December 2018 | Issue 39
Mind and heart in the right place

Anne (Custom).jpgBy Anne Loh, Assistant Director, Communications and Outreach

"My interest was actually mathematics," said Assistant Dean for Year 3 Associate Professor Koh Nien Yue. "But at the end of the day, I was looking for a career that would give me the satisfaction of making a difference day to day – medicine was the answer."

Having joined LKCMedicine in 2015, A/Prof Koh has been instrumental in developing the clinical programme for the MBBS course. She is a Senior Consultant at TTSH with specialist accreditation in internal medicine and palliative care who has also been actively involved in the education of house officers, medical officers, residents, senior residents, and nurses at TTSH since 2004.

"At the interview to enter NUS to study medicine, I told them that I think medicine is a combination of art and science and I still see it that way," she said. "Although you can't see the purpose until you come to the clinical years, when you actually interact with patients."


The art and science of internal medicine and palliative care
It was clear to A/Prof Koh that procedure-based disciplines are not for her and she decided to go into internal medicine. "It comes back to my love of mathematics where everything starts off with formulae and concepts. If your principles and concepts are correct, you can apply them in many settings.

"The other part of it is establishing human relationships. It's only from patients' stories that you gather all the evidence so the establishment of that relationship is important because only when the patients trust you enough, then they will tell you their story. The science of it is the detective work but the art of it is the human aspect of it," she said.

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A/Prof Koh teaching a class of LKCMedicine students

While attached to the National Cancer Centre, A/Prof Koh saw how patients didn't get much palliative care as it was not established in Singapore in the 90s. What triggered all this was she was in oncology at the National Cancer Centre. A whole new world opened up to her when she attended a palliative care course conducted by Dr Rosalie Jean Shaw, a pioneer of palliative care in Australia, who had been invited to Singapore in 1992 by Hospice Care Association to develop palliative care in Singapore and the region, as Medical Director.

"From that point, I thought this is something that I can do. It was thanks to Professor Chee Yam Cheng at TTSH who let me have time off my internal medicine training to join palliative units in NCC and Dover Park Hospice, and to train in Australia," she said.


Surviving the pivotal years
Many have called Year 3 "the darkest year in medical school". As Assistant Dean for the Year in question, A/Prof Koh said, "Those who survive Year 3 well are able to carry it through to the fifth year. Although LKCMedicine's integrated curriculum has polyclinic and hospital contact early on, it's still not the same as the real thing. The acuity is not there, the chaos is not there until you step into the ward and you actually see what happens."

There are actually two other major transition points in medical school: the first year and from fifth year to housemanship. "It was a difficult transition for me as well. Coming  from a situation when you don't have much problems passing exams to starting to fail tests, and exams too. From a high functioning, high-flying sense of yourself to understanding what is humility, and learning how to fail better."

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As a passionate teacher, A/Prof Koh is well-liked by many of her students

The first day of housemanship could be traumatic for many people, said A/Prof Koh, herself included, which is why she remembers it till today. "I didn't eat lunch, I didn't eat dinner, I hardly drank the whole day… I knew nothing about half the things I'm supposed to do like discharge patients, mixing medicine, prescription, administer tests," she said. "I wished we had what they have today: simulation, clinicians coming in telling you what you can expect, knowing who to go to, how the system works, how you can serve patients."


Training then and now
Joining LKCMedicine in 2015 as Lead for Medicine was very exciting for A/Prof Koh as the new clinical curriculum for Year 3 was launched. The curriculum team felt they could do better.

"Before, the point was to pass exams. The biggest difference is that we're not just looking at third year but right up to the time students exit the MBBS programme. It's intentionally building situated learning: we wanted to embed students in the ward. We've been encouraging all the ground teams to see the third year students as a member of the team: so they present cases, participate in the ward rounds; only then can you get to know people, know the system, how the real world works. The marriage of what to learn at school, at the bedside in a very exam-oriented way and marrying it with reality, that is the missing link," she said.

Taking the final examinations before going into the Student Assistantship Programme, after which the students start their Post-graduate Year 1 makes the transition into working doctors much gentler, she believes.


The future of managing expectations
Students nowadays find alternative answers online which they then challenge their subject lead with, which is a good thing, as it keeps all parties on their toes in keeping abreast of new knowledge, but they also have to learn what to believe. Patients and their families too search for answers online and they do not know what is right or wrong.

"We must be humble enough to know that we can't be all-rounders but have to collaborate. At the end of the day, the art of dealing with a fellow human being is still necessary," said A/Prof Koh. "What does it mean to be human at the end of the day? When do you exercise your judgement, when every human has its uniqueness? These are humanistic aspects of medical practice."


Keeping positive
Having hobbies that tap a different part of her brain helps A/Prof Koh remain on an even keel, "Working in acute medicine means you tend to see more distressed humans, suffer  the mental strain of working long hours as well as negative outcomes. It helps that I can completely switch off during my downtime with singing, making bread and doing beadwork. Escaping into fantasy by watching the occasional Korean movie helps as well!"

The one thing that has remained constant for A/Prof Koh through her career in medicine is the one thing she can control. "Your heart must be in the right place, whether you deal with students or patients."