Graduation

You may have seen my photos of our recent graduation ceremony on Facebook. Every year, we have a small ceremony at the US Ambassador’s residence, in addition to the official University of Health Sciences graduation, which is often quite late (in the fall, or even the next January one time) and big - all the residents from every program, plus the medical students. Often foreigners (AKA, HF volunteers) aren’t invited to the UHS ceremony. Having a second ceremony allows us to individually celebrate our residents, if only briefly. It was a lot of work preparing for graduation last week, but it was totally worth all the stress and errand running. I can’t remember the last time I smiled so widely and sincerely for so long. That includes my own residency graduation, about a year ago now.

Me and all 7 of my grads, plus some other residents.

Why did this event seem so much more special to me? I saw my own residency graduation as more of a formality - a “Here, you didn’t kill anyone, or otherwise royally screw up enough for us to notice you and kick you out, so take this diploma and please be on your way.” Some of that jaundiced view may have come from end-of-residency burn out. Some of it may have come from going to a big program where I didn’t really get to know many of my staff that well - I can count on one hand the number of people I had as supervising staff for more than one solid 2 week block. (Don’t get me wrong, my big program had lots of advantages, and I wouldn’t go back and go anywhere else, but being a personal, close-knit program was not one of them.) Some of it may come from the fact that in America, residency is just one more required step on the road to being an independent doctor - an important one, and one I’m glad I completed, but not something special.

The crowd looking on - the fathers of Lao medicine are in the R foreground.

In Laos, I feel like graduation IS special and meaningful. There are more than 100 Lao medical school graduates each year (and the number is growing every year.) Our programs each accept 5-8 new residents each year, and even if you add in the surgery, ob-gyne, family practice, and anesthesia residencies, still most practicing doctors in Lao have not completed a formal residency training, and there aren’t residency spots for everyone graduating from medical school. So our residents are special just by virtue of being in residency - they have taken a test for admission and many have had to move away from their families and live in dorms for 3 years to complete residency. They also give up any income they might have from private clinics during the 3 years they are here, so they have to really want to come. They are, almost uniformly, eager learners, gracious, and very concerned about doing what’s best for their patients. So it was exciting to celebrate the graduates, the new residents, the teachers, and the program in general.

Three of my residents arrived in these dapper suits - Men in Black!

The formal part of the night was relatively short - just over an hour. I welcomed everyone and introduced the Ambassador, who gave a short speech in Lao and English. The current Ambassador, Her Excellency Karen Stewart, was the Charge D’Affairs (interim head of the embassy) when the tradition of having graduation at the Ambassador’s residence was started 10 years ago, and this is her first year back as Ambassador, so that was nice. I was impressed that she spoke in both Lao and English. The Lao people were impressed by how tall she is for a woman - she is quite tall, and towered over (in a very friendly, welcoming way) all the Lao guests. I bet she gets really, really tired of comments about her height.

Libby + Ambassador Stewart

Then, Margie introduced Dr. Bounkong, one of the founders of the IM program, who has supported HF since we started working in Laos, through multiple job changes for him. His most recent promotion was to Vice-Minister of Health, so he spoke on behalf of the Ministry of Health. Then Margie introduced Dr. Alounyadeth from UHS, who welcomed everyone again and spoke briefly about the partnership with UHS. Margie’s introductions included this: “The success of the pediatric and internal medicine residency programs is built on the strong leadership of the Ministry of Health and the long-standing collaboration between the Ministry of Health and Health Frontiers. This year, Health Frontiers celebrates its 20th year of partnership with the Ministry of Health with our mutual goal of improving the capacity of the health care workforce in Lao PDR.” The same is true of UHS, so we were happy to have representative of both organizations in attendance at the ceremony. It’s also great that HF has been in Lao for 20 years this year- not many groups have been working here that long. We are small, and our mission is small, but we keep at it, and every year we finish training a few more pediatricians and internists!

Dr. Bounkong addressing the crowd.

Next, The peds section began. Dr. Khampe, the director of Settathirath hospital, gave a brief speech to the graduates. Then Amy and Margie introduced the new Peds residents and gave them their stethoscopes; each year HF buys decent-quality stethoscopes for the new residents. They gave the award for Best Teacher, and the awards for Best Resident from each class. (Voted by the Lao teachers.) This year, they added a new category - best resident by vote of their peers, and the selections all highlighted residents that Margie and Amy do consider to be excellent residents and leaders in their classes. (Despite my jaundiced view of my own graduation, I will say that our resident awards seemed to go to the appropriate people as well.) Finally, they announced all the Graduates, and gave them otoscope/opthamoscopes, certificates, and flowers.

The graduating class of Peds with the Ambassador

Then it was my turn to MC the IM section. (This was a lot of public speaking for me. I’ve gotten better at it over the years, and lecturing weekly has helped, but I still wasn’t totally comfortable.) I’m going to paste in a few more quotes from the actual ceremony, because they pretty accurately capture what I think was important to say.

“Tonight we celebrate the 7th class of internal medicine residency graduates. Upon graduation, there will be 43 Lao-trained internal medicine specialists working in Vientiane and 11 provinces. This year, we send our first graduates to work in Salavan and Louang Prabang provinces. We now also have 2 graduates who have completed sub-specialty fellowship training in Thailand, and 5 who are in fellowship training currently. It is exciting to see our graduates grow into competent and confident physicians but to also see the impact they make as they teach the next generation of medical professionals. All of this has been made possible through the hard work and dedication of the internal medicine teachers and the Lao Internal Medicine Association.” Then Dr. Vang Chu, Chair of the Cardio ward, president of the Lao Cardioloy association, and another wonderful, long term supporter of the residency program gave a short speech, in which he congratulated the residents and encouraged them to be lifelong learners, come to CME, and call their teachers if they ever needed help.

Dr. Vang Chu addresses the IM residents

Next, we introduced the new residents. “This is an exciting time of the academic year as we celebrate the graduation of one group of residents, rejoice in the promotion of our continuing residents and welcome a new group of physicians to start this amazing journey. It is a difficult decision to leave your job and for some, your home and family to pursue further medical education and all the hard work that goes with it. But we are pleased that this year, six more physicians have decided to take the challenge.” Residency selection was such a challenge for IM this year, I can sincerely say that I do rejoice in having these 6 residents finally started and learning. I’m glad they all have decent stethoscopes now, too, we can start (gently) pimping them on heart and lung findings. . .

I present Ammala with her stethoscope.

Next, we thanked last year’s chief residents, who have tirelessly, and often thanklessly, worked to make sure they had lectures scheduled (I help with this, but they usually remind the teachers the day before and make the calls for a fill in lecturer when someone cancels.) They also gently and patiently steer me back to the correct path if I’ve gone astray on some planning or communications issue, and translate English lectures into Lao for their classmates who aren’t yet fluent in English. Our chiefs are just second and third year residents, and they don’t get any extra compensation for doing this delicate job. Then the graduating chiefs presented the Best Teacher award. This year, it went to Dr. Bouachanh from the GI ward. Last year too, and probably many years before that. I think the vote was probably unanimous (Novalinh counted it for me.) So no one was surprised by that. :) Dr. Bouachanh did residency in IM in the soviet bloc, and he is a soft spoken man, but also a truly excellent clinical teacher. The GI ward gets all the patients who don’t clearly belong on the Cardio, ID, or Pulmonary wards at Mahosot, so he’s really a great general internist as well, and he knows a lot about Lao presentations of confusing diseases. He is old enough to retire, but still comes to the hospital every single day to check on the patients and teach.

Phanivone and Phonpadith present Dr. Bouachanh with his award.

Then we gave resident awards - to the outstanding residents and most improved residents in each class. Voting for this was close, and the results changed several times in the 2 days before the ceremony as more people called in last minute votes. My introductory statements were: “Each year, the teachers like to acknowledge the most improved resident in each class. I am glad that I was not asked to vote for this award, because I am continually impressed by how much each one of you has learned, and what great questions you ask that require me to learn.” and “Each year the teachers also acknowledge an outstanding resident in each class. Again, I am glad not to have to vote, because each of you exhibits excellence in different areas, and it would have been hard to choose just one.” Both of these statements are sincere - I really don’t know who I would have voted for in either category for most of the classes - because there are so many residents who exhibit a keen ability to learn and / or clinical excellence.

Chief resident Saysavath accepts the best resident award for the 2nd year class.

Finally, in the end of the formal ceremony, we announced the IM graduates. They got a certificate, flowers, and a glucometer as a parting gift. In years past we’ve given them text books, but I think the glucometer is a practical gift that will get used - even by the residents who don’t read English well enough to really make use of a text - so I’m pleased with it. Last year, the presents didn’t get here until after the ceremony, and we ended up giving them at the University ceremony for peds and at CME for IM, so it was also nice to have them to give on the actual night of the ceremony. This is what I said: “We would like to honor and congratulate the Internal medicine graduates of 2010. I have only known them for 9 short months, but I feel confident that each and every one of these doctors will go on to be a teacher and leader in the hospitals in which they practice. Four of them will be returning to provincial or district hospitals this year, and three of them will be the first specialty-trained internists in the hospital when they arrive.” Dr. Bounkong, Dr. Vang Chu, and Dr. Bouachanh presented the certificates and presents to the residents as I read their names, so they were literally each surrounded by their incredible, supportive teachers who are great role models for them as the enter independent practice again.

Dr. Chirapha surrounded by her teachers.

The Ambassador briefly closed the official part of the event, and we proceeded to a flurry of snacking and picture taking. I hope the above description captures some of why it was such a nice event for me. At 8, we cleared out of the Ambassadors house and the peds residents went for karaoke. There, I got to see a very different - less serious, less shy - side of them, which was nice. Plus there were some very inappropriate videos with the English Karaoke songs, which was, well, not so nice, but pretty hilarious.

Ambassador and all IM grads