Not accidental

Although at times my workplace resembles a hell hole and at times you get really jaded and cynical, I have managed to reserve the last ounce of my sympathy for a group of patients who suffer a rare and seldom publicised disease. It is not a disease mediated by bacteria or viruses, neither is it mediated by the body's immune system, nor by tumour cells that divide uncontrollably.

It is a disease called humanity.

The discourse of weariness

So there I was today, helping this nice friendly registrar (NFR) review one of my ward patients. As NFR was writing his notes he randomly asked me, "What do you want to do in life? You like Paeds?" No I said I don't want paeds. So he asked, "Surgery?" Of course, he made the common sterotype that since I'm so well nourished, I must be a surgeon wannabe. It's something that many people assume.

I told NFR... Well I like adult medicine.... Or GP. And NFR said, nonono dont make the decision too early to be a GP. Limiting your personal growth prematurely. Spend time exploring what you like first. Work at a job you don't like and you won't do well anyway. Well at least I think that's what he said. NFR has a nice big moustache and a very thick accent, very hard to make out his words.

So one month ago I and fate cruel fate crossed swords. Passed the greatest exam of my life. But at the same time got hit with my first career setback even before the career began. Got thrown into this strange place I thought I'd never see again. Had to change my decision to turn my Paeds notes into a bonfire. Had to do procedures in miniature veins even when I already wasn't confident working with adult ones. Had to hear ear piercing screams everyday.

So what am I now... World weary and ready to find easy ways out? Ready to make personal comfort and luxury the top priority? Or courageous and faithful enough to chase what I believe in. But what do I believe in now. Just gotta wait and see. Anyway the wind blows doesn't really matter to me.

Been wanting to do something meaningful with my time after work. Read a book. Read up on Paediatrics to plug my titanic knowledge gap. Run. Spend time with family. But everyday I just come home really tired, surf the internet for a while, then sleep.

Thankfully today I managed to read up on neonatal jaundice a bit and talked to my mum and sis. But still can't run.

Despite all these there is much to be thankful for. Nice nurses, great colleagues. The opportunity to learn many things I would never have, had I got my first choice postings. The chance to watch people's childhoods.

So I guess I can't complain much after all.

The rolling stone

When you make yourself take stock of your blessings, are you learning to be thankful or are you simply compromising your standards? When you rue what you did not have, are you being ungrateful and unreasonable or are you simply asserting your right to have that ambition?

How does it feel

How does it feel 
To be on your own 
With no direction home 
Like a complete unknown 
Like a rolling stone ? 


When you got nothing, you got nothing to lose 
You're invisible now, you got no secrets to conceal.

When you told me to carry on and be the best I can, perhaps it was one of those things you'd say to console people but it meant more to me than you can imagine. I'd carry on.

Work-life: A balance or an unnecessary dichotomy?

It coincided with my first week at work: Today's Sunday Times published an article by Rachel Chang ("Why work so hard unless it's fun?, Sunday Times 6 May 2012 Page 39) that spoke about the attitudes of Generation Y towards work. Generation Y, driven by the desire to live a life that is "broad, rather than deep", "enjoyment driven, rather than achievement oriented", are the generation that are living "work-life balance" for real."

The article ends with a call to live what it thinks is a wholesome life: "Since the great majority of human beings are going to be quite average in the grand scheme of things, why spend our lives striving for ultimate mediocrity, working 100 hrs a week for a two-bedder near Somerset and a set of broken personal relationships?"

The suggestion that "work" needs to be balanced by "life" implies that they exist at the opposite end of the scale. They are sundered rather than integrated, incompatible rather than complementary. Yet, I question if such a dichotomy must necessarily exist.

Perhaps for a 9 to 5 white collar worker, it would be easy to divorce work from personal life. After all, he would be dealing with seemingly meaningless trivialities at work- minutes, proposals, accounts, contracts. All other people are clients or colleagues. Life begins when he steps out of the office and returns to friends or family. But in the case of many people for whom fellow human beings are their "work"- nurses, teachers, social workers, paramedics, PTs and OTs- there is much personal energy and emotion invested, and even their own safety may be compromised. The barrier between "life" and "work" may not be so insurmountable.

I've  realised that in these first few days of work there have been a few personal ideals pushing me on, ideals which as a student I never realised I had. After all, my family have been on the side of the patient- or nurse-  and have seen loved ones suffering from illness and death. We've seen our fair share of incompetent or uncaring doctors and have complained about them. I have asked myself these few days, "Do I want to be the kind of doctor my family would complain about?"

I mean, imagine the shame I'd feel if next time my loved ones complain about the healthcare system, and I realised I was one of those incompetent healthcare workers that disappointed them.

Of course I also work to survive the day, survive ward rounds and grillings. But at the end of the day, what you want is a peace of mind as you face yourself at night, as you face your family members, as you face the cross and the worship band on Sunday morning. You want the peace of mind that you have done your job well and deserve to relax and enjoy your time outside work. In this manner, I don't see why work should be treated as a sort of dark secret to be put away, something that needs counter-balancing.

Work-life needs not always be a dichotomy. Our worth as human beings may not be limited to our professional endeavours, but work is one of the many things that contributes to a wholesome existence.

---------------------------------------------------

By Rachel Chang
The curriculum vitae of a friend of mine would throw any headhunter a curve ball.
It is impressive and not padded out at all. She did a financial-type degree at one top school and then a humanities-type master’s at another.
And while in a management position in her day job, she spends an almost equal amount of time outside of it indulging her love for art - working at galleries, interviewing artists and writing for an art magazine.
She was asked once why her professional pursuits seem so unfocused. ‘Why not?’ was her reflex reaction. We were always encouraged to be well-rounded, and to follow every passion.
Surely the enjoyment of many activities in one’s life is as valuable - if not more so - than a single-minded, intense pursuit of one career path.
But one man’s definition of well-roundedness may well signify dilettantism to another. Perhaps what Generation Y defines as good living is what older generations may call lazy and capricious.
We want to have a life outside of work, have an array of hobbies, and switch jobs early, and often. They call us jacks of all trades and masters of none.
I once attended a women’s networking event, where a politician in her 50s was imparting words of wisdom to professionals in their 20s.
One participant said that she was in her third job, after graduating in 2007.
‘Wow,’ said the politician. ‘I’m in my second job, and I graduated in 1978.’
I saw a generation gap yawn open in the silence that followed.
It’s the same sort of chasm between workaholic bosses and their resistant underlings in offices around the island. An editor once told a few of us young journalists not to put work ahead of our personal lives.
When she was a cub reporter, the demands of the newsroom superseded everything, she recalled. Even if you were meant to celebrate your mother’s birthday, if the newsroom needed you, you worked.
Don’t be afraid to ask for that time off for personal commitments, she told us. The thing is, I don’t think it ever occurred to us to be.
Of course, there are still people out there burning their 20s off in blocks of 100-hour work weeks. Presumably, they will wake up one day when they’re 35, look at the worn face looking back at them in the mirror, and quit their jobs to run a scuba kiosk on a Malaysian beach.
But by and large, this isn’t the generation that had to invent a term to remind themselves that their jobs aren’t their lives. It’s the generation that is living ‘work-life balance’ for real.
The circumstances that enable this well-rounded, unfocused lifestyle are the same blessed ones that engender all of Generation Y’s other failings.
Affluence, choice, entitlement, time spent on the Internet - all abounding in inverse proportion to real responsibility.
But what if this isn’t just the whimsy before the wake-up call of adulthood? What if it’s not Peter Pan syndrome, but a genuine desire to live a different sort of life - one that is broad, rather than deep; one that is enjoyment-driven, rather than achievement-oriented?
I cannot deny that well-roundedness seems unlikely to be a trait of anyone who has ever changed the world. Steve Jobs, Bill Gates - those guys probably didn’t take archery classes on weekends and spend time perfecting their downward-facing dogs.
They probably didn’t have a thing for Werner Herzog, or a Pinterest board that is repinned constantly by like, everyone.
But how many of us are really going to be one of those people anyway? And since the great majority of human beings are going to be quite average in the grand scheme of things, why spend our lives striving for ultimate mediocrity, working 100 hours a week for a two-bedder near Somerset and a set of broken personal relationships?
Why not spend quite a bit of it just having, well, fun?
I believe it was a dilettante who drank too much and flunked out of law school who envisioned a world where nobody would be defined by an ‘exclusive activity’ - what we would nowadays call a career.
He dreamt of a world where it would be possible to ‘do one thing today and another tomorrow, to hunt in the morning, fish in the afternoon, rear cattle in the evening, criticise after dinner - without ever becoming hunter, fisherman, herdsman or critic’.
I guess Karl Marx never changed the world either. But he sure had a lot of fun.
rchang@sph.com.sg

The night before work

Whoever tries to keep his life will lose it, and whoever loses his life will preserve it. (Luke 17:33) 


Whoever finds his life will lose it, and whoever loses his life for my sake will find it (Matthew 10:39)


Some verses that I have been meditating on the past few days.


I guess I should have seen it coming. What seemed to be a slap in the face in return for my past arrogance and cocksureness. A slap that would take a long time to recover from.


Let's just say that I tried to find my life, to build it. I had plans, I did my calculations. In spite of everything seemingly going well, it just didn't happen.


Anyway, I remember an email the ex-Dean sent us last year, about how the key to many people's successes was not about finding oneself in life, but to lose oneself in work, or whatever endeavour you undertake in life. I don't have that article anymore but I'd like to read it again. Lose- to immerse, to commit, to give. In the verses above, the one who loses his life does so with his lord and savior at the centre. 


I hope that in the course of my career I can find something to lose myself in, and hopefully the same goes for anyone who reads this.


And yes I really hope I don't kill or injure anybody.


Now listen, you who say, “Today or tomorrow we will go to this or that city, spend a year there, carry on business and make money.” ¹⁴ Why, you do not even know what will happen tomorrow. What is your life? You are a mist that appears for a little while and then vanishes. ¹⁵ Instead, you ought to say, “If it is the Lord’s will, we will live and do this or that.” ¹⁶ As it is, you boast in your arrogant schemes. All such boasting is evil. ¹⁷ If anyone, then, knows the good they ought to do and doesn’t do it, it is sin for them.

An online code of conduct!

Recently, it has been proposed by the government that a code of conduct be written for internet users, with the intention to regulate xenophobic, racist or any inflammatory online comments. Naturally, many bloggers have objected vehemently to it, for example here and here.

I too object to it, but not because I don't believe in the necessity of a code of conduct, but because I can't see any plausible way it can be implemented.

For a start, I believe that freedom must be balanced by responsibility. I tire of the various inflammatory and unproductive online comments that spread around the cyberworld like viruses, especially because they are hidden beneath the cloak of anonymity. Some people do not stop at spewing vitriol, they resort to revealing the personal details of the people they want to attack.

Such are actions of cowards. You are free to make any comments you wish, but you will have to account for your words. You have to put a name to them. As such, I admire Richard Wan of TRE for revealing his true identity in a recent forum, although this immediately attracted two lawsuits from our "royal family". Well, at least he was accountable.

But a code of conduct? Who are the authorities kidding? You can write down such a code and put it somewhere but I daresay no one will follow it. No one will visit that webpage, if any. On the other hand, Singapore can try to make sure people follow it by tracking down IP addresses and sending warning letters. Yet, given many other pressing issues at hand such as the MRT breakdowns and rising COE prices, this is a fine waste of public resources. Our government can emulate their Chinese counterparts by shutting down website after website, including Facebook and Twitter, but surely this will attract a great deal of trouble not just from the local but also international community.

As such, the most practical options would be to develop a thicker skin, and also be mindful of any online posts. And although I don't know how it can be done, if the authorities manage to reduce train breakdowns, lower COE prices and narrow the income gap, I'm sure the stupid useless comments will dwindle.

For many bloggers, especially those who are in professions that are under huge public scrutiny, it is important to be aware of the ever increasingly aggressive and open cyberspace. As a true litmus test of whether your post should be published, ask first if you are willing to stand in front of a crowd to defend and account for your words. No hiding behind pseudonyms, no hiding behind computer screens. If you are willing to do as such, then proceed.

A game of shadows

There were some events today that made me more aware of my nasty side. I don't think that part of me grew without reason. I guess if I were to look at myself as a Year 2 or 3 student, the main difference would be that back then I was so full of hope and optimism about everything in life. But in between then and now there have been several events which disappointed me significantly, and slowly eroded away this upbeat altruistic side to my character.

Jenna Talackova, a transgender, was disqualified from Miss Universe Canada.

Anyway, I've read about the recent change in rules to allow transgender women to compete in the Miss Singapore Universe Pageant. My first thoughts were, "REALLY?! SERIOUSLY?!"

Let me explain myself. Firstly, I am no fan of this pageant because it's just another occasion for many pretty bimbos to strut their custom made sexy figures and terrible English on the national stage. No doubt, the memories of Ms Ris Low have forever tainted my impression of beauty pageants.

Nevertheless, the issue has brought to my mind the evergreen Nature vs Nurture debate. On one hand, you have the "natural" ladies (ie born female) who may have been born beautiful, yet also may have starved themselves or underwent cosmetic surgery and ten layers of makeup to achieve their external beauty. On the other hand, you have the transgenders who have underwent very extensive surgery indeed. A common argument would be that if you can accept ladies who have underwent plastic surgery and strict dieting regimens, why not be a little more receptive and accept men who have underwent the same?

I have no doubt that external beauty has a huge "nurture" component to it. Yet, I don't know if we are crossing the line by allowing men to compete as women. I'm not going to pretend that the original Miss Singapore pageant celebrates "authentic" feminine beauty in the first place, what with all the vacuous talk and politicking and cosmetic surgeries, but I think allowing transgenders in this competition will remove the last vestige of authenticity, of female beauty, that this competition was originally meant to celebrate. Simply because these new candidates are not female. I've studied human biology like many others. Their chromosomal make-up remains XY. You can give them fake breasts, fake noses, fake lips and lots of hormones but it doesn't change the fact that they are biologically male.

What is real?
This brings me to the wider issue of authenticity in our world today. Personally, I've tried to be a devout follower of the idea of authenticity. Something real. Something that didn't need pretending. Something that was given rather than manufactured. And yes I am away that this idea doesn't have a lot of strict definitions and boundaries, henceforth much debate on what constitutes authenticity. I'll use sport as an example:

In today's sporting world, many countries allow naturalised citizens to play for their sports teams. You have people like Miroslav Klose, Lukas Podolski (both born in Poland) who were raised in Germany and who are regular starters for the German national team. The same team consists of many German born players with foreign blood such as Mario Gomez (Spain), Mesut Ozil (Turkey) and Sami Khedira (Tunisia). But nobody has a problem with that because after all these people were raised in Germany and are as German as Angela Merkel.

It becomes more of an issue if the player wasn't raised in their adopted country. Look no further than my own Singapore. Our table tennis, swimming and soccer teams are full of athletes from China, Serbia and Nigeria, among other countries. Many of them came over as teenagers, even adults, to play for Singapore. I have no doubt about their excellent sporting ability but my simple question is- are they even Singaporean? Looking at them, can you feel a social connect, as compared to the people around you you went to school with, served NS with, lived with? However, it seems that according to the authorities, what makes a Singaporean would simply be words on a passport and an ability to bring trophies and glory to the country.

Somehow I see a parallel with allowing transgenders to compete in this pageant. You change the external form (breasts, buttocks, face) but internally (ie chromosomes) the person is still a man. Now of course the situation is more tricky because psychologically, these people are female. They are certainly entitled to that but surely they can compete in their own transgender beauty pageants.

Now if you allow me to let loose a little, it is because of things like these that lead me to question what is real  in our world. And as you know that is a dangerous question because there are no answers, only the feeling of emptiness at the end. But enough of that! I'll end of with what I think is "authentic female beauty", since I talked so much about it.

To me, beauty has both physical and intangible components. First up, we will start by acknowledging the importance of physical beauty. You can say that as a  guy I am being same old superficial, but hey, no lady wants to be caught dead with a fat ugly hairy balding man? Yet, physical beauty isn't everything. There are plenty of "vases" out there- pretty women who are simply vacuous. For me, the foundation of beauty is charisma.

Now this is where my words are limited because I don't think you can fully put charisma into words. Similarly I can't fully describe verbally why van Gogh's Potato Eaters had me staring at it for minutes, or why I can listen to the ballad of Queen's Bohemian Rhapsody ten times in a row, or why Led Zeppelin's Kashmir and Stairway to Heaven is so mesmerising.

But here are some examples: Kate Winslet, for her stunning, daring portrayals in movies like Titanic and The Reader; and you have Paige Chua, who exudes charisma from her reserved, composed demeanour coupled with a million dollar smile.

That, my friends, is female beauty, which Miss Singapore Universe was originally supposed to celebrate. Physical beauty combined with charisma and intelligence. I'm sure Singapore has no shortage of born-females to step up to the task. Nevertheless, now there is a possibility that an ex-male can be deemed more worthy of the job, something that can only be a slap in the face of born-women in Singapore.

A song I wrote

I was inspired to write down my thoughts about transiting from an undergraduate to a working adult. Once again, I wanted to blend clarity with subtlety and what better way to do it than to write it in the form of a song, sung to the tune of John Lennon's Working Class Hero

Four and twenty

Well I’d been to my dad’s grave one drizzling day
He said many things that he might have to say
He told me his dreams and the same come-what-may
They say life commences at four and twenty
They say life commences at four and twenty

“Such a boy, such a boy” echoes within
They want you to be friendly but not such a teen
They want you to grow up but be free of sin
They say life commences at four and twenty
They say life commences at four and twenty

You win the maiden over with firm intent
You chase the career, money and apartment
You serve mankind, be holy, be superman
They say life commences at four and twenty
They say life commences at four and twenty

When you make your steps on that long winding road
When you feel your shoulders sag under the load
You'll see the dim light of a humble abode
They say life commences at four and twenty
They say life commences at four and twenty


Man in the moon is now turned into stone
Mama, I killed a boy and now I am alone
Sister is happy and so much at home 
They say life commences at four and twenty
If you want to take it then come follow me

I pissed in the face of idealism today

Being an Apple addict, I've always considered the iPhone as the natural successor to my cranky geriatric Nokia phone that I've been using since end 2008. This was until I had second thoughts after being reminded of Apple's exploitation of Chinese sweatshop workers.

So which brand to buy? I gave social justice a chance and googled "HTC sweatshops", "Nokia sweatshops" and "Samsung sweatshops", among others. It turns out that everyone is guilty, although I can safely say HTC and Apple are still the major culprits. And even if Nokia is relatively... innocent so to speak, it's quite likely there is some dirt not yet uncovered.

Screw it I bought the iPhone anyway.

Perhaps the very act of existing in a first world country can burden you with enough sins to send you to a very warm place after you die.

Do you like technology and gadgets? Do you like running? Do you like jewellery? Look at the things around you in your house. I bet ten dollars at least some slave died or got significantly injured to produce one of the things in your house. But again, not that you can do anything much. The only solution is to go live in a cave.

Many events, including the realisation that my iPhone is very much a clone of my old iPod touch thanks to iTunes syncing, have left me feeling really helpless.


Mama,just killed a man,
Put a gun against his head,
Pulled my trigger,now he's dead,
Mama,life had just begun,
But now i've gone and thrown it all away-
Mama ooo,
Didn't mean to make you cry-
If i'm not back again this time tomorrow-
Carry on,carry on,as if nothing really matters-

Too late,my time has come,
Sends shivers down my spine-
Body's aching all the time,
Goodbye everybody-i've got to go-
Gotta leave you all behind and face the truth-
Mama ooo- (any way the wind blows)
I don't want to die,
I sometimes wish i'd never been born at all-

Stone slabs

Day and night, as the hustle and bustle of life went by, the stone sat quietly for months untouched and unnoticed. Occasionally it would smell the scent of fruits and flowers or the stench of smoke, it would hear the chatter of the cleaners or the visitors. It would weather the rain and the wind and the merciless tropical sunshine.

Today the boy stood by the stone, sometimes head on chin, sometimes arms folded, sometimes face buried in hands. He wants some quiet time with the stone. But the cleaner would not allow it.

"GOOD MORNING SARRR!" He grins at the boy. The boy smile back politely.

Quick and efficient and ever opportunistic, the cleaner grabs his cloth and wipes the stone corner to corner, end to end. His strokes are rapid and eager. His back is turned, and he does not notice that the boy behind him has reached into his wallet and produced the $2 note.

This is a custom that the boy's mother taught him.

The cleaner doesn't stop cleaning the stone. But the boy wishes him to stop and just go away. He puts the $2 note in view of the cleaner. "Here. Thank you very much"

The cleaner is happy. "THANK YOU SARRR". He flashes a white toothy grin and goes away out of sight and mind.

The boy continues looking at the stone, sometimes head on chin, sometimes arms folded, sometimes face buried in hands.

The boy takes a walk around the place. He is familiar with some other stone slabs. The neighbouring stone whose photograph has grossly faded. The stone of the plump bespectacled young man. The stone of the man who was knocked down by a truck in 1964. The stone that was once an empty hole that had an exam paper slotted inside, dedicated to "Mummy"

This particular stone was Terence's stone.

Terence was a down to earth man, and a man of the old world. He scrimped and saved for his children. He spared no expenses when it came to his children's education. He didn't have any particular ambition for them but simply wanted them to be "useful to society".

Day and night, as the hustle and bustle of life went by, Terence would sit quietly for months untouched and unnoticed.

Second lives

It has been in the news that a 19 year old girl got into trouble for using racist language on Twitter. There is quite to talk about the subject, especially about racism in Singapore, but since it is past 2am I'll focus on one aspect which is the use and abuse of the Internet among our citizens.

When I was a teenager, I made friends with the Internet, first through the use of my old blog. I mean, it liberated me and gave me an outlet for expression. You can guess how important that was to a shy, awkward 15 year old. It was almost as if it gave me a second chance at a life which I had some trouble living out as a human.

The mentality persisted throughout medical school. The need to showcase or exhibit that I "have a life" led me to write many personal details down on my blog or facebook. Looking back, there wasn't really that need. In fact, it could be a liability because a simple slip of the tongue can create trouble, especially since you don't know who are your real friends out there. And I've experienced that sort of trouble a few times before.

It's not difficult to see why the Internet can be a conduit for strong, even hateful, expressions. I mean, it is a cheap watered down version of real life. In real life, to express an idea, you have to speak in front of a person or people, you have to show your real face and identity and be prepared to face conflict. Can you imagine making a racist remark in the middle of a crowded MRT station. That's spooky. But on the other hand, on the computer, you just move a few fingers and with that you can act and talk like a superhero on facebook, on blogs, on forums. You face only an inanimate computer screen and the words of people you cannot know or see.

Anyway, as of 1st Jan this year, I've deactivated my facebook account. Very ironically, I got that idea because I was facebook surfing and I saw an article on disconnecting oneself from the Internet to find inner peace and rejuvenation.

The main reason for the deactivation was of course to study for the MBBS. But there were other reasons too. Chiefly, I thought it important to return to "real life" as it is. I didn't want the virtual world to become a convenient substitute for my humanity. I wanted to talk to people, discuss things with people, do things with people in the physical world. Secondly, I realised I was overloading myself with useless details on what other people were doing. Now put it in context- can you imagine studying for the crap MBBS, only to see one friend after another clubbing/touring the world/going for funky gatherings? So I decided to spare myself the agony.

On to blogs now. I mean, in the past, I'd write every stupid damn thing on this blog, but perhaps something came over me in Year 5. I guess, I decided to fulfill a higher meaning with my writing, and by that I mean a purpose that is beyond simple self absorbed accounts of daily life. I decided to write about ideas instead, with the hope that anyone reading this can leave this webpage with his mind somewhat stimulated. You do not need to agree, but I hope you didn't waste a few brain cells reading boring accounts of my life.

And I suppose my mission was greatly helped by the fact that my private life in Year 5 was utter shit. Few outings, few breaks, few moments of inspiration, no girlfriend, full time mugger. There is nothing to write about except more intellectual stuff.

Now back to the topic of facebooking- will I abstain from facebook forever? No. I told myself the facebook page would be reactivated if I were to pass the MBBS, and I would know on April 16. Right so I'd still be using facebook after all, because at the end of the day it really helps make communication easier. If you want to catch up with friends, arrange gatherings etc, just use Facebook. But online media such as these are meant to facilitate human to human interaction, not substitute it. And with that I have to use the FB page differently from how I used to use it. How so? If I were to tell you here on the internet, it will be a supreme irony right?

Anyway, since I'm in the mood, I decided to indulge in some cheap exhibitionism anyway and show you the food I've enjoyed over the past year, starting from Xmas dinner (yes I took time off studies to celebrate. And yes it seems this entire discourse is pretty incongruent and incoherent but to hell with it anyway. Just look and enjoy):

Below you'd see the lunch I had at Aston's a couple of days back:

What has MBBS got to do with defensive medicine?

So, thankfully, the horror has ended. It has been more than nine months since my mind was totally free of the burden of exams, exams which cost me a large amount of time with family and friends and doing things I like.

My friend, who is obviously not from Medicine, asked me before why we are so worried about these exams. She couldn't understand why, when 95% of us pass, we'd let such an exam turn us into stressed out, freaked out studying machines. But she's right! She has a point, and so do we, in actually being paranoid about that fearsome 5% chance. Unfortunately, at that time I was too obtunded from studying to explain to her properly.

Firstly, although there is a 5% (or so) chance, it is a very unpredictable 5% of people who fail. Back in secondary school or junior college, those who fail exams are the jokers who spend all day playing computer games, wasting their lives away. (By fail I mean get below 50%, not fail to get an A grade) In medical school, those who fail are actually people who still study very hard and know a lot and want to pass, but many unforseen circumstances occur:

1. You get very very nasty examiners and you freak out in front of them

2. You get patients who can tell you the wrong things or refuse to tell you things

3. Under pressure, you make up things to say to the examiner and get caught.

4. Sometimes you think you did well but you may have said the wrong things and the stupidest things, not out of ignorance of the art and science of Medicine, but for want of simple common sense. Eg. saying that a patient hasn't been treated correctly by doctors.

And thus these people fail. Of course, it is a mix of student and examiner factors, but it really is quite unpredictable. A significant proportion of these students are actually academically strong.

Secondly, need I not reiterate that the consequences of failing are immense. There is a gigantic psychological blow because you spent almost a year putting yourself through tremendous mental and emotional and physical stress, only to... fail. It is hard trauma to your self esteem. More pragmatically, it means a few thousand more dollars of daddy and mummy's hard earned savings down the drain.

That's why MBBS scares the shit out of final year medical students, despite them having a clear statistical advantage. The zenith of the fear comes during the Surgery long case, where a mere 30 min of clerking decides the course of the long case examination, which if you fail, you fail the ENTIRE exam. There is only one Surgery long case. Comparatively, you get second and third chances during other exams.

Little surprise that, before the Surgery long case, I knew of more than one person who wanted to puke. Another person shared how she cried the day before the exam. Another person told me that the morning after, he woke up in tension. These aforementioned people aren't your average softies. They are athletes and leaders, some of whom the common citizen may fear meeting in a dark alley. Personally I didn't vomit or cry, but I had nightmares and palpitations and an entire butterfly sanctuary in my stomach.

So, to sum it up:

1. There really is a low chance (5-10%) of failing the MBBS

2. But it is very unpredictable who actually fails

3. And the consequences of failing are catastrophic.

4. Hence, people study their asses off for MBBS

And I have been thinking for the past month, that very similar principles apply to defensive medicine:

1. There really is a very low chance of unexpected catastrophic events occuring (eg. a healthy patient electively admitted for surgery who dies of severe infection)

2. But it is very unpredictable when such events occur

3. And the consequences of these events are catastrophic. Patient dies. Family sad. Dr sued. Dr defamed in newspapers.

4. Hence, some doctors practise defensive medicine.

Fear is a strong strong word. Our technology of today has enabled us to conquer many diseases and many natural barriers, and thus our fear of those, but we have not fully conquered the unknown. As such, we fear it so, so badly. Even the narrowest of possibilities have many of us subjugated through fear.

Ok, now I think we should move beyond this vulgar four lettered f- word. To me, it is not just about fear, but also the want of being safe and thorough, which, well, is a cousin of fear.

A few months ago, a senior physician gave us an MCQ quiz. One of the questions were as follows, as far as I can remember. This 30ish female lawyer with no past medical history came in for a chest infection. On the day of discharge, she complains of leg pain. Do you a) leave it alone or b) do a Well's score and a doppler ultrasound? (and there were other options too)

So of course the class was pretty much split between a) and b) when our the physician told us that we should actually leave it alone, because according to statistics there is unlikely to be anything wrong with her (Note: the story is as I can best remember and is no substitute for academic or medical advice. Defensive blogging haha)

Later on, my friends and I discussed the case. I was adamant that the Well's score and doppler ultrasound should have been done. I mean, what's wrong with being safe than sorry? My rationale was that although very rare, it only takes 1 in 100000 incidents to ruin someone's life and your career, not 1 in 5 or 10. Most importantly, these investigations wouldn't cost the patient much. Well's score is free of charge and the doppler maybe costs about $10? Surely as a lawyer she can afford it.

On the other hand, I find it morally wrong if you order an unnecessary MRI (which is very expensive) for a patient who has obvious financially difficulties. If you let your fear burden a patient, that is not acceptable.

On yet another hand (assuming I have three hands), I have had the experience of really letting shit happen when I tell myself "there is nothing wrong". See this, under the section "Pseudo-malingerers".

And also, there was the time my HO, MO and I were caring for this patient and I noticed "increasingly dry skin" on his feet. Time and time again, I wanted to tell my HO but we always spent very little time on this patient so I never did so for many days.

Hey, there's nothing wrong right? Even the HO or MO didn't notice anything. But one fine day, I decided to open my stupid mouth and my HO agreed, "Let's write a derm referral". I wrote a fine letter stating how "Mr XXX has a dry scaly rash affecting intertrigonous areas of the feet, with the likely impression of tinea pedis (ie fungal infection). Kindly review patient and advise on management." Derm came back and stated that PATIENT HAS SCABIES. SCABIES FREAKING SCABIES. He had to be sent to the isolation ward.

Do I feel proud or downright ashamed of myself in such a case?

Now back to the main issue, is defensive medicine "the right thing to do"? Having read many diatribes in the newspapers and the internet, of course the simple answer is that it is wrong. Of course it is easy to say that defensive medicine is wrong.

But I am also of the opinion that having healthy patients die unexpectedly is also not exactly right either. And having doctors defamed in newspapers for such unexpected circumstances is wrong wrong wrong wrong wrong.

What is right and what is wrong?

You can choose to be "right", and not practise what you think is defensive medicine, or choose to study only moderately hard for the MBBS. But if you end up being the lucky one killing a patient, or failing the exam, what can the world do to reverse this disaster other than to have a few human beings weep for you? If I walked on the street and a drunken driver rammed his lorry into me, me being in the right and he being in the wrong does not at all change the fact that I become dead or paralysed.

So perhaps there is a "right and wrong". Unfortunately, in this world today, it seems that this "right and wrong" is a mere fleeting shadow, a passing wind that cannot withstand the indomitable might of "action and consequence". May actual clinical experience give me more wisdom regarding this.

The joyful art of stalking external examiners

It is quite an interesting experience googling your MBBS examiner and then watching him on Youtube delivering a speech in fluent Cantonese.

Two years ago I was a happy traveller residing in Hong Kong's Sha Tin estate. Who knew that two years later, someone working in the same area would be deciding my MBBS fate?

Rights and responsibilities

I'll take a break from the horrendous MBBS revision to talk about something that has caught my attention. In this particular entry in the Singapore MD blog, the author angrydoc has highlighted the following quote by the Singapore Democratic Party:

But that's not the way things should be. Healthcare is not a commodity. It is a right. Medical treatment is not a product that we buy as we do a handbag or a watch - the richer you are, the better quality product you can buy. And if you are poor and cannot afford it, too bad, you don't get treatment. - The SDP

(Emphasis mine. See the complete article here)

Yes I agree that people deserve to stay alive, to have a decent quality of life regardless of social class. Yet, to give a universal statement that "healthcare is a right" has its pitfalls:

1. Firstly, healthcare to me is a shared responsibility by the healthcare team and the patient. To say that it is the patient's right absolves the patient of responsibility for his or her own healthcare. It is my right to get quality healthcare, and the doctor's duty to provide it for me. Actually, that is only half the truth. Patients are many times the deciding factor in determining their bio-psycho-social wellbeing. For instance, they decide if they want to be compliant to the drug or fluid regimen the doctor has prepared for them, or to the lifestyle modifications decided by the allied health team.

The first patient I saw die in front of me had worsening heart failure because he was not compliant to his medications. He was literally drowning in his own fluid, and while he could still speak a few words when he came, a few hours later he collapsed and was unresponsive to CPR. All this because he did not take his medications. (Despite considerations about his possible long and irregular working hours as a truck driver, I don't think it takes a lot of effort to pop a few pills in your mouth every day) As much as the healthcare team wanted to help him, they cannot be around him 24/7.

Even if my healthcare is my right, I have to play my part in earning it also.

2. With such an entitlement mentality, the abuse of healthcare workers will not stop. Let's not talk about doctors, let's talk about our poor nurses. A couple of months ago there was an article on nurses being abused by their patients, not just verbally and physically. Sexual harrassment was involved also. I mean, there will be delirious and demented patients who cannot control themselves, but there are also patients and relatives who have less of a medical problem than a character problem.

By viewing healthcare as a right, it becomes easier for patients to take healthcare workers for granted. They forget that despite imperfections in the healthcare system, the nurses, physios, occupational therapists, speech therapists, medical social workers and doctors are have to put in great effort and a large part of their time in keeping the system going. They are humans too, and deserve to be treated as such!

In today's political climate, people resent what the establishment have been constantly reminding them: The concept of "self reliance" and the notion that "no one owes you a living". Such ideas are seen as callousness from the elites who live in their ivory towers.

No. People want to hear that this and that are their "rights", and it is not surprising to see some politicians make use of such an entitlement mentality. On the other hand, these are the dreaded words that no one wants to hear- "I have a part to play in this. I am also responsible for this"

P.S. If time permits, I will be interested to read the SDP's National Healthcare Plan

It ended where it began

Though I have been born and bred in the west of the island, my medical education can be said to have originated in the east.

5 years ago, as an eager wannabe student fresh out of the A levels, I went for a clinical attachment in St Andrew's Community Hospital to boost my CV for medical school

3 years ago, I began my first ever clinical posting, the clinical skills foundation course, at the neighbouring Changi General Hospital

Today, I ended life as a medical student (hopefully) in the same place

And that too, closes a chapter in the fellowship with the elven prince and the elf maiden.

Moral ambiguity

An article I read a few days ago

"One of the basic humanitarian functions of a civilized society is the help the poor, the sick, the suffering and the elderly and not to abandon them as other people’s problem, or worse, to protest and deny them a right to a physical, psychological and social space. To do the latter is to dehumanize society even more than the blind pursuit of money would."

vs

This letter to the Straits Times today

"If the HDB had stuck to its original aim of selling flats at cost and for residing in rather than as investment assets, residents would have less of a leg to stand on if a host of socially enhancing facilities like childcare and elder-care centres are built."

Ok so I know it is less than 19 days to MBBS and I should be studying, but I happened to read a letter in the Straits Times today that caught my attention. How fitting that it came in the middle of a geriatrics posting.

Actually, there was a similar case a few months ago when TNP interviewed this caucasian lady who opened her condo unit to destitute foreign workers. Some people actually wrote in to criticise this lady for being a bad neighbour, because the presence of the foreign workers posed a security threat and brought down property prices. This kind of things make you ask... why?!

Let's say you were to go down the street with a mike, and ask people why they are such money minded assholes. Other than being punched and mocked you'd get a heartfelt reply that no one set out to be an asshole. Few people are born assholes, but there is a lot of shit in life, examples being a rising cost of living and soaring property prices, that put pressure on us to be assholes. It is easy to judge someone, less so to understand why.

Nevertheless, at the end of it all, it is only real shit like the MBBS and the stress of city living that truly test our humanity. It would be very questionable if, in our quest to protect our money, we lose the basic ability to care for fellow human beings.

Geriatrics

I thought I would positively hate Geriatrics. After all, I have had bad experiences with old people, ranging from being spat on by delirious old men, coming close to collapse trying to clerk drowsy old people at night, and being given the stick by old professors.

But during the posting I somehow imagined these people as future versions of my mother and things got a little better.

Yet, it still sucks having to attend long ward rounds, present during ward rounds and even present during multidisciplinary meetings when IT IS OUR LAST WEEK IN THE WARDS AND 20 DAYS BEFORE MBBS. No not funny at all.

And as a side note, to round off this short geriatric entry, you could savour this:

http://theonlinecitizen.com/2012/02/rejection-of-the-old-a-crying-shame/

Reciprocal shit warrants reciprocal service

There was a period in my life when I was angry at the way doctors had to bend over backwards to accomodate some patients and their families. Now I've realised that it is more often than not the patients and their families who have to doubly bend over backwards to accomodate the same doctors while they were students. In the process of acquiring the MBBS, don't forget also the hoardes of people you have disturbed or distressed.

Dedicated to:

The old man with right sided Bell's palsy who grudgingly agreed to let us examine him even though dozens had already done so. I really wanted to walk away already but he told me to come back, so I guess it isn't my fault.

The infant whose head I allowed to bob backwards.

The ladies whose breasts were examined by six people, including two men.

Any pre-op or imminently discharged patients who were delayed because of us.

And all the many patients with lumps, bumps, varicose veins, cardiac signs, abdo signs and whatever other signs, with special mention going to those with cancer.

Year of the Dragon!

It is apt that, at the end of this Year of the Dragon, we travel to the Lonely Mountain to slay the mightiest of them all, Smaug the Magnificent. See ya on 14 Dec!

A Discourse in Shitology. Part II- The Golden Rule

Do not use shit to fight shit, for you only create more shit

Over the years, as I was collecting ideas to form what would become my philosophy of Shitology, I developed a gloomy and sobering perspective: All shit can be created and destroyed, but it is more often created than destroyed. It is also transferred from one form to another, and very often is in the process thus augmented.

The rapid and exponential augmentation of shit arises because we simply don't know what to do with it. As we have discussed in the prelude, neither submission, nor vengeance, nor self pity, nor arrogance can serve as long term viable solutions to shit. This is the Great Paradox of Shitology, as a result of which shit is not just a nuisance but also a ticking time bomb.

Human beings have, throughout their history, tried to fight back, but in many pitiful ways which ensure that the shit returns to smack them hard in the face.

I bring to you this case which serves as a negative example of the Golden Rule of Shitology. This man, a compatriot of mine, was fed up with all the shit that Life gave him: bad public transport, rising cost of living, scarce housing and of course the influx of all those foreigners. The bald patch on his head presumably didn't do much to help.

In response, he decided to create some shit of his own and fling it back at the government, whom he viewed as the shitstirrers. Unfortunately, this came in the form of violent political cartoons which the authorities didn't find at all humorous and long story short, he is in very very deep shit now.

Do you need any more examples of how people have used shit to fight shit, only for more shit to be created? Sure. Read also the case of the teacher who used the f-word on his student in retaliation. I hope by then you'd get an idea of the golden rule.

Have you had the experience of having so much shit on your hands, so much shit that Life throws you, that you don't know what to do with it? I have. It happens often in my life, and I am sure Gary felt the same way too. But, the handling of shit is a sophisticated art and it is highly unwise for angst or impulse to turn things haywire.

Naturally, we would thus want to know the highest form of the art of shit handling. We want to know how to deflect that shit and reduce its disastrous effects. Regrettably, I'll do it another time and by then, I'd be invoking the name of a certain Sir William Osler.

A discourse in shitology. Part I The Prelude

The first post of the new year will be about shit.

There are several ways to interpret shit, which comes in all shapes and sizes. Some are brown, some are black, some are soft, some are like hard pellets, and some pour down like heavy rain. Some are passed without incident, some take up those precious minutes of yours when you could be doing something constructive, and some burn and tear your anus.

It could be that you woke up early every morning faithfully to travel across the country to see day surg patients, with very little yield, and the day you decide not to come is the day you miss three good patients. Or it could be that you get caught in the trap of drugs, poverty, crime, abuse and whatever not. Never mind, shit is still shit, and all shit is smelly.

So what to do with all that shit?

You can choose to dump it on other people but you know where that brings you. You create more victims of shit. You create more shit, and I see people in the wards, bruised and broken, who have to carry that shit. Shit

You can choose to eat your shit regularly and pretend nothing has happened. But you know, things WILL happen. And one day, all that shit will come dripping out of your ears, and heck you'd realise you yourself have turned into some form of shit. Man is what he eats. Shit.

You can choose to get drowned by your shit but you know that is game over. Shit

You can choose to wallow in your shit and act like the world dumped all that shit on you, but guess what? People will hate you for all your shit, people will say you are wallowing in your shit. You become unpopular, you have no friends, you become alone, and that is even more shit. Shit.

Ahah! And some self important people think they have found the solution by taking pride in their shit:

"Look at me world, I went through SO MUCH shit. Bow down before me ye shitless farts."

"I ate more shit than you ate rice, son. My word is more important than yours".

Yes perhaps it is tempting sometimes to develop the illusion that one day all this shit will turn into gold, and that you are part of some grand scheme in this wide world which aims to turn your shit into a golden badge of honour. No one is prepared to think that sometimes they could be just going through shit for shit's sake.

Trouble is, how can someone smeared with so much shit be that dignified anyway? You'd never know if some other people take out their shit and show it to you and say "Hey, I too have shit". And perhaps the worse realisation is that you are not the only one with shit, and you are nothing special. The shit you are swimming in is no longer special shit. That is even worse shit. Sh-- oh forget it you got the idea.

So what to do with all that shit?

So, disappointingly, shittily, I don't have an answer yet. But one of life's purposes is to find that out, and perhaps in the meantime the solution is to not take that shit so seriously. Laugh the shit off. Play with it. Bathe in it. Have fun with it. For me, I've dedicated myself to writing about it, holy shit, and thus you now have

The Discourses in Shitology

Which, I say, will be pretty awesome shit.

2011 reasons to be unhappy

I suppose I will ignore all of them and focus instead on the blessings amid what has been a terribly draining year:

1) CG mates

In M3, M4 and M5. After 5 years of being in YLLSOM, I've encountered many people who give me negative vibes, and heard of many horror stories of CG mates quarrelling, politicking and engaging in cold wars with one another. There must be more than one lucky star shining on me because all these years my CG mates have been AWESOME. Not only that, but most of the time people in the neighbouring CGs are great folks, some of whom I've had a great chemistry with.

Central to this bliss are a very pleasant model couple whom I've had the privilege of getting to be friends with.

2) India and Vietnam trips

Cannot belabour the point. While 45 weeks this year have been pretty much dull and laborious, the other 7 were journeys into fantasy worlds where there was no work or responsibility or expectations. In India I learnt how people could live simply but happily, and how to eat with the very same hand I use to wipe my butt. In Vietnam I learnt to conquer a mountain with 3/4 of my luggage stuck in the airport and with only one healthy painless eye.

In Singapore this notion of "heroism" is replaced by how many patients you diagnose correctly, how many questions you can answer during tutorials and your chances of getting into coveted Residency programmes. Nevertheless, I treasure the memories

3) Research mentors

Ok, so it was a long drawn out project. But whatever it was it was a privilege to work with a groups of driven individuals who never failed to be nice no matter how tough the going. Who were genuinely interested in my progress

4) Family

Sister graduated from JC, now moving on to tertiary education. Mother graduated from being a working mum, now moving on to become a teacher by day but fully fledged ah soh by night, what with all the line dancing classes at the community centre. Still the same old pleasant folks that stand tall in this gigantic shit stirrer that is life

My wishes for next year

Personally, I wish to pass the MBBS and find joy in whatever I do again, among other things. As for my wishes for the wider world, here they are:

1) America to clear her rubbish

I consider myself one of those old fashioned people who believe that if you have a problem, you either solve it directly or learn to be happy with it. That does not include sitting down, irritating the hell out of your government, and hoping that something falls from the sky(scrapers of Wall Street). If I ever find myself short of money, I'd either work harder and smarter, or learn to spend less, or both.

Apparently, in this New Age, it is fashionable to whine your way to a solution. And if you can find thousands of like minded people with whom to form a collective public nuisance, why not? Not as if your government, who goes by the ideals of democracy and free speech, can do a Tiananmen and mow the whole lot of you down.

Last I read, nations like America and Singapore weren't built by immigrants who sat down at the beach holding stupid placards.

Is that your name? Hahahaha

2. A vision
The heavens will open, a host of three headed angels will appear singing, and this gigantic guy with a shiny face will read from a golden scroll.... telling us where our healthcare system is headed to.

Why not? First there was just Singhealth and NHG, then suddenly there was NUHS. Now there is the Eastern Health Alliance whose pillar is the gigantic CGH, an enormous tertiary hospital in the east of Singapore that provides an extensive range of healthcare services.

Well to think of it, competition is good. Man Utd needs a Man City to keep them on their toes. YLLSOM needs the Duke-NUS. Gandalf needs Saruman. So, more healthcare alliances to break the monopoly can only be beneficial to patients. Way to go, government!

3. Our country to stop failing further
To build on the above point, I believe SMRT has monopoly over our public transport system. As such, it is indestructible. If another transport alliance group (whatever that will mean) were to compete with them, I'm sure there will be more vigilance.

Although we have not achieved the lofty heights of certain European countries in the art of screw-up, by our high standards bad things have occurred this year. The clean, green, orderly utopia of the 1990s may not appear ever again but hopefully there won't be further deterioration in the standard of public transport, healthcare etc.