My reflections on 2010

On my wall there's this gigantic newspaper article on Lee Kuan Yew. Everyday, I can't help but look at his face for a few seconds. Sometimes, I take some time off to read the article itself, which is about how LKY avoids ageing.

On the other side of the room is the bookshelf and there are two books which I take out to read occasionally: Men in White, a book on PAP's early history, and the Memoirs of LKY (in Chinese). (To be fair I have The Fajar Generation too, it is a book written by LKY's enemies)

In a sense my room, other than being used for studying and recreation, is somewhat of a shrine to LKY. I can't say that I've met the man in person or really know how he's like, but he's become the very symbol of pragmatism and excellence that I have come to put on my "shrine". It's not really the man, but the symbol, or rather what I have interpreted of the symbol.

So why am I writing about this all of a sudden? Actually it's not a random musing, rather I just want to share here how 2010 for me has been characterised by a struggle between two invisible forces in my private world: pragmatism, personified by my elderly hero, and altruism/idealism. It is so inevitable, as you cruise along in life's journey, that you learn to cast aside your ideals and look at stark reality as it is. But yet you don't want to lose your ideals and your soul as well.

Besides being an intellectual struggle, there were real repercussions of this battle in real life, namely how I've come to view Residency and my career choice. It is tempting that at some point, you hop onto the bandwagon because everyone is doing so and you don't want to lose out in terms of material progress. In fact, LKY himself sanctioned the building of casinos because he noticed the Westerners were doing the same!

I've in fact come close, like what LKY has probably already done so, to believing that the world is not about who's "right" or "wrong" but rather the "winners" and the "losers". So what if the Barisan Socialis politicians were truly righteous? They rotted in their jail cells anyway, unable to make any tangible change to society during that time. So what if you think that Residency has 101 flaws, such as forcing people to make early decisions? You don't like it, then it'll be given to the grateful Dukies and foreign based students and rightfully or not, you'd most likely languish outside the system, unnurtured and neglected.

But by the grace of God, I've not lost my grasp over the knowledge of what is more righteous than the other. The idealistic/altruistic force, visualised in my mind as the person of Jesus Christ, has stopped me from sliding into mere nihilism. (Jesus stands for many other things as well but I'll leave it here).

And hence, that was the role of God in my life in the year 2010. It is not the ideal role of God in anyone's life but I'll just write about what is, rather than what should be.

Also, by God's grace, I've learnt that it is possible to come to behold the true value of your endeavours, beyond material enrichment. Honestly the idea of doing research started out simply as a means of jumping on the Residency bandwagon. Somehow in the middle, perhaps through some epiphany, I saw the value of exploring the deep dark unchartered territory which is Cancer.

And it's not because it has claimed the lives of some family members. Big deal, I mean, it is such a common disease, and I'll be blunt enough to tell you that the same calamity is likely to befall YOU as well. Statistics show that. On the other hand, the real reason is that I've come to see how the world is facing such a massive, complex enemy.

Mention TB, and we can say that it is caused by Mycobacterium tuberculosis which replicates in macrophages, and it is treated by isoniazid, rifampicin, pyrazinamide etc. Talk about jaundice, and we can classify its causes, and very likely an ERCP removes the stone responsible for the condition.

But cancer. We are not entirely sure of how Nature and Nurture interact to produce this calamity. The drugs that we give cause terrible collateral damage, and more often than not the cancer cells, seemingly with a mind of their own, learn to be resistant. It causes tremendous pain and discomfort, it can be recurrent and it certainly deserves the title of the Emperor of all Maladies.

I've come to see this disease as more than a chapter in the textbook, or the killer of some people I know, but as sort of a dream. I need not be an oncologist (but by God's grace, God's grace...), and I'd like to do whatever I can in the future to participate in the battle against it. Screening at the primary healthcare level. Maybe palliative care. Research perhaps.

How nice it would be, to be part of a generation that ushers in a giant leap in the revolution of cancer treatment. Ways and means that are not painful, not nauseating. That are precise and efficacious. There is much research done on immunotherapy, on genetics and epigenetics. You'd know, friends, that someday you'd likely be part of it. General surgeon, immunologist, paediatrician, nurse, healthcare policy administrator. Anything.

So I mean with regards to the book above, it is a chronicle of how great clinicians and scientists of the past have fought against the disease. I've bought it recently at $26 and it has been a page turner (when I find time among patho revision to look at it). Not only is it informative, with a crisp style of writing that I aspire to, but it reminds me that there's so much to look forward to in Medicine. More so than the grades, the residency, the people you don't like and some questionable organisations.

It is a pleasant reminder that we are not here just to survive or to climb up the social ladder. But to find our niche in this world and perform our duties to the best we can. To fulfill dreams.

And to borrow a quote from a great movie: Don't chase success. Chase excellence, and therafter success will chase you pants down.

My meditations on human desire

If you read the Bible, there are many verses turning its reader away from sensuality. I have often wondered why some simple human passions are frowned upon by religion. The simple desire for money and success, the admiration of another's beauty, seems to be discouraged. The cynic may even ask if this a political weapon for religious organisations to subjugate mankind.

Nevertheless, if you want to believe in a God of order, which the Scripture illustrates, then some things may fall into place. As much as chaos exists in this unpredictable universe, a modicum of order is needed for life around us as we know it to function. Humans can live, breathe and eat because cells are organised in a structured manner and perform their required functions. Necrosis, which is death, occurs when this structure is lost.

Same goes with our desires. The ambitions to get into a residency, to have a companion, to drive the best car, must be put into place. For when they become our only perspective of life, the only means of shaping our identity, it is only too easy for there to be perversion, leading to one of the many woes that you see plaguing mankind today. The greed of Bernie Madoff. The terrible crimes of some Catholic priests. Or simply put, disgruntledness among the common men like us.

Might I suggest then, that the call to discipline our desires is not just a weapon for the power hungry and the pious. This discipline must come from inside out in the hope that we who practise it attain new life, free from the burden of materialism.

True enjoyment comes when our passions are disciplined. For me, it will come when I finally realise the true value of my salvation, which is the knowledge that God has come to empathise with man. It comes with the feeling that I'm at peace in the world and the intuitive knowledge that I'm in the part of this universe that I should be. And actually, all the rest are secondary.

Christmas, come and gone

It's a slightly belated post actually, I didn't manage to catch in time the swift exit of Christmas Day.

I believe that whatever what we do, whether we know it or not, is a manifestation of our desire for some sort of salvation. Salvation from mediocrity, from previous hurts, from disappointment, from poverty, from fear, from some inner insecurity, from our conscience. That's why we do stuff like study, go gymming, take part in social activities etc. Maybe we want to prove somebody wrong, and that could be a certain other person, or an intangible but real shadow that exists within you.

Well, Christmas, as Christians believe, marks the birth of salvation. Of course, it is higher and more wholesome than the salvation I described up there. It's not something I can describe readily, but throughout this year I've learnt that it has to be worked out and that it can be elusive.

Hopefully, whoever reads this, regardless of their beliefs, will find some sort of salvation in their own way

Long way to go

A few days ago this relative of mine had a little neck lump and I was asked to examine it. After some history taking and the examination, I came up with a certain diagnosis. Today on hindsight, I realized what a stupid diagnosis I made and went to correct it.

It was really a very elementary error, laughable even. The thing is, if this had been a hospital setting, or an exam case, I would have done it much better. I guess I learnt lots today about the necessity of always carrying around the medicine brain. Ican be glad I didn't make this mistake as a doctor

A study of people singing in a circle

Today there was caroling at Kwong Wai Shiu Hospital, followed by a party at Jonny's house. Near the end we decided to form a circle to sing songs.

I was tempted to take out the camera because what I saw in front of me was a great variety of emotions and expressions, which I had to record for posterity.

More importantly, it occured to me that the circle of singers was but a microcosm of society, with people playing all sorts of roles:

The lead singer with the nice voice and the one who expresses herself very well while dancing. They are the centre of attraction

The skillful guitarists, without whom there would be no music. They, together with the lead singer and dancer, decide what songs to play.

The rest more or less sing along, or chip in with random suggestions. Those who can't sing keep quiet, then return to the chorus of voices when they can. Some sit there rather meekly but smile sweetly, making a sincere attempt to fit in.

And of course there's the Idiot, who can't sing anything since he listens to classical music, so he takes photographs.

A study of Coronation Plaza food

There are two types of women men would like. First are very gorgeous kind which any guy can't help but feel affection for. Second, you have those who are more plain looking but are very much loved by their spouses because of the years of marriage that have cultivated deep feeling. You examine them a little more, and you realise that the second group do have attributes of their own that make them worthy.

Same goes for food. Which person ever notices chicken+fish rice sold in an eatery in one corner of the top floor of a not-too-well-known shopping centre? Furniture is spartan, waitresses are in their 50s and the food isn't as breathtaking as the crab I ate the other day (see previous entry)

But Coronation Plaza's Ke Ai Ji holds great memories for many Hwa Chong alumni. I remember eating there with the String Orch pple when I was in The Chinese High School (now known as the High School Section of Hwa Chong Institution), and also with my JC classmates after S-paper lectures.

I went back there today with CY, an old friend from TCHS, after studying Patho in the library. We also took the chance to go back to TCHS to take a look.

There was only one dish we could order and that was the fish+chicken rice we all loved when we were still HwaChongians. No photo editing today. Photos are sacred.

End of the school year in pictures

Will miss you guys loads. Had some great times and great conversations with a bunch of nice, vibrant and smart people like you guys. Whether or not we continue as a CG in M5, we are not going to see each other for at least 6 months so that's going to be a long time. Will treasure the memories, starting all the way from Ortho posting 14 months ago.

After ENT EOPT we basically bummed around in the student lounge playing Wii and table soccer with other very random Medicine people, and then we watched the Playhouse video again. Though it was only two weeks ago, it brought back some nostalgic memories of the few rehearsals the stage crew had, and a sense of achievement shared by all who participated in the event.

I left immediately after the screening to celebrate Joshua's (church friend) birthday and we had crab in the famous Mellben Restaurant in Ang Mo Kio Ave 3 St 22 Blk 232.
For starters, this was some tofu like dish. The exterior was tough and crispy but once your teeth go past that layer, the inside virtually melts in your mouth. It has a softness that is quite beyond description and your teeth, though gently manipulated by the jaw, smash through them with amazing ease.

It's just like how some people seem tough on the outside but crumble the moment they are harrassed.
This was the first crab dish. The bee hoon, from my experience, play the role of the wing-man, the sidekick, but today it deserved as much mention as the main character, the crab. The sauce brings a multitude of delight to your tongue, which disseminates through your entire palate. It seems that the oropharynx and nasopharynx have at once experienced this heavenly joy (sorry I'm still having ENT hangover).

Crab was not too heavy on the taste buds, though very fresh and tender. This dish reminds me of a richly adorned, glitzy looking housewife married to a down-to-earth husband.

Chilli crab- a dish whose name adorns many a restaurant menu for the sake of mere customer attention. Yet the disappointed customer has tasted only a ghost of what it is supposed to be. Today, justice was served to the hallowed name, for this fine specimen of a crustacean not only had the freshest meat I have tasted, it was bathed in thick and tasty chilli sauce which balanced spiciness with texture with flavour.

Anything, ANYTHING, save Joshua's chocolate cake, can be dipped in the sauce and thoroughly enjoyed. Hence, the beauty of the sauce is in its universality, for it cries out to many a dish, "Come to me, all who are dry and unadorned and plain. Take up my yolk and be tasty"

But the star of the night had to belong to this wondrous contraption you see above. Had the crab been alive and able to walk, I would have personally laid out a red carpet so that it could strut down the aisle, with sauce dripping, while people revel in its golden glory.

Butter crab! Nevertheless, had you been alive, you would have been inedible. Hence it is one of the grievances I have in this world that you are dead as a donut- mute, unseeing, and unconscious.

Were I to talk to you, butter crab, I would liked to have known your journey as you were dipped in this wonderful amazing butter sauce, whose origins I am tempted to accredit only to heaven itself, for it is only from the stars such earth-shaking liquid could have fell.

So anyway after this life-changing, earth shattering dinner that made a dip in the flow of the universe's cosmic energy, we proceeded on to cut Joshua's cake in Macs. Despite its dark mysterious hue,the majestic cylindrical Goliath of a .... ah ok la the chocolate cake was also very good. Was getting very tired after that and am very tired now. Pictures are on facebook if ever you want to see haha.

Medical developments I'd like to see in the future

Today in the Saturday segment of ST there were a series of articles on clinician scientists and their projects. It's really cool stuff because what they are investigating now could be the mainstay of healthcare when we become doctors. I remember too approaching Prof Yeoh earlier this year to help out with his gastric cancer project but I suppose since it was a high stakes $25 million dollar enterprise he didn't want a medical student bungling it up.

Anyway, I'm quite inspired to write down the new developments I wish to see in the medical field, say, half a century from now. I reiterate that I only wish to see them happen, yet whether they come to fruition or not depends on many other things.

Moreover, as you can see later, they are not limited to the field of science, but also public policy as well.

1) Cancer immunotherapy

The idea came about in the 80s but as of now, it is yet to become the mainstay of cancer treatment in Singapore. Why I want it to be the mainstay is because I've seen the poisonous effects of chemo and radiotherapy, and it is rather shocking how such a barbaric form of treatment, with so much collateral damage, is still given so many cancer patients. Unfortunately, this is because medical science hasn't offered us better alternatives that can be implemented en masse.

It'll be great if one day, for every single cancer available, we can offer the appropriate form of immunotherapy- to stimulate the appropriate immune cells to destroy the tumour cells and only the tumour cells. This comes about if we are able to recognise and tag various tumour cell receptors. More importantly, this form of treatment must be affordable.

2) The affordability of gene testing

Ian and I were talking about it during CTS on Thursday. He was saying how wonderful it could be if gene testing could one day be done en masse, just like today's FBC and U/E/Creat, which are very cheap investigations. We have it now, but it's very expensive. For instance, to test for gene translocations leading to GIST would cost around $1500.

We can test for patients' susceptibility to various acute and chronic illnesses, but the caveat is that these illnesses must be curable, or else you are just creating more misery. Better let them live in blissful ignorance!

3) Epigenetics and preventive medicine

I first read about it in TIME magazine earlier this year. They drew a small circle representing genetics and a larger circle around it representing epigenetics. How cool is that? It is the study of the bridge between nature and nurture, how environmental factors can turn on and off various genes within you, thus determining your susceptibility to various diseases. With that, we can relook patient's lifestyle factors and work on them.

I am reminded of a lecture a few days back during my current ENT posting, whereby the Prof was selling his theory about how the avoidance of certain foods can actually cure allergic rhinitis, eczema, asthma, and even rheumatoid arthritis. Apparently, the intradermal provocation food test which he is a proponent of can show a wider range of foods a patient is allergic to, whereas the skin prick test only shows IgE related food allergies.

Something like that. I wasn't really listening, but it was obvious that the Prof was more interested in selling his idea than teaching students. There must be more evidence based research, most ideally double blinded clinical trials, to prove his words. Nevertheless, I know at least a friend who will be interested in this field of study. YOU! Yes you, you know who you are.

4) Greater empowerment of primary healthcare

I'm moving from the realm of science into the realm of sociology from now, but nevertheless I consider these developments nonetheless.

There are many times in specialist clinics when I see the patient being put on a dose of steroids, or being given expectant management, and I wonder if a primary healthcare physician couldn't have done the same. I believe that the larger the proportion of healthcare burden is shouldered by specialists, the higher the healthcare costs, which need not necessarily be the case

For that, I hope the new family medicine residency programme can train a sufficient number of primary care physicians well equipped to manage a wide range of acute and chronic illnesses. I also hope more people will recognise the importance of family medicine as a means to provide affordable primary care, rather than treat it as a default career path and be unhappy doing it (eg being a GP cos they didn't get into a speciality).

Nevertheless, Singapore is likely to move in the opposite direction. Elitism (which I actually mostly subscribe to), is a driving philosophy behind many aspects of our society, healthcare industry included. Our healthcare system of the future will aim to cater to a larger international population so as to bring in more revenue and cement Singapore's reputation as a biomedical hub. As a result, disciplines like Orthopaedics, Oncology, Plastic Surgery, ENT and Ophthalmology will become more subspecialised and sub-subspecialised so as to provide greater cutting edge treatment.

After all I've said, I admit Fam Med is still my second choice, the first being Internal Medicine (cos I can't stand working with only one small part of the body) But I hope I'm not making Fam med a last, default choice but rather a second choice, if you get what I mean.

5) Making medicine a post graduate course

Yea maybe I'll be unpopular by saying this but I really hope we'll seriously consider going down America's path. This is so that prospective medical students are more mature in making their choice to commit to this discipline, which really isn't easy to commit to. Fresh out of an elitist public education system, an 18-year-old may want to do Medicine because it is another "elite" course, but it'll be rather tragic if this is the only reason. You'd preferably want someone older, someone more likely to have the heart to serve and who can rationally consider the pros and cons.

Weekly dose of sarcasm

Desire leads to suffering

Had you ever desired to get better academic results, you would have studied harder and smarter. Had you ever desired to run a marathon, you would have come up with an effective training schedule and stuck to it.

Yet, have you ever been so consumed by a desire which you cannot meet? Due to its fulfillment not being totally decided by you, or not being appropriate for the current time and situation?

the play and the marathon

Photo courtesy of Alvin

Alright. I had the best weekend ever in medical school so I must do a nice chronology of it. Playhouse was fantastic and our play was epic, sweeping nearly every award available. Will be looking forward to watching the video playback, and maybe hopefully I'll catch myself bringing the throne and part of the bridge onto the stage.

This was the first major performance I've taken part in since 2004 (Hwa Chong Institution's 85th anniversary concert) and the first major Medicine activity I've taken part in, if you exclude Medicamp. I'm glad to have known some wonderful people in crew like Jon Chan, Debo, Ruth, Poying, Sheila, Quan You, Perry, Wei Ping , and my old friends Shaun Chan, Emmett, Sok, Jon Tang and Alon. Hope I didn't miss out anyone.

After that was the long awaited Standard Chartered Singapore Marathon. I was surprised to have slept well from 8 to 2am, waking up once only to pee. Maybe it was Playhouse making me very tired. I met Emmett, Wei Ping, Ben Ding, Fred and Mingzhou at the baggage deposit and we started off together, though some people including me ran off at our own pace.

Everything went fine until 20km until I noticed a very slight dull ache in my vastus medialis, and I was surprised the cramps could have come on so early, testament to how I had not been training well. They became signficiant at 24 km and by 32 I had a major onset of cramps that left me on the floor. Somehow, I just stumbled my way to the end and I believe my timing was a decent 4h 41min.

So anyway, I was thinking these past few months that running has become less enjoyable, maybe more of a chore. But I just keep on running because of the end result, namely the marathon T-shirt and the knowledge that I had run in good time, which I can then happily show off to people. There is also the sense of achievement that you have soldiered on bravely despite the pain and the terrible cramps, but in all honesty who shares it? Who saw your toil? This is all very self absorbed. The process of running is also really quite painful and burdensome.

Against my instincts I've signed up for Sundown 2011, which will be my third marathon and last in medical school. So why still sign up? Namely because of the shirt, and also because I know it could be the last chance in a long, long while, with my time as a junior doctor likely to swallow up my youth.

Some have suggested that I relax this time round and run marathons again in NS, but as far as I have estimated it would be at least a three year wait between Sundown 2011 and the next marathon. Three years... it's more than enough for a perfectly healthy person to turn into the perfect wretch, or the perfect corpse, through some cruel act of fortune. Who knows what will happen? Therefore, run as much as you can now and savour the memories later.

Anyway, to keep myself excited, I have decided to take on a new challenge in the form of the Men's Health Urbanathlon 2011, which is a 12km route consisting of 9 obstacles. It is a plunge into the unknown, especially since in NS I had trouble with the monkey bar that you see above. Nevertheless, despite the $128 price tag, the goody bag includes 2 shirts, 1 singlet, a free 6 month subscription to the Men's Health magazine, 1 water bottle and also a condom. Best. Am looking forward. 20 Feb 2011

ggxx

Ophthalmo. A posting crammed between playhouse rehearsals and ncc meetings. But there's no excuse for some of the answers I wrote down today. Hai. I guess if I ever wanted to do internal medicine I have a long long way to go man. Must use electives to improve knowledge ttm.

Never mind. Playhouse tml, followed by marathon. Awesome weekend