Graduation

[Above photo: Graduation Day: Dr. Hnin Aye, holding her certificate, wearing traditional Kayin dress and Professor Stewart in traditional Myanmar formal dress.]

27 October 2019

The events last Monday went something like this: 9:30am gift giving, 10:30 review exam questions and course feedback, lunch with my students, back to my apartment to change into formal Myanmar wear, 3:00pm graduation ceremony, supper sponsored by the Myanmar Psychiatry Association at a snazzy restaurant..

I gave to each student a briefcase in which to carry their child evaluation toys and documents, a carved jade cat (symbolizing their group identity), a cast brass bell (To keep order when teaching. One of them gave me a little bell early on in the course.), a cat tote bag from Chiang Mai, and a personalized card. The presents from them to me were astounding, in addition to the many intangible gifts and kindnesses. They gave me a teapot and 5 tea cups carved of jade, a very traditional style framed portrait of me, taken from a photo and rendered in mixed media, including chips of alabaster, ruby dust, and other mineral grains, and a bracelet with 5 solid gold ornaments woven into it: 2 stars, 2 cats, and a squiggle that looks like a “G”. On the portrait it is written, We love [Baba] George. The Baba means uncle and was rendered in Myanmar script. I now learn that Baba was the name they used for me amongst themselves.

Since I think of the value of tests as primarily for learning more than for assessment, reviewing the written exam was a useful exercise,.  This included learning to be careful on the exam: 2 selected delirium tremens for a delirious 4yo with pneumonia! They all knew that wasn’t right and were rushing through the test. I again made—hopefully cemented—points about early attachment and the Internal Working Model which so powerfully influence all of our subsequent relationships.

Skipping to graduation, it was a fairly formal affair, except that many of the students were weeping that the course had finished and I’d be moving on. I’ll admit that tears crept down my cheeks as I was giving my talk, encouraging my Cats to go forth to practice and teach what they had learned. Then one of the best of the students—she who always scores highest on the exams—gave her take on a group appreciation of me during which she broke down weeping. I think it was a first for the senior faculty who were gathered, as well as an eye-opener for the new Pro-Rector. My style of engaging the students really fostered a lot of feelings on both our sides. To his great credit, the 2^nd in charge at the Embassy, George Sibley, made a point of telling me afterward how terrific he thought all the emoting was in such an ordinarily staid event.

The next day the students took me on an outing to the huge WW2 military cemetery (Perhaps it wasn’t  conscious but there has been a death in all our lives with the conclusion of the course.) in Bago. Then on to a nature preserve/wood sculpture garden of immense dimensions where we drove around and wandered and ate lunch. Not content to leave it at that, we stopped for soft drinks at a spot on the way home where several of the women disappeared into the toilets to weep. I think all the outpouring was, as one of them said to me “about bonding and attachment”. Good, they took that message away. It also was about my dropping the pretense, defensiveness, and rigidity to which they are all accustomed with many of their professors.

To better explain my thoughts, I’m including my graduation speech.

 

Mingalabar (Hello, Welcome, Bless you, an all-purpose word)

Pro-Rector, Members of the US Embassy Staff, Professor Tin Oo, other Faculty, other guests, and the Graduates.

I am very pleased to be with you today, honoring our graduates and their commitment to learning child and adolescent psychiatry.  It is a bold first step for Myanmar.  And to honor all of you who helped make this day possible, in ways both large and small.

I am aware that I have undoubtedly made many cultural mistakes in Myanmar; I probably am doing so right now. You all have been very gracious in accepting me despite these.

Also, since Bama zaga ma pyaw bu [I don’t speak Myanmar language.] I especially appreciate the graduates as you have worked hard to learn a new discipline—that of Child and Adolescent Psychiatry—in English, a language that is not your mother tongue. I have been very impressed by all of your efforts, as well as your patience with me when we were not understanding each other.

When I began to teach the course, I was aware of the idea of ana deh—to me it meant don’t make another person uncomfortable or embarrassed. In an educational setting that could mean don’t challenge what your professor says because it might question if he or she knows everything or is actually mistaken and thus he or she might feel bad.

In any case, I suggested to the class on the first day that this person, Ana Deh, did not like students’ asking hard questions of their professor and, thus, did not belong in our classroom, so we locked her out. All of us make mistakes and no one knows everything. What is important, it seems to me, is to accept our mistakes as learning opportunities and to try not to repeat them. Also, we all need to know how to look things up if we don’t know them. Students’ questions make me learn more and we know that students engaged in active learning also learn more in the development of their critical thinking.  Quietly and obediently writing down what you are told in a lecture makes for a bored professor and bored students, in my experience.

Hence, our often vigorous, if not rowdy, classroom discussions. At one point early in the course, trying to get the students’ attention so I could move ahead with the day’s lesson, I said, “This is like trying to herd cats.” Suddenly they were making cat sounds: “Meow, Meow.” I knew then that these cats would be good learners. Cats are independent thinkers and they are both observant and curious, all qualities central to being a good psychiatrist. And these cats had a sense of humor, as well, a necessity in our work.  They are kind, however, unlike most cats.

I wanted their openness to thinking, to questioning, and to discussing to mirror what their patients would feel when seeing them: safe, open, listened to and able to say whatever was on their mind without fear of criticism or judgment. As psychiatrists we are in the unique position of being able to provide that for our patients.  The Buddha has a perfect wisdom for the talking part of a psychiatrist’s work: “If you propose to speak always ask yourself, ‘Is it true? Is it necessary? Is it kind?’”

This has come to pass and the students are all good observers, listeners, and speakers. They have each completed supervised evaluations on numerous children and participated in evaluations and discussions of over 100 more, as well as conducting many follow-up visits. Follow-up visits are a gift to us, where we can see if our work is helpful or if we need to modify our approach.  Each one of the graduates now has the skills and knowledge to be a safe and helpful child psychiatrist.

Psychiatry is an infinitely interesting and complex specialty, a reflection of the human mind told in varied and fascinating stories by our patients. The students will hopefully be lifelong learners. It would be a mistake to think that completing a course of study such as this is the end of our learning. It gives us the foundation for future learning, a beginning only. Imagine living in a house without walls or a roof, only a foundation. And it would be too bad if in 10 years we are practicing the same as we do today. Like a plant, as psychiatrists we must grow or we professionally shrink and die. [Block these metaphors!]  With your excellent library facilities and a little bit of discipline, it is now easier than ever to stay current in our field. Imagine, reading only one new research or review paper a week adds up to over 50 papers in a year. That is a lot of knowledge on the way to wisdom.

50% of adult mental illness is apparent by 14 years of age; 75% is visible by 21 years. Approximately 1/3 of the population of Myanmar is under 18yo, a child or an adolescent. Identifying and treating mental illness early is humane, is more effective than doing so later, and makes good economic sense. Recent studies from Harvard University demonstrate that money put into children’s health and education has the highest rate of return by far of any social or human resource program, returning many times its costs.

Training child and adolescent psychiatrists alone will not address the mental health needs of all the children in Myanmar, no more than they can anywhere. Child psychiatrists are sub-specialists and our training is extensive and expensive. Public health advocacy for measures such as ending corporal punishment at home and in schools, strengthening the laws and their enforcement regarding child sexual abuse, and addressing school bullying is an important, if unpaid, aspect of a child psychiatrist’s professional life.  Yet another role for our child psychiatrists, after they acquire some experience, may be to train non-physicians to triage and provide basic mental health services for children and families in distress. The limited numbers of child psychiatrists can then save themselves for more complex referrals, consultation, and teaching, whether in academia or not. For example, there is a great need for child psychiatrists to provide information about mental health and mental illness to the schools, to the courts, to the juvenile justice system, and to the public in general.  Professor Tin Oo and I have begun to discuss how to meet these needs.

There are challenges to making progress in any country and Myanmar is no exception. As a great American writer, Mark Twain, once commented, speaking of the card game of poker as a metaphor for life, he said, “Life is not a matter of holding good cards. It is about playing a poor hand well.” We are all trying to play a poor hand well, given the obstacles we face.  A phrase I have often heard here is, “This is our life.”, a mature and honest acknowledgement of the struggles you all face.

So, in concluding, I want to say to each of my Cats, go forth and practice what you have learned. Your tasks are to listen with compassion, to attempt to understand, and, only then, to try to help, although listening and understanding are already powerful therapeutic interventions, as you know.  I know that you can and will succeed at this. Know that I will be with each of you on every step of your journey. It may get confusing or frightening at times, but with careful, critical thinking you can most often have good outcomes. Another quotation I like, attributed to John Watson, a Scot, is: “Be kind, for everyone you meet is fighting a great battle.”

Thank you from my heart for giving me this opportunity—a rare journey in anyone’s lifetime—to get to know you, to teach you, and to learn from you. I will always remember you, your kindnesses, your generosity, and our time laughing and learning together.

I want to thank, especially, Professor Tin Oo for his unswerving vision and support of children’s mental health training and services in Myanmar, as well as his many thoughtful personal kindnesses to me. And Dr. Kyi Min Tun, who in addition to being a member of the graduating group, has been my chauffeur, my IT advisor, my cultural consultant, my fashion resource, and my go-to man for any help— where to buy eyeglasses or watchbands, how to find a tailor—all while supplying me with a steady stream of longyis.  Dr. Kyi’s generosity of self is exemplified by his most frequent English phrase, “Sure, no problem.” And of course, I want to thank the United States Department of State Fulbright Program, which has enabled and supported my participation here.

I want to end with two quotations from the Buddha that seem entirely appropriate and timely to me. I apologize for only having the English versions.

The first fits the graduates, who have introduced me to sharing in many ways, but especially with food at lunch times:

“If you knew what I know about the power of giving, you would not let a single meal pass without sharing it in some way.” You now have the obligation, and opportunity, to share what you have learned— with patients, with parents, with other psychiatrists, with pediatricians, with medical students, with schools, with the public.  It will return to you much more than you give.

And apropos of our chosen work, the Buddha said, “If anything is worth doing, do it with all your heart.”

Thank you.

 

It has been a moving few days and I’ll begin to teach the next group in January for three months. Hnin Aye, one of my wonderful students, has two tee shirts she wears with the Lewis Carroll quotation: “In the end, we only regret the chances we didn’t take.” I certainly have many regrets in my life but none for my Fulbright experience.

Now I’m off to Bagan for 5 days of viewing amazing monuments, zipping to and fro on an electric scooter and generally relaxing. We’ll see how I do with that.