Conversations with Dr Mala Satkunanantham

By Tan Yu Han
Dr Mala Satkunanantham works as a Hand Surgeon in the Department of Orthopaedic Surgery at Tan Tock Seng Hospital. Dr Mala completed her undergraduate medical studies at the National University of Singapore Yong Loo Lin School of Medicine. It is not the only school that has left quite an impression on her, however; she also remembers how, in her primary school, students were made to sing a song called the “4 ‘C’s” (Courtesy, Cooperation, Carefulness and Consideration) – which she, at that time, definitely did not take well to. Looking back, she is surprised at how relevant the “4 C’s” are to the values and competencies that form the practice of medicine.

Dr Mala: I am a Hand Surgeon. Hand Surgery is a combination of Orthopaedic Surgery (mainly work on bones and limbs) and Plastic Surgery (reconstructive surgery). We perform surgeries on the hand, the forearm, and reconstructive surgery for upper limb and lower limb. That includes nerves, blood vessels, and tissue coverage. Another name for this speciality would be “Hand and Reconstructive Microsurgery”.

(In Singapore, unlike many other countries, Hand Surgery is a specialist training programme in itself. One does not have to go through Orthopaedic Surgery or Plastic Surgery training before specialising in Hand surgery.)

In general, the job of a doctor encompasses various roles. As a junior doctor, you would spend most of your time doing clinical work, which means dealing with patients.

Clinical work in Hand Surgery involves emergency work and elective work. Bad wounds or fractures that require immediate attention, would be considered examples of emergency work. In elective work, there are less urgent issues, such as arthritis, numbness in the hand, or chronic problems like tendonitis.

Aside from clinical work, a doctor also has other duties, such as research. We publish and share our research results so that hand surgeons from other parts of the world can learn from us. All doctors are also involved in teaching from the minute they graduate; teaching medical students, mentoring junior doctors, teaching colleagues and teaching people in other departments. Doctors also have administrative work. It’s really not just clinical medicine, after a while.

In my speciality, we get quite a good workout in the operating theatre! It really is manual labour – we need to pull bones, lift heavy legs and arms, use saws, drills, put in metal implants – it’s quite physically taxing. Some microsurgery cases can take as long as 15-20 hours. Persevering through these cases requires patience, stamina, a good team and ideally some nice music playing in the background.

Dr Mala: I think as a surgeon (or a doctor), one may be afraid of doing something wrong, or not being good enough. Maybe it’s the same in some other lines of work. I remember once as a junior surgeon in the operating theatre, the most senior doctor asked the second-most senior doctor (who in my eyes was already very senior) to stitch a wound. It was a simple task; something the most junior doctor in the theatre would usually do. I remember the doctor picking up the needle holder and the needle with his hands shaking, but managed to complete the task well. When we asked him later why his hands were shaking initially, he said, “No matter how senior you are, when that senior doctor asks you to do something, no matter how simple, the amount of stress you feel is a bit overwhelming.” This taught me that if someone so senior could be nervous, it was alright for us to be, too.

Dr Mala: Absolutely – most jobs involve some degree of stress, though. The important thing is to recognize that and learn how to manage it.

One of the best ways is to talk to your colleagues about it because often, they have experienced it before. We tell our younger colleagues during morning rounds (which can be very stressful) that we’ve all ‘been there.’ We tell them, “Don’t worry! Just keep learning and don’t be afraid to ask for help.”

Dr Mala: No. The medical track can begin quite soon after JC. You may enter medical school immediately if you choose to do medicine at the undergraduate level. Alternatively, certain universities offer medicine as a postgraduate degree such as Duke-NUS in Singapore, where you do an undergraduate course before medical school.

I did my undergraduate medical studies in NUS. After medical school, graduates are often bonded to government hospitals, which is good because you get work immediately. Sometimes, if you study medicine overseas, it may be a bit difficult to find work when you return home.

When you start work, you complete a few different postings, where you spend several months in different departments. It allows you to better understand the work you do, rather than simply having theoretical knowledge. After your postings, you can apply for training programmes where you learn more about your field in order to become a specialist.

Dr Mala: Something that people talk about a lot nowadays is passion. I struggled a lot in the beginning because I didn’t really know what ‘passion’ was – I didn’t know whether you had to feel it in order to do a good job. I recently heard from another doctor, though, that his mentality was, ‘You don’t need to have passion. You just need to have determination, the ability to do your job properly, and you can make things work.’

If you hate your job, that’s something else altogether, but I don’t think you strictly need to have passion to be successful; you just need to have a bit of determination, and the tenacity to go ahead to do what you want to do.

I have great colleagues and a good working environment where I am now, so that helps too!

Dr Mala: No! As a child, I wanted to do fancier things that were perhaps less pragmatic, but more ‘fun’ at the time. I wanted to be a palaeontologist when I was small because I was very interested in dinosaurs. However, practically speaking, it’s probably not the best job to do, especially in Singapore.

I also wanted to do geography as a profession, because in secondary school it was my favourite subject.

In the end, I chose medicine because of its versatility, and how it has a mix of logic, science and even the arts. People often talk about the ‘art of medicine’, or the ‘science of medicine’. The ‘science of medicine’ is the medical knowledge, and research; the ‘art of medicine’ is the ability to communicate with and understand your patients or your colleagues properly.

No matter how you ended up doing medicine, there may be a field that you can find that you are interested in, because it’s so broad; whether you like to talk to people, prefer not to talk to them, enjoy microscope work, or delight in planning and dealing with public health or international health problems. Medicine is huge.

Dr Mala: I asked some of my colleagues about this. We all have different opinions, and if you’d asked me this five or ten years ago, my answer then would’ve been very different from now.

I think the traditional answer would be, “Don’t give up, medical school is just the start of it.” Medical school, ultimately, is still school, so you can use your school-coping mechanisms to cope – which can be going out with your friends, going for exercise, or taking a break. This way, you can really put in the effort to do well in your studies.

It is also important to realise that sometimes, your sources can be wrong, especially when it’s hearsay. Due to this false information, you may change your path, and later if you do find out your decision was based on wrong information, it can be disappointing.

However, my response now is that if it deters you, then don’t do it. If you compare yourself to the other university courses, you do get fewer holidays, you may need to study more, you might have less time to do extra-curricular activities and less time to go on vacation. However, medicine is a tight-knit group, at least it was when I was in school. Everybody goes through the same struggle, so you don’t need to feel bad, or compare yourself with students in other faculties. If you want to compare, then compare with your fellow faculty members who got the same lousy holiday schedule and have a good laugh about it.

You know, a funny thing about many surgeons is that if you ask them, “How was medical school or surgical training?” They’ll often tell you that they failed an exam during their school or training. Some surgeons did anatomy twice because they failed anatomy the first time (anatomy and surgery are closely linked), and some had to repeat their specialist exam. The thing about them is that they didn’t let it stop them – maybe they were down for a few months, I think that’s pretty normal. As you grow older, you’ll find that a few months, one or two years delay, doesn’t make much difference.

I wouldn’t tell people not to study medicine if they were interested in it; just that they’d need to work hard, as with everything else. There are postgraduate options to do medicine, so if you study something related as an undergraduate, and after that, decide to pursue medicine, you have the option to do so. You may be older than some of your colleagues, but again, in the long run, 3-4 years doesn’t make much of a difference.

At the end of the day, I think that if you really don’t want to do medicine, then don’t do it. If the thought of it terrifies you, and you’d rather do something else, then you should follow that feeling and do something else instead. However, if you want to do medicine, but you’re worried about the difficulty of medical school, then your determination to do medicine should get you through.

Dr Mala: It would be naive to say that women in a mostly male environment would not face some kind of challenges, whether it is in the form of jokes, insensitive comments or stereotypes. I’ve been pretty lucky, though – the department I work in values surgeons for their skill and compassion, rather than for their gender!

There are more female surgeons nowadays too. Even most of the lead characters in ‘Gray’s Anatomy’ are female surgeons! Gray’s also highlights some of the real difficulties that female surgeons may face – from family, friends, colleagues and patients.

When I was going to medical school interviews many years ago, the female candidates were told to prepare for a certain question. “When (not if) you get married and have children, will you continue to practice medicine?”

The problem is that people forget that marriage should be a partnership. Parenting should be a shared responsibility, and I hope that the person I choose to have a child with shares my views so that we can look after the child together. There is no reason why they should ask a woman this, and not a man. Thankfully, they don’t ask this anymore! I think people are more aware of how insulting these questions are.

Just recently, I was asked, outside of my work, if female hand surgeons were just not (physically) strong enough to be orthopaedic surgeons. It seems like an innocent enough question, but it isn’t. The underlying assumption is that women are weak – no one ever asks male hand surgeons if they’re too wimpy to do orthopaedics. Most people aren’t even aware that they’re exposing their bias against women with questions like this – but they might understand if you point it out to them. So point it out! Start with friends and family, and work your way up, spreading awareness.

Some people still think that women should just raise children and cook. Whether it is insinuated by friends, relatives, colleagues or even patients, this is particularly hurtful if said at a time of insecurity – for example, if already struggling to balance family and a career. It can break the spirit of a potentially excellent surgeon. I sometimes witness such situations and find that I need to pull the trainee aside and tell them – no, it’s not true, you are strong; persevere and ignore the said naysayers!

The reality is that we are going to face challenges as female surgeons. To get through it, first, acknowledge that it happens. Next, try to change it step by step. Get some support from friends and family and if possible, find a role model that you respect, and can turn to for advice. And when it’s your turn, be a strong role model for younger surgeons. Make it better for them that it was for you.

(To aspiring female surgeons/women aiming to reach greater heights, the interviewer highly recommends reading ‘Our Lives to Live: Putting a Woman’s Face to Change in Singapore’ for inspiration on the history of women in Singapore. Credit goes to Dr Mala for introducing the book to the interviewer.)

Dr Mala: Safety awareness. In the medical profession, particularly in surgery, we are extremely careful never to put our patients at unnecessary risk. We avoid surgery in which the risks are high and the benefits doubtful, and we’re always aware that our patients come to us for help with problems – we mustn’t make their problems worse!

We also place great value on developing others and building a successful team. As you age (as we all do), somebody else needs to be able to fulfill your role. You need to teach them to be as competent as you are – or even more competent. Most patients have a preference for senior doctors. The truth is that we can’t go on working forever, so the young doctors need to have enough experience, so they can take over at some point.

Communication is important, aside from the obvious reasons of needing to work with doctors from other disciplines and other healthcare professionals, if you do not communicate the full medical history of a person, mistakes may be made, such as not knowing drug allergies.

Continuous learning was also one of my choices. You’d think you’d already learned everything after medical school, but as a surgeon, when the skill becomes hands-on, the next few years will be a steep learning curve. That’s probably why many people feel anxious about junior doctors, but we always work as a team, so there’ll always be a senior doctor around to guide them. That’s part of our responsibility to our patients.

Technical/Professional knowledge and skills – we are very skills-based. It’s hands-on, and you’ve got to learn fast.

Oh yes, in my primary school, we were made to sing a song called the 4 ‘C’s. We sang it – it had an awful tune – and the 4’C’s were Carefulness, Consideration, Courtesy and Cooperation, maybe not in that order. But these sound like things you have to live your normal life with. As a surgeon (doctor), it goes without saying, you have to be extremely careful. You have to be very considerate, for example when a patient is in pain or anxious, the doctor should be gentle with them and try to understand their problems. Courtesy is especially important in any role where you have to deal with people. A hospital doesn’t function on one discipline alone, so cooperation is needed across disciplines, and also between the doctor and the patient, to try to achieve a good outcome.

Enjoy your career choice! And remember, they say it’s never too late to start something new.