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REFLECTIONS

DOING A PhD IN THE MIDDLE OF RESIDENCY..

I was gobbling down some lunch in the operating theatre pantry when my boss

came to me and said: “Aaron don’t disappoint me, do a PhD.” To be honest, my

initial reaction was: “Huh… really arh?”. Deep down in my heart I had mixed

feelings about it. Would embarking on such an endeavour be worthwhile? What

would become of my clinical skills? Wouldn’t it be such a great career setback?

“Just focus on the science Aaron; God gave you the brains, the talent and the

capability to do a PhD. It would be such a waste if you had not. Sometimes you

got to rise above the mundane routine of day-to-day work and see the big

picture for our division and the hospital.”

That conversation between my Division Head and I took place approximately

a year ago. My Division Head, A/Prof Yeo Tseng Tsai, deserves great credit for

his exemplary vision of building a full-fledged clinician-scientist driven

neurosurgical unit in NUH. Mission-driven, he made every effort to turn this

vision into a reality. At that point of time I was starting my fifth-year of

neurosurgery training, and had successfully published 10 manuscripts. I had

considered the option of pursuing a PhD, but was not entirely convinced that it

would be the best thing to do given that I was already quite close to finishing

residency. I was married with two young children, and had to support my in-

laws as well because they lived with me. Several senior clinicians had also

commented on the drawbacks of pursuing research in the midst of residency

training, and their advice further sapped the faith I had in a research career.

Prof Yeo swatted those fears away. He was truly convicted. He broke down

doors, overcame administrative hurdles, pulled strings, found funding, all so

that I could embark on what would for me become a life-changing experience….

One afternoon a few months later I found myself sitting with Prof Yeo at a small

table in the Department of Physiology at MD9 just across the road from NUH.

Opposite me sat A/Prof Lim Kah Leong, the newly appointed Head of

Physiology, accompanied by his most senior postdoctoral fellow Dr Chai Chou.

Prof Yeo and Prof Lim had a long-lasting friendship dating back to the time the National Neuroscience Institute’s (NNI’s)

Research Department was established in the late 1990s. Prof Lim had just joined NUS after relinquishing his role as Deputy

Director of Research at NNI.

*For internal circulation only.

All rights reserved*

NUHS RESEARCH RESIDENCY PROGRAMME

Quarterly Newsletter

Issue No. 13 ● March 2019

Resident’s Corner

By

Dr Aaron Foo

(Neurosurgery Residency Programme, R5)

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“Go ahead and fail; failure will make you a much better scientist “

“Kah Leong, I need your help to train this guy in science. He is a smart guy and he will complete the training. He could be

your future collaborator.” Those were Prof Yeo’s words. Prof Lim was very accommodating. In parallel with the government’s

goal to promote translational research, he was very supportive of clinicians cross-training in science. Prof Lim turned out to

be another wonderful boss with a great passion for basic science. He very generously allowed me to join his research team,

which was a huge blessing because it exposed me to a very high standard of scientific research from the very beginning. A

few weeks after I joined his laboratory Prof Lim was conferred the President’s Science Award (Team Category) for being

part of a team that discovered an early biomarker for Parkinson’s Disease. This was one of the most prestigious awards

conferred in the local scientific scene, and here I was - a new member of his lab! Only then did I realize how lucky I was to

have been inducted into his group.

But not all the going was nice and rosy. Adapting to the PhD curriculum proved to be a demanding task. I used to believe

that if I succeeded at neurosurgical training (which involved doing up to 10-12 calls a month with no post-call most of the

time), no other challenge would faze me. I was sorely mistaken. Although trading my surgical scrubs for the lab coat provided

me with a lot more control over my time, the amount of effort required to excel at scientific work was paramount to that

needed for neurosurgery. I did not do well in my first semester and got an academic warning. I made some careless mistakes

in the lab (like forgetting to put some solutions back in the fridge after using them, causing them to spoil) and became the

routine suspect whenever something went awry. Whenever I went for department seminars, I failed to understand even

one-fifth of what the presenter was talking about. My experiments failed to produce the results that I had hoped for. For the

first few months, I felt like a house officer again, ascending a steep learning curve.

But hey, what is science without some hiccups right? A/Prof Mikael Hartmann (Research Director, University Surgical

Cluster) once told me: “Go ahead and fail; failure will make you a much better scientist.”

And so I responded. I made some adjustments and did some experiments… and made some more adjustments and did some

more experiments… and made even more adjustments and did even more experiments. I used up the reagents in the lab so

quickly that every time my lab manager opened the -20 degree Celsius fridge she saw that the blocking agents that were

topped up just the day before were again depleted.

“Aye, you drinking the reagents arh?” she used to joke.

“No, he uses them to shower.” my colleagues would laugh.

My transformation from clinician to scientist continued. I came to the realization that I had gotten too comfortable with

clinical medicine; science plunged me back to ground zero and demanded that I leave this comfort zone. At night I would

spend time reading to my daughter, and once she fell asleep I would go into student mode – staying up to read, write and

consolidate. I ploughed through Kandel & Schwartz (the basic neuroscience textbook) page by page, and started to look at

papers in Nature and Cell instead of Journal of Neurosurgery.

Has it been worthwhile for me so far? I must say that the intellectual growth I have experienced in the past six months has

been astounding. Never by doing another 5-10 more years of clinical work would I have developed this new perspective for

dissecting a problem nor this grounding in the basic neurosciences.

Does it make you a worse clinician? No I don’t think so. In fact, achieving a profound understanding of the biological

processes that underpin diseases makes you a better clinician if anything. This understanding comes from being able to

comprehend upstream basic science research; it is not something that one could acquire even by seeing another 1,000

patients with a similar condition.

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Most importantly, embarking on this journey has allowed me to develop newfound respect for my scientist colleagues who

are superior to us clinicians in so many ways. The need is mutual – clinicians need scientists for their basic science research

and scientists need clinicians to translate their work into therapeutics. Respect is quintessential to any successful

collaboration between the two parties.

So here’s my advice to those who are contemplating to take up a PhD and/or the clinician-scientist path:

1) Sometimes life plays tricks on you. Taking the path less trodden does not necessarily spell doom. In fact, many a

time, you might find the most unlikely road leading you to your next passion.

2) Find a great mentor. There are currently not many clinician-scientists in Singapore hence there are more naysayers than believers in the ranks. You need someone to inspire you to stay strong and rise above criticism in order to succeed.

3) Firm up your clinical training before you embark on research. I believe that the best time to embark on a hiatus

from clinical practice is halfway through senior residency. This is especially true for surgeons. The window for research training, set between residency years 4 and 5, was dictated by my Division Head based on his fellowship experience at the University of Toronto Neurosurgical Unit, the most successful academic neurosurgery unit in the world. After actually testing it out myself, I could not agree more. Why is that so? Because it takes time to chalk up your surgical logbook. If you look at learning from a neuroscience perspective, it takes numerous repetitions before the performance of a complex action becomes ingrained in your muscle memory. Once the memory is consolidated it will not be forgotten. This applies to learning how to drive, ride a bike and type on a keyboard and can be applied to examining patients and learning a surgical procedure. When I left full time practice to pursue science my surgical logbook had approximately 900 neurosurgical cases. I had performed sufficient repetitions of some of the simpler procedures for them to become entrenched in my procedural memory. I still do 3 to 4 calls a month nowadays to maintain my clinical competency and guess what? I think I am still improving, albeit at a much slower pace, in terms of surgical skills. I do not think this would be possible without the foundation that I had built by doing the numerous on-calls during my three-and-a-half years as a full-time neurosurgery medical officer / registrar. Leaving clinical training without having consolidated this body of skill and knowledge will only lead you to struggle upon your return to the system after a long hiatus.

As I write this I find myself sitting on a small bench in the animal facility, observing my mice go round and round in circles

in little buckets – demonstrating the asymmetrical rotatory movement characteristic of successful lesioning of dopaminergic

neurons that comprise the nigrostriatal tract. A smile of triumph appears on my face. This is my first taste of success after

half a year of performing animal experiments, and it feels… ecstatic.

Contributed by Dr. Aaron Foo

Course Assessment

Write an essay on hypothesis testing in clinical research

Deadline: 30 April 2019

Include in your essay (not limited to) the following points:

i) errors in hypothesis testing

ii) the relationship between hypothesis testing

and the p value

iii) the role of chance

iv) sample size calculation

v) limitations of hypothesis testing

- Word limit of 1000-1500 words

- It is recommended to use your

intended research study as an example

to address the listed points

- Your work will be checked for

plagiarism upon submission

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Click on link for more information on grant call

Deadline till 22 April 2019 ExxonMobil-NUS Research Fellowship for Clinicians

Eligibility: Registrars, Associate Consultants, Consultants

Award: 60% protected time, S$20,000 consumables

Clinical Trial Grant – Industry Collaborative Trials (CTG-ICT) Scheme (Open Call) The aim of the Clinical Trials Grant (CTG) is to enable the clinicians to carry out clinical trials for the development of novel therapies, interventions and diagnostics, focusing on healthcare needs.

Funding Opportunities

Research Residency Notes

The materials and its content are

confidential information and

copyright materials of the rights

holder.

The materials are provided to you

solely for your personal use in

advancement of your residency

training and research purposes.

All rights are expres sly reserved

by the rights holder. You may not

distribute or exploit the content,

commercially or otherwise.

You may not transmit the

materials or store it in any other

website or other form of

electronic retrieval system as

well.

Remember to arrange our

clinical roster for the following

training dates:

30 Mar 19

13 Apr 19

4 May 19

1 June 19

6 July 19

3 August 19

21 September 19

5 October 19

2 November 19

7 December 19

Contact Us Programme Director:

Dr See Kay Choong @ kay_choong_see@nuhs.edu.sg

Programme Coordinator:

Peishan Tan@ pei_shan_tan@nuhs.edu.sg