Dr. Anand Ramanathan
“First of all, please briefly share with us about your background and your journey of becoming an oral pathologist cum lecturer here at University of Malaya.”
I did my schooling in Chennai, India and proceeded to do my undergraduation in Saveetha Dental College, which is also in Chennai. After I finished my final exam, I was working under one of my seniors at a private dental clinic. He was doing his post-graduation and I worked there for a couple of months. Later, I got a job in another dental college called Rajah Muthiah Dental College and Hospitals in Chidambaram, India. As a tutor, I worked for one and a half years in the Department of Oral Surgery under Professor Dr. Tangavelu. Then, I shifted to Oral Pathology for one and a half years under Professor Dr. CR Ramachandran before joining as a postgraduate there.
When I was doing my post-graduation in Oral and Maxillofacial Pathology, I got married, and my better half is a Malaysian. So that's how I came down here. She is a medical doctor working in the Ministry of Health. My undergraduate degree was not recognized, therefore, I had to go through an attachment at University of Malaya, called the spouse program. That was for two years and at the end of the program, I had to take a clinical examination at the Ministry of Health to get my APC.
I hadn't done much Basic Dentistry during my postgraduates, that’s why I was very rusty when I came to do my attachment. It took some time for me to get the hang of Basic Dentistry again and I should thank quite a few people during that time. During that period, I also came across Prof. Dr. Rosnah Mohamad Zain, an oral pathologist and the Deputy Dean during that time. I met her and I told her: ‘ I'm losing touch with Oral Pathology. Can you help me out? ’. She was very gracious to take me in and I started my second time in Oral Pathology.
I brushed up my Oral Pathology with her, she mentored me. She is my 2nd mentor. When I was going to take my exams, she called me and asked me whether I would like to join as a lecturer here and I would love to. Then she asked me, what will you do when you come to the academic side? And I hadn't had much of experience on research. I thought it was teaching and I said that I'm very passionate about teaching. But then she told me, it's not only teaching, you have another part called research, and she introduced me to research. And during that attachment time I went through, I gain experience in research, wrote some papers for her and then she put me into those few projects. And that's how I got introduced to research. And after I got my practicing license, she was gracious enough to take me in as a lecturer at University Malaya. I should thank University Malaya as well as the Malaysian Dental Association, which had given me permission to do my FYDO and SYDO at University of Malaya. I was doing again, Basic Dentistry for the first two years as a lecturer, honing my skills of basic Dentistry. It looks like I did my undergraduation twice. So that's how I came into this. It's all because of Prof. Rosnah, I was at the right time with the right person.
“You have a Master of Dental Surgery in Oral and Maxillofacial Pathology, do enlighten us on what this specialty is about, and is it lab primarily, or is there any patient interaction involved?”
Oral and Maxillofacial Pathology as such if you take it is more of lab based, you're going to get specimens from the oral surgeons, process them into thin slices of the tissue, and stain to see under the microscope to give the diagnosis. The challenging part in Oral Pathology is that you have to give a definitive diagnosis. So based on your diagnosis, the surgeon is going to do the treatment. You should have a very good communication with the oral surgeon so that you can give the best treatment for the patient.
You are indirectly helping the patient through the oral surgeon in Oral Pathology if you're looking at only Oral Pathology. 60% of the cases are very easy for the diagnostic part and another 30% is a little difficult, you might have to put special stains or immunohistochemical stains and try to find the diagnosis or dig into the diagnosis, whereas 10% of the cases are very difficult and you might need to take expert opinions from other oral pathologist or even general pathologist. In that way, I should thank Professor Siar who was here previously, she's an Oral Medicine and Oral Pathology professor. She helped me a lot whenever I had difficult salivary gland cases. Similarly, there are some cases which might go up beyond the maxillofacial region, which we might not have seen much. In that case, I take the help of general pathologist and there's a very nice dental pathologist in PPUM called Professor Mun. She has helped me a lot in very difficult cases. It's not you working alone as solo; when you have difficult cases and you might have to get the expert opinions too. As you gain experience, it might become much easier.
In Malaysia, it is not only Oral Pathology, but Oral Medicine as well as Oral Pathology. When it comes to Oral Medicine, you're going to see a lot of cases, and that is pretty challenging. So here you have a four-year course of Oral Pathology and Oral Medicine with 50% Oral Pathology and 50% Oral Medicine and UM is the only center where we have the training for postgraduates. I have been training postgraduates in Oral Medicine as well as Oral Pathology. If you see throughout the world, you will have Oral Pathology and Oral Medicine as a separate specialty but here, it is together. That makes great sense because if you're going to do the biopsy clinically, you're going to see the patients, the lesions, then you're going to make it into a slide and read the slide. You have a continuity here from clinical to the lab. That is a great difference from the rest of the world than in Malaysia, which has 50% clinical work and 50% lab work.
“You have completed your undergraduate and postgraduate studies in India, do share with us your experience as a student there. And how is it different from studying in Malaysia?”
Taking back to my memory lane, in India, it's more competitive because you have a lot of people there who are doing the same course. I should thank my batchmates for that because they were always keeping me on my toe. There was always a healthy competition between us. So if they are going to study, then I also need to push myself to make sure that I get my grades. I did my undergraduation in 1997, we are called the 97 batch and we called ourselves as SMILE 97. I should thank all my friends and all my batchmates who had helped me since I'm not very adapt in clinical, especially my hand skills. So initially, I struggled, I learned step by step with the help of my friends, especially tooth morphology and tooth carving. Later on, when I was teaching Oral Pathology, I taught people how to carve.
There’s a lot of theory there in India. You have a lot of theory, a lot of patients and you will do also a lot of practice. The difference between India and Malaysia is that here you have limited theory. Whatever you learn, you tend to apply on your patients in your practice. I've been through the old curriculum and the present hybrid integrated curriculum in University of Malaya. The old curriculum is like my curriculum back home in India, which is more departmentalized. When you have an endo patient, you just do the endo, when you have a prostho patient, you do only the prostho work. But when I see the integrated curriculum, that gives a more holistic approach. When I see the University Malaya students write their exam papers, we might have set the answers to a very narrow range, but they usually give answers which are very holistic and that's fantastic. I think that's the strength of integrated hybrid curriculum by having vertical and horizontal integration and it is pretty nice.
“During your undergraduates, how many students are there in your batch?”
We started with 78 students. But when we cleared out the final year, we are only 28, it was very tough and not easy to pass. You are going to be always with the patient, doing a lot of handwork on the patient and by the time you finish, you are mentally and physically exhausted. This is not only in Malaysia, it's throughout the world. If it comes to Dentistry, you're going to be mentally as well as physically exhausted at the end of the day. So that's how we learn.
“You have a specific research area of interest on oral cancer. So what sparked your interest in this topic? And what is the most challenging aspect that you face in the research?”
I did talk to you about my second mentor, Prof. Rosnah and she was working in oral cancer and we had Malaysian Oral Cancer Tissue Bank and the database system in which is coordinated by the Oral Cancer Research and Coordinating Center at the Faculty of Dentistry University of Malaya, she was the head of that. When I started my Pathology training with her, I was doing the diagnostic pathology cases with her. I used to read after she gives her diagnosis. We were also doing research projects and most of the research projects we were doing were on oral cancer. So that's how I came into oral cancer and oral potentially malignant disorders.
There are numerous challenges which we faced. For example is the data. We are trying to get all the data for these oral cancer patients and that was a big challenge that still goes on. I started in 2010 and I'm still collecting data for patients such as survival data. There are numerous challenges we have faced, but I do remember one lecture on research with Professor Dr. Tilakaratne, who is an oral pathologist from Sri Lanka. When he came visiting UM, he gave on the problems within research. Although it could be man, money, and so on, the only solution he gave for all these problems is collaboration and teamwork. It is no more that the hare and the tortoise run against each other. It's they run together. If in the land, the hare has to carry the tortoise and in the water, the tortoise carries the hare. In that way, you tend to achieve much better results. That’s why I have a lot of collaboration with wonderful humans. I have worked with a big team, especially in OCRCC, I should say three people, Dr. Nabila, Dr. Karen, and Mr. Wong who helped me a lot. My weak point is biostatistics, whereas they are very good in that. However, I am very good in the Pathology part. So we complement each other. There's another person who I worked with in OCRCC is Dr. Vincent. He's now in the US. They've been a wonderful team. And I've had quite a few other projects with very eminent persons. Probably I will tell you a little later about that.
“Cancer is a frightening word to most of the people out there. However, oral cancer is usually detected when it has already progressed to a late stage. What can a patient do to detect early signs of oral cancer?”
This is what I've been doing for the last 10 years. I joined as a lecturer in Faculty of Dentistry, University of Malaya in 2011. Even before that, I started a bit of research with Prof. Rosnah. She has come out with a nice learning technique, which called ‘Spaced and Repetitive Space Learning’ technique. This training and calibration for early detection of cancer is called Oral Detect. We did successfully published a paper on Oral Detect this year. We have done this training for many dentists in Malaysia. On the other hand, we also have a program called ‘Training of the Trainers’ where oral surgeons from the Ministry of Health come for a one and a half day or two-day workshop. We train them to identify these different oral mucosal lesions that are quite a lot and they mimic each other. There are very similar lesions, but different treatment you might need to do and so on. We do this training and calibration so that every one of them can identify the lesions. I've started this in 2010 with Prof. Rosnah and this is an ongoing journey still, which where I have learned a lot. We have done this program in Cambodia, Indonesia, Nepal, and India. At present, this program is no more. We used to do this as a one-day workshop for the final year undergraduate students in UM. But now what we have gone further is to bring it as a competency into the curriculum itself for the Year Five students and so you will have an one day workshop as a competency.
In Oral Medicine, especially in early detection of oral cancer and oral potentially malignant disorders, is now embedded into the curriculum and UM was the first to do it while the other universities have followed. I've done training in UKM while my colleague, Associate Professor Dr. Thomas has gone to USM to do it, almost all the colleges in Malaysia are now doing this program for the undergraduate final year students. That is one way we can actually make sure that the dentists are able to detect these oral cancer lesions at an early stage. I have also worked in another multi-country project under Prof. Rosnah and this project was on urgent diagnostic tools and we use an autofluorescence imaging tool which is called VELscope. And initially, I was given this Velscope and I had no idea what to do, I went through a very steep learning curve. After some time, there was a workshop where Prof. Camile Farah from Australia had come down here to teach us how to use the Velscope and I learned it from him. I'm really thankful to him about that. Now with this adjunct diagnostic tool, I'm always called by my oral surgical colleagues to come and see whether that lesion is sinister or not. It was a multi-country project with Indonesia, India, and Taiwan. Now we are using this VELscope in our clinics, and my postgraduate students are also using it. Whenever the oral surgeons asked us to come to the operation theatre and help them mark the margins of the tumour, we do go in as oral medicine specialist to do that and that's very interesting. That's another way where we can help in early detection of oral cancer.
There was a mobile-based project called MeMoSa, in collaboration with Cancer Research Malaysia. I should thank Prof. Sok Ching for this project. We had a lot of technical issues and she is still continuing it. It is actually a mobile-based app where the dentist takes a photograph of a patient to consult with a specialist from far away. We have published a paper on that and it is a work in progress in Cancer Research Malaysia. They have a wonderful team and hats off to Prof. Sok Ching.
Another project which I did was with Dato’ Prof. Dr. Ishak. He was previously in UM and now he's in MAHSA University. We did something called Mouth self-examination where the patients are taught how to examine their mouth and find any lesion to report back. This project took me to Sabah, East Malaysia, for the first time, it was a wonderful trip. It was coordinated with the Ministry of Health, where they had identified two villages in Kota Belud. I had to screen the patients for any oral lesions for about five days, wonderful experience I had. I could see the village life in Malaysia and there was quite a lot of them who are using the betel quid chewing habit, just like back home in India. I was very surprised when I saw and that was a very good learning experience. We have been doing quite a lot of work in OCRCC on oral cancer for early detection of oral cancer. Some are clinical work, some are lab-based work and we are still on the searching for better ways to actually detect oral cancer much faster. So these are certain programs which have done for early detection of oral cancer.
“You have been actively working in Malaysia for about 10 years now. What is the one unforgettable memory you have throughout your career of being an oral pathologist?”
I've got a lot of unforgettable memories in Malaysia. To start with, I never been to a prison in India. But in Malaysia, I went to a prison, not because of a crime I committed, but this was for research. And I should thank Associate Professor Dr. Jacob for that we had a project in prison for, again, screening oral lesions. We were able to pick out a lot of lesions and we were able to report that and try to help these people who are in prison to get them some treatment, so that was an unforgettable one. Then, the other one I could say is when I was asked by Dr. Aide, he's now in MAHSA University. He was previously in UM and he approached me for a project where he told me he needs to read the pathology of rat. They were doing a chemopreventive and chemotherapeutic drug on rats. That was the first time I came across and I read a lot about the histology of rats and so on.
I had another project again on rat with Prof. Norhayati, she's a UKM Dean now and with her student, they wanted to see the hair follicle growth and they were studying stem cells and so on. So I started reading about the hair cycle. I've also had one project with SEGi University. We've just completed the project where we saw an enzyme level in vapours. Now I have another project with Dr. Siti Mazlipah and Associate Professor Dr. Zuraiza. We are looking at the cancer related inflammation and I do a lot of immunohistochemistry where I usually do one marker in a tissue, it comes as brown color. But then I have had a wonderful experience doing two markers with two colors, and another project with him on immunofluorescence three colors, thanks to Professor Ian Patterson for bringing the project to me. There's an ongoing project on oral cancer histology where we are trying to look at various parameters in oral cancer histopathology and that is with Professor Dr. Tillakaratne. I also collaborate with some of my colleagues from the engineering department, which we are doing on image analysis and certain mathematical modelling.
I'm very happy to be collaborating with them. These are wonderful memories I have in Malaysia, especially in the research side. If you ask me about the pathology side. Yes, it's been a great learning experience from my colleagues. I should thank Associate Professor Dr. Thomas Dodge, Associate Professor Dr. Zuraiza , my juniors, Dr. Chan, Dr. Goh, and Dr. Nurul Izyan. They come with difficult cases. I might go with difficult cases to them. It's always a learning process. All my elective students have done a wonderful job and even my postgraduate students have done a wonderful job. I've worked with wonderful people. Very good memories I have about my work of these 10 years in Malaysia.
“What are the characteristics a student should possess to pursue Oral Pathology and what advice would you offer them?”
It’s not only for Oral Pathology, but it could also be any discipline and any department you want to take. First you have to like it. There are two types of people in the world, one who ‘gets what they like’ and the other one is ‘like what they get’. I'm mostly ‘like what they get’. I started liking Pathology once I went into it. Slowly, I started loving the subject after some time. It was wonderful and I kept learning a lot. It’s not only I learned from my teachers, I learned from my colleagues and my students. I learned a lot from my students. In fact, when it comes to technology wise, they are much better. There is only one thing constant in the world, that is change. So you have to embrace the change. And as you start to love the subject, you will have passion for it, and ultimately you have passion to carry on with it. If you want to achieve something, the passion should be there. If you do not have the passion, you might succeed but to a limit. But if you have that passion, then it will take you longer. What I would advise to anyone who wants to do any subject, in Dentistry or apart from Dentistry, first, like it, then you will start loving it. So those are the qualities you really need to be anything you want in your life.