Oncosurgery or surgical oncology  is the branch of surgery applied to oncology; it focuses on the surgical management of tumors, especially cancerous tumors. A surgical oncologist is a surgeon who has special training in treating cancer. Surgical oncology is one of the many short appointments under Surgery for us - medical students - and its a two week posting. We - a group of 15 students - were posted for this appointment, under a prominent surgical oncologist,  during the last two weeks (of September) in the National Cancer Institute (NCI), the leading hospital under the Ministry of Health dedicated to the diagnosis and follow-up treatment of cancer patients, in Maharagama.

The NCI offers both the diagnostic facilities necessary for the identification of all types of cancer, and specialised care in surgery, chemotherapy and radiotherapy. A team of expert Consultants manage the hospital services alongside medical doctors, nurses, pharmacists, medical physicists, laboratory technicians and minor workers. Anyone can access the services, free off charge. In addition to delivering quality care services the NCI is the major training centre for medical undergraduates and postgraduates of the Postgraduate Institute of Medicine (PGIM).

We couldn't have asked for a better consultant. He had twenty years of experience as examiner in final year MBBS exams in various universities - and he was still invited to as examiner. Thus he knew all the ins and outs of how our short cases and long cases are examined. He stressed the point that as house/medical officers we would come across patients in the Ward and the Clinic setting, as well as the emergency section. How are our competencies in these settings evaluated? Our long case examinations evaluates our competency in the Ward setting - where we have to do a holistic history taking and examination to reach a probable diagnosis with differential diagnosis and a plan of management. Our short case examinations evaluates our competency in the Clinic setting - where we may come across new patients or follow up patients for a shorter period of time. As for our knowledge and skills in  Emergency Medicine, which cannot obviously be resurrected for examination purposes - this would be covered in our written exams and MCQs.

I've never come across a more cheerful, witty, talkative consultant as this one. He was a blatant contradiction to the gloomy sad place this was. I thought at first this was a coping mechanism but then realized otherwise. Here was a man with perfect confidence in his job - who loved doing his job (surgery was like to him like playing a first person shooter game was to me) and who achieved immense satisfaction in doing his job - which literally saves countless lives. Why should he be other than cheerful and happy and optimistic? His emotional and rational intelligence was off the charts and he knew exactly what we were thinking at all times - and made succinct witty remarks now and then. He had two sons who were rebellious medical students too and so he knew exactly what we were like. He signed and gave back his thank you saying he didn't like to be reminded of .... well he sure had some strangeness in him.

The consultant and his senior registrars and others - wasted no opportunity to teach us things. These guys loved showing off their knowledge and skills - but it was the attitudes to their work that was really exceptional. They had/have to go through a minimum of fifteen years of formal medical education, training and experience and there simply was no end to the stuff we could learn from them. Two weeks was never going to be enough. Wednesdays and Fridays were surgery days. Tuesdays and Thursdays were clinic days and the rest of the time this group of doctors were at the wards. Each of us were allocated patients for history taking and follow up. In the clinic sessions we helped with the examinations and learnt a low through observation and classes. In the surgery sessions - each of us got an opportunity to assist.

More than half of his male ward (which was just one of the many wards) were of patients with oropharyngeal cancers - mirroring the national statistics. Heavy smoking, heavy alcohol consumption and betal leaf chewing have been associated with the high rates of these cancers. if you have a friend who you badly need to stop with these habits, just take a walk across this ward.  The mirroring with national statistics was also true with breast cancer and the female ward. Unfortunately breast cancer cannot be prevented simply by healthier lifestyle and the cessation of addictive behaviors. But there are stuff you could do to prevent dying from it. Other cancers seen were osteosarcomas,  thyroid cancers, colorectal etc etc There were many patients in pain and on strong opiod analgesics. Some were clearly on the last stages of their life with multiple complications.

During the clinic sessions, we got the opportunity to practice our history taking and examination skills yet again. Lump, breast, thyroid examinations were practiced over and over again. Sri Lankan patients in the free healthcare system are really helpful and willing to be used for such purposes fortunately. It was a privilege to be posted in a tertiary care center. During surgery days, we got the opportunity to assist surgeries. There were many many masectomies done as well as removal of osteosarcomas, liposarcomas, thyroid lobes etc etc the surgeons made it all look so very easy.

Over 100 types of cancers affect humans. Tobacco use is the cause of about 22% of cancer deaths. Another 10% are due to obesity, poor diet, lack of physical activity or excessive drinking of alcohol. Many cancers can be prevented by not smoking, maintaining a healthy weight, not drinking too much alcohol, eating plenty of vegetables, fruits and whole grains, vaccination against certain infectious diseases, not eating too much processed and red meat and avoiding too much sunlight exposure. If you have any questions or want to know more (about anything) feel free to ask in the comments below.

The problem of what to do about rising obesity rates is a major preoccupation of the early 21st century. Obesity has been linked with a range of chronic diseases. Fat shaming has not shown to work though. Thread about HAES 👇

The main components of the HAES approach are (1) intuitive eating, (2) body positivity - acceptance regardless of size or shape, and (3) physical activity for movement and health rather than for elite performance or to shape the body.

(1) Intuitive eating is an approach to health and food that has nothing to do with diets, meal plans, discipline or willpower. It teaches you how to get in touch with your body cues like hunger, fullness and satisfaction while learning to trust your body around food again

(2) All human beings should have a positive body image. All bodies no matter the form, size, or appearance - should be receive nothing short of acceptance. Beauty is a construct of society - which should not infringe upon one's ability to feel confidence & self-esteem

(3) Physical activity should not merely be viewed as a way to burn calories — it has much broader health benefits. Do exercises and move - not simply to lose weight or burn fat, but to be happy and have fun, and to inprome both physical and mental performance/health

HAES = intuitive eating + body positivity + fun physical activity

This is >>> diet restriction + fat burning, which has not shown to work at all in spite of the massive weight loss industry. It's time for a radical paradigm shift and the prioritisation of overall health

Whenever you come across "try to lose weight", replace those words with "eat intuitively, do more fun physical activities, and be more body positive" rather than "go on a diet and burn calories". Go beyond reducing a number to taking care of your overall health

According to the World Health Organization, #breast #cancer is the most common cancer among women worldwide, claiming the lives of hundreds of thousands of women each year and affecting countries at all levels of modernization. A thread 👇

Breast cancer is the most common cancer amongst women in #lka, accounting to 20 per cent of all cancer cases reported in the island. In the case of men, Lip, Oral Cavity and Pharynx cancer is the leading type of cancer and accounts for 20 per cent likewise.

Females have a 100 times higher risk of getting breast cancer than males
(female: male = 100:1). Males when they do get it tend to present unfortunately at an advanced aggressive stage.

Both screening and early clinical diagnosis are vital interventions to control cancer. Both screening and early clinical diagnosis are vital interventions to control cancer. Unlike oropharyngeal cancers in men caused by smoking, breast cancers in women cannot be totally prevented

If you notice new breast changes, discuss these with your doctor. Though most breast changes detected during a self-exam* for breast awareness have benign causes, some changes may signal something serious.

*this should be carried out by all women over 20 years once a month

If breast cancer is detected at an early stage, it can be cured by applying
appropriate intervention early. If breast cancer is detected at a late
stage, it is difficult to achieve a complete cure. This is the usual referral pathway when a major breast abnormality is detected

Breast screening helps identify breast cancer early. The earlier the condition is found, the better the chances of surviving it. You're also less likely to need a mastectomy (breast removal) or chemotherapy if breast cancer is detected at an early stage.

From age 50 – 69 years, screening mammography is offered once in every 2 years if the woman requests it. Screening saves about 1 life from breast cancer for every 200 women who are screened.

If you reside or are visiting Colombo you can have a mammogram done for yourself or a loved one (grandmother, mother, aunt) in the Cancer Early Detection center.

Cancer Early Detection Centre★★★★☆ · Medical Center · 519 Elvitigala Mawathahttps://maps.app.goo.gl/EgKVox1y2G6aF1bn6

The facilities of this walk- in clinic are available to any member of the public. Open five days of the week from 9 a.m. to 4 p.m. , the Centre offers screening and early detection - free of charge - with a focus on breast cancer, cervical cancer and oral cancer

How is breast cancer diagnosed? It is made at the tertiary care level and through triple assessment.

Breast Cancer is treated by 5 standard treatment options depending on the type and stage. Surgeons are doctors who perform operations. Medical oncologists are doctors who treat cancer with medicine. Radiation oncologists are doctors who treat cancer with radiation.

Thank you for reading.

The power distance index (PDI), developed by Dutch social psychologist Geert Hofstede, is an index that measures the distribution of power and wealth between individuals in a business, culture, or nation. It is the degree to which unequal distribution of power is socially accepted within a society. Power distance inequality in a society is very important aspect of national culture. For example, Sweden (PDI 31) differs from France (PDI 68) in the way its society handles inequality. This table summarises the differences between a high power distance index culture and a low one.

With a slightly high score of 80, Sri Lanka is a relatively hierarchical society. This means that people accept a hierarchical order in which everybody has a place and which needs no further justification. Hierarchy in an organisation is seen as reflecting inherent inequalities, centralisation is popular, subordinates expect to be told what to do and the ideal boss is a benevolent autocrat. 

SELF-RESPECT

Once a consultant I was a student of was describing how things were at his time when he was a student. He was trying to explain why they grew up without having the need to tell any lie nor conform to corruption. Why they never did any stuff that was below them nor even thought those things appropriate.And why today people take bribes left, right and center and cannot go a day without lying. Why they didn't respect themselves enough to not do thing that were unworthy of a person in their status. He boiled it down to a fundamental difference in power distance index. Students then were shown respect and were treated as individuals with an equal or greater capacity of mind. They were not required to stand up when a senior or a teacher comes - like what is practiced in state faculties today. They had lots of respect for themselves so much so that their pride and prestige disallowed them from partaking in any vice.

We should NOT be bringing up children on the basis of obedience and dependency. We should  bestow upon them the values of individuality and reinforce their innate God-given sense of respect and dignity. It's okay in taking pride in yourself and your upbringing. This sense of pride is your first line of defence against the evils and vices of society. Treat yourself with dignity and respect and you'll be soon finding yourself drawn towards good and intolerant of evil in yourself and your actions.

FURTHER READING

https://www.hofstede-insights.com/country-comparison/sri-lanka/
https://www.colombotelegraph.com/index.php/dependency-within-sri-lankas-sir-madam-culture/
https://www.colombotelegraph.com/index.php/sir-madam-and-the-political-culture-of-sri-lanka/
http://www.onlinejournal.in/IJIRV2I10/147.pdf

It’s undeniable that each and one of us who is sane and conscious tries to live by a moral code of our own making or imagination. It might change with time and circumstances, with the adaptation of new beliefs and the rejection of previously held ones. We might be inconsistent or even break it once in while, and in that case we feel guilty. But all of us do have an idea of what is wrong and what is right; we wouldn’t do what we think is wrong given a choice.

But what exactly does it mean to have a moral code? Why do we have it, and from where is it derived? Can we live without it? Is some moral codes better than others? Is there a golden moral code, an objective framework to guide our decision making process, that is better than all other moral codes?

I define a moral code as not just guidelines you live your life by and govern your decisions by, but rules — with penalties in case you break them and reward in case you chose the right one over the wrong one. I think if it weren’t for the penalties and the reward, we wouldn’t keep the moral codes for ourselves — humans are generally selfish creatures. There is no action we take that is no carried out in our own best interest if you really get into the bottom of it. In this case it is similar to the Law societies introduce for themselves, reflecting the moral codes of the Lawmakers.

Is it derived from a higher authority? I cannot believe otherwise. It is always the case that we derive it from some higher authority who also tend to prescribe the punishment/penalties for breaking the code and the rewards for keeping it. Some of us derived it from God and Revelation/religion scholars, others from Science/Reason, while most of us derived it from a variety of sources. It is obvious to note that it is the threat of “punishment” and the offer of “reward" that actually builds the instruction into the moral code. For example science may prove that smoking is bad for our health (prescribes a punishment for smoking) and so we could adopt a rule in our moral code “thou shall not smoke”.

From this it is clear that we adapt a moral code only when there is a selfish reason so as to do so. I do not believe in pure altruism. I decide to jump into the water to save a drowning soul not purely because of unselfish reasons. I have somehow given value to the act of saving life and punishment for the act of neglecting to do just that. This is something that needs some quite deep and radical thinking to accept.

Is there some objective framework we could live our lives by? Does there exists a moral code that we could derive through the application of reason and logic — one which is as objective and universal as the laws of maths and physics? I believe the answer is yes, but I vehemently disagree that this golden moral code could be derived purely through our collective reason and use of logic.

But that is up for debate.

There is a reason why the moons, the planets, the stars, the electrons — everything — have their own orbits around objects and beings far greater than them. These heavenly objects have no choice in this matter, and thus they are alway on track, always in an orbit. But human souls on Earth, they are not all in their orbits. Some wander and are lost, while others were never in orbit in the first place. This rather ambigous “story” tries to capture how one soul found her way back to her orbit, all the way from the furthest point she had strayed away to.

---

She almost let herself laugh. There was not a soul in sight, as far as she could see. Neither a dog straying the ground, nor a sea gull flying the skies. For once she would have it all as she planned, and there was not an eye to watch over her now. She would script the ending of her life, all by herself - at least this part of her life was fully in her control.

So why was she waiting?

She had parked her car just in front of one of many "Unstable Cliffs, STAY BACK!" signposts.

She pulled herself out of the car, and slammed the door shut. Her life was over, her past was over. She was about to be set free, she told herself. No more expectations, no more need for hope. No more need to breath in and breath out. No more burning in the cold. No more pain.

The force of the wind took her by surprise and the hissing of the wind coupled with the sounds of the breaking of the waves underneath to give the place as dangerous as it seems an eerie serenity, as did the bright autumn rays of the dying sun striking and warming her face. The atmosphere was surprisingly clear and lucid, and she noticed that her mind too was as clear and lucid. The demons of her mind seemed to have gone away to celebrate their victory, but was she glad of that! For once, the pens have been taken away from them and she could, she really could, write the last page of her life for herself all in peace.

She wondered how long her bloody body would have to wait for the eyes of someone. She walked on. Do not stop, do not look back. Do not think, do not fear death. What is there to fear when there will be no future, what is there to grieve when there is no living heart to do so?

But she kept her eyes open.

---

"You see, young lady," said he, after a minute or two of silence, "we all are a minute or two away of giving up, of choosing eternal silence and darkness over a painful life…"

He paused as if a sudden memory struck him from down below, for suddenly he took his eyes away from the heavens above and drop them down unto the rocks below.

Anne, for that was her name, would have broken his sentence mid-way, by arguing that the choice was rather between the known and the unknown. The known full of suffering and sleep, regret and fear versus the unknown, a blank white world - but she was too overwhelmed with the world around her like she had never been before. Her thought kept revolving around the fact that for once she was worrying about the life and health of someone else, that poor girl that the papers would probably later reveal was saved by one Anne purely through her apparent love for the workings of nature. For that was why she was at the cliffs and happened to spot this poor girl half dead down below? How ironic...

The police officer finally seemed to have realised that he was out in the world rather than lost in his thoughts, and then did he notice her staring at him?

"Were you really here to watch the sunset?"

"Yes," she lied and to mask the obvious continued hotly, "I find them beautiful. The setting of the sun is as beautiful as the her rising, but a little sadder, I guess..."

Her eyes gave it all away. He sighed and looked back at the full moon. He sighed again, the sigh of a man who thought his entire life has been for nothing. When he spoke finally, his voice was deep and almost a whisper...

"When my little sister was entering into this beautiful world - she could only do so by killing my mother - I was the only family beside them. My mother held me by my hands as if they were the only remaining thing she could hold onto in this life and looked me in the eyes..."

She could see he was tearing up, but he allowed the tears to flow.

"This is my last month in my job. I've been doing this for forty years; I just can't wait to retire..."

"What did she say, sir?" She was now genuinely curious. It'll make him cry, but she wanted it. She wanted anything that could heal her, make her think, give her the limbs to climb up and the wings to fly away.

"She asked me to look after my sister like she did me. She asked that she should be buried fast. She said that the dust would cover but her spirit would live in me and in those that loved her. She was a blind woman, but she thought me many things."

---

She could fell the breeze of the cool night wind caressing her face and hair. She could actually smell the saltiness of the ocean. She heard the waves breaking over the rocks, and the swoosh actually did
comfort her. For the first time in a long time, she found herself taking delight in these things - these little things of nature that tend to be taken for granted, forgotten for the fantasy of the artificial world. This was the true reality, the beauty of the natural world, of things that were made for our eyes, our ears, and our hearts and minds. These were not the products of some fallible human hands but that of God himself for his creation.

She was indeed mesmerized. She allowed her gaze to travel upwards towards the heavens. Like a child, short-sighted from birth only to receive a pair of spectacles, gazing at the stars and enjoying it for the first time in its life. Why were they called stars? They were all dead but still they shine for all the world to see. They looked tiny, but in reality are larger than our earth many times over. They seem to serve no purpose but yet their beauty inspires us to realise our own beauty. ...A beautiful artist creates beautiful art. A beautiful architect creates beautiful architecture. A beautiful creator creates a beautiful creation. The beautiful universe was made just to be seen by my eyes, by He who made them both the universe and the eyes, she realised.

So much was her ecstasy that she found herself stumbling. But it didn't matter to her. She was lost in the infinite beauty of the Eternal One, but she knew she must find her orbit. Every time she fell, she had the energy to pick herself up.

---

Only when she was almost back home did she realise that the radio was on and the evening news were being read. Her mind was far away, in the past and in the future at the same time, but she could gauge what the voice was saying. A 19 year old girl died on the way to hospital following an "accident", she had fallen from the cliffs. There was no mention of any hero. She wondered if this was how they described that similar incident all those years ago, when she had saved two souls. Herself and that poor girl. Oh yes, that was all those years ago... whenever she drove alone returning home, her mind left her to dwell upon those fading memories. Unfortunately there wasn’t another hero like her to save this girl’s life today, but more unfortunately it is to realise that there were still children out there who don’t enjoy their childhoods, who haven’t been taught how to live.

But why should she be sad now? Tomorrow would be her twin daughters' tenth birthday and she had promised her husband that she would help throw a surprise party for them. She wondered what best to gift them both. Her mind was creating a colorful list. She was no more thinking of the past…

By saving and serving others, we save and serve ourselves. By being in orbit around them, we would never drift away to burn in the cold. Find your orbit around those who deserve your love, and save yourself ☺