The Farce

A farce: an absurd event. The great honourable National University of Singapore has accepted 2 students from polytechnic into the ranks of their Yong Loo Lin School of Medicine. Yes indeed, I say this in utter jest and disgust.

Background information: Polytechnic students in Singapore are taught the practical approach to technical sciences, e.g. biotechnology. Generally, a poorer grade in the GCE O Level exams is required for polytechnic entry as compared to the competitive entry into Junior College (JC). The JC route is the much preferred route of enterprising students wanting to do a professional degree in university, i.e. medicine. For many years, this has been the case and never has a polytechnic graduate entered NUS Medical School.

Precedence was set some years back when a female polytechnic student was offered a scholarship to read medicine in the University of Leicester, UK. Both my folks, doctors, frowned upon this, as did I. Entry into medicine was now available to the technical students? *ponders…*

This year, the uproar grew. NUS accepted 2 polytechnic graduates into the ranks of medical students – acclaiming their academic results as well as their hospital attachments and other co-curricular activites. Having a hospital attachment before entering medical school is indeed a plus point, but the nature of this hospital attachment would also be worth looking at. E.g. ‘Hey I was attached to a hospital to clean the toilets, wipe the windows etc.’

I believe the role of the hospital attachment is for the prospective students to experience the working life of a doctor and to be immersed in the medical subculture – firing himself a warning shot before blindly succumbing himself to the endless world of study and clinicals.

Now people from the various polytechnics believe that they have a fighting chance at entering medical school. Fact is, only 2 out of 250 students that are due to be enrolled in the prestigious course at NUS will be polytechnic students. False hope has arisen within the hordes of polytechnic students that one day, they will be scalpel-yielding surgeons ala Grey’s Anatomy, or limping geniuses like House M.D.

This uproar is exacerbated amongst the applicants this year because it is the ‘dragon year babies’ that are due to enrol in university. The dragon year (1988) sees the most births due to some archaeic superstition perhaps. Already thousands of more qualified junior college students have been turned down. To rub salt in their wounds, that they would never learn how to stitch or clean, their ‘lesser rivals’ have been handed seats in the previously exclusive course.

I do not know what NUS is trying to prove from this step to ‘further mediocrity’. They already are the most backdated school in terms of teaching, they still use the traditional ‘anatomy’, ‘physiology’ etc subjects in preclinical years instead of a patient-centered or problem based learning concept that even Harvard has adopted. Moving away from cadaveric dissections and into the 21st century technology of ‘virtual anatomy’, NUS has been the target of many criticisms of late. This latest fiasco plainly puts the nail in the coffin for NUS.

As the world aims to put ‘general education’ as an undergraduate focus, NUS seems to have special interest for those who have done purely ‘biology related courses’. The U.S. encourages arts or social sciences course in college before applying for Medicine, the A level curriculum from Cambridge no longer allows TRIPLE sciences and math to be taken as the 4 subjects, but instead at least ONE cross-faculty subject must be offered – NUS medicine wants biotechnology as YOUR qualification.

It may seem a extremely elitist, then again, isn’t that the medical profession for you? The Singapore Management University’s upcoming Law Faculty will be enrolling polytechinic ‘paralegal studies’ graduates into the illustrious law profession soon. I believe this will lead to as large an uproar from the wretched lawyers as much as the elitist doctors have lashed out at the horseplay looming at NUS.

I have few words to express my disgust for this bold and unorthodox step – expletives aside. I hope the stand taken by NUS will be adjusted next year to rectify the clearly erroneous decision.

Fat hope and a slim chance laddies….

PLEASE READ: sgforums

The Argument FOR Paternalism

Oh no he didn’t! Yes indeed ‘autonomy’ is one of the pillars of medical ethics but I’m gonna have a wild shot at rooting for paternalistic healthcare instead.

Firstly, I would like to credit Jezza for writing his thoughts on the doctor-patient relationship. It is indeed quite an interesting read that I would recommend to anyone.

Back in the day, before any of us computer literate folk were born, there was the birth of a great idea in medicine. This idea would define the practise of medicine for many generations of doctors to come. The concept of paternalism in the doctor-patient relationship was the way many physicians preferred to do things in the past.

Today we’re not so inclined to let these nerdy doctors control our life. We as the patient have a right to our own treatment options! So much so that the doctor cannot ethically or legally force us to undergo life-saving therapy. Frank Vertosick in his acclaimed bestseller, When The Air Hits Your Brain, discussed a real-life situation where a pregnant lady had a brain tumour and was faced with the dilemma whether to abort and carry out treatment, or carry the baby to full term and die from the cancer. She, like all other dramatic stories, chose the latter.

First point: Patient autonomy is overrated. How often does your doctor want to do something to you that will not in the end benefit you? Sure, doctors do slip up, but compare an experienced practitioner of medicine and a layman with no medical knowledge, who’s likely to make a poorer judgement on a treatment option? Damn right there newbie.

Second point: Patient autonomy is overrated. In an ethical sense, patients deserve to know it all, decide for themselves etc. But this is accentuated in the legal field of play where failure to comply with these ‘rules of autonomy’ can get a doctor into serious malpractice suits. I believe it was an Australian court that first ruled against the Bolam principles; and it still doesn’t use the Bolam principles today with regards to ‘disclosure of information’. Legal action son, don’t mess around with those lawyers – their stand is clearly with ‘ethics’.

Third point: Patient autonomy is overrated. As a rough estimate taken from an irrelevant source published in an irrelevant era, I would say that about 90% of patients will comply with a doctor’s treatment suggestion. So what’s the big hoohah about patients now wanting their own voice? They’re just gonna listen up to the credentials in the end.

Fourth point: Patient autonomy is overrated. Talcott Parsons‘ sick role model says that sick people aren’t morally culpable for their illness, but as a clause, must do their best to improve their condition. Hence, I declare that patients not following best advice (from non-else than the doctor) are morally culpable for their declining state of health – this is antisocial behavior.

Fifth point: Patient autonomy is overrated. “It is an oversimplification and distortion of the
Western tradition to view respecting autonomy as simply permitting a person to select, unrestricted
by coercion, ignorance, physical interference, and the like, his or her preferred course of action
from a comprehensive list of available options.” (Emanuel and Emanuel) ‘Nuff said there..

Sixth point: Patient autonomy is overrated. In no other of the 4 models is the physician’s obligation so in line with the Hippocratic oath. I quote Emanuel x2 again, ‘physicians use their skills to determine the patient’s medical condition and his or her stage in the disease process and to identify the medical tests and treatments most likely to restore the patient’s health or ameliorate pain. Then the physician presents the patient with selected information that will encourage the patient to consent to the intervention the physician considers best’. The Hippocratic Oath states, ‘I will follow that system of regimen which, according to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous’ as well as ‘Into whatever houses I enter, I will go into them for the benefit of the sick’.

As such, I lay down my case FOR the paternalistic model of the doctor-patient relationship. Please advise and comment.

N.B.: I do not actually believe this to be the best model, just some opinions of mine to stir controversy.

References:
Jezza. (2007) The Last Resort – When Procrastination Becomes Sloth, Blogspot [Available online: http://jman-jezza.blogspot.com/2007/06/when-procrastination-becomes-sloth.html, Accessed: 23 June 2007]

Emanuel E.J. & Emanuel L.L. (1992) Four Models of the Physician-Patient Relationship, JAMA 267:2221-2226 [Available online: http://www.davidhildebrand.org/teaching/courses/fourmodels.php, Accessed: 23 June 2007]

The Oath of Hippocrates [Available online: http://www.imagerynet.com/hippo.orig.html, Accessed: 23 June 2007]

Supersize Me

This is going to be a very insensitive post – those people who can’t take jokes shouldn’t read on.

I’m sure you all know the sitcom Scrubs. It has finished its 6th season in the US and I’m dying for more of JD and Turk. I remember not too long ago, somewhere in season 5, episode 2, there was something about sucking up to lame jokes. JD asked his interns to check out a CT scan and said, ‘his tumour’s getting so big, it’s starting to look like a threemour.’ LAME you think.

So instead of threemour, how about a fifteenmour? This bloke has the largest ever neurofibroma ever recorded. Weighing in at 15kg, this massive tumour on his face is due to be surgically removed. It has grown larger and larger and larger since he was a kid and he never had the common sense to get it removed earlier.

If you watch the video clip, you’ll see that he has severe kyphosis due to the sheer weight of the thing. Surgeons say they’ve successfully removed 2 facial tumours of the sort in Southern China but they say this one was still going to be tough, commenting on the numerous vessels in the tumour.

Neurofibromatosis is a autosomal dominant condition subdivided into type 1 and 2. In type 1 (90% of NF), multiple neural tumours form under the skin and used to be known as von Recklinghausen disease. They are generally discrete, uncapsulated nodules that are soft to touch. Overlying skin is often hyperpigmented. These tumours can arise at ANY site on the body.

In 3% of patients, the benign neurofibroma turns into a malignant neoplasm and can be life-threatening. These patients are also at higher risk of getting other tumours – glioma, meningioma, phaechromocytoma (I love that name…). 30-50% also see associated skeletal lesions like scoliosis, bone cysts and other erosive bone defects.

So what’s gonna happen to this dude? I have no idea. They’re probably gonna resect the tumour which is likely to have arisen from either the facial nerve or branches of the trigeminal nerve. Loose skin would definitely have to be cut off and he might lose some of the facial muscle function because muscles of facial movement are attached to the skin and I have no idea how they can preserve that function.

On a side note, here’s a good video of a total parotidectomy with facial nerve preservation: it’s quite cool! And, I didn’t know the branching of the facial nerve into the superior and inferior branches outside the stylomastoid foramen was called the pes anserinus. Pes anserinus means goose foot and I believe it refers to a structure on the medial tibia as well – where the gracilis, sartorius and semitendinosus muscles are attached.

References:
Kumar et al (2003), Robbins Basic Pathology 7th ed, Saunders
The Straits Times Website

Total Recall

I did some thinking about the semester gone by today and here are some of my thoughts on it.

Semester 1 of year 2 seemed like ‘real’ medicine compared to first year. We learnt more about the CVS and the respiratory system. We also touched on renal medicine and covered a bit more neuroscience.

I had a few projects like the Student Project Case on Asbestos, Health Promotion and Knowledge Management and the Rural Placement Case Report. These were all quite interesting projects to research and write.

For the SPC, we actually did some creative presentation: a House M.D. like skit, describing asbestos related lung diseases. I hope we got a good grade for that because we practised and prepared quite abit.

There were a few setbacks as well – I didn’t get a good grade for the HPKM ethics proposal, not because there were blatant ethical flaws in our project, but because we didn’t read the guidelines and attend the lectures pertaining to the submission of the ethics proposal and the whole group mucked it up badly. The other setback was getting ‘poor rapport’ commented in a few stations of my OSCE toward the end of semester 1.

Also, the semester 1 exam was postponed much to my dismay – I was ready to study hard for it and do well. Now I’ve lost my momentum of study and struggling to cover 2 lectures a day. I hope I still manage a respectable grade although it’s a meagre 5% of the year’s grade.

Out of school, things went pretty well I think. Other than a plan to moving out with a friend falling through. I bought a new MacBook Pro, the one I’m using to blog this entry right now. I also made some new friends, and strengthened other ties.

Overall, I must say it’s been a good first semester for me! Expectations and resolutions for the next semester to come along soon.

That Wretched Aedes

Mosquitoes have been around for millions and millions of years; dinosaur DNA was extracted from a fossilized mosquito in the movie ‘Jurassic Park’. Today I am not crediting the mosquito at all, in fact I am writing about a serious disease that mosquitoes transmit.

Aedes aegypti mosquitoes carry the Dengue virus – a type of flavivirus. Other diseases involving flaviviruses would be Japanese Encephalitis (SEA) and Murray Valley encephalitis (Aus).

All 4 types of dengue have similar clinical presentations – sudden onset fever, headaches, backpain with severe myalgia. Macular rash and red eye are also signs of dengue fever. Other symptoms include anorexia, nausea and paraesthesia. Due to the severe thrombocytopenia (low platelet count) associated with dengue, epistaxis (nose bleeding), gum bleeding, petechiae and bleeding from existing GIT lesions are common. The disease usually lasts between a week and 14 days in an uncomplicated case.

As with other viruses, you can’t get dengue from the same serotype a second time. (You can’t get dengue 1, twice) However, a second infection from a different serotype of dengue can cause Dengue Haemorrhagic Fever – fortunately, this is rather rare.

Diagnostic investigations include FBE, IgM ELISA (serology) and RT-PCR during the acute phase.

A report from Singapore tells the tale of the situation there

The dengue situation here has hit epidemic level for the first time since 2005, with 401 cases reported last week.

The outbreak is officially regarded as an epidemic when more than 378 cases are reported in a week. The last dengue epidemic was in October 2005, when the weekly tally hit 387.

Last week’s figure is a hefty 37 per cent increase from the 293 reported cases the week before.

The 2,868 cases in the first six months of this year is double the number for the same period last year.

As you can see, the scale of the problem is NOT small. Researchers are already confident that a vaccine will be found; but even after that, clinical trials will take ~7 years before the vaccine can be approved and released.

From the same article as above:

Scientists are racing to find a vaccine for dengue and to discover the reasons why dengue epidemics are becoming more frequent.

And while a drug could be ready for human testing by the end of next year, the research still has a long way to go. Professor Paul Herrling, chairman of the Singapore-based Novartis Institute of Tropical Diseases, said it would take up to seven years to get the drug onto the market if initial trials are successful. In the meantime, there is a risk the virus will mutate, he said.

Lucky for me, I’m not residing in a dengue-endemic area at the moment. If you ARE living in the tropics, please protect yourself from dengue: use some insect repellent and avoid densely forested areas.

Also refer to the dengue prevention checklist provided by the National Environmental Agency of Singapore to see how you can keep your environment mosquito-free.

Reference: Kasper et al (ed.) (2005) Harrison’s Principles of Internal Medicine, 16th Ed., McGraw-Hill

My First Surgical Experience

Well it really depends on what you consider ‘surgical experience’. I’ve been into the OR with my dad heaps of times to watch all sorts of surgeries. A kind orthopaedic surgeon let me scrub in on a ‘below knee amputation’ and watch a total knee replacement, I’ve stood for hours watching a complicated laparoscopic cholecystectomy on a screen, witnessed multiple caesarean sections and a Wertheim’s procedure.

They were mostly passive experiences, except for the amputation, in which, I got to cut the sural nerve – wow. The first time I saw a disarticulation procedure, I actually felt ‘upset’ because the poor man lost a toe: the surgeon reminded me that it would be his life that he lost if the toe wasn’t removed, the gangrenous toe would’ve caused sepsis and killed him. It has been a few years since that diabetic lost his toe and I’m in medical school now – with my first ever real surgical experience.

This experience I consider my first because I had the honour of giving the local anaesthetic, incising, removing and stitching up the patient (or you might think in my case, the victim). The whole shebang! I was on a medical mission trip in a rural province of China and I helped out in many minor surgical procedures for 2 days before the plastic surgeon asked me to do one myself.

It was a simple lipoma, roughly 2cm in diameter. He used a surgical pen and marked out the areas for me and stood by to watch me do the rest. He was there throughout the entire 5 minutes; which really felt like half an hour at that time. I administered the lignocaine and made the incision. The first incision was not deep enough and I had to deepen it. Using forceps to go around the lipoma, I had to clip the ‘vessel’ that supplied it that was deep to the tumour. Then I removed the mass and did a ‘mattress stitch’ which was only shown to me once before I attempted it. After that was all done, I closed up the wound.

The commendation from that surgeon was just one of the things that made me ecstatic. It was the first time I cut into a living person’s flesh for therapeutic reasons – I probably did accidentally cut a sibling or myself before. I ‘flew solo’. How many medical students, just out of first year, would get that chance? Not many I assume.

It might have seemed unethical initially and I quickly relayed this concern to the senior doctors present. They did not seem to have any qualms about it because there was a supervising consultant around and these people were too poor to pay for surgery. I feel that I could have at least told him that I was a very junior medical student and had no prior experience. The prick of the conscience soon faded and it was back to helping clean equipment and dress wounds for the surgeons.

I learnt a lot that trip and I would jump on the next chance to volunteer for that again. This event, together with all the other exposure to the surgical discipline I’ve had, has strongly boosted my interest in surgery. But for now, it is just concentrating on my studies as a 2nd year medical student that matters most.

The Interview For Medical School

This is in relation to the post I made just slightly earlier titled Communication.

There has been some debate going on in Monash Medical Student’s blog about the med school interview and I intend to discuss that for both future candidates and disgruntled individuals.

Most medical schools will require a personal interview with students before considering them for entry, in some cases, a telephone interview would be held. I am not a big fan of these interviews because I personally find them extremely nerve wrecking.

To speak the truth, I have never PREPARED for an interview. I’m not trying to blow my own trumpet here, it’s just that I never bothered to sit down for hours in preparation of one. Frankly, I did not fancy my own chances of entering med school upon comparison with my peers who prepared extensively for the interview. My idea of the interview was for the administration to find out who they might be admitting to their medical curriculum: not a quiz of knowledge and a test of eloquence.

Sadly, many times, this IS the case. The better prepared you are for an interview, the success rates would be better. If you’re considering a future in medicine and still have no gained admission, I would strongly suggest that you prepare for this elusive interview.

I sat 2 med school interviews out of the 3 schools that I applied for, one not requiring an interview. One of the interviews was conducted over telephone, the other was a face-to-face interview in front of a panel of interviewers.

I shall walk you through what the face-to-face interview was like: As with every other interview, they ask about your academic qualifications, motivation to be a doctor and co-curricular activites. I have had prior experience with ‘medicine’ in the form of being exposed to surgerys by virtue of my father’s job, as well as having paramedic training. All these came in handy; so I advise you to have some exposure to medicine. They also asked me to read an article. According to my peers, everyone got different articles. Mine was related to high cholesterol levels and IQ; following which, an question pertaining to medical ethics was asked. The last part of the interview was to get the interviewee to ‘detechnicalise’ a familiar chemistry term; ‘isotope’. I was dumbfounded and I just said that I would use the aid of a diagram to help me explain this term.

These components all have a purpose. The self-advertisement would show the interviewers your confidence and ability to initiate conversation in an unfamiliar setting. The ethical question was to test if you can appraise an article quickly and give your fair thoughts about it: this is an issue doctors face all the time; a patient enters with inaccurate information over the internet or needs ethical advice over it. The last part tests you ability to make jargon understandable: another problem faced by doctors everywhere. After 1.5 years in medical school, I find myself speaking in jargon alot more now but I still practise detechnicalising them to my friends who are not medical students.

This is unrelated to the debate going on in the abovementioned blog but has relations to my post on communication. Getting through the med school interview does not mean you are a good communicator, it just means you’re slightly better than the odd other candidate. This is definitely an area I must improve on.

For starters, I shall stop blogging and start talking to real people.

Communication

Today I retrieved the marksheet for my formative OSCE held some weeks ago. Though I made clear passes in the stations, there was one thing amongst the comments that stood out – and not in a good way mind you.

3 of the station markers commented on my ‘poor communication’ or ‘poor rapport’. Initially I was rather cynical about those comments, thinking those being procedural stations, a 6 minute station can’t possibly expect lengthy conversation to be made. After a few moments pondering about how I could have done it better, I began to realise that the doctor-patient relationship is indeed important, even in a short consultation simulated in OSCEs.

The rapport established in a doctor-patient relationship cannot by underemphasized. It is of paramount importance that ALL doctors (maybe except emergency physicians) communicate well. In doing so, it aids the clinician to elicit more symptoms and take a more complete history. The whole touchy-feely aspect of medicine never fails to make me stop and have a good laugh but I guess now it’s laughing back at me.

How could I regain this ‘compassion’ or communication skill that was ever so vital? I looked to a non-medical student friend in it. Over MSN messaging, it is impossible to tell tone of voice but this is what happened:

I told him I was upset over my OSCE results. His immediate reply was a complaint of the strength of the Australian dollar now, making exchange rates very high. Then it struck me, all my life, I’ve not been listening. I have always been a lousy listener and it shows by the friends I keep. I’ve known this bloke for many years now and it didn’t hit me till today – we aren’t the best of listeners.

Today I start on a new focus. Instead of spending hours studying anatomy, physiology etc, I will try to learn how to communicate better. This isn’t only going to help me in my professional life, but also in my personal interaction with friends and family. A basic human-human communication skill that I lack so starkly must be restored.

Wish me luck.

Dealing With Death

As I enter the medical profession in a few years, this has to be one of the things I inevitably have to think about. A close family friend was diagnosed with stage IV small cell lung cancer a few years ago. Her prognosis was bad initially but somehow managed to survive way past the predicted length of 2 years.

It was unoperable and chemotherapy had to be administered, resulting in some drastic changes in her looks and overall well being. Though you would not consider ‘well being’ an important factor to consider in a terminal illness, it might actually extend life by a few months and help the family cope better as well.

It happened 5 years ago perhaps, when I was told that she had cancer. Then, I knew nothing of cancer; now I probably know ABIT more but still find it cruel. It’s a death sentence that can hit you when you least expect it. She never smoked, never was exposed to environmental or occupational carcinogens, how could she have contracted such a disease.

I guess in life such things are unexpected. As Frank Vertosick Jr. writes in his excellent book ‘When the air hits your brain, Tales of Neurosurgery’, cancer is natures way of weeding out undesirable genes. He describes cancer as a separate organism living within our body, competing for nutrients and space (especially in brain tumours). Will Darwinism really result in cancer being removed from the human species in say 200 generations of weeding out cancer-prone people?

I ask myself, why has God allowed such a faithful servant of his to suffer this affliction? Fact is, I really should be asking God. The arrogance of medicine (well, actually even before entering med school) has made me rely on my own mortal knowledge way more than God. Will medicine and spirituality find a balance in me sometime soon? I hope so. Nay! I pray so.

Thinking about death is kinda surreal. I have never thought about it in depth like that before; apart from the occasional telling myself that ‘I DO NOT FEAR DEATH’ before I sleep. Seeing someone else close suffer to her death is so different, it factors in the pain, suffering of yourself as well as the people close to you as well.

Tonight, I will be in prayer. Not for her but for her family – I know her time is done and she will be in the midst of God soon. My mother updates me: anytime within the next 48 hours. 2 days?! Isn’t that too short? For her, these 2 days spent with her family will seem like many years. Still, I can only imagine.

On her death bed, I hope she remembers the 2 Timothy 4:7. ‘I have fought the good fight, I have finished the race, I have kept the faith (NIV).’ Because she indeed has.

Thank you so much for all the lessons you have taught me and the time you have spent nurturing me. Rest in peace.

Oyster Pharming

Nature’s ‘most potent’ aphrodisiac has now become MORE potent. New South Wales, Australia, reports that one oyster farmer has now grown oysters with Viagra.

We all know what viagra does, it gives 60 year old men a new lease of life! True, but does the little blue pill work esprit de corp with oysters in achieving that effect?

This dude underwent prostate surgery being told that impotence was one of the possible complications; after he recovered, he thought he could be some sort of hero by lacing oysters with viagra. The move, he claims, is a commercial one – targetting a reported 300 million dollar market in Asia.

Come on, we all know that Asian men are the most fertile and potent, what else explains the population of China? Asia doesn’t need that nonsense, besides, Asian cuisine doesn’t incorporate the use of oysters that extensively. This guy must be doing it for himself; fearful of being flaccid, he goes ahead and makes viagra part of his diet!

Before you decide to feast on viagra oysters, let me tell you what my little readings on viagra told me.

You should know the cute mnemonic: Parasymapthetic puts it up, sympathetic squirts it out; referring to the autonomous nervous system (ANS) component that is resposible for erection and ejaculation respectively.

Parasympathetic fibres to the penis cause vasodilation via the NO-guanyl cyclase mechanism. This forms cGMP which causes vasodilation of the blood vessels in the penis and sustains an erection.

cGMP is broken down by an enzyme called PDE5. Viagra INHIBITS PDE5 and thus results in more cGMP available to cause erections. Thus, without sexual stimulation (parasympathetic), erections still do not occur. Viagra merely sustains and strengthens an erection, yet does not cause one.

Some of the reported side effects are disatrous: priapism (sustained painful erections usually due to spinal cord injury), severely low blood pressure, heart attacks and arrythymias.

So think about whether you’ll be eating Australian oysters next time. Was that an ectopic beat I felt? …

References: The Daily Telegraph (2007) Hard sell for Viagra oyster farmer [Available online: http://www.news.com.au/story/0,23599,21834254-2,00.html, Accessed on: 16 June 2007], Sildenafil, Wikipedia