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.

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" 

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.

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.

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.

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! 

Rising of The Phoenix

I don't like to write about advice. In fact, I am poor at teaching people, guiding them. There are a handful of juniors under me that seems to have not benefited anything at all after they left from my department. I just like story-telling, narrating of the whole event, from the beginning to the end. 

I was sitting by the beach, eagerly waiting for the sunrise. It was a long time that I didn't find my 'inner peace'. Despite they said I am fortunate to live in this town that has beautiful beaches, scenic mountains, and a peaceful river carved the beauty of this small town, but I didn't see it. The sound of the waves hitting on the white sands attracts tourist from far far away, but I didn't hear it. The coolness of the rushing waterfall on the skin that washes away all the troubles, but I didn't feel it. These few years I had been severely disconnected to the environment.

Watching a sunrise is a good chance to think about our life. Every sunrise is like a hurdle in life. It gets dramatic in the early part, and became very hot and difficult to manage during its peak and when the sun settle to the west, so does the problems. With time, things will work their ways. When a new day starts, the cycle repeats again. There is not a day without sunrise, nor a day without sunset. Similarly, there is no life without problems, nor solutions to every problems.

I am making comparing this to my education. When I first step into the primary school, I were so elated. When the happiness wears off, left with hard facts of life. Homework, co-curricular activities and exams... Then came the UPSR examination. The hard work put into preparing the exam till I faced head on with the exam. Finally, I passed the examination and moved on to secondary school and the vicious cycle repeats itself, again. Fast forward till now. I had just crept out of my comfort zone as I have been accepted into Masters degree program in internal medicine. And its all rise and shine again. Time to wake up!

The Dog-faced and The Dog-breathed

Someone to hold your hand

Last night, another kid try to take his life.

He is the dog-faced. We (the semi-alert on-call doctors) are the dog-breathed.

He is an 18 years-old. He had met his hurdle in life, and I am sure this might not be his first. There is always a mixed feelings when examination results were released. Yesterday was SPM results announcement. He is unhappy with his results. And he took a total of 50+ tablets, containing a mixture of paracetamol, loratadine, cinnarizine, and maxolon. The mother found him 4 hours later, in severe abdominal pain, but luckily he is not intoxicated.

I could remember how elated my feelings were when I get hold on to the results slip. It wasn't because my results were that good, just seeing that what I had worked for bring fruits and what I prayed for were answered. It is a relief that is beyond words. It is a feeling of putting down a stone from the inside your heart. But soon after that, another stone will starts to grow and the cycle repeats again...

There are many ways we can choose to handle the critical situation. He might had flung his examinations, but there is always a way to go about it. He can ask for help. He can talk to his friends or parents or his teachers. He can share it out. He can get self-help, or learn to forget. Is there something wrong with our society's support system that makes it difficult for young adults like him to get help?

I try to talk to him, to peel into his self defense. Unsuccessful. He choose to keep it a secret. Or he is too shy and regretted to what he did. All his vitals were stable and blood parameter were luckily normal. IV's were pumped in to rehydrate him. He survived, at least for another day.

If we try to see our problem from different perspective, or just stand back and looking at the problems again, the matter might just shrunk and disappeared after all. There is always a way to every situation and there is always something good behind things that seems so bad. For example, you fall sick, very very badly and recovered from it, you will develop immunity and become stronger.

For me, the best way to overcome a problem is with a song. Singing put away all your stress. It is as good as any tranquilizer. And there is just the perfect song for all troubles. "Let It Be" by The Beatles. My all-time favorites.

Suffering of a Soul

What is this?

Ask yourself, if you met a beggar coming to you, will you spare some sympathy or some loose coins? Or you just turn away and ignore his agony, whatever his suffering is all his wrong-doing and bad luck, nothing of your concern. Or you will kick him squarely on his butt, chasing him out of your sight and solve the problems once and for all? What about this is a stray dogs?

I saw a viral video on Facebook about how people tortured their pets, and this feeling came to me. Human has both good and evil side, just like the face of a coin. It is up to our control that which sides prevails. The choice is ours, to choose the dark path or walk the path of light. Seeing the animal cries in pain simply heart-breaking, needless to say it is much more worse for the accomplice.

The situation took a twist in the hospital settings. Often, we gets patients from the prison. They come in bright and colourful clothes, and for a peculiar reasons, their clothes stinks, sour and hard. Some are not well, but truth be told, they are less of a person when they are being admitted. They came in chains, and with a bodyguard. But doctors (generally) thinks they are nuisance, self inflicted illness, or worse still, want to be admitted because wanted to take a 'prison break' and occupy a softy hospital bed instead of a hard cells. Their IV's are difficult to established. Their complaints, no less than a handful, and their stay usually prolonged.

Yet, they are human too. They have names, they have stories, and they have their family who waits for their release one day and pray for their well-being, just like us. Whatever done in the past is NOYB. We can't segregates them just because they are convicts. They are our guest, too. Treatments and care should be given same, if not more for these people. Just offer your service with a sincere heart.

The picture above is the hangman's rope. One day when our life come to end, wouldn't it be nice to know that someone cared for you, too?


NOYB = none of your business!

Time Waits For No One

Year 2009 just zoomed by. I was taken by surprise. Without a sign, Spring turns summer, then autumn and now its winter. December in just a flicker of candlelight. Looking back to my resolution made in 2008, I was shocked that I achieve few, if not none.

For one, I did reunite with old friends. We had good time going up Mount Kinabalu. We had nice foods. We chat till dawn. The old company is still close together. I really appreciate these old dogs. They coloured my life.

Regrettable, my weighty issue still not settled. Maybe I did nothing about it. Guess this is gonna be my 2010 resolution.

While I didn’t joined or affiliate with any organization, this is due to the fact that I was not ready, I can’t meet up with people’s expectation while not having adequate skills and knowledge. I always love to help people.

Another wish that was fulfilled, that is I got my first dSLR. Its a Nikon D40. It might not be the very best one, but it served the purpose well. I am still learning on how to use it, though. Right now, it churns out pretty good pictures. I just love it.

My hope for year 2010:

1. Enjoy my work and doing what I know best. I am going to finish housemanship soon. Hopefully I can get to do what I want then.
2. Health, not only me, but my father, mother, and everyone.
3. Love. I wish that I can bring the relationship to another level
4. Travel. The next destination is China/Taiwan. And if possible the States.
5. Weight loss

Same Mistakes

Unable to sleep yesterday. Was pondering over things that happens lately. Not sure I had done my best. Worse still, did I do something wrong?

At times, you did your best, but things just don’t go your way. Then, all of a sudden, someone kind enough would point to you, saying “hey, You made a mistake. Buckle up!”. I don’t hate them, but thanked them. They make me learned my mistake. After all, we are human.

I did save life. That is what I mean to be, but the mistakes always come and knock your door, disturb your inner peace, making ripples in what supposed to be a calm lake. There are things that you are so sure the minute before, turn out to be opposite. The outcome that you anticipated, turn out to be no more than a waste of time. The effort, the sweat, and the name, all go down to drain!

I can’t help but realized, Is this what they mean by the difference of working life and student life? What makes the difference? Is it responsibility? Is it remorse? I don’t know. Honestly.

What I know is I will fight on! Come what may. I welcome every challenge. 

How to Avoid The Fear of Change

Have you seen lately that more and more people start to fret about the posting they are going into? Some said they are going to the worst posting, some says they are going through hell. All mean the same. We don't enjoy our posting, or the rotation is not meant for human.

Most of us prefer to dwell in the latter one. Blaming other people is always easier than working out our self conflict. Yes, we work extra long hours, sometimes up to 36 hour non-stop. We seldom get adequate rest, most of us came to work with 'panda' eyes. Most of all, we get all the work, plus the scoldings as well. Isn't that what we have expected? Is that what we have signed up for? Why regret now?

People loves to tell stories, and most of the time, the stories aren't what it is. Sad to day, we chose to believe the stories. People might tell us, how bad it is to go into this posting, how bad the superior is, how hard it is to work extra hours, all sorts of things. These are stories anyway. Stories that will bring us down and demotivate us. We cannot predict what will happen in future, nor we can change the past. Its now that's most important. We lived out each seconds like its the last. We work like one at a time. There is no problem that cannot be solved. We choose to write our own stories, not dwell in theirs.

Be a non-conformist. Do not live by others' shadow. You are the best, and no one else. Just be who you are, not dictated by the stories.

Reflections: Obstetric and Gynaecology

The end is near. I can see the light at the end of the tunnel now, but what lurks ahead might be total darkness to me. The once happy go lucky, couldn't-care-less person I used to be now underwent changes. Every words I said, everything I did now carries weight, and I have to be responsible to it.
Four months of delivering babies, supposed to be the happiest moment in life. Why I didn't feel the joy? Was I not passionate with my job? I think not. Come to think about it, I think it was due to the medicolegal stuffs that daunt every doctors. How could you be happy if you wake up everyday waiting for phone calls that one day will bring you down, tear your reputation, take away your hard-earned pay and ruined your medical profession. With these thoughts, how could you be happy?
Speaking of hardship, I am already anticipated long work hours ahead, scowling from boss, friends that's take advantage. Its already a norm. What I need is excitement, excitement that brings fire and passion in this job, to get me through.
On the light side, I've someone to share with me the ups and down through the hardship. I've count my blessings. Thanks to the one, that make my life better and more complete. For now, I just want to go home.

On Call Blues

Today, I am on call again. On a straight EOD calls for three days in a row! Since I go on call for quite sometime, I had seen many types of people lingering around me:

Some, albeit rare, are the hardworking type, working beyond the time limit set, working beyond their boundaries, never feel tired and always ahead of other colleague. They help you to take blood for the patient, arange for caesarian section, buy you dinner, talk to you and tidy up the mess. So far I have seen only 1 out of 25 housemen.

Some always watch the clock, punch card ready since 4.30 pm, eager as ever to go home. As the clock strikes 5, they will transform from little filthy mice into a handsome stalion. With a magical "pop", they will vanished into thin air, like never existed. Any new cases that pops in at 5.00:29 will be considered cases for the on call people. Haha. What do they care about other people?

Some people feels like chips more (T). Now you see it, now you don't! They are mentally and spiritually be with you during your on call, but not physically. When you need them the most, they will say:" Hey ya, I need to go and pray, can you sort of cover me for a while?" Then they are gone. After prayer, they will text you again, saying that they will go and take a bath, and then go for dinner, and then spa, and then meet the uncle's best man durinmg high school... then only they will be back on call.

No matter what type of people you are, please respect you job. When you are dealing with live, they deserved nothing second best. Do the right thing and do it right.

Making Heaven Out of Hell

Lately, I had been having conflicts with my new department. Being accused for the things that I didn't do, senior officer talking bad behind us, colleague that is very calculative and no team work spirits and many more. All these had been burdening me quite a lot lately, to the extend of almost feeling depressed.

Yesterday, I had a revelation...

I was walking down the alleyway towards the cafeteria. Suddenly a thought stuck me... I was making my own living hell. Why not make a heaven out of it?

Now, I am working in one of the wards. My senior officer in the ward is what a common people would call 'bitch'. She was the kind of people that likes to gossip. She has a couple of horrible gossips partner, that not only tell nothing but lies, but also love to wreak havoc. What makes the matter worse is she is also likes to report to the big boss regarding small matters, and exaggerates things. Her mood swing is as fast as the F1 racing machines.

Lately, I had been called to an inquiry, no less thanks to her. She had been telling lies behind the big boss. Glad the things I did was acceptable under standard medical practice, I was spared from getting a punishment.

How can I clear up this mess?

First, make truce with her, my senior officer. I said to myself, why would my mood be affected by someone that is so less important to me? She can curse, talk bad, laugh about me, but she can't control the way I feel. Follow her order, my day will be fine. Against her, she makes the hell out of me. So you tell me, which way I should go?

Being nice to people doesn't always equals to people being nice to you. There are people who takes advantage on other people. I notice of late, there are colleague that fits into the criteria above.

She came late to work. She doesn't want to clerk cases. She does not want to present to a consultant during rounds. She does not like to wake up during night call. In the end, who needs to cover her? Me. Who needs to clerk case? Me. Who needs to present cases? Me. All me, and me and just me. Naturally, I was up in smoke. How is it justified that who of us get paid but only one get to work?

And again, why should I be not happy for some other people's problem? If she doesn't like to learn, it is her problem. If she doesn't want to work, it is her problem. The more I work, the more I gain, in terms of knowledge, experience and improves on my patient relationship. At least, I know the hard-earned money I get at the end of the month are worthy.

Working is fun, only if you can make heaven out of the living hell.

Insider Vs Outsider

"Chinese are the immigrant, squatters"

I can't believe I am still hearing such a low mentality statements being made.

Despite being independent for more than half a decade, the fundamental mentality is still stopping at British colonial times. As a Malaysian Chinese, we had rooted here for such a long time that we have little or no memory that we originates from China. I am born as a 'Malaysian'.I do not have a place in China for me. My mainland is here, Malaysia.

Despite all the moves to recognize every entity as 'Malaysian', there are people who still can't get over the overwhelming feeling of their own race being the greater one. Understandable. When we are equal, lost are the special privileges, unfairness, and foul play. Having a divided race entity is important in this context.

We may be independent at the outside, but inside, there is still a long way to go.

The Doctor With Fxxxed Up Teeth

How do you feel, if a doctor walks up to you, when you are sick, lying down on the bed. She oped her mouth: "What brings you here to the hospital?" You almost fainted with the stench of an unmanaged teeth.

This reminds me of a colleague of mine. Whenever he is post-call, he never care to brush teeth. He will carry on with the next day job. While this may be good as responsibility towards his job is high, it doesn't help in term of his personal image as a doctor. When he speaks, I stood 3 feet away.

Halitosis, or commonly known as bad breath, is a under-addressed issue. It doesn't affect only doctors, but people from all walks of life that doesn't find it necessary to brush their teeth. It is as bad as having a body odour.

Being in this field, talking sometimes play a therapeutic role. Having a bad breath does not help the situation at all. Not to mention the yellowish stained teeth and what it can do to the doctor's image. So a reminder to myself and my friends: Take good care of your oral hygiene.

The Power of Believe

I had been helping out in a secondary school lately. There is this young boy, who is delinquent, create a lot of problem to the teachers and the friends. It seems like law does not applies to him. Law were mean to be broken anyway. In fact, her mother is a teacher in the same school. There is some sort of high expectation from him to perform well in academic and behaves well. Alas! It turn out that he failed several subjects in the school test. The mother had lost hope with him. His teacher thought he is just another naughty student that refused to study. His friends think that he is a bad company to mix around. Even he himself does not believe in himself that he is capable. This creates a self-fulfilling prophecy, as he try to fulfil the low expectations in his surroundings.

Then, came along the school counsellor. She found out he is an intelligent boy. She never lost hope in him. She told the mother to tell him one day that he is actually a good person and the counsellor believe that he will succeed one day. After listening to such a simple word by her, his life changed totally. It takes one person, only one, to have hope and believe in him that he can do it. From that day on, he changed to become an obedient student, never missed a class, and does not create trouble for the school anymore. His academic performance improves. Now, he even became favourite student of his class.

Sometimes, we unwittingly condemned a person without thinking twice. Without knowing it, we might actually strip off the person's hope in themselves by giving negative remarks. It is easy to notice a person's mistakes but it is very hard to appreciate a person's good. Next time, before we passing out a comment to a person, think twice, thrice or more. Our words might done a damage beyond repair to a person's life, or save a person from the brink of destruction. Choose carefully.