The Tuanku Muhriz Travelling Fellowship in Rural Surgery 2023

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The Tuanku Muhriz Travelling Fellowship provides Fellows or Members of the Royal College of Surgeons of Edinburgh, a rewarding opportunity to gain further experience and training in rural surgery in Malaysia. 

The 2023 Fellowship was awarded to Consultant Orthopaedic Trauma and Hand Surgeon, Adeline Clement. In her report, Adeline, shares how she was inspired to revisit her Malaysian roots in addition to sharing her experiences of rural surgery in Scotland with her new Malaysian colleagues and improving her own practice. 

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The philosopher Lao Tzu once said `A journey of a thousand miles begins with a single step’. I was inspired to submit my application for the Tuanku Muhriz (TM) travelling fellowship in rural surgery 2023, to take that step in revisiting my Malaysian roots, instilled with the hope of sharing my experiences in rural surgical pathways and hand surgery in the North of Scotland with my Malaysian rural surgical colleagues. I also had hopes on learning ways to improve my own rural surgical practices in return. 

The TM travelling fellowship is an initiative by Tuanku Muhriz himself in collaboration with the Royal College of Surgeons Edinburgh (RCSEd), through the college’s International office based in Malaysia. The fellowship encourages healthy networking and an exchange of expertise between a rural surgical establishment in Malaysia, with the fellowship sponsored, UK based rural surgeon. I was the third recipient of the fellowship after a successful selection process through the RCSEd, and was to spend time in the rural district of Jempol in the state of Negeri Sembilan in Malaysia.

The previous two recipients of the fellowship are decorated surgeons in rural surgery in the UK and visited other rural districts in the east Malaysian states of Sabah and Sarawak.

In September 2023, I began my fellowship journey travelling from Inverness in the Highlands of Scotland to Kuala Lumpur, Malaysia. I was excited but equally nervous about what was expected of the travelling fellow. Being Malaysian, I thankfully still had some grasp of Bahasa Malaysia, but having left Malaysia to reside and work in the UK 20 years ago, I was nonetheless nervous of clinical language barriers and cultural faux pas.

The first day of my fellowship began with meeting Mrs Shidah Abd Lah, manager of the RCSEd International Office in Malaysia who had arranged an educational session with the orthopaedic hand team at Hospital Cancellor Tuanku Muhriz (UKM) in Kuala Lumpur. I was given the opportunity to meet with the head of department, Professor Sabarul, and the head of hand surgery, Professor Shalimar Abdullah. Prof Shalimar had organised an evidence based educational session centred around wide awake no tourniquet local anaesthetic (WALANT) technique in hand surgery, the way forward in cost effective, accessible hand surgery.

I delivered a presentation titled `WALANT: a sustainable future in hand surgery’, that was well received, generating discussion and exploration of the challenges the team at HCTM face in training hand surgeons in this technique. The main challenge faced in training is incorporation and acceptance of WALANT as a viable technique for mainstream hand surgery. I learned that a visionary team of hand surgeons under the care of the previous head of department at Hospital Tuanku Ja’afar, Seremban in the state of Negeri Sembilan had incorporated WALANT successfully into its delivery of hand surgery. 

I felt this was an area I could work closely with Prof Shalimar and her team to develop for their department beyond the remit of this fellowship through ongoing networking and planning. The first day concluded with an interactive discussion on medical education and training, an area I am actively involved in, with the CEO of HCTM, hepatobiliary surgeon Prof Razman Jarmin, who simultaneously reacquainted me with the delights of the durian!

At brief notice, I had the opportunity to have an audience with Tuanku Muhriz himself at the Negeri Sembilan residential palace in Kuala Lumpur with Prof Dato’ Dr Hanafiah Harunarashid, the vice chancellor of HCTM. Despite royal protocols, this was a relatively informal opportunity for Tuanku Muhriz to be acquainted with the fellowship recipient. Tuanku Muhriz was also personally invested in the third instalment of the fellowship as it would involve a visit to the district of Jempol which is in Tuanku’s home state of Negeri Sembilan. It was an opportunity to reassure him of my intention to keep working with the clinical team in Jempol on key areas identified during the fellowship.

Following this audience, I commenced my stay at the lovely, Seri Menanti Resort in Kuala Pilah, Negeri Sembilan. The welcoming, green backdrop of rural Kula Pilah village and the friendly, accommodating staff at the resort made my fellowship stay a true home away from home.

Over the next eight days of the fellowship, I had the opportunity to explore the rural surgical, community and specialist services currently in place at the Hospital Tuanku Ampuan Najihah (HTAN lead specialist hospital) cluster and its non specialist hospitals, Hospital Jempol and Hospital Tampin. The cluster hospital concept was introduced in Negeri Sembilan in 2016, was the second pilot under the transformation of Malaysian Healthcare systems and recognised as one of the most successful clusters.

The state of Negeri Sembilan lies east of the federal territory of Kuala Lumpur and borders the state of Selangor on the north, Pahang on the east and Malacca to the south. There are seven districts within Negeri Sembilan Jelebu, Jempol, Tampin, Kuala Pilah , Seremban, Port Dickson and Rembau, with my travels taking me between Kuala Pilah, Jempol and Seremban.

I met the team at HTAN led by Dato’ Dr Harlina Abdul Rashid, Director of State Health Department of Negeri Sembilan and Dr Gunaseelan Kumar, Deputy Director of HTAN. The head of departments for orthopaedics, Dr Mohd Shaharil Bin Abdul Aziz, and general surgery Dr S Sivapiragas Sivasupoaniam presented their pathways for orthopaedic care, acute vascular pathway and global surgery initiatives. The head of ophthalmology services, Dr Khairul Husnani Mohd Khalid with her team, lead the delivery of an impressive and successful current pathway for ophthalmology care between HTAN and the cluster hospitals including the mobile clinic services (KLIP Mobile). 

The opthalmology team have achieved an impressive optimum balance of delivering accessible, efficient and affordable care to rural patients. The team at HTAN however do face challenges similar to most remote and rural healthcare systems including the remote and rural NHS healthboards in Scotland. These challenges are mainly centred around lack of institutional funding either for new or sufficient equipment, or recruitment and retention of staff. A later visit to Jempol Hospital led by Dr Zul Iskandar Zainudin, the director Jempol Hospital, allowed me to explore the outpatient orthopaedic and emergency areas including a visit to the surgical ward, operating theatres and intensive care facilities. I had a useful discussion with the orthopaedic lead and one of the local hand surgeons as well as nursing staff based onsite.

The main issues at Jempol Hospital, which is a relatively new building, stem around the underutilisation of their outpatient space, theatres and intensive care partly due to lack of anaesthetic and nursing staff. One way to overcome lack of theatre capacity and staff shortages, would be to use the clean procedure rooms based in the outpatient department for WALANT technique in hand and foot and ankle surgery, as well as minor operations for any surgical speciality.

The medical officer on site also described the lack of rotation through a specialist hospital for surgical trainees when based at a cluster hospital, makes the rotation less attractive to encourage workforce retention in remote hospitals.  The day came to a close with an opportunity to have a discussion with the Menteri Besar (head of state government) of Negeri Sembilan, YAB Dato’ Seri Haji Aminuddin bin Harun at his main office in Seremban. Accompanying me for the discussion were Prof Dato’Dr Hanafiah, Dr Mohd Ferrous Alias, Deputy Director of the State Health Department and Mrs Shidah from the college.

The subsequent days, I visited the various healthcare facilities in Tampin, Kuala Pilah and Jempol. The Pejabat Kesihatan Daerah PKD (District Health Office) at Tampin hosts a mobile clinic for auditory, opthalmalogy and ENT care and holds a specialist clinic in the equivalent of a village hall. The KLIP Mobile van and University Science Islam Malaysia (USIM) initiative for provision of auditory and eye care to rural patients also run some of their care from this PKD on rotation.

I had the opportunity to meet the healthcare professionals and the wider team who delivered presentations on how the clinics and service is run. I was empowered to see many strong, professional women leading the healthcare team in a rural setting. Accompanying Mrs Shidah and I over the next 3 days, were Dr Zaza Hulwanee Mohd Zainee, Head District Health Officer of Kuala Pilah and Dr Farah Edura binti Ibrahim a Public Health Specialist in Kuala Pilah.

One of the highlights of my fellowship was a visit to the orang asli village in Guntur where I had the opportunity to engage with the village head and witness first-hand the delivery of vaccination program, screening and health education at the clinic in the village hall. In many orang asli villages around the country, most of the younger indigenous folk have moved to bigger cities and villages for employment leaving mainly a geriatric population based in the remote settlements.

The Guntur village is unique as it sits on the fringe of remote and city life and therefore retains many of its working class residents. The healthcare demographics therefore match its average population age of 45 years. This was followed by a home (domiciliary) visit with the community health team to a young, home bound paralysed patient from the effects of spinal tuberculosis treated late due to delay in presentation of the patient.

I witnessed the effect of cultural differences, family dynamics and traditional medical treatment as a barrier to receiving hospital care which is a common scenario the healthcare team in rural Malaysian communities face. Patient rapport, regular visits and a strict monitored drug regime is vital for patient benefit and in this case vigilance of multi drug resistant TB.

A visit to the Modern Wound Care Services at the Klinik Kesihatan (Health Clinic) in Johol was a further highlight. Here I met an exceptional team led by  Dr Liyana Zainal Abidin a Family Medicine Specialist and a remarkable medical assistant Mr Syed Faiz who has been managing difficult wounds exclusively in a community setting using modern wound care techniques such as maggot treatment and specialised dressings. These wounds are mainly lower limb wounds in patients who would otherwise have been prescribed life altering lower limb amputations. The challenge Mr Faiz faces running this service is succession planning and inadequate funding to train another allied health professional to help with his workload and in doing so access more patients. The team would also benefit from more specialist input and advice either through regular face to face or virtual multidisciplinary meetings to guide patient care.

The physiotherapy and occupational therapy department and team here have also dedicated years to improving their services, infrastructure, rehabilitation hub and expertise but struggle to deliver the service they aspire to due to chronic staff shortages.

In Jempol, I had the opportunity to visit the Ayer Hitam, and St Helier SIME Darby oil palm plantations to gain understanding of their Klinik Kesihatan set up and screening and vaccination programs for malaria and filiriasis. The health and safety aspect and injury education programs were also visited.

The Klinik Desa at Lui Barat run by the community nurses is predominantly a women and child health clinic which covers assessment, education, contraceptive care and vaccination programs for women, mothers and children. It is a useful and clearly valuable outreach clinic for rural communities however chronically understaffed. The community nurses at this clinic are so dedicated despite this and willingly give up their time and effort, and on occasion I am certain at the cost of their own family time.

At the healing and rehabilitation in the community (PDK) services in Bahau, I had the opportunity to interact with members of the allied health services who deliver the care and secure the funding for this valuable service, more importantly I could interact with the children and young people with special needs who most benefit from this service. I attended a rehabilitation session they usually run with volunteers and special needs teachers assisting in the program.

The individuals with special needs are taught life skills, self hygiene, arts and crafts. The Department of welfare provides RM 150 per individual to each family to attend the PDK, but provide RM300 to keep their child or relative at home.

The PDK provides beneficial workshops to improve their ability to gain employment and deliver career counselling to help these individuals become useful members of society. It would be useful for the department of welfare, to raise the allowance for attendance to PDK to match that of staying at home.

On the final day, I attended the mobile dental health services at Sertang Hilir in Jempol with access to the mobile dental clinic and lab at an activity day run for the FELDA settlement of Sertang HIlir. It was well attended by the town folk, cadets from the police academy and training college and school children.

We made home visits to elderly patients requiring dental assessment, a new mother in confinement and to the local primary school. Dr Samuel Goh who is an innovative dentist, his immediate assistant, Dr Prasath Subramaniam and their team are not only enthusiastic but are constantly developing new ways to engage patients and young children to take dental care seriously. They are extremely involved in evidence based practice and seem to be leading regional innovations in dentistry education. The dental pathway for remote and rural patients are far more advanced than what is set up in my own rural catchment of practice in the North of Scotland where dental care is poorly structured for rural patients.

There is certainly much I have learned from the team here and am inspired to lead innovation in the future. They included me in the day’s activities and discussions which were extremely helpful. Finally, I was given the opportunity to attend my alma mater the International Medical University at Seremban for an audience with the student surgical society and present my experiences as a Malaysian female surgeon trained in the UK. I was privileged to present alongside the esteemed Prof Dato’ Dr Hanafiah who aside from being the vice chancellor of HCTM and heavily involved in the Global Surgery initiative is also significantly active in the RCSEd’s work at its International office in Malaysia.

He presented the pathway both historically and currently on surgical training in Malaysia. Mrs Shidah was also on hand to introduce the RCSEd’s work and some information on the TM fellowship to IMU students mostly in their penultimate and final years of university. I had the opportunity to engage with some of the future brilliant minds in surgery after the talks and offer some career advice before returning to Kuala Lumpur.

Following my experiences on the TM fellowship, there are key areas that I have identified where I can continue to aid change. Firstly, in aiding Prof Shalimar and the hand department at HCTM drive their WALANT technique practices. I intend to discuss this further with Prof Shalimar on a virtual platform and share my department’s standard operating procedure on WALANT. Secondly, I would like to aid Dr Ferrous in developing a more balanced, training platform to help retention of medical officers and encourage surgeons to uptake a more rural practice. I would like to aid the surgical teams at HTAN better utilise their facilities at the cluster hospital such as use of the procedures room, and look at ways to fund new equipment and improve sterilisation services within legislative remit such as a new outpatient microscope and more vascular surgical trays.

I would like to aid the modern wound care team in improving their access to specialist MDT and training of new staff but I feel this may be beyond my capacity working out with Malaysia. Similarly, increasing workforce of child psychologists, occupational therapists and physiotherapist as well as increasing the welfare department’s budget of RM150 to RM300 for individuals with special needs to attend PDK are out with my capacity. However, highlighting these needs will give Tuanku Muhriz an outline of where services can be improved upon within the HTAN cluster. Ultimately, the change in these areas will need to arise from policy change and additional funding. Having said that, the cluster set up and services such as ophthalmology, ENT and dental health are already achieving exceptional levels of ideal patient outcomes and access to care. The teams who have worked hard to achieve this in the district of Jempol should be commended and valued.

Throughout my fellowship experience I had the opportunity to meet so many inspiring and motivated individuals who are so dedicated to improving remote and rural healthcare in Malaysia. Some of the challenges they face are very similar to the challenges I face in my remote and rural surgical practice. Every individual I met was warm, caring and brought something to the team. What was outstanding but truly Malaysian, was that the welcoming atmosphere, genuine kindness and hospitality offered by each individual was beyond expectation and extremely humbling. Language was never a barrier no matter who I met.

Each team and area I visited shared a part of their community, their culture, their local delicacies and in doing so their love and friendship with me. I am reminded that this is my legacy as a Malaysian and that our love is shared through the simplest acts of genuine kindness and hospitality. I was also grateful for the company of Mrs Shidah from the International office who had painstakingly coordinated each visit and trip and whose company on the trip I cherished, and has remained patient and helpful in completion of this fellowship. Where possible, Prof Dato’ Dr Hanafiah had also made his best efforts despite his busy schedule in joining me on this fellowship experience.

I would like to think I have built a friendship for future networking on an international platform with Prof Shalimar and Dr Ferrous and hope to aid them in driving change within their remit of healthcare. I have found the TM fellowship has opened doors between two regions with hopefully successful working partnerships in the coming future. With communication over distances now less of an obstacle with virtual platforms, I hope to offer my abilities beyond the fellowship to my fellow Malaysians.

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