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Between May 9 and May 30, I was a patient in the Klinik Kepakaran Pembedahan Kardiotorasik (Cardiothoracic Surgery Unit, CSU) of the Penang General Hospital. I had an open-heart operation to treat my enlarged aorta, and severe aortic regurgitation. Datuk Dr Basheer Ahamed Abdul Kareem, the director of CSU, performed the “Bentall procedure”, aided by a team of doctors and nurses, on May 11. I was discharged on May 30. During that period, I thought of my experiences with the ward, patients, nurses and doctors.
The rectangular ward was a relatively modern, air-conditioned and brightly lit part of an old building. It had 22 beds divided into four spaces, two each with four beds and six beds. Some beds were used for the newly admitted. Others were designated for post-ICU recovery. The rest were occupied by patients awaiting discharge. Since the ward had its beds facing the nursing stations, little inhibited communication between nurses and patients. The ward could have been improved. Its connection was well guarded at one end. The other end was occupied by a cupboard full of patients’ uniforms and rooms filled with unused stuff — older machines, surplus furniture and so on. From my impressions, the ward was well equipped but lacked a few items, such as consumables that included adult pampers and wet wipes. In the morning, patients sat on long heavy chairs of which some of the armrests were worn out. There were specific times for changing the patients and their bedding, giving them meals and medicine, providing them with hot water and the doctors checking on them. The lights were partially dimmed around 9pm and mostly turned off around 11 pm. The next morning, “lights out” would be finished at 5am.
Patients stayed for different periods, a week to 10 days being the norm. The patients were racially well distributed. In age, they were mostly in their 50s and 60s. The majority were men. I did not know the patients’ socioeconomic profiles. Their appearance and speech suggested they were there for the most basic of reasons. The operations were performed free, or virtually free, except for special payments for replacement “spare parts”. The CSU has a very good reputation and the hospital is convenient for people who live in its area of coverage, Northern Peninsular Malaysia. The patients I was with came from lower to moderate-level government service or smaller-scale private sector backgrounds. They were often retired. They had undergone or were being prepared for major cardiothoracic surgery.
A patient initially stayed in bed, spending long hours under sedation or semi-conscious before coming around to full awareness. It was tiresome to be bound by tubes. But one could not have expected much more since the operations were major ones. As one’s condition improved, one was put through physiotherapy — simple breathing methods to expand the chest cavity and guided walks through the ward. A doctor said tersely, “We discharge those who can walk to the toilet and bathroom on their own.” Perhaps that explained why a number of patients walked but, despite the urgings of the physiotherapists, not many went through the breathing techniques.
Bound to their monitoring devices or because of their condition, the patients were largely quiet. They spoke with their visitors and or their neighbours in soft tones, or kept their own counsel. The mood was somehow sombre, the voices hushed and the smiles faint. The unofficial rule of the community was empathy and help in the smallest things — alerting a nurse, pointing out fallen things and offering advice: there was a community of the sick.
The nurses were mostly young to middle-aged Malay women and some men. They were formal and proper or worked in good spirits. The older female nurses were more informal, conversing as they worked. The more vocal among them maintained cordial relations with the doctors, laughing and bantering with them. The nurses performed many kinds of service. They checked the monitoring devices, took blood pressure, drew blood and sent it for testing, applied intravenous medications and saline solutions, distributed oral medicines, did dressings and removed sutures, changed bedding, clothing and pampers, cleaned the patients, removed portable urinals, took the patients to other departments (for ultrasound scans, for example), maintained records of the patients and so on. Those services were performed from the patients’ admission to their discharge.
As a cohort, the nurses were remarkably competent, courteous and cheerful. They addressed me as “Uncle”. To my embarrassment, they unfailingly said, “Sorry, Uncle”, before or while doing anything for me. I tried not to bother them; yet I often had to call on them for small matters. They worked in shifts. I did not investigate their salary levels. They were probably placed at the lower end of the civil service salary hierarchy. One hopes that they receive terms and conditions commensurate with the calls placed upon them, and the excellence with which they responded. I am glad I thanked them each time they did something for me. Perhaps they knew me better than other patients who had not stayed as long as I did. To me, they provided a level of service not inferior to that of Japanese nurses who operated in a wholly unfamiliar cultural context.
Many doctors served in the ward, men and women in approximate balance, racially well distributed, and ranging in age from the 30s to the 50s. As a group, they spoke to the patients in Malay, Chinese (both Mandarin and some dialects), Tamil and English. There was no “white coat syndrome” on this ward of adults. Some doctors wore blue “scrub suits” as they came to the ward between surgeries, for work shifts or rounds. Many wore non-uniform clothes, simple as those worn by the majority of the hospital doctors. Their work dress imparted a strange quality. One did not distinguish between them by their dress, only by their faces, and these were partially covered by masks, and patterns of speech.
One assumed that they would be inured to their patients’ suffering. They were but they remained compassionate. One saw this when one or more doctors stopped during their rounds, called to the side of the patients, to check their condition and ask for special forms of treatment. At such times, the doctors spent more time with the patients, focused on the latter’s condition, seemingly not worrying about other cares.
Mostly the doctors came twice a day to see the patients, in the mid to late morning and in the late afternoon or early evening. These rounds enabled the doctors to ask how a patient was doing and to see if any medication or treatment had to be adjusted or changed. The doctors came in groups of four or five with a nurse with the files. One or more of the senior doctors consulted these notes and decided on the next course of action. Roughly the same questions were posed to the patients: How are you? Have you had any pain or fever or nausea, or any other problem? If a patient did not display any such symptom, he or she would be passed over fairly quickly, for example, after a brief check of the shins to rule out water retention. The patients relished the doctors’ rounds because they broke the daily tedium and allowed a patient to take in what the doctors said among themselves, or to ask about oneself, or to seek some reassurance. Beyond a time, every patient wanted to ask, “When can I go home?”
It is astonishing that the doctors could have done so much for the patients, expecting little if anything in return. “I wouldn’t undertake your operation if I couldn’t have the cooperation of my team,” my chief surgeon said to me. For my operation, he had the assistance of a large team of five surgeons, five nurses, three anaesthesiologists and three other doctors manning the by-pass machine. They attended the operation from 8:30am to 4pm. It was a full day’s work, and still some of them conducted ward rounds. It was crazy for a doctor to work over 30 hours in a shift. Yet the doctors did so in turn. They remained jovial, complaining of their burden but in a lighthearted, head-shaking and almost disbelieving manner, as if it could not be avoided. And some had even to work outside Penang during their shifts.
The CSU is an important unit of the hospital, small compared with the much better known Institut Jantung Negara (National Heart Institute) in Kuala Lumpur. The unheralded CSU provides more than essential cardiothoracic operations. It regularly gives warfarin to certain patients, post-operative reviews and advice to potential patients. Its surgeons periodically perform emergency operations in different parts of the country. Each day, many demands are placed on them, judging from the number of patients who called at the CSU for outpatient consultations. These are the days of the Covid-19 pandemic, an ageing society, the unstoppable move of public specialist doctors to private practice, and rising inflation — especially of the costs of private sector medical care. The hospital is crucial to those who look to CSU for excellent, free or almost free, cardiothoracic surgery. Besides, patients consult the doctors many times even after their operations. Government servants or retirees pay nothing while non-government patients pay only RM5 per visit. But the CSU’s ameliorative role can only be maintained if there is an adequate expansion of its specialist and nursing personnel, the purchase or refurbishment of technical equipment, and an improvement in the terms and conditions of the doctors’ and nurses’ employment.
So much remains to be done that calls for a substantial and sensitive allocation of financial resources to the public sector hospitals. Money is presently invisible in the ward. Money is not something that is considered by the doctors, nurses or patients in the daily ward scenes. That is the crux. The Penang General Hospital offers services to the public at no cost or, at most, at minimal cost. The CSU operations are very expensive if performed in a private hospital. I paid RM1,000 — RM500 each for the replacement aorta tissue and the aortic valve — and that because the doctors knew I could afford the amount. But I saved about RM250,000 by having my operation at the hospital. The post-operative recovery is costly, too, because of the high expense of staying in the ICU and the ward, and the many kinds of medication prescribed. The patients are rarely burdened by the costs of medical care. Nor are the doctors and nurses. Medication and special equipment are used as needed, never primarily decided by monetary ability.
Services are performed as between professionals and patients. Never is race an issue. When I was discharged, more than one nurse held my hand and warned me in Malay to have no visitor, to wear the “chest hugger”, to desist from heavy work, to stop carrying heavy things and so on, for three and maybe six months. What a contrast this conduct presents to the obsessions with race that are toxic to our politics. At the CSU and the hospital, public service is provided with no care for the racial identity of the patient. That is how the service should be accepted. One can imagine Malaysia being a more comfortable place to live in if the country was managed like the CSU and the hospital.
On the Sunday evening of May 29, one day before my discharge, the chief surgeon and his close assistant, Dr Dalvinder Singh, came to check on my condition. A proud Dr Basheer showed me a smartphone photo of a ceremony with a large number of well-dressed members of the medical community that he attended in Kuala Lumpur. The photo was part of an examination of “wannabe specialists” and a medical conference. “I’m so glad we have seven cardiothoracic specialists this time,” he remarked. “And I hope they will stay in public service … to serve the rakyat.”
Khoo Boo Teik is professor emeritus of the National Graduate Institute for Policy Studies, Tokyo, and research fellow emeritus of the Institute of Developing Economies, Chiba, Japan. He is the author of Paradoxes of Mahathirism and other books.
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