Monday, August 24, 2015

Superficiality

Can't we just be plain honest with each other?

If only we could just say 'Yes' for Yes, and 'No' for no. If only we could sincerely lend, and not behave like disgruntled money lenders towards our friends. If only we stopped our false humility and our false courtesy to voice out what we really felt and thought.

It's a difficult world to navigate ourselves about nowadays.


Wednesday, July 29, 2015

Ending Third Year

This is quite stale news, but just for the record, I am already in fourth year. 

Yes, done with Intermediate Cycles 2 and 3, and voila, here I am facing Senior Cycle 1.

May God grant me patience during my Paediatrics posting. And help me appear less fearsome in countenance when dealing with young children. I know I have a reputation for making babies cry, so dear Lord, I ain't sure how to not make them cry, but I'll try.

Intermediate Cycle 3 is something I call an 'oddball, clown in the box' semester. The perfect combination of chaos, a whirlwind of God-knows-what hustle and a rude introduction to the pricks of the medical world. Thankfully I did not get to see such ruinous lack of piety or tyrannous rape of medical ethics when I was in my formative years, else I would have given up the idea of studying medicine. 

I couldn't have survived IC3 without plenty of help (the same way I might not have survived IC2 without some assistance, both temporal and divine). 

Been down in the pits since January, and noticed a rise in the recklessness of my tongue in the past few months. Thankfully my brains did not fry, else I might not be here typing out what I deem, the perfect hodge-podge of IC3 madness. 

Imagine not knowing even basic Orthopedics after your introductory 2-week orthopedic posting! The feeling of rejection when the so-called 'professional' specialist who was hired to guide students throughout the Orthopedic posting at X Hospital decided to just 'makan gaji buta' and treat us like wall flowers. 

Even worse was the Breast and Endocrine posting! The MOs and some of the HOs were really cocky bastards - and you know what, at the end of the day, they just blamed their cockiness on their workload. Which is actual bullshit, because I've done two electives in Penang General Hospital, which believe me is way busier than that country-bumpkin settlement out in the middle of nowhere, and I was treated with respect by HOs and MOs who were willing to teach any medical students eventhough they weren't paid to do so. So, shame on you, Hospital X. 

Well, IC3 was the semester that drove home the point: Do not be like Dr X when you grow up, because he was such a pain-in-the B. 

Shouting will not teach anybody anything, And blaming your workload for your lack of manners is a poor disguise of your wrong choice of profession. 

Wolves in sheeps' clothing indeed.

Overall, I am glad IC3 is over, and I did well for the IC3 finals despite the carnage that was IC3. 

So, that's it. Done with the craziness of IC3. And now saying hello to the great unknown (or is it?) of Senior Cycle 1!

Monday, July 27, 2015

Misfit

It has been a long time since my last post.

To be honest, it isn't because I have been busy.

I mean, yes, I have been busy, but that isn't the reason for my relative silence on this blog. 

These past few months I have realized my utter loneliness. For all the hustle and bustle of life, I feel somewhat empty. 

On every side, I begin to see the dark side of some of those people I call friends. And although I try to turn a blind eye but guess what, the people I am desperately trying to offer the benefit of the doubt just make it all the obvious that they don't deserve it.

I feel alone, in the midst of the crowd. I may laugh so much, but inside, I know that I'm doing that to make up for the sadness inside. I say 'It's nothing' but actually there is so much that I cannot express.

I try to speak to the few friends I still have, but it appears that they don't see the problems I see, or even offer to try to see things the way I see it. I get frustrated, more so because I've always tried to put myself in other people's shoes. But the same is not being done for me. 

I begin to loathe certain people more. I know you're supposed to forgive, but inside, I have often railed out against God. I feel life has been unjust to me. I mean, is it true that we ought to do unto others what we desire others to do unto us? Because I think whatever good I may have sown has not been returned in like, nor has it seen even the first fruits yet. 

I tried to fit in, but for some reason or another, I never completely did. 

I am a frustrated man. I am frustrated because I feel like an odd ball.

I feel rejected by my own race, betrayed by my clumsy tongue which cannot speak Mandarin with the fluency I would have loved it to, disappointed by certain judgment calls my friends have carried out against me, and crushed by the fact that I feel so alone.

You step into a church to find some sort of solace, but all you feel is emptiness. You talk to your parents but it only provides relief for a short time, after which I once again feel lonely. 

I drown myself in my books, and tire myself out by running round hospitals and staying long hours on electives, but to no avail. I feel desperately empty.

The worst part is I look at myself and I loathe it. For some reason I feel that I may have been responsible for my own state. 

All the intelligence in the world is meaningless to me. Because I feel very much alone.

I feel a sadness I cannot express, a disappointment with life I cannot exactly pin point, and a sense of loneliness I cannot explain. 

I feel like a misfit. But I cannot let that despair destroy me, because I know my parents need me. They need me, so I cannot let myself perish in my depression.

So help me God.

Sunday, May 3, 2015

The Face of Sickness

Your face is your identity - when we think of someone, we inevitably picture their faces in our minds. Before all else, the face of the person will be the foremost of memories - way before we start thinking of the memories associated with that person.

And what kind of faces do we remember? That depends on what we tend to associate the person with. Happy thoughts with happy faces, sad thoughts with sad ones, and unpleasant memories with the ugliest depictions of the person we can recall. 

The face is our most important edifice of identity - in fact, it has been the subject of such adoration and infatuation that the cosmetics market is a booming one. It is so important that many of us, at a point in our lives, have wished that we could upgrade our looks. It is the premier asset we want to flaunt, the foremost display of confidence, and the very tool we use to attract attention to ourselves. Let us be honest, many of us wake up each day and stare into the mirror, only to find ourselves wishing that we could somehow look much better than our current state.

But for the medical student and the accomplished physician, the face is more important that just being a tool with which to garner social attention - it is one of the most important markers of one's health.

For example, you know a sick dog when you see one - the limping leg, the scabies-infested skin, the forlorn eyes, the gaping mouth with its weakly lolling tongue and the lifelessness of its gait.

The same applies to a human being. Ever thought of the phrase - to look like Death? 

Can it be that the diseased state of your heart, or lungs, or liver, or kidneys could be carved onto those facial creases - that one's dying moment can be seen in one's eyes? That one's failing bodily functions be set in that ashened face?

Having walked the wards for the past few months, I have learnt to identify what I call, the 'facies of the sick'. Somehow, having seen the faces of so many sick and dying, it is no longer difficult to tell the face of a healthy person from a sick patient. The dull eyes and sunken cheeks of the patient dying from stage 4 cancer, the heavily heaving chest and the pale lips of a person suffering from a paroxysm of asthma, the fatigued yet anxious face of a man with acute exacerbation of COPD trying his best to breathe through a venturi mask, the half delirious face of a man with hepatic encephalopathy or diabetic ketoacidosis and the hopeless look in an elderly man lying in a hospital, shaking from his rigors and driven half mad by his fever, knowing he is far from his loved ones in a foreign nation. 

The eyes are the window to the soul - true indeed. In sickness and in health, your eyes can be a very useful storyteller. And combined with a carefully taken history and a sharp eye, one can make a relatively good diagnosis of what is perhaps afflicting the person in question. 

Monday, March 30, 2015

In Hora Mortis - Death and the Physician

Many things made the headlines in the past week - the shockingly unimpeded preliminary approval for an amendment to Kelantan state legislature regarding Hudud; some chap deciding to be a doomsday prophet and announce Lee Kuan Yew's 'death'; the green light for the implementation of GST come April; hearsay of a possible collapse of the Opposition coalition and the 'cultural genocide' agenda of the Islamic State. Whilst the rest of the world was preoccupied with these matters, something else - significant in a way because it highlighted a commonly overlooked area altogether - stole the limelight in cyberspace.

And no - it wasn't about Nurul Izzah, some GST-bashing parody, or another dumb gimmick by some attention craving artist.

It was a photo of a grieving Emergency physician.

Crouched by the sidewalk to be alone with his thoughts, away from the hustle and bustle of hospital, with one hand clinging to the railings - and still in his white coat - is an ER physician. Grieving for the death of his 19-year old patient.

Some may ask - with such a hazy grainy out-of-focus quality - how could such an apparently amateurish piece of work garner so much attention?

The answer lies not so much in the external beauty of the picture - rather it is the message it conveys, the emotion it captures – now that, dear readers, is what makes this photo so special.

Poignant. Raw. True.

There was this patient I knew of, a young lady aged 30, diagnosed with chronic hepatic failure secondary to an overdose of traditional jamu about 3 months ago. She had been transferred to our hospital just earlier that morning, and had been in a semi-conscious state ever since. Her speech was incoherent, she was confused, her breathing was heavy, her eyes and her skin were as yellow as Stabilo highlighters. In between her laboured breathing, she would moan and call for her mother. Holding her hand, was her older sister. Seated beside her bed, and watching anxiously as her younger sister drifted in and out of furtive sleep, the patient’s sister could be seen reciting a few quiet prayers for her sister and every now and then, caressing her sister’s forehead.

And around the bed, one could see the flurry of activity– the housemen, the medical officers, the specialist – all in a heated discussion about what to do next. This patient was a Child Pugh C case – with all the lab results pointing towards a rather poor prognosis. To make things worse, her coagulation profiles weren’t too good either. And she had multiple esophageal varices too. There was heated debate about the necessary pre-emptive measures, a desperate flipping of medication and observation charts, alongside raised voices concerning repeated calls to the blood bank that weren’t getting the desired response, and beneath all that, the gnawing knowledge that there was once again all that bureaucratic red tape to beat. The fact that the patient’s sister persistently asked if the patient was going to survive didn’t make things better.

Later that afternoon, whilst the physicians were trying to stabilize her – the patient suddenly gave out a shrill throttled desperate cry – ‘Doktor, saya tak boleh bernafas!’. Her breathing was shallow, her pulse was tready, her tongue was blue and her face had that mask of fear and panic. Her fingers were digging into her bed, and her chest was heaving like a bicycle pump. The medical officers were shouting out orders, calls were made to the head of department, the housemen did all they could to resuscitate her – ventilation, inotropic support, fluids, heparinization, nearly everything they could do, was done. The entire place was chaotic. The drapes were drawn around the patient, and the doctors were racing against time.

The chaos of the ward suddenly died down when the cubicle where the patient was became dead quiet. The flurry of activity had stopped. And the housemen exiting the cubicle appeared ashen. We all knew she didn’t make it. She had died of a massive pulmonary embolism.

The patient’s sister started crying bitterly. She sat rooted to the chair, unable to stand, stumped by her sister’s untimely death.

And in the heaviness of that moment, I spotted the houseman who had attended to that patient. At the first glance, it appeared that she was busy doing the necessary documentation of the death, whilst cleaning her glasses rather repetitively and vigorously. But upon closer inspection, one could see a few tears in the corner of her eyes. Her glasses – were stained with tears.

When she saw that I noticed her tears, she immediately turned away, gave those glasses one more round of violent polishing, and then turned back – this time her face was stoic. And she told me – we cannot cry in front of the patient. It is unprofessional.

It is a rather interesting to note, that whilst we accept the weeping of patient’s relatives as perfectly normal, we stigmatize the weeping physician as ‘unprofessional’.

Why is it, that a man who has raced against time, placing the responsibility of saving his patient before everything else, to do everything that can be done to resuscitate a dying patient, to save someone who isn’t his flesh and blood – why is it that such a man should not be allowed to shed a tear when the patient under his care perishes?

A family member weeps because death has taken away someone close to them. But how about the physician, who is literally involved directly in the health and life of the patient?

In theory, we are taught (or rather, hinted at) to maintain a professional attitude towards the death of our patients. By common interpretation, this ‘professional’ attitude towards death means that one must maintain the theoretical separation between your personal feelings and your job. I have heard some doctors state that ‘You are not the one who’s dying – why do you weep?’

Some say – ‘You weep only if you know you haven’t done enough.’

And some prefer – ‘Tears cannot resurrect Lazarus’.

What irony – that we, who encourage teenagers to speak to their parents if in trouble; who cleverly  advise people to take good care of their emotional health; who confidently direct patients to seek help to reduce stress -  ignore the fact that in more ways than one, a physician is also bound to come across certain events on the wards where personal emotions and work will get closely mingled.

The junior doctor who puts in the drips, ventilates the patient, and administers the antibiotics – is the same person as the man who in his heart, hopes sincerely that what he is doing will be in some way helpful to the patient. The very same person as the man who, like the patient’s mother, hopes against all odds that the patient will turn out alright.

It is surprising that in a working environment where people still consider ‘pulling a fast one’ while performing certain aseptic procedures as rather ‘acceptable’, in an environment where empathy for patients is still considered perfectly ‘theoretical’, and in a work culture which accepts poor communication as an all-time norm – it is surprising that in spite of us closing our eyes to these (and many more) issues, we have decided to stigmatize ‘soft doctors’ rather than hit out at the larger issues pervading our hospitals.

In some ways, it may be reasonable (being overly attached to a patient and mourning unreasonably would have a disastrous impact on the flow of work in a busy ward). But perhaps we have taken it a little too far to so-call set it in stone that ‘a doctor cannot cry’. It is very much as un-empathetic as the men who coined the statement ‘real men don’t cry’.

Doctors do cry. It’s just that we have often glorified the image of the unperturbed, professional, steely-eyed doctor. So much so that we have forgotten that like everyone else, doctors do not lead double lives. A life where we have two perfectly compartmentalized aspects – personal and work – does not exist. There can be no such thing. If there was, then we wouldn’t need to employ psychologists and psychiatrists to deal with the ever rising hordes of patients who complain of work-life balance issues, or work-place related distress. The phrase – separation of work and personal life – disregards the reality that work and life will intermingle, since work is a part of life. It is the same mind, the same soul, the same person who is involved in these two aspects of work and personal life – it would be rather unrealistic to tell a person, especially a doctor, to forget everything work related once he steps home.

The fact that this picture has become so popular speaks volumes for itself – it captures an image which the public rarely see. It depicts a side of us which the world at large hasn’t been introduced to – our human side.

The picture does not depict a moment of weakness. In fact, weeping is not a trademark of the weak. Weeping is not a sign of breakdown. No, tears shed in hora mortis are not a sign of unprofessionalism, since medical ethics dictates that the major principle underlying our concept of ‘professionalism’ is ‘Primum non nocere’ (First do no harm). In what way is a weeping doctor of any harm to his already dead patient? I rather believe that forcefully burying all that grief deep down inside and trying to distance ourselves from our patients, is the one thing that is harmful to the emotional health of the physician himself.  True, our profession comes before all else – but it does not mean that we have to lose our humanity to achieve this.

Why would a doctor weep for his patient? A man who weeps for any Tom, Dick and Harry’s death probably has a problem, but a man who weeps for the person he has tried to help – that, is something else.

We encourage empathy – but suddenly in hora mortis, we require our doctors to be as distant as possible. Food for thought?

Thursday, March 19, 2015

The Med School Report Day 905 - SSC Stress

I am glad that this semester has seen me cut down on my coffee intake by nearly 80%.

On the other hand, my frustration levels (with certain parties) have reached an all year high. 

One thing for sure is, if I ever get married, it will definitely be to an Asian. At least our mannerisms, concepts of what is polite and what isn't as well as our higher tolerance threshold for even the most jarring differences in cultural practices, is better than getting hitched to somebody who doesn't know how our community functions. Period.

Whatever works on Mars does not work on Earth. Not in the same way. And maybe not at all. Or maybe it will, with plenty of tweaking needed. 

I think it is time we stop borrowing concepts whole-sale from others, and start formulating our own brand. That way we can suit it to our Malaysian context. Make it applicable to our local context, to the reality of our hospitals, to the reality of our patients (we must admit, with all honesty, that Malaysian patients are a whole different ball game altogether - ask any doctor).

Anyhow, I learnt from the wards today that pride never goes down well with your underlings. Yes, boss yourself around and try to use your 'bad day' as a cover up after that - but it doesn't matter. What matters is that you have just made yourself hated, feared to the point that it paralyzes working relationships even among your Housemen, denied innocent students of optimal support in learning (from you, you cocky bastard!) and perpetuated the curse of the Malaysian hospital - pecking order, pecking order, pecking order! 

I told myself - one day I shall make myself competent, to the point that I will sit in a place of influence and stop this nonsense. Monsters give hospitals a bad name. And it is because we let them run the wards, instead of putting them down and straightening the bad apples. 

No, this is not the SSC stress talking. It's that burning sense of anger with the sad state of medical education in Malaysian hospitals. Students know when somebody plays Jekyll and Hyde, or when somebody is on the take of blind pay. Putting on an air and forcing us to give you a rimming sadly only helps you to boost your pathetic ego. Which is unfortunate since medicine was never supposed to be like that. 

Unfortunate indeed that many forget 'Pride goeth before destruction, and an haughty spirit before a fall.'. 

Tuesday, March 10, 2015

Fragmented Thoughts and Poor Understanding - The Problem with Medical Education Today

I think I have forgotten - such a common tagline. So common that we have accepted it as part of life. 

But is it really an integral part of our medical career. Let's think.

It is alright for a medical officer to forget the finer details of physiology or those rare pearls of pharmacology, or  the in-depth anatomy of the Facial nerve. Lack of use, being out of touch with a student's life and aging - all these are important factors which contribute to the acceptable gradual degradation of knowledge so meticulously accumulated in 5 or so years of medical school many moons ago.

But when medical students begin to complain that they forget things easily - or that things don't really stick for more than a quarter of a year (or even over the summer break) - and that too, not just one but at least three quarters of the class - then this is a major problem.

Why so? Because if we can't remember what we've studied the previous semester, then what are we ever going to remember? Are we going to enter the hospitals with amnesia? Are we going to be so heavily dependent on DynaMed and Medscape that we can't even be confident in making clinical decisions for our patients without having to resort to these apps, or worse, resorting to that so-called Britannica of the Google age - Wikipedia. 

Ask any student in JC2 onwards - What are the anatomical landmarks demarcating the pathway of the great saphenous vein? Chances are that in every 10, at least 6 to 7 would have forgotten half of it. Or worse, ask a year 2 student about the various classes of anti-arrhythmic agents, and maybe they'll give you glazed looks. 

Oh. Wait. Most likely they will tell you: I know I've read it somewhere. On X SLIDE, in XX lecture. 

Was this meant to be? That we think in terms of SLIDES? That we're unable to understand a lecture as part of a greater structure, or see that Biochemistry isn't just a collection of 36 lectures but is instead a study of very interconnected topics - which, whether you believe it or not, has an important role in medicine (when you're wondering why a patient's having lactic acidosis, you'll know how important Biochemistry is). Ask a student about essential pharmacology, and they'll struggle to define what a therapeutic window means. Or if you could see thought bubbles, most likely you'll see students wondering 'Where the hell does this pharmacology lecture fit in?' whenever a pharmacology lecture comes around the corner.

It is alright for the older ones to forget some things, but when many students of our age begin to complain of 'failing to make the cut' memory-wise, and we KNOW that these students actually passed their exams, and of course, giving the benefit of the doubt that our exams are impeccable (so to speak), then what could have gone wrong? Are we more forgetful than our seniors of old? Something is wrong. But what is it?

Having been a tutor myself, I think I know what our problem is. I have a theory and I call itthe theory of FRAGMENTED THOUGHTS

Of course, I am not saying that students are to be spoon fed. But the point I am driving home is the need to provide students with a logical structure which allows students to see the flow in subject matter. 

Especially if we are going to use SLIDES as our major teaching tool. 

Slides are nice to look at, easy to read, and or course, less wordy than paragraphs. But what we fail to notice is that slides tend to lack one thing - FLOW. Unless you are a teacher par excellence, many of us have to be reminded time and again that good teaching involves making your student aware about the context of everything - how does one topic fit into the whole corpus of medical knowledge.

So why did I put 'slides' on the hot seat here? There is a tendency to make everything cut-up and piece-meal when we're constructing slides for lectures compared to when we're writing lecture notes in continuous prose. This is because when we are writing actual continuous prose, we are more aware about making the flow in thought obvious for our readers. However when it comes to slides, any disruption in the flow of thought is less obvious, since it is after all, a very much visual presentation. With the usage of slides, it really is up to the presenter to tell students how one slide is related to the other. Fine, so we actually have a so-called way of circumventing that problem - good presentation skills. But let's do a reality check - Do we actually do that? Do we actually help students see the whole picture when delivering our slides? Or do we just read off our slides and rush everything to fit it into 50 minutes. 


Some might say - we have learning objectives , so why not let the students be on their own two feet and let them learn based on the learning objectives? Well, that is true only if you make your learning objectives clear and memorable. Some institutions actually have a list of up to 15 learning objectives per lecture. But we fail to realize that although it looks nice on paper, there are many factors to take into consideration - having a detailed list of learning objectives in one lecture would necessitate that we be equally meticulous with all other lectures, and the problem about listing such a detailed list of learning objectives is that we turn students' brains into tick-box machines. 

Slides are bad at conveying 'flow of thought'. And if not properly delivered, there is a high tendency to think of a topic as stand-alone instead of being in congruence with other topics in medicine. Slides can't beat text when it comes to 'fitting it all in'. No, slides are meant for easy presentation, but not for excellent teaching (unless you are a seasoned teacher). Otherwise, being dependent on slides to deliver is a really bad choice. 

It is already well-acknowledged that comprehension and memory work is easier and less momentous when someone has been taken on a well-delivered narrative overview of a subject, and understands how each topic fits in. Being a Chemistry tutor myself, I know my student has literally got it all muddled in his head when he cannot confidently tell me in succinct sentences the connection between Oxidation, Reduction, Alcohols, Aldehydes and Carboxylic acids. However, if he knew (or if the tutor had taken the time before pluinging into all the nitty-gritty of electron transfers and bond-breaking to explain) that alcohols, aldehydes and carboxylic acids are all merely different oxidation products of the same primary substrate, and that these were common everyday compounds, then the student would be able to appreciate organic chemistry better. That oxidation isn't merely a play of electron counts on exam papers but is a process that happens on a daily basis, which we can actually harness using special methods to produce an array of useful chemical products. See, that is something bone-dry, piece-meal slides accompanied by 'monotonous read-along sound overs', cannot deliver. 

The same thing goes for Medicine.

We need to help students see the subject matter. Don't let them have the impression that Biochemistry is just a time-filler subject for First Year students. Or when it comes to pharmacology we ought not to say 'this you don't need to know' or 'that you don't need to know'. Instead we need to pay more attention to drawing a proper outline for students, telling them how each lecture is related to the other, how it can be applied to life, and why we need to know it. That Krebs and Glycolysis ain't really theoretical, they're very much daily life kinda practical. And once students know the flow, memory work won't be such a chore. 

A proper outline and consolidating the flow of thought is always the FIRST STEP. Not a long list of learning objectives. Not a thousand slides. A clear thought process is always the first thing to consider. Having an exhaustive list of learning objectives is never effective if one doesn't understand where everything fits in. 

If a student can only think of something as being 'on X slide, in X lecture' then we seriously need to consider another solution. Perhaps it is time to stop, think and reflect - have we been doing it right?