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Smooth operator

...under the National University Health System. 'Accuracy, completeness...per cent attrition rate, the Health Ministry told The Straits Times...specialists in 2007. Health policymakers and public hospitals...businessmen. Travel has honed his appreciation
The Straits Times - July 16, 2011
By: Chang Ai-Lien
| More
Smooth operator

AS THE trainee surgeon peels open the patient's chest cavity, Professor Lee Chuen Neng barks out a warning: 'Gently, gently! This is an old lady. Everything we do, we must do delicately and with finesse.'

Prof Lee, affable and easygoing outside the operating theatre, becomes a strict disciplinarian in his domain, intent on ensuring the surgery goes flawlessly and limiting the time the patient's heart is stopped as she goes under the knife.

'When you operate, you are in a trance-like state. All that exists is the job at hand and the people around you,' says the chairman of the University Surgical Cluster and chief of the Department of Cardiac, Thoracic and Vascular Surgery under the National University Health System. 'Accuracy, completeness and speed are the three tenets we work by.'

Prof Lee is passionate about passing on these medical skills, although he admits that training an apprentice to do his job takes far more patience, skill and effort than simply doing it himself.

But he worries that the exodus of doctors to the private sector is creating a dearth of such teachers.

Senior doctors are being offered double and treble their pay to join private hospitals, notes Prof Lee.

Successful specialists can make three to five times more than their peers in the public sector, with some raking in more than $1million a year.

While a few private surgeons continue to teach and do research, no one focuses on these activities, he says.

'My main worry is that if many senior doctors go out to private practice, there won't be enough to supervise the management of the poorer patients, to guide, to teach, to train and be role models.

'A top hospital cannot be run by mostly junior staff, especially in surgery where experience is essential. We can't just read a textbook and operate on patients.'

Public sector hospitals lost more specialists to the private sector last year than ever before, with 103 jumping ship - a 6.9 per cent attrition rate, the Health Ministry told The Straits Times.

The previous high was a loss of 87 specialists in 2007.

Health policymakers and public hospitals are considering various ways to stem the loss.

One solution could be to set up a private wing on campus, suggests Prof Lee.

Creating a few hundred extra private beds would allow the hospital's most mobile bunch - senior doctors - to take on private patients while continuing to train juniors and lead research at the hospital.

They will also avoid set-up costs such as rental space, which can be extremely high.

'It's important for Singapore medicine as a whole to get doctors to stay in the public sector because once they go out, they are unlikely to continue with training and research,' says Prof Lee.

'It is the public sector with its stringent peer review process that has to take Singapore medicine to new heights.'

Prof Lee himself left for private practice in 1992, frustrated when he was not given the opportunity at the National University Hospital (NUH) to expand the number of heart surgeons or develop the speciality properly.

After 10 years at Gleneagles Hospital, he was among a group of hotshot private doctors enticed back to NUH, taking a 40per cent pay cut in the process.

'Frankly speaking, I was quite comfortable by then and I wanted to do more to build up medical training and research,' explains Prof Lee.

'Now things are so different and I can fully develop many surgical specialities.

'Heart surgery itself has nine surgeons, thoracic, three and vascular, three. Each doctor can develop interest in particular areas of the speciality, and be world-class.'

He is so committed to training and research that he donates 20 per cent of his fee from private patients to the department kitty, which is used for anything from funding research projects to sponsoring medical students and nurses on conferences overseas.

Prof Lee has led teams from his hospital on teaching trips all over the world, from North Korea and Myanmar to Armenia and China, as well as training foreign surgeons here.

'People think that surgeons just go in and operate, but there's a lot more to it, it's a science that looks at everything from the type of operation to handling complications and post-operative care.'

But he was not always so focused and admits to running a bit wild after his mother died from cancer when he was eight.

He also sacrificed study time in favour of activities such as the police corps, debating, reading Chinese classics and head prefect duty at Catholic High School.

When he had to repeat Secondary 1, his father, former diplomat and politician Lee Khoon Choy, thought he would end up as a taxi driver, he says with a laugh.

He studied hard enough in Pre-U 2 to make it into medical school but 'woke up' only in his third year when he began seeing patients, he admits. He began to excel, topping his cohort in the final-year medical exams.

'It was then that I saw the relevance of my studies and felt I could spend my life doing something worthwhile.

'For those late bloomers out there, it's never too late to find something you can do well in.'

At the hospital, Prof Lee is also credited with turning a fractious surgical department into a well-oiled group with a united vision.

'Surgeons are famous for their big egos, but I think in C.N. they recognised the ultimate alpha male,' said a colleague.

And he has operated on the world's rich and powerful, ranging from Indonesian governors to Mongolian horse traders and Siberian businessmen.

Travel has honed his appreciation of different cultures and religions, as well as his eye for artefacts. His four offices at the NUHS Tower Block spill over with unusual works ranging from delicately painted pages from Persian books to a walrus baculum bone intricately carved with whales.

Paintings by his father, now 87, also adorn the walls, while a towering stone mural by Singapore sculptor Ng Eng Teng featuring a mother and child is on display in the basement garden area.

Pointing to the mural, Prof Lee reveals that he asked for it when its former home at the Garden Hotel was torn down.

'The owners were willing to donate it and we found a way to dig it out from the wall and transport it here in one piece,' he says.

'In life, there are always opportunities, but you have to be able to see them.'

TEAMWORK: Open heart surgery calls for a large team of experts - three anaesthetists to keep the patient sedated, three surgeons and several nurses, and two perfusionists to operate the heart-lung machine which takes over when the heart is stopped (this is done because it is difficult to perform delicate procedures on the moving, beating heart). An iodine scrub is a must before every operation, and the surgeon's headgear is given a thorough wipe to make sure no specks of dust enter the operation site. The patient's body is swabbed with antiseptic to prevent infections. The operation is filmed and screened in the operating theatre, and can also be streamed to the auditorium for trainees, or used for training videos. -- ST PHOTOS: CHANG AI-LIEN

MAKING THE CUT: Incisions are made with an electrical knife that cauterises and coagulates the blood, to reduce blood loss during surgery, so that most of the time,a blood transfusion is not needed. Apart from slicing through skin and flesh, the surgeon also has to saw through the sternum to reach the heart. It is wired back together at the end of the operation. Professor Lee first cuts open the covering of the patient's heart to reach a damaged heart valve. The heart has three layers. The outer covering, the pericardium, is a tough sacthat surrounds the heart. The middle layer, the myocardium, is the heart muscle. The inner layer, the endocardium, is the thin, smooth lining of the chambers of the heart. A metal rib spreader holds the chest apart while the surgeons work.

HEART-STOPPING MOMENT: Cardiopulmonary bypass is a technique that takes over the function of the heart and lungs during surgery, when the patient's own heart is stopped, maintaining the circulation of blood and the oxygen content of the body. This is done with the help of a heart-lung machine, which takes over function of the two organs when the patient's own heart is stopped: There are The equipment is run by a team of perfusionists, and has at least five long tubes connecting it to the patient's heart, doing things like delivering chemicals to stop it, adding oxygen to the blood, and filtering off unwanted materials. The procedure is commonly used in heart surgery because it is difficult to perform delicate procedures on the moving, beating heart. The heart can be stopped for up to four hours before serious damage occurs.

STATE OF THE ART: Professor Lee (right) wears a surgical loupe, which is equipped with a wide-angle lens and magnifies images 3.5 times. It also protects his eyes against blood splatter. In addition, hHe also wears a headlamp and a camera which allows his work to be screened in real-time or recorded for training. Time is of the essence and the nurse in charge ofsupplying the instruments has to have any of the hundreds of instruments at hand immediately, so the operation can proceed asspeedily as possible.

MAKING THE CUT: Prof Lee (right) making an incision into the patient's heart to locate the diseased valve which is going to be replaced.

FOR RESEARCH PURPOSES: While a normal heart valve is semi-translucent and flexible, this patient's diseased valve, which had to be removed and replaced, was stony and hard. The tissue, removed with the consent of the patient, is taken by the scrub nurse to be stored in the hospital's heart tissue bank for research.

THREADING THEIR WAY THROUGH: Sixteen pink and green threads are sewn onto the heart, in preparation for attaching them to the artificial heart valve. Surgeons alternate the colours used so it is easier to tell where each thread is attached and so they do not get tangled up. The threads are attached onto the ring of the artificial valve and tightened before sliding the valve down to the heart. The disc is made of an extremely hard carbon material and has been shown to function for the equivalent of 200 years without wearing out. Once the valve is in place and the artery is closed, the patient is taken off the heart-lung machine. An ultrasound of the heart done through the oesophagus is used to verify that the new valve is functioning properly. Tubes are also inserted to drain fluids from the chest and pericardium (a thin double-walled sac which contains the heart) following the surgery. The patient can generally go home in about five days if there are no complications.

INSTRUMENTAL DEVICES: A complex operation such as a valve replacement calls for hundreds of sutures, clips, needles, forceps, retractors and clamps. All the needles, swabs and equipment used in the operation must be accounted for before the patient is 'closed'. If anything is missing, a magnet is used to locate the lost item.

ON THE CUTTING EDGE: Professor Lee Chuen Neng says that accuracy, completeness and speed are the three tenets skilful surgeons work by. -- ST PHOTO: CHEW SENG KIM



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