Peer Tutor

So for my long break I have enrolled myself into IMU's peer tutoring programs for phase 1. 

I still vividly remember how I corrected a semester 6 junior with a much stern voice and attitude when he presented a case to my fellow colleague and I during our surgical posting. 

Two students clerked the patient at the same time due to language barrier. 

Student A: "This is a middle aged man who was diagnosed with chronic liver disease came in to us presented with 1 episode of hematemesis.... He did not consume alcohol. There was no history of hepatitis. "

Student B: "Eh but he told me he was diagnosed with hepatitis many years ago..."

Us (the seniors): "Would you like to include that in your history since that would be something very significant?"

Student A: "But this is the history that I have gotten and I am only going to present what i clerked." 

Me: "This is not an assessment but a discussion. We are trying to get to a diagnosis and try to help this patient. If you only present what you have gotten, the diagnosis may be diverted and so is the management. "

Student A: "But I didn't get that history myself and that's not fair. "

Me: "You are not working alone as a doctor. You have a team. And if you can throw that ego away you would have done better justice to your patient. "

I guess I was too angry then, I strolled off. Now when I looked back, I was very impatient and maybe a little irritated. I have probably set my expectations a little too high. Not everyone would have understood the meaning of comprehensive health care and team work when they just passed out from phase 1. Not all of the semester 6 students understand the meaning of ward work and patient care, when what phase 1 taught them, was how to pass the exam and osce with correct techniques. If time turns back I guessed I should have probably tone down my voice and be more gentle...

I may not be the best teacher, but I am still learning. And to be able to identify strength and weaknesses in not just myself but also other people, and tailor accordingly, would be something I have to really pick up in years to come. Learning is a continuous process and so is teaching. 

As what Dr. Sow always says, "To teach, one must have passion. And to teach well, one must not be rigid and teach only one way because everyone learns differently. "

*looking forward to peer tutoring*

Kaiyunn

Bento Diary

So about a month ago, I have decided to start a mini project for myself, called the "Bento 101". 

My initial intention was just to save some money (because GST is making everyone's life a bit more difficult), stay more nutritious and sometimes to de-stress. 

Before starting clinical school I didn't know much about cooking. Over the last 2 years in Seremban, undeniably I think, staying away from home has made me acquire some new cooking skills, but to cook for leisure and to cook daily within limited time, is very different. 

On my first week of bento making, it took me more than 40 minutes to prepare the ingredients the night before and to cook the next day morning, respectively. I will cook something that I am familiar with, something I have tried and cooked before and will not fail. 

But then the second week arrived, when I ran out of "used-to" recipes, I began searching online, watching videos on how other people cook and then create my own combinations of recipe. Surprising i didn't really fail in any particular dish! 

Over the next few weeks, things are getting better and I enjoyed my cooking and my bento very much. Needless to worry about what to eat, how much I will be spending, and the amount time spent eating out, I think I became happier and a little more satisfied with my life here. 

Today marked the last day of my bento making, as we all will be leaving Batu Pahat in just a couple of days. I would say it has become my habit to make daily bentos, and to also cooked extra food for my housemates, and literally forced them to eat, and they will still finish the dishes every single time. (Awwwww) Just when I thought I am getting used to all of this, we are leaving, and I feel sad sometimes. I think I am going to miss this cooking habit and more so, these people. 

Bentos have taught me to be discipline, be innovative and be kind to share. This is just my personal experience. I hope to inspire all of you to do something you enjoy even though life seems to be really busy. And when you think life is boring and aimless, start a new project! Even the slightest effort counts, and with persistence you will end up somewhere further than you believe. 

Good luck to everyone for your exam preparations. Don't forget to eat and stay healthy! Get enough rest and be in your best shape! 

KY

A World Without Barriers...

I have come across this video few days ago. This video is a commercial ad filmed by Samsung and it is based on a true story. *Disclaimer: im not promoting on behalf of Samsung!* This video shows a deaf man from Turkey named Muharrem, who was moved to tears after learning that his neighbourhood had learned sign language just for him to promote the heartwarming message: 'A world without barriers is our dream.'

He was out with his sister and unaware that he was being filmed. He first encountered a stranger who signed 'good morning' to him, you could see the astonished look on his face. Later, he was offered 'hot bagels' through hand signals by a shopkeeper. His next encounter involves a stranger dropping a bag of fruits. When he went up to him and helped him to pick them up, again, the man used sign language to offer him an apple as gratitude. The shock is well written on his face when he said to his sister, "is he hearing impaired?". Later, he bumped in to a lady who apologized to him with sign language. He was also welcomed by a taxi driver into the car with sign language. The stunt, which took a month to prepare, was organized by Samsung to promote its call centre for the hearing impaired.

This is a heartwarming video and it caught me thinking, why would Muharrem think if someone was hearing impaired too when a man used sign language to offer him an apple. I guess, the reason being, deaf people have always been living in a world that is different from others, they have limited ability to express themselves and most people dont seem to comprehend what's on their minds and the only way they could communicate with others is through sign language. And often, when we see someone who communicates with sign language, the first thing that comes into our mind is that 'does he/she has hearing impairment?' A social stigma I would say. If the barrier they face is communication, the bridge to communication will be sign language. 

Using sign language as an alternative communication form is less about the production of sounds and words but more about the expression which involves creativity that enables them to express their inner ideas. 

If you were in their shoes, being less privileged than others, i guess you would wish to understand and to be understood. Not that i have many encounters with them but i think this is just something to ponder upon.

-Pei Li-

By hook or by crook.

I was taking care of a patient diagnosed with locally advanced breast cancer, and just had the mass removed. The other day I dropped by just to make sure she was doing fine, and while we were discussing about her future management plan, she broke into tears.

"I don't want to have that chemotherapy, it would make me suffers more!"
 "I'll consume more vegetables and fruits, stop taking any canned food or processed food, and eat some traditional medications', she was firm about it.
"Please don't make me go through that suffering with chemotherapy".

After spending half an hour explaining to her about chemotherapy, healthy lifestyle and traditional medications, she seemed to be shaken a little bit, but........
"I shall ask Tua Pek Gong for comments", I think my ST elevated acutely.

If a person is willing to listen and believe what a lay person told them about their disease, why can't those with professional knowledge do the same charm? They rather believe the facts (posted by dono-who) on the internet, but not to take in a single word from us, a group of professionals who spent five endless years in med school, and many many more years ahead in order to understand the disease deeper, a group of people known as DOCTORS.

Why are our patients rather turning away from us to alternative traditional medication?
Our drugs are nicely labeled with contents and side effects. (at least you could win a lawsuit shall anything went wrong)
Herbs tasted a hundred million times worse than any of the tablets we could offer, but why are they willing to spend time to boil it from five bowls of water into one saturated bowl of.......well, you know how it taste like.

The only acceptable explanation I could think of is, these every other options give them hope. 
(even if it is a false hope)

"If you take this herb, the cancer will melt away, you will be fine in 3 months time!"
"My friend's mother's daughter's friend once was diagnosed with cancer, doctor said she only left with 3 months time. That was 3 years ago. After drinking this (dono-what health products), she is still alive. I met her last weekend, she just had a baby girl"
 
As opposed to how we sell our treatment plan.

"You will need to go for radiotherapy, where your skin might get burn, but no worry, we will give you some cream to put on it"
"You will have chemotherapy, where we inject very toxic medications into your veins to kill the remaining of the toxic tumors. You might feel nauseous or even vomiting, losing piles of hairs, having skin and nail changes. Ouh yea, your immune system are basically knocked down by the drug too, but no worry, we will take care of it".
"And despite all these, you might still have a recurrence and die from it"

You see why we fail?
They lost hope in us.
Apparently a crook does a better job than us.

We have what known to be the best treatment in hands, but have no idea how to sell it. Other healthcare-related faculties seems to have marketing included in their curriculum, why not ours?

We failed badly in encouraging our customers to use our products, we failed horribly in engaging them in services we provide. Despite being able to label them with fancy diagnosis, we failed every other thing.

Now, try selling that iron tablets to a pregnant mother, push a little harder, and be gentle!
You better make sure she takes it, BY HOOK OR BY CROOK!
(that's a good idea for OSCE counseling station?)


-FiShe-

Optimizing patient care

Despite being held in a state so far from Batu Pahat, my friends and I decided to participate in the Annual General Meeting & Annual Scientific Meeting of College of Surgeons, Academy of Medicine of Malaysia held in G Hotel, Penang on 29^th -31^st May 2015. The theme of the conference is “Optimizing Patient Outcomes” which emphasizes a critical and fundamental goal of a surgeon.  

As this is an informal write-up, I will try not to sound academic but more to how I felt and what I gained from this conference.  But this may not be touching on the essence of this blog where we share our experiences during patient encounter in the ward. 

 

At the moment, I am interested in surgical-based specialties, thus hopefully I will gain some knowledge by attending this conference and have a bird’s eye view of a surgeon’s profession.  Maybe it’s still too soon to decide on should I become a physician or surgeon; taking MRCP or MRCS, but I personally think it will be beneficial to set a target in mind. 

The various topics scheduled in this conference were very compact and informative, so much so that some topics are too overwhelming and not for us to know yet such as the surgical procedures and techniques. Overall I think that when the speakers are explaining the basics of diseases, current updates of management and research findings, we could comprehend and acquire some simple take home messages. 

As two symposiums occurred concurrently, we could only choose one of them. The topics were: surgical trauma, breast and endocrine, urology, vascular, colorectal and upper GI. Another topic that I find it very useful is the talk on surgical education, which explained the entry to surgical training in Malaysia, formative and summative assessments of a Masters candidate. With this, I have a rough idea on what lies 10 years ahead of me if I decide to become a surgeon. It is certainly not easy and very much competitive. 

This is a long and tough journey requiring hard work, persistence, determination, great discipline and lifelong learning to eventually be near to the end point. From where I’m standing now, I am definitely lagging behind and there are so many potholes that I have to repair. Comparatively, I doubt my own capabilities and fear that I could not succeed. But I came across these inspiring words that strengthen me to believe in myself and stop comparing with others, I will keep on improving myself till the day I achieve my goal. 

"Life is full of disappointments, failures and setbacks. None of those things can permanently stop you. You have the power in you to overcome anything that life throws at you. There is nothing as powerful as a made up mind. Surround yourself with people who remind you that you matter, and support you in the ways that matter most to you. No person, situation, or circumstance can define who you are. Don't give up, cave in, or stop believing that it's possible. It's not over until you win." - Internet 

Before embarking on the journey to become a surgeon; I have to take the first step of becoming a safe and competent house-officer by providing optimal care to my patients and ensuring that they receive the best of care from me. And the next checkpoint soon we will pass, is our Part II Final Professional Examination. 

All the best to everyone! 

Another point that was conveyed in the conference is that medical care has been compartmentalize compared to the era before, and in modern medicine there are so many specialites, subspecialites and new technologies. However, specialists are restricted in their own specialites and tend to forget to treat the patient as a whole and addressing their basic needs. We tend to refer our patients across specialites and sometimes, patient care is compromised. 

There was once I encountered a patient in the surgical ward where he has uncontrolled diabetes, and the surgical MO referred him to medical for diabetes control. After a day, his glucose reading was still poorly controlled, the surgical MO then blamed the medical team for not doing a good job. From this, I reflect and think, aren't we supposed to treat a patient under our care, and do we lose our capabilites to treat medically when we are in surgical department? (I am not referring to complex medical diseases) Do we have to refer every other poorly controlled hypertension or diabetes and not managed ourselves? An elderly patient once asked me, "Why are there so many different doctors talking to me at a different time, who is the real doctor whom is in-charge of my well-being?" And at that point, I have to answer, they are all in-charge of you, but taking care of different diseases from different department. I understand that multi-disciplinary approach is very important but in that kind of situation I think we have the capability to manage the deranged glucose reading effectively and not put the blame or point our fingers at others.

That's all for now.

Lastly, photos from the conference with our IMU lecturers, Dato Kanda and Prof Lum :) 

-IngChing

"I understand..."

I have recently encountered a patient who was diagnosed with enterocutaneous fistula and has been put on long term nil by mouth and supplemented with total parenteral nutrition. Day in and day out I realised that she is getting more depressed, not only because she has to be hospitalised for a long period but on top of all, she is unable to eat. 

Often when we are in situation as such we tried to show our empathy and support. We care for the patient and we try to understand their sorrow.  

It's not wrong for us to try to cheer the patient up. It's okay for us to tell her the truth and her progress, to tell her that I am very sorry you are not allowed to eat and have to be on intravenous nutrition,  because what patient wants from us, is to be genuine and honest. 

But it's not okay to use use "I understand your situation," loosely, because to be frank, we can never really understand. I can never imagine if I have to be in the situation like this, where I cannot eat at all, for the next 2 to 3 months.

Sometimes as managing doctors, it's actually not so important for us to emphasise that "we also understand your pain", because that is only doing justice to our own conscientious and guilt,  but to be able to be by their side, and listen to them, addressing their concerns and checking their progress while only conservative management is being carried out, may mean so much more. 

KY 

The first time...

The first time of everything is always the most exciting one and you will always remember your 'first time' in doing something. 

I was watching an emergency LSCS yesterday and a senior MO was teaching a junior MO on how to perform the surgery. It was her first time in performing a surgery. To her, it may be an exciting experience that she cant wait to share with her loved ones but to the senior MO, it may be just like any other day that he scrubs in and performs a surgery. As I was standing aside and observing, suddenly the thought of doing something for the first time came flooding into my mind. I remember the first time when I learned to swim, the first time when I learned to speak in public, the first time I clerked a patient, the first time I did venepuncture on a patient, and the list goes on. There is a lot of excitement loaded in those events, but there is also fear in doing something for the first time. When trying something for the first time, you may be doubting yourself, whether or not you are able or capable to perform well enough, or what would other person think of you if you fail and the consequences when you fail. Often, these thoughts of negativism and fear would limit someone from doing what they think they cant do but in fact, they can. The feeling of insecurity often kicks in without you knowing and when that happens, you stop trying for the first time. Instead of having thoughts like that, what if you turned the first time into something exciting and positive?

Our days are built so routinely consisting of endless cycle of breakfasts, lunches, dinners, house chores, work and building relationships. It has been designed in such a way that there are days when you wake up, you just dont feel like doing anything at all. You will find yourself hard to get motivated. In order to make life a bit more exciting, a bit more meaningful, and to feel the thrills again, one need to come out of this routine and do something out of the box, for instance, go on a travel alone for the first time.

It doesnt matter how old you are, how mature you are and how experienced you can be, doing something for the first time in life could be sometimes exciting, unique and extraordinary. And to some, doing something for the second time may be boring or dull, however, if you could recall the mixed feelings you had when doing it for the first time, you may find the second time as exciting as the first time. And remember, you will never be fully prepared for the first time at everything and second experience may not be as smoother as you thought. 

So, when was the last time you did something for the first time?

-Pei Li-

The Etiqutte of A Doctor

If you ask anyone who is not in a medical profession on their perception of doctor, words that can be predicted such as, they are very noble, smart, patient, rich.. etc and the list goes on. However, things seem to change a little lately. And, I was wondering why such a change. 

Is there any problem with the competency of doctors? communication skills? or just attitude problem of medical professionals?

I believe most of the graduates have a certain level of competency and we have keep ourselves updated with the latest guideline provided to maintain optimal patient care. There are much emphasis on patient care, but has anyone thought that the relationship between medical professionals play an important role in a health constitution?

In my point of view, a doctor's behaviour is very important in many aspects and I believe not many doctors are aware of it. How does the doctor treat his patients, his communication with their subordinates or even someone who is very junior matters a lot. 

As a final year medical student who is going to graduate in few months time, I am learning how to be a good doctor. And being a good doctor encompasses many good criterias. One of it is being kind and humble. It may seem like a common sense, but many doctors have failed to do so. 

Doctors who are arrogant and inconsiderate to their juniors will cause unnecessary emotional disturbance and it will indirectly affect the performance of the junior. Of course this does not include reasonable criticism by a senior doctor. 

I always believe doctors should speak and act in a proper manner. If you think bullying/stepping on juniors makes you feel greater? THINK AGAIN! It just kills the interest of the junior in being part of the team. 

In other way, if a doctor who is very encouraging and kind, juniors will start to develop interest in learning and it will make a very friendly learning environment. 

Sandra Liew

Right or Wrong?

During our Sem 9 surgical posting in HTJ Seremban, there was a patient wrote to the star newspaper, filing his complain named "Why rob patients of their sleep and rest?"
http://www.thestar.com.my/Opinion/Letters/2015/01/19/Why-rob-patients-of-their-sleep-and-rest/
The patient complaint that the patients were waken up as early as 4.30 - 5am by the doctors for history taking and physical examination, robbing the time for their sleep and rest. However, I noticed some of the housemen nowadays are actually copying the files from the previous entry, some even just sit at the counter and copy the files without even talk to the patient or examine the patient. Hence, if the doctor is waking the patient up to talk to them and examine them, at least we know the houseman are really doing their job. However, from patient's point of view, it is true that they do need rest. As consultant round starts at 7.30am, so the MO round usually starts around 6am+, it is understandable the houseman have to start reviewing the patients as early as 5am since they have about 6 to 9 patients to cover.
Is the houseman wrong for waking the patient up early in the morning to take history & examine patients? I don't think there's right or wrong here. Perhaps it's just different point of view. 

- l.a.u -

If you could...

I have come across this video few years ago. This video left an impact on me and I believe if you watch it, you will experience the same way as i do.

Everyone has a story to tell. He or she may be the person standing right next to you, a patient that you attend to or even just a passerby. They do not carry an expression that is easy for you to read. The thing is, how many of us are willing to search for the story of what lies behind. Often, we are confined to the mindset of "getting work done" and we tend to ignore their feelings. When you diagnose a patient with terminal cancer and then you just sleep through the night without having to worry about it. That patient whom you just diagnosed, may have a sleepless night, perhaps countless sleepless nights with the fear of death or even persistently worrying about how to break the news to his/her family or what they gonna do when he/she is gone. But, do you know all these? Do you care how they feel? When a blind man sitting right infront of you, do you know how he pictures you or what lies in his imagination? Empathy is a gift and it is accessible to all of us, but we have to find ourselves the opportunity to explore, to identify. Sometimes, a question as simple as "how are you?" would make someone's day. We may not be able to cure every sickness but listening is often the only thing needed to help someone and to discover great stories.

Take a step back, think it through, and reflect on what you have done for someone today.

"If you could stand in someone else's shoes, hear what they hear, see what they see, feel what they feel, would you treat them differently?"

-Pei Li-

Mistakes

It has been five weeks since we stepped into the last 6 months of medical school. As being a medical student, we can still afford to do mistakes and learn from them. We were told to do as many mistakes as we can as a student before we directly dealing with patient’s live as a doctor. And I told myself, it is okay to make mistakes now.

When we told the patients and families that we are final year medical students which meaning that we are going to be a real doctor in less than a year time, they put trust on us. They will be willing to listen to our advice. The truth is, we are indirectly and actively participating in managing a patient. For instance, we give appropriate advice to patients regarding their lifestyle modification, diet control, handling of medication and illnesses. However, before we could give a good advice to patient, we should really equipped ourselves with knowledge because wrong information can be life threatening to a patient. 

I had made a huge mistake that day because I gave wrong information to a patient which can lead to life threatening consequences in her illness. I felt so awful and even hard for me to forgive myself in doing such a mistake which I should not. For the first time, I felt the responsible of being a healthcare professional in directly dealing with one’s live. When we carrying our lab coat which represent our profession, we should give our best in everything we do, be it prescribing medication or just talking to a patient. This can create a “butterfly effect” which lead to serious consequences later.

Yes, I told myself to do as many mistakes as I can in these 6 months before I become a real doctor. But, I really find it so difficult to accept the mistake that I have done. Even if the patient did not affect by the mistake, the thought of me almost caused life threatening situation to the patient is horrible. However, to admit, apologize and correct the mistake that one have done as soon as possible are equally important too. For this instance, I am glad that I was still able to amend the mistake that I have done before it is too late. This mistake had really gave me a huge lesson to learn.

So now, try to do as many mistakes as you can? 

No, think twice before you let anything slip out of your mouth. It’s more than pain to do mistakes. 

-K-

The reality

Originally posted on Kazayo

Have you ever wondered why the patient rather lie to you than being honest about their medical condition?

Yesterday, a patient was scolded so badly by the Medical Officer, because she defaulted the computed tomography (CT) appointment given to her due to her malignant status. She was in very bad shape, having really bad pain, sobbing away. Having surrounded by 5 fellas at once in a small room,  having to bear with the pain while these people do an ultrasound scan. She was left all alone in the room while the rest just walked away, discussing about her case. The poor thing was shouting for pain more than half an hour ago, no one bother to relieve the pain before doing the scan.
Then, the Medical Officer came in and started asking her why she defaulted the appointment, and refused medical treatment previously. My point of view, that MO was directing her frustration of having to do more work just because she wouldn't have to make another appointment for the imaging if the patient had turned up for the previous appointment.

Did anyone take a chair, sit beside her bed and ask her why she refused the medical treatment at the first place but rather turned towards some traditional treatment which made her condition worse?

I can totally understand why the patient refused treatment. There's no surprise if she is doing the same thing again for this recurrent thing, if she is treated like this.

This morning, I went to the hospital right after my Sahur, it was 6++. A patient stopped me at the first cubicle and told me there's one patient in deep pain, curling on the bed. I asked that patient if she was given any pain medication and when was the last dose. Then I attended to the HO at the nursing counter.

"Dr. the patient at bed x is having very bad abdominal pain, pain medication was last given at 3 in the morning. She came in because of dysmenorrhoea, and diagnosed with.......bla bla bla"

"It was written on the drug chart a BD dose right? At 8 in the morning and 8 at night"

"Yea, but she is in a bad shape now, you might wanna give her something to ease the pain?"

"You saw the drug chart right? It is a BD DOSE", he stared at me.

"Anyway, you might wanna have a look at her", I tried to hold on not to explode.

He walked off so unwillingly.

I almost whacked him with my messily-filled logbook - Eh harlo bro, you have a damn MBBS with you and you can't prescribe a damn pain killer for that poor patient who is curling into a ball because of the pain?! Damn you......
*spit on the basin*

Now I see why the Old Man is so upset.

For the first two weeks, I was really upset about the posting. We have different professors in charging for different wards and taking us for different topics on bed-side teaching. Each of them have different preference, each of them see things from a totally different point of view and of course have different expectation.
These people never came into consensus, but rather expect us to fulfill what they expect us to do. This is very unfair.

Covering all the beds in the wards, crowd around in the clinics, follow patients to the OT for surgery, having to complete the clinical skills assessment, speak up during classes or teaching sessions. We rarely have time to eat or shit, not to say extra time to mug up our medical facts. Then, during bed-side teaching, we screwed it up.
At times, we sneaked back to the school to be assessed by our Sister regarding the clinical skills, which is compulsory, then the Professor in the ward is making noise, saying why aren't we in the ward. When we went to the clinic following one of the professors, another Professor blamed us for wasting time in the clinic where we don't know what we are learning. One said go ahead to get some experience and observe different operations being done in the theater, the other one said there's no point going into the theater. Worst thing, when our logbook looks pretty empty on the procedure page, another one make noise.

We, the vulnerable one, always keep quiet, taking in every blame.

But hey, that's the reality isn't it? In the real world, that's what exactly happening. 
There is never a consensus being made.
You mold yourself according to different situations, and try to survive between the gaps. 
Now that's reality!
Stop complaining and find your way out!
"Be the change you want to see"

You are not here to learn the right things, you are here to learn things right - Prof. S.

-FiShe-

Introduction to Med Tutee.

In conjunction to MedTutor, a group of final year medical students have been inspired to create a platform to share their thoughts and dreams.

In this blog, we would like to share our views and perspectives beyond sickness, suffering and death.

Through each footstep, it helps us in understanding the core of humanity and brings us closer to what is beyond.

In the end, it is not how much you know about the medical world, but what you have gained from it.

How far we've come, and how far to go......

-Med Tutee-