More than a millennium ago, Xuanzang left China for the "West" (India) in search of knowledge. However, he faced innumerable challenges – even an imperial travel ban – in getting to his destination.
Just like Xuanzang, the preamble to my Health Manpower Development Plan (HMDP) fellowship did indeed seem to be fraught with the demons of uncertainties and obstacles in actually getting to the "West". Also like Xuanzang, who tasked himself with obtaining Buddhist sutras, I was to bring back knowledge and skills to augment clinical and academic practice at home.
While I did not quite have the colourful companions Xuanzang had, in the form of the Monkey King (Sun Wukong) and Pigsy (Zhu Bajie), I was fortunate to have the company and support of my wife and one-and-half-year-old son, whose antics perhaps surpassed those of Sun Wukong at times.
The preamble
I've always felt that it is important for a trainee in medicine to get exposed to various methods of clinical practice and management. I benefitted from the "old" traineeship system, through which I gained experience in ophthalmology from various institutes including the National University Hospital, Tan Tock Seng Hospital, Changi General Hospital, KK Women's and Children's Hospital and the Singapore National Eye Centre (SNEC). Exposure to the many mentors and methods enshrined in me that there is no one perfect system and that there are many equally effective ways to manage different conditions. Such varied exposure also enables one to be less rigid in one's ways, and pick and choose the best treatment modality for one's patients.
As such, when I decided to take up subspecialty training in glaucoma, I was hoping to build upon the good foundation I would receive through my local fellowship at SNEC, with a HMDP in a compatible institute abroad.
However, I was told that the procedure for an HMDP award would change from my batch onwards and that it might not be possible get an HMDP from the Ministry of Health like before.
"Grant me the serenity to accept the things I cannot change, the courage to change the things I can and the wisdom to know the difference." – The Serenity Prayer by Reinhold Niebuhr
I'm not much of a believer but the Serenity Prayer has been my go-to mantra whenever I find myself at any crossroads. Thus, assuming that I would not get HMDP support, I decided to apply for a competitive glaucoma fellowship spot at two institutes I held in high regard – Johns Hopkins Wilmer Eye Institute in Baltimore, US and Moorfields Eye Hospital in London, England. I was fortunate enough to get accepted into both fellowship programmes and much to my wife's initial irritation, I chose Baltimore over London. I was subsequently also fortunate enough to secure the HMDP award for it.
The administrative hurdles that I encountered do not quite make for as interesting a read as the many battles Xuanzang and company waged on the demons they encountered throughout their journey, so it should suffice to state that the ultimate journey was well worth these long and dreary processes.
The Hopkins fellowship experience
I had always wanted to go to Johns Hopkins. I had initially considered applying for the Johns Hopkins School of Medicine but was put off by the costs and the fact that it was a postgraduate programme. During my fourth year of medical school at the National University of Singapore, I was supposed to have done an ophthalmology medical school elective there but I (perhaps foolishly) turned that offer down for another opportunity. Following medical school, I wanted to apply for an ophthalmology residency there and for this reason did my United States Medical Licensing Examination while serving National Service. However, given that my wife and I had both secured traineeship spots here in Singapore, it seemed more sensible for us to stay on. A fellowship at the Wilmer Eye Institute was my last shot at a Hopkins experience and I'm glad I saved the best leg of my training for last.
For starters, it was fascinating and daunting to work in a department where nearly every faculty member was a dedicated clinician-scientist. Each one was a global leader (or was working toward being one) in their subspecialty interest within glaucoma, and weekly intra-department "Fresh Air" meetings allowed for very stimulating discussions of future direction in various aspects of glaucoma.
Only two glaucoma fellows are taken in every year at Wilmer. This ensured that each fellow received at least about three to six months of direct clinical, academic and surgical mentorship from each of the eight full-time members of faculty. Some of the attending surgeons like Dr Randy Craven were innovators of novel surgical techniques (eg, minimally invasive glaucoma surgery or MIGS) while others like Dr Harry Quigley were among those who set the gold standard for traditional glaucoma surgery (eg, trabeculectomy). This made each session at the operating room challenging and interesting. We also had fortnightly rounds, during which fellows discussed and debated management strategies employed by various attending surgeons in their management of challenging cases that come through our clinics. All this made for a very fulfilling clinical fellowship experience.
I have been interested in humanitarian work since my traineeship days and wanted it to form a significant portion of my career after the completion of my specialist training in 2014. This was another reason why I chose Wilmer for a fellowship. Dr David Friedman is among the world authorities in angle-closure glaucoma and is also the director of the Dana Center for Preventive Ophthalmology, which focuses on global ophthalmic public health work. Many of my research and global health interests were aligned to his and he continues to be a mentor as I work on some of my research ideas and global health work following my fellowship at Wilmer.
Mentorship
"I never learned from a man who always agreed with me." – Robert A Heinlein
During my time at Wilmer, the ability to disagree and openly challenge various management strategies or techniques was liberating. It made for a vibrant environment in which the trainee and mentor both taught and learnt from each other in the best interests of their patients.
What was also striking was the investment the senior faculty placed in each of their fellows and residents in training. This was evident with the frequent references they made of former Wilmer fellows/residents who are now pushing the boundaries of care in ophthalmology globally. When research ideas were borne out of discussion, the faculty generally made it a point to place the trainee at the forefront of these ideas while guiding him from the backseats.
A great mentor is one who continues to learn even as he teaches. An example of this was when I suggested a particular suturing technique I had learnt during my fellowship in Singapore as an alternative way to that which was being taught to me by one of my attending mentors. Despite his many years of experience, he asked me to show him the method and now continues to use it for his surgeries. This humility in mentorship was another good lesson I picked up from my one-year stint at Wilmer.
Summary
My HMDP fellowship inculcated in me a keen interest in academic and research work, gave me opportunities for collaboration in humanitarian and ophthalmic research work globally and broadened my approach to glaucoma management, while also deepening my foundation in the subject.
Singapore's HMDP programme is unique. It facilitates doctors to do a fellowship and learn from the best globally. I hope my juniors will continue to benefit from HMDP just as I and the many seniors before me did, so that Singapore continues to be a global hub of medical care and research par excellence.
Acknowledgements
I would like to specifically thank my mentors, Prof Aung Tin, A/Prof Ho Ching Lin, Prof Wong Tien Yin and A/Prof Shamira Perera in supporting my fellowship application, and the many mentors in Wilmer, including Dr Pradeep Ramulu, Dr David Friedman, Dr Harry Quigley, Dr Randy Craven, Dr Henry Jampel, Dr Michael Boland, Dr Amanda Bicket and Dr Ian Pitha, from whom I learnt a great deal and upon whose shoulders I am trying to stand. I also thank my wife Dr Srividhy Jayant Iyer – who ultimately enjoyed the Baltimore experience – for taking a back seat in her career for this year so that I could continue to learn, and my parents and siblings who've been instrumental in supporting me through my career and in setting my moral compass.