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

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.

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

Parasite’s Graduation

Mother parasite must be really proud of her daughter when he finally graduated from the school of parasitology and finally attained her degree in virulence and pathogenesis.

This abstract is taken from the Channel Newsasia Website, 15 June ‘07.

PARIS – Dutch doctors treating a woman for a badly inflamed colon were stunned to discover that the cause was a tropical parasitic worm that had probably infected her at least 27 years earlier.

The 49-year-old unnamed woman had been born and raised in Suriname, South America before emigrating to the Netherlands at the age of 22, according to the case report reported in The Lancet on Saturday.

She was admitted to Nijmegen Medical Centre with vomiting, diarrhoea and abdominal cramps.

Tests showed her faeces to be riddled with the larvae of Strongyloides stercoralis, a 2.5mm-long threadworm that lives in tunnels in the intestines’ mucal lining.

The patient was given ivermectin, an anti-parasite drug, and was discharged.

The authors believe the woman was highly unlikely to have picked up the parasite either in the Netherlands or Spain, the only place she had been, for a short holiday, since emigrating to Europe.

As the worm is endemic in Suriname, she must have been infected there, the case report says. And as she had no previous history of intestinal problems, the likely trigger for the infestation was chronic alcohol abuse and malnutrition, it suggests. – AFP/ir

So why am I so sure this fresh-grad parasite is a female? S. stercoralis reproduces via parthenogenesis and thus is no need for a male parasite to be present in nature; true feminists.

Breaking the skin/mucosa barrier, S. stercoralis enters the lung, bloodstream and then into the GIT, usually residing in the upper GIT. There it reproduces and usually does not cause symptoms – the autoreinfection however, can persists for up to decades after the person leaves an endemic area.

Lucky for this lady, the fresh-grad parasite did not cause some of the complications known to be associated with strongyloidiasis. This parasite manages to evade the immune system if the patient is immunosuppressed, hyperinfection occurs to form large numbers of larvae. GIT symptoms like colitis, enteritis and malabsorption follow – like in this patient’s case.

The disseminated form of strongyloidiasis is much much worse – GI, respiratory, nervous, hepatic and renal systems involvements might kill the patient if not diagnosed early. But particularly, it’s the septicaemia, pneumonia or meningitis from gram negative bacteria that is most likely to kill her. And some geniuses would still administer corticosteroids to this patient…

See also: HTLV1 (Human T Lymphotropic Virus Type I), a common precursor to strongyloidiasis.

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