KAMALIKA PIERIS

The History of Surgery published by the College of Surgeon of Sri Lanka (2022) has   provided a very positive picture of the role of our general surgeons. The first surgeons in the island were General Surgeons” who were expected to   deal with all surgical cases that came their way.  All surgical operations were done by them till the end of the 1950s when specialist surgeons started to appear. But some general surgeons had to carry on even after specialist surgeons made their appearance. As late as 1970, the general surgeon in Anuradhapura said he had to do a craniotomy for a head injury and had to deal with orthopedic complaints as well.

The College of Surgeons pointed out that the general surgeon was particularly skilled in assessing surgical patients on admission, and deciding on who needed urgent treatment, also the treatment required (triage). They also dealt skillfully with any surgical problems that arose in the hospital wards.   

In the early period, when there were no specialist surgeons, the general surgeons had voluntarily engaged in specialist surgery.  They did it as a service. This is not well known. The pediatric surgical service at Lady Ridgway Children’s Hospital in Colombo was for a long time run by general surgeons who agreed to operate there.

While serving at the Ratnapura Hospital in 1992 Dr. Wijaya Godakumbura had seen many patients who had serious burn injuries due to unsafe kerosene bottle lamps.He invented a safe bottle lamp where the kerosene did not leak out when toppled. He received the Rolex award for this in 1998. He used his Rolex award and other contributions to distribute one million of these safe low cost lamps to families in Sri Lanka.  Godakumbura received inquiries from all around the world for the lamp design which he shared freely.  He has given presentations on injury prevention at international conferences in many countries.  

The surgical service expanded during the seven decades after independence and   surgical treatment is within reach of even the poorest patient today, said the College of Surgeons, proudly. From 60 general surgeons in 1986 the state service had expanded to 176 general surgeons in 2019. 

The number of surgical units in hospitals had   also increased, over the years. The general surgical units in National Hospital Colombo were increased to 7 in 1958.  The quota of two general surgeons per provincial hospital was increased to   three general surgical units in the 1960s.  Base hospitals had only one surgeon till 2004,  this increased to two, but with only one operating theatre.

However, the figures given in the History of Surgery do not show a spectacular expansion. There is no huge leap in bed strength or surgeons. In 30 years, the number of surgeons in the Western Province only rose from 35 to 53     Beds in the surgical wards only increased from5627 in 1991 to 11,734 in 2019 for the whole island.  There has always been a shortage of surgeons, noted the History of Surgery.   

Initially doctors had to go abroad at their own expense and qualify as surgeons. The cost was prohibitive and only those who could afford it were able to do so. They usually sat the exams of the Royal College of Surgeons, London, (FRCS) or the exams of Royal College of Surgeons, Edinburgh or Glasgow.

From 1947, the Primary FRCS exam was conducted in Ceylon. This was due to the   efforts of Sir Nicholas Attygalle who had successfully negotiated with the Royal College of Surgeons, London to obtain this. The exam was held at the Medical Faculty of the University of Ceylon. Candidates were examined jointly by the professors of the Colombo Medical College and examiners from London.  In 1960, the government   started to bear the cost of holding this exam in Sri Lanka, and the examinees did to have to pay anything.

Local training for surgeons, instead of London, came up for discussion in the 1970s. The desirability of locally trained surgeons, which had been tentatively suggested much earlier, now came into the open.

Dr Shelton Cabraal in his Presidential address to Sri Lanka Medical Association in 1974 said that specialist training in the west was unsuitable for two reasons, the disease patterns in the west were different to ours and their   theatre facilities were superior to what we had here. Therefore our doctors when they return find it difficult to work with the limited facilities in the provincial hospitals.  . Doctors should be trained in the environment in which they will be working and there is a clear need for local Post graduate medical training I advocated this when I was President of GMOA in 1958 but the younger doctors were against it,” Cabraal said.

In 1973, the Advisory Committee on Postgraduate Medical Education recommended to    the government that it should start to train medical specialists locally.The Postgraduate Institute of Medicine (PGIM) was set up for the purpose at the University of Colombo. In 1980 the government decided that the specialist qualifications given by the PGIM would be the only qualification recognized in the state health sector. The degree of Master of Surgery from the University of Colombo would be the sole qualification recognized for a surgeon in Sri Lanka. 

The Primary FRCS exam in Colombo was stopped    but those already possessing the FRCS continued to be recognized as surgeons. The transition took place smoothly observed the History of Surgery.   My own view was that the two qualifications should have run parallel for a few years, to give the local qualification time to develop.

The Board of Surgery of the PGIM was responsible for training surgeons.  There were nine specialties, offered by this Board, general surgery, gastro intestinal, oncology, urology, pediatric, plastic, cardiothoracic, vascular and neuro surgery.  General surgery had seven special interest areas which included breast surgery and trauma surgery. Trainees had to select one of these as a special interest.This gave the trainees a far better exposure to the specialties than they received in London, said the editors of the History of Surgery.  

The trainees were from the state sector and they continued to be paid while in training.  They only had to pay nominal amounts for registration, tuition and exams. Those who were successful at the first attempt had their exam fees refunded.

The training was carried out by the teaching staff of the universities and by consultants in the Ministry of Health. College of Surgeons has contributed to the PGIM training in various ways, including mock exams.  There had been continuous evolution of the exam structure and in 2015, the Board of Surgery   started to evaluate both the exam and   also its individual examiners.

The ready support given by the medical profession to this sudden transfer of qualifications from London to Colombo has not, in my view, received the appreciation it deserves. This venture, where the legislation preceded the training, instead of the other way round, would not have succeeded if not for the whole hearted support of the specialists who were already in service in Sri Lanka.

The examinations were   conducted at the Medical Faculty, Colombo jointly with examiners from the Royal College of Surgeons, London.     The written papers for the first MS Part 1 was held, under police guard at a neutral venue, the Agrarian Research and Training Institute, in Colombo as the GMOA was opposed to local post graduate qualifications. 

 There was also a period of compulsory training aboard. The initial preference was for training in UK, but later trainees went to Australia, Germany, Hong Kong and Singapore as well.  Placement was not easy and Sri Lankan doctors working abroad were extremely helpful in obtaining placements in their hospitals. Some of these doctors are mentioned by name in the book.

Local postgraduate training in surgery was an important factor in the development of surgery in Sri Lanka said the History of Surgery.  The general and specialized services expanded over the last four decades specifically due to the PGIM.  The brain drain of surgeons slowed down after the PGIM came in, because, among other factors, they could now practice the surgery that interested them.By 2019 PGIM had trained 269 surgeons in general surgery and 95 in orthopedics.  

The PGIM training in surgery is much in demand in the region and there are more than a dozen foreign students in the progamme. The PGIM could be an important regional   center in the future, said the History of Surgery. (Continued)