Exhaustion by Expectation...AAARGH!!!

I am currently in the 3rd week of my medical posting...or at least i am supposed to be. I practically slept through the whole of last week; i could barely keep myself awake. This week i'm plagued by insomnia, waking up at 3am and unable to fall back asleep. I am very much interested with my studies, but just overwhelmed because there is too much to do. Its draining just thinking about it & planning my next course of action and frankly, i have little energy to do anything. Forget eating or socializing; i'm too tensed most of the time anyway.

Let me give you a tour of the expected life of a final year medical student in University Malaya.

My current posting : Internal Medicine.
We are rotated among the 8-10 sub-specialty wards each week (cardiology, neurology, geriatric, hematology, etc.) for the 8-week posting. Depending on the ward, each student will have about 7 patients to cover; meaning to fully clerk the history, full examination, trace lab results & X-rays, study the case notes, and follow-up until discharge. By exam standards, full clerking + examination + diagnosis + plan investigations should be done in <1 hour (experienced doctors can do it within 10-30mins depending on the illness...that's y the GPs shoo you away after 2 minutes). Simple math will tell you it will take minimum 8 hours in the ward including breaks & moving between patients, just to cover the patients...without even checking reference textbooks about the disease. 8 HOURS OF BASIC EXPECTED PREPARATION FOR JUST 1 HOUR OF CLASS (TEACHING WARD ROUND). We have 2-3 teaching ward rounds a week. And some of our lecturers expect us to be in the ward 7.30am-5.00pm to join with the consultant/medical officer ward rounds or help with blood taking and other things like that. Then we have on-call duties once a week so we have to stay at the ward or emergency department at least until midnight & follow the doctors.

That is just the ward work. Mind you, its not like we are getting paid...and neither are we actually treating the patient...just aggressively observing.

Then in every posting, we are expected to observe procedures like X-rays, CT scans, endoscopy, biopsies, blablabla...at our own time. Regardless if we have seen such procedures before (perhaps in different postings), failure to obtain the the attending doctor's signature to complete/fill out log books would reflect poor attitude and less marks. On top of that, we have tutorials on various topics once or twice a week, each taking about 1-2 hours. Because the lecturers themselves are specialists/consultants, they are very busy thus last-minute schedule changes are not uncommon. Then in some postings we also have to attend to the clinics, to learn about follow-up, clinic vs ward setting, learn how to decide which patients need to be admitted, so on and so forth. And because UMMC is very sub-specialized, different clinics are on different days!!! Then there are additional stints with the Departments of Pathology and Radiology every other week....sometimes requiring searching for additional patients or writing up reports. Then we also have 1-2 hours of general lectures and 2 hours of Clinical Pathology Conference (CPC) once a week. Attendance for EVERYTHING is compulsory, anyone with <80% per posting will be subjeced to inquiry by the Dean's Office and barred from our final exam. Oh, and did i mention that we have end-of-posting exams every 8 weeks?

Overwhelmed yet? Noticed that i haven't even mentioned READING or STUDYING.....let alone RELAXING. Ideally, they expect students to read up on the disease/conditions of their allocated patients in the wards as well as their treatment options, read up in tutorial topics beforehand, revise the contents of the general lectures, and prepare for the CPC which are very complicated cases like you see on House. I personally think one has to either be manic or hyperthyroid or hyperactive or addicted to coffee/red bull/crystal meth to be able to cope. That's why i am contented with my C-mark at every major exam.

Hospital staff (doctors, nurses, dentists alike) always say this about UM grads : UM grads are excellent, they are very skilled with clinical work and have a lot of knowlegde, but have bad attitudes. Well, that's because in the process of our training/grooming/education we have learnt to say FUCK YOU!!! We'll go around doing out own business, as long as the patient is safe/stable, the filing & documentation is up-to-date, we really don't give 2 shits about anything else.

Ain't we a fun bunch. Now...has anyone got some crystal meth for me?

Buttering Myself Up

I've been in somewhat of a bad mood for the past several days. Although i remain motivated, my temperament has been foul; thanks to no small part to the hypocrites i call family. If u had read my previous post with regard to sex out of wedlock, you can obviously see how strongly i feel about it. I have to be honest and say my stand has been conditioned by upbringing, religious education, and to no small part influenced by the incidents that lead to the wreckage of my only family institution : the inability of 1 man to control his sexual desire + 1 immoral woman who had no qualms about having sex with just anyone.

Do i not feel ashamed writing that down? why should i, when the offenders themselves have never truly been apologetic. Not my problem. Yet apparently the collateral 'victims' to the ordeal don't feel as strongly as i do. So i guess its everyone for themselves, they way it should have been from the start. No good deed goes unpunished. For trying to stick to what i believe in and truly spend time with my relatives, I get unadulterated version of the unspoken resentment and end up being the soundboard & the reliable one when it comes to...well, anything.

So. Let's butter me up to make me feel better.
Definitely better than beating myself up, right?

I come from a very educated family. On my mum's side, you have the ultimate definition of academic : my grandma, Prof Emeritus Puan Sri Dato Dr Fatimah Hamid Don. Yep, my grandma has a PhD. Google her and you'll get her journal contributions, newspaper articles & the sorts. As if that wasn't great enough, she is the founder and held high positions in several of the women NGOs in Malaysia. Then you have my late grandfather, Tan Sri Dato Ishak Pateh Akhir. Google him and you'll see his face as chairman of SPA & MIDA...he was a high-rank government officer. My mum, Dr Fawziah Ishak, Obs & Gynae specialist. She's well-known in Penang, esp in the mainland. On my father's side, my maktok Jumabee (MJ) was a teacher for over 40 years. I think she started teaching when she was 14...mostly math & art in primary school. My grandfather Daud was also a teacher, a high school art teacher (oil painting, pottery) ...its pathetic how i did not inherit ANY art skill. Although my MJ & tokwan aren't as high-powered as my other 2 grandparents, i am still very proud of them...many in their generation are illiterate, many never went to school, let alone have careers. My dad Mohd Rafi started as an engineer/technician and has long ventured in to business and the world of economics/venture capitalist/investments that i dont understand one bit.

That's them.

What about me? I always say i'm average but my friends always disagree. I guess academically i've been blessed. 5A UPSR + offered Sekolah Tun Fatimah, 8A PMR + offered MRSM Taiping, 9A SPM + offered PASUM, 4.0 PASUM + offered UM Medicine. According to my dad's calculations, among the ~200,000 that took SPM my year, ~2000 got straight 9A1..... since i only had 8A1+1A2.....that puts me at around the top 2-5% among my fellow batchmates. Now, I'm in my final year of Medical school where everyone is crazy brilliant, i haven't really felt smart in a long time. In medical school, i'm in the bunch who gets just enough to pass (so far).

So nevermind academics, i've always tried do to other things. Like my ventures into drama/theatre/performing coz i really enjoy doing so. Regardless of the feedback i get, i just cringe seeing myself on stage. Unsuccessful there. Art, i won't even bother. I've never been good in sports, probably because i've always been on the heavy side thus i get winded quicker than others. Nevertheless, i really did enjoy my 3 years in Goshin-ryu Karate and i still wish to continue till i get my black belt, if & when i have the time. I don't read much until recently (political blogs), I'm the worst when it comes to technology & gadgets, and in person i am pretty 'blur', not very eloquent and in my opinion, not really that interesting.

But i am intelligent.

It is only recently that i realized that. In searching of my forte, something that i can rely on and feel confident about, finally i could connect the dots. I am smart, as 'evidenced' by my academic track record. So what am i good at? what is my forte : STUDYING!

So what am I doing about that...refer my earlier post about turning 24. I am currently :
1) taking Mandarin classes
2) reading political/social/religious blogs & giving my opinions
3) reading Mahathir's book : The Malay Dilemma
4) studying a compilation of hadith : Tajzibu Athraf
5) studying the tafsir Al-Quran in english
and of course, i cannot leave out my medical textbooks & notes...but i have to admit, i get distracted with the aforementioned.

Perhaps i am being overzealous...i have 2 more books to read once i'm done : The Other Malaysia by Farish Noor, Kisah 25 Nabi & Rasul, tafsir Al-Quran in BM...novels & Chicken Soups. I can't help it, i'm excited but reading is taxing. Writing in this blog also helps keep me interested. Frankly i was surprised to see >50 hits on my blog in within a week, coz i really thought i had maybe 5 friends who actually read what i write.

That's enough buttering. Now i'm craving butter-fried prawns..Ooohhh...

Premarital Sex & Caning of Women

I am just fuming. This topic has got me all riled up in a bunch. Oh, I don't know, maybe because it most likely concerns my generation, people in my age group? The many comments i've read about this topic is actually the fan to my fire.

Its not my intention to mimick Dr. Mahathir's blog style, but i need my thoughts in order

1. I am against pre-marital sex. I do think it showcases loose morals and irresponsible behaviour on both sides.

2.It is not something intrinsic of the East...it is not advocated in any religion i know. Blame the media or whatnot; it is only practised by a certain bunch of 'liberal' Americans (ie, the MTV or any form of protesting bunch which happen to get most of the airtime) and European countries, where ignorant young people compare the age of losing their virginity.... thanks to that UK has the highest incidence of teenage pregnancy. Is that really something to be proud of? Is that really 'modern' & 'progressive'? Sounds like young African tribal brides to me.

3. Most of the idiots i know who 'terlanjur' (i hate this term coz who on earth can 'accidentaly' have sex? its a lot of effort man!) usually i hear they cry after their 1st time coz of shame, 'regret', because 'it just happened' (yeah right...)...then ignore their conscience do it again & again because 'it doesnt matter anymore now that virginity is lost' and 'alang-alang'...and of course, who can deny the pleasures of sex? Now, their initial reaction of self-realization n regret MAY be described as the feeling of 'insaf'...judging by the events that followed, is it really?

4. Having said about 'insaf', lets talk about the caning of women issue. Look, i am not a die-hard fan of caning, neither am I a religious extremist, but what the hell is the big deal? Why on earth are you arguing on basis of women's rights and what nots....Men have been caned for ages and when its time for women to get cained u claim injustice... You want gender equality, you gotta take it as a whole...not 'selectively' when it suits you, you bigot. You get same jobs as the men, same opportunity as the men, same punishment as the men.

5. From what i know Shariah caning is different than the usual caning we see : the graphic images of the buttock skin torn from the many lashes revealing the angry bleeding red flesh underneath. Shariah caning is not like that. For one thing, you have clothes on. Second, it is not meant to cause permanent injury. Third, they dont use big scary rotans. Fourth, they dont ask a huge masked burly man to smack the life outta you

6. If someone is a Muslim, it is only logic to assume that they KNOW the do's & don'ts...so please dont act surprised when authorities say what you do is wrong especially when you are guilty / caught in the act (making out, consuming alcohol, lying through your teeth)...and especially, dont even bother covering it up or say it is unjust. With that, i'd like to express my respect to Kartika, because she did not petition against her punishment; she accepted that she has done wrong and deserves her sentence. It shows she is not ignorant, and that she is a woman who has self-respect.

7. Having said that, i think it is pointless for these 'raids' by Jabatan Agama Islam.... There are a lot more pressing issues to be dealth with, like ajaran sesat, high corruption, public education, reforming the eduation of Islam for the benefit of younger generations. Moral/akhlak issues are between a person and his/her immediate environment....their family, friends, teachers. It all starts from waaay back when

8. I am an advocate of educating & councelling. As i've said, premarital sex or casual sex or extramarital sex is all a reflection of loose morals...which begs the question of their upbringing. Parents should really educate their kids about the true value of sex...it is incredibly sad to see people being punished for their natural God-given urges. Or are the parents themselves behaving like reckless teenagers in heat, with their own porn stash and extra-marital affairs?

I guess that's sufficient for my 'lepas geram'. Let's all work & pray for a better future.

Polygamy?

This point of view just came to me yesterday for some reason.

Perhaps one could view the allowance of polygamy in Islam through the lens of early feminism. It could be a way of saying :

" Yeah if u still wanna go & f*ck around even though you're married then go ahead; but you're gonna have to marry that woman too. You gotta treat her well, provide for her & care for her as you do your wife. There aint no such thing as free bonus 'ride' for you, honey!
And if you STILL wanna go ahead and pursue that subsequent marriage, you can only do so with blessing from your wife. If she is kind or unconditionally patient then fine, you're safe. Otherwise you'll find yourself facing divorce, annulment or other forms of dissolution and by that you have already incurred the wrath & heartache of God for executing His least favoured of righteous acts."

Just a thought.

Doctor, doctor

As I awaken at 2am from my slumber, realizing I haven't done the presentation slides of my ICU patient, I sat on my desk and turned on my laptop. I then proceed to Facebook and Farmville, harvested my crops, commented on walls, and read a few posts. So ingrained is my routine of delaying unpleasantness, i now function my best once the world has gone to sleep. Not to mention i have grown disturbingly comfortable and skilled at churning out just-enough-for-passing-grade academic assigntments in a matter of hours. Perhaps it is now evident that i am no workaholic.

Anyway. I've been wanting to lay my opinions on the recycled issue concerning doctors : that there aren't enough doctors in Malaysia.
http://www.bharian.com.my/Current_News/BH/Wednesday/Mutakhir/20100127125427/Article/
Pure hogwash. The statement was probably true a few years back, but now with more than 20 medical schoold in Malaysia, plus the many more studying overseas, pretty soon Malaysia will be flooded with doctors. Even now, there are too many students-per-teacher, and in the working world, too many House Officers per ward.

What we need are better doctors, or perhaps more doctors with better mindsets. Ask the question, why does it seem we never have enough doctors?

Number 1, its the massive amounts of patients. Not just the usual Monday crowd (MC-seekers.) Its not that Malaysians are a sickly bunch, but most Malaysians are not medically-literate and come in too late, usually from very preventable complications. It is obvious that they have no idea what is going on with them especially when they come thinking 'angin' is the root of all evil. Headache= angin, abdominal pain = angin, chest tightness = angin, shooting nerve pain down the leg = angin. But, one good thing with these patients is that they are more likely to stick to one doctor, although by no means are they more compliant to medication and therapeutic advice.

Number 2, the certain bunch of demanding patients. Not every headache is a brain tumour, and most headaches dont need a demand for a CT scan. Dont believe everything you see on Spektra or House or Grey's. Doctors in private hospitals would probably entertain such requests, because they dont have a long waiting list plus the extra money in their pocket, justified as "for the patient's own ease of mind". Wouldn't it be better if these resources are used for the people who actually need it? In government hospitals, the doctors would tell you to go fly kite...then doctors get the bad press. These bunch of patients are the ones who go 'doctor hopping', which is not good. One visit to a doctor who didnt 'cure' them, they find another doctor a few days later who can give 'better medicine'. This is potentially dangerous because without existing records, there is no continuity of care.

Here's an example of unrealistic expectations of a patient :
http://www.themalaysianinsider.com/index.php/opinion/sazlin-daud/47633-doctor-doctorcant-you-see-im-waiting-waiting

But of course, doctors are not without faults. More often than not they are too focused on what they need to do for/to the patient that they forgot that they have not explained much to the patient what is going on. I've read somewhere that doctors overestimate the time they spend with patients by 900%. Now as a student, that is where i come in. Whenever i speak to my patients, young or old, i try my best to talk to them as friends. Hopefully if they are receptive, then they feel more at ease and open to ask me stuff, and I will gladly explain what i know about their condition.

For example, my Gynaecology patient was admitted for heavy periods, but she was also desperate to conceive and she asked me to help her understand the various methods of assisted conception. Then there was this man at the ENT clinic whose wife was having her ear examined & cleaned because an insect flew in it. We were both looking at the monitor (along with many other nurses & medical students) and i just asked him what happened. Then i just pointed to the screen and told him that the white thing was the eardrum, and that was where the insect was attached too. The a big ooooOOhhh came from him, learning a bit of trivia, almost with a hint of amazement for seeing an actual eardrum for the first time. Also like my uncle, curiously listening to his son's heartbeat with my stethoscope. Then there was this man back in Klang who had a heart valve condition (if i'm not mistaken) and having students flock around him day-in and day-out to have a listen at his heart. His daughter was there when it was my turn, and I told them that because of his condition his heart sound was different from the norm, and as students we had to learn to differentiate. I also demonstrate how it was different, and if i remember correctly i even offered my stethoscope.

PATIENT EDUCATION. Get them interested with their own health and illness. No time to counsel? Provide useful reference or websites. In short, i completely disagree with extending compulsory government service. I also believe that as long we provide f.o.c healthcare, peeple will not wise-up and take responsibility of their health, because they do not understand the cost of the medications & equipment used. I am of the opinion that the resources should be focused on patient education and more community outreach programmes. Don't even get me started on medical tourism. Look inwards and improve the health of Malaysian citizens first before offering 7-star treatment to foreign patrons. To paraphrase a Malay proverb : dont go breastfeed baby monkey in jungle while your own baby dying of hunger.

Time to get back to calculating my patient's potential death risk.... (does anybody know how to work the APACHE score??)