the beginning of May this year.
With much of the world denied access to the
country, Tyebally and his team found themselves
operating for the first time without the
coordination and resources of the UN.
Undeterred, the 23-man team managed
to treat nearly 5,000 patients in just 2 weeks,
operating from their base in Twan Te – a
town around an hour’s drive southwest of
Yangon. They worked out of a local hospital
but also set up mobile clinics and travelled
by boat to deliver aid to the region’s more
remote corners.
Two weeks had passed between the advent
of the cyclone and the arrival of international
aid, and the team mostly encountered
a similar post-disaster caseload to that seen
in Aceh. There were also many patients with
untreated chronic diseases such as hypertension
and diabetes who took the opportunity
to seek medical attention from the doctors.
Myanmar also presented Tyebally with
one case that he will never forget – a young
girl with ascariasis, a parasitic infection in
which worms mature in the intestine and
migrate up the respiratory tract.
“The family didn’t seem very upset
or perturbed by it. In fact she came in for
something else and oh, by the way, there are
worms coming out of her mouth,” he says.
Everywhere Tyebally has been he has
been struck by the gratitude that the people
have shown him. Sometimes he wishes he
could do more, he says, but adds that even
when nothing can be done the patients are
often glad of the sense of closure that comes
from knowing their fate.
He shrugs off the notion that his work is
heroic, describing it simply as a form of charity
work like any other.
“It takes so little for us to give to make a
big difference to the lives of the people. Not
many people want to go on such missions
because there are dangers, but I think that
the benefits – the sense of satisfaction and
the fact that you can help people – outweigh
these.”
His experiences, he adds, have helped
him not just in a professional context but also
to grow and develop as a person.
“You gain as much from the patients as
they gain from you. You see how resilient
they are in the face of suffering, and how
they can turn their lives around and get back
to their normal routines despite all that has
happened. It really makes you appreciate
what you have.”
Tyebally, it seems, is just one of those
whose lives were forever changed by that
fateful day in 2004. And next time disaster
strikes, he says, he’ll be ready to go where
the people need him.

The David Beckham of science? Get real Dad

Medical Tribune August 2008 P16 - 17

Winning the Nobel Prize earned Sir Paul Nurse the respect of doctors, scientists
and reporters the world over. He told Medical Tribune’s David Brill what it
takes to become a Laureate, and why his daughter was less convinced.

There can be few achievements
in life that surpass
being knighted. But for a
Nobel-winning scientist there’s an
obvious trump card.
Sir Paul Nurse is one of the
privileged few who can say which
feels better. Driven by a passion
for wanting to learn how the natural
world worked, his career as
a biologist led to the “very pleasant
shock” of royal recognition in
1999.
But while his father was more
excited about the knighthood,
Nurse himself doesn’t hesitate
to name the 2001 Nobel Prize for
Physiology or Medicine as his
greatest success. Recognition of a
different kind was to follow, with
The Sun newspaper in his native
UK dubbing him “the David Beckham
of science” – an acknowledgment
of his failure to conform to
public stereotypes of white coats
and safety spectacles.
Seven years later the award
has finally sunk in, he says, but
the rapid elevation of status that
accompanies the Nobel Prize still
takes some getting used to.
“You’re really no different from
what you were before but it’s simply
that people take more notice
of you. Suddenly you become the
expert on almost anything, and not
just science. This can be slightly
embarrassing, because every time
you open your mouth you think
that someone’s going to write it
down.”
Nurse received the Nobel Prize
for his work on the molecular regulation
of the cell cycle – a research
interest which began in the 70s,
when his studies of yeast led him
to identify the cdc2 gene, which
plays an important role in controlling
the progression between the
stages of cell division. In 1987 he
discovered the human equivalent
– the CDK1 gene which encodes a
cyclin dependent kinase.
At the time of the award he
was director general of the Imperial
Cancer Research Fund (ICRF),
which later became part of the
charity Cancer Research UK. He
shared the Nobel Prize with Tim
Hunt, a British biochemist, and
Leland H. Hartwell, an American
scientist who is now director of the
Fred Hutchinson Cancer Research
Center in Seattle, US.
There are certain prerequisites
to winning the award, Nurse says,
noting that hopefuls need to be
“reasonably bright, but not necessarily
super-bright, and a reasonably
good scientist and experimentalist.”
Beyond the basics, however,
the first factor he identifies is circumstance.
“It does require a certain combination
of being in the right place
at the right time, which singles out
certain advances as being iconic,
and which can be clearly identified
with a few individuals. There are
many other advances – sequencing
the human genome is one which
everybody will talk about – but it’s
very difficult to identify the person
or limited group of people who are
involved in that.”
The second key to becoming
a Nobel laureate, he says, is to be
seen to be doing something that
other people aren’t. In his case a
long-standing interest in cell division
led him to begin his research
while the competition was limited,
and by the time others recognized
the importance of the field his reputation
within it was already established.
Author of over 200 scientific
papers – many of them in Nature,
Science and Cell – Nurse also emphasizes
the importance of being
able to write clearly and insightfully.
“Often people write papers
which can never be wrong because
they just agree with everything
that’s out there and then they’re
very muddy. You’ve got to stick
your neck out a bit at a stage where
you’re prepared to be wrong… if
you end up being right, then that’s
more clearly identifiable than if
you write something which says
‘it could be this or it could be that,’
because that lacks clarity.”
Nurse grew up in Wembley in
north-west London, going on to
study at the Universities of Birmingham
and East Anglia before
joining the ICRF in 1984. After a
5-year stint as chair of the department
of microbiology at The University
of Oxford, he returned to
the ICRF as scientific director in
1993 and was appointed director
general in 1996.
In 2003 he left the UK to become
president of Rockefeller
University in New York, a position
he still holds today. He is
also a regular visitor to Singapore,
where he chairs the scientific advisory
board of the Temasek Life
Sciences Laboratory.
Becoming a Nobel laureate is
like having another job in itself,
Nurse says, admitting that the many
extra requests on his time can be difficult
to manage. But describing his
profession as “a privilege,” it’s clear
that he wouldn’t want it any other
way. And should he ever get carried
away with his new-found fame, he
need only speak to his family to be
brought back down to earth.
“I’ve got two daughters – one’s
a scientist, the other’s a TV producer
and interviewer for soccer
who has interviewed David Beckham.
And when I pointed out The
Sun headline to her she just said
‘Get real Dad. You are not David
Beckham.’”

Unraveling complexities in cancer research

What has been the greatest
breakthrough in cancer
research in the past 10 years?
Identifying which genes become
altered in cancer, and in
which combinations, has been
a major advance. We now know
that there are 300 to 400 genes that
are important, and knowing those
does two things: firstly, it helps us
understand this immensely complicated
disease much better, and
secondly it gives us new targets
to think about for both diagnosis
and therapy.
What are the greatest
challenges facing the field in
the next 10 years?
The greatest challenge is dealing
with the wide range of changes
that can bring about the cancerous
state, and producing a rational
therapeutic response to all of
those different changes. Given that
complexity, it’s not going to be like
infectious disease research, for example,
where penicillin had a major
impact. Cancer’s going to be a
more brick-in-the-wall approach
– it’s going to gradually get better.
Cancer and breakthrough don’t go
together.
What advice would you give
to doctors who want to make
a career for themselves in
research?
There is one crucial factor: they
have to be driven by a passion for
wanting to know. Doing research
is very demanding and often not
rewarding. People think that it is,
but real success is very difficult to
achieve. You have to have a real
passion to cope with the fact that
the recognition and success that
come through are limited.
Who are your scientific
heroes?
Well I’m a biologist so I’m going
to be traditional and say Darwin
as my all-time hero. I can’t
help it. And he’s English, too. In
more recent years I think I’ve got
to say Francis Crick and maybe
Sydney Brenner, both of whom I
knew.
Several countries in the
Asia Pacific region are
becoming up-and-coming
centers for research. What
advice do you have for the
scientific community in these
countries at this stage?
The difficult trick to balance is
that you need to support science
across a fairly wide base. If you
only support research which is just
before application, which is the
tendency to do if you are looking
for commercial return, you really
are not investing in the future. And
if you only support basic research
which is looking for the future then
you don’t get the immediate commercial
return. What is required is
a broad-based approach that covers
the whole timeline.
What’s the best memory
from your childhood in
London?
I think my best memory really,
scientifically at least, was
being able to access all the great
museums in London. I happened
to be a bit of a museum kid so I
thought they were fantastic. I
think it inspired me, certainly in
part.