President’s Diary

President's Diary


Dr Duminda Munidasa

A new year amidst constraints!

January 2023, another year. Growing up, we used to eagerly anticipate the beginning of yet another year. However, I believe that, the beginning of 2023 is not that simple for CCP members and the general public of Sri Lanka alike. Reeling from the effects of the pandemic followed by the economic debacle, we still have not recovered our footing. Every day is a challenge marred with uncertainty. Yet, we still stand.

Personally I begin the year feeling both humbled and privileged by your resolve to bestow upon me the prestigious presidency of the Ceylon College of physicians in the 56th year of its existence. I am determined to do my utmost to deliver the best possible service to present and future college members, to our patients and to the country at large, using available resources amidst all the challenges we face at present.

I send best wishes for a happy new year and thank all past presidents who trusted in my ability to serve our college as the president. I would like to express similar sentiments to all those who applied and showed their desire to be in the council this year. Irrespective of finding a place in the council, all pledged to support the work of the college. I very much appreciate this level of understanding, trust and loyalty. No matter what constraints are going to be there in the new-year, the college will stand tall with all flocked around the “Mahagedara” of all physicians.

CCP 2022 team showed the true spirit of resilience: not just surviving obstacles but standing taller and stronger for having gone through the trials. We survived, but the challenges are only beginning. In the year just begun, we anticipate the full impact of the economic crisis to manifest particularly with dire effects on the health sector. The college will need to use all resources at its disposal gained by “bridging gaps and crossing divides” to help our membership to deliver “holistic care amidst constraints” to our patients.We will need to work closely with the administrators at the Ministry of Health to foresee the problems and find solutions in a timely manner.

Using the available resources with care through shrewd management is a way in which we can contribute. Using lessons from the history, moving towards more clinically oriented medicine may help to rationalize the use of investigations and medications, thereby preserving resources. I intend to continue our academic programmes with more clinically oriented input for the benefit of our clinical team members including medical officers and postgraduate trainees. Ability to lead, communicate well and manage work related stress, are going to be key areas that will contribute to successfully overcome the crisis that is likely to befall the health sector in 2023. I envisage to incorporate these into the proposed academic programme for 2023

In these troubled times, maintaining the clarity of mind and the sanity of our membership will be important. I believe that activities carried out to stimulate the right hemisphere of our brain as well as opportunities to have fellowship among members are as important as carrying out academic and administrative activities at this juncture. We intend to carry out such activities regularly with wider participation of all regions.

The 2023 presidential induction will be held on the 21st of January. Considering the economic constraints, it will be held without much splendour while preserving the elegance, with limited invitees for physical participation while delivering it to the wider membership via a virtual platform. I humbly apologize for the inability to physically gather all membership.

Finally, may I greet and salute the membership, who always works in silence. Who, without expectation of glory or splendour, has been battling the past months trying to provide the best possible care to our patients under difficult circumstances. In the absence of print papers or fuel to travel, many services would have come to a standstill. But even in the absence of many essential tools of trade, physicians of all tiers have still chosen to continue to work- the unsung heroes!

Knowing the capabilities of the members of the council 2023 and members at large, and with blessings and good wishes of the past presidents, we will strive to deliver the expected, with the magic of a strong will.

Wish you all a Happy New Year !

“Holistic care amidst constrains"

It is with great pleasure I pen this message as the President Ceylon College of Physicians 2023. I am honored to be given this opportunity to lead an organisation with dedicated members, continuously spent their time and energy while expecting nothing in return, to continue college activities and fulfilling its long term goals to its full potential without divergence. The ultimate goal being, to serve our patients to the best of our ability, while not being content at the best, striving for new ways to make the best better. I wish to salute our membership, always working in silence, without expectation of glory or splendor. You have been battling the past months trying to provide the best possible care to our patients under the circumstances. In the absence of print papers or fuel to travel, many services would have come to a standstill. But even when many essential tools of trade were scarce, physicians in all tiers still chose to continue to work and care for their patients – they are the unsung heroes.

The concept of holistic care is that patient management needs to be addressed in many facets. Like the many petals of a lotus flower make a picturesque end product, bringing all relevant components for a holistic care together, will result in a healthy person true to the WHO definition.

Delivering that in gloomy environment like today is no easy task. But ladies and gentlemen, we have to aspire to and build a brighter future for the sake of our motherland. Hence our theme for year 2023 – “Holistic care amidst constrains”. Reverting to our simile of the lotus, the nature has provided us with the perfect example which grows in the most unlikely of places to produce a beautiful and fragrant result that brightens the gloomy surrounding it sprang from.

As a college I propose to empower our members and their teams to deliver holistic care amidst constraints through our academic programs. timely manner.

The ability to lead, communicate well and manage work related stress, are going to be key attributes that will enable us to successfully overcome a crisis. I envisage incorporating these into the proposed academic programme for 2023. All components of the academic programme will have an emphasis on clinical decision making, rational use of investigations and medications to benefit our clinical team members including medical officers and postgraduate trainees. In these troubled times, maintaining the clarity of mind and the mental wellbeing of our membership will be important. To achieve this, I believe that opportunities to have fellowship among members and activities that take our minds beyond medicine should be an essential component.

I invite all members of the CCP to join hands with my council and myself to make these endeavors truly successful. Let’s embark on this challenging year ahead together, knowing we might have to go backwards in order to move forwards, sometimes re-learn, maybe even un-learn to do our best for our patients, to the profession, and our nation, staying true to the spirit of our College.


Professor Arosha Dissanayake

Crossing Divides and Bridging Gaps

The Presidential Induction Ceremony of the CCP was held at the Waters Edge on the 25th of January. My heartfelt thanks go out to all those who contributed in making it a success, the limited number of those who attended in person, the online attendees and the numerous well-wishers who sent congratulatory messages. Messages from Presidents of all three Royal Colleges UK, bear testimony to the high standing that the CCP has attained in the international setting through the efforts of Fellows and Members of our college.

In the congratulatory message from my friend Mike McKirdy, President of Royal College of Physicians and Surgeons of Glasgow, he mentions that our ceremony was held on Burns Night, in Scotland. Robert Burns, the 18th century poet, is the Bard of Scotland and is probably its favourite son. Though St. Andrew's Day is the National Day of Scotland many celebrate Burns Night more. Many of us are familiar with his ‘Auld Lang Syne’. Burns wrote many poems on how humans are equal and how social order should change to remove disparities. Today we know that social determinants of health play a crucial role in how healthy a society is. Reducing inequities in access to basic needs such as food, shelter and sanitation, as well as access to healthcare is a responsibility thrust upon all of us as physicians. In his celebrated poem ‘For a’ that, an’ a’ that’, Burns writes,

That man to man, the warld o’er, Shall brothers be for a’ that.

These words resonate well with the theme of CCP for 2022 unveiled at the induction ceremony, “Crossing Divides and Bridging Gaps”.

Busting Vaccine Myths

More than 90 percent of Sri Lankan adults have had both doses of the COVID vaccine but only about one third have taken the recommended booster dose. This is a cause of worry for both clinicians and health administrators as numbers infected from the Omicron variant is soaring while the number of daily deaths from severe COVID infection is slowly creeping up.

The ‘Infectious Disease Forum’ of the CCP conducted a well-attended webinar for doctors, on myths and facts related to booster dose of the COVID vaccine, last week. The objective was to update doctors, both at primary and secondary care level, with the information needed to convince themselves and their patients that booster doses of the vaccine reduced deaths from severe COVID infection and carried little or no significant side effects. This was done considering the best data available both locally and globally. The resource persons provided an excellent insight into the issues at hand.

How does ‘Vaccine Hesitancy’ occur? Can it be explained with the ‘Health Belief Model’ (HBM). This model, developed in the 1950s and updated in the 1980s, theorises that the willingness of persons to change their health-related behaviors is primarily due to health perceptions. Perceived severity, perceived susceptibility, perceived benefits, perceived barriers, cues to action and self-efficacy are the six components described in the model. When applied to COVID and vaccination, in terms of perceived severity, it is likely that most, if not all, are indeed worried about getting severe COVID and dying. Perceived susceptibility poses little problem except the belief that outsiders bring COVID to them and not their near and dear family members. Perceived benefits of vaccination seem to be an important issue that require us to address the public about. Translating scientific evidence into an understandable format for the general public is the need of the hour and we all need to work on it. Perceived barriers which include potential side-effects seem to post the greatest challenge. A survey by a colleague from community medicine has identified three important myths regarding side-effects of the vaccine.

  • Tiredness and body aches which last several weeks preventing them from engaging in daily work
  • Increased risk of blood clotting and precipitation of strokes and heart attacks
  • Subfertility

These are powerful beliefs and this is where all our print, visual and social media campaigning should be directed at.

The fifth factor in the ‘Health Belief Model’ is cues to action, i.e., external events which prompt a desire to make a health change. This could be a Facebook post from a friend or their doctor expressing that the booster can help them save their lives and those of others. The physician community needs to develop ubiquitous cues to action which can make vaccine-hesitant persons change their minds. The sixth factor is self-efficacy - the belief that they can actually take an active role in their own health and wellbeing. We need to convince that ultimate eradication or suppression of COVID cannot be achieved by physicians alone but it will be the task of the community at large and each individual has to contribute. An important step in that direction is for each person to obtain the booster doses of the vaccine immediately.

If we can understand the ‘Health Belief Model’, then we can better understand why vaccine hesitancy occurs and plan interventions to change behaviour. Countering vaccine myths and vaccine hesitancy is the duty of one and all.

Book of the week

On the 4th January 2022, US District court delivered the judgement in the Theranos scandal and it’s founder Elizabeth Holmes was found guilty. It was just in 2015, the beautiful, intelligent, articulate, creative and ambitious entrepreneur who dropped out of Stanford to become the ‘next’ Steve Jobs was, according to Forbes magazine, world’s youngest self made female billionaire. Six years down the line she faces a lengthy prison sentence and has a net worth of zero. This sordid saga is set out in the book I wish to share with you today. Bad Blood: Secrets and Lies in a Silicon Valley Startup written by the twice Pulitzer Prize winning journalist John Carreyrou.

At present, each blood test needs a vial of blood and the holy grail of laboratory science has been the development of a method to do multiple blood tests from a single finger prick blood sample. So many scientists with massive research funding and access to cutting edge technology have searched for it but it has eluded them all. Holmes claimed to have cracked the code with her machine named ‘Edison’, started testing blood at commercial centers and in the process defrauded hundreds of millions of dollars from investors and most importantly provided doctored results to patients endangering their lives whilst being fully aware that the technique her company Theranos had developed was a complete failure. An investigative journalist from the Wall Street Journal, John Carreyrou, with the support of a few whistleblowers from the inside, relentlessly pursued the story till the truth was revealed leading to the downfall of Elizabeth Holmes and current court ruling.

Bad Blood provided me with a stark reminder about how easily business interests in medicine could compromise and supersede patient care and patient safety. Even unprecedented disasters such as COVID offered ample openings for the opportunists to feed their greed. We need to be constantly vigilant about our moral compasses and be mindful about where in the slippery slope we are positioned. Holmes’ lawyers claimed patients did not die as a result of this medical misadventure. But it is believed that the suicide of the chief scientific officer of Theranos was due to his inability to bear the extreme pressures on him from the company. The life of a good man and an award winning scientist was lost in vain.

Bad Blood is available on Kindle and I would recommend it as the book for this week. It teaches us many lessons and prepares us to be more vigilant about medical shenanigans. The Kindle link is provided below for those who want to delve deeper. Happy reading!!

Antibiotic stewardship; Need of the time

Two seemingly random but related events happened last week. A past president called me to express his concern about the irrational and excessive use of antibiotics, both in the inpatient and outpatient settings. He requested the attention of the CCP to take up this matter. On the same day, the CCP received a letter from the MOH, requesting nominations for a subcommittee on AMR (Anti-Microbial Resistance) combating activities. They wish to have five nominees for activities such as ‘governance and coordination’, ‘awareness education and training’, ‘surveillance and research’, ‘infection prevention and control’, ‘anti-microbial stewardship’.

I then set about bringing together the Infectious Disease Forum of the CCP with the aforementioned past president to work out a plan on how best the CCP can contribute in this MOH effort. We should not halt our efforts there, instead we should delve further to consider how the CCP could take the lead, in this nationally and perhaps globally important endeavour.

“Antibiotic stewardship is the effort to measure and improve how antibiotics are prescribed by clinicians and used by patients. Improving antibiotic prescribing and use is critical to effectively treat infections, protect patients from harms caused by unnecessary antibiotic use, and combat antibiotic resistance.” CDC, USA

CCP Fellows and Members are frontline antibiotic prescribers. Do we need to wait till administrative authorities advise us on antibiotic stewardship? Let us take the lead! I do not know where to begin but leave it to the experts among us to decide. Perhaps identifying barriers to the rational use of antibiotics (I am certain are very reasonable, for example, doubts about laboratory reports or the quality of antibiotics) will be the place to begin. Easy to use, ‘home-grown’ interventions will be our tools for the job.

But first, we need a wide ranging discussion amongst ourselves. Let’s start the discussion … now and here.

How to become a “Good Doctor”

My personal mission in medicine has been simple. I wanted to become a good doctor. None of the lectures I attended, none of the books I read, could give me a clear, precise answer on how to get there. Obviously there are many good doctors around, but to get there I believe one had to discover one’s own truth. I have spent hours observing the good doctors, trying to learn. The doctors whom the patients would say, just seeing the doctor made them feel well. Is that possible? What is the quality that the good doctor has which can make these miracles happen? Hence I have been on a lifelong quest to identify which attributes go to make good doctor. And I share those thoughts with you.

The first attribute is, Technical prowess, the possession of uptodate knowledge about illnesses and treatment, bedside medical examination skills, ability to perform relevant diagnostic and therapeutic procedures.

The Second attribute is, Analytical thinking, the ability to understand and solve complex problems, that is to analyze the problems in order to arrive at a comprehensive differential diagnosis, determine most suitable tests and instituting patient centered care

The third attribute is Communication skill, the ability to understand the told and untold stories of patients. Doctors need to communicate with patients, families, colleagues and other staff in the medical setting. Our successes and failures depend on how well we communicate. An often made mistake in communication is to limit it to imparting information. Communication includes how we look at patients, how we smile and put them at ease, how we listen to their stories and not merely take histories, being empathetic, being able to understand how patients think and feel, being a friend to them whom they can approach to discuss their innermost worries, and make them feel that the doctor has their best interests at heart. As John Stone, contemporary poet and cardiologist pens in his celebrated poem Gaudeamus Igitur, “For you may need to strain to hear the voice of the patient in the thin reed of his crying, for you will learn to see most acutely out of the corner of your eye, to hear best with your inner ear”. This is the communication and comfort the patients seek from doctors.

These were indeed the three attributes I had identified as making up the core of a good doctor. But over the past two years, as we grappled with the greatest of challenges doctors of our times have faced, with the COVID pandemic, I came to recognize the existence of a fourth attribute or a fourth dimension. That is resilience.

Resilience means the capacity to see through difficult times and recover quickly. The physicians who handled the pandemic better had greater resilience. As Epictetus, the slave turned philosopher wrote in ‘Enchiridion’, the most important thing is our ability to understand that external events are not under our control but we control how we respond to them. We could always look to survive a crisis, battled and bruised. But resilience means not just survival, but coming out of the tragedy with a greater set of skills, a greater ability to face up to similar situations in the future. In effect to become better than we were, before the pandemic. As Marcus Aurelius, the great Roman emperor and philosopher wrote, in ‘Meditations’, impediment to action advances action, what stands in the way, becomes the way.

Medical Humanities and CCP Book Club

Dear Members, The CCP started it’s ‘Book Club’. My dear friend Prof. Dinithi Fernando gave the club a brilliant start with her impression of Dr Victoria Sweet’s acclaimed book “Slow Medicine”. Drawing inspiration from the ‘slow food movement’ which originated in Italy in the mid 1980s, “Slow Medicine” is a relatively new concept first appearing in medical literature in 2002. Though the term is relatively new, it revisits the age-old concept of practitioners taking sufficient time and imparting a personal touch in patient care. “Slow Medicine” attempts to counteract the over-emphasis on fast processes and efficiency which is the hallmark of 21st century medical practice. Dr Sweet speaks to us about “efficiency of inefficiency”, an oxymoron like no other!!

Origin of humanities can be traced back to Ancient Greece of the 5th Century BC where a course of general education was imparted to young men to prepare them to be active citizens in the polis (city-state). The early European universities initially taught only on divinity. Subsequently, another branch of education developed, the humanities, which were considered to do with aspects of human thought (and not divinity) such as grammar, rhetoric, poetry, history, moral philosophy, and ancient Greek and Latin studies. In today’s context humanities encompass all expressions of human thought other than the natural sciences (life sciences and physical sciences) and the training received for a specific vocation. Today it includes the studies of ancient and modern languages, literature, philosophy, history, archaeology, anthropology, human geography, law, religion and art.

As the British scientist and Novelist C. P. Shaw wrote in “Two Cultures and Scientific Revolution”, the separation of humanities and sciences led to the intellectual thinking becoming split in the middle with ever more fence building. This is believed to have led to our inability to find solutions to most of humanity’s problems. Medicine is unique as it practices the most evidence-based, cutting-edge science on human beings whose behaviours and thoughts are moulded by the humanities. There has been an ever-increasing need in medicine to break the fences and meet on middle ground. This has seen the rise of Medical Humanities and its incorporation into the natural sciences base of medical teaching and clinical practice.

Medical Humanities help doctors to understand patient experiences better and relate to patients with greater empathy. It helps doctors to become better human beings and ward off ill effects of the extreme stress the vocation brings upon them, such as exhaustion and burnout. The “CCP Book Club” is yet another step towards promotion of Medical Humanities among the physician community. We will have monthly book reads by our fellows and members, on books which helped make them a more humane doctor. The club meetings will be notified via emails to you. In addition, the club members have their own forum where there will be a continuous discussion and sharing of thoughts on what club members feel are books which make us better.

“Cricketing” Doctors

The all-conquering CCP cricketers coasted to victory over the College of Cardiology cricketers on the past weekend. There were some mixed feelings as the Cardiologists are an integral part of the CCP and in some ways this was a home versus home match. None the less, excellent cricketing skills were on display and one was left wondering if only some of these doctors had taken on cricket as their chosen careers. This made me reflect on whether it is possible to be a doctor and be able to play cricket at the highest level?

The most famous of all doctor cricketers is Dr W G Grace (1848-1915). Known as the “Doctor” he was a general practitioner and is considered as one of the greatest cricketers of all time having captained England and accumulated more than 50,000 first-class runs, scoring 126 first-class centuries in the process. Such was his cricketing eminence and brash self-confidence, when given out LBW, he once supposedly told the umpire, "They came to see me bat, not you umpire”, took guard again and batted on.

His elder brother Dr E M Grace (1841-1921) was a surgeon and went onto play for England and Gloucestershire. Such was his cricketing prowess, once in a club match, he scored 192 not out and took all ten wickets. Grace senior was known as the “Coroner” in the cricketing circles, hopefully not as a reflection of his surgical skills.

Dr Aron (Ali) Bacher is from more recent times. He was a general practitioner who went on to captain South Africa’s greatest side in 1969/70. The doctor was good enough to captain a team comprising of the likes of Barry Richards, Mike Proctor, Graeme and Peter Pollock, and beat a formidable Australian team in all four matches he captained. His greatest achievement was bringing together the black and white cricket boards together as the United Cricket Board of South Africa and facilitating its entry to world cricket in 1992 after 22 years of sports isolation.

How about those closer to home; the Sri Lanka scenario? Brigadier Dr H. I. K. Fernando played for Ceylon in the 1960s and was considered widely to be one of the finest wicketkeepers in the world at the time. He was the Director of Army Medical Services and played a pivotal role in establishing Ranaviru Sevana in Ragama.

Dr Buddy Reid, an opening batsman, captained Ceylon on the first occasion we beat the MCC in 1968. He was a double international and captained the Ceylon table tennis team too. Upon migration to Australia, he practiced as a surgeon there.

Dr Sarath Seneviratne, was a stylish batsman who captained Sri Lanka in the early 1970s with future captains Warnapura and Mendis playing under him. Presently, he is a consultant gynaecologist in the Cayman Islands.

A ‘polymath’ is a person of wide-ranging knowledge and skills. Doctor-cum-cricketers may not fit in strictly within the traditional frame of polymaths such as Da Vinci or Benjamin Franklin, but they are all-rounders of an exceptional nature. They inspire us doctors to go in search of excellence in other fields. We may not receive national level recognition like the above six, but we may become better persons in this quest.

The above are a few of the doctor cricketers, the cricket historian in me could think of. If other cricket enthusiasts among the members of the CCP could add to the list, especially the Sri Lankan list, I shall be most obliged and will share with the members.

On a parting note, I had the pleasure of seeing a newspaper cutting from 1977 which listed the top scorers for the Sara trophy cricket season. In a list topped by Roy Dias (obviously), a few places below Sidath Wettimuny, shows the name ‘M R Mohideen’ of Colombo Campus with an accompanying article stating that these high scorers are causing all kinds of headaches to national selectors. If medicine, Ruhuna Medical Faculty and subsequently the CCP, had not drawn our past president Professor Rifdy Mohideen away from cricket, one can only conjecture what might have been. The loss for cricket was certainly the gain for medicine and the physicians who trained and worked with him.

"The Law-Medical Nexus"

The collaborative efforts of CCP with other professional organizations started with our Health Discussion Webinars with the Bar Association of Sri Lanka (BASL). Although it was previously planned to have one programme, due to the enthusiasm of BASL we held three, which included discussions followed by Q and A sessions on heart disease, diabetes, asthma, chronic kidney disease, obesity, bone health and stress. The CCP was invited to address the BASL membership via the regular BASL Sunday webinars, which usually comprises sessions featuring senior lawyers for three consecutive weeks. Such was the enthusiasm and demand.

One of the ways in which a professional organization or our nation itself could develop resilience to overcome adversity, is for professionals from all disciplines to collaborate and support each other with ‘common good’ being the ultimate achievement strived for. In the past, we have had much fellowship with the legal fraternity over ‘highly spirited’ cricket matches, dinners and dances. The present initiative is a collaboration based on professional expertise. This is merely the beginning. The long term objective is to meet together to promote societal wellbeing, reduce social disparities, raise a voice together against discriminatory and detrimental policies.

In addition, it is envisaged to address a few hiatuses related to medical practice where the legal bearings are not clearly outlined. This is an important area where we could seek the guidance and support of our legal counterparts. One area in which all doctors encounter on a daily basis, which is a legal quagmire, is making Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions.

What is legal in Sri Lanka comes from two sources.
  • The written law which includes the constitution, enactments of parliament (Ordinances and Acts) , Subsidiary Legislation, Provincial Statutes, Proclamations, By-Laws of Local Authorities, Regulations, etc.
  • Unwritten Law - Which includes the Law of Precedent (binding judgments) from cases, Customary Law, etc.

DNACPR decisions are not covered by any of the written laws and so far there have been no case decisions. It is within the realm of possibility that such a legal challenge be made against a DNACPR decision by an unhappy next of kin. If the presiding judge were to decide that the doctors’ duty of care equates to preservation of life and the DNACPR decision was not in keeping with preservation of life, it is possible the medical team may be held responsible. This is a stark reality that doctors need to be aware of when they make DNACPR decisions. Through proactive measures such as new legislation, if we are able to get legal validity for DNACPR decisions, then the doctors working in good faith with best interests of the patient at the centre, including not prolonging life unnecessarily, would tread a safe and secure path.

There are a number of similar legal lacunae in the Sri Lankan medical setting that require identification and remedial action. Let our collaboration be the catalyst for the medical and legal professions to work together using their expertise to make the lives of all better.

P.S. Medical ethicists are debating as to whether there is a difference between withholding “futile” treatment (such as DNACPR decisions) and withdrawing ongoing treatment, the continuation of which is considered futile (such as disconnecting a ventilator etc). We tend to somehow feel better about the former, compared to the latter, but according to clinical ethicists there may not be any significant difference between the two actions from an ethical or legal perspective. For further reading on withholding versus withdrawal, I share with you the following article which provides an excellent insight into the complexities in operation.

Is withdrawing treatment really more problematic than withholding treatment? In Journal of Medical Ethics. Cameron, J., Savulescu, J., & Wilkinson, D. (2020). (Vol. 47, Issue 11, pp. 722–726). BMJ.

Between Stimulus and Response …

Prof Channa Wijesinghe, the first Professor of Psychiatry of the Faculty of Medicine, University of Colombo was one of the 12 founding members of the Ceylon College of Physicians when it was established in 1967. Although specialist psychiatrists later formed an association, the CCP membership has remained open to psychiatrists, some of whom have been elected Fellows of the CCP too. The CCP remains an all encompassing professional organisation. It is the equivalent of Zeno’s Stoa Poikile or Plato’s Academy or Aristotle’s Lyceum, where intellectuals meet to discuss and deliberate on great ideas, discover the unknown, learn from each other and contribute to the betterment of the society we live in. The CCP 2022 continues to take strides forward in the quest to bridge gaps and cross divides.

Psychiatrists continue to provide academic excellence to the CCP. Last week we witnessed two such instances. Professor Raveen Hanwella, a Fellow of the CCP delivered a most thought-provoking and an erudite lecture under our “Colleges United in Science” (Collegia Unitum Scientia) initiative, speaking on “Hysteria, Pseudoseizures and Possession states”. From the story of Anna O, which was a case discussed in the 1895 book “Studies on Hysteria”, whose treatment is considered the beginning of psychoanalysis to evolution of hysteria to conversion, somatisation and medically unexplained symptoms, the lecture provided a fascinating insight to physicians. The important take home message on management was the four step strategy outlined below.

  • Reduce reinforcement by paying minimum attention to the physical deficit
  • Explore stresses and conflicts which led to the problem
  • Changing the agenda by shifting focus to the real problem from the pseudo-problem
  • Working with patients to enhance coping skills
For those of you who missed this exceptional lecture, the link is provided to listen at your convenience.

The Bar Association of Sri Lanka (BASL) requested a lecture on “Stress Reduction” and another member of the CCP, a past council member, Dr Harshini Rajapakse, obliged by delivering the lecture on behalf of the CCP. In these extremely difficult and stressful times, her timely lecture provided many important messages and described strategies all of us could adopt to lead less anxious and less stressed out lives. She quotes Victor Frakl, “Between stimulus and response, there is a space. In that space is our power to choose our response. In our response lies our growth and our freedom” pointing to us an important way to prevent getting stressed, coping with our anxieties as well as growing in our humaneness.

Victor Frankl (1905-1997) was a Professor of Neurology and Psychiatry at the University of Vienna. He survived the holocaust and incarceration in a Nazi concentration camp. His “Man’s search for meaning”, written in 1946, depicting his experiences as a prisoner in the concentration camp and the methods used to survive the trauma, is considered one of the greatest books ever written.“The Diary of Anne Frank” and Frankl’s book stand as the two of the most moving books written about one of the darkest periods in human history.

"CCP and the Health Crisis"

I said 'No'!!
“We know how much effort the COVID task took. We have many thousands of medicines used in hospitals. To start with, no one knows what is in short supply at which hospital. The Health Ministry, which could possibly provide this information, would never admit a shortfall publicly. NRMA registration of donated medicines, customs clearance, safe storage and countrywide distribution – these are impossible logistics for us to handle”. Hence, at the CCP Council meeting on the 8th of April, when the suggestion came that we should try to obtain donations of medicines and provide them to hospitals, I told the members that I felt that the barriers were insurmountable. I was apprehensive. Were we about to fall into the proverbial ‘rabbit hole’? I asked myself.

In the 1865 Lewis Carroll’s classic ‘Alice’s Adventures in Wonderland’, Alice falls down the hole of White Rabbit and is transferred to a surreal and nonsensical world. The idiom is used to mean one getting into an extremely time-consuming task from which one finds it difficult to extricate one’s self. Nevertheless, the meeting ended with us agreeing to explore the possible roles CCP could play in this calamity.

Just eight days later, on the 16th of April, we unveiled to the members and well-wishers an ambitious, but what appears to be an accountable, transparent, sustainable, and robust mechanism to harness the support of well-wishers from overseas to help overcome the medicinal and consumable shortages envisaged to occur over the forthcoming months. How did this transformation happen? That is the story I wish to share with you.

Over the past few days, numerous messages from well-wishers sent to us personally, requesting a way to help, reached us. Though many had lost faith in the state mechanisms, they indicated that they had faith and trust in the CCP to support with donations for the country’s health system. Dr Ananda Wijewickrema, a past president, agreed to take the leadership in the project. Rather than reaching out to the world as one college, we saw strength in unity and invited the colleges of Paediatricians, Surgeons and Obstetricians to join us as partners in this endeavour. Presidents of the four colleges are the co-chairpersons of the project.

The first task in the process was to identify medicines deemed essential / critical to have an operational health system. Members of the College helped the Ministry of Health to compile this list.

Next, we had to go through the complex process of setting up a purpose specific foreign currency account with special authorisation from the Central Bank. This account permits us to retain our account in USD and make outward payments in, also, USD. Dr Shamitha Dassanayake and Dr Dumitha Govindapala worked tirelessly to get this account authorised at the highest levels of the central bank and finance ministry.

As we set out, we knew that any attempt to build a system in parallel to the MOH, which has 1000s in full time employment doing this task, would be futile. Hence, we designed a method to supplement the existing system but to retain control to a larger extent on how disbursement of funds occurs. The model operates as follows.

  • We make a global appeal via emails and flyers.
  • Funds are collected from overseas colleagues and well-wishers and transfers are made in USD to the account.
  • The State Pharmaceuticals Corporation (SPC) which makes purchases on behalf of the Ministry of Health, on request to the Medical Supplies Division (MSD), will appeal to the fund administrators to provide funds in USD for a particular purchase.
  • The joint committee comprising members from the four colleges will consider the request and determine if it is keeping in with our objective of overcoming the medicine shortage.
  • Once the committee endorses the request, funds will be released to the SPC.
  • SPC needs to provide documents on proof of purchase to us and the MSD, the hospitals that the purchases were distributed to.
  • All details of donations and disbursements will be available for scrutiny on a dedicated webpage linked to the website of the College.

This model was developed after much thought and deliberation. We feel that though it may not be flawless, it is perhaps the best we can have in terms of meeting the dual objectives of maintaining accountability as well as having a process which is logistically feasible.

There have been many enquiries from donors worldwide and the recurring theme has been, ‘We have implicit trust in the CCP and if you all are leading it, we will come forward to help as we have little faith elsewhere’. This attitude is a tribute to all the past presidents and the councils of the CCP over its 55 years of service and integrity to the nation. I along with the team of volunteer members pledge to uphold the same exemplary standards.

This is the story of the ‘Save Lives in Sri Lanka – A joint fund of the professional colleges of medical specialists”. We are still at the first step. As the first line from ‘The Hollies’ immortal song, ‘He Ain’t Heavy, He’s My Brother’, states, “The road is long, with many a winding turn”. Much remains to be achieved and I seek your guidance and help in this endeavour.

Hamlet’s Soliloquy, “To be or not to be"

Our beloved nation is in crisis. Over the past 50 years, the country has survived two youth insurrections, one civil war, the tsunami of 2004 and the COVID-19 pandemic, but never has the country been so close to oblivion. It is a time for much soul searching and identifying how we, as individuals and the College as a collective, could contribute to help the country come out of this quagmire.

CCP is facing two clear challenges. The first one is the health crisis evolving before our eyes, though the health authorities seem to be still in ‘denial mode’. As a member of the intercollegiate committee, the CCP was a signatory to the letter written to the President of Sri Lanka, urging immediate attention to prevent a total collapse of the health system. This letter was picked up for wide dissemination by the social, print and electronic media. The occasional contradictory statements and news updates we have been receiving from the health authorities have not been helpful in our global appeal for help. The denial is understandable as public admission that the country is fast running out of some essential medicines such as Insulin and ARS, could spell further political disaster for the already embattled government. We know the problem is real and have been proactive in organising the Save Lives in Sri Lanka (SLSL) project to win over the commitment and support of overseas donors. We have now, a system in place and what is needed at present is merely to fine tune it, learning from the new experiences we gather.

The second crisis before the CCP is indeed the ‘elephant in the room’. What is the role the CCP should play in supporting society activities aimed at resolving the current political impasse? This brings us to the fundamental question, “what is the societal and political role of the CCP?”. Does it have one at all? Isn’t our duty merely to help soothe the health-related crises as that is where our expertise lie? Or should we recognise that health encompasses peace, security, preservation of people’s fundamental rights and the CCP has a role to play in providing the direction the country should move in? These are difficult questions but unless we move out of our comfort zones and ask ourselves these questions, we will not know what the answers are and miss opportunities. I looked at the constitution and the objectives of the CCP are set out in sections 2.1.1 to 2.1.5. These objectives confine our activities to a narrow spectrum limited to health provision, teaching and fellowship among members. It does not define a role for the CCP in the wider context of society. Perhaps the time has come for us to evolve further to meet these unprecedented challenges.

In the future we could discuss, debate and seek a wider consensus among members whether the CCP should go beyond its traditional enclave and consider the wider social and health implications the political crises pose to the society. Not merely to consider but whether to play an advocacy role, always retaining the welfare of patients, our primary responsibility, a dilemma that is difficult to resolve. Perhaps a good starting point will be to reflect whether the CCP played a political advocacy role in the previous social crises such as the youth insurrections in 1971 and 1988 as well as during the 30-year civil war. I am not aware but may be our past presidents and senior members could enlighten us.

Difficult to resolve dilemmas confront humanity often. None more eloquently elaborated than, in the words of the Prince of Denmark.

“To be, or not to be? That is the question.
Whether ’tis nobler in the mind to suffer
The slings and arrows of outrageous fortune,
Or to take arms against a sea of troubles,
And, by opposing, end them”
        - Hamlet, William Shakespeare, 1599

To be or not to be, is the dilemma we the CCP is also grappling with today.

A tale of 61 tattoos

Otzi, the Iceman was discovered by two tourists, in a glacier on the Alps, on the Austria-Italy border in 1991. Archaeologists consider Otzi to be the oldest, well-preserved human body and is on display at the South Tyrol Museum of Archaeology in Bolzano, Italy. He is more than 5000 years old and offers a fascinating insight into human life in the Bronze Age. Amongst points of interest, Otzi wore 61 tattoos on his body. He had degenerative disease of the spine and the knees, and many of the tattoos were over these areas which would have undoubtedly been painful. Archaeologists believe that these tattoos were made as therapeutic procedures with the hope of reducing pain from illnesses. Hence, the origin of therapeutic tattoos predates most other therapeutic approaches to disease known to mankind.

Opinions on cosmetic tattooing divide us right in the middle. For some, it is an object of beauty, creativity, fashion and of artistic expression, much like the fashionable clothes and jewels we adorn ourselves with. For others, it is “not my thing”, a sign of moral decay and an intrusion into one’s natural appearance. May be some among us may have our own sneaky tattoo well hidden from prying eyes; it is our secret pleasure. Let the debate on the cosmetic tattoos rage on.

Therapeutic tattooing is making waves in the medicine realm; research papers and meta-analyses are appearing on PubMed. There is a specially trained group of therapeutic tattooists in countries such as the USA, helping doctors empower and create better lives for patients. Scars from burns and past surgeries, mucosal vitiligo, alopecia areata are conditions in which shame and stigma have been replaced with the confidence to feel and be ‘normal’ for a long-suffering patient.

Perhaps the most profound changes from therapeutic tattooing, has been experienced by breast cancer survivors. Many surgeons perform breast reconstruction surgeries, but no matter how symmetrically a breast is created, he is not able to create a nipple-areola complex. ‘Micropigmentation’ techniques (scientific term for therapeutic tattooing) enable the creation of a breast which appears the same as a non-diseased one.

A patient narrative was most enlightening. Following reconstructive breast surgery, the patient actually had showered for years wearing a brassiere as she did not want to see the grotesque lump on her chest. With creation of the nipple-areola complex through tattooing, she could bring herself to look at her own body and feel good. Such is the potential for empowerment and healing of both the body and the mind, with tattoos.

For Otzi, the Iceman, the 61 tattoos may have been treatment for the degenerative lumbar spondylosis and osteoarthritis of the knees. It is also possible that it was part of a healing ritual. We can only surmise. I for my part, have decided to view tattoos in a brighter light, leaving my narrow confines and prejudices aside and appreciate their expanding cosmetic and therapeutic potential. All of this is still confined to the West but it will be at our doorstep soon enough.

Tattoos, dearest fellows and members, are no longer only skin deep.

A Black day in May

For this week I leave my column black as a mark of protest against the attack on democracy and citizens’ right for peaceful protest

Insulin from vial to pen: brilliant innovation or major health hazard?

Recently I met a patient with Type 1 Diabetes Mellitus who was being treated at a District Hospital in the Southern Province. She told me that she was injecting herself using an insulin ‘Pen’ device. She was unemployed and her husband was a cinnamon peeler.

Insulin is available in state hospitals and is dispensed by hospital pharmacies free of charge. This includes mixed human insulin vials too. Patients are given one or more vials depending on the monthly requirement and they inject themselves using insulin syringes and needles. This method of administration carries well recognised problems such as issues with storage (need for a refrigerator which is not available to most and ineffective to those affected by power interruptions), pain of injections and anxiety/phobia for needles.

Use of Insulin pens and pen-fill cartridges minimises these problems but are unavailable in the state sector as they are prohibitively expensive. Hence, a patient has to spend a considerable proportion of their income to purchase pen-fill cartridges. The question for me was how this lady with a minimal monthly income could afford to use the insulin pen for insulin administration.

The story she related was quite surprising and revealing. She would get the premixed insulin vial from the hospital clinic. At home she would use a syringe and a needle to draw out insulin from this vial. Then she would inject the insulin back into an empty insulin pen-fill cartridge. Thereafter she would use the insulin pen to inject herself. She would keep the insulin pen with the filled cartridge inside as well as the remaining insulin vial in the refrigerator. She has engaged in this practice for the past two years and her glycaemic control has been relatively satisfactory. When I enquired about how she got to know about this technique and who taught her the process, much to my surprise she said the healthcare personnel in the clinic in the District Hospital taught her. This meant that the technique was not merely having ‘official approval’ but was being actively promoted. She believes a number of other insulin users attending the clinic follow the same technique.

I did a brief search of medical literature to discover any references to this practice. I could not find any research papers which had assessed the safety or efficacy of this technique. Whether this is a uniquely Sri Lankan practice, I do not know. Interestingly there were some references to the opposite procedure from the NHS UK. Some hospitals had a method of using insulin manufactured specifically for pen-fills (e.g., Mixed 50:50 insulin) in an alternative way. They would practice drawing this insulin out of the cartridge into a vial and injecting the patient via needle and syringe. Manufacturers had given explicit warnings against this practice stating they are unable to assure safety and efficacy. The same guidance was provided by Primary Care Diabetes Society Guideline to NHS hospitals.

The major concerns are, possible contamination, disintegration of insulin molecules leading to reduced efficacy, dosing errors, risk of cartridge bursting when air is injected (cartridges are not pressurized systems like insulin vials), needle stick injuries to the untrained hands, and transmission of infections.

If indeed this unique technique works, then we have a cheaper method of delivering insulin via a pen device to the patients who are financially incapable of purchasing the same.

As yet, we do not know which of this is the reality. In all probability it is partly both. Only rigorous scientific assessment will give an answer. A research opportunity beckons an enthusiastic researcher.

A brilliant innovation or a major medical hazard? A poser for you and a humble request to share your thoughts and experiences so that together we may attain greater clarity and arrive at an evidence-based consensus.

Doctors cycling to work - Recharting the future or a mere midsummer night's dream?

Tulips, windmills and bicycles. Throw in the Anne Frank House and Max Verstappen, the reigning Formula 1 world champion, into the mix, it is the Netherlands. It is the bicycle paradise of the world and it was no surprise to see, splashed across the newspapers, a photograph of the ambassador for Netherlands in Sri Lanka, cycling to work when a severe fuel crisis is engulfing the whole of Sri Lanka. Even the Dutch prime minister is known to cycle to work on occasions.

Cycling has many advantages. It is a supreme form of exercise and cycling an hour a day covers the recommended week’s quota of exercise for cardiovascular health. It reduces state expenditure on fuel and import of motor vehicles as well as creating more space for people. Carbon emissions to the environment are low, reducing global warming and environmental pollution.

When the rest of the world went hurtling down the motorised transport precipice, how did the Netherlands manage to go in the reverse direction and become the iconic country for cycling? It was not always the same and for many years the Netherlands took the same route as the others. Following the conclusion of the Second World War, the country’s economy was taking forward strides and the number of motor cars on the roads were ever increasing. The Dutch had a centuries old canal system for transport of goods on boats and barges. (Similar canals built by the Dutch during the colonial period such as the Hamilton canal stretching from Puttalam to Colombo survives in Sri Lanka to this day). There were suggestions to fill this canal system in Netherlands with concrete and turn them into roads. There were suggestions to demolish old buildings and create more car driving and parking space. Protest groups opposed those moves. In 1972, the Netherlands recorded the highest number of fatalities from traffic-related accidents including the deaths of 500 children, giving rise to a campaign named “Stop de Kindermoord” (Stop murdering our children). Antipathy against motorised travel was building. The penny dropped when the oil crisis occurred in 1973. The Dutch government first declared a car free day of the week, to cope with rising fuel expenditure. At the same time the bicycle revolution began with support from the state. Today the Netherlands has a population comparable to Sri Lanka and its 17 million people own 23 million bicycles. Many 12-year-olds get their own bicycles for personal use as presents for their birthdays and 75 percent of secondary school children cycle to school. The Netherlands is the bicycle capital of the world.

Considering the extremely dire economic situation in Sri Lanka, a country which even at the best of times can ill afford fuel importation costs, as well as noting that there is on average one traffic accident-related death per day, it is perhaps time to start our own bicycle revolution.

What stands in the way of us cycling to work? Safety of cyclists is the most serious impediment. A cyclist plying the Sri Lankan roads stands a significant risk of sustaining serious injury from being knocked down by a fast-moving motor car. How did the Dutch overcome this barrier? They have cycle paths in many cities, totaling about 500 km. They have closed roads in inner cities to motor traffic and converted them to bicycle only roads. In the roads shared by cyclists and motor cars, the roads have been converted in such a manner that motor cars can only move at very slow speeds. Research shows that where the density of bicycles was higher, the number of road accidents were lower indicating a trend that displays strength in numbers.

The second barrier is cultural. For the Dutch, cycling has little to do with status in the society. If at all, the indication that one can cycle to work may indicate that one is living in a more expensive, close-to-the-city-centre region and amounts to be a symbol of status. In contrast, in the Sri Lankan setting, cyclists are the less affluent, those who lack the economic wherewithal to purchase a car. Hence, a paradigm shift is required to promote cycling in Sri Lanka. What better way than to have the high-flying members of the medical profession leading the way, cycling to work.

The third barrier would be the dusty and humid weather of Sri Lanka. Obviously wearing the tie and long-sleeved shirts may not be suited to riding a bicycle to work. A place within the working premises for a change of clothes and greater emphasis on lighter clothing such as cotton scrub suits may help us.

As we, hopefully, come out of the economic doldrums, it may be the time to think afresh and reflect on the way we conduct our affairs, learning from those countries which are doing better. There are organisations such as the Dutch Cycling Embassy which collaborate, support and provide expertise to cities which are keen to join the cycling movement. As we look for support from friendly nations, establishing cycling friendly road networks and promoting a cycling culture might be the specific help that the Netherlands can provide Sri Lanka.

We cannot just take out our bicycles today and get on the roads now. It remains too unsafe. But a committed movement from the medical profession, energy experts, environmentalists and policy makers could direct the nation towards this health promoting, cost effective, energy saving and environment friendly, cycle path.

Let us rechart the future

P.S. I have heard that there was a very rich bicycle tradition and culture in the northern parts of Sri Lanka in the past, where university academics, students, consultants and junior doctors all cycled to work.

The Tie and the Tortured Genius

COVID threat is receding. The shirts and ties which took a back seat making way for surgical scrubs, are making a comeback. I chose a tie for work, which I had not worn for quite some time. I thought I would share an image of it with you, both to enjoy the exquisite beauty of the painting as well as to reflect on a medical mystery which has puzzled medics for more than a century.

Vincent Van Gogh (1853-1890), the Dutch painter is considered the most popular, beloved and great artist of all time. He painted two sets of ‘still life’ paintings of ‘Sunflowers’. The first set were of sunflowers lying on the ground. The second were of sunflowers in vases, in different coloured backgrounds. The tie depicts the fourth version, in yellow background and the original painting is on display at the National Gallery in London. In addition to ‘still lifes’ (‘still lifes’ being works of art depicting inanimate commonplace objects which are either natural, like flowers or man-made, such as jewellery), he painted landscapes, self-portraits and portraits of others.

The most famous of the landscapes is the ‘Starry Night’ depicting the village he saw from the mental asylum in Saint-Remy where he lived for months and painted prolifically while receiving treatment. Vincent is the original ‘selfie-king’ with 43 self portraits and the one with the fully bandaged ear, perhaps being the most famous of all. In a fit of rage and despair, Vincent is said to have sliced off the whole or part of his ear lobe. Though he cut off the left earlobe, the self-portrait done while looking at himself in a mirror depicts Vincent with the right ear fully bandaged. His portrait of Dr Gachet fetched 82.5 million dollars in 1990, making it the most expensive painting in the world at the time. The medical interest of this painting lies in the foxglove plant which the doctor is holding. There is belief that Vincent received Digitalis as a treatment for epilepsy. Some attribute the bright yellow in many of his paintings, including the one on the tie, to have been the result of xanthopsia induced by digitalis toxicity.

Van Gogh supposedly shot himself in the abdomen and died two days later at the age of 37. It is believed that poverty and mental ill health drove him to suicide. He was indeed very poor and sold only one painting in his lifetime. Those who own his paintings today, possess four among the most expensive 30 paintings in the world. The exact illness which tormented him is still being debated by physicians, neurologists and psychiatrists alike. A cursory PubMed search on Vincent Van Gogh’s illness brings up more than 400 publications. Vincent’s illness started in the third decade of his life. He had episodes of acute mental derangement and disability including stupor separated by periods of lucidity and creativity. Some of these episodes would recover rapidly in a few days whilst others lasted for weeks. There were seizures associated with auditory and visual hallucinations. He had frequent gastrointestinal problems. Episodically, he had severe depressive episodes with associated anxiety. He self-mutilated during depressive periods with physical discomfort, most notably the issue with slicing off the earlobe and ultimately, suicide (some believe it was severe Ménière's disease which prompted him to damage the earlobe). He associated with prostitutes (commercial sex workers in today’s parlance) and contracted Gonorrhoea. He was malnourished and consumed large amounts of alcohol, especially absinthe, which is a spirit derived from several plants which has psychoactive properties. He also had long-term occupational exposure to paints. That is the clinical picture. No EEG, no MRI in 1890.

Was it, Depression with anxiety, Bipolar Affective Disorder, Schizophrenia, Alcoholism, Complex partial epilepsy, Acute intermittent porphyria, Neurosyphilis or Lead poisoning as medical experts have been varyingly claimed in the medical literature? A poser for the excellent clinicians of the CCP!!

As the medical debate goes on, the paintings of the tortured genius will live on in the centuries to come, giving pure joy to all humanity. How he transformed the pain of his life into ecstatic beauty is the legacy Vincent left for the world.

As Don McLean’s immortal song ‘Vincent’ tells us

Starry, starry night
Flaming flowers that brightly blaze
Swirling clouds in violet haze
Reflect in Vincent's eyes of china blue
Colours changing hue
Morning fields of amber grain
Weathered faces lined in pain
Are soothed beneath the artist's loving hand
Now, I understand, what you tried to say to me How you suffered for your sanity
How you tried to set them free
They would not listen, they did not know how
Perhaps they'll listen now

The hospital for the Blind and the Crippled, in Padaviya

Whenever I get the time, I watch the ‘Neth FM, Unlimited History’ programme on YouTube. This is a very popular weekly radio programme tracing ancient Sri Lanka. The show is hosted by Mr Nuwan Liyanage and Prof Raj Somadeva, a senior professor at the Postgraduate Institute of Archeology, University of Kelaniya. He has taken his listeners on a wondrous journey of the nation’s history from basing his commentary collating both archeological and literary evidence. There have been more than 100 programmes to date and to someone interested in history, each one is a treasure.

In a recent programme, covering the last century of the Kingdom of Anuradhapura, he spoke of the reign of King Udaya the first, who ruled in the early part of 10th Century AD. King Udaya from the Manawamma clan the successor of Sena the Second, built two hospitals, in Polonnaruwa and Padaviya. The hospital built in Padaviya, Prof Somadeva mentioned, was dedicated to the ‘Blind and the Crippled’. The significance of this statement escaped me till my dear friend and CCP council member Dr Himantha Atukorale wrote back to the programme pointing out that we were discussing probably the first rehabilitation hospital in the country, established 1100 years ago. As Himantha pointed out, it is unlikely that there were successful treatments for conditions such as blindness and physical disabilities/ deformities and the hospital mentioned had to be a rehabilitation centre.

The reference to the existence of this hospital comes from the Chulawamsa, the ‘Lesser chronicle’. The Mahawamsa the ‘Greater chronicle’ written by Venerable Mahanama in the 5th Century AD during the reign of king Dhathusena, covers the period of history of Sri Lanka from the 5th Century BC to 5th Century AD. The first part of Chulawamsa, was written in the 13th Century by Venerable Dhammakiththi during the reign of King Parakramabahu from where the Mahawansa ends, and carries a record of events from 4th Century AD to the 12th Century AD. The Chulawamsa records the event as follows.

“In Pulatthinagara he built of his great pity a large hall for the sick, and likewise is Padavi, each provided with a maintenance village, also halls for cripples and the blind in different places.”

A cripple has been defined in the document as follows.

“who moves with aid of a chair (pitha), i.e. a support that one pushes in front of one.”

Hence the crippled persons used walking frames back in the 10th Century AD !!! What illnesses did they have to become blind or crippled? Cataracts or diabetic retinopathy for blindness? Stroke, rheumatoid arthritis or neuropathy for being crippled? What treatment did they have? What physical therapies did they undergo? Who were the rehabilitation and palliative care doctors? Were there physiotherapists? Were there nurses? Who helped them to wash, dress and feed themselves? Who were the ‘bystanders’ or carers? Were they here long term or for short periods of rehabilitation? Questions abound. We can only surmise or imagine.

The Chulawamsa mentions that there was a ‘maintenance village’ for the hospital. It is likely that supporting services such as food, laundry and cleaning all may have come from the village. May be some if not all medical and other professionals resided in the village. Though the chronicles have mentioned many kings who built hospitals, we have archeological evidence of only three hospitals from ancient times so far and there are no archeological remains of the Padaviya rehabilitation hospital. More about the three hospitals in a President’s Column on a later date.

To my limited knowledge on medical history, dedicated rehabilitation hospitals were not part of medical settings in the world by the 10th Century AD. Could this be one of the world’s first rehabilitation hospitals? A delightful thought indeed.

CCP Annual Academic Sessions 2022 Excerpt from the Presidential Address at the Inauguration Ceremony 22.09.2022

"The Chief Guest for the evening, Prof Nalin De Silva, the Guest of Honour Sir Andrew Goddard who is joining us online, the CCP Orator Prof S. A. M. Kularatne, the Council, the Board of Trustees, Past Presidents, Fellows, Members who will be receiving fellowships this evening, Members, award and prize winners and distinguished guests in the audience. A very good evening and the warmest welcome to all of you.

This is a joyous occasion but we begin with note of sadness. The CCP was founded in 1967, 55 years back, by 12 members. I wish to announce to you the passing away of a founder member of the CCP, Prof Channa Wijesinghe, in Australia, this week. May we at the outset observe a minute of silence in memory of this great person, knowing that his blessings are with us at this ceremony?

What of the CCP over the past eight months?

I am certain many of you are familiar with the music of Billy Ocean, the Trinidad born British R and B singer. He did the theme song for the film "Jewel in the Nile" and sang "….. When the going gets tough, the tough get going". He did not say it like that. He said "…. WHEN THE GOING GETS TOUGH, THE TOUGH GET GOING". When the going got tough, the CCP got going.

We started with the traditional CCP academic activities which have earned so many accolades over the years. These included the college lectures, specialty updates, the young physicians forum and the training courses for the entry examination as well as the MD Medicine examination.

In the midst of all these difficulties we set in motion a number of fresh initiatives: 

The “CCP Quiz” is a novel item added to the specialty updates The “Cutting Edge” series has lectures delivered by overseas experts with international recognition. “Peripheries to the fore” programme provides a platform for physicians from hospitals in the  distant provinces to showcase their excellent work in limited resource settings.  “Pearls of Wisdom” is a programme where we tap into the minds of our senior colleagues, often past presidents of colleges, to learn from their enormous clinical and life experiences. “Collegia Unitum Scientia” i.e. Colleges United in Science is the programme where we reach beyond our traditional sister colleges and link with non physician colleges.  “Beyond Medicine” is the programme aimed at stimulating right cerebral hemisphere of physicians and takes physicians beyond the confines of medical academia.   The “Book Club” is an initiative in which members speak about a book which changed the way they practice or the way they see life.  “Bridging gaps with Non Medical Professional Associations” helps to share our expertise with these professionals in addition to forging close relationships.  The “Communication skills course” conducted by a Fellow of the College, Prof Raveen Hanwella, extends over six weeks and aims to bridge a gap in our quest for clinical excellence. “Save Lives Sri Lanka” is an ambitious project launched in collaboration with a number of other specialties colleges to raise funds from overseas well-wishers for supplying medicines in short supply which has crippled our hospitals. When the country ran out of soluble insulin, it was the CCP’s donation of a large stock which saved lives. When the kidney transplant patients had no Tacrolimus it was the CCP’s collaborative effort with the Sr Lankan Medical Association of North America which saved the day. The iron chelating medicine for patients with Thalassemia, Desferrioxamine was made available through the fund. Much remains to be done and the CCP strikers are on the ball.   How did the CCP manage all this while the country was in the direst of situations in an economic meltdown, compounded by civil unrest ?

It is the philosophy we believed in. We believed in obstacles. We welcomed what stood in the way. We embraced impediments. The great Roman Philosopher-King Marcus Aurelius wrote in “Meditations” – “What stands in the way, becomes the way. Impediment to action advances the action”.

In one word it is Resilience. Those who recall my address in January will remember that I listed resilience as the fourth attribute of the good doctor. Resilience means, not merely surviving difficult times, but using these as a catalyst to become better than before. The new initiatives carried out with success is ample proof that “when the going got tough, the CCP got going”.

Turning to the present, the academic sessions itself –

Our chief guest for the evening is Professor Nalin De Silva, Professor of Chemistry and the foremost expert on nanotechnology in Sri Lanka. Why nano technology? You will notice that futuristic medicine is a thread that runs through the entire academic programme. The future of medicine is very likely to be, “Personalized medicine through nano technology and gene therapy”

Our guest of honour, is Sir Andrew Goddard, the immediate past president of the RCP. He is a dear friend of the CCP.  Sir Andrew left office as President two weeks back after an immensely successful tenure. We are holding this academic session in collaboration with the RCP. RCP has helped us to design the session on medical leadership and also arrange speakers for the plenaries. The RCP has accredited this conference and provides 16 CPD points for attendees and a further 8 CPD points for those participating in the medical leadership session.

Over the last two days we conducted four extremely successful, well attended Pre Congress workshops titled “How to get your research published”, “Supporting underperforming trainees”, “Experience sharing: working overseas” and “Medical Leadership”.

We also conducted online presentations of research abstracts both oral and posters with nearly 50 researchers presenting their work.

The sessions will have four orations. The most prestigious CCP oration will be delivered later in the evening by Prof S.A.M. Kularatne, one of the finest medical researchers in the country. Drs Rohitha Amarawithana, Nilanka Perera and Inoshi Atukorale, who will be delivering the Prof K Rajasuriya, Dr Cyril Fernando and Dr EV Pieris orations respectively, are three of the finest from the next generation of medical researchers in Sri Lanka. I congratulate them all.

There will be seven plenary lectures, delivered by thought leaders in medicine. There will be 9 symposia covering the length and breadth of clinical medicine. We have speakers of the highest standing locally and internationally, delivering these lectures. The 10th symposium will be on medical humanities and will include lectures on medical anthropology and poetry from Sri Lanka.

“CALL THE REGISTRAR !!!” is aimed at our specialist trainees to enhance their knowledge and skills on managing medical emergencies.

The concluding segment of the academic proceedings will bring into focus the trials and tribulations we as a profession had to face and the most difficult questions we had to answer – the social and political responsibility of the CCP. Two eminent and eloquent past presidents of the CCP will present their differing perspectives in the session titled “Should the CCP participate in political movements – Aragalaya, (the struggle) and beyond”. Let’s take this opportunity to open a discussion on defining our socio political role as the foremost professional medical specialist college in the country.

Conducting these beautifully crafted academic sessions with such elegance after all the turmoil in the earlier months is nothing short of a miracle. This is an academic feast replete with exquisite academic delicacies. As the greatest of all professors, Professor Albus Dumbledore, the headmaster of, Hogwarts school of wizardry and witchcraft, standing at the head table in the enchanted great hall would have declared, … “Let the feast begin!”.

Thank you ladies and gentlemen for your gracious presence this evening."

Professor Arosha Dissanayake
Ceylon College of Physicians

A new History

The CCP held its fourth ‘Beyond Medicine’ lecture for 2022, last week. One of Sri Lanka’s greatest archeologists, Prof Raj Somadeva, from the postgraduate institute of architecture of the University of Kelaniya, was our guest speaker.

Of the many archeological excavations conducted by teams led by Prof Somadeva, one of the most remarkable has been the prehistoric house discovered in a remote village , called Uda Ranchamadama, close to Kolonna, in Ratnapura district. The foundation of this house was unearthed when excavating near the priests’ abode at the Jayabodharama Viharaya.

It is believed that the house belonged to a prominent member of this pre historic village. (Pre history means history that precedes the recorded literary forms). The house foundation indicates, it had a living room, two other rooms, a kitchen and a semi circular verandah. The charcoal found in the kitchen helped carbon date the house to 1200 BC. There were earthenware, painted pots which had been made smoothly rounded in a turning wheel (sakaporuwa), which itself is a remarkable technological creation. There were clay beads. A high technical skill is required to produce clay beads. A bronze tool which was discovered, was identified as a ‘Kohl stick’. Khol is a mix of mineral powders used as eye make up in ancient times. Khol was applied using a tapering stick, the Khol stick. Similar Khol sticks have been discovered in excavations in ancient Egypt in 1400 BC. Hence not only Egyptian princesses, but ladies in this country too made themselves prettier, using eye make up, 3000 years BP. (Archeologists use BP to denote ‘Before Present’).

Sri Lanka’s written history, from Mahawamsa (the greater chronicle) written in the period of King Datusena in the 5th century AD, records history from 500 BC onwards. Hence these discoveries describe, how advanced life in Sri Lanka was, hundreds of years before the arrival of Prince Vijaya and clan which is supposed to have occurred in 543 BC. It is evident from the archeological excavations that there is much more in the history of this nation, which predates what is documented in the great chronicles, Mahawamsa and Chulawamsa.

Prof Somadeva’s Beyond Medicine lecture titled ‘Beyond the conventional past: New findings of SriLankan history’ provided a glimpse into this glorious past, prior to the recorded history, we limit ourselves to. His new book ‘Yakshi’ provides a comprehensive, scientific, and an in-depth analysis of the history of our nation. The book contains 15 years of exploratory work from Prof Somadeva and should prove to be an essential book in our libraries.

An oxymoron is an instance when two contradictory terms appear together. For the linguistic enthusiast, a “New history” is probably an incomparable oxymoron!!

With warm regards,
Arosha Dissanayake
President, CCP

Compassionate Leadership

It is already December and 2023 is drawing to a close. The CCP AGM is on the 9th of December where I will relinquish duties as PCCP. This will be the last Presidents Column in a CCP Weekly that I will be writing to you. I hope you have enjoyed the diverse topics we discussed and my efforts to engage the membership all the while. Thank you to all those who wrote in with comments and suggestions.

As the final write up, I thought I will write on something that is close to my heart and of something, I have been giving considerable thought to - “Compassionate Leadership”. Compassion is considered to be sensitivity to suffering in self and others, with a commitment to try to alleviate and prevent it We live in a world of paradoxes. Whilst promoting compassionate care for the patients, our conduct towards healthcare staff is at times devoid of compassion. Even when we see junior staff struggle, we maintain our brusque and detached ways. ‘If you can’t stand the heat, get out of the kitchen’ we would mutter self righteously and move on. All this, while there is a large evidence base that well supported, cared for, motivated staff bring about higher quality patient care and outcomes.Even for medical students doing clerkships under us, how harshly and humiliatingly do we at times treat them? All this whilst there is mounting evidence that adult learners (which, medical undergraduates are) learn better when they enjoy the learning process. At the end when they become doctors, we quite paradoxically, expect them to turn out to be most compassionate towards their patients.

Compassionate leadership involves four aspects. Listening, understanding, empathizing and helping. Those working with us would then feel valued, respected and cared for. The leader and the team member finds shared solutions to problems individual and organizational problems. The well motivated team members with high levels of wellbeing (less stressed and less burnt-out) provide higher quality care. (West, 2021). The days of hierarchical leadership where the mantra is, ‘theirs not to reason why, theirs but to do and die’, are numbered. There is increasing evidence that it results in demotivated, insecure teams which shelve creativity and end up performing poorly.

We hold leadership positions at different levels. It’s time to turn the torch of compassion inwards towards ourselves and our team members and become the compassionate leaders who truly care for all those around us, both team members and patients.

Merry Christmas and a Happy 2023 to you !!!

Professor Arosha Dissanayake
Ceylon College of Physicians