Time flies, really...
This year was an important year for myself.
Finally I had graduated after 4 years of endurance. Further studies when you are having other commitments is really tough. I need to juggle between work and family, to ensure a balance between both. If I had not took the leap of faith 4 years ago, I am still a rotting flesh sitting in a small place, waiting for time to past. If I never leave my comfort zone, I would have not known my potentials and my strength. If I choose to stay the way things are, I may have not known many great friends from around Malaysia and the World.
The arrival of the bundle of joy really makes a difference in my life. He has been my source of inspiration, my happiness and my motivation to go on. He makes me want to go home on time every day. He is a walking 'destresser', giving us joy and laughter.
I wish that year 2017 will be another great year, just like before.
Wednesday, December 14, 2016
Friday, July 10, 2015
How to Excel in MMed Part II - Short Case
Short case session for the Master of Medicine Part II is, no doubt, the make-or-break session. If you are able to grasp the case, you will sail through; if you have no clue at all the findings that lay in front of your eyes, it could be the longest twenty minutes in your life. I am going to share my personal preparation tips as well as a brief look into the format of the exam.
Format of Short Cases
First of all, the exam will test on four major systems, namely cardiology, respiratory, abdomen and neurology stations. The minor area such as rheumatology or dermatology will not be tested individually, but they can appears as part of a major stations and candidates are expected not to missed it.
Timing for each station is 20 minutes. Ten minutes for the examinations and the rest of the time is for the presentation and discussion. There is no rest time in between stations and you are expected to start the next stations immediately as the bell rings.
Upon approaching the case, you will be greeted by the examiners. There will be two examiners per station. Sometimes there will be an observer too. Among the examiner, there will be one person that dominate the discussion. They will ask you to read the print-out instruction and you will decide your approach to the case. At times, they can hint you that you are starting to derail. Do take those hints seriously.
After you have completed the examinations, the presentation and discussion of the case happens by the bed side. After the bell rings, you move on to the next station.
Preparation for Short Case
The key to excel in short case is to practice more. The examination technique has to have finesse in it. The steps is systematic. There is no going back and forth. Most importantly, both you and your patients are comfortable with the examination. There is no room for mistakes such as causing pain to the patient.
You are expected to present the case as if you have done it thousand times. Points are laid out systematically. The content of presentation should be succinct without too much words. The relevant positive and negatives are put up first. Skim on non relevant points. Differential diagnosis should be mature and reflect your readiness as physician. Discussions are logical and reflects your wealth of knowledge about the disease.
The only way to reach this level is to practice more. Practice to present to your colleague, to your lecturer, to your spouse, to the mirror. Don't be afraid to make mistakes as they are the only way we can improve ourselves. Listen to how you present by recording your own words. If the presentation does not appeal to you, most likely it will not to the examiners as well.
Participate in local PACES preparatory courses will help you tremendously. Not only it gives you a similar feel of the exams, you get the chances to practice on very good short cases that is hard to come by.
Practice whenever you have the opportunity. Be it a case during your oncall, during clinic sessions, during rounds, during evening sparing with friends. As the technique is a very personal thing and you will develop your own style in examination. Try to examine in full sequence if the time allows. A tip from my teacher is to practice short case examination during on call time. You will be doing the case under stress of fatigue and time constraints, So you will polish your subconscious mind on examination. Don't worry is you are doing simplified examinations; as long as you constantly try to remind yourself that you are skipping this steps and that maneuver. This is to make sure that old habits does not appear during exams.
As of the script of presentations, there are many textbooks that can be a good guidance. If you like systematic way of presentation, you can go with Oxford Specialty Training series. If you like a more abbreviated presentations, Ryders would be your options. Read Jansen Koh for a good foundations in the short cases as the author lay out almost all type of cases in an organized manner, which is easy to remember. My take would be to read Jansen Koh then follow with either Ryders or OST. Get the foundation right then polish the individual scenarios so you are prepared in every type of case.
D-Day
Time management is very crucial. Often the only clock you can depend on is your inner body clock. If the examiner allows, you can request to bring along a stop watch. This is to gauge the time took in examination and when to speed things up.
Cortisol level invariably will be much elevated during the exam. There is no easy way to alleviate this stress, except learn to control your mind. Take every exams as your day-to-day practice. Learn to overcome your fears. Tell yourself that you are prepared for every circumstances and you are going to impress the examiners today with what you know. That's why during the waiting time prior to exams, it's not advisable to cram in anymore new information. Breathing exercise helps to maintain the inner peace.
If the particular station not turned out as you would have expected, or you did exceptionally well until you think you have nailed it, please put that aside and let's not carry any emotions to the next station. As each stations is individually marked by 8 different examiners, no one will know how you perform the station before. The moment is now. Each case is a new challenge to take.
Finally, enjoy every moment. You had come this far. You have done whatever you could. Put aside toughts such as ''I should have' or 'given more time'. Think of the journey, not the destination, just yet.
Hope you will benefit from my sharing. Please do comment if you have any questions.
Format of Short Cases
First of all, the exam will test on four major systems, namely cardiology, respiratory, abdomen and neurology stations. The minor area such as rheumatology or dermatology will not be tested individually, but they can appears as part of a major stations and candidates are expected not to missed it.
Timing for each station is 20 minutes. Ten minutes for the examinations and the rest of the time is for the presentation and discussion. There is no rest time in between stations and you are expected to start the next stations immediately as the bell rings.
Upon approaching the case, you will be greeted by the examiners. There will be two examiners per station. Sometimes there will be an observer too. Among the examiner, there will be one person that dominate the discussion. They will ask you to read the print-out instruction and you will decide your approach to the case. At times, they can hint you that you are starting to derail. Do take those hints seriously.
After you have completed the examinations, the presentation and discussion of the case happens by the bed side. After the bell rings, you move on to the next station.
Preparation for Short Case
The key to excel in short case is to practice more. The examination technique has to have finesse in it. The steps is systematic. There is no going back and forth. Most importantly, both you and your patients are comfortable with the examination. There is no room for mistakes such as causing pain to the patient.
You are expected to present the case as if you have done it thousand times. Points are laid out systematically. The content of presentation should be succinct without too much words. The relevant positive and negatives are put up first. Skim on non relevant points. Differential diagnosis should be mature and reflect your readiness as physician. Discussions are logical and reflects your wealth of knowledge about the disease.
The only way to reach this level is to practice more. Practice to present to your colleague, to your lecturer, to your spouse, to the mirror. Don't be afraid to make mistakes as they are the only way we can improve ourselves. Listen to how you present by recording your own words. If the presentation does not appeal to you, most likely it will not to the examiners as well.
Participate in local PACES preparatory courses will help you tremendously. Not only it gives you a similar feel of the exams, you get the chances to practice on very good short cases that is hard to come by.
Practice whenever you have the opportunity. Be it a case during your oncall, during clinic sessions, during rounds, during evening sparing with friends. As the technique is a very personal thing and you will develop your own style in examination. Try to examine in full sequence if the time allows. A tip from my teacher is to practice short case examination during on call time. You will be doing the case under stress of fatigue and time constraints, So you will polish your subconscious mind on examination. Don't worry is you are doing simplified examinations; as long as you constantly try to remind yourself that you are skipping this steps and that maneuver. This is to make sure that old habits does not appear during exams.
As of the script of presentations, there are many textbooks that can be a good guidance. If you like systematic way of presentation, you can go with Oxford Specialty Training series. If you like a more abbreviated presentations, Ryders would be your options. Read Jansen Koh for a good foundations in the short cases as the author lay out almost all type of cases in an organized manner, which is easy to remember. My take would be to read Jansen Koh then follow with either Ryders or OST. Get the foundation right then polish the individual scenarios so you are prepared in every type of case.
D-Day
Time management is very crucial. Often the only clock you can depend on is your inner body clock. If the examiner allows, you can request to bring along a stop watch. This is to gauge the time took in examination and when to speed things up.
Cortisol level invariably will be much elevated during the exam. There is no easy way to alleviate this stress, except learn to control your mind. Take every exams as your day-to-day practice. Learn to overcome your fears. Tell yourself that you are prepared for every circumstances and you are going to impress the examiners today with what you know. That's why during the waiting time prior to exams, it's not advisable to cram in anymore new information. Breathing exercise helps to maintain the inner peace.
If the particular station not turned out as you would have expected, or you did exceptionally well until you think you have nailed it, please put that aside and let's not carry any emotions to the next station. As each stations is individually marked by 8 different examiners, no one will know how you perform the station before. The moment is now. Each case is a new challenge to take.
Finally, enjoy every moment. You had come this far. You have done whatever you could. Put aside toughts such as ''I should have' or 'given more time'. Think of the journey, not the destination, just yet.
Hope you will benefit from my sharing. Please do comment if you have any questions.
Tuesday, June 2, 2015
How to Excel in MMed Part II Long Case
Master of Medicine part II is honestly a very tough exam. What intrigues me is the absolute lag of guides in part II exams for long case. There were no books or tips and tricks to tackle this exam. This triggers me to share my experience and my personal tips to prepare for the long case and how to handle it during real exam settings. A word of advice though: as this is a personal experience sharing, do take it with a pinch of salt as some advice may not be suitable for you. Feel free to post questions or any comments.
Long Case Exam Structure
Long case constitute a quarter (25%) of the total mark (theory + clinical). As you may have known, it is crucial to pass the long case to be considered as passing the part II exam. The minimal passing mark is 45%.
As this is a exit exam, you are expected to perform like a specialist in terms of your presentation skills. The thinking process has to be mature and a sound plan is expected from you. You need to be analytical in your though process. The cases included in the examination is usually a long and complicated management issue. Examples like long-standing diabetes with target organ damage, issues with adherence and hypoglycaemia, hypertension and disability at work caused by his poor eyesight due to PDR. Otherwise, you may get a case with diagnostic problem like rare combo disorders such as MEN 2a, Miller Fisher variant. Most often its a mixture of both diagnostic and management problems.
You will be given 1 hour with the patient. History taking, clinical examination, analysis of the case and formulation of a sound plan is expected during this one hour. There will be a 10 minutes gap to gather your thoughts and organizing your words. This is followed by 30 minutes of discussion with 2 examiners. During this time, you are expected to present your case and the examiners may bring you to the patient to elicit some signs. Then the discussion moves on to the management of patient.
Truth be told, time flies during the exam. I will share on how to approach and divide your timing during the exam in the following section.
Before The Exam: How To Prepare?
There is no standard textbook. I guess this is due to the vast diversity of cases that may occur in exam. However, there is always a pattern to be spotted. There are main diseases in each subspecialty that need to be covered before going for the exam. Examples are diabetes mellitus and its complications, SLE, HIV etc. One need to prepare for the diagnosis and its differentials, investigation and a sound plan for the patient. The book I used was "Mastering the Medical Long case 2e" by S Rohan.
The first examples history as its selling point. Technically it is not wrong, but it feels like the candidate did not put effort to analyze the case. The latter example puts a reasonable differential up front and followed with the supporting history. This is the preferred way to sell your case as it exhibit maturity and confidence.
Do not skimp on the detail. You will be surprised the amount of information they (the examiners) has in their answer script. As the script is based on not only clerking, but also the investigation and intervention done on the patient, it is crucial to get as much details as possible. It's rather embarrassing for the moment of silent when they try to extract the information that you don't have and trying to confabulate doesn't help as well. One useful tip is try to get the detail picture of admission or visit of patient into the examination hospital. Usually the detail of admission to the respective hospital will be most detailed and will be asked the most.
Examination of the patient should be done in systematic manner and prioritize the systems that the patient complains. Do not forget the vital signs, urine dipstick, body weight and blood glucose if relevant. As the examiner may ask you to demonstrate the finding later, make sure get the relevant positive and negative signs ready.
The last part of the preparation is the summary of case, construct your long case into a logical and interesting case. You may want to go back to the main history and add on any missed points. More importantly you need to construct differential diagnosis, investigations and formulate a plan for the patient. After all is done, take time to construct the opening statement.
Opening statement is a powerful and catchy phrase that contains all the crucial points of your case, yet not too lengthy. If it is too short, it will not give the examiner a whole picture of the case. If it is too lengthy, it will bore down the examiners. Starting with a weak opening statement will cost you dearly in the exam. To make the matter worse, there is no standardized way to make a good opening statement. Let me show you an example.
Ms Janet, is a 36 years old clerk from Puchong with diagnostic and management issues of SLE complicated with lupus nephritis now in end-stage renal disease. Other inactive problems such as exogenous Cushing's syndrome secondary to prednisolone and osteoporosis. She is also having depression and in financial constraints.
From the examples above, it gave the examiners a snippet of the case of SLE complicated with ESRD due to lupus nephritis. She is also depressed and having financial difficulties. Putting in a social issues makes you look holistic and concerns about patient psychosocial aspects. Always identify 1-2 of the most important part to include in the opening statement and in the clerking later.
Put Up A Good Show
After the bell rang, you have approximately 10 minutes till the examiners call you in. Use the time to rehearse your case, especially the opening statement. Try to picture it like a movie and see the flow of the history. You are given 30 minutes. Present like a salesman, convince the examiners to buy your story. Eye contact is very important. There will be 2 examiners and try to give them both equal attentions. They may stop you intermittently to clarify your case.
If they are satisfied with your case, they will bring you to bedside to demonstrate the findings.
Next part of the discussion is about investigation and management. Time is scarce and investigation must be focused to the case. There may be a scan or radiograph that need you to interpret.
The tip is to be calm and engaging to the examiners. The examiners can feel your knowledge and understanding of the case by looking at your non-verbal cues. In no time at all, the examination will be over. If you did badly, try not to carry forward any feelings ito the next section as you may still have a chance to redeem yourself.
Long Case Exam Structure
Long case constitute a quarter (25%) of the total mark (theory + clinical). As you may have known, it is crucial to pass the long case to be considered as passing the part II exam. The minimal passing mark is 45%.
As this is a exit exam, you are expected to perform like a specialist in terms of your presentation skills. The thinking process has to be mature and a sound plan is expected from you. You need to be analytical in your though process. The cases included in the examination is usually a long and complicated management issue. Examples like long-standing diabetes with target organ damage, issues with adherence and hypoglycaemia, hypertension and disability at work caused by his poor eyesight due to PDR. Otherwise, you may get a case with diagnostic problem like rare combo disorders such as MEN 2a, Miller Fisher variant. Most often its a mixture of both diagnostic and management problems.
You will be given 1 hour with the patient. History taking, clinical examination, analysis of the case and formulation of a sound plan is expected during this one hour. There will be a 10 minutes gap to gather your thoughts and organizing your words. This is followed by 30 minutes of discussion with 2 examiners. During this time, you are expected to present your case and the examiners may bring you to the patient to elicit some signs. Then the discussion moves on to the management of patient.
Truth be told, time flies during the exam. I will share on how to approach and divide your timing during the exam in the following section.
Before The Exam: How To Prepare?
There is no standard textbook. I guess this is due to the vast diversity of cases that may occur in exam. However, there is always a pattern to be spotted. There are main diseases in each subspecialty that need to be covered before going for the exam. Examples are diabetes mellitus and its complications, SLE, HIV etc. One need to prepare for the diagnosis and its differentials, investigation and a sound plan for the patient. The book I used was "Mastering the Medical Long case 2e" by S Rohan.
Apart from the clinical aspect, one need to go in depth with patient's social issues. How does the patient cope with the disease, and who provides support for the patients? Assessment of a person's functional status gives an overview to the implication of disease to the patient. The idea is to see patients as a whole and practice holistic approach.
Try to practice long case as if you are taking the exam the next minute. Limit yourself to 1 hour. Divide the timing into 3 blocks of 20 minutes each. First 20 mins is crucial to get the targeted history and the presenting complaint in depth. Relevant past history should be obtained. The next block is the physical examination. Do a relevant systemic examination according to history. You can still ask the patient and clarify any doubts. Lastly which is most important is to organized the thought and prepare your opening statement. If the history is longer than anticipated, you can change the block into 30 minutes of history, 10 minutes of examination and 20 minutes of structuring your case. In short, non of the component can be neglected, especially the last component.
During The Exam
Patient, to me, is the most important factor. You need to establish rapport as soon as possible with the patient. Convinced them this is a professional exam and no information shall be withheld and to put forward the medication list up front. This is to avoid unnecessary surprises towards the end of clerking. If there is a surrogate around, try to involve them as well.
Leave the opening statement to the last. You need to gain as much picture into the case, then only you can come out with a good summary.
For the history segment, try to write each issues in separate pages. Pay as much attentions to the chief complaints, as this is most likely to be scrutinized during the presentation. Try to move away of presenting symptoms, instead analyze the collection of symptoms and give a reasonable differentials. Examples:
a. "Mr Jude presented with 3 weeks history of shortness of breath especially on exposure on dust. Symptoms worsen during working days and wane during off days."
b. "Mr Jude has symptoms suggestive of occupational asthma as evidenced by worsening shortness of breath at work and better during off days"
During The Exam
Patient, to me, is the most important factor. You need to establish rapport as soon as possible with the patient. Convinced them this is a professional exam and no information shall be withheld and to put forward the medication list up front. This is to avoid unnecessary surprises towards the end of clerking. If there is a surrogate around, try to involve them as well.
Leave the opening statement to the last. You need to gain as much picture into the case, then only you can come out with a good summary.
For the history segment, try to write each issues in separate pages. Pay as much attentions to the chief complaints, as this is most likely to be scrutinized during the presentation. Try to move away of presenting symptoms, instead analyze the collection of symptoms and give a reasonable differentials. Examples:
a. "Mr Jude presented with 3 weeks history of shortness of breath especially on exposure on dust. Symptoms worsen during working days and wane during off days."
b. "Mr Jude has symptoms suggestive of occupational asthma as evidenced by worsening shortness of breath at work and better during off days"
The first examples history as its selling point. Technically it is not wrong, but it feels like the candidate did not put effort to analyze the case. The latter example puts a reasonable differential up front and followed with the supporting history. This is the preferred way to sell your case as it exhibit maturity and confidence.
Do not skimp on the detail. You will be surprised the amount of information they (the examiners) has in their answer script. As the script is based on not only clerking, but also the investigation and intervention done on the patient, it is crucial to get as much details as possible. It's rather embarrassing for the moment of silent when they try to extract the information that you don't have and trying to confabulate doesn't help as well. One useful tip is try to get the detail picture of admission or visit of patient into the examination hospital. Usually the detail of admission to the respective hospital will be most detailed and will be asked the most.
Examination of the patient should be done in systematic manner and prioritize the systems that the patient complains. Do not forget the vital signs, urine dipstick, body weight and blood glucose if relevant. As the examiner may ask you to demonstrate the finding later, make sure get the relevant positive and negative signs ready.
The last part of the preparation is the summary of case, construct your long case into a logical and interesting case. You may want to go back to the main history and add on any missed points. More importantly you need to construct differential diagnosis, investigations and formulate a plan for the patient. After all is done, take time to construct the opening statement.
Opening statement is a powerful and catchy phrase that contains all the crucial points of your case, yet not too lengthy. If it is too short, it will not give the examiner a whole picture of the case. If it is too lengthy, it will bore down the examiners. Starting with a weak opening statement will cost you dearly in the exam. To make the matter worse, there is no standardized way to make a good opening statement. Let me show you an example.
Ms Janet, is a 36 years old clerk from Puchong with diagnostic and management issues of SLE complicated with lupus nephritis now in end-stage renal disease. Other inactive problems such as exogenous Cushing's syndrome secondary to prednisolone and osteoporosis. She is also having depression and in financial constraints.
From the examples above, it gave the examiners a snippet of the case of SLE complicated with ESRD due to lupus nephritis. She is also depressed and having financial difficulties. Putting in a social issues makes you look holistic and concerns about patient psychosocial aspects. Always identify 1-2 of the most important part to include in the opening statement and in the clerking later.
Put Up A Good Show
After the bell rang, you have approximately 10 minutes till the examiners call you in. Use the time to rehearse your case, especially the opening statement. Try to picture it like a movie and see the flow of the history. You are given 30 minutes. Present like a salesman, convince the examiners to buy your story. Eye contact is very important. There will be 2 examiners and try to give them both equal attentions. They may stop you intermittently to clarify your case.
If they are satisfied with your case, they will bring you to bedside to demonstrate the findings.
Next part of the discussion is about investigation and management. Time is scarce and investigation must be focused to the case. There may be a scan or radiograph that need you to interpret.
The tip is to be calm and engaging to the examiners. The examiners can feel your knowledge and understanding of the case by looking at your non-verbal cues. In no time at all, the examination will be over. If you did badly, try not to carry forward any feelings ito the next section as you may still have a chance to redeem yourself.
Thursday, April 23, 2015
Lift a Finger
The one in front is the hero. She takes all the lime light. The "unsung hero" is my mom in the grey shirt in the back ground providing emotional support for the aborigine who suffered a great loss in the flood.
In normal day life, everyone can be a hero. You just need to see inside yourself. Find the heart to love. Love the people around you. Pity those unfortunates. Help the one in needs. Help a visually impaired cross a road, put food for the less fortunate, take care of stray dogs. A small step goes a long way to make this world a better place.
Sunday, June 2, 2013
Etiquette of Attending Chinese Wedding
I met a colleague of mine, who happens to be a Malay in a function lately. It was a Chinese wedding dinner in one of a nice hotel ballroom. We had a little chat and it turned out that it was the first time he attends a Chinese wedding dinner. So I shared with him the following:
1. Be serious about RSVP. Think about whether you really can attend the function. Once a invitation card is out, the host automatically assumes that you are coming and expect a little red packet. By any chance that you can't make it to the dinner, you still have to send in a representative or substitute with ang pow. In the recent wedding that I attended, there were many seats vacant. It is a disrespect both to the host and the function.
2. Be absolute about number of people attending. Chinese wedding dinner are usually 8-course meal with prefixed number of seats. If you are expected to be there alone, you better be there alone; any extras will be relocated to the next vacant seats. So you may be seated seperately with your partner, which is not a very nice thing to be. Usually there will be reserved tables as well but if it is not more than half full, the host may not open up the table.
3. The gift. Unless your present is a wearable bling-bling object with some weight, I suggest that giving ang pow is a better option. Firstly, the couple may have trouble bringing around your presents after the wedding and secondly, the things given may serve no use. At least, ang pow helps the couple to some extend to cover the expenses during the wedding process. Chinese wedding has become a very expensive affair of late.
4. The ang pow. It is not a donation, certainly not a token. There is absolute math in deciding the amount of the ang pow. Given too small a sum, you will be remembered as the stingy one; given too much, unless you are filthy rich. So how much to give? The best answer is to Google the average cost for a dinner in that particular restaurant or hotel. If not, give a call personally to the hotel to inquire about the price of a wedding dinner set.
5. Be reasonable drinker. Free flow of liquor is served sometimes during a Chinese wedding dinner. Just because it's free, you don't have to drink yourself till drunk and make you a total embarrassment. I had seen too many mediocre people that disrupts the flow of the wedding because of the ethanol toxicity. Some host actually refrains from serving alcohols because of this reason.
Having said all this, a Chinese wedding is a merry and loud place to be, especially the toast. I am sure you would have lots of fun.
Cheers.
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1. Be serious about RSVP. Think about whether you really can attend the function. Once a invitation card is out, the host automatically assumes that you are coming and expect a little red packet. By any chance that you can't make it to the dinner, you still have to send in a representative or substitute with ang pow. In the recent wedding that I attended, there were many seats vacant. It is a disrespect both to the host and the function.
2. Be absolute about number of people attending. Chinese wedding dinner are usually 8-course meal with prefixed number of seats. If you are expected to be there alone, you better be there alone; any extras will be relocated to the next vacant seats. So you may be seated seperately with your partner, which is not a very nice thing to be. Usually there will be reserved tables as well but if it is not more than half full, the host may not open up the table.
3. The gift. Unless your present is a wearable bling-bling object with some weight, I suggest that giving ang pow is a better option. Firstly, the couple may have trouble bringing around your presents after the wedding and secondly, the things given may serve no use. At least, ang pow helps the couple to some extend to cover the expenses during the wedding process. Chinese wedding has become a very expensive affair of late.
4. The ang pow. It is not a donation, certainly not a token. There is absolute math in deciding the amount of the ang pow. Given too small a sum, you will be remembered as the stingy one; given too much, unless you are filthy rich. So how much to give? The best answer is to Google the average cost for a dinner in that particular restaurant or hotel. If not, give a call personally to the hotel to inquire about the price of a wedding dinner set.
5. Be reasonable drinker. Free flow of liquor is served sometimes during a Chinese wedding dinner. Just because it's free, you don't have to drink yourself till drunk and make you a total embarrassment. I had seen too many mediocre people that disrupts the flow of the wedding because of the ethanol toxicity. Some host actually refrains from serving alcohols because of this reason.
Having said all this, a Chinese wedding is a merry and loud place to be, especially the toast. I am sure you would have lots of fun.
Cheers.
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Saturday, May 25, 2013
Pain in the Nether Region
Lately, I had encountered a difficult person. She had a few medical conditions, but worst of all, she had manic depressions. My first encounter with her was back in February. She was admitted for a lung condition which needs anticoagulation therapy. However, she refuses to go home when the therapy was initiated and going on well. Everyday, she would follow us for ward rounds, interferes with our ward discussion. She come with many little complaints. Finally, after 3 weeks or so, she was discharged back home.
She had a complicated history, due to her illness, her husband left her for another woman, and the disease manifest itself, like a vicious cycle. She had been to many private centres. All with the similar complaints of short of breath. She did CT coronary angiogram that was normal but found and incidental pulmonary embolism. Then she was referred to us for further treatment.
Due to her psychiatric condition, not many people can tolerate her. She was even being scolded by a renown private cardiologist for her persistent complaints, saying that she is a pain in the nether region and she is going to die with her illness!
I saw her again in clinic last week.
She was with her usual flowery and bright dress. I thought trouble came back knocking on the door again. The first few minutes of consultation, I was half hoping that she didn't dwell into the old problems. I let her talk. She went on with her family problems, how her disease actually concerns her. She had been compliant to the treatments and her INR was within target range. I praised her for her effort. I didn't interrupt her and I let her ventilate. She went on and on. After 15 minutes I came to a conclusion, set her targets and set an appointment date for her.
It seems to go on very well this time.
The morale of the story is, we can't cure a disease all the time. Nor we can solve the family matters, the financial woes and issues around. We can listen. Hear the problem out. Take some time to let them ventilate. Give a reassurance nod from time to time. Be patience. The answer to the their problem often lies within them.
Cheers.
She had a complicated history, due to her illness, her husband left her for another woman, and the disease manifest itself, like a vicious cycle. She had been to many private centres. All with the similar complaints of short of breath. She did CT coronary angiogram that was normal but found and incidental pulmonary embolism. Then she was referred to us for further treatment.
Due to her psychiatric condition, not many people can tolerate her. She was even being scolded by a renown private cardiologist for her persistent complaints, saying that she is a pain in the nether region and she is going to die with her illness!
I saw her again in clinic last week.
She was with her usual flowery and bright dress. I thought trouble came back knocking on the door again. The first few minutes of consultation, I was half hoping that she didn't dwell into the old problems. I let her talk. She went on with her family problems, how her disease actually concerns her. She had been compliant to the treatments and her INR was within target range. I praised her for her effort. I didn't interrupt her and I let her ventilate. She went on and on. After 15 minutes I came to a conclusion, set her targets and set an appointment date for her.
It seems to go on very well this time.
The morale of the story is, we can't cure a disease all the time. Nor we can solve the family matters, the financial woes and issues around. We can listen. Hear the problem out. Take some time to let them ventilate. Give a reassurance nod from time to time. Be patience. The answer to the their problem often lies within them.
Cheers.
Saturday, September 29, 2012
Happiness, Found!
 |
| You are my sun |
Nothing can hide my elated mood. Nothing can put away the smile on my face. Absolutely nothing can make me feel less of you, every single day.
Before this, I always have hesitations. Second thoughts. What-ifs. Buts. Negative in everything I do. Skeptical about our future. Now things have changed. After I have your hand that day, things are different now.
I am more positive. Felt everything is possible. Give my very best in everything. Felt like protecting you every moment. Love just about everything about you; your freckle on the right cheek, the naevus on the right nose. The way you hum your little tunes when you talk. Everything felt so right. Even our hand felt so apt together.
This is the power of love. And it strengthen the bond between us. So strong...
Wednesday, August 29, 2012
眼泪与累
最近一直被一些事打扰，做事也不起劲，凡事都欠东风。也许是筹备过程中遇上了不少坎坷路，也许是在适应新生活，况且身在远方的我无法控制局面，让不愉快的事发生了。偶尔在夜深人静的时候就会开始胡思乱想。
所有爱情，都要到开花结果的阶段吗？ 一定要共度一生吗？一定要白头到老吗？会不会厮守一生吗？偶尔勉强带来很多不愉快的事，更糟的是，把两个人给疏远了。到头来，忘了要的是什么，渴望什么，追求什么，恨什么！
两个人要一生相守，不止在于你和我，还有很多新旧成员，有父母，兄弟，舅弟，公公婆婆，姨妈姑姐，还有他的狗。怎能只有我和你？如果往好的方面去想，家庭成员大了，凡事都有人关照；往坏的方面去想呢，就会觉得多人来烦，打扰私生活。
想到这里，一声叹气。眼泪也开始流下。了解不代表看开，爱情不是一切。有时吵架，心情低落，身心疲惫。一个字，累！
爱情不可以容纳后悔， 若有一丝的悔意，就会带来麻烦。
可是。。。
所有爱情，都要到开花结果的阶段吗？ 一定要共度一生吗？一定要白头到老吗？会不会厮守一生吗？偶尔勉强带来很多不愉快的事，更糟的是，把两个人给疏远了。到头来，忘了要的是什么，渴望什么，追求什么，恨什么！
两个人要一生相守，不止在于你和我，还有很多新旧成员，有父母，兄弟，舅弟，公公婆婆，姨妈姑姐，还有他的狗。怎能只有我和你？如果往好的方面去想，家庭成员大了，凡事都有人关照；往坏的方面去想呢，就会觉得多人来烦，打扰私生活。
想到这里，一声叹气。眼泪也开始流下。了解不代表看开，爱情不是一切。有时吵架，心情低落，身心疲惫。一个字，累！
爱情不可以容纳后悔， 若有一丝的悔意，就会带来麻烦。
可是。。。
Sunday, August 19, 2012
There's No Monkey Business Here
Today my consultant taught me a very important lesson, especially for the young doctors like me. It struck me like a thunder. seriously.
My wards have been a dumping zone, nursing home, shelters for some and house for some permanent residents. One of them is a very old Chinese man, very unkempt, bed ridden for 3 months and came with multiple bed sores, dehydration and pneumonia. The relatives called an ambulance to pick up this man and since then, passed the responsibility to us to take care for the rest of their parent life. Since that day of admission, we never see any relatives, nor any number to contact. This old man remains gaga. Another man is young and fit man, unfortunately get involved with drug early in his life. He is unemployed, staying with a drug lord in Chow Kit and runs errants for him. In return, he gets his high. Recently, he had a row with the Boss, and he is left on the street. Left with no food or clothes, he had to fake his signs and request for admission. Lastly, there is another middle age man, active smoker and heroin chaser, had burned holes through his lung. He needs long term oxygen, yet reluctant to give up his cigarettes and old habits. A little bit of cough will straight away bring him to the hospital and the admission unit is always kindly enough to put him to our ward. He will be admitted at least 3 times a week, and scowled at us if we discharge him.
It has been a serious headache for me and my other colleagues. Our registrar is under constant pressure to reduce these unnecessary workloads.
On the contrary, my consultant is exhibiting la belle indifference towards this matter. He just nod when we shoved him with loads of our complaints. If the man do not want to go home, keep him for another day. We were puzzled at first, but today he shared with us a story.
He is used to be a very proactive, eager, hot head doctors once upon a time. He always upright the juctice, not allowing any wrong, no allowance for these hanky panky stuffs. One fine day, he received a call from his son's headmaster, asking permission to meet him in person. His son was in primary five in a nearby Chinese school. On a separate occasion, his wife received another phone call from their son's form teacher, asking to meet in another time. Puzzled with this events, they decided to turn up together to meet up the headmaster. The headmaster was shocked initially, seeing both of them turn up together. He explains that the reason for meeting them in different time is because they thought there were family issues between both parents, i.e a divorce. The headmasters proceed to inform them that their son, who was a top scholar, drastically deteriorates in terms of school performance lately. My consultant was taken aback, when the headmaster ask for how long they haven't check on their son's school work and academics. The son was so into the video games that makes him neglect his school. All these time spent up holding the rights, making sure the ward runs in order and all other stuffs had cause a toll on his family. Since then, he had taken a step back. Prioritized the important things in life and learned to put family first.
That little story suddenly give me an insight. Learn to prioritize.
Sunday, August 12, 2012
Chong Choon Cafe: 'THE' Famous Laksa Sarawak
My fiance has a very odd tummy. Whenever in Semenanjung, she can eat anything, from meat to soup, nothing goes amiss. When we were in Kuching, her tummy can't tolerate any type of food. She gets diarrhoea whenever she eats any local delicacies, while I am fine. Weird, ehh?
Despite the diarrhoea, we brace ourselves to the famous shop, the Chong Choon Cafe, which is on the right side on Abell Road. Sometimes it is hard to locate this shop as it has the nondescript and so-small-till-its-hard-to-read signboard. Just look for the car that double park on the street, you will find it.
Layout of the cafe is pretty simple. There are 4 food stalls, but 99.9% of the customers orders the laksa. Laksa is a rice vermicelli in soury prawn curry broth serve with fresh bean sprout, Chicken slices, prawns and coriander. Honestly, I find it taste the best here compares to most other stalls that do the same dish. The prawns are of XL size. The noodle is tad bit soft, but the broth is tangy and fragrant. Can't describe more, you have to taste it!
However, the popiah and yam cake that we ordered is a straight no-no. The composition of the materials is substandard and the wrapping easily falls apart. The yam cake flaws in the lack of yam. Definitely not our taste. Not to order if you are not on prolonged starving.
After food, she had diarrhoea again. (Not due to this stall as the matter of fact, probably she has stomach upset earlier)
Despite the diarrhoea, we brace ourselves to the famous shop, the Chong Choon Cafe, which is on the right side on Abell Road. Sometimes it is hard to locate this shop as it has the nondescript and so-small-till-its-hard-to-read signboard. Just look for the car that double park on the street, you will find it.
Layout of the cafe is pretty simple. There are 4 food stalls, but 99.9% of the customers orders the laksa. Laksa is a rice vermicelli in soury prawn curry broth serve with fresh bean sprout, Chicken slices, prawns and coriander. Honestly, I find it taste the best here compares to most other stalls that do the same dish. The prawns are of XL size. The noodle is tad bit soft, but the broth is tangy and fragrant. Can't describe more, you have to taste it!
However, the popiah and yam cake that we ordered is a straight no-no. The composition of the materials is substandard and the wrapping easily falls apart. The yam cake flaws in the lack of yam. Definitely not our taste. Not to order if you are not on prolonged starving.
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| Popiah and yam cake - yucks |
 | ||||
| Laksa Sarawak - The best of it's kind |
After food, she had diarrhoea again. (Not due to this stall as the matter of fact, probably she has stomach upset earlier)
Saturday, August 11, 2012
Pu Tien: Chic but Not Cheap
After all the hype and a nagging fiancé that wants to eat at this eatery, we went there straight after touching down from Kuching. This is the first store locate in Malaysia, and found in 1 Utama (ground floor Promenade, or the old wing). The entrance to the store is rather obscure, but they have friendly staff to guide you. It's Saturday and it is packed to the brim. Menu is nice and clear and price are all written down. Service is fast. But the downside is, as with all Chinese restaurant, it is noisy and we can hardly have a decent conversation without having to resort to shouting.
Food: Presentation is good. Taste is excellent, however tends to be on the oily side. Portion is small too. If you are a big eater, better upgrade to big size or more dishes.
Prices: Steep. A simple vegetable can go up to 20 ringgit and a cup of Chinese tea costs a whopping 7.90
Service: Good staff. Very swift service. Food served within 10 minutes
Summary: does every penny well spent? I would beg to differ. However, the indulgence once in a while should bring no harm. It's a great place to start if you want to taste Heng Hua cookings.
Food: Presentation is good. Taste is excellent, however tends to be on the oily side. Portion is small too. If you are a big eater, better upgrade to big size or more dishes.
Prices: Steep. A simple vegetable can go up to 20 ringgit and a cup of Chinese tea costs a whopping 7.90
Service: Good staff. Very swift service. Food served within 10 minutes
Summary: does every penny well spent? I would beg to differ. However, the indulgence once in a while should bring no harm. It's a great place to start if you want to taste Heng Hua cookings.
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| A very hearty soup |
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| Fried oyster with eggs |
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| Slice bitter gourd with honey sauce- a must-try appetizer |
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| Chinese tea serves in a cup |
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| Chicken meat cooked in red sauce, very good! |
Tuesday, August 7, 2012
Make It Count
In measuring a person's life, how old is old? How young is young? When is the ripe old age? When is dying young?
The irony is Death pays us a visit at any time. There is no fixed schedule. You may have plans in life but the ultimate plan is seldom revealed.
If I die young, I would wish that I lived. Every single day is a rich and meaningful day. Every day has a purpose. I wouldn't want to fret on the past, or worry about the future. I would enjoy my present moment.
I would thank my parent, and return their good deed of raising me. I would tell my loved one how much I loved her, and I would tell my kids to live their life without regrets. I would ring up my friends and ask them how they are. Alas! There are so much things to do when you live.
If you know Death comes anytime, appreciate your life now. Make it count. Make a present. Make it meaningful. Make it rich. Make it worthwhile. Make it the fullest you can be.
The irony is Death pays us a visit at any time. There is no fixed schedule. You may have plans in life but the ultimate plan is seldom revealed.
If I die young, I would wish that I lived. Every single day is a rich and meaningful day. Every day has a purpose. I wouldn't want to fret on the past, or worry about the future. I would enjoy my present moment.
I would thank my parent, and return their good deed of raising me. I would tell my loved one how much I loved her, and I would tell my kids to live their life without regrets. I would ring up my friends and ask them how they are. Alas! There are so much things to do when you live.
If you know Death comes anytime, appreciate your life now. Make it count. Make a present. Make it meaningful. Make it rich. Make it worthwhile. Make it the fullest you can be.
Thursday, July 12, 2012
Presint 2, Putrajaya
Since I moved down to Kuala Lumpur, I had chance to do the things that I always wanted to do. Photography is one of that 'thing' I consider as my passion. Initially I wanted to go to the wetlands, but having multiple turns and rounds, I still can't get to the opposite side of the road. The road in Putrajaya was made in such a way that a wrong turn will take you another 5 km to turn back, which is all the hassle. Drawn by the height of this bridge, I drove towards it instead.
From far, it looks like a yacht. From near, it looks awesome. This is one of the structural marvel that should be seen in real life. Many, including me, had make this bridge as their wedding photo shooting scene. Not unsurprising, as the lines drawn are very sharp and geometry wise it is in its harmony.Simply beautiful.
From far, it looks like a yacht. From near, it looks awesome. This is one of the structural marvel that should be seen in real life. Many, including me, had make this bridge as their wedding photo shooting scene. Not unsurprising, as the lines drawn are very sharp and geometry wise it is in its harmony.Simply beautiful.
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| The complex network of wires and frames |
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| Parallel lines |
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| Sky curtain |
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| The thick pillar |
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| Twisting of the lines |
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| Butterfly |
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| Geometry is simply brilliant! |
Tuesday, July 10, 2012
Last Moments of A Bachelor's Life
I guess a man always want to feel belonged. After having a stable career, he wants a family, a wife to journey the life, couple of children to share the joy, a house to live in and a group of good friends. He can't wait to start the family and get married. But I guess, human are always confused. He will have mixed feelings. On the verge of marriage, he will think of all the responsibility that is going to fall on his shoulders. Is this the right decision? I mean, what can a person lose when getting married? My married friend told me, you loose a lot. Gone were the days of partying till the wee hours in the morning, hanging out with friends, traveling alone to odd places, talking simply about everything: who is the new 'chic' pharmacist, who is going to win the election or what is the best condom brand. Welcome to the real world. Now who is going to wake up to attend to the baby cry? Who is going to change his diaper, feed him milk? All the talks centered around the best formula milk, the most ergonomic stroller, and the nursery that abuse their kids.
It sounds like nightmare, isn't it? I feel scared sometimes.
My friend also told me, you will gain a lot. You'll have a life partner, to share the joy when you are up in the sky, and to comfort you when you're down on your knees. Behind every success man, there is always an even more capable woman to support him, to buffer him and most of all, to love him. There will never be a dull moment in your life. When the right time comes, and you are blessed with your first born, that joy is indescribable. It felt like your life is complete. If gives you a reason to come home after work, to quickly put aside your work and start your life. It puts a smile on your face that worth a million dollar. Though there are hard times, sleepless nights, seeing him grow up is the best thing you can hope for.
Now, I am not scared anymore.
Sunday, June 24, 2012
The Painted Window
I was on a walking tour in Ho Chi Minh City. There was this very tall pair of stipples standing in the park of the town. Out of curiousity, I entered the church. I discovered this pair of painted glass on the side wall.
It tells a story. I do not know what the story is about, but I believe during war times, people seek refugee in this church. When the world is full of chaos out there, this place will bring them some peace and shelters. Many had carved words onto the walls, saying their prayers.
We live in a world of chaos, where brothers and sisters fights; the society fights; the government fights; and the nation fights! On the other hand, some had inner war, where there are conflicts of thoughts. All these will bring to unhappiness to us.
Hope you finds your inner peace tonight.
Saturday, June 23, 2012
夜深人静
又是失眠夜，翻来覆去都无法入眠。一个人躺在双人床，总觉得缺少了一些。
感觉无比强烈，一份思念，一份爱恋和一份渴望，全都交接在一起。如何入眠？
时间和距离逐渐拉近，心和心就此零距离。希望遥远的她能够感应。
感觉无比强烈，一份思念，一份爱恋和一份渴望，全都交接在一起。如何入眠？
时间和距离逐渐拉近，心和心就此零距离。希望遥远的她能够感应。
Monday, June 18, 2012
The Days of The Blue Skies Are Gone
I had an exacerbation of asthma yesterday, not because I am a smoker, but all thanks to the recent haze. The friendly neighbour country began their yearly rituals of burning forest to make way for plantation. The results is the smoke that makes the road looks like in Genting highlands and the lungs congested. Despite many meeting and consensus made between our country and theirs, yet the old habit sticks. A month ago it was a beautiful sky in KL, but now its just haze.
I wonder all the effects of open burning and forest clearing on the wildlife such as the Sumatran tigers and rhinos? Are they being barbequed as well?
Hopefully someone please remind them again that we are suffocating here because of their doing.
I wonder all the effects of open burning and forest clearing on the wildlife such as the Sumatran tigers and rhinos? Are they being barbequed as well?
Hopefully someone please remind them again that we are suffocating here because of their doing.
Sunday, June 10, 2012
Saving Every Cents in a Pre-Wedding Photography
Just had my pre wedding photoshoot done earlier. It was a huge relief. No doubt, a very exciting experience for both of us. Thanks to the professionalism of our photographer, the photoshoot was a breeze. However, the bridal shop will find ways to incur more charges to us, in a way or another. My fiance and I managed to keep it within the budget.
We had many great shots, booth indoor and outdoor. When the photographer ask us to select the shots to be included in the photo album, to choose 50 out of 300, it was a difficult task. Moreover, the friendly staff will try to interfere with the selection process by giving unnecessary opinions. The ultimate aim is to include more photos and the extra pages can really mount up to the exorbitant amount. some times 50% more than the original amount.
Budget are tight when we plan for marriage and money are well spend into other aspects. So how to avoid falling into the trap?
We had many great shots, booth indoor and outdoor. When the photographer ask us to select the shots to be included in the photo album, to choose 50 out of 300, it was a difficult task. Moreover, the friendly staff will try to interfere with the selection process by giving unnecessary opinions. The ultimate aim is to include more photos and the extra pages can really mount up to the exorbitant amount. some times 50% more than the original amount.
Budget are tight when we plan for marriage and money are well spend into other aspects. So how to avoid falling into the trap?
- Choose the package wisely. I have friends that is getting married and they took up the packages that mount up the the sky high charges. Sometimes, the more expensive things doesn't mean it is better. Same wise, Cheap will mean nothing if it is not up to standards. Try to shop around, asking their prices. Ask opinions from others about the shop. Read online forums and blogs about the bridal shops. Do some background research then only sign up.
- Bring your own. Things that are consumable like the make up requirement are usually chargeable. Alternatively, you can bring your own and ask the make up artist to use yours. Things like the ampoule for make up sells 10x more expensive than outside (RM 35 compare to RM 3). So bring your own to save more but always consult the make up artist regarding what they need for the day.
- Always ask for hidden charges. There are some cunning bridal shop that incurs extra charges for items like gown or suits. Always ask them up front. There are shops that charges extra RM 100 per dress for their so called 'designer piece'. Sometimes they will charge extra for going outdoor. Bringing makeup artist along also cost more. So, be wise! Plan your shooting and think how you want it to be to avoid these charges.
- Say no to extra. When me and my fiance were choosing the photos, the photographer kept on pestering us that this shots is nice and that pose is perfect and so called un'delete'able. Then they start to arrange for more photo books and more shots than what we had agreed upon. The extra shots cost a staggering RM 1500 more. When we almost succumb to the trap, luckily my fiance were alert enough to stay on track. We manage to exclude all the shots that are not what we had wanted, even though it was a good one. We rate the photos from 1 to 10. Most of the below par were excluded in the first round and finally we have the most precious 50 shots that is nothing but the best shots. You need to see what you want and what is needed. That simple.
Monday, May 28, 2012
If I Am Not A Doctor
If I Am Not A Doctor
If I am not a doctor,
My life would be free,
As I neither care for a stranger's life,
Nor about his itchy hives,
I wouldn't get needle prick,
Nor get prolonged cough and TB,
Nor jaundiced because of Hepatitis B,
Spending months in recovery.
If I am not a doctor,
I would be home by five,
Have dinner with my wife,
Spend time with my child
Missed the moments they grow up,
Missed their graduations,
While I am busy in OT,
Saving someone ailing heart.
If I am not a doctor,
I wouldn't have this heartache,
Of leaving everything behind,
And everything I loved.
Moving to another new places,
Meet strange people and new faces,
Only to find the city craze,
Nothing compares to my home,
My favorite place.
Sunday, April 22, 2012
Crawl...Walk...Fall...Walk Again
A baby learn to walk is no easy feat. It will start with a small steps, small and uneasy steps. The gait is waddling, the toes are in-curling. There will be numerous falls and bumps. Numerous bruises on forehead, scratches over limbs and endless cries. Given enough time and practice, small steps become big steps, uneasy become steady, then there is no more falling down, Walking become the second nature.
Isn't it the same with life? House officers learn from experience, numerous failures, many ups and downs, to become a safe doctor, and a better person?
New ruling created by the day to help these 'underpriviledged' group of people. First come the rule of house officers not allowed to follow in ambulance. Then came the shift work system to cut back the working time to 60 hours. Now there are hospitals that won't allow them to clerk case and examine patients! Looking at all these rules, it follows after certain events.
First, there were an incident of a house officer in Melaka Hospital involved in road traffic accidents while transporting patients. While we cannot predict the future, shit does happens to anyone. I witnessed a case of a staff nurse sustained a fracture of the radius bone while transporting a pregnant mother to general hospital for delivery because the new ambulance driver hit on a wild boar and the ambulance go turtle. Do we bar the nurses from sending patient? Certainly not! While I cannot say the ambulance is the safest ride home, even a fully registered doctors like us cannot prevent any untoward things to occur.
Then, house officers complaining of long working hours in the hospital. Hospital basically become the second home. There is no social life, love life or party life next to working. Then came the shift work implementations. Initially was full of glitches, but thing smoothed out in the end. The draw back is the oncall claims was with held. Then complaints starts again become there is not enough money to cover the car installment and side expenses, so another 600 bucks given on top of the shift work. What they didn't realized that without the adequate exposure, there is simply a disaster in the making. Not only more officers will be extended for the lack of skills and knowledge, they will be less equipped when sent to places that has no senior people to back up. The situation is similar in most of the government hospitals.
Are we doing them any good? Ask yourself, in years to come, will you want to go to any government doctors when you fall sick? If the answer is no, then please review the system again. For me, to be a great person, one have to fall many times, then when he stand up one day, he will be standing up tall. The scar is to mark how resilient you are, and prove to the world that you are not a weak doctor!
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