Murky Clarity

Pride: be the noun, not the verb

 

I wrote to The Star sometime ago, but since they haven't responded, I'll go ahead and post what I wrote here. Oh, well.

--@--

 

Pride. One beautiful word that has two polar opposite connotations; both have deep significance in the medical world.

Eight years haven’t been that long since I started my career, but that first day at work feels like a lifetime away. We had Facebook then, but our interactions were limited to our circle of friends. We didn’t have Twitter, and our personal blogs did not generate much traffic. Not like today, where everything is out in the open. I still can’t tell which is better, though.

I consider myself luckier than most because my first days as a house officer were gentle. I had supportive medical officers and senior house officers to ease me into the real world. Their first advice, which I still pass on to junior doctors: do not hesitate to call for help if a patient collapses. That was my biggest fear. How should I, how would I, react should a patient collapse.

My first few days were decent, if somewhat scary. However, within the same week, a specialist humiliated me without reserve in front of patients and medical students. I wanted to shrink within myself. I wanted to hide. I didn’t feel angry or spiteful. What I did feel was a sense of inadequacy. Even in that numbed condition, I knew the specialist was right, that a patient’s well-being should not be in incompetent hands.

That was my first lesson in humility.

My second week as a house officer, my fear came to pass. A patient collapsed and had stopped breathing, her heart had stopped beating. I did not hesitate to proceed with CPR, but I did not know what else to do. I called for help. The nurses, cool and collected, helped me with the CPR and instructed me on further acute management steps. They knew I knew what to do. They also knew my nerves needed calming down. They were much more experienced in dealing with dying patients, and I followed their advice. By the time the medical officer arrived, the patient was stabilized. After that day, the nurses were warmer toward me, friendlier.

That was my second lesson in humility.

No, I did not have a breezy experience as a house officer. Lessons in humility kept coming in various forms: a mother of three toddlers asking me why, of all people, she had to be the one with breast cancer; medical officers and specialists reprimanding me (quite loudly) for not being fast enough, knowledgeable enough; nurses teaching me the best ways to get intravenous access without hurting patients much; other house officers teaching me how to get things done smoothly. My colleagues and I worked extra hours, and we had to do 24-hour calls between three to four times a week because we didn’t have enough house officers. We weren’t saints. We did complain with one another, with our family members, with university friends we still kept in touch with. We kept going, knowing that each hit we received was meant to make us stronger, better, safer.

I am neither the brightest nor the best, but I’ve learned a lot along the way.

I’m still learning.

Reading all the letters of complaint to newspapers, rants on Facebook, Twitter and personal blogs, and watching videos posted on YouTube, I think I know what is causing these new house officers much grief. To be a doctor, you ought to have a brilliant mind. Let’s be honest. Almost all of us doctors were overachievers back at school. We were among the top in our classes. When we were in medical school, we competed with people as bright as us--if not brighter than us. Naturally, when working life jolts us into reality, when we are reminded again and again--by doctors, nurses, even attendants--that we are worse than scum, that we are merely bottom feeders, the one thing that gets hit the most is our pride. To be publicly humiliated for not being good enough, that’s something new.

This brings us back to my opening paragraph. Pride, as a noun, is an ugly thing. If you leave medical school naively thinking that you are the best, that everybody else is beneath you, the first hit will knock you down into the muck. It doesn’t matter if you’re made of titanium. You’ll keep getting hits until resentment builds and all you can think of is the hours you spend at the hospital instead of elsewhere, all you can see is the nurses at the counter passing over cases between shifts instead of helping you doing a procedure, and all you can concentrate on is getting the job done.

Take a few steps back and observe your surroundings. Maybe you’ll notice your specialists and medical officers worrying about patients who aren’t doing as well as they should. Maybe you’ll notice heavily pregnant nurses leaning toward an unconscious patient, feeding that patient on time. Maybe you’ll notice an attendant running late when summoned because he has to walk a great distance to retrieve lab results.

Most of all, I hope you’ll notice the fear, the anxiety in the eyes of patients and their relatives. For us, coming to the hospital is a routine; for them, it is a big event that may lead to either celebration or devastation. Patients trust us with their life. We have to respect that trust.

Please remember that respect is not freely given. It is earned. If you want your colleagues to respect you, to treat you better, earn it. Once you earn that respect, everything will fall into place, insyaAllah.

Take pride in what you do, and you’ll derive joy from it. Let pride consume you, and you’ll end up bitter and resentful. When that happens, no amount of pay, no amount of lenient working hours will ever be enough.

Live. Work. Learn. Have fun while you’re at it.

What Nurses Do Best

 

 

The internet is a beautiful thing, and, like all things, it is neither good nor bad. We make the internet good. We make the internet bad.

We, the people.

There is a post circulating in Facebook about a nurse in Hospital Kota Bharu who allegedly abused a newborn child. A picture is attached, showing a baby lying sideways toward one side of a cot, with blood splatters in an arch across the lower half of the cot. I shall not post the picture here, so you either have to search for the post yourself--shouldn't be hard, as the post is ALMOST viral--or you just have to visualize based on my scanty description. The description that comes with the picture alone is bad enough (toward the nurse). The comments, however, get worse with each share button. Not just nurses, but all public hospital staff are bad and dangerous.

There is a good reason why we forbid people from snapping pictures in the wards, you see. Not to hide what we do, but to prevent misunderstandings.

Of course I'd say this, you say. I'm a public hospital staff myself. Of course I want to defend myself and my work.

Not this time. If you're convinced I'm a jerk, there's no dissuading you. I can't be bothered, anyway. I do, however, want to protect the nurses. They are my colleagues, my friends, my family. And I'd do anything to protect my family.

First off, about the picture: I don't know the whole story myself, but judging from the baby's position and the pattern of the blood splatter, an intravenous line (branula) must have been dislodged due to movements and blood seeped out from the open wound. Happens to little children, happens to adults. Because, you see, this usually happens when the patients have no control over themselves. Precautions are taken, and sometimes they need restraining, but branulas get dislodged because we don't tie them onto the skin. We slide the branula in and then secure it with plasters that are gentle to the skin. Any alleged exchanges between the nurse and the person who took the picture...well, that's between them. That is their truth.

Let me tell you a different story (not fiction). This is my truth. Some years ago, some random visitor accidentally started a fire in our old elevator shaft. We didn't see any actual fire, but the smoke filled our half of the building. It was a weekend. I was oncall. I only realized there was a fire when smoke filled up my on-call room. I ran out to see the commotion, and my consultant, Dr Ramesh, was leading the nurses to evacuate the patients. Come to think of it, I don't recall any fire alarm. Huh.

Anyway. We couldn't find the source of the fire, but we opened up all the emergency exits and evacuated the patients. But you have to understand that we are the Neurosurgery department. Half of our patients were in no condition to even get out of the bed.

In the excitement, I belatedly realized that there were no screams. No one was panicking. The nurses carried the pediatric patients, supported the adult patients who could walk, and returned to their wards up to the second floor to repeat the process. No one was panicking.

But we also had a major problem: the patients in our ICU, HDW and the acute cubicle in the male ward were all ventilated. Some of them were in critical condition. They could not be moved. So the nurses taking care of them continued what they did best.

They took care of their patients.

Not one of them left their patients. Not a single person.

The nurses I work with often have to work double shifts because there aren't enough people. Some of them are well into their pregnancy, and they have to waddle. Not walk. Waddle. They expose their unborn child, they expose their loved ones at home, to airborne hospital superbugs, but still they take care of their patients. They bathe patients who cannot bathe themselves. They feed patients who cannot feed themselves. They comfort patients when their families are not around. They comfort families of patients who are dying and who have passed on.

They go home tired and trodden, yet still they make time for their family.

We sometimes forget this. In our anxiety having a family member in the hospital, we forget that nurses are also people, people who are overworked, overwhelmed, underpaid, and under-appreciated.

Despite everything, in spite of everything, they do what they do best: take care of patients.

I know I don't show my appreciation enough. I know that saying 'thank you' and 'great job' may not be anything more than a temporary high, but I will say it anyway.

Thank you.

Great job.

Keep up the excellent work.

 

Love always,
Fadz.

 

Neurosurgery Intensive Care Unit

 

N6B - Pediatric Ward

 

N6A - Female Ward

 

Neurosurgery High Dependency Ward

 

N4A - Male Ward

 

Neurosurgery Clinic

 

Neurosurgery Operating Theater

So You Want to be a Doctor: on stress and suicides

We doctors are the best when it comes to suicide; we are among the most creative at it, too. We also have the highest suicide rate compared to other professions.¹ It's no surprise, really. In learning how to heal, we indirectly learn how to kill. Armed with the knowledge, we only need the proper motivation. And stress can be a powerful motivation indeed.

Every so often, an almost brave house officer--Americans call them interns, I think--writes to local newspapers about the amount of stress they face at work.^{2, 3} Almost brave because they don't reveal their identities in said letters/articles, which is wise because they'll only be targets for further bullying. I do not use the term 'bullying' lightly because this reflects badly on my colleagues--and perhaps, even myself.

But our general response to these open letters of complaint is laughing at the article and giving snide comments, because, let's face it, we've been through the same process. As house officers, we had experienced working seven days a week, over forty-eight hours at a stretch, and we had experienced being yelled at by senior medical officers and specialists in front of nurses, students and patients. It's a rite of passage, we say. It's something we all have to go through as doctors, so buck up and shut up.

We doctors dive head-first into a world of death and disease. Among the first things senior house officers teach fresh ones is how to react when a patient collapses. One of the most vital steps is to call for help. Unfortunately, speaking from personal experience, help doesn't necessarily come--not on time, at the very least. During such times, even the most arrogant house officers will be humbled at how professional and quick-thinking nurses and other support staff can be. However, no matter how quick we are, no matter how good we are, we cannot defeat Death. We can't even defeat diseases, sometimes. Several of my friends have contracted tuberculosis even though they have taken all necessary precautions when treating patients.

Shit happens.

Don't get me started on dealing with patients' difficult relatives.

I love working, and this is partly due to the excellent working environment. The whole department is like my extended family, and we share laughter and commiserations. I usually don't feel the long hours, and sometimes I still come during non-working weekends to check up on my patients. Still, no matter how good the environment is, sometimes it gets too much. Especially when patients you've come to care about passes away, or complications you cannot control happen during surgery.

Imagine how it feels when superiors treat you like scum, and your support staff treat you like a snot-nosed infant whose incompetence fills them with contempt.

This example may not be relevant, but I'm going ahead and use it anyway. When I started doing surgery some long years back, we used old and tired bone cutters (which are still in use today), and to do a craniotomy (sawing off part of the skull) alone would take me almost twenty minutes, making the total surgery time longer. I heard that before my time, they used a manual saw, and surgeries took way more hours than I would have been comfortable with. High-speed drills were for surgeons only. Now that the old craniotomes are dying off, we get to use the high-speed drills and an uncomplicated surgery only takes up slightly over an hour for me. Junior medical officers start their career in Neurosurgery using these high-speed drills, and the old craniotomes are an urban legend for them, just like the manual saws are an urban legend for me. We're moving toward a better future.

Still, I count myself lucky for working at the heart of the service. Other centers still use the old craniotomes and sometimes the manual saws.

What I'm getting at is that as the generations move along--one doctor-generation is around 5 years, so don't get any weird ideas on how ancient I am--we get better. We teach our junior better and more efficient ways to treat patients, and we are also armed with better tools for the job.

So why do we slam house officers who want a better work environment with reduced stress levels? Why do we keep on saying "we've been through that. These house officers are such babies."? We've been through it, and it was hell. We know how terrible it is to work for more than twenty-four hours straight, and we sure as hell know the mistakes we tend to make when sleep-deprived. When we hear about a doctor committing suicide, we wonder if we knew that doctor, we wonder how he or she did it, and that's about it. We've been so inundated with  extreme stress levels that we now believe that extreme stress is the norm, and is expected.

Maybe a better pay will help. Maybe shorter hours will help. Maybe a full day's rest after a twenty-four hours shift will help. Maybe even a mandatory one-week leave will help. That last one will definitely help, in my opinion.

All of the above are rendered useless if the work environment is toxic. No amount of compensation will matter if senior doctors believe that in order to build good junior doctors, you have to break them first.While it is true that fresh house officers start off their careers with a certain amount of arrogance--after all, we are among the brightest over-achievers--we don't have to make them hate their jobs. Humility and humiliation are two vastly different things, and to be honest, I think we have lost sight of that.

Being a doctor is stressful enough as it is. To ensure a better future for the younger generations, why not show our support instead of shooting them down? Why not show solidarity in securing a better life for all of us in and out of the workplace? And even if the authorities will do nothing other than write an empty response letter, why can't we create a healthy work environment?

Don't let a hard life make you just as hard. The next time we think about laughing at an article of complaint written by a house officer, why not think about the hell we've been through, and feel a little compassion toward these juniors. The people who voice out their concerns and complaints are courageous people who want a change for the better. These people should be lauded, lot laughed at.

Though I have to admit, with certain people, no amount of love and attention will make a difference.

 

 

_________________________________________________________

¹ Ilan Shira. The Occupation With the Highest Suicide Rate. The Narcissus in All of Us, Psychology Today; August 1, 2009.

² Houseman, Kuala Lumpur. Stressed From Still Working Long Hours. The Star Online; January 8, 2013.

³ Loh Foon Fong, Lim Wey Wen, P Aruna, Shaun Ho. Housemen still being overworked and bullied, sending some into depression. The Star Online, April 14, 2012.

Related articles

Study: Physicians Have Higher Than Average Suicide Rates

Why aren't more people talking about physician suicide?

How do you measure success?

I had a patient last Saturday night. He was involved in a road traffic accident, didn't lose consciousness but had this massive headache, went to a clinic, and was discharged with analgesia. It wasn't until a few hours later that he lost consciousness.

Textbook description of an epidural hematoma. In layman term, he bled between his skull and the outermost covering of his brain. When he was brought to us, one of his pupils (the eye, not a student) had already dilated, his blood pressure was lowish, and he had to be intubated for artificial ventilation support. To be honest, I only received the patient at the airlock of the operating theater; another colleague had managed the primary survey and care of the patient.

And since I'm being honest, the surgery was exhilarating. It was challenging, and I always love a good challenge. I had to be extra careful not to injure a major vessel, and as the bleed was over the cerebellum (just above the back of the neck), inserting a drain wasn't an option. I had to make sure the bleeding was fully secured.

Alhamdulillah, the surgery went without complications. There was no change in the patient's condition, but he was stable. The dilated pupil had shrunk to normal. He went for a post-operative CT scan in the morning, but his condition deteriorated a few hours later. Both his pupils were dilated, and he lost his brain stem function, which is the most primitive of the brain's functions.

Groggy from lack of sleep for over 32 hours, I reviewed the patient. I was disheartened when the nurse informed me about the patient's condition. Then I reviewed the CT. The clot had been fully evacuated, and there was no residual bleed. Judging from the scan, the surgery was a success.

Was it?

The worst part was that the patient's family is in another country. I had to break the news to his friends, I had to gently inform them that there was nothing else we could do, that they had to call the patient's family to tell them that he would not make it. He was in God's hands, now.

I know that when the patient came to us, it was already too late. I know that I did my best. But I wonder. I wonder if there was something more I could have done. A more aggressive surgery. A more aggressive post-operative management. Something. Anything.

I also wonder if what I had done had amounted to anything. Not for me, but for the patient and his family members who are oceans away.

Sometimes I just want to roll the windows down, close my eyes and feel the wind whipping against my face, and let God take the wheel. Because I don't know how to measure my success; not in this field.

A little Guidance, Perhaps

I seldom talk about my medical life. With good reason, too, as people have twisted my words and accused me of malpractice and murder. Haters are gonna hate, I'll give you that. As usual, I have to write a disclaimer. To quote Baz Luhrmann, "the long term benefits of sunscreen have been proved by scientists whereas the rest of my advice has no basis more reliable than my own meandering experience." I do not represent Neurosurgery or Hospital Kuala Lumpur. I do not represent the doctors of Malaysia, or post-graduate residents. This is all me.

Savvy?

I often hear complaints about house officers--newly graduated doctors who have to undergo compulsory rotations for 2 years before they are eligible for a permanent practicing certificate. Though house officers are as varied as monkeys in the jungle, the complaints are almost invariably the same: they're useless. They're spoiled brats who cannot do anything right. These statements are more often than not followed by lamentations on the death of good freshly-graduated doctors, or how things were not like this when the complaining senior doctors were house officers.

Let me be honest with you guys. The first few days of starting my housemanship, a specialist humiliated me in front of medical students when I could not answer his question. One of the students answered right, and the specialist scoffed at me and commented that I should not have graduated in the first place. In front of the students, in front of a perfectly coherent patient. My first month at O&G? Hated the department. Hated everyone in the department. Nothing I did was correct. I had to juggle between 4 teams, and I got the heat for forgetting something.

When I left, however, the specialist in charge of house officers in each department I worked for, when finding out a new batch of house officers were from USM, would ask them whether they knew me, and that they had big shoes to fit in.

While not the best in terms of knowledge, I was a proficient house officer. But I did not start off an excellent specimen. I had good teachers: senior nurses, senior house officers, medical officers and specialists. They spent time to teach me. In the span of a year, I learned so much more than I did the five years I spent as an undergraduate. I gained valueable knowledge that made me a safe medical officer.

So. Enough about me. For the moment.

We do not have house officers in my department. The first time I had house officers was when I did a 6-month rotation in General Surgery at Hospital Selayang. Suddenly I had this group of doe-eyed youngsters who kept referring me as "Dr Fadz/Fadzli". Just like in any other groups, be them humans or animals, there were those who stood out, whether from excellence or from sheer incompetence. Most of them were of average qualities, but hey, that's normal distribution curve for you. Sure, the number of these house officers is mind-boggling. When I was one, we had a maximum of 30 house officers throughout the whole hospital. When I went to Selayang, there were almost 20 of them per ward.

So yeah. When I was a house officer, there were so few of us that we had to make up for the slackers lest we would face the wrath of medical officers and specialists. Nowadays there are so many of them that they assume someone else would and should get the job done, and nothing gets done instead. The large number also reduces the chance for them to learn essential skills.

Is this their fault? I don't know. The country needs more doctors, so the government is churning out new doctors to meet the need. When you mass-produce something, the quality is bound to decline. But come on, to have newly-appointed medical officers complain about house officers, when they themselves had just been raised not too long ago?

Something's not right somewhere.

Let me ask you this: for those who complain about how house officers are made of suck, have you spent time teaching them, guiding them?

When I worked at Selayang, the specialists and medical officers organize classes for house officers on a weekly basis. During rounds they asked house officers about patient management. These youngsters were treated with respect. They were nurtured. There were several hopeless cases, but they were closely monitored.

Sadly, when I worked in another hospital (which shall remain nameless, but I'm sure you can venture a guess), there were plenty of house officer-bashing but an alarmingly lack of guidance. House officers who had almost completed their surgical rotation had never been taught about short central lines, ABG interpretation, even fluid balance. Sure, there were compulsory CMEs, but that was for the whole hospital and lacked individual touch.

I took some of them under my wings and did my best to guide them to the best of my knowledge and experience. Those who were interested to learn, anyway. My colleagues were surprised that house officers were willing to help me with inserting IV lines and getting blood for investigations, when they had to do those things themselves. They teased me when they found out I was teaching these house officers.

But someone's got to do it.

It's easy to give up on people. It's easy to complain about others on Twitter and Facebook. It's easy to create a group just to bash house officers. Sometimes people are made of suck, be them house officers, medical officers, and even specialists. I'm not judging anyone.

When I was a house officer, I was raised with love and respect. I was given the freedom to grow, to learn, to prosper. As a medical officer, I afford house officers the same love and respect. Imagine, then, when new house officers are treated with scorn and derision, how they'll treat their house officers in a few years' time.

They end up complaining about house officers when they're posted at another hospital as medical officers.

Break the cycle. Spend the same amount of time complaining about house officers to teach them instead. Treat them as friends instead of merely subordinates. Show a little love.

And a little guidance, perhaps.

Hope

"It is not the world I hope to change; if I could make a person's world better, I have done my part."

Two weeks ago, right after my first year exam, Ailani and I took the first weekend call. Needless to say, the call left me sleeping like a log the whole of the next day. I couldn't even afford the time to breathe a sigh of relief that exam was over, that despite what I had gone through, and still was--am--I didn't do so badly.

But this post is not about that. During the day, we received an urgent referral from Kuala Krai. A 16-year-old boy had met with an accident while riding his motorbike to school earlier in the morning. The accident occured at Kuala Lipis, Pahang, which was four hours from my hospital. He was comatose on arrival at the clinic in Kuala Lipis, where he was immediately intubated and rushed to Hospital Gua Musang. Unfortunately, the hospital doesn't provide CT-imaging and because of that, he was brought to Hospital Kuala Krai. Even then, the hospital was a good two hours away.

When the boy finally reached HUSM, a good seven hours had passed since the accident. He was stable, and since the intracranial bleed on initial imaging wasn't all that bad, we decided to insert a catheter to monitor his intracranial pressure. To my dismay, the pressure was well over the upper normal limit. Medical therapy did not help much. My specialist told me to operate on the boy post-haste.

It was over a year since my last bifrontal craniectomy. In our program, the first year is dedicated to strengthening the basics of neuroscience as well as clinical skills. I have to be honest: a part of me was itching to operate again. Thankfully surgery is somewhat like riding a bicycle or driving a car. Once you get the hang of it, you can spend time away but when you're behind the wheel, everything comes back naturally.

The surgery took me two-and-a-half hours, from three to five-thirty in the morning. Not my best time, but the patient was bleeding copiously. But what's more important was that the patient's intracranial receeded back to normal after the surgery. However, I had to prepare his parents for the worst. The patient had severe brain injury, and chances of survival were guarded; chances of recovery were even slimmer.

One thing I can tell you is that children are resilient. I don't know where they get their strength, but they are not as fragile as we believe them to be. This particular patient is no different. Against all odds, he not only survived, but recovered. When we thought he would need tracheostomy to facilitate ventilation, he proved us wrong. Within four days, he was extubated, and was transferred out of the ICU to the acute trauma ward. He was also able to respond to his parents, and was able to eat normally.

Earlier today, the patient was well enough to be discharged. He was sitting on the wheelchair, and he was smiling. He may or may not have understood what was happening, and he still wasn't talking, but this was the same patient we had expected to remain in a vegetative state, if he survived the first fourty-eight hours.

The patient may or may not fully recover; only time will tell. Life will definitely be more challenging for his family, and he may not be able to reach his full potential, the potential promised to every growing child. But everytime I looked at his parents, I could clearly see that no hardship would be too difficult.

Because their child lived. He's still living, he's still with them.

When I sat for the entrance interview, one of the consultants asked me why I decided to pursue Neurosurgery.

"Because people have the impression that a patient under the care of neurosurgeons will either die or end up a vegetable," I say.

"So you want to change how people look at Neurosurgery?" he said.

"No. I don't care what people think. I just want to heal people, one person at a time."

That was my answer, and it was the entire truth. It still is, and whenever I start to lose track of my goal, miracles like this patient occur.

I am not the sharpest tool in the shed. I doubt I will have publications in international journals (one can always hope), or make groundbreaking discoveries. I may end up publishing stories instead of medical journals, and novels instead of chapters in neurosurgical textbooks, but it matters little to me.

Because I treat my writing like I do with my day job. I'm not interested in changing the world. If I can touch only one person's heart, if I can make his or her world a brighter place even for a flickering moment, I have done my part. Mr Saffari, my boss in HKL, told me to write stories and blogposts about neurosurgery to raise awareness. He also advised me to keep honing my surgical skills, and to keep learning to improve myself. Because of this, I don't mind being the candidate everyone else loves to hate. I know I'm doing the right thing.

Let me heal people. That is all I ask for.

So you want to be a doctor

The physician's highest calling, his only calling, is to make sick people healthy--to heal, as it is termed.

- Samuel Hahnemann

 

I have noticed that my blog is listed under a doctors' blogroll, by several people, either newly-graduated ones, or those aspiring to be doctors. It's weird, because my posts are far from doctorly. Not exactly writerly as well, but no one is complaining. I am honored beyond measure to have people reading my rants, but to get listed on their pages? Dude, you guys rock!

To show my deepest appreciation, permit me to share some anecdotal tips, especially for doctors-to-be. First, a disclaimer. I am employed under the Ministry of Health, and I am now a Neurosurgical trainee, but this post is personal, and does not reflect my official position and my employers. Also, there is no scientific or factual basis to this post. We clear? All right, let's go.

 

 

Let's talk about the why

So. A doctor. Why? This is a recurring question, sometimes by people around you, and sometimes your inner self will ask you this. Especially when you're up at ungodly hours attending patients who just have to get involved in that frakking accident. I don't think you'll get over asking yourself why you insisted on becoming a doctor in the first place; God knows I still ask, "Why oh bloody why?"

 

1. I want to heal people, and make this world a better place.

Let's face it. This is the standard answer you'll give (and get), while your inner self will say an entirely different thing. Yep. I can read minds. I know what you're thinking. Don't worry, your secret is safe with me.

However, believe it or not, there are people for whom this reason for being a doctor (or a nurse or a paramedic) is real. It's easy to spot them. They're the ones who genuinely care about others--not just patients, but everyone around them. They shine the most when they help others, when they save lives. You can't fake this. Some people have inborn compassion toward perfect strangers, while others can't care less. These people are healers, and a rare breed.

 

2. I want to be like House and those amazing people in Gray's Anatomy, ER, Chicago Hope, and (insert your favorite medical drama here).

Don't laugh. I know you're one of them. Yes, you, the one who's snickering. We grow up drooling over the glamorous lives of these beautiful doctors, who get to save lives between rampant sex (sometimes even during rampant sex. Wait. That's a certain porn that shall remain nameless). We look at the doe-eyed patients and their family members, all gushing with eternal gratitude for saving their lives, for salvaging a limb to near perfect condition, for bonking them when they're about to die--wait...nevermind.

Point is, some people grow up deeply influenced by these medical dramas, and believe that they want to become great doctors like these fictional characters. Yes, they are FICTION. Sure, some doctors are supermodel-good-looking, some do enjoy rampant sex, but then there are people like me. A 30-year-old virgin, whose face only small children love and trust. No, I'm not a pedophile, dammit. Don't put words into my mouth!

When I was younger, I loved watching medical dramas. I liked how they saved lives. I liked how when they cardiovert a patient, the doctor rubs the pedals together, places them on the patient's chest, yells "Clear!", and turns the thing on, and the seemingly dead patient convulses mightily on the bed and then wakes up. Day saved. When I first cardioverted a patient, I knew that rubbing the pedals together is a BIG NO NO, and even though I got to yell "Clear!", the patient just flipped limply on the bed. His heart reverted back to sinus rhythm, but he passed away after 10 minutes anyway. I was left with a sense of disappointment and the sting of burnt flesh in my nostrils.

Needless to say, I stopped watching medical dramas altogether. Yes, even Gray's Anatomy. Nurse Jackie, now that's a different matter. Screwed up doctors and nurses. Now that's more like real life. You should watch it.

 

3. It's all about the money, money, money

Don't be surprised that a majority of those who answer (1) actually have this as their deep, dark secret. To be honest, I don't see why people hide this. You love money. You want to make lots of it. You believe that doctors make moolah, lots of it. You want to buy that certain CLK-550 (drool). You want a penthouse overlooking KLCC Park. What's wrong with wanting expensive things? At least you plan to do it honestly. Be proud of it.

But don't forget about those who want a better life for their family, those who come from a low socio-economic background, who want their parents, siblings, and children to have a living of much higher quality. God, this is one powerful and noble motivation. Never ever be ashamed of this. Make it your strength.

So. Can doctors make money? In an effort to prevent doctors from leaving the public sector, the government has given us a special pay scale that automatically increases the longer we stay in service. I've worked 6 years, and my pay before tax deduction is RM6900 a month. That's excluding on-call claims. Yes, compared to doctors in other countries' public sector, our pay sucks, but among other government staff, that's considered high.

And we have one of the greatest potential to make more. If you work part-time at private clinics, you get paid between RM30 and RM40 per hour. If you write medical reports, you get paid RM40 per report. If you leave the private sector and work full-time at a private clinic as a Medical Officer, you get around RM15,000 per month. If you own the clinic, you'll get so much more. If you work as a specialist in the private sector, you can easily make between Rm30,000 and RM60,000 per month, and that's excluding extra pay from surgeries and procedures. Like other lines of work, it depends on how badly you want to make the money, but unlike other lines of work, the opportunities are more, with numerous options.

 

4. It's a glamorous job. People respect doctors.

Quite a number of such people are influenced by medical dramas (see (2)). Let me get this straight: it ain't glamorous, and people no longer treat doctors like demigods. You save a life, you get blamed for not restoring the patient to his former self. You don't save a life, you get blamed for not doing your best, for being a screw-up doctor, for being a racist (yes, this happens). You give patients information, they challenge you with articles they read from the internet, which are by and large unverified. But they don't care about that. The internet says this, and who is the bloody doctor to say otherwise?

Sure, some older people still put doctors on a pedestal. They entrust their lives to you. They'll give you their house if you ask for it. They'll offer you their unwed daughter(s) even when you don't ask for her/them (yes, this happens, too). But then their children come into the picture and treat you like shit.

Being a doctor is an honorable job, an honest one. Be happy with that. Respect is never freely given, but has to be earned.

 

5. Being a doctor is a challenge. I love challenges.

As long as you don't faint at the sight of blood, by all means, bring it on.

 

6. Doctors have fancy tools and gadgets. I want them!

Buy a set at a nearest Toys R Us. Better yet, train to be a spy.

 

7. My parents insist that I become a doctor or they'll disown me.

I'm saving the best for last. Let me be absolutely honest with you. Most of those who flunk out of medical school belong to this category. Most of those who get mental breakdown belong to this category. Most of those who quit the job and become house-spouses belong to this category. Most of those who still work as doctors but hate the job until the day they die, yep, they belong to this category. And those who don't care about the patient, who just treat the job as a job and nothing more, you got that right. They belong here.

You have to realize from the start that you'll be dealing with human lives here. You'll be dealing with people who have families, jobs, mortgages, a future. You deal with individuals with names and faces. You can end up murdering a patient. If your dream is to become a banker, a teacher, an artist, an engineer, an architect, a horse rancher, a space cowboy, anything other than a doctor, go for your dreams. You'll do so much better doing what you love, trust me. If you don't see yourself as a doctor, and you hate it with all your heart, tell your parents the truth. They'll fume over it, accusing you for being ungrateful, but they'll get over it. Eventually.

Still. If you're totally trapped into doing this, then do your best not to resent the path chosen for you. Open up to the wonders and possibilities that lie ahead. Have fun, will you?

 

 

What to expect when entering Medical School

So you're a fresh high school graduate. Or you've gone through your STPM or A Levels or matriculation, and are one step closer toward becoming a doctor, regardless your reason(s). From the blogs you read, from stories you hear from people you know, from medical dramas (see how much I resent medical dramas?), you must have a few expectations.

I'm quite certain most of you are academic over-achievers. After all, the competition to fill up slots in public universities is beyond tough. Even though private universities are always an option, they don't just let anyone in, do they? Oh, wait. Some of them do, and end up producing dangerously ignorant and unequipped doctors.

God, the amount of things you have to remember, and most of them in Latin, if not French. Here the teaching medium is English, but if you're studying in Indonesia, the medium is Indonesian, and in Russia, you've got to learn a whole new alphabetical system! I have friends, highly intelligent ones, who had a hard time the first (crucial) year because they had a poor grasp for the English language. That, plus having lecturers teaching in English, thickly flavored with Indian, Burmese, Vietnamese, the likes.

I'm lucky in the sense that I use fluent English. I comprehend things fairly easily, too, especially when they come with diagrams. But I'm freaking lazy. I'm writing this instead of studying, am I not? I don't like memorizing things for the sake of memorizing, and I suck at mnemonics. That's why I scraped by, just enough to pass the major exams without hitches.

If you expect praises from lecturers and peers for being brilliant, guess what--to a certain degree, they're as brilliant as you are, if not more. Sure, at school you were the smartest of the lot. Everyone else was scum. But there are thousands of schools in Malaysia alone, and each of them has its own top students. You can always aim for straight As and Distinction Viva, and by all means, go for it, but if you expect people to bow in awe of your greatness, be prepared to be disappointed. There are always bigger assholes than you.

Do expect medical school to be expensive, even with sponsorship. The textbooks can have a pricetag reaching over RM500. Each. Some post-graduate books are over Rm1,000, but by that time, you were supposed to have saved up a lot to be able to afford those books. Yes, I'm berating myself here. Anyway, the food you consume late at night to fuel your midnight studying sessions, they cost money. The monthly trips home, some more money. The long-distance relationship with the significant other who you are convinced will wait for you, it costs a BOMB. And these relationships usually don't last. Trust me.

Expect to alienate your family and friends. Your schedule is different from other schools/disciplines, and you're supposed to be studying anyway.

If you brace yourself for a tough life ahead of you, you'll do fine. Learn humility, and learn it early on. It'll make your life so much easier. Again, trust me.

 

 

...and once you've graduated 

Congratulations!

 

 

 

Eh. That's it?

Of course not.

Life has just begun. Remember high school, when other students were scum beneath you? You're the scum now. If your family has thrown a party to celebrate your graduation, or has rewarded you with shiny toys or that trip to Europe you've always coveted, well, savor them. That's the last you'll feel good about yourself for the next two years.

I've read numerous rants and complaints in blogs belonging to House Officers. I find most of them ridiculous simply because they fail to grasp the enormity of their responsibility. For most, it's their first job. However, unlike any other jobs, one small mistake can kill a patient. You may think that clerking a patient is a silly, redundant task, especially since the Medical Officer has already clerked the patient. But the Medical Officer on-call has to attend to a lot more patients and new referrals. They may glance through the history and examination, only seeking vital information. A house officer has more time to deal with individual patients, or is supposed to, and can find out about, say, a patient's allergic history. If that is missed, and the patient develops anaphylactic shock and dies, that house officer has to take responsibility too. If your first reaction is "Don't blame me. The MO prescribed the wrong medication," then you'll spend your whole life blaming others for your mistakes.

When something goes wrong in the ward, the house officers are the first to be called. Imagine yourself a fresh graduate, attending a patient who's blood pressure has crashed, and whose oxygen saturation is too low to be picked up by the monitor. The nurses expect you to do something. That was my biggest fear when I started working. If you really don't know anything, suck it up and ask the nurses for help. The senior ones know their shit. Don't be too proud, because your pride can kill a patient. Get help from the Medical Officer, from the specialist, and don't be a hero. If you wanted to be one, you should have joined the army. Or the League of Extraordinary Gentleman.

Some complain about ungrateful patients, difficult patients, and patients with poor compliance. We have to keep reminding ourselves that these people are unwell. At the bare minimum, they have discomfiture. When you have a fever or a flu or whatever ailments, you're not your perky self. You're irritable, you bare your teeth. Why would you expect patients to be any different?

I have a pet peeve, and that is irresponsible parents. People under 18 cannot sign the consent form, and parents or guardians who delay or refuse treatment rob their children of their right to seek medical attention. As for others, well, we can only advice them about healthy lifestyle and the importance of medications or surgery. If they refuse, or are not compliant, it's their lives. When they come back with complications, derive the pleasure by telling them "I told you so."

I heard now there are more House Officers than there are patients. I used to take care of a whole ward by myself, and between 3 and 6 wards when I was on-call. I'm not going to be one of those who keep on saying "During my time...". Even with an abundance of House Officers, the workload is still high, especially with the burden of being responsible for the safety of patients. The first time I drove home after a 36-hour day, I rammed into a Volvo, which was static from the massive traffic jam. I had dozed off and accidentally tapped on the gas. Even now, I still have to periodically slap myself so I don't fall asleep while driving home. My family knows not to disturb me whenever I'm post-call, because I bite their heads off.

To make matters worse, some specialists and MOs take pleasure in reminding House Officers that they're scum, simply because they can. If you're dangerous, you're dangerous. If you get extended for this reason, then you have no one to blame but yourself. But sometimes, even when you know you're competent, there are always a certain senior who makes your life miserable. Here's a little insight: it'll never change. There will always be a superior who makes you feel worthless.

How to overcome this? Be the best doctor you can, and manage your patients well. That in itself is a reward. Forget the insults, and cherish the smiles from patients who recover.

Plan you career. I cannot stress this enough. It's never to early to figure out what you want to be, and being a doctor is no longer enough. Whatever your field of interest, prove your worth while you're a House Officer, so that specialists and/or the head of department may back you up and pull you into the department once your tenureship as a House Officer is over.

Don't take too long to take up a Master's Degree. I've been in service for 6 years, but I didn't spend those years reading academia and brushing up my knowledge. As a service Medical Officer, that was what I gave: my service. Sure, I gained a wealth of experience--not nearly enough, though--but I don't have to discipline to study without being pushed. Entering the program is indeed the push I needed to better myself.

 

 

Last piece of advice

Have fun no matter what you do. Have a life. Being a doctor is a facet of your existence; you have lots more to explore. Learn the piano and guitar. Take dance classes. Write stories. Play futsal with friends from your old school. Date the girl and/or guy you've always had a crush on. Go to the movies. Make movies. Use protection. Laugh. Cry. Laugh so much that you cry.

Wear sunscreen.

The Familiarity of Change

 
All changes, even the most longed for, have their melancholy; fore what we leave behind us is a part of ourselves; we must die to one life before we can enter another.

 - Anatole France

 

Change. It's something we long for. It's something we dread. Whether we like it or not, change comes upon us, eventually.

 
I wrote a post about this in January. In a short span of five months, change came upon me, some good, some I wish did not happen. Mama wears the hijab but remains the most fashionable mother around (no, I'm not saying this just because she's my mom or the fact that she reads my blog). And yes, people still say she looks young for her age. Arwen is growing up so fast, and is more intelligent than the whole family combined. I am now in Kelantan, paying rent for the first time in my life. I lost my best friend, anyway, though not from growing apart. I also made new friends, good friends. And best of all, I got reacquainted with old friends, which is always a good thing.

 
Fazrin told me a few times that Kota Bharu has changed much since I left six years ago. I drove to Kelantan expecting major changes, new streets, new places to hang out. When I arrived, however, the familiarity of the city (town?) seeped in. I drove past KB Mall, which opened a few months before I graduated in 2005, past a florist where I used to buy fresh lilies for my room (say what you want), past a banana-leaf Indian restaurant where Siva and Kean Khang used to take me for lunch, and a few other places that essentially remained the same. Billboards and buntings still use Jawi in addition to Rumi (Roman) spelling. And there are still separate payment counters for males, females, and families.

Of course, there were changes. They're building a new bridge and a flyover toward Pasir Pekan, and there's TESCO where I can get Big Apple donuts (I'm a J. Co guy, sorry), and surprisingly, the apricot juice I love, plus some fresh apricots! Most KB roads are one-way now, which still doesn't contribute much to the abysmal traffic, but the most apparent change has occured in and around my campus. The golf course has been replaced by an open stadium and a few sports complexes, and a few new buildings are cropping up, and along the road in front of the campus, well, the wooden stalls have been replaced by proper shop lots. Kubang Kerian seems to have transformed into a little town, complete with shopping complexes, inns, and bistros.

 
But the school and the hospital essentially look the same despite the fresh coat of paint and brand new staff uniform color scheme. I'm thankful that doctors don't have to adhere to staff uniforms. I don't do purple well. And it feels like wherever I turn, I greet old undergraduate friends who are pursuing their Master's degree in USM. Some are in their first year like me, while others are in second or third years. One is now pursuing his PhD. I don't want to admit it, but somehow coming back here feels like coming home.

So. Change. Instead of slaving at work, I now have to read academic books. Sure, I do feel stupid when the professor asks about things I've been taking for granted the five years (give or take) I've been in Neurosurgery. Sure, I find that my head is filled with cobwebs, and I've forgotten much of the things I've learned in my undergraduate years. But I find that reading up on the situations and conditions I come across fun. I'm filled with 'Aha' moments. I even borrowed two library books, which is totally out of character. I'm thankful that things are familiar despite the changes, that I can adapt easily.

 
I don't know what will happen in the next five months, or the next five years, but I realize that my old life has ended. For better or for worse, I've consolidated my path toward my future. Maybe I'll be a Neurosurgeon in four years' time. Maybe I'll stumble along the way. But I hope I'll be able to pick myself up. I don't like giving up.

As for writing, I've managed to write this post, haven't I? I've also written two complete stories and a Tender Moment. Maybe I'll even publish an anthology.

Yes. I am saddened by the loss of my best friend. I am saddened by my hesitation at exploring romance. I feel the pang of being away from my family and the accompanying drama. I miss going to the cinema on opening weekends. I miss my usual dose of Venti Caramel Signature Hot Chocolate from Starbucks. I miss my Unifi and its limitless bandwidth. I miss arguing with Arwen. I miss operating on patients. I miss my friends back in HKL.

I miss a lot of things. But I am open to new experiences.

Change.

Bring it on.

 

Senthil, Adrian, me, Jon Kooi, Jason, Yew Chin, Ailani, and Raffiz.

Your Apathy is Killing Me

Two days ago, while managing the outpatient clinic, I came across a pleasant old lady referred from another department. Why am I being subtle? The referring department was Orthopedics. The patient has long-standing hypertension and diabetes, and she already has peripheral neuropathy. In other words, she has high blood pressure and high blood sugar, long enough to cause end-organ nerve damage. She does not have any sensation on both feet, extending beyond her ankles. No sensations of pain, heat, cold, pressure, nada.

She must have stubbed the toe of her left foot, because in August this year, her daughter noticed pus seeping from the toe. It was a bit dusky, but she could still move all her toes. She was seen in the emergency department, and was promptly referred to Orthopedics. The patient was discharged with a course of oral antibiotics. Unfortunately the story didn’t end there. Her daughter brought her to the emergency department a few times in subsequent months, and she was also seen at the outpatient clinic. She was last seen in November, where the attending doctor referred her to General Surgery to exclude peripheral vascular disease (blood vessel damage). Maybe they didn’t have a Doppler machine to hear the pulsations of the vessels, but they could have at least done some investigations, such as feeling for the peripheral pulses and taking the Ankle-Brachial Pulse Index.

That didn’t irk me. Something else pulled the trigger. I did the bedside examinations and verified that the patient did not suffer from peripheral vascular disease. The left foot, however, was warm and slightly swollen. I suspected cellulitis (a nasty infection that crosses tissue layers from the skin inward). I called the Medical Officer on-call, to refer the patient back to them for further management.

What did the doctor tell me? “The patient doesn’t need surgery, right? Refer her to Medical.”

I said, “You’re the primary care team. The patient needs further treatment, and you cannot push her around.”

“That’s our policy.”

“Fine.”

I hung up and promptly called the Medical Officer on-call for General Medicine. She was kind and accommodating, but was overwhelmed by referrals at that time. She asked me to send the patient to the Emergency Zone, so that the ED Medical Officer could refer her to her colleague. Yeah, a bit convoluted, but at least they were more than willing to attend to the patient.

Let me make it clear that in no way whatsoever I am dissing the Orthopedics department. This is not the first time something as screwed up as this has happened, and this will not be the last. I have even witnessed pervious colleagues from my own department doing this to patients.

I am far from perfect. I come late to work, and I usually leave a half-hour early. I take extended lunchtimes when I know my patients are stable. Every so often I’ll lose motivation, and when I’m dead tired from hectic call schedules and cases, I’ll get cranky as hell. I make mistakes, though in my defense, I try to learn from them. But I am saddened by the prevalence of apathy among my colleagues. When we first decide to pursue this line, most of us are aware of what we’re getting ourselves into. It’s not an easy occupation, and the pay—if one stays in the public health sector—is nothing to brag about. As a matter of fact, a majority of us develop an inferiority complex when we compare ourselves with our contemporaries in private sectors. Those of us in major centers have a huge patient load, and we tend to overexert. We wear ourselves thin.

I can understand if a colleague is overwhelmed and cannot cope with additional patients. But pushing patients elsewhere when they have the resources to treat them, that’s just wrong. When asked, the common response will be, “this is a public center. If a patient wants better treatment, they can go to private centers.”

This “government” excuse for apathy is so overused, it’s a cliché. Yes, we concentrate our resources on treatments and medications that patients receive next to free, so much so that we cannot afford more comfort for patients and their families. This doesn’t mean Medical staff cannot offer the best possible comfort possible. People come to clinics and hospitals because they are sick. They want to get better. A little comfort goes a long way in facilitating this. I’ve seen some of my closest colleagues, both doctors and nurses, sigh and complain about their work—I join them in complaining, sometimes—but when they attend to patients, they put their game face on. They are at their best when attending to patients’ needs. I have nothing but love and respect for these colleagues.

Everywhere in Malaysia people are complaining that there are too many new House Officers produced each year, and their quality is steadily declining. One House Officer for every 2 to 3 patients. When I was one, the ratio was one house officer for every ward (28 patients). Theoretically, patient care should be better nowadays, right? I’m on the fence with this. I’ve seen good House Officers, and I’ve seen bad ones. However, I’m not so concerned about the sheer number of House Officers. The apathy of existing Specialists and Medical Officers should be addressed first.

Is this the example we want to set for the younger generations?

And to all, a good night

I knew this day would come. All my life, my family and I would drive back to JB to celebrate the Eid (or Raya, in my language) the day before Raya itself. I can still recall our trips back in the days before the North-South PLUS highway. It would take us between 6 and 8 hours to get there from KL. My parents would be up front in our silver Isuzu trooper, with Kasha sprawled across the back seat, and Faiz and I, well, our parents would organize our luggage, the food warmer, a large number of tubs and containers filled with rendang, biscuits, cakes, and other foodstuff, and then lay the pink-and-gray-stripes sofa mattress over the cargo. That was where my brother and I hung out for the duration of the long drive. We would always stop at this particular mamak shop at Yong Peng, and Mama would take the chance to do some pottery shopping (typical).

 

Back then, Raya used to be magical. Partly because we were eligible to collect packets of money whenever we went visiting relatives, or when they came to our grandparents' homes. But most important, we got to meet up with our grandparents, aunts and uncles, and cousins. Yeah, we're bad relatives that way, only meeting up occasionally (at least once a year, though).

 

But life happened. My favorite cousins, the Roslans, moved to Perth in 1989. Then my dad's parents passed away one year apart. Dad's siblings sorta drifted apart (family drama). We made new traditions. Every year, on the first day of Raya, we would go visiting our grandparents' graves. We would always get ourselves lost, but whenever I go there, I can recall their general position, as well as the grave numbers. We'd stay at Mama's parents' house for the whole duration of our stay in JB, and when we could no longer visit relatives in Singapore (more family drama), we'd meet them at my grandparents' house.