Shaping Tomorrow: Dr. David Choon’s Journey, Challenges, and Vision for APAS in 2024 and Beyond

From what I understand of the state of medical and orthopaedic care in those languid post-war, post-Independence days, it was only marginally more advanced. Conservative treatments with plasters and traction seemed to be the norm. A trip to the operating theatre wasn’t relished by either the traumatised patient or the equally overworked and stressed surgeon, who often also had to administer and maintain the anaesthesia.

The cars and bikes at the time matched the relaxed lifestyle. My father fondly remembered being served picnics by a bevy of young women, whom he regularly chauffeured in his government-issued car from a small jungle town to Kuala Lumpur, where he would visit his parents and enjoy weekend soirĂ©es. Needless to say, one of those young women became my mother, and that’s how I was born, right in the heart of the jungles of old Malaya, lulled to sleep by the sounds of woodpeckers and cicadas.

Until I was 17, I either walked or cycled to school and tuition on my own in Kuala Lumpur. After that time, it was considered somewhat riskier, with more motor vehicles and accidents on the roads.

I then went to medical school in the United Kingdom, where even more surprises awaited. In pharmacology, the therapeutics lecturers openly acknowledged that while medicine had advanced, it was still largely in its infancy. Indeed, not all advances were what they seemed—many were just expensive variations of existing medications. (Does that sound familiar?)

One lasting and valuable lesson from that time was the constant encouragement from tutors to question everything, rather than simply accept what we were told. I didn’t fully understand the importance of this at the time, but it seemed like a good idea, so I embraced it. Imagine trying to fact-check with only the assistance of the Index Medicus!

I fondly remember lecturers who taught me that understanding human behavior and practicing mindfulness were the keys to success. As a surgical registrar, I was once guided through a highly selective vagotomy by the Professor of Surgery, with every detail expected to be regurgitated perfectly during the FRCS exam. Of course, such procedures are obsolete today, thanks to Barry Marshall, a plucky Australian who seemed mistaken and misguided at the time, but later won the Nobel Prize for his work.

Such is the nature of medicine.

My introduction to orthopaedics came by chance, when I needed a house job and discovered that the Professor of Orthopaedic Surgery didn’t have a houseman. The hospital had three senior orthopaedic surgeons, and joining them felt like becoming part of the musketeers. Their wit, gentle humor, and sharp insight were intoxicating. The spirit of “can do” and “make do” was inspiring. I loved the simplicity of elegant solutions that worked. Even more, I discovered that I possessed the necessary skill set, developed through my love for the newly invented sport of video gaming. I was in my element!

Then came my stint at Massachusetts General Hospital, where I doubled my experience and honed my surgical skills under the supervision of kind, generous, and talented attending surgeons of international repute. What I loved about the system was its insistence that the attending surgeon assist and guide the trainee. If it took twice or three times as long, so be it. My surgical skills quadrupled during this period.

Finally, I returned home to beloved Malaysia as a lecturer at the University of Malaya Medical Centre, where I juggled spine surgery, microvascular surgery, hand surgery, sports medicine, complex neglected trauma, and arthroplasty as a junior lecturer—often independently and simultaneously. One night on call, I had to unscrub in the middle of a thumb replantation to perform a life-saving below-knee amputation before resuming the original surgery. Both the thumb and the patient in extremis survived. During this period, I also invented and patented a tibial bone transport fixator in collaboration with a senior Professor of Engineering, trained at Imperial College London, to treat patients who would have otherwise gone untreated due to lack of funds.

I worked with a plastic surgeon friend to perform free flaps for exposed fractures and completed spinal fusions for scoliosis, both anteriorly and posteriorly as chief of spinal surgery. While my efforts weren’t up to today’s standards, the memory of the satisfaction and joy on my patients’ faces still brings a smile to mine. I continue to see the results of those surgeries in the community.

We also launched the Masters training programme at the University of Malaya Medical Centre shortly after my arrival. I am proud to say that we established a system that has produced students who have far surpassed us. I consider that to be my greatest achievement.

Throughout this time, I taught countless medical students, who still occasionally invite me to their annual reunions. It’s heartening to see how well they have fared.

I spent four years away from mainstream orthopaedics to establish the Masters in Emergency Medicine at the University of Malaya Medical Centre. What an incredibly talented and committed group of students we had! They easily surpassed me and took over the running of this excellent unit. After all, isn’t the definition of a double-blind trial an ECG and two orthopaedic surgeons?

My passion for electronics later led me to online education, which I still pursue today. During the pandemic, my eight-week introduction to medicine course for fledgling medical students, reached our students who were kept home and unable to attend school. It was based on Moodle, a great Australian contribution to the world. We got students who had never met in person to collaborate on vlogs and other activities, achieving impressive results like critiques of papers in Nature magazine and video essays on the poor state of facilities for the disabled. This gave me insight into the immense talent of our young students, which is often wasted because our generation cannot fully meet their needs.

That’s a brief history of my life thus far. I’ve written this to give you a glimpse into my passions and beliefs.

APAS is a great organisation with a long history and an even longer future. It was the brainchild of Wui K Chung, my friend and teacher, who embodies many of the fine qualities I admire in an orthopaedic surgeon. As APAS grows, it becomes harder to keep it united through human bonds, but that is our task.

Orthopaedics is becoming more complex, largely due to innovations driven by the lure of profit. The usual justification for change is that many are dissatisfied with our services. Technology and technique are, of course, important. Looking back, the original hips and knees that were implanted had the benefit of master technicians, though perhaps not the superior materials or implants of today. Yet those patients seem to have had stellar results in comparison. How so? Perhaps it’s because the surgeon of yesteryear was a jack of all trades before becoming a master of one. Along the way, they acquired technical, medical, and human skills that complemented their daily practice. Today’s surgeon is trained to be part of a larger team looking after the patient. Both approaches have their merits. I leave it to the reader to decide which is preferable.

Some of you may know that I give lectures on my perioperative management of diabetes. Since taking over this aspect of my patients’ care, I have never had to delay discharge due to uncontrolled blood sugar levels. Am I a maverick? Perhaps. But I am not the only one. I followed the lead of another bold and outspoken Tasmanian surgeon, Gary Fettke, who stood his ground, proved his merit, and silenced his detractors.

Surgeons need to be leaders. They must provide comprehensive care for their patients. It’s not just about technique and implants; it’s about sensible thinking, based on thoughtful analysis of published data and experience. The former is well-covered, but the latter less so. APAS will serve better if we include both in our discussions and teaching.

I am no Luddite. I love technology, electronic wizardry, and the internet. However, sometimes, these are just toys. I am inspired by my countrymen who have combined their love of technology and business acumen to provide some of the most cost-effective air services, urban transportation, and logistics systems in the world. Asia is emerging from a long slumber, and its people need good, cost-effective care from dedicated doctors. Let’s make it happen.

I would like to end my somewhat lengthy address with two quotes from Albert Einstein for your reflection:

The first: “Insanity is doing the same thing over and over again and expecting different results.”

The second: “Any intelligent fool can make things bigger, more complex, and more violent. It takes a touch of genius—and a lot of courage—to move in the opposite direction.”

God bless.

David Siew-Kit Choon

Honorary Professor of Medical Education University Malaya Medical Centre
President
Asia Pacific Arthroplasty Association
Past President