In search of the best Ipoh hor fun/prawn wonton soup

Lately, my tastebuds have seemed to haven taken a new and profound delight in one of Malaysia's prized dishes: Ipoh hor fun and prawn wonton soup. No doubt, the best Ipoh hor soup still originates from Ipoh but KL does offer a few good eating outlets like Soo Kee and TK Chong coffeshop that serve good imitations of the fragrant and wonderful bowl of soup noodles. What is not comforting about a piping bowl of rich and fragrant stock that has boiled for endless hours using poached tender chicken and prawns on a cold, drizzly aftenoon? Furthermore the savoury broth with a hint of prawn oil is immersed in silky smooth rice noodles, lusciously tender chicken pieces and juicy, fresh prawn wontons. You definitely cannot find a single flaw in this nourishing bowl of soup that is easily digestible and soothing for the stomach making it an ideal choice for children and elderly.

I think what strikes me more about this bowl of soup is the fact that I have grown up loving and accquiring the taste since the tender age of 6 years. I am flooded with an array of childhood memories and I recall the trips I took with my parents on a Sunday afternoon after 1 1/2 hours of Malay tuition (till this day I have yet to master that language) to the famous Soo Kee restaurant which has been awarded as the best Ipoh hor fun in the Klang Valley by the Foodster awards and gorging myself on a bowl of Ipoh hor fun with prawn wontons. I enjoyed slurping up the delicious soup and sometimes grabbing a forkful of steamed chicken pieces drizzled in oyster sauce which is another one of the shop's specialities. I recall the shop's owner barking orders at the workers and frantically attending to the bustling queue of long waiting customers as well as the lady in the corner (probably the owner's wife) who was carefully wrapping each prawn wonton with the right amount of minced meat each with a single, glazed prawn. Or the man in the front counter expertly chopping the chicken pieces on his cutting board and drizzling it with splash of a dark oyster sauce before hollering instructions on who it should be served to. Since the portion they serve is rather small, my parents and I would sometimes hop over the Chinese store next door to buy some good old assorted Chinese snacks such as sak ke mah, chicken and pork floss, dried barbeque meat slices, peanut cookies, rice crispies candies coated in creamy caramel or stack up on bak kut teh or herbal chicken packet soups. Sadly, that shop is no longer available as some food bloggers have pointed that the owner has retired. I've still yet to try Soo Kee's famous Ipoh hor fun prawn wonton soup since returning from Sydney and kind of looking forward for an opportunity to do so.

Another big rival of the Ipoh hor fun business is TK Chong coffeeshop which boasts legendary steamed chicken, 'shiok' ipoh hor fun soup and delectable prawn wontons. My breath was literally taken away when I first had a taste although I was wondering whether they added MSG to enrich the sweet and flavoursome soup and I later found out that a food blogger who is intolerant of MSG dubiously agreed that they do indeed add MSG to their soup. How disappointing...but I doubt this small mishap will prevent me from future visits to the shop. I can assure you that that I will be still be enjoying my Ipoh hor fun/prawn wonton soup when I am 80 years old as its not only a scrumptious bowl enriched with nutrients but with a subtle hint of childhood memories.

Digress and obsess

Feeling the desperate urge to rant out my feelings right now. I'm actually feeling a tinge of fustration because I still have not got a reply back from Dr Philip Jones regarding resitting my O&G term in 2010 plus news about my portfolio examination which I have obtained an 'unsatisfactory' performance in. Its either he hasn't received it yet (quite unlikely as I have been sending out other email to friends which I have gotten prompt replies the next day), can't be bothered to reply back or is still making further arrangements. I know my level of patience is extremely low but then a line that must be drawn when you are waiting ricdiculously long for just one simple, mundane answer/reply. Furthermore, the anxiety and tension starts to pile up and you can't do anything except just fret, digress and obsess about it.

These past few nights as I was heading off to sleep, I couldn't help but wonder if my situation had been reversed and that I had passed the O&G exam and would be back home for at least a year recuperating from a year of intense study. But at least I would have known that its all over and that I just need to prepare myself for internship. Unfortunately, this is not the case and I have to trudge myself back to Sydney for at least another 8 weeks to redo my O&G term and portfolio exam, sit for the dreaded OSCE and VIVA exam that will determine whether or not I can finally pass and achieve my much desired and anticipated MBBS certificate. I honestly don't care even if I don't attend the graduation ceremony in May, so long as they just hand me the certificate in black and white; I'll be happy to take it and pack my bags and leave the country as soon as possible.

So right now, I'm feeling overwhelmed and heavily burdened. The future looks so grim and filled with unexpected and unfortunate events. I don't know even if I can make it this time around and I have already been wounded deeply from my previous two failed attempts so I hardly have much strength, will and determination left. I'll have to try to take it as it is; as the saying goes 'Come what may' and 'If it's meant to be, then its meant to be'. I always thought of myself as highly inadequate and unworthy to be called a medical student and its amazing that I have managed to scrape through 6 years of medicine with the stroke of luck on my side. I don't possess intelligence, confidence, self-respect and awesome communication skills that enables you to pass any interview or oral examination with flying colours. Basically I am not blessed with the qualities of a doctor or maybe I simply don't even have any good virtues/traits/characterisitics. I feel pretty much of a failure all the time and I often beat myself up about it either by lashing it out on others or on myself. These acts of 'repent' often form a vicious cycle and sometimes I start to feel insecure and weird if I do not engage in these acts as they are way to help cleanse me off my 'sins'. I feel like a disappointment to my parents especially who have sacrificed so much for me to have a better education in Sydney, who have used up all their savings and earnings on me in the hopes of me fullfilling my ambition as a doctor and who have dedicated their lives to see me lead a normal, healthy and happy life. And what hurts the most is that I was UNABLE TO FULLFILL ANY OF THESE TASKS....What kind of disrespectful and despicable daughter am I? I don't think I deserve much happiness from now on the fact that I have sunken so low to hit almost rock bottom.

Back home

As things didn't work out as planned, I have migrated back to my beloved home and country, Malaysia, in the hopes that it will bring some comfort in the depths of my despair. I still feel pretty sore about failing my O&G supplementary exam and I carry this wound with me everyday...it's a constant reminder of why I did not graduate with the rest by the end of this year and telling me that life can be very harsh and unpredictable. Still I am determined to give it one last try before I call it quits so I am going to spend the next 4 months back in KL religiously studying O&G especially those topics I have trouble with and try to gain as much clinical exposure as possible. Also when I get back to Sydney, I will have to redo my O&G term which will be conducted by my supervisor which will hopefully provide me with more background clinical skills knowledge. By then I pray, SINCERELY PRAY AND HOPE that I will be ready to sit for the O&G OSCE and VIVA and finally pass. However, the last incident has taught me that one can never be too sure about passing and even though you think that you have prepared well, the examiner can still fail simply because he holds the power to. It could just be a simple slip of the tongue, your mind freezes up on that day which leaves you unable to recall anything that you've studied, your mannerism that may be irratating to the examiner or basically being very unlucky call lead to impending FAILURE. Anything can happen on that day and its so ricdiculous for the faculty of medicine to pass a student on the basis of just ONE MISERABLE VIVA AND CLINICAL STATION. Does this mean you have profound knowledge and grasp of O&G if you are able to pass just that station which just tests you on a tiny fraction of O&G? Furthermore, you may be extremely lucky and need not even demonstrate your clinical skills though its an OSCE station as it could simply just be a history or counselling station which saves those people (like me) who are clearly lacking and deficient in clinical skills.

At least for now, the tension of the upcoming exam is a lot less since I am back home and the exam is only next year. But this time I am going to prepare myself for failure so that if I do fail once again, I won't feel the torrent of painful emotions that washes over me filled with hurt, disappointment and self-hatred. This year has more or less been an emotional roller coaster ride; filled with many ups and downs, truimphs and tribulations. Altogether, 2009 has not been a lucky year for me in terms of academics, well being and health.

Besides that, I am currently enjoying the comforts of being back home. For now, its a luxury to wake up anytime I want and not procastinate over the daily errands. I also get to try the various food that I have sorely missed as they were unavailable in Sydney and the best part is its a whole lot cheaper and the owners are less fussy and particular especially when the customer requests for extra soup, sauce etc. So far, I've tried some Ipoh hor fun soup from TK Chong and I absolutely love the delicious, enriching, shrimpy stock with bouncy mouth-watering prawn dumplings, steamed chicken also from Thong Kee with its flavourful, smooth and tender meat, springy siew mai filled with succulent lean meat that happens to rival the ones back in Sydney located just opposite my house and tapioca kuih which has been a childhood favourite of mine. And for dinner we had tiny deep fried pomfret fish which you pop into your mouth, hear it go crunch and savour the crispiness and natural taste of fish with bones that are completely edible. No doubt, this should be packed with calcium.

Apart from the good food, mum and I did some window shopping at 1 utama and the curve. These two shopping malls that are located within walking distance from my house brings back a truckload of memories since my high school days. As I was strolling around, I caught glimpse of cafes, restaurants, clothing stores that I often visited after school ended or during the weekends. Of course, there have been some changes but some things remain the same, the malls are still packed with busy and bustling customers, the cinemas are brimming with never-ending queues and there are still clans of school uniformed children bombarding Mcdonalds, Burger King and KFC. I did some grocery shopping at Jusco supermarket and Cold Storage and stacked up my cart with food items are a lot cheaper as compared to the ones in Sydney as well as being welcomed by food advertisers offering free tasting/sampling of their products. All in all, things have hardly changed and that's the way I like it as nothing beats coming back home to be awakened by long lost memories and childhood experiences that touches your soul and brings back a bittersweet nostalgia.

The end of my medicine career

Today has more or less marked the final straw of my medicine career. After failing the supplementary examination for O&G, I'm really contemplating right now on quitting medicine once and for all. I have accepted defeat and have lost all confidence, faith in myself and I strongly believe that history will just repeat itself if I were to resit the second supplementary exam in December which will involve more components of the O&G exam (written, viva and osce). I had previously failed my OSCE component in both the supplementary and mainstream examination which proves that I am clearly lacking in 0&G clinical skills. Or maybe its a stroke of bad luck as the mainstream examination didn't really consist of a clinical O&G station; it was more a history and viva station which I would have surely passed if I had stuck to my ground. And yesterday the examiner told me that my performance in taking a PAP smear and doing a pelvic bimanual examination was unsatisfactory (although I did say the right things). On the other hand, I managed to pass the VIVA station but in the end you are guranteed a 'pass' only if you pass both components.

This O&G OSCE has really been my downfall; the only obstacle preventing me from achieving my MBBS certificate and title as a 'doctor'. It has made a devastating impact on me and I've lost all self-esteem and motivation. I don't think I was meant to be a doctor in the first place as surely God would not have made this exam to be such a barrier. I'm deciding between giving up medicine altogether and return to Malaysia to choose another course or whether I should credit transfer to another university (either in Malaysia or Australia) with the hopes of repeating 6th year medicine. But I am postively sure that if I do decide to repeat the exam in early December and if I were to once again fail it, I will NOT be continuing my studies in UNSW. I never liked Sydney in the first place and these past 3 years has brought a lot of suffering and hardship upon me. Although it can be tolerable at times, I never truly had one fleeting moment when I can declare myself as being content in Sydney and that I had made a right decision to choose UNSW. There has always been a cloud of doubt lingering over my head and I was never free from a set of misfortunes throughout the 3 years in Sydney. Only this time, it has doubled in magnitude. Since arriving in Sydney, I faced the huge problem of trying to adjust to a new country, being away from home, starting in a new university with hardly any close friends around and sharing an apartment with two other medical students (which I have not met before in my life). It was already a bad start of the year. The following year I managed to shift out and settle more comfortably in a single bedroom unit (thanks to mum and dad) but I faced a bigger set of problems mostly consisting of struggling with my own inner demons. I had to fight off dark lurking doubts in my mind, voices that kept telling me that I was not good/worthy enough and a huge torrent of emotions that envelops me in a split second ranging from intense anger, sorrow or fear forcing me to make rash decisions or act in inappropiate ways. These 'bad' cycles often repeats itself and I am left feeling numb and regretful of my foolish actions or words that I could not control during the 'heat' of the moment causing me to despise myself even further. And this year I feel as though all my effort and discipline that I have put in has literally gone down the drain. Maybe I shouldn't blame it all on external forces, I know that a large part is due to my irresponsiblity and that I could have rectified it in the past such as emphasising more on the OSCE component. Or perhaps this is the way I am repaying for my 'sins' or 'bad acts' I have committed in the past.

All I really want right now is to crawl up into a hole and bury myself inside. The pain and disappointment cuts like a knife and it tears me up even more knowing that I will be unable to graduate with the rest in December. I have no desire to speak to any of my friends although I know that they will be supportive and sympathetic. And I have a strong inclination to go back home and to break away from this dreadful place and 'nightmare'. I don't know whether it would be a wise idea to actually go back for a week or two first. It might help calm and soothe me once I am back in the comfort of my own home and in a warm, welcoming and familiar environment.

The only thing right now that is probably making the situation more bearable is the fact that both my parents are around. I know that during hardship and troubled times, it always helps to have family and your loved ones around to offer support and encouragement. This 'failure' has made a devastating impact on me and I don't think I will be able to easily brush aside the matter and sweep myself off the pits of despair. I am unfortunately not very strong-minded who can take failures and defeats lightly and see it in a positive light as a way to learn, grow or mature. Those are the people I truly admire but unfortunately I do not possess such hard-core determination. Even physical pain cannot really justify or rival this inner pain which shatters my heart into a million pieces. I don't know how I can EVER pick myself up from this and try to focus and prepare for the exam in December which will probably be my last attempt in achieving a medicine degree. I believe I have wasted 6years of my life, slaving away in medicine when I could have chosen a much less stressful, demanding and easier course. I'm just not cut out to do medicine and there is no point in reassuring myself that this is just a setback . All I know is that I will decide on Monday whether or not i should try for the final time in december when I meet Dr Phillip Jones who is the Phase 3 course coordinator. And if I were to try again, I do not know whether or not I have anymore inner strength, courage and determination left inside. Either way, I've realised that life can be very cruel, harsh and unfair.

Over the next few days

The end of the exam is almost approaching. I'm only left with the final portfolio before I can officially say I AM DONE. Luckily, it isn't as stressful as the rest (like what most people say, the worst is over) yet this exam poses a whole new era of challenges. I'm suppose to talk for about 7 minutes on my written portfolio submission which touches on 3 graduate capabilities and then answer the examiner's questions relating to my written submission as well as the remaining 4 capabilities. These graduate capabilities such as patient assessment and management, social and cultrual aspects of health and disease, team work, effective communication etc are used to evaluate your development as a Phase 3 medical student and an upcoming practitioner. Basically we have to cite relevant evidence from past submissions, patient encounters, past clinical exams, assignments, oral case presentations etc to illustrate our learning process during the clinical years and how we can improve in these disciplines. This sort of examination is best suited for those blessed with the ability to express their thoughts clearly (unlike me). There is no right or wrong answer but you have to validate your opinions/thoughts with substantial evidence and attempt to persuade the examiner to believe your side of the story. I suppose its very similar to an interview but in this case you are 'buying the examiner over'. I'm a bit worried about this exam as I am never good with oral case presentations as I get anxious and nervous whenever I speak in front of an audience and I often fumble for the right words to say. I also sometimes find it difficult to translate my thoughts into spoken words as I am much more of an 'written essay' person. Over the next few days I'm cracking my head to try and list out the possible clinical scenarios that I have encountered during my Phase 3 which can be used to address these capabilities.

Despite that, I feel a lot less tense and high-strung as compared to the previous 3 nights ago. I cannot believe that I actually did not sleep a wink the night before the VIVA exam and managed to stay awake for 28 hours. I was very zombified the day after which I thought was a bit unusual as during the 28 hours I didn't exactly feel all that exhausted and I could still muster the energy to drag myself throughout the whole day. I think that sometimes when the body is pushed to extreme limits such as no sleep, no food or too much physical exercise it is able to endure the stressful situation but then eventually collapses the day after when the stressful trigger is gone as all it's fuel and supplies have been depleted. Its not unusual for people to remain alert and active during stressful times but then suffer a 'hang-over' period the few days after. And talking about the exam, it was no doubt very hard but at least I said something which I hoped proved logical to the examiner. I still don't have a good feeling about the exam as there were 2 stations (pharmacology and psychiatry) which I really fumbled and couldn't exactlu arrive at a correct diagnosis. Plus the pharmacology station was a complete killer, I had absolutely no idea which one of the drugs was causing the lady's hyponatremia thus leading to the lady's confusion (delirium) and I tried to distract the examiner by talking about the management of delirum in the attempt to buy some time. It did work for awhile but then my examiner (young Asian lady) was persistent and kept reverting to the drugs that were potentially causing her renal failure, hyponatremia and delirum. First of all, the case was a polypharmacy one (which involves several drugs interacting with one another to cause adverse drug reactions) and I had no idea which were the ones that were contributing to it or the mechanism behind the polypharmacy issue. She even asked me the mechanism of how the drug works and I just stared at her speechless. There's no doubt I probably failed that one; almost all the students in my group were groaning in exasperation over the pharmacology station. It is so unfair that the exam the previous day was so much easier than mine with simple straightforward cases mostly derived from the VIVA list given to us by the faculty of medicine. The complete list that covers medicine, surgery and emergency consists of 125 case scenarios which are supposed to be the building blocks of the VIVA examination. I was so disappointed that only 4 of the cases from that list came out for the exam.

Furthermore, I am doubtful as to whether I passed the remaining 7 stations as after thinking it over, I found that I missed out on a couple of important things that I should have said which makes me feel like kicking myself in the shins. We are given about 5 minutes for each station except pharmacology, o&g, psychiatry and primary care which are 10 minutes and involves only one case presentation so you really need to think fast and immediately say all the vital aspects in the investigation and management of the patient before the buzzer rings. I don't know whether what I have said is enough to give me a pass in that station. And since I did horrendously in my MCQ exam I really need my marks in OSCE and VIVA to be good solid passes (at least a P) so that it would help to bring up my overall grade. Even then, I still stand a high chance of failing the exam altogether which means I have to resit the supplementary exam the following Monday or repeat the whole year (the worst case scenario). Its times like these when I absolutely lose faith and hope in myself and feel very helpless. Its impossible to turn back the hands of time and the future looks so bleak and uncertain. I'm really anticipating the worst for this exam as never in my life have I sat for an exam when I truly and deeply feel that I have failed.

Avolition

Avolition is one of the words used spontaneously in psychiatry to descibe a psychological state characterized by general lack of desire, drive, or motivation to pursue meaningful goals. It is commonly seen in patients with schizophrenia, and is one of the four main "negative" symptoms of that disorder. Well I guess in this case it more or less applies to me.

I feel unmotivated to prepare for VIVAs and portfolio. I had my OSCE exam which in my opinion, was a just a margin lower in terms of difficulty in comparison to the MCQ. Time again was a huge limiting factor and I was really fustrated that they didn't tell us beforehand that we NEEDED TO TAKE A 2-3 MINUTE HISTORY before proceeding to physical examination. Plus answer the questions that are thrown at you by the examiner which includes relevant investigations and management and explaining it all to the patient. I mean, this is suppose to be a clinical examination not a VIVA so why include so many aspects into it? We are given only 12 minutes for one station which is already a very short time for you to do the entire examination and come up with your differential diagnosis and present your positive findings to the examiner. Furthermore, there were a few examiners who actually rushed me through the physical exam explaining that it was unneccessary to perform certain steps (probably because you won't find anything significant) which added to the chaos. I know I completely stuffed up the O&G station and I partly blame myself and the examiner. The station was a clear cut 'pre-eclampsia' case which I did IN FACT DERIVE as my provisional diagnosis but due to the examiner who kept questioning me over and over again, I began to feel very doubtful and changed it last minute to a urinary tract infection. I know it sounds so utterly dumb right now but at that time, my mind was racing and the fact that she kept on pestering me made me reconsider other differential diagnosis. As a result, my investigations were defintely wrong. I felt so stupid afterwards. The other stations, I made some mistakes here and there and I am doubtful whether or not my technique was correct (or appeared 'believable') in the examiner's eyes and I am not sure how 'correct' my answers were and whether or not I could have expanded on them or at least delved a bit deeper. And the GP station was like a counselling session, the examiner just sat there observing how well I communicated to the patient so I just went on babbling like some nonsensical fool about everything I could regurgitate about exercise-induced asthma in lay-man's language. Please note, I am not good in explaining things to patients and I tend to have poor communication and rapport building skills i.e patients do not love me. Overall, the exam was just as hard but at the least, I did or tried something (whether or not its correct or not) in front of the examiner. Everyone else found the exam equally hard and DEMANDING due to time constraints and the absolute neccessity to think at lightning speed. I'm really furious at the faculty of medicine for imposing such a difficult exam for the final year students, why not just pass us? We are going to receive further training as interns and in our upcoming professional years so why make this exam seem so much like a barrier exam? I know several good students who crumbled during this exam not because of inadequacy in knowledge or skills or intelligence but because this exam is really pushing them/us to insane limits.

So I feel like its pointless to really try studying for vivas and portfolio. Half of my motivation has disappeared because I really and sincerely feel like I've failed in the exam (FULLSTOP) so it seems hopeless to pursue further or press on. A part of me just wants to give up, there's a part of me who desperately wants to rewind the clock and rectify or amend all the mistakes that I've made during the past two exams and the other part who just wants it to be over so that my mind can just rest in peace. The agony and torment that is building up inside me can be very unbearable at times and its not just affecting me; I know a lot of other people who are shedding tears and complaining how utterly unfair the whole exam is. There already has been numerous complaints about the MCQ exam that Phillip Jones (head of year 6 medicine and exam coordinator) had to reply and email all of us that they will take into account time as a limiting factor and will readjust the passing grade accordingly. They've just created a bigger catastrophe for themsleves if you ask me by creating such an unjustifyingly difficult exam.

One of my friends asked me today whether or not I have 'emotional support'. I guess she is referring to family members (especially parents) who will provide you with encouragement, empathy and basically just to tell you that they will be there for you even if the worse does happen. Just like the passengers on titanic who knew that the ship was inevitably going to sink and that there was nothing they could do to stop or prevent it. Even though they were heading towards their doom, its comforting to have your loved ones there to help make the situation a lot more tolerable and to allievate the pain and suffering.

As time draws closer, a sense of dread and anxiety is increasing in the pits of my stomach. The pressure to perform well and the absolute neccessity to save myself from the brinks of failure (due to the recent MCQ exam in which I performed horrendously in) is nerve-wrecking. Its an attempt to rectify my mistake and help boost up my overall mark in the examination.

I was never good in clinical examination i.e Physical examination and history taking; in fact they were and still are MY WEAKEST POINT. And don't get me started on neurology, I have absolutely no heads or tails about the matter and the same goes with ECGS and radiology (CT scan/MRI and X rays). Furthermore, i haven't been very keen and optimistic in looking for patients with good signs so that I can recognise them easily which help put me in an advantage in the examination. I have almost nil experience in detecting murmurs, crackles, wheezes which are highly likely to be tested which means I am basically going to fail this exam.

Doomed to fail

Yesterday marked a very grimful headstart into the 6th year final medicine exam. I sat for a 3 hour excruciatingly painful mutliple choice question and short answer written exam (which were all computer based) and the only word to describe the exam is CRUEL. I am not exagerrating but everyone (or should i say almost everyone as I have not specifically asked the entire batch) was literally traumatised after the exam was over. Even high distinction students said the exam was difficult. When I incorporate the word 'difficult' I just don't mean hard questions, I am also referring to the unfairness of the exam. Firstly they give 120 questions for section 1 which is MCQ (choose the best answer out of 5 possible choices) which are all equal to the AMC standard (or probably harder) which is an insane amount to complete within 2 hours. When the timer at the side of the screen striks 2 hours your page automatically shifts to section 2 which is a mixture of both MCQs and short based answers. That means you have approximately 1 minute for each question in the first part. Furthermore, each question is a small case scenario with clinical symptoms, results of relevant investigations to interpret with occasional imaging findings for you to intepret which does take a substantial amount of time to process. And the answers are all so ambigious...most of them are applicable to the situation so its so damn difficult to select the most appropiate answer.

The second part consists of 12 totally different scenario, 3 questions each with a mix of MCQ and short answers. You are provided with a little bit of information in each relevant section and must type/click the right answer before proceeding. Once you click the submit button, there is NO OPPORTUNITY for you to go back to your previous answer to change or rectify it. That means you can only go forwards. The next question normally gives you a set of investigations to help you obtain the diagnosis and you have to select about 4-5 out of a possible 10-12. Almost all the investigations are deemed neccessary so I don't know how you can only select just 4 or 5. Furthermore there was a paediatric growth chart to plot (by yourself) which was very time-consuming.

Anyway, I left about 5-6 questions in section 1 and only reached up to question 11 in the next session which means I couldn't complete the exam in time. I feel so fustrated and irratated both at myself and at the injustice delivered by the UNSW faculty of medicine. They shouldn't give so difficult questions that are aimed at the AMC exam level or higher for final year medical students as well throwing in other specialiaties such as dermatology, ENT and opthalmology which we are not taught much of at hospital. At least if they are inclined to give such hard questions, at least give fewer questions or more time. A lot of poeple couldn't manage to finish the questions; several leaving out 20-30 questions. On my part, I think I failed as even with the remaining questions I did answer, I am 50% or less confident of the answer. How can they expect the medical students to cope with these questions? My colleagues said that even in the AMC exam, there was more time allocated and the number of questions were much less than this one which altogether makes this exam more difficult. As I reached the halfway mark of the exam, I could feel my heart sinking further and further into the pits of my stomach and all sense of hope, motivation and determination just disminished. Now I have 3 more exams to go which I fear will be even tougher and less managable especially the clinical (the one I am most afraid of) and VIVA. The probability of me passing this exam is close to 1/1000000 so it will be a miracle or shall I say God's Gift to me if I am able to pass this exam.

Top things that make me happy

In spite of having to slave away for endless hours in preparation for the upcoming exam, I've decided to compile a small list of the things/activities/places that never fails to cheer me up or brighten my mood during the clouds of sorrowfulness (like now for example). I suppose every individual has their own specific list of things that they enjoy doing whether its by their solitary selves or shared joyously with others. For me, I'm more of a solitary person; I've never been much of an extrovert for the majority of my life and prefer to dwell in pleasures that can be attained by my ownself. So anyway here's the list:

1) Watching movies either from dvds, cinemas, series or just downloading videos from youtube.

2) Listening to invigorating updated music or tunes that soothe the soul with the likes of Josh Groban/Celine Dion/Mariah Carey while talking a brisk walk outdoors. I find that the simple act of just walking (preferably outdoors where you can enjoy the scenery rather than a treadmill where you just basically walk on the spot) really helps to calm my nerves and release tension. Its by far one of the most rejuvenating experiences and very much of a stress reliever for me. Furthermore the music helps make the walk more relaxing and enjoyable. After some time, you hardly feel as though you are walking more like drifting in your own private world.

3) Looking at scrumptious food posted on food blogs and researching on the best restaurants/coffee shops/cafes which serves the best food. Its quite fun to read other people's reviews of the place and nothing beats reconfirming your opinions/beliefs when you actually go to the place. Nowadays its extremely popular for people to find good eating places on the web and you can actually earn a living by becoming a well-known food critic. There are countless or millions of food blogs or websites set up by the restaurants/coffee shops themselves (note: even durian and mamak sellers have their own official websites) or by random ordinary people in the hopes of sharing their culinary tastes, their discoveries of wonderful or interesting food or displaying their home-made recipes.

4) Reading novels (although I do not have the freedom to do so) and magazines especially celebrity gossip.

5) Meeting up with old friends or those that I have formed an exceptional strong emotional bond with which includes relatives. Socialising with others is important although I have mentioned that I am not exactly a very sociable, outgoing person but neverthless the art of conversation helps to bring people closer together to share similar or opposing views, lend a helping hand and offer support and advice in times of crises or just the very presence of someone close to the heart (whether or not words are actually spoken) is enough to make anyone feel warm, loved and special.

6) Window shopping at shopping malls, street markets/pasar malams or anywhere interesting. I'm actually very careful about not being thrifty and will only buy things of absolutely necessity or items deemed on sale. So I often live by the slogan 'Look but do not touch' or in this case not buy.

7) Spending time with family. I've been brought up my entire life to be a homely person and my family has always been a well-knitted one so its vital for me to be in close contact with my parents who have been with me during my ups and downs and trials and tribulations.

8) Basically having the entire day free of stress (even if there is absolutely nothing to do) and not having to worry about exams/assignments/deadlines/urgent errands. Having the luxury to wake up, sleep and eat whenever I like, unlike nowadays when I am basically rushing through even my own basic needs and hygiene (eg: eating or taking a shower hurriedly so that I can quickly get back to the books and feeling absolutely guilty even if i watch a single dvd/movie as every second is extremely crucial).

9) Taking a trip to the supermarket. Many people often find it a chore to do their gorcery shopping but I actually find it quite entertaining to walk down the supermarket aisles and catching a glimpse of the newest food products or stocking up on old supplies. Its good to be updated and nowadays with modern technology, food supplies and kitchen-ware are advancing so rapidly you hardly need to spend hours slaving away at the kitchen whipping up a decent meal when you can have your favourite food already cooked or just pop it into the oven/microwave or else dump everything inside a slow cooker or a turbo-oven and let the electromagnetic heat waves slowly and surely stew/roast your meal to perfection (not to mention its far healthier than deep fried foods). Furthermore, the nutrients from the food are retained if they are roasted/oven convectioned or stewed as often fried or even stir-fried foods especially vegetables lose their vitamins and minerals when they are cooked in oil or boiled at high temperatures just to produce a dish that is fast and easy to cook. Its been noted that the essential vitamins, minerals and enzymes which are proteins denature at high temperatures. That's why soups/stews are extremely nutritious (not to mention very tatsy due to the many hours of stewing and boiling from a lower heat source) as the actual minerals, vitamins and even collagen from the meat, bones (calcium included) and assorted vegetables leech out and are retained in the broth. So even if you just drink the liquid you are consuming the soup that is enriched with these essential nutrients. That's why soup is well known for its health benefits which includes cough and cold remedies, ensuring proper rehydration and correcting salts that are lacking, replenishing certain dietary deficiencies, curing fatigue and helping osteoperosis due to the calcium that has leaked from the bones especially if its a fish soup.

So there have you it. As you can see I'm very much of a simpleton and don't really require extravagenous things to satisfy me.

Depressing post

Maybe the upcoming exams are driving me a BIT mad. Okay, that's a little bit of understatement...I think its practically driving me to the brink of insanity due to the pressure to perform, the lingering feelings of doubt, pessism and impending failure knowing that you could have done more, tried harder or prepared more effectively for the exam. I am not being selfish in raving on about my emotional turmoil as I suspect that everyone at my stage or current situation is at least suffering from similar feelings if not probably more. Everyone handles stress differently and I envy the ones that are able to take things in a cool, light-hearted manner or perhaps the ones that only explode once the exams are over (as in 'supressed' stress or 'the burnt out after-phase'). There's just TOO much left to gobble down and I fear I am unable to finish at least ROUND ONE SATISFACTORILY. Flying through topics at a lightning speed in the aim or hopes that in doing so, you at least covered more or less everything and praying that you retain as much information as possible in the process is not very EFFECTIVE. But I have NO CHOICE at the moment due to scarce amount of time left (approximately a bit more than 3 weeks). I know you can never be fully prepared for an exam but in my case I'm not in the medical student category of 'smart' or 'above average' hence more effort and perserverance needs to played on my part.

The anxiety about the exam has also affected me physically and psychologically. It has basically sapped away most of my energy as well as leaving behind traces of guilt everytime I take a 'breather' or fail to accomplish the tasks I set out to do beforehand. I feel out of control which is the one feeling I DESPISE THE MOST. Therefore I turn to several coping mechanisms to deal with the fustration, pain and anger. I will not mention any of them here as the majority of them are quite self-destructive in nature and I am not promoting or encouraging unhealthy habits just so that you can obtain a certain form of temporary 'relief' afterwards. Mind you, these acts work on a vicious cycle and just like an addiction to a drug, your body builds up tolerance to it after some time and you continuously need to engage in these repeatitive and ritualistic behaviours in order to get back the same euphoric feeling afterwards. Everyone has their own special way of dealing with stress and when you are a medical student with exams constantly bombarding you, 'stress' has become the norm. Its no wonder a lot of us are very hot tempered, inpatient and cranky.

Pre-exam woes= Physical and emotional turmoil

The title says it all. Right now I have less than 6 weeks left till my dreaded FINALS. Apart from feeling overwhelmed by the vast amount of studying that still needs to be done, I haven't exactly been in top form lately. I've recently come down again with a 'stomach bug' which seemed to have phantom-ly crept up on me unexpectedly. I have no absolutely no idea what its due to as it lasted a bit too long for the diagnosis of 'gastroenteritis' to be established and it could very well be due to stress related gastritis or even irratable bowel syndrome. Its better now at least but I still occasionally throw up after eating certain foods that seem to trigger off the nausea. I hope it goes off soon otherwise I will have to consider seeking medical advice and treatment and not presumably basing it upon my own differential diagnosis and assumptions.

Apart from being physically unwell, I've been a bit low in spirits. The majority of it is probably stemming from exam stress but I find myself more irratable these days and easily lash out at the slightest mistakes not to mention being more prone to fleeting episodes of 'sorrowfulness'. It takes a lot of determination and motivation everyday to sit down and study for endless hours, trying your absolute hardest to digest everything you read and making sure you don't forget the vital aspects of it. And it gets even more fustrating when you can't seem to recall much of the information that you had previously studied a few weeks earlier which immediately drives my mind into 'PANIC MODE'. I admit that I am definitely hovering a very pessimistic attitude towards my exam and reminding myself everyday that it will be a 'MIRACLE' if i can pass my end of year exam which is the final ticket to becoming a doctor. I wish that I had more inner strength and faith in myself instead of harbouring irrational thoughts and emotions when I haven't even sat for the exam yet.

Jobless international medical students in Oz

The title explains it all. A lot of my International friends and medical colleagues have been groaning in protest, expressing their disappoint and some even throwing tantrums at how disgustingly unfair the current internship allocation is in Australia. The first round offers have been released and not a single International student had been confirmed a place to work as a medical intern in Australia. This doesn't apply only in NSW but all states in Australia. The main reason why this has happened is that this year, IMET has enforced a priority listing for students applying for internship positions which means all Australian citizens in NSW are GURANTEED A PLACE. The remaining places will be filled by next in line which are the New Zealanders and other Australians that have graduated from Universities in other states. Which basically puts us International students last on the list and its very likely that even if we do get a job it will be at some crappy rural hospital. Furthermore, there is only a 'limited' number of positions available as IMET has been specifically instructed that they are not allowed to 'over-allocate' under any circumstances. Thirdly I suspect that the intake of International students doing medicine is steadily increasing as each year commences.

For me, it doesn't affect me all that much as I have sort of made my mind that I am not going to work in the land of Oz and is strongly inclined to apply for housemanship at Singapore. Still, I can empathasise and sympathise with my fellow medical colleagues who have high hopes of working as junior doctors in Sydney. Some have expressed regret of not applying to other states in Australia to increase the proability of securing a medical position; however there are a few paranoid cases (I have one guy friend in partiucular) who have applied to all states in Australia. Perhaps now its a good time to look elsewhere for a job? Anyway, since this so called 'internship crisis' has never happened before, there have been numerous emails sent out to help try and clarify the situation due to the many angry accusations and bombardment of unanswered questions. Furthermore there has been a scheduled talk organised by the NSW Medical students council and AMSA on the 30th July at Uni of Sydney in the aim of shedding some light into this matter. Well all hope is not lost, the second round offers will be confirmed on the 5th August and IMET has strongly emphasised that International students do stand a good chance at working in Australia.

This is the email I got from the Student Medical Council from Uni of Sydney which does clarifies the stituation somewhat:

Q. What is the current process of intern allocations in New South Wales?
This year NSW Health made the decision to implement the priority listing for students applying for internship positions in NSW. The priority listing has existed for many years. It has not been applied for some years, due to there being fewer available graduates than positions available. IMET informed NSW Health late last year that the numbers of graduating students from NSW Faculties was similar to the numbers who graduated last year. However, NSW Health was concerned that there may have been an increase in interstate graduates applying to work in NSW since some states have significantly more graduates this year, and Area Health Services (the employers of interns) indicated that they did not have funds to employ the increased numbers of interns in 2010.


Each year a number of students in each category of the priority listing do not accept their placements. In recent years, when all offers have been made simultaneously, this means that vacant positions remain that can only be filled by late applicants. This year, when IMET has been told it can not "over-allocate" under any circumstances , we have to wait until the first round offers to students have been accepted or declined (about 10 days from now, and then offers can be made for the remaining places. Initially, offers have to be made to the next group on the priority list, which is Australian or New Zealand citizens who have graduated from Universities in other states. Following that group, international students studying in Sydney on student visas are the next group


If the uptake rates are similar to last year, IMET anticipates that the numbers of students who accept places in NSW will be very close to the number of applicants who genuinely wish to work in NSW. One of the problems is that each group on the priority list has a non-acceptance rate, and this is compounded by the fact that some students accept places in multiple states and leave it until January to decide which one they will turn up at! Some students, having accepted a place (or even several places) simply don't show up in January at all. Some of this frustration would be minimised if we had a national "wash up" forum, whereby each state could share which students had accepted a place, and students who had accepted multiple places would be asked to select one only position. Unfortunately, the state jurisdictions do not undertake such a meeting at this time.


In summary, international students are likely to be offered a place in NSW, but these places may cannot be offered until a vacancy is identified, which could occur any time between mid August and January of 2010.


Students will be randomly allocated into the allocation pool from the pool of international student graduating from NSW Faculties, as positions become available for each "round" of allocations. From the above comments, it is anticipated that there will be more than 2 rounds. There is a good chance that if international students do not receive an offer in the second round, they may get an offer in a subsequent round, but this can not be guaranteed.



These arrangements for international students has come about because, unfortunately, the decision made this year to absolutely limit the number of places, along with the instruction that "over-allocation" was not allowed despite good data about acceptance rates from previous years has not allowed any other alternative.


Q. If I obtain an offer on the second round, do I have the option of trading offers with other candidates? If I do NOT obtain a second offer, then what are my options if I wish to remain in Australia? At this time, is there anything I can do/anywhere I can apply, any appeal I can make, in the event that no second offer is pronounced on August 5th?

Any appeal process is unlikely to be successful, given that the process has been determined by a government instrumentality. You can apply for positions in other states of Australia, but be mindful of the fact that other states have similar processes in place.


Ultimately most if not all international students will be able to get intern places in NSW starting next year, and in the unlikely circumstances that you don't, there is very chance that there will be vacancies elsewhere in Australia.
Please continue to check the IMET website for the updates.

1 week break

Right now, I am officially on my 1 week break. I've just finished my endocrine posting so I have basically only two more selective terms (gastro and respiratory) each spanning a month's duration before I face my DREADED FINALS. As each day passes, I can't help but get more jittery...I feel very unprepared considering the limited amount of time I have left. And it doesn't help that my friends from my previous medical university have posted countless photos of their convocation/graduation day/graduation ball openly to the public. There's no need for words, the pictures themselves reveal their inner happiness and triumph of finally graduating as a doctor after salvaging for approximately 6 years. It does make me feel incredibly envious of them; wishing I was in their place instead of trying to fight the hands of time. I desperately need to MAKE FULL USE of this 1 week to try and squeeze as much revision as possible especially targeting the VIVA questions and other subspecialities like paediatrics, O&G and pyschiatry. I haven't yet properly touched the subspecialities yet; I've been focusing mostly on trying to complete the surgical, medical and emergency viva questions (in total there are 125 questions) and at least I'm almost there. Each question covers a particular clinical problem. Of course, you can take the easy way out and refer to the senior's notes on the management of that specific clinical scenario but you will be clearly LACKING in knowledge about the disease. I've been citing clinical practice guidelines online as well as referring to my ever-so-dependable Kumar & Clark clinical medicine textbook and Oxford clinical handbook to tackle each problem. That's why its so time consuming for me and furthermore the most irratating thing is that I always tend to forget most of the important stuff when I move on to the next topic. I need to re-revise the entire stash of viva questions (at least 2 more rounds) before I sit for my exams to ensure that I instil all the vital aspects and recall them at the tip of my fingertaps. Because on the actual day, when you are nervous and tense plus given only 5 minutes to prove/convince your examiner that you know your stuff; you are definitely bound to forget some important detail. We have been advised to practice our vivas among our colleagues so that it will come like second nature to us during the exam.

Sigh, I feel so overwhelmed with the vast amount of information I need to learn. I wish that I was blessed with a memory like some of my other friends who only need to read the material once and yet recall the information almost perfectly the next time you ask them. I mean, even normal human beings have a limited capacity of memory space in their brains. But no, medical students are an entirely different race; we need to gorge ourselves with endless information at lightning speed and regurgitate the entire stuff out as if we have had numerous lectures and teaching sessions on it. In reality, we only get one class (sometimes two if we are lucky) that touches briefly on the topic and its up to us to take the initiative to delve further and expand on the topic during our spare time (or whatever time we have left).

A lot of my friends are strong Christians which makes me feel that religion can be a useful tool in times of hardship such as facing exams. I am amazed with the amount of faith they have in themselves and the will of God that He will see them through the exams so long as they trust and believe in Him and themselves. One of my friends told me that it doesn't matter whether or not she passes the exam the first time, it could actually be a blessing in disguise and that God has a 'Bigger Plan' for her. Eventually God will lead her down the path that is intended for her for eg: her parents and relatives were steadily pressuring her to accept her offer to study pharmacy in UK but somehow she had self-doubts as she felt that this was not the 'career' God had chosen for her and that she was destined for 'bigger things' such as contributing back to the society and helping others in need so she opted to choose medicine at IMU instead of pharmacy at a much more prestigious university in the UK. And she is currently happy and has absolutely no regrets at ever having made this decision. I know one shouldn't turn to religion in the hopes that God will help them achieve what they desire but nevertheless, it does help a lot to know that there is someone out there watching over you and ensuring that you will eventually make it through the darkness. So I actually do feel its quite comforting to engage in a prayer or two everday despite not being a Christian or not really having any kind of religion to help calm my nerves and enable me to achieve a state of tranquility and harmony as I definitely need a clear and strong mind right now to concentrate on my finals.

R.I.P Michael Jackson

This is a tribute to Michael Jackson who sadly passed away at the age of 50 years old due to a cardiac arrest. No one can confirm the cause as the autopsy is currently being conducted and also toxicology results take a couple of days; if not days to be released. Despite being accused a sexual molester on two occasions whih both cases ending up in court, was seen by the public dangling his baby on the balcony thus stirring up news instigating him to be a bad parent, suffering years of physical and verbal abuse from his father (or so he claims), building a Neverland park intended for young children to visit and shamelessly saying in a video footage that it was perfectly alright for young boys to sleep in his room, going through astounding physical transformations such as his nose lift and his skin bleached, and his less than 2year marriage to Lisa Marie Presley, he was still an extremely good entertainer and will definitely remain a legend in the history of musicians and in the entertainment industry. In my opinion, his dance moves and singing probably sparked a new era of music videos that not only included the artist singing the lyrics to his song but an actual video/movie. He was seen as an inspiration to many famous artists today including Britney Spears, Madonna, Justin Timberlake, Usher and if you actually watch their videos, some of their moves are an exact imitation of Michael's like the legendary 'Moon walk'. He has apired many artists and dancers who one day dreams of making it big like MJ. For instance, there was this tiny chap called Wade Robson who idolised Michael Jackson so much that he spent endless hours practicing and copying his moves. He was spotted on Star Search in 1990 and impressed and captured the hearts of the judges and people as well MJ himself worldwide as an upcoming protege dancer. (He has also starred in one of Michael Jackson's music videos although I cannot recall which one). Today he is a well known music video choreographer and hosts his own show called the 'Wade Robson Show' on the lookout for similar talented dancers across America. Anyway I'll leave you with one my favourite videos 'Smooth Criminal' by MJ and a video compilation of his live performances and two footages of the Wade Robson one as a child and now as a successful dance choreographer.

Danish pastries and Croissants haven

I've always been rather fond of bread/buns and pastries ever since childhood. I can recall when I was much younger (about 10 years old), eagerly accompanying my parents to the bakery store and picking out (or rather using a pair of plastic tongs) the best looking assorted pastries, buns and sandwiches. I never grew tired of the tuna mayo, ham and cheese sandwiches/buns, barbeque pork/chicken buns/paos, garlic bread toasts and even the sweet ones like the local red bean or lotus buns, pandan sponge cakes, chocolate chip or apple and cinammon muffins and dark chocolate brownies that melt like heaven in your mouth. I was perfectly contented to eat a toasted sandwich slathered with a generous helping of rich butter and pandan kaya that oozed its deliciousness during the afternoon (rather than a boring bowl of noodles) washed down by a steaming cup of hot sweetened green lipton tea that seems to perfectly compliment the meal. Parents these days will be absolutely delighted if their kids devour a healthy and nutritious turkey sandwich stacked with thick slices of cheddar cheese or a smoked salmon and avocado wrap rather than a Mcdonalds french fries or a deep fried McChicken burger. So I guess I was more or less cultivated this good eating habit since I was young as my mum often packed salami, nutella or tuna mayo sandwiches in my lunchbox before heading off to school.

They are extremely convenient to eat, you can eat it on the run while you are waiting to catch a bus, walking down the street or even while your window shopping. They make a fantastic snack when you are too busy to make something like eg: instant noodles (which are brimming with MSG) and can be very nutritious too; such as the ham and cheese croissant which is packed with protein, dairy and your daily essential carbohydrates. And they do leave you feeling quite satisfyingly full afterwards. Back in KL, I always looked forward to the evenings (around 8pm) at shopping malls where they offer discounted prices on the various pastries and everything is up for grabs. Swarms of customers would be queuing up for these delicacies, snatching them off the racks before the next person could even get the chance to catch a glimpse of it. Unfortunately, they do not seem to have the local buns/pastries like the ones I adore in KL (kaya filled buns, red bean polo buns, char siew or dried meat with chicken floss buns etc) and are only available in several stores if you are willing to catch a bus to Chinatown.

And even right now, POW hospitals offer free food during clinical meetings or presentations which largely comprises of delicious meat wraps, muffins, finger sandwiches and assorted pastries. So I was attending one of those meetings and spotted a few scrumptious looking Danish pastries and decided to try one. After I took my first bite out of a strawberry jam filled Danish pastry, I could taste the loveliness of the bread that was crisped to perfection and didn't even bother that the jam was probably spurting out the corners of my mouth. I did not regret choosing this over the finger sandwiches. From that day onwards, I took a complete infatuation with danish pastries and lattices and similar looking savoury croissants (like ham and cheese). Luckily they are available near my apartment and are often sold at bakeries such as Bakers delight or even Coles supermarket where they pack different sorts of Danish pastries at a reasonably affordable price. (I HAVE TRIED ALL THE DANISH PASTRIES AT COLES SUPERMARKET). All I have to do is pop it into my electric toaster. I must admit that my electric toaster/oven has become a very valuable kitchen appliance (like my new best friend) as it is being fully utilised. So much, that one day my toast actually caught fire due to my carelessness of leaving the bread too long in the oven. It's actually more convenient for me to buy the pastries from Coles supermarket as they expire in a couple of days which gives me ample time to eat it, are actually cheaper if you divide the total cost and are stored in air tight sealed plastic containers which conceals the freshness and flavour. I normally buy several packets to keep during the week which saves me the trouble of making trips back and forth. Yeah, so there have you have it, my new found love and staple diet: Danish pastries and croissants.

Exam Stress

I have barely 3 months left till my dreaded final exams. I need to utilise these precious 3 months to the maximum in order to drill as much information as possible into my head(pray that it doesn't disintegrate) and patch up weak areas eg: neurology, ECG intepretation and other diagnostic imaging such as CT scan and MRI scan. I am currently in a study group comprising of two other fellow students and we have had several VIVA sessions together (which have proven to be useful) where we tackle the problems and present it to one another under examination conditions. We've also had a few practical clinical examinations supervised by an intern/resident/registrar where we see patients and are given approximately 15 minutes to take a history, perform a physical examination and present our findings. Plus come up with a possible diagnosis. This area is probably a lot more difficult than VIVA as it involves practical skills, possessing a sharp eye in detecting abnormalities and trying to figure out the probable illnesses. It is more likely for students to fail this examination due to improper technique thus not eliciting the correct signs, poor communication skills with the patient and poor summary of our findings.

Apart from having a mini study group (it is best to not have a group that big otherwise it will prove ineffective as not everyone will be able to have the opportunity to practice)there have been organised tutorials at POW hospital by enthusiastic registrars/interns and consultants willing to lend a helping hand to the 6th years in preparation for the exams. Like there is a surgical viva tutorial every friday which just commenced recently conducted by Dr Shing Wong who is a lower gastrointestinal surgeon as well as the examination head and coordinator of the POW clinical school. I have been under him during my lower gastrointestinal surgical term and I must say that this guy has very high standards. He expects students to be dilligent, have a good background and knowledge of the common surgical diseases and to be precise and confident during the exams. If he is your examiner at POW, the chances of you failing is as high as 60%. So even if you manage to scrape through his station, it probably means that you will get a distinction in the other stations.

Anyway, he conducts his viva session by randomly picking students and throwing a VIVA question at them in which they have to basically rattle on for about 5 minutes on their approach to assessment and management of a patient in a particular clinical setting. Furthermore, the student has to present his case in front of all his other colleagues which further adds more tension. I was lucky today in that I didn't get picked but I can be assured that my turn will surely come if I continue attending his VIVA sessions. The students he picked were all good in my opinion, they demonstrated good knowledge and a focused sequential approach. The examiner can choose to ask you questions during the VIVA to test whether or not you do understand what you are saying and not literally regurgitating everything you've memorised from the textbook or divert the scenario to another clinical problem. But Dr Shing Wong told us that due to lack of time most examiners will allow students to talk non-stop for about 5 minutes before asking the vital questions. He advised us that it is best to display AS MUCH KNOWLEDGE AS POSSIBLE and not hesitate or keep information that may actually prove useful and show that you have superior knowledge in that area. The whole idea is to IMPRESS the examiner and demonstrate that you are capable of handling the situation as if it were in real life. I thought that the students today did really well and would probably have done even better if given more time.

Apart from preparing for exams, I am currently in my endocrinology term where it is mainly outpatient based with the majority of the cases being diabetic. I am lucky in the sense that my next two terms are all selective postings (respiratory and gastrointestinal) with no formal assessments or presentations. I'm always contemplating on ways to spend as minimal time as possible at my attachment (except for important tutorials, lectures and teaching sessions) to stay at home and study (due to the scarce amount of time left) and even if i go to the hospital it would be to search for patients in other wards (cardiology, neurology, rheumatology) to practice my examination skills and to recognise the physical signs present in them. Not that I am being a bad student, in fact a lot of my colleagues are doing the same thing as you are now given a choice: Either go to hospital and be a pro-active student in the posting you are allocated to OR spend your time wisely in preparing for exams. Of course, I choose the latter...I mean which student wouldn't when you are already so close to the end of your course?

Oh, I found this rather cute picture on google which typically represents the detrimental effects of exam stress physically and psychologically. Click on the picture to enlarge.

Social gathering

Tonight, my friend Sarah invited me over to her place for steamboat with a couple of friends from church. She supplied most of the ingredients (although we split up the total cost among ourselves) as well as boiling a wonderful mix of chicken and pork stock/soup and a huge plate of stir fried meehoon. Since its the beginning of Winter, I think that everyone was very grateful that we had something warm, nourishing and delicious in our bellies. (Although the guys were complaining that they didn't feel 100% full afterwards). This was then followed by a short CG session mainly aiming towards those that were sitting for their end of semester exams next week. Afterwards, we spent an hour or so of leisurely chat about studies and life. It's always inspirational and stimulating whenever friends engage in conversations about life and exchange ideas and opinions. You can learn a lot from listening to others (especially those that are heading down a similar path as yours) and it enables you to reanalyse or re-evaluate your own thoughts and opinions. The act of bonding is essential to any human being; we are not created to be solitary beings. Friends can give you support, encouragement and advice that greatly differs from your own family members. Most of all they make you feel less alone in the world; after all life is full of so many trials and tribulations, ups and downs, so it always helps to have someone to lean on for comfort and reassurance.

Being a final year medical student in the midst of preparation for finals and going to hospital on daily basis, we are left with very limited time for social interaction. Not that we don't converse with one another but I am referring to gatherings or functions not related to medicine. I guess when we are interns, residents or registrars we will be left with even less time which even includes caring for our ownselves. I heard that interns back in Malaysia work like 'donkeys' and their overnight shift is 36 hours long that they do not even have time to take a shower so they develop a rather dishevelled appearance. Not to mention eye bags, dark circles around the eyes, wrinkles, oily hair and bad complexion. Sometimes I wonder why medicine involves so much sacrifice. We kill ourselves trying to soak up everything that is taught to us like a sponge, fret about the things that were not taught so we turn to a torturous hours of self-study, endure the daily drilling and questions fired by our consultants, face exams/assessments, sleepless nights worrying about the next day where the entire vicious cycle starts all over again. And when we are finally graduate as doctors, the happiness lasts temporarily and we are worked to the point to exhaustion where we live by the motto that 'the patient always comes first'. We have to work a minimum of 5 days a week, endure night shifts that can seem to last for an eternity and perform procedures that we have not done in our entire life (I have heard horrendous stories from interns and residents claiming that they were forced to do minor surgeries/ clinical procedures that they have only witnessed once or read about from textbooks but never have actually done it in real life). It is no wonder interns dread days when they are 'on call' as they are basically unqualified doctors clearly lacking in clinical experience. If you are posted to somewhere rural, it is highly unlikely that many of your colleagues or consultants will be available during the wee hours of the morning and if you are the only registered doctor around, any patient that comes in is under your 'duty of care'. This can mean any sort of patient (especially in the ED where all sorts of patients can present to you) and you are in charge of managing the patient regardless of whether its a psychiatric, obstetric, paedetric or surgical case. Most of the interns at POW walk around with a 'stressed look' on their face. That's probably going to be me in the future. Its kind of like a scene from a superhero movie; you come when you are called irrespective of whether you are in the midst of something (sleeping, eating, etc) and you try your very best to save the victim (in this case its the patient) even if it involves your life (in this case sacrificing your physical and mental health).

End of E.D.

Today is the last day of my ED term and next week I will be starting my selective term at the respiratory ward. So what has been the benefits and downfalls I have experienced during this ED term? Well for starters the ED term is a fantastic place to gain clinical experience as you will be the first or one of the first to examine the patients when they symptomatic as opposed to the patients in the ward who are mostly stable and undergoing treatment(thus may not have the signs and symptoms they orginally presented with). The cases you do see at the ED are mostly chest pain, dyspnoea and respiratory distress, acute abdominal pain, sudden collapse and syncope (loss of consciousness), trauma and other accidents, and sometimes patients presenting with an acute psychotic episode (suicide, mania attributed to drugs/alcohol/halliconogens). These cases are commonly encountered by primary care physicians and you will DEFINITELY be expected to know how to diagnose and manage them as a final year medical student. Also, you get to see the consultants, registrars, residents and interns perform resuscitative measures (which you don't see much of at the wards) such as CPR, electronic cardioversion (note that the patient does not literally jump off the bed as depicted by movies; at the most their entire body just jerks momentarily), insertion of chest drains for pneumothroax etc. And if the patient requires emergency surgery, you can be sure that the surgical team will be around and you are welcome to follow them and witness the surgery provided you have obtained the patient's consent and permission. Once the patients are haemodynamically stable they are either discharged or sent up to wards for further monitoring and maintanence of treatment and students are welcome to follow up these patients.

The main pitfall of the ED term is that we have not been allocated a specific supervisor so we just have to latch ourselves on whoever is on call that day. And since most of the consultants and junior medical officers are all SO BUSY, they might not have the time to actually teach you properly and might get irratated if you ask too many questions. However, most of them do appreciate the final year medical students as we are able to lighten their workload quite substantially by taking a history and examination beforehand and writing in the clinical notes(all they have to do is just reconfirm the findings and history), perform simple clinical procedures such as cannulation and filling in the laboratory forms for the tests being ordered.

I was fortunate to find an intern and resident (both their names are Grace) who are keen to teach enthusiastic medical students and are willing to share their knowledge. Today I had a bedside tutorial with Grace Aw (the resident) and two other medical students in a very formal examination style. We went up to the wards to hunt for patients and each of us had to examine a patient (i.e. take a history, physical examination, summarise our findings, come up with a provisional diagnosis and answer Grace's questions regarding the patient). It was very generous of her to actually spend three hours today teaching the three of us and giving us feedback on our strengths and weaknesses. So the three cases encountered today were biliary colic (probably attributed to gallstones), a post-stroke patient and a patient with myasthenia gravis.

I was the unlucky one to get the myasthenia gravis patient which is a rare neuromuscular condition that causes muscle weakness and fatiguability. These patients are unique as their muscle weakness progressively worsens on bried periods of activity (eg: one of the tests involves you asking them to stretch out their hands for 60s and you will notice that their arms will slowly move downwards to rest position or get them to count to 50 and you will slowly notice slurring of the speech). Often, their presenting complaint is difficutly in swallowing foods and inability to keep liquids in their mouth, slurred speech or weakness of the eye muscles. This patient came in with difficulty swallowing food and inability to drink liquids as they would dribble down her chin. If the patient didn't tell me she was diagnosed with myasthenia gravis I would be thinking more of an extrinsic or intrinsic esophageal cause due to her difficulty in swallowing foods such as esophagitis or a tumour or enlarged thyroid gland compressing the esophagus which are more likely. Furthermore, I didn't really know much about the condition so I couldn't really ask all the appropiate questions to confirm her diagnosis. After the examination, Grace told me that this was in fact the first time she has encountered a patient with myasthenia gravis and that it was not in her area of expertise. If we get this sort of case in the exam it will be very difficult to diagnose her condition and we will probably be leaning towards asking questions that are of gastrointestinal origin such as gastroesophageal reflux disease, esophageal conditions etc. Grace said that it will be very unfair if we were given this case and expected to diagnose it right on the spot. So why did we choose this patient in the first place? Well, this patient was recommended by her boyfriend who is a neurology resident and he claimed that she was one of the few patients on the ward who could actually give a coherant history and examination (most of the patients are stroke patients or patients with cerebellar or frontal lobe problems so are not able to speak properly or understand the instructions you give to them during the physical examination). Nevertheless, my neurology is one of my WEAKEST AREAS and it definitely needs much improvement. I kind of wish I could swap my respiratory term to a neurology one. Neurology is extremely wide and variable and even the entire neurological examination takes about an hour to perform. I desperately need to work on this area before the exams as I am clearly lacking in knowledge and clinical experience. I guess it will be a bit of a struggle as I don't really like studying about the brain as it is just too complex.

Overall, I believe that my experience at the ED has been a beneficial one. One of the highlights is that since the ED is open 24/7, we can can basically come and go as we please (however you must at least attend the ward rounds either at 8:00am or 4:00pm). I actually wouldn't mind redoing the ED term instead of my selective as I will be able to see a variety of patients instead of just patients with respiratory illnesses. I just hope that for my next term, I am not assigned a supervisor that it strict and demanding as after all, the selective posting is supposedly one of the easier and more relaxed terms which gives time for students to revise for finals.

Starting E.D.

This week officially marks the end of my O&G term. I'm starting a 4 week rotation at Emergency Department which I am quite looking forward to as it should be more interesting plus the cases that I will be encountering are very relevant for my final examination. The management protocols for any patient that presents in an emergency situation is a DEFINITE MUST KNOW for the finals which includes the correct, appropiate steps of diagnosis, relevant investigations, immediate treatment and follow up management. We're supposed to split ourselves up into two groups and you are either allocated to the morning shift (8:00-1:00pm) or the afternoon/evening shift (1:00-6:00pm) which leaves ample room for studying in between. I'm hoping to gain more exposure in practicing my procedural skills which is something that I am facing difficulty in due to lack of experience and partly because I'm really scared that I might end up causing a haematoma when i insert a cannula in (which I have done before on one occasion), do the procedure incorrectly or cause pain to the patient. A lot of the registrars and consultants have told me to just 'Go on and just do it' as the more you hesitate, the more uncomfortable you become (not to mention your self-confidence further deterioates)and you put the patient at unease. How am I going to do these procedures at ease when i am a future doctor? I've just got to gather the courage and DO IT without thinking too much of the potential consequences. I know most of the time these stuff are done by the nurses and midwives but it just means that its an accquired skill a doctor should possess hence he/she need not waste time on it.

Anyway, I received some feedback from my supervisor. She told me that I need to work on my communication skills. By that she means I need to make an effort to build a good patient-doctor relationship and have a broader view of the social, occupational, cultural factors that may contribute to the problem. I mean it is neccessary to ask the questions relating to the physical health of the patient but you should ask the patient about his/her concerns, worries, understanding of the disease, social support as this can impact on treatment outcome. Eg: A patient may be suffering from menorrhagia (heavy menses) but has suddenly come to her GP after only a pariod of 2 years. As a doctor you have to find out what is the reason why she has come to address this problem today; could it be that it is affecting her marriage i.e. sex life or perhaps she is worried that she may be having cervical or endometrial cancer? Just like any clinical scenario, a doctor plays a 'detective' role; you are given the clues and have to work backwards in order to find the source of the problem. If you don't ask the right questions, you don't get the right answers. That's why my supervisor emphasised that its vital to build a good rapport with the patient. She says that its probably due to my 'timid and introverted' nature but I think its probably due to a lack of self confidence. I admit I'm not that much of an outspoken person so its something that I need to work on in the future. It will not only make my job as a doctor easier but you will get along better with the nurses and midwives which can make your life a living hell if they wanted to. Otherwise, she mentioned that my academic knowledge is adequate but 'knowledge is only a small part that makes a good doctor'. Her exact words were 'To be a good doctor, you need to possess knowledge, adopt a caring, responsible and reliable attitude i.e. chase results, follow up conscientiously on your patients'. That's why medicine is so demanding, you not only have to study/work extremely hard and possess some kind of intelligence but you need the right sort of character/personality to deal effectively with your patients and other colleagues. There are things that you can change but some things you're just born naturally with like a high IQ, an outgoing personality or leadership qualities which I apparently don't seem to have. That's why sometimes, I think that maybe I am not cut out to be a doctor; there's so many qualities that I clearly lack. But then I'm already almost at the finishing line of my course; I've just got to try and make use of whatever I have and pray that its sufficient to meet the demands and expectations of my exam and future career as a doctor.

Delivery suite

This is going to be a relatively short post as I am pretty tired. Anyway, this Sunday I was rostered for a 12 hour shift at RHW delivery suite from 7pm-7am. I already anticipated beforehand that there will be a lot of waiting and there will be times when complete boredom takes over. The entire process of labour is a very slow but gradual process and it can take up to 20 hours for nulliparous women (women who have never given birth to a child)in just the latent phase of labour. And the fact that each birth is very unpredictable eg: a woman who appears to be commencing well initally may suddenly develop an arrest of fetal descent due to poor maternal pushing, fetopelvic disproprotion, abnormal fetal position etc. In Sydney, a midwife is assigned to every pregnant lady that is going into labour and the actual delivery is performed by the midwife and another person (eg: nurse, medical student) with the obstetrician only intervening when the labour is not progressing efficiently. Basically she is in charge to make sure that the whole labour process is going smoothly by doing regularly hourly checks on the mother and fetal monitoring, performing vaginal examinations to check that the mother is fully dilated and the fetal head is engaged and provide advice and support to the mother, husband and other family members once labour begins. She also assists in the actual delivery of the baby and the removal of the placenta as well as suturing up the vaginal and genital tract lacerations afterwards. The newborn baby will be assessed by her eg: the baby's weight, height, Apgar scores etc and she will educate the mother on the proper techniques of breastfeeding. It is her duty to contact the obstetrician registrar if she encounters any problem during the labour eg: sudden onset of fetal distress show on the cardiotocograph, maternal compromise or if a particular stage of labour is prolonged.

Tonight I witnessed one live birth and the seoond lady who was supposed to go for a spontaneous vaginal delivery finally ended up with a Ceaseran section as her cervix was not dilating. I was quite disappointed as I hoped that I could observe at minimum two deliveries but then again, it is all very unpredictable and you might not even get the chance to see a vaginal delivery if you are extremely unlucky. The first lady's labour went exceptionally well and progressed at a very fast pace considering the fact that she is a nulliparous woman. Her entire family was there (mum, dad, sis, husband) to provide her with encouragement and emotional support which I believed to have helped in speeding things up quickly. I oould see the tensed looks on the family members faces as they eagerly waited to see whether the baby's head will emerge as this signalled the completion of birth (it only takes one more contraction for the entire body to be delivered). And when finally the baby is born (it was a girl), I could see the overwhelmed and joyful expressions on their faces especially the mother who broke down in tears of happiness. I guess every birth is a miracle but not without the suffering, pain and turmoil. It does make me a bit frightened as I can't imagine myself going through the physical and mental exhaustion and torture of a normal delivery. I can expect that any woman's first delivery will be an unforgettable one which makes her child even more special. The first moment of bonding between mother, father and baby is a magical moment as it is the stepping stone in the long and tedious process of nurturing, caring and providing love and affection.

The second lady was not so simple and straightforward. Although her membranes ruptured at 3:30pm earlier today, she had a prolonged latent phase and poor progress in the active phase of labour i.e. a cervix dilation of 1cm/hr. She had a previous caeseran section before due to a breech baby so she has to be monitored more closely as she is predisposed to more maternal and fetal complications eg: postpartum haemorrhage and uterine rupture. She was practically moaning in pain everytime a contraction started and was urgently requesting that an epidural analgesia be administered. She was finally given one and was assessed 4 hours later to check whether she had made any progress. I was instructed by the midwife to take her vitals (blood pressure, pulse, temperature) and general observations every half hourly, plot my observed findings and results on the partogram (labour curve), write in the progress notes and assist the midwife when she examines the woman. It gets a bit monotonous and boring after awhile especially in this case scenario where the woman is hardly making any progress at all. Four hours later, the decision was made by te obstetrician registar to do an elective Caesearan section due to obstructed labour.

I luckily managed to finish my shift by 2am as the last lady had to go for a C-section (I am supposed to just observe and assist in vaginal deliveries) and there were no other women in the delivery suite going into labour until tomorrow afternoon. I still have two more delivery suite shifts so hopefully they'll be a bit more eventful than this one. Then again, I am much relieved to have ended earlier than expected as I don't think I would have survived until 7am in the morning. And thank goodness I don't have to go for clinic tomorrow, either. Now I can truly appreciate the amount of sacrifice interns, residents, registrars, nurses and midwives have to go through during their night shifts as it is very physically and psychologically draining.