News - Where Innovation Meets Medicine Dual Accreditation in Nuclear Medicine and Radiology

News - Where Innovation Meets Medicine Dual Accreditation in Nuclear Medicine and Radiology
               VO L . 5 1 N O . 7 | J U LY 2 0 1 9 | M C I ( P ) 0 8 3 / 1 2 / 2 0 1 8

Where Innovation
Meets Medicine

Dual Accreditation
in Nuclear Medicine
and Radiology
News - Where Innovation Meets Medicine Dual Accreditation in Nuclear Medicine and Radiology
News - Where Innovation Meets Medicine Dual Accreditation in Nuclear Medicine and Radiology
                                                 CON T E N T S
Vol. 51 No. 7 2019

                                                 04 The Editors' Musings
                                                    Dr Tan Yia Swam and Dr Jipson Quah
Dr Tan Yia Swam
Deputy Editors
Dr Tina Tan
Dr Tan Tze Lee                                   Feature
Editorial Advisors
                                                 05 Radiology in Singapore –
A/Prof Daniel Fung                                  Where Innovation Meets Medicine
A/Prof Cuthbert Teo                                 Dr Lim Chee Yeong, Dr Xie Wan Ying
Dr Toh Han Chong                                    and Dr Tan Bien Soo
Dr Chie Zhi Ying
Dr Jipson Quah                                   President’s Forum                       Doctors in Training
Dr Jonathan Tan
Dr Jimmy Teo                                     08 Dreams and Ruminations               18 Two Months in Fiji:
Dr Alex Wong                                        Dr Lee Yik Voon                         My WHO Internship
                                                                                            Dr Ivan Low
Dr Lee Yik Voon
Dr Lim Kheng Choon
                                                 Council News                            20 Growth as a Physician
                                                 10 Highlights from the                     Dr Nigel Fong
EDITORIAL                                           Honorary Secretary
OFFICE                                              Dr Lim Kheng Choon                   22 New Challenges Await New Doctors
Senior Manager                                                                              Dr Benny Loo and Dr Lee Pheng Soon
Sarah Lim
Assistant Manager                                Reflections
Sylvia Thay                                      11 An Insider's Take                    From the Heart
Editorial Executive                                 on Radiology                         24 Celebrating Our Little Fighters –
Jo-Ann Teo                                          Dr Chan Wan Ying, Dr Jonathan Sng       Paediatric Brain and Solid Tumour
                                                    and Dr Sonia Lee                        Awareness Day 2019
                                                                                            Lau Kin Mun and Candy Tan
Li Li Loy
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News - Where Innovation Meets Medicine Dual Accreditation in Nuclear Medicine and Radiology

                  Tan Yia Swam                                For this special "Doctors in
                                                              Training" issue, we feature the
                                                                                                            Jipson Quah
                                                              field of roentgenology – better
                  Editor                                      known as radiology these                                 Guest Editor
                                                              days. In 1895, Wilhelm Conrad
               Dr Tan is learning new skills and              Roentgen was a professor of           Dr Quah is in private practice as a GP
               stretching new boundaries in her private       physics at the University of          with a special interest in pathology.
               practice. Meanwhile, she still juggles         Würzburg when he made his             He enjoys discussing pathology
               the commitments of being a doctor,             greatest discovery: X-rays (also      reports with patients, music-making,
               a wife, the SMA News Editor, the Vice-         known as Roentgen rays). He           fitness and editorial work.
               President of the SMA and a mother of           noticed that, as a cathode-ray
               three. She also tries to keep time aside for   tube was being operated in a
               herself and friends, both old and new.         darkened room, paper lined with     important paper on obstetrical
                                                              barium platinocyanide lying         and gynaecological sonography.
                                                              some distance from the tube “lit    It contained illustrations of
                  My surgical work is closely                 up with brilliant fluorescence”.    B-mode sonograms of various
                  intertwined with radiology. During                                              normal and pathological
                  the training years, one learnt how to          Rontgen theorised that           abdominal conditions, while
                  read CT scans and arrange urgent            unknown radiation was formed        also discussing the safety of
                  vascular interventions. Being able to       when electrons struck the           diagnostic ultrasound. The
                  have valuable discussions with like-        wall of the cathode-ray tube,       diagnostic ultrasound has since
                                                              giving rise to a fluorescent        become an indispensable tool
                  minded radiologists to truly “correlate
                                                              chemical reaction. He found         for obstetricians, surgeons and
                  clinically” was a joy. What do we
                                                              that it affected photographic       emergency physicians, facilitating
                  make of the non-enhancement?
                                                              plates and he took the first        more accurate and efficient
                  How about these tiny locules of air?
                                                              photographs of metal objects        management of patients.
                     Now, doing pure breast work,             and the bones in his wife’s hand.
                  being able to work with dedicated           Unsurprisingly, the study of            The dynamic field of radiology
                  breast radiologists is another great        physics and radiation has always    has been largely defined by
                  joy. We’d review mammograms                 featured prominently in the         technological innovations
                  together (which cluster of                  training of a roentgenologist.      combined with groundbreaking
                  microcalcifications should we aim                                               clinical applications; this has
                                                                 Another radiologist,             given rise to rapidly advancing
                  for?), decide on which modality to          Sven Ivar Seldinger, introduced
                  use next (if necessary, supplementary                                           subspecialties, such as
                                                              the eponymous Seldinger             interventional radiology, nuclear
                  ultrasound or MRI?), and discuss            technique, a key procedural
                  the technique and accuracy of                                                   medicine and now, even artificial
                                                              innovation for the insertion of     intelligence. I believe that all of
                  localisation and peri-operative             chest drains, central venous        us will agree that it is impossible
                  marking; such joint management              catheters, pacemaker leads,         to practise medicine without the
                  gives patients a better outcome.            etc. The groundbreaking             fine services of our radiology
                     It is, therefore, my pleasure to focus   technique revolutionised            colleagues and we are delighted
                  this July issue on radiology. We have       angiography, which had a high       to have senior and junior
                  invited various writers across different    rate of complications back then,    radiologists from the various
                  institutions and subspecialties to          and set the foundations for         healthcare institutions share their
                  share the recent developments and           interventional radiography.         insights in this issue. I trust that
                  progress in radiology, as well as the          Ian Donald, Professor            the rest of the medical fraternity
                  training woes and rewards. Enjoy!           of Midwifery, published an          will have a fascinating read.

            04 JUl 2019 SMA News
News - Where Innovation Meets Medicine Dual Accreditation in Nuclear Medicine and Radiology
                               RADIOLOGY IN SINGAPORE

WHERE INNOVATION MEETS MEDICINE  Text by Dr Lim Chee Yeong, Dr Xie Wan Ying and Dr Tan Bien Soo
                                Photo by SingHealth Diagnostic Radiology Residency Programme

Technological advancements are               in Singapore, translating to 19.4 and      volume-based model. In 2013, the
relentless in the modern era and few         14.3 units per million population,         American College of Radiology
medical specialties have embraced            respectively. The ratios are mid-range     published their influential strategic
innovations quite like radiology.            when compared to developed nations         blueprint, Imaging 3.0, setting the
From the emergence of MRI to                 in the Asia-Pacific, Europe and North      stage for the next phase of radiology
early ventures towards artificial            America, which ranges from 7.4 to 97.3     targeting optimal imaging care.3 This
intelligence (AI), continual disruptive      CT units and 5.6 to 43.1 MRI units per     initiative comprises active radiology
evolution renders the specialty              million population.2 The modalities        involvement in managing imaging
abstruse to patients and professional        may work in union too; for example,        appropriateness, clinical decision
contemporaries alike. To understand          fusion of real time ultrasound with CT     support, safety, quality and providing
the essence amid such vicissitudes,          for hepatic interventions or combining     patient-centric care. The goal is to
we will have to connect the dots             anatomical information from CT             acquire the right, personalised and best
of recent key advances along                 or MRI with functional analysis in         imaging for each individual.
the journey towards the cutting              positron emission tomography (PET)             These paradigm shifts in mindset
edge. This article will focus on the         CT/MRI. 3D printing has also recently      have brought forth changes to the
ongoing transformation of clinical           created much excitement in the             daily practice of a typical radiologist. A
practice in radiology, the growth of         field due to technical breakthroughs       typical workday begins with a clinical
interventional radiology and nuclear         and decreasing cost. The models            radiology round where radiologists and
medicine, as well as opportunities in        generated from radiology images            other clinicians from various disciplines
digital informatics.                         are used to optimise pre-operative         get the opportunity to work together
                                             planning across many disciplines, such     by reviewing images and pertinent
Transformation of                            as orthopaedics and vascular surgery.      clinical information to optimise patient
clinical practice                                                                       management. Strides are being made
                                                 Most radiology centres in              in enhancing the effectiveness of the
Since the first X-ray department began       Singapore now provide subspecialised       radiology report, trending towards
in the new Singapore General Hospital        services, employing consultant             standardised structured reporting.
(SGH) within the historic Bowyer             radiologists specialising in               Scoring systems such as BI-RADS
Block in 1926, radiology has grown           specific interest domains such as          (Breast Imaging-Reporting and Data
tremendously in scope and clinical           cardiothoracic, abdominal, neurology,      Systems) and LI-RADS (Liver Imaging-
impact.1 Within a century, that nascent      head and neck, musculoskeletal,            Reporting and Data Systems) are
single modality general practice has         breast, emergency, vascular,               now in practical application, using
metamorphosed into today’s multi-            intervention and nuclear medicine.         consistent terminology to reduce
modality subspecialty-based practice         The conventional imagery of a solo         imaging interpretation variability and
in all hospitals in Singapore.               radiologist enclosed in the dark           errors, enhancing communication with
   The radiology departments today           reading room churning out endless          fellow clinicians and facilitating quality
provide a wide variety of imaging            radiology reports in front of a blue       assurance and research. Many centres
techniques such as radiography, CT,          screen has become irrelevant and           have concurrently introduced new-
MRI, ultrasound and nuclear medicine         superseded by progressive radiologist      wave integrated multimedia reports,
imaging under one roof. Local data           clinician teams. Globally, radiology       enabling educated patients of today to
from 2015 revealed 106 units of CT           has pivoted towards a value-driven         better understand their own radiology
scanners and 78 units of MRI scanners        ethos, departing from the traditional      report findings.

                                                                                                              JUL 2019 SMA News 05
News - Where Innovation Meets Medicine Dual Accreditation in Nuclear Medicine and Radiology
Growth of interventional                   articular injections and bone tumour        are now used as diagnostic criteria
  radiology                                  cementoplasty under musculoskeletal         biomarkers in dementia with Lewy
                                             intervention, as well as breast biopsy      bodies and amyloid.
  Interventional radiology is a specialty
                                             with wire localisation under breast             The growth in theragnostics has
  well positioned to lead radiology          intervention, also play integral roles in
  towards value-centric goals, extending                                                 been exponential in the past decade
                                             various clinical pathways.                  with the advent of personalised
  our roles beyond diagnostics. It
  involves utilising minimally invasive         The impact of interventional             medicine and therapy. Some of these
  image-guided procedures to diagnose        radiology in medicine today cannot          newer therapies include 90 Y selective
  and treat diseases in every organ          be understated. For example,                internal radiation therapy (SIRT)
  system. By using the least invasive        24-hour emergency embolisation              for hepatic malignancies, peptide
  techniques available, risk to patients     for management of pelvic trauma-            receptor radionuclide therapy (PRRT)
  is minimised and health outcomes           related haemorrhage is now standard         for neuroendocrine cancers and
  are improved. These procedures have        of care within all our major trauma         prostate specific membrane antigen
  less risk, pain and recovery time in       centres. Interventional radiology           radioligand therapy (PSMA RLT) for
  comparison to open surgery.                residency has become one of the             metastatic castrate resistant prostate
                                             most competitive medical specialties        cancers. In 90 Y SIRT treatment of
     The story of interventional radiology   in the US and is poised to remain           hepatomas, super-selective intra-
  in Singapore began as early as 1959        so in the near future. While local          arterial targeting improves tumoricidal
  when Dr Chow Khuen Wai introduced          residency programmes currently do           radiation doses delivered to the
  the Seldinger technique of vascular        not offer a dedicated interventional        tumour within a minimally invasive
  catheterisation after returning from       track at the moment, we have                procedure, significantly improving
  advanced training in the UK.4 Today,       definitely noticed its increasing           patient outcomes. SGH is also one
  every radiology department within          popularity among our graduating             of the pioneers in introducing PRRT
  local academic centres and most major      radiology senior residents as their         and PSMA RLT in South East Asia,
  private imaging practices provide          eventual choice of specialisation.          attracting up to 40 referrals annually
  dedicated interventional radiology                                                     from neighbouring countries, as well as
  services around the clock. For example,    Nuclear medicine, molecular                 China and Taiwan for PRRT alone.
  the largest interventional radiology       imaging and theragnostics                      Given the unique position of
  service within SGH developed into
                                             Nuclear medicine, as a specialty, grew      nuclear medicine straddling expertise
  a full-fledged clinical department in
                                             out of the Therapeutic Radiology            between imaging and medical
  2017. Armed with eight interventional
                                             Department and became an                    therapeutics, its main local specialist
  radiology suites and 17 interventional
                                             independent Department of Nuclear           training programme is now a senior
  radiologists, it performs more than
                                             Medicine, SGH, in 1980. Over the years,     residency programme under the Joint
  10,000 procedures per year.
                                             nuclear medicine centres have also          Committee on Specialist Training,
      The indications, frequency and         been set up in other public hospitals       accepting trainees from both internal
  variety of procedures performed            and private institutions to meet            medicine and diagnostic radiology
  in the interventional suite increase       the increasing demand for nuclear           residency tracks. The specialty also
  steadily year after year. Procedures       medicine services.                          has training pathways for dual
  are broadly divided into endovascular          From the 1980s to 1990s,                accreditation in nuclear medicine and
  and non-vascular methods, but              majority of the imaging work                radiology, equipping residents with
  interventional radiologists in Singapore   centred on Technetium-99m                   essential skills required for the exciting
  are slowly but surely moving into super    (Tc-99m) radiopharmaceuticals               future in functional imaging and
  subspecialisation based on systems.        and radioiodine (I-131) therapy             targeted molecular therapy.
  Neurointervention has, over the last       for thyroid conditions. The
  decade, evolved into the first treatment   discovery of accumulation of                Digital informatics
  of choice for hyperacute strokes and       18F-fluorodeoxyglucose (18 F-FDG) in        A major inflection point for radiology
  cerebral aneurysms, improving patient      tumours revolutionised PET imaging          was the introduction of picture
  prognosis through intravascular            in 1980. 18F-FDG PET was soon               archiving and communication
  thrombectomy and coil embolisation,        established as a routine imaging            system (PACS) before the turn of the
  respectively. Similarly, in appropriate    tracer in neuroimaging and cancer                             millennium. As the
  patients, vascular intervention has        diagnosis and management. Today,                                world accelerated
  enabled definitive treatment of aortic     18
                                                F-FDG remains the workhorse of                                towards the
  aneurysms and peripheral vascular          PET imaging, although there are                                   computer age,
  disease through endovascular stenting      newer, more specific radiotracers                                 our pioneers
  and angioplasty. Percutaneous              which have gained interest due
  biopsies, radiofrequency ablations         to their clinical applications
  and radioembolisation of visceral          in neurology, neuro-oncology                                   1
  neoplasms by abdominal intervention        and oncology. For example, 18
  increased treatment permutations           F-fluoroethyl-L-tyrosine (18 F-FET)
  and improved quality of life in many       is a promising biomarker for
  oncologic patients. Vertebroplasties       response assessment in gliomas; 123
  for spine fractures, ultrasound-guided     I-ioflupane and 18F-Flutemetamol

06 JUL 2019 SMA News
News - Where Innovation Meets Medicine Dual Accreditation in Nuclear Medicine and Radiology
readily embraced new technology,           of AI-augmented radiology practice.          References
transiting images away from printed        The lamentable regret from the               1. Chow KW. Reflections of a septuagenarian -
form onto digital screens. The impact      introduction of PACS is the unwanted         radiology: past, present and future. Ann Acad
was exponential. Rapid scrolling           effect of radiologists retreating deeper     Med Singapore 2004; 33(5):671-5.
of multiple images in digital form         into the dark room, losing invaluable        2. Cheng Tim-Ee L, Sng LH, Lim CCT, Tan BS.
                                           rapport with other clinical colleagues       Imaging in the Lion City: Singapore Radiology
enabled more complex cross-sectional                                                    Country Report. Journal of Global Radiology
imaging to be obtained and optimised       and patients. In an ironic twist, thought    2016; 2.
with innumerable post-processing           leaders now believe that as AI/ML
                                                                                        3. Ellenbogen PH. Imaging 3.0: what is it? J Am
techniques. Easy access to prior           algorithms are trained to perform            Coll Radiol 2013;10(4):229.
imaging data improved reporting            repetitive mundane diagnostic tasks,
                                                                                        4. Teo TKB, Tan BS, Tay KH. A brief history of
standards and efficiency. Most             radiologists will finally be able to         interventional radiology in Singapore and its
significantly, the ability to review       concentrate on adding value, improving       current status. Biomed Imaging Interv J 2011;
high-quality images anywhere in the        inter-human communications and               7(2):e13.
wards and consultation rooms on            managing patients beyond mere                5. Choy G, Khalilzadeh O, Michalski M, et al.
demand contributed to ubiquitous           diagnostics. There is concurrently           Current Applications and Future Impact of
                                                                                        Machine Learning in Radiology. Radiology 2018;
application of medical imaging in          potential for radiology to venture
clinical workflows today.                  further into precision medicine, with
                                           many researchers reporting early results
    Fast forward to the 21st century,      of combining avant-garde techniques            Legend
rapid progress in AI and machine           in radiogenomics and AI.                       1. Modern collaborative approach to add value
learning (ML) research arising from                                                       into medical imaging
advances in computing infrastructure          In Singapore, efforts towards
and deep learning techniques, such as      developing our radiology AI
convoluted neural networks, promises       capabilities are rapidly picking                                       Dr Lim is a consultant
a Fourth Industrial Revolution. It is no   up pace. The Radiology Artificial                                          radiologist in SGH
                                           Intelligence Machine Learning                                     Department of Diagnostic
surprise that radiology is one of the                                                                         Radiology specialising in
first medical specialties to take the      Imaging Informatics committee
                                                                                                              musculoskeletal imaging
leap of faith by incorporating AI into     under the Singapore Radiological                                       and interventions. He
our practice.                              Society was formally formed in 2017                                      is also the associate
                                           to facilitate development of this                                       programme director
    AI is the branch of computer science   domain within Singapore. It has                                             of the SingHealth
devoted to creating systems to perform     been working closely with different                                    Diagnostic Radiology
tasks that ordinarily require human        radiology departments, as well as                                    Residency Programme
intelligence. ML is the subfield of AI                                                                                  and Secretary of
                                           domain experts, such as the Agency                                   Singapore Radiological
in which algorithms are trained to         for Science, Technology and Research,                               Society Musculoskeletal
perform tasks by learning patterns         to explore novel methods harnessing                                     Imaging Subsection.
from data rather than by explicit          this exciting technology clinically. The
programming. Image recognition             College of Radiologists, Singapore,
within scans is of particular interest     and the local radiology residency            Dr Xie is a consultant
in research, translating to clinical       programmes have also made                    nuclear medicine
applications such as automated                                                          physician with the
                                           progressive steps to insert informatics
                                                                                        Department of Nuclear
fracture and bone age classification       and data science into the standard           Medicine and Molecular
from radiographs, pulmonary nodule         training curriculum, preparing the           Imaging, SGH, and has
detection on CT and cartilage defect       future generation of radiologists for        an interest in molecular
detection on MRI. Furthermore, AI          our next iteration.                          imaging in oncology and
applications are not confined to                                                        neurology. She is also
                                                                                        the programme director
automated image detection – these          Change is the only constant                  of the SingHealth
algorithms are starting to extend into                                                  Nuclear Medicine Senior
                                           Radiology is a specialty that continues
other operational domains such as                                                       Residency Programme.
                                           to improve patient care by challenging
decreasing scan acquisition times,
                                           established mindsets, inventing
automated clinical decision support
                                           new diagnostic and therapeutic
and scan triaging.5
                                           techniques, and assimilating the latest                                      Dr Tan is senior
   As true clinical applications of        advancements in digital technology.                                        consultant at the
             AI applications have          As a medical discipline that is neither                             Department of Vascular
               continued to grow           considered new nor old, she has                                          and Interventional
                                                                                                              Radiology, SGH. He is the
                beyond the computer        chosen to advert mid-life crisis though                               academic chair of the
                laboratory over the        relentless reinvention. Although her                                  Radiological Sciences
               last few years, facile      face is ever-changing, her immutable                                      Academic Clinical
                  fears of machines        spirit of innovation will always remain                                   Programme at the
                    replacing human        the pillar of strength, the northern star                             SingHealth Duke-NUS
                                           and the guiding light. Like the city we                               Academic Centre and
                     radiologists have
                                                                                                                Chair of the Division of
                      shifted towards a    live in, work in progress is always status                            Radiological Sciences
                      more sanguine view   quo since we know no other way.                                                      at SGH.

                                                                                                                   JUL 2019 SMA News 07
News - Where Innovation Meets Medicine Dual Accreditation in Nuclear Medicine and Radiology

                               Dreams and
                                 Ruminations                          Text by Dr Lee Yik Voon

                      Moving onward! All I want to do when     minds as to what is material to them      doctor will do his/her best for the
                      I wake up every morning is to take a     when things don’t turn out well?          patients. That doctor of choice would
                      look through my patient’s eyes.                                                    have stood the reasonable test of time
                                                                  Some patients come in and quote
                         Do we prefer to look at healthcare    “Dr Google”, but you will find that the   and possess qualities that the patients
                      through our patients’ eyes or bow                                                  like and prefer. These qualities may
                                                               context is often missing. When your
                      to our fraternity’s approval so that                                               be the way he/she explains various
                                                               patients do this, it may ruffle your
                      we may see eye to eye with our                                                     medical conditions and steps that the
                                                               feathers. However, a good doctor will
                      colleagues? It’s a delicate balance,                                               patient needs to undertake to be on
                                                               need to be patient and spend time
                      but one we have to tread as we are                                                 the road to recovery. Some patients
                                                               on the patient sitting in front of them
                      trying to make healthcare more                                                     may prefer certain doctors by the way
                                                               to make a relevant analysis in the
                      patient-centric.                                                                   they break bad news and their use of
                                                               right context.
                                                                                                         the right comforting demeanor.
                                                                   What can patients do when they
                      Understanding patients
                                                               encounter alarming medical news           Thinking of the future
                      Does this mean that we have to           that appear seemingly true (eg, that
                      know what different patients want?                                                 We have to do our part but what
                                                               vaccinations cause autism)? Many
                      Do we have to know their likes and                                                 happens if we only see this as a day
                                                               laymen will choose to believe the
                      dislikes, their preferences on how                                                 job or an occupation to bring home
                                                               fake news and use them to challenge
                      they receive advice and are informed                                               the bacon? I believe that once you are
                                                               our best effort to be true to our
                      on treatment choices? When we                                                      a medical doctor, you will always be
                                                               profession. When fake news spreads
                      have an established patient-doctor                                                 one till you retire. However, in this day
                                                               like wildfire in the public domain, it
                      relationship that spans a decade or                                                and age, how many would share my
                                                               becomes very real to our patients who
                      more, will we always know what is                                                  view? I hear through the grapevine
                                                               may choose to believe what they hear
                      material to that patient? Our patients                                             that many would disagree with me,
                                                               and read. We should strive to dispel
                      want their right to be heard yet they                                              and that our younger generation of
                                                               the myths.
                      know they are at a disadvantage                                                    doctors may only see medicine as an
                      as they lack domain knowledge.              I believe that our patients have to    occupation and not as a profession.
                      Will this information asymmetry          trust their personal or family doctor     At the opposite end, while we
                      influence them to change their           whom they have chosen because that        try our best, our patients need to

                    08 JUl 2019 SMA News
News - Where Innovation Meets Medicine Dual Accreditation in Nuclear Medicine and Radiology
Dr Lee is a GP practising
reciprocate and understand that               or be replaced by robots with artificial
                                                                                         in Macpherson. He
we too are humans with bodily and             intelligence (AI) and deep learning.       is also a member of
psychological needs.                          Perhaps one day AI may even simulate       the current National
                                              compassion and empathy instead             General Practitioner
   As I move into the later part                                                         Advisory Panel. He is a
                                              of merely having the superhuman
of my life with my cohort, I often                                                       pet lover at heart who
                                              capability of processing mountains of
wonder who will look after the older                                                     is the proud owner of
                                              data and quoting them accordingly.         a dog, and regularly
generation of doctors when they
succumb to sickness. How will the                How many of our colleagues              feeds neighbourhood
                                                                                         community cats. He
older generation of doctors manage            can see this problem and attempt
                                                                                         also enjoys playing
their expectations of the younger             to make a change? How many can             online war games and
generation of doctors and vice versa?         see the problem but will only whine        thinks that playing
                                              repeatedly? How many are oblivious         Pokemon Go is a good
    Perhaps we need to work harder                                                       form of exercise.
                                              and will only worry when the
to groom our children, students and
                                              machines start to appear at our front
interns early on in life. We should instill   doors to take our jobs away?
values that physicians are expected
to hold steadfast throughout our                 I am up now, having just woken
lifetimes. We would need to select            up from a nightmare. We need to
those who have the heart and inspire          really wake up and get out of our
them at a tender age so that they may         comfort zone. While the Ministry
seek that calling when the time comes.        of Health plans the next step
We will need to set good role models          with a focus on the sustainability
for them to follow.                           of healthcare, and monitoring
                                              and managing the health of the
                                              population, our medical community
The threat of AI
                                              should seriously think not only
What we endeavour to do may come              about our future but beyond that. I
to naught if society changes and              look forward to your support in the
expects all doctors to behave similarly       coming months.

                                                                                                                     JUl 2019 SMA News 09
News - Where Innovation Meets Medicine Dual Accreditation in Nuclear Medicine and Radiology
council news

                                                          Report by Dr Lim Kheng Choon

                                           Supporting student-led initiatives              with them her personal journey of being
                Dr Lim is the
                                                                                           on the editorial board of SMA News and
                Honorary                   On 22 April 2019, SMA supported the
                Secretary of                                                               later on, the SMA Council, emphasising the
                                           workshop “Called to See Patients” by
                the 60th SMA                                                               benefits that members would gain from
                                           providing refreshments for participants.
                Council. He                                                                an open feedback channel and avenue
                is currently               The workshop was organised by Dr Ivan
                                                                                           for practice resources. In addition, Dr Tan
                an associate               Low, who was the past president of the
                                                                                           also mentioned that the SMA Council’s
                consultant                 68th National University of Singapore
                at Singapore                                                               advocacy work in light of the recent
                                           Yong Loo Lin School of Medicine’s Medical
                General Hospital.
                                           Society, and his peers. It was conceived        medico-legal cases can only continue with
                                           shortly after they received requests from       the strong support of our membership.
                                           their M5 juniors for essential tips on how         On 31 May 2019, SMA Honorary
                                           to approach and manage important                Secretary Dr Lim Kheng Choon addressed
                                           situations as house officers (HOs).             graduating students from Duke-NUS
                                              SMA, through the SMA Doctors in              Medical School (Duke-NUS). Like Dr Tan,
                                           Training (DIT) Committee, actively              Dr Lim shared about his personal journey
                                           supports student-led initiatives that           as part of the pioneer batch of Duke-NUS
                                           promote education and collegiality.             and the important role SMA plays in
                                           Interested parties with good ideas may          advocating for doctors and patients. SMA’s
                                           approach the SMA DIT Committee at               advocacy efforts in the recent medico-
                                  for assistance and support.      legal cases regarding consent taking and
                                                                                           communication of confidential medical
                                           Connecting with local                           information were also highlighted.
                                           medical graduates                                 SMA thanks TTSH, MOH Holdings
                                           On 22 April 2019, SMA 1st Vice President        and Duke-NUS for the opportunity to
                                           Dr Tan Yia Swam spoke to HOs posted to          address their HOs and graduates to
                                           Tan Tock Seng Hospital (TTSH). She shared       showcase our work.

               A big thank you to all our readers who took part in the “Play and Win: How Well
               Do You Know Your SMA” pop quiz published in the May issue of SMA News.
               Congratulations to Dr Yong Wei Sean for winning the lucky draw prize – A 3M LED
               P1610 Polarizing Task Light (worth $299).

                                                                                   Dr Yong Wei Sean
                                                                               SMA Member since 1995
      Text by Dr Chan Wan Ying, Dr Jonathan Sng and Dr Sonia Lee

                                         Is the transformative age of radiology already here or has it not yet
                                         arrived? Do radiologists really dislike people? Do radiology trainees
                                         trod a lonely life of examinations in isolation?
                                                     Many, including aspiring medical students, may hold
                                                certain misconceptions about this dynamic and ever-advancing
                                                    specialty. SMA News has thus asked three radiologists to
                                                  each share with us a short snippet on their thoughts and
                                              experiences. Read on to find out more.

I believe that we are witnessing the   shaky ground, with sweaty palms
transformative era of radiology. The   and casting a suspicious glare… on
specialty has come a long way since    the normal film. The dark reading
Roentgen’s famous hand X-ray in        room ended up hiding my flushed
1895. My radiology training is very    face more than once.
different from my mentor’s, and his
                                           I have come a long way since that
generation practically wrote the
                                       first film, with more than 10,000
textbooks of radiology as we know
                                       films under my belt in the span of
today. Especially in the last few
decades, the scope of our practice     my residency. A wise person once           Dr Chan Wan Ying
                                       said: To struggle is to grow. When I       is a fifth-year senior
has been expanding as rapidly                                                     resident from the
as the advancements in medical         reflect on my residency, the person
                                                                                  SingHealth Residency
technology.                            who has emerged is not the same as         Diagnostic Radiology
                                       the one before.                            Programme. Her
   In my first year, X-rays were                                                  interests are in
taught as the foundation of                With artificial intelligence looking   body and oncologic
radiology. Yet during my entire        to be the next frontier of radiology,      imaging. She can
medical school training, I have        perhaps my juniors’ residencies will       be found in a dark
                                       also be vastly different from mine.        reporting room
read more microscope slides than
                                                                                  or under a pile of
X-ray films. This is how I remember    The transformative era of radiology        non-fiction books.
reading my first X-ray: standing on    is, to me, already here.

                                                                                                           JUl 2019 SMA News 11
What do I like about                    are captured for posterity as
                       Dr Jonathan Sng is
                       a senior resident in
                                               radiology?                              imaging is stored forever.
                       his fourth year of      I enjoy the rapid pace of work,
                       radiology training      being involved in the care of many      Are there any
                       in the National
                                               patients with diverse conditions        misconceptions?
                       University Health
                       System. He is happily   and interacting with the doctors        Some stereotypes about
                       married and enjoys      caring for them. For example, it        radiologists include us disliking
                       the depth and           is challenging and exciting to          people and having a relaxed work
                       breadth of his work.    switch to discussing neuroimaging       day. While it is true that our day
                                               with a neurologist shortly after        is not physically intense (apart
                                               performing an ultrasound with           from interventional radiology),
                                               the paediatric surgeons.                there is almost never a time in
                                                                                       which we stop thinking or are not
                                               What do I dislike                       mentally engaged with the scans.
                                               about radiology?                        While all specialties have a variety
                                               We can never have an “off” day. If      of personalities, radiologists as a
                                               we are tired or pushing ourselves       whole are quite friendly, although
                                               to interpret examinations               it may be true that many prefer to
                                               faster, the mistakes we make            talk to doctors rather than patients.

      One of the many special things           Dot Course, run by senior residents     juniors’ training, and
      about training in radiology is the       for junior residents. We aimed to       we seek to continue to
      sheer number of examinations             provide our juniors with a fresh        improve this course and
      that we take over the course of five     perspective on the most effective       nurture educators of
      years. That’s 17 to be exact. Our 14th   strategies in acing this exam in a      the next generation of
      examination, the FRCR 2B, is our most    non-threatening environment. By         radiologists.
      challenging hurdle. It is incredibly     doing this, we hoped to not only
      tedious and expensive to prepare for,    improve the overall pass rate but
      and the overall pass rate averages       also create a strong teaching culture
      60% to 70%. That may seem pretty         among residents.                          Dr Sonia Lee is the
      reasonable, but in an average cohort                                               current chief resident
                                                  We have recently completed our         at the SingHealth
      of 14 candidates, that translates to     second annual run of this course,         Residency Diagnostic
      four friends staying behind.             which has been well received by           Radiology Programme
         A close-knit group of us who          our juniors and well supported by         who is on hiatus for
                                               our residency programme. We are           maternity leave. Life
      were studying together for this                                                    has acutely shifted
      examination in 2017 agreed that          happy to report that the overall pass
                                                                                         from interpreting
      we would pay it forward after            rate improved to 90.9% in 2018 and        256 shades of grey
      clearing this hurdle. We created a       100% in 2019, hopefully in part due       to satiating her very
      comprehensive preparatory course         to our efforts!                           own eat-poop-sleep
                                                                                         machine with her long-
      simulating examination conditions,          We are heartened to be able
                                                                                         suffering husband.
      appropriately named the Little Red       to make a positive impact in our

12 JUl 2019 SMA News


          THE       ROADS           BOTH         TAKEN
          Dual Accreditation in Nuclear Medicine and Radiology
                                                          Text and photos by Dr Peh Wee Ming

          My beginnings...                              of what we do – the half in diagnosis –        But this transition was made easier by
                                                        is almost exactly like that of a               the kindness of colleagues. I remember
          Having spent four years in diagnostic
                                                        radiologist, while the other half in           asking a senior, Dr Low Han Chung, to
          radiology residency, deep within the
                                                        therapy is akin to that of an internist        sit in my initial clinics to make sure I
          dark corners of the west and away from
                                                        physician or radiation oncologist. In          was not telling my patients nonsense.
          people (as the running joke goes),                                                           I remember the shining examples of
          my inner internist resurfaced and called      fact, a second and historically dominant
                                                        pathway into nuclear medicine training         classical internists like A/Prof David Ng
          me back to the wards. After some                                                             and Dr Kelvin Loke, who showed me
          not-so-gentle cajoling by my friend and       exists and leads from internal medicine.
                                                                                                       what it meant to do your best for
          mentor Dr Khor Lih Kin, I decided to                                                         patients. And of course, the sweet, sweet
          take the plunge and signed up for dual        One half as clinician
                                                                                                       nurses who made everything better.
          accreditation in radiology and nuclear        Unbeknown to some, Singapore General
          medicine – then a new and relatively                                                             With time, I learnt to titrate thyroxine.
                                                        Hospital (SGH) Nuclear Medicine sees a
          untrodden road with only three brave                                                         I relearnt how to defuse explosive
                                                        significant proportion of thyroid cancer
          souls before me. In lieu of my fifth and                                                     situations in clinic, how to feel necks and
                                                        and Graves’ disease patients in Singapore      hard livers in the ward, how to convey
          final year in radiology, I crossed clusters   for radioactive iodine (RAI) therapy.
          to central Singapore to do two years of                                                      the nuances of a single elevated cancer
                                                        Armed with a measly year of HO-ship            marker and how to hold the hand of a
          senior residency in nuclear medicine.         clinical experience, albeit one enhanced       fellow human being to break bad news.
             The practice of nuclear medicine is        by toxic luck, I tried my best to be a
          about the use of radioactive substances       physician again. This was not an easy              RAI has existed for decades and is the
          to diagnose and treat disease. It exists      transition. Instead of clearing scans and      template “theranostic” compound – in
          as a separate specialty from radiology        X-rays, I had to run full-day clinics. Scans   the context of differentiated thyroid
          and is often confused with sister             do not holler at you after waiting for half    cancer, it tells you where the cancer
          specialty radiation oncology. Part of the     an hour, while hyperthyroid patients (as       is and treats it at the same time. This
          confusion probably arose because half                                                        theranostic concept, a portmanteau of
                                                        any endocrinologist would attest to) do.
                                                                                                       therapy and diagnostics, has become a
                                                                                                       buzzword in recent years and it is finding
                                                                                               2       expanded scope in other cancers, eg,
                                                                                                       peptide receptor radionuclide therapy
                                                                                                       (PRRT) in neuroendocrine tumours and
                                                                                                       prostate-specific membrane antigen
                                                                                                       (PSMA) therapy in prostate cancer.
                                                                                                       These services at the cutting-edge have
                                                                                                       been started in SGH Nuclear Medicine
                                                                                                       and have injected a new vitality into
                                                                                                       the clinical practice. The potential for
                                                                                                       more receptors to target and more
                                                                                                       cancers to treat is compelling and
                                                                                                       awaiting realisation by the plucky.

                                                                                                       One half as imager
                                                                                                       The other part of nuclear medicine in
                                                                                                       imaging has many similarities to that of

          14 JUl 2019 SMA News
diagnostic radiology. I often tell medical    of the very old and very new. For instance,   The added perspective is a means of
students that five main tools exist in        there is deep knowledge hidden behind         immediate feedback for personal growth.
the imaging toolbox: X-ray and related        the humble bone scan, stored in tomes            And of course, the great theranostic
techniques, CT scan, ultrasound, MRI          and journals from the 1980s. On the other     promise is that what we can see, we
scan and nuclear medicine. In essence,        hand, the new PET tracers coming into         can also solve. How far this promise
the joy of the diagnostic imager is the       mainstream use carry with them a rapidly      goes and how much of it can be
same joy of diagnosis shared by the rest      metamorphosing body of knowledge.             applied to our Hippocratic Oaths, can
of medicine. Instead of using open ears       As illustration of the currency expected      be limited only by our imagination.
and a patient heart to hunt for clues in      of us, my programme director and
the history, we use our eyes to look for      mentor Dr Winnie Lam would regularly               I am glad to be walking both roads
clinical meaning on stacks of pictures.       quote papers hot off the press in her         in this yellow wood, even though
                                                                                            it is a journey without end.
   Running the operations of the              presentations. These new tracers have the
imaging service is common to the              potential to image hitherto inaccessible
practice of both nuclear medicine and         problems plaguing humanity (eg, in
                                              the field of dementia, we may one day            1. Society of Nuclear Medicine & Molecular
diagnostic radiology, and is a less visible                                                    Imaging’s Image of the Year 2018. Paired
aspect of our daily routine. We work          image in vivo the key pathogenetic               pre- and post-PSMA therapy scans
closely with allied health professionals      proteins of all major syndromes).                showing marked imaging and prostate-
– nuclear medicine technologists,                                                              specific antigen response in metastatic
                                                 The depth of the nuclear medicine             castration-resistant prostate cancer
medical physicists and radiochemists          kung fu has also been far more                   patients who have failed standard therapy
– to acquire the best images and              profound than I had expected, with the            2. Simulated clinic encounter featuring
deliver radiopharmaceuticals safely.          fundamentals drawing from different              fellow colleagues on the dual-
    Also common to all imaging services       branches of the basic sciences compared          accreditation pathway, Dr Gideon Ooi
                                              with radiology. Knowledge of how the             (left) and Dr Lenith Cheng (right)
is the need for close communication
with the rest of the clinical specialties.    tracers are chemically synthesised,              3. Mini department lunch outing with
The parable of the blind men trying           how they move within the body,                   rotating radiology residents of the SGH
                                                                                               Department of Nuclear Medicine and
to identify an elephant is central            how they bind to target receptors,               Molecular Imaging
to all aspects of the medical craft.          and how the receptors are normally
Communication of what we know from            expressed, are required for proper            Title image and permission obtained from
our respective vantage points is required     interpretation of the scan images.            Prof Michael Hofman, Centre for Molecular
                                                                                            Imaging, Peter MacCallum Cancer Centre,
to approximate truth in each patient.                                                       Australia
    The classical dichotomy of nuclear        The yin and yang –
medicine is that it images functional         coming together
processes, as opposed to the structural                                                        Dr Peh is currently an
                                              Just as PET-CT is a hybrid imaging option
detail yielded by the other radiologic                                                         associate consultant
                                              whose whole is more than the sum of its          with National University
modalities. This is a division that will      parts, I have found that this path of dual       Hospital’s (NUH)
likely blur both ways in the foreseeable      accreditation has been complementary             Department of Diagnostic
future, as newer positron-emission            to both my radiologist and nuclear               Imaging, nuclear
tomography (PET) scanners yield               medicine physician selves. On one                medicine section. He
improved spatial resolution and the           hand, PET-CT is like radiology with cheat        serves on several tumour
other radiologic modalities gain              code on, highlighting morphologically            boards and contributes
improved functional capabilities.             subtle and barely perceptible lesions            to the diagnostic
                                                                                               neuroradiology and
   Another dichotomy that arose in my         in brilliant hues of red. On the other,          nuclear cardiology
training, one that was slightly jarring,      the specificity of the structural findings       services. He was formerly
coming from radiology, was that nuclear       limits the false-positives that come with        chief resident, NUH
medicine imaging was an eclectic blend        imaging ubiquitous biological processes.         Diagnostic Radiology.


                                                                                                                       JUl 2019 SMA News 15

                                                               The X-ray that saved his life
                                                               Chest X-ray. “21/M, RTA.” It was the
                                                               second week of my first rotation in
                                                               radiology. I feel sorry for this young
                                                               man. I opened the electronic notes
                                                               from the emergency department
                                                               to find out more. He had gotten
                                                               together with his buddies for one
                                                               last night out before leaving for
                                                               university in the UK. Despite having
                                                               a few drinks too many, he decided
                                                               to drive home. Ah, the folly of youth.
                                                               Not noticing the lorry in his blind
                                                               spot, he accelerated to overtake
                                                               another car. His car hit the lorry and
                                                               went into a tailspin before hitting
                                                               the expressway divider. He’s lucky to
                                                               be alive, really. Fortunately, he walked
                                                               out of the car relatively unscathed. A
                                                               series of trauma X-rays was ordered
                                                               to confirm that there were no broken
                                                               bones. What a shame – a black mark
                                                               on his record for drunk driving! On
                                 Text by Dr Siva Subramaniam   first glance, the chest X-ray looked
                                                               normal. I methodically went through
                                                               my review areas before I spotted
                                                               the abnormality – a single subtle
                                                               undisplaced rib fracture! Good pick up!
                                                                 Just as I was about to click “next”,
                                                               something caught my eye. The

          16 JUl 2019 SMA News
mediastinal contour appeared a little     component, during which we have              Another way in which you can
lobulated. Mediastinal haematoma?         35 minutes to diagnose 30 X-rays,         help us to help you is to provide
Aortic injury? The aortic contour was     with a passing mark of 90%!               relevant clinical information with
normal. There was no pulmonary                                                      each request. While there are no
contusion or haemothorax. The             Compassion and coffee                     formal statistics on this, anecdotally
findings don’t add up – better ask                                                  the most common clinical indication
                                          Apart from examinations, night
for a CT scan. That same afternoon,                                                 for imaging across specialties is “.”.
                                          calls are the toughest challenge
a CT chest scan was performed                                                       Clearly communicating the clinical
                                          for radiology residents. There is a
and revealed multiple enlarged                                                      picture and your differential
                                          constant tussle between radiology
mediastinal and hilar lymph nodes.                                                  diagnosis allows us to correctly
                                          and other departments on call when
The patient had lymphoma.                                                           protocol the scan, titrate our
                                          it comes to urgent scan requests. The
                                                                                    diagnostic sensitivity and tailor the
    Moments like this are what            radiology resident has to approve
                                                                                    report to the individual patient.
radiologists live for – picking up an     every CT, MRI and ultrasound scan
incidental early cancer and saving        performed while on call. As the
a life, putting disparate imaging         resident on call has to report all the    A new era of imaging
findings together to clinch a rare        scans for the entire hospital, he/        My hope is that radiologists
diagnosis, or allaying the fears of an    she must be selective in accepting        and clinicians will continue to
anxious patient by giving them a          scans. We try to only accept scans        communicate with each other
definite answer to what’s ailing them.    that are likely to affect the patient’s   effectively to better understand our
                                          management overnight. Our clinical        patients’ stories and provide them
The secret lives of radiologists          colleagues who request for urgent         with the best of care. The story of the
                                          scans often interpret our detailed        young man with lymphoma piqued
Many people think of radiologists as      cross-examination over the phone          my budding interest in radiology – I
court stenographers or uninspired         as a bid to block the scan. In reality,   was fascinated by how the humble
journalists who simply report what        we are trying to triage the scan’s        chest X-ray eventually saved his
they see. It is not a glamorous job –     urgency and decide whether it can         life. With the advent of high-end
radiologists are rarely consulted on      be performed during office hours,         scanners, new imaging techniques
Grey’s Anatomy or House. Likewise,        when there are more resources (CT         and artificial intelligence, radiology
patients don’t see the radiologist’s      and MRI scanners) and expertise           is at the forefront of innovation in
role in their care – we don’t get         (radiographers, sonographers and          medicine. However, I believe that
many thank-you cards or cookies.          consultants) available to give the        these advances will augment our
To me, being a great radiologist is       patient and referring team the best       practice rather than replace us, and
really about being a great doctor. We     possible scan and report.                 that radiologists will always remain
need to have a working knowledge
                                             When we are inundated with non-        at the heart of medical imaging.
of every organ system, the mental
agility of an internist and the keen      urgent scans on call, we may only get       Clinical correlation is advised.
instincts of a surgeon. In many ways,     to read scans with critical findings
radiologists act as the invisible force   much later. Furthermore, the more
                                          scans we report, the less time we
that propels patient care across the
                                          are able to spend on each, the more       Dr Siva is Dad to
gamut of specialties.
                                          fatigued we become and overall, the       a mischievous
   To equip us for this challenge,        more likely we are to miss important      toddler. When not
we undergo five years of rigorous         findings. Imagine putting all of your     child rearing, he is
training, which includes rotations                                                  a senior resident at
                                          knowledge of anatomy, pathology,
                                                                                    the Department of
in diagnostic and interventional          physics, pattern recognition and          Radiology, Changi
radiology. Each study we report           logical reasoning to the test multiple    General Hospital. He
as a resident is discussed with and       times a night, with only minutes          has a special interest
vetted by a consultant who guides         to make a critical judgement call         in uninterrupted
and teaches us. Our skills are further                                              sleep, though it
                                          on each case. Though the physical
                                                                                    has been a while.
honed and tested during weekly            demands of a night call in radiology
tutorials, multidisciplinary rounds       are few (hey, it gets pretty cold
and, of course, examinations – which      sometimes), the mental stress on
are tough and numerous. We are            the resident is immense. On a busy
examined on a broad range of              call, a little compassion towards the
subjects, including anatomy and           radiologist can go a long way. (And
physics. Our final FRCR examination       a hand-delivered cup of hot coffee
includes a rapid reporting                never hurts!)

                                                                                                             JUl 2019 SMA News 17

                          2 MONTHS IN FIJI
                             My WH Internship
                                                                             Text and photos by Dr Ivan Low


                      In medical school, we were given the              headquarters for the Pacific Health          Ms Nilva, a consultant from my
                      liberty to fill our time with any “learning       Systems and Policies department of           department, by the tranquil poolside.
                      activity” and have it count toward                the Western Pacific Regional Office          She pulled out a brown envelope (just
                      our elective programme. Some of my                – one of WHO’s six regional offices          like in the movies) and in it was my
                      friends milked cows on a farm in Japan,           around the world. This meant that            brief. WHO Fiji was hosting a conference
                      while others engaged in high-level                I would be able to experience both           on Pacific health information systems
                      research at Karolinska Institutet. But            regional-level and country-level work,       (HIS), and my first task as part of the
                      I knew I wanted to utilise the time to            and get a better understanding of the        Secretariat was to scribe for meetings,
                      explore something closer to heart.                organisation’s roles and interactions with   facilitate discussions, host an exhibition
                                                                        various stakeholders in the complex          and take photographs with my
                         It all started with a text message to
                                                                        field that we call global health.            trusty iPhone.
                      a public health mentor, Dr Clive Tan,
                      who was at that time seconded to World                To answer the second question,              In the weeks to follow, I had an
                      Health Organization (WHO) Manila. He              Fiji is an archipelago-country in the        abundance of opportunities to work
                      was immensely helpful in guiding me               South Pacific approximately 2,000            on some of WHO Fiji’s projects in HIS
                      through the application process and               kilometres northeast of New Zealand.         and health service delivery. Regionally,
                      thanks to him, I received an acceptance           It has more than 330 islands, of             I helped to fine-tune and launch
                      letter a couple of weeks later. That was                                                       the “Healthy Islands monitoring
                                                                        which two-thirds are uninhabited!
                      how my two-month internship with                                                               framework”, assisted in the publication
                      WHO Fiji began in the summer of 2016.                                                          of a Pacific HIS report, and developed
                                                                        Work begins                                  a questionnaire on health service role
                         Why Fiji? In the first place, where is Fiji?   My first day at work was somewhat            delineation policies for Pacific nations.
                          Master “Obi-wan” Clive had it                 surreal. After a ten-hour flight, I headed   Locally, I was part of a team that looked
                      all thought out – Fiji serves as the              over to the Tanoa Hotel where I met          into mapping the healthcare needs of

                      18 JUl 2019 SMA News
Fiji’s rural Northern Division through        valued my contributions, yet there was
qualitative interviews and site visits.       always a comforting layer of supervision
     Many people have asked me what           and gentle guidance. Furthermore,
a typical day as a WHO intern was like.       the team comprised individuals from a
Frankly, there was nothing sexy about         diverse range of backgrounds – there
it. The day would begin at 7 am, with a       were nurses, pharmacists, physicians,
45-minute crowded bus journey down            statisticians, environmental scientists
to the business district. All morning I       and administrators; every conversation
would be flipping references, crunching       broadened my perspective on what
data or typing furiously, save for a          public health (and the profession
couple of minutes spent walking to the        that runs it) was, is, and can be.
pantry for rehydration and deep vein
thrombosis prophylaxis. Lunch would           Other than work
be at the nearby mall with some fellow        Apart from work itself, I spent a great
interns. After recharging, the afternoon      deal of time exploring the capital Suva
will often be filled with meetings,           and the surrounding districts. I witnessed
sometimes held at the Ministry of             an environmental protection public                                                             2
Health’s office down the road, till 6 pm.     campaign at the park, trekked through
    Gradually, amid the routine buzz          (and subsequently got lost in) a tropical       essential to understand how health
of work that surrounded me, I began           rainforest that sat on the edge of the city,    issues affect our communities, and
to appreciate the “WHO method”. The           drank kava with the locals (and felt my         know our roles in our public strategy
Organisation’s strengths lie in being a       tongue and mind go all tingly), partook         toward combating these challenges.
neutral broker, having strong in-country      in their massive meals with gargantuan
                                              portions of rice, and strolled down long            After all, public health is much
presence, and being (relatively) well
                                              stretches of idyllic coral-laden beaches        more than just a professional career
resourced. This enabled it to carry out
its mission of providing leadership and       (1-0 to me for steering clear of Vibrio         or a specialised field of practice. It
setting standards for important health        vulnificus). I have come to realise that this   is a mindset and a way of life.
issues, providing tailored evidence-based     too has strengthened my appreciation of
technical support for capacity building,      sociocultural determinants of health in
monitoring and assessing health               Fiji and the Pacific.
outcomes across the board, and shaping                                                          1. Colonial War Memorial Hospital – Fiji's
                                                  Needless to say, it was an incredibly         flagship hospital
the international research agenda.
                                              illuminative experience. I think all              2. Kava – locals drink it more often than water
   Being an intern in the Organisation        medical students and junior doctors               or wine
was indeed eye opening. The team              should immerse themselves in some                 3. Every Friday is Bula Shirt Friday
entrusted me with critical responsibilities   form of public health exposure during
for important WHO projects that               their formative years of training. Whether
addressed emerging health trends. They        as a full-time clinician/radiologist/             Dr Low is currently
encouraged independent thought and            pathologist/medical innovator, it is              a medical officer in
                                                                                                Singapore General
                                                                                                Hospital, Block 1. He has a
  3                                                                                             passion for public health,
                                                                                                community outreach and
                                                                                                medical education. In
                                                                                                his spare time, he can be
                                                                                                found relaxing at the park
                                                                                                with his family and loved
                                                                                                ones, his dog and a cup of
                                                                                                kopi c peng (siew siew dai).

                                                                                                                           JUl 2019 SMA News 19

                        AS A PHYSICIAN                                                     Text by Dr Nigel Fong

                          A junior doctor’s reflections on what he has learnt so far, and how much more he has to go.

                       I’m rarely sentimental, but recent conversations with starry-eyed 19-year-olds
                       considering a career in medicine (or otherwise) has made me ruminate about “old
                       times” as a pre-clinical student.                                                                Dr Fong is a SingHealth
                                                                                                                        Internal Medicine
                          As a student, it often seemed that the journey as a physician was all about
                                                                                                                        resident. He enjoys
                       clearing the next hurdle – passing MBBS, entering a residency of choice, passing                 teaching juniors and
                       more exams, becoming a registrar, passing even more exams, before finally exiting.               medical students, and
                          As a house officer (HO), priorities changed. Most of us wanted to grow an                     hopes that his recent
                                                                                                                        book Algorithms in
                       extra pair of hands to cope with the never-ending admissions and incessant                       Differential Diagnosis
                       phone calls. We learnt how to keep sick patients alive till dawn and not get                     is helpful for future
                       scolded the next morning.                                                                        generations of
                                                                                                                        medical students
                         But what truly is growth as a physician? I’ve come to realise that it is so much               and house officers.
                       more than jumping through hoops or becoming battle-hardened.

                       A physician grows by…
                                                                                                                                 Learning to manage
                                Developing clinical                   treatable differentials, trying                            uncertainty
                                reasoning                             not to diagnose motor neuron                       Clinical reasoning is important, but
                                                                      disease, because it is such a terrible             sometimes not enough. Patient cases
                        Clinical reasoning – not knowledge
                        – makes the difference between a              disease. So the process of diagnostic              are increasingly complex and one often
                        student and a seasoned medical                reasoning matures from guessing,
                                                                                                                         faces acutely unwell patients with no
                        officer. When I teach students, I find        hypothesis testing, to a combination
                                                                                                                         clear diagnosis. This makes many of us
                        that many can quote evidence-based            of structured algorithms and
                                                                                                                         uncomfortable. But a physician grows by
                        treatment of heart failure, yet are           unstructured intuition.
                                                                                                                         learning to manage uncertainty.
                        stumped when given a breathless                  Algorithms can be learnt and I have
                        patient and told to “figure out what is                                                              First is to have situational awareness.
                                                                      put together some of these with the
                        wrong”. Many can list differentials for                                                          In a sick patient, stabilising physiology
                                                                      caveat that they are not a substitute
                        a symptom, but struggle to interpret                                                             (airway, breathing and circulation) often
                                                                      for seeing real patients. That would
                        what the patient in front of them says.                                                          requires little knowledge of the exact
                                                                      be a tragedy, for an algorithmic
                                                                                                                         diagnosis. When there is little to lose,
                            One critical aspect of clinical           framework without illness scripts is
                                                                                                                         multiple possibilities must be pursued
                        reasoning is the ability to diagnose          akin to a well-organised library with
                                                                                                                         and even empirically treated in parallel.
                        – if one can’t diagnose, one can’t            no books. Indeed, patients have
                        treat. Suppose a 40-year-old                                                                     Conversely, in an elective setting, there
                                                                      proven to be my best teachers time
                        lady presents with a three-                   and time again.                                    ought to be some diagnostic certainty
                        month history of progressive                                                                     before starting higher-risk treatment.
                                                                          Another critical aspect of
                        quadriparesis. Examination finds                                                                     Secondly, I have learnt to think ahead
                                                                      clinical reasoning is the ability to
                        symmetrical weakness with wasting,                                                               and strategise how to go forward. For
                        fasciculations, brisk reflexes and            ask the right questions – going
                                                                      beyond “this patient has asthma” to                example, in a patient with recent cerebral
                        normal sensation. A student might                                                                haemorrhage, a CT pulmonary angiogram
                        connect wasting to nerve or muscle            “why is she having such frequent
                                                                      flares?” or “is this simply asthma,                is of little value, for even if a pulmonary
                        disease, or equate brisk reflexes                                                                embolism is diagnosed, treatment (ie,
                        to stroke. A resident might use an            or something more?” This requires
                                                                      intellectual curiosity, plus the                   anticoagulation) would be contraindicated.
                        algorithm and localise the lesion
                        to bilateral brain or motor neuron            discipline of deliberate reflection                   Thirdly, I have also learnt to engage
                        pathology. A registrar might                  to extract key lessons from patients               the patient (and family) to have an
                        immediately and intuitively recognise         seen, integrate new insights with                  honest conversation about treatment
                        motor neuron disease. Finally, a              existing knowledge and apply these                 options and their risks and benefits, and
                        consultant might think hard for               takeaways to new patients.                         also to make a shared decision.

                      20 JUl 2019 SMA News
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