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Has the Colombo Medical Faculty (founded in 1870), the oldest medical school in South Asia, been able to produce a Caring Doctor for the community at last is yet to be seen, with the first batch of doctors to come out recently trained under the Faculty's new curriculum, designed for the purpose.

Health Watch met the Faculty Dean, Prof. Lalitha Mendis and Professors S.P. Lamabadusuriya, Colvin Goonaratna, and Senior Lecturer Dr. Mrs. Chandrika Wijeratne last week to talk about this batch of doctors and the new curriculum and we found that they (Faculty head and the professors) had much faith and confidence that time will prove - (for this batch will have to complete its internship training to go out to the community) whether the Faculty has been able to do what some of us think as the impossible, turning out a competent, compassionate, caring and a kind doctor, (a C'3 doctor) to the community, as one member of the Faculty put it.

The Faculty has taken six years to deliberate and evolve the new curriculum based on five streams, one of which is the Behavioural sciences stream, where in medical ethics the students have been told among other things that Doctors should always try to resolve their disputes through negotiation and never - the strike action, putting poor patients into inconvenience and their lives in danger.

We devote this page today to tell you the story of this curriculum change, and of some of its features, as told to us by Prof. Mendis and the two professors.

"In this Faculty we are not only concerned about student studying and learning to be a Doctor. WE expect then to develop as a person and to become a mature and responsible professional who can serve as both a leader and a part of a team in the community.

We expect students to learn not only the skill of healing but to develop the quality of caring for patients and for fellow human beings. We expect them to develop the ability to communicate effectively with all categories of people that they are called upon to interact with when they become doctors.

We expect students to interact with students from the different social backgrounds, ethnic groups and religions in a way that you will understand and appreciate their different life styles, practices and points of view.

Until 1995 the M.B.B.S. course was on traditional lines where the course was punctuated with the 2nd M.B.B.S. and 3rd M.B.B.S. examinations and terminated with the Final M.B.B.S. examination. Clinical teaching was mostly in the tertiary setting of the Colombo group of hospitals. However, even within this traditional course, many changes were made over the years in both training and evaluation.

In 1995 the M.B.B.S. curriculum was changed after six years of planning. The main objectives of the new curriculum are to reduce content and quantum of teaching by didactic lectures and instead to make learning more student centred.

Towards this end teaching methods such as Problem Based Learning, Small Group Discussions, Seminars, Tutorials, Debates, Inter-Disciplinary Activities. Fixed Learning Modules, field attachments and family attachments have been introduced. The student is encouraged by these methods to be a self-learner. System based learning, emphasis on behavioural sciences and the community are other important features of the new curriculum

The following Centres/Units/Laboratories were set up to support the new curriculum.

* The Medical Education, Development and Research Centre (MEDARC)
* The Skills Laboratory
* The Audio-Visual Unit (A-V Unit)
* The Computer Assisted Learning Laboratory (CALL)
* Stream Offices (Introductory Basic Sciences Stream, Applied Sciences Stream, Behavioral Sciences Stream, Community Stream and Clinical Stream)
* Examination Unit

In the new curriculum there is an increased emphasis on student centred learning, life long learning, communication skills and use of Information Technology.

Well developed English language skills in writing, reading comprehension, listening comprehension, listening comprehension and speech are a great asset for learning as well as performing well as assessments.

The English for the Medicine course is designed to develop these skills in relation to medical studies and also includes development of group skills, study skills and appropriate attitudes.

The course is conducted jointly by the staff of the Medical faculty and the Department of English of the University of Colombo.

In the year 2000, a BSc course in Pharmacy was begun by the Faculties of Medicine and Science of the University of Colombo.

On completion of the M.B.B.S. course, a graduate should be able to do the following at the level of general professional practice.

1. Identify important illnesses and other health related problems in individuals and in the community and plan and implement appropriate preventive, curative and rehabilitative measures.

2. Identify, recommend and implement activities, which promote health of the individual, family and community.

3. Work harmoniously with others as a leader/member of a health care delivery team.

4. Educate and train other individuals, health care personnel and the community, towards better health.

5. Develop and maintain personal characteristics and attitudes for a career as a health professional.

8. Develop into a self directed learner with the capacity to recognise the need for self evaluation.

The teaching programme of the Community Stream commences in the second term and continues throughout the five-year course.

The objectives of the Community Stream are to enable to student to identify health related problems in the community; plan and implement preventive, curative and rehabilitative measures at community level; identify, recommend and implement activities which promote health of the individual family and community; conduct health related research; and to work as a leader or member of a health care delivery team.

The contact areas covered include concepts of health and disease, health promotion, basic epidemiology and statistics, gathering of health information, handling of information, health indicators, basic research methodology, concepts of prevention of disease, community, environmental and occupational aspects of health and disease.

Most of the learning experiences are student centred and include lecturers, tutorials, seminars, student presentations, small group discussions, field work, field visits, field assignments, family attachments and conducting a community based research project.

The teaching programme of the Behavioral Sciences Stream commences in the second term of the first year and continues through the five-year course. The objectives of the Behavioral Sciences Stream are to help the student to develop skills in effective communication and for useful interaction with others; self awareness and the skills and attitudes which will facilitate development of self, both as a professional and as an individual. A subsection in the Behavioral Sciences Stream is ethics. Theoretical aspects of ethics as well as ethical issues are covered in the ethics section. Small group discussions are the main method of instruction, interspersed with a few lectures. Speaking on conduct and discipline. Prof. Mendis said: "In this faculty we believe that strikes are not weapons to be used by doctors and students to settle issues. They have to be dealt with discussion and dialogue. Thats the tradition in this faculty. In the Behavioral Sciences Stream headed by Prof. Colvin Gooneratne, students are taught and trained on these matters.

The teaching staff of the Colombo Medical Faculty responsible for turning out its first batch of caring doctors under the changed curriculum (from left): Professors Jennifer Perera, Dulitha Fernando, Ravindra Fernando, L.R. Amarasekera, Harsha Seneviratne, Sanath Lamabadusuriya, Lalitha Mendis (Dean of the Faculty) Rohan Jayasekera, Rezvi Sheriff, Dr. Nanda Karunaweera.

Around sixty years ago, when I was a little fellow in a family of five boys, almost daily one or more of us had to be treated for an ulcer, cut or a similar injury. These were all treated by our mother and I do not recall any of us having to visit the family doctor for a dressing at any time.

There were no antibiotics then. In fact the only antiseptic lotions available were Condys lotion and Hydrogen Peroxide. The application was generally Zinc and Boric Ointment or Boric Powder. This was the usual treatment for a fresh wound. Then there was no Triple Injection or Tetanus Toxoid either and wounds had always to be very thoroughly cleaned. Anti-Tetanus Serum was available but this could have serious reactions and was seldom given.

With the first sign of infection however (inflammation and/or pus formation) my mother's standard treatment was warm bread poultice, applied daily for a few days. This was invariably successful and the wound healed.

During my fifty years practice as a General Practitioner I have been using bread poultice for 'difficult' cases with the same amazing results. I have used it regularly for infected wounds, whitlows, infected toe-nails, abscesses, boils, chronic eczema and all such similar conditions and the results have been excellent. Duration of the treatment is generally two to four days and seldom more than six days and often the patient can be thought to do it himself or herself at home.

During the past one year I have been working as a Medical Officer in an Outdoor Medical Centre at a University. Here I have had the opportunity of using bread poultice treatment extensively on an average of 3 to 4 patients per day for the above-mentioned conditions - for a total of around 700 patients. As far as I am aware, we have had no failures at all. Of course, where there is obvious signs of infection - inflammation, enlarged glands, fever etc. - we use oral antibiotics also. The results have been so good, that I have hardly ever had to use a scalpel for the past year !

The method is to use a piece of rusk (we use baby rusks as they are a convenient size), wrapped in a piece of clean cloth or lint, like a toffee. This is placed in a bowl or cup and boiling water poured over it. Leave to boil for two minutes, squeeze out the cloth, getting rid of the excess water, open it out and allow to cool for awhile. Spread the soft rusk poultice over the affected area, previously washed clean with dilute antiseptic solution. Cover with a clean piece of lint or cloth and bandage. Renew the poultice daily till wound is perfectly dry, healthy-looking and healed.

The treatment is simple and could be done in any home. There are no side-effects at all. The cost of treatment is negligible! Safe, effective, easy and cheap-what more !

I shall be most grateful if readers who might wish to try this out would please write in to Health Watch and keep us informed of their experiences.

Health watch - At a time when the majority of people are thinking of ways and means to cut down on living costs, your bread poultice recommendation as a doctor will be most welcomed by them. Thank you for writing this article to the Health Watch.

Are you immune-fit?How Immune fit should a patient be before major surgery, particularly for abdominal surgery for cancers or cardiac problems? Medical belief on this issue is under going a major change.

Where once patients who needed major surgery for treatment of the pancreas, the oesophague and the heart were simply not given food, but just intravenously administered drugs and antibiotics, research today is increasingly moving towards nutritive care via the abdomen.

The more criticaly ill a patient is the earlier he or she needs nutritive care, two eminent lecturers on the subject told the Sri Lanka College of Anaesthesiologists at its annual scientific sessions last month. They were Professor David Bihari, FRCP, FRACP of the University of New South Wales Australia and Dr. T. Varsha MSc. PhD (Clin. Nut) of the Sri Ramachandra Medical College, India.

They held that immunity enhancing nutrition was vital both before and after operations. Specialised diet plans are important they held. A typical plan has sources of carbohydrate, protein and fats. Immunity enhancing diets should also have amino acids like arginine, Omega 3 and Glutamine which help lower post operative stress levels and lets his or her system recover faster.

"Essentially" Dr. Bihari said," what I mean when I talk of immuno nutrition, I mean the addition of two or more specific nutrients in greater than normal concentrations so as to modulate the immune function in order to improve the outcome".

"And by outcome, I mean the patient has fewer infections, spends less days in the Intensive Care Unit and the hospital so that the cost of care goes down and in the long run, one hopes for improvement in survival".

Research on a nutritional supplement now being introduced in India and Sri Lanka after its successful use in Europe and America has revealed higher survival rates and reduced the length of a patient stay in ICU, thus reducing costs significantly.

"These exciting studies show that immunotherapy with a supplement like this reduces the illness and costs associated with major surgery, freeing up much needed resources for health care" Dr. Bihari said.

This article by Willion de Alwis is based on a lecture delivered by Dr. David Bihari of University of New South Wales Australia, at the Annual Scientific sessions of the Sri Lanka College of Anaesthesiolosists recently.

"If sambol and mallum made with grated coconut is digestible and good to eat, Why not the refuse? which is also the grated coconut less some carbohydrates fat, protein and water extracted.

He poses the question? Considering the escalating price of coconuts which is about Rs. 12 to 17 a nut to day, time has come for us today to incorporate and use the refuse in some of our food preparations rather than throw away to the dustbin. He continues.

Coconut refuse contains significant amounts of carbohydrate and protein; it is low-fat coconut. Can coconut refuse be used in human diet"? Is it digestible? If sambol and mallun (made with grated kernel) is digestible, why not coconut refuse, which is grated coconut from which some carbohydrate, fat, protein, and water has been extracted?

It is not suggested that coconut refuse should be a principal article of food in our daily diet! However, considering the escalating cost of coconuts, the time has come for us to incorporate it into our food preparations rather than throwing it into the garbage.

Coconut refuse can be used entirely or mixed with grated coconut in preparations such as roti and pittu. It is also useful in the diet of those who should avoid the fat in coconut. (read below) It also contains dietary fibre which is known to bring down the level of cholesterol. Unfortunately it is referred as coconut refuse, a derogatory term. Why not call it "low-fat grated coconut".

The fat in coconut has a high level of saturated fat - P/S ratio is very low (This is the ratio of polyunsaturated fats to saturated fat. When the saturated fat content is high, as in coconut fat, this ratio becomes low; when the saturated fat is low and the unsaturated fat is high, as in corn oil or soya oil, the ratio becomes high). This has caused an unnecessary fear and controversy about consuming coconut. It should be noted that the type of saturated fatty acid in coconut, is what is termed "medium chain fatty acids".

These fatty acids are used up, in the first instance, to produce energy, and therefore there is little left to be converted to the harmful cholesterol. Coconut kernel, as pointed out earlier, contains carbohydrates, proteins and fibre, in addition to the fat. Recent studies in Sri Lanka and abroad indicate that when coconut oil is consumed, along with coconut kernel in any form, HDL - the 'good' cholesterol - is increased, and LDL - the 'bad' cholesterol - reduced. It is reported from Kerala (India), 2001, that an amino-acid, arginine, which is present in the protein of the kernel in coconut, counteracts the harmful effects of a high cholesterol diet by manipulating the levels of free radicals.

Taking into consideration the pros and cons of coconut fat consumption, it can be said that coconut is a nutritious food which need not be cut down. However, those who consume large amounts of animal fats, such as fatty meats, (pork, bacon, etc), milk and milk products (butter, ghee, curd, youth, cheese, etc) and egg yolk, all of which are high in cholesterol, should either cut down their intake of coconut fat oil, or avoid such foods.

It is the cumulative effects or the intake of such foods, very often in the form of fast foods, which have recently become a part of our food culture, and the increasing tendency to a sedentary and stressful life style that is causing a concern about the consumption of coconut, as opposed to the earlier era when these adverse conditions were minimal. Those who have diseases due to atherosclerosis, such as coronary heart disease or strokes, or those who have a strong family history of such diseases, should also cut down the coconut oil, unless it is taken together with significant amounts of coconut kernel. Such people should get used to preparations made from soya, soya oil, corn oil, etc.

The Colombo Medical Faculty is organising an international conference on the `curriculum change' to produce a better caring doctor, which the faculty had introduced in 1994.

The conference is to be held from June 30 - 03 July at the faculty. The conference will deal with the following topics:

(1) Strategies for changing curriculum
(2) Evaluation of Curriculum
(3) New teaching techniques e.g. Problem based learning small group discussions computer assisted learning clinical skills learning
(4) Accreditation and standard setting
(5) Best evidence based medical education
(6) Teaching medical ethics
(7) Social Accountability
(8) Consumer (Student and public) Expectations.

New causes for new diseases
By Prof. John M. Last
We invite you to send your health problems on the above to:

Health Watch Coordinator
Edward Arambewala
Daily News
Lake House
Colombo 10
Fax: 429210
Email: editor@dailynews.lk