Wednesday, October 11, 2017

'Don't be late for tea!'

'Is that all you've got?' the old man with multi-pack tissue rolls in front of me asked as we were queuing at Farmfoods.
'Yes, but don't worry bout me.' I said hurriedly as I gestured him to go ahead, with a 2L bottle milk in my hand.
'Don't let me hold you back. You go first. Really, go ahead!'

So I went ahead and paid £1 for the 2L milk. What a bargain, I thought. 

As we both left Farmfoods, he shouted 'Don't be late for tea!' I don't quite know how to respond to that as I was really going to make tea when I reach home, so I just laughed at his comment. Then we both went on our way.

That was a short exchange between an old Bedfordshire man and I while we were shopping at one of the cheapest frozen food stores in town. Not that I am a fan of frozen meat, but the things on sale there are cheap, and since it's the direct opposite of where I stay, it's the place I frequent almost daily when I am on my hospital placement here. The short exchange we had in this store was heartwarming to me. It may mean nothing to a regular member of the extremely polite British society, but it meant a lot to me. It made me doubt, should I even leave this country? 

Just a few days ago, it dawned on me that this is actually the final year I will be in this country. 5 years ago, I arrived in this country for the first time. I knew almost no one apart from the freshers who were travelling with me, and I could not understand what the immigration office was asking me to do. I thought I spoke reasonably well English (at least for the Malaysian standard) but this British accent was something else - it was like a completely new language to me! 

During my undergraduate years, I interacted mostly with Malaysians or Singaporeans only, and I shy away from all the local students. Partly because the MAS/SGeans were the cure when I felt homesick, but partly because I could not understand why do the English students love to 'go out' so much! ('go out' meaning go partying, go to the club, dance etc.). I was not a fan of alcohol, and I have been brought up with the idea that 'one who drinks alcohol' is probably 'one who is morally wrong in every other aspect of life', what more on going to the club and dance!? It was hard to mix in with the local students when you always miss out their social events. So during my first three years, the English people I actually interacted most with are my supervisors. 

Most people graduated after 3 years, including the group of friends whom I regularly hung out with. The only people left are medics and a few engineers, who hid in their labs most of the time. 

Year 4 is the first clinical year in Cambridge. As a clinical student, you're like a nomad - you move from one hospital to another, almost every month. I was barely in Cambridge at all. And in placements, the only 'friends' you have, are other medical students, and probably a few FY1s. It was also daunting for me initially as this is the first time I have to go into the hospitals and talk to patients from various backgrounds in the English cities/towns/villages, young and old, white and non-whites, and most of them, not in the perfect mood 'to have a little nice chat' with you because they are sick, that's why they are there in the first place. However, thank God for my very helpful supervisors, doctors and colleagues, I actually had not much problem doing things a medical student is supposed to do in the hospital/GP surgery. 

Fast forward to now, I am actually quite comfortable talking to patients, to my seniors and to my peers in clinical school. Although I do get the occasional well-intentioned, curious 'Where are you from, dear?' 'Are you from China/Vietnam/Japan/Korea?', and the occasional purely racist comments (esp when I don't have my stethoscope or my student doctor badge on me), I have been getting along well with most people. I don't blame the regular white guy/girl who hurled racist comments at me on the street because, in some of these villages, I am literally the only 'Asian' face they see. The last time some of these old men saw an Asian face was probably during the Vietnam war they were in during the World War! 

However, I do get quite anxious when I am having group discussions in non-clinical settings, eg during student conferences and in the church. It is particularly difficult whenever I am the only true, Asia-born Asian in the group, carrying a thick Malaysian accent. Perhaps I am just being overly-sensitive, but there were times when my opinions were ignored conveniently and what I wrote glanced over during a discussion. There were times when I spotted a room for improvement in the discussions, but I just put a foot in my mouth because who cares about my opinion anyway, just let it be, even though the work will not produce the best result it could. And sometimes during breaks/lunch during conferences, I was left with no seats in any group so I had to plant myself in any seat I could find.  Sometimes, I approached other people and try my best to strike up a conversation; sometimes, people who took pity on the girl who sat by herself and came to talk to me. However, often, the same person whom I had an interesting conversation with just an hour before, somehow can't recognise me at all when we met again because I am just another Asian face and they couldn't tell the difference between our Oriental faces. 

I am not saying this sort of situation happens on a daily basis, however, it does not happen too infrequently as well. It makes my heart aches whenever it happens. At first, I thought it's probably my lack of communication and persuasion skills to charm strangers that resulted in people not taking my opinions seriously. However, I've experienced these things when my aSEAn friends were with me as well, and they agreed, it was clearly...racism, subtle or not. 

Racism is a common thing around the world, regardless of which country you visit. I grew up in Malaysia, where there are many races, ethnicity and religions. Racism is just part and parcel of our daily life there. We either take it as a joke, or it's just institutionalised racism forced upon us, what can we do?Live your hard, work hard and be the person who changes this fact, top-to-bottom (if you're one of the leaders of the country) or bottom-to-top (if you're like me, a normal person on the street). We all make racist jokes against each other and have a good laugh about it. There was not much ill-intentioned racism going on on a daily basis, or at least I know that I can confidently fight back if anyone tries to do that to me because Malaysian Chinese is a 'minor race' in Malaysia but it's actually not quite 'minor'. And I can fight back because I was born in Malaysia, how dare you ask me to go back to China?! Besides, we live with people of different races and interact with them on a daily basis, there really isn't an excuse for someone to be outright racist to everyone every single day. 

However, in the UK, I am truly a migrant, a minor race, a historically-viewed-upon-as-inferior group of people. I have enough insecurity within myself as a medical student and my language skills which I need to deal with, I just not guts to fight back when people present with subtle racism against me, especially in a professional setting or in a church setting. And if I decide to fight back against that random racist dude on the street, it is completely possible that I may get beaten up. Therefore, most of the time, I just ignored and get on with life. It was during those moments, I felt like I want to go home, I don't want to tolerate this for the rest of my life because what have I done to deserve this? I came here, studied hard and contributed to the economy (shopping!). What have I done that made me less than a random dude on the street to deserve those racist acts? 

That being said, there are many moments and people that made my time in the UK extremely lovely. Just so I don't forget this country, with her 'many curves and edges', once made me feel that this is my second home, I'm going to list them here before I leave:
  • The countless waves of laughter my placement buddies and I had in the pubs and in our kitchens, in Bedford, in Bury's and in Ipswich. We often laughed about insignificant things, but that's how we kept each other sane after a full day in the hospital. (People thought we were drunk when in fact, we only drank soft drinks and the free tap water!) 
  • The carpool with Calum, Sreela etc to and fro placement. Why did they want to go out of their way to drive me home, without expecting anything in return? I don't know, but they are probably the nicest English (and very importantly, Scottish) I've ever met and the ones who made me feel I am not alone in this country. 
  • The F1 on my respiratory ward in Bedford, Ahmed, and the SHO, Laura, who I only met a few weeks before, who taught me so many things on how to be a 'doctor', who were more anxious and excited than me for my first ever job interview and couldn't stop asking me how the interview went and when will I know the outcome. And Ahmed, who walked to Tesco to buy Prosecco and a chocolate cake just to celebrate when I got my first a job offer. 
  • My GP practice in Year 5, that went above and beyond what was required for them to teach us and inspire us to become GPs. And for providing us with an unlimited supply of coffee and tea to last us through the GP weeks. They were the ones who cultivated the love for English tea in me. 'Nothing a nice cup of tea can't solve.' 
  • The generosity of my college, Caius, and Trinity College, for providing me with luxurious student accommodations at unbeatable prices for the entire duration of my time here. 
  • The patients who let me poke and prod them about, when they were at their sickest, just so I can be a better doctor, one day, hopefully, treating someone, somewhere on this planet. 
  • The pretty changing seasons - the many colours on the trees during autumn, the snow-covered Cambridge in Winter, the flowers and bees filled spring when there is the 'just-right' temperature, and the hot-but-not-so-hot summer which you can just lie on the grass the whole day. I hated the cold at first, but I've grown to love these beautiful seasons and perhaps, I have become more used to living in the cold than the hot and humid weather now. 
  • The formals, the college gowns, the Latin grace before meals and the cheap and great wine from neighbouring European countries. (haha! Looks like I've learned to love something else apart from tea.) And you know, the countless things which are weird to do anywhere else in the world, apart from Cambridge. 
There are many more instances which made me feel like I don't want to leave this country, ever. I will continue to add to this list until the day I depart, the wonderful moments I want to remember forever. And hopefully, I will return to this tea-filled land one day. Regardless, home will always be home - where there's 24/7 good food, where there's barely any grey sky and where I can speak in the languages I'm truly comfortable in and be fully myself, again. 

Tuesday, October 3, 2017

An Elective in Peru and Cuba: Peru

This was written as part of my elective report 'What is a Hibiscrub?', so excuse the cringy formal/reflective language used. 


The Inverse Care Law

The healthcare system of Peru is made up of a public sector and a private sector. The public sector is funded by two main types of health insurance – the Social Health Insurance (EsSalud) and the Comprehensive Health Insurance (SIS). While EsSalud is a mandatory insurance paid by the employers of all formal sector workers, SIS is an insurance funded by the government and international aid, which aimed to provide free or low-cost healthcare to those living in poverty and extreme poverty. Each of these insurances has their own healthcare facilities. While the EsSalud facilities provide more comprehensive and modern medical treatment, the SIS facilities only provide essential medical treatments with an emphasis on maternal and child health.
Before I arrived, I did not know how important the hospital I was placed in, Hospital Antonio Lorena, was to the people of Cusco. Cusco is one of the major cities in Peru, situated at 3500m above sea level, in the valley of the Andean mountain ranges. The city is the main commercial centre for the Quechua-speaking indigenous people of Peru; many whom still reside in the surrounding villages. In contrast to the Peruvians who live in the urban areas, who were literate in both Spanish and English and who were the beneficiaries of the EsSalud insurance, there was a high level of illiteracy, poor living conditions and transgenerational poverty amongst the indigenous people. Their rights were often neglected. There was no health insurance for this group and thus, no modern health care until the SIS was introduced in 2002. While there are many EsSalud hospitals in Cusco, Hospital Antonio Lorena is one of the two hospitals dedicated solely to the SIS beneficiaries in Peru.
When I arrived at Hospital Antonio Lorena, I was shocked to see the hospital buildings were made up of blocks of shipping containers. This was different from the photo of the hospital I saw online. The gate of the hospital was shut tight, with a big banner saying ‘National Doctors’ Indefinite Strike’. There were many doctors congregated outside the buildings, shouting, raising their placards and drumming. They seemed to be protesting about their low pay. There were another group of people outside the hospital’s gate, shouting, raising their placards and drumming as well, but they seemed to be protesting about an entirely different issue – ‘Save our Hospital!’ was written on one of their placards.
Fortunately, I could register myself for my elective. Initially, I planned to do three weeks of Emergency Medicine. Due to the doctors’ strike, I did not have much choice but was placed in Paediatrics for two weeks and Infectious Diseases for one week.
Later, I learned that the doctors had not been paid for months and this indefinite strike had happened a few times since last year. I also heard that the original Hospital Antonio Lorena was undergoing a major refurbishment. Therefore, this was just a contingency hospital until the work completes. However, doctors told me, even though it has been three years since the work started, the new hospital was nowhere near done and will probably take at least another three years to complete. I visited the construction site of the hospital, but there were no workers there at all on a Wednesday afternoon. What about the group of people protesting outside the hospital? I learned that they were probably the representatives of the poor. Instead of funding the refurbishment of Hospital Antonio Lorena, the local authority decided to channel the funding to building a new international airport in a nearby village to boost the tourism industry to Machu Picchu. The work on Hospital Antonio Lorena was therefore halted.
Unlike EsSalud or other social insurance schemes, SIS’s budget is fixed and does not adjust to the increasing number of beneficiaries. It also does not help that the General Government Expenditure for Health in Peru has remained stagnant at 4-5% GDP for decades. In the past decade, the government worked hard on the issues of inequality in access to health services. However, due to political corruption (a pervasive ‘culture’ from the ministers to the farmers, as the Peruvians put it), the opportunities to boost the personal economic situation took precedence over the welfare of the people. In this adversity, the poorest group suffered the most as they were left with almost no accessible health services. 
Fuelled by the poor access to health services, poor public health education and high illiteracy rate, the vulnerable rural population bears the brunt of nutritional deficiencies, maternal and perinatal death and communicable disease in Peru. These patients often present to health services, if at all, when the conditions are dire. In Paediatrics, I saw a 5-month-old boy with Kwashiorkor disease and globally-delayed development due to parental neglect; In Infectious Diseases, I saw cases of severe mucocutaneous leishmaniasis and advanced AIDS. In a short period, I saw many extreme pathologies which I thought only exist in textbooks. More appallingly, these diseases hardly exist in the metropolitan of Lima, just few hundred kilometres away. Based the Dahlgren-Whitehead rainbow we learned in our Public Health lectures, I knew that to resolve these heart-wrenching problems we will need to tackle the wider social determinants of health. However, in reality, how much influence do health professionals have over these factors? 

The effort to reverse the Inverse Care Law

While I was overwhelmed by the inequality I saw, a few doctors in Hospital Antonio Lorena showed me how they maintained professionalism and improved the lives of those who needed them most. For example, several paediatricians chose to stay in the ward and care for their patients instead of joining the indefinite strike with their colleagues, because they knew that no one would be saving those children if they choose to walk out indefinitely. Besides, even with the constraints of funding, they tried to deliver an evidence-based practice. When first-line investigations and treatments were not available in Hospital Antonio Lorena, the doctors were resourceful in seeking evidence-based alternatives for the patients to achieve comparable outcomes. Even with the little they had, they were relentlessly helping those neglected by their society. Therefore, at times when I am fixated with the disputes we have in the NHS, these Peruvian doctors’ attitude towards their patients reminded me to look beyond these dissatisfactions and to be a doctor who truly cares for the people. 

Unfortunately for the Peruvians, there were times when the second-line treatments and investigations were not available in Hospital Antonio Lorena. During these times, the patients could buy those services and items from third-party laboratories and pharmacies in town. This creates a strange picture which there were many pharmacies and laboratories situated right outside the hospital’s gate, and patients would bring along their cannulas, saline intravenous solution and drugs to the clinics and wards. However, this also means that these services, which are available only on out-of-pocket payments, are not available to those who just cannot afford to pay anything at all.

Conclusion

In conclusion, this elective gave me an experience which I did not expect at all. When I departed from Heathrow, I expected this elective to be an extension of the Infectious Disease placement we had in clinical school. However, it has taught me much more than clinical knowledge alone. This elective showed me what ‘lack of resources’ truly means; it is a harsh reality for millions in the Latin America.  It had taught me to appreciate every little thing I have been taking for granted in the NHS: the ubiquitous Hibiscrubs in Addenbrooke’s, the freedom to do audits and to access the latest scientific articles, the capacity to order fancy investigations, the support each of us has to groom us into a safe and competent doctor and so much more. It has also taught me that if an opportunity arises in the future, I could and I should contribute more to the developing nations either directly, by being a doctor for the people there, or indirectly, through doing researches which the results are easily accessible to the doctors in these developing nations.   

























Sunday, October 1, 2017

An Elective in Cuba and Peru: Cuba

This was written as part of my elective report 'What is a Hibiscrub?', so excuse the cringy formal/reflective language used. 

I did two weeks of General Surgery rotation in Hospital Manuel Fajardo and two weeks Obstetrics in Hospital Gineco-Obstetrico Ramon Gonzalez Coro. As expected, the biggest problem I had during my time in Cuba was the language barrier. Even though I could understand basic Spanish, the Cubans spoke at a breakneck pace and with a strong accent, which made it almost impossible for me to take a history from the patients. However, there were more surprises for me apart from the language barrier. 


The Lack of Resources

When my General Surgery supervisor brought me to the theatre changing room on my first day, I was surprised to be offered reusable surgical masks and head covers made of cotton fabrics. When I was changing into my surgical shoes which I brought from home, the other doctors were surprised to see the odd looking ‘flip-flops’ and offered me a pair of cotton shoe covers. I was at loss of how to use those covers until a nurse showed me how to tie them over my shoes. When I arrived outside a theatre room, a registrar told me to scrub in. ‘What is a Hibiscrub?’ she asked when I asked her where can I could get Hibiscrub from, a soap ubiquitous in Addenbrooke’s Hospital. She proceeded to show me how to scrub: first, by using a bar of regular soap for 5 minutes; after rinsing, apply an alcohol mix, which left strange white residues on my hands and caused the skin on my palm to peel.
The equipment in the theatre was all reusable: from cotton surgical gowns to the enormous pieces of green cotton fabric used as drapes, to the metal yankeur suction tube. The only things which were disposable were the swabs and sutures. The waste they had after any surgery was a little 2L plastic bag, as compared to the 2-3 large garbage bags we had in the UK. While in the General Surgical Ward, instead of the usual surgical site drainage bags we have in the UK, a white surgical glove connected to a plastic drainage tube with duct tapes was used in place of a drainage system.
Apart from disposable items, the hospitals lacked laboratory-based investigations, imaging equipment and medications. This used to be the reason why Cuban doctors were so good at diagnosing based on the clinical picture alone, instead of relying on imaging. However, I also witnessed the harsh reality of not having X-ray machines, CT and MRI scans readily available in clinical practice. An 80-year-old lady with painless jaundice was admitted during my placement. Although the doctors suspected that she had pancreatic cancer, they were unable to offer her CT scans to check for metastases. The only thing they could offer her was a staging laparotomy. I secretly hoped a palliative care doctor was referred for her, but judging from the lack of a CT machine, I wondered about the availability of palliative care here. During the laparotomy, they found multiple metastases and a blocked duodenum. She deteriorated rapidly after the surgery and died the next day.
Due to the economic sanctions, the Cuban surgeons had few disposable items and imaging equipment at their disposal. Although I was at awe with the creativity of the surgeons, there is a limit to their improvisation skill. After the death of patient with jaundice, I became more aware of our reliance on technologies in our daily practice in the NHS. These experiences made me realised the luxury we have always enjoyed in the NHS, both as a doctor and as a patient. For example, as a junior doctor, I would be able to order any investigations just with a few clicks on the computer without actually considering the costs behind them, and I can be sure that the results will return me soon. These experiences revealed to me the real costs of these investigations and treatment. Thus, I should be more mindful when using the resources available, using them only when there is a valid clinical reasoning behind each investigation, instead of doing it ‘just as a baseline’.  

The evidence-based practice?

Since the beginning of medical school, I learned about the importance of evidence-based medicine and how a simple study like Ignaz Semmelweis’ comparison of the mortality rates in obstetric wards cared by doctors and those cared by midwives had spared countless women and newborns from agonising deaths. As medical students, we were all told to wash our hands numerous times since day one of our clinical years to prevent spreading pathogens to our patients and ourselves. Despite so, I often washed my hands in the wards with the sole intention of avoiding reprimands from the infectious control nurses. In Cuba, I witnessed the consequences of not adopting this simple yet effective evidence-based practice. Due to the lack of proper hand-washing facilities nor gloves in the clinics and wards, I often witnessed doctors examining patients, one after another, without washing their hands in-between. As a result, surgical wound infections, wound dehiscence and large surgical hernias were familiar sights. It was strange to see these iatrogenic pathologies every day, yet no measures were adopted to improve the situation.  It was even more strange to see patients keep coming back to the same doctor to seek help and even thanking the doctor for his willingness to treat their complications! This would have earned the doctors lawsuits in the UK! 

The lack of resources might have curtailed any effort to do audits or research to improve the situation. However, I believe there is another factor dampening the research culture – the constant use of socialist-based propaganda to reassure themselves and the public of the current state of the healthcare system. After Fidel Castro’s successful use of propaganda to unite the Cubans in the Cuban Revolution, the government maintained an intricate propaganda machine, including all broadcasting facilities and publishing houses. The culture of using propaganda to unite the Cubans seemed to infiltrate the medical field. When asked about their health system, the Cuban doctors have only the highest praises and nothing less. Their unacceptance towards criticism was evident when a Colombian trainee doctor lamented about the state of the system to one of the elective students. The doctor later received very disapproving comments from his colleagues. Besides, as elective students, we were not allowed to conduct audits too. This surprised me as I learned from another elective student who was at the same time as I did that each primary care centre has a statistician and they were obsessed with collecting data! Several African medical students studying in Cuba told me that they were not taught to conduct any audits, partly due to the lack of resources, and partly since all statistics were heavily monitored by the government. The doctors were pressured to produce favourable statistics to protect the international ranking of Cuba healthcare system and Cuba hardly ever allow independent verification of its statistics. I have also witnessed how clerking sheets and observation sheets were completed in the hospital. The doctors filled in clerking sheets, which in theory would aid in taking an extremely comprehensive history and examination, without having interacted with their patients for more than 2 minutes; the 4-hour-post-partum observation sheets were filled in within the first hour postpartum. Although I would not generalise these actions to the culture of the whole system, they provoked my scepticism towards the stellar statistics reported to international organisations from Cuba.
Furthermore, Cuba is also a country with an inadequate and heavily-censored internet connection. Although I was unsure if this was due to the US embargo or it was part of the government’s effort to prevent Cubans from assessing outside culture and information, I witnessed how their healthcare system suffered from their isolation from the international medical community. During my four weeks in both hospitals, I have attended several teaching sessions and teaching ward rounds with the local medical students. However, during those sessions, I did not see any professors quoting any evidence from any scientific journal during their teaching. When questioned about their clinical reasoning, anecdotal pieces of evidence were often used to justify their actions. However, how are the Cuban doctors supposed to assess the latest NEJM when the internet costs USD 1.50 per hour, but an average Cuban doctor earns merely USD 60 per month? Besides, most Cubans who have never been outside of the country were unable to understand simple conversational English.


Throughout my time there, I worried about the quality care received by the patients and at times, secretly blamed the doctors who did not wash their hands for the infected surgical wounds. On hindsight, perhaps the cause of those infected surgical wounds was more than the bacteria on the doctors’ hands, rather a cumulative consequence of the environment they were in. 

We had to wear white coats! (and I really wore the sunglasses on the way to hospital)

An actual Caribbean beach, where we spent hours doing nothing but chill

They said the friends you made during the hardest time in your life will last. I think so too. 

My new friends in La Habana (and the ones without which I couldn't have survived the hospital)

Salsa - the Cuban way

A must.

Learned about the dual currency, and learned how to use them to our benefit. 
Those stains are not blood.





Friday, September 29, 2017

An Elective in Cuba and Peru: The Ultimate Packing List


When we first booked the trip to Cuba and Peru, we didn’t realised the huge contrast in climate between the 2 countries. Cuba, a hot and humid country, just like Malaysia, but probably at the peak of the hot season; Peru, a dry and cold country, at the peak of the Southern Hemisphere winter in June-July. We did not realised these differences until 1 day before our departure when I was busy moving out of my rented house + packing for the trip when Kevin checked a Salkantay trekking website which said, ‘The temperature may drop before zero degrees.’ It was then when I removed a Cuban hat (it was a souvenir from my friend, Han Rong, a few years back) from my luggage, frantically dug my winter coats from the boxes I have packed and squeezed it into my exploding luggage. So unless your trip involves travel to an extremely hot country, then an extremely cold country, which requires you to have equipment for 5-days long trekking and equipment to work in the hospital as a medical student, the following list shouldn’t bother you too much:
General
  • Winter coat
  • Thermals
  • Sweaters/jumpers
  • Beanie
  • Gloves
  • Swim suits
  • 2-3 casual shirts
  • 2 jeans/casual pants
  • 2 trekking trousers or exercise pants
  • 3-4 set of working clothes
  • A nice dress – for nice dinners or to go to nice places
  • Enough underwear to last you for ages…
  • Sport shoes
  • Flip-flops
  • Work shoes
  • Souvenirs for our hosts
  • Plastic bags and zip-loc bags   


For working in the hospital:
  • Stethoscope
  • A thin, short white coat ‘batas’ – not the type we used in the UK for dissection or biochemistry lab
  • Surgical scrubs
  • Surgical slippers
  • A small Oxford handbook/medical pocket book


For Salkantay trek (5D4N):
  • Sleeping bag – one which can protect you from -10 degrees + wind during the night in the snowy mountains
  • Extremely durable, water-proof trekking shoes – one which fits perfectly, else you’d get blisters
  • Small bag pack
  • Water bottle
  • Snacks – can be bought right before the trip
  • Walk stick (optional) – I didn’t had one
  • Hat – to protect against the strong UV in Cusco-Machu Picchu 


Toiletry bag
  • Shampoo – toiletries were not provided in any of our accommodation throughout the trip
  • Body Soap
  • Facial cleanser
  • Insect repellent
  • Lip moisturiser
  • Face and Skin moisturiser
  • Waterproof sun screen SPF 45 and above
  • Alcohol hand gel – you’ll need it for hospitals and for eating out
  • Tooth brush
  • Tooth paste


First aid bag
  • Lots of plasters
  • Antiseptic cream
  •   Paracetamol
  •  Antihistamine
  • Activated charcoal
  • Loperamide (antidiarrhoea) – not advised to take this but for just in case
  • Mountain sickness drug – we had acetosalicylic acid + caffeine, instead of acetazolamide as we don’t want to take diuretics during hiking for obvious reasons!
  • Courtesy of our Occupational Health Department, we actually had sutures, SteriStrips, swab and cannulas with us in our first aid bag too. (LOL. I have yet to suture outside the theatre!) 
Tip: I also brought my ever-handy Longchamp handbag and a cloth recycle bag so I could use them when walking around in town. 

This seems like crazy amount of stuff, but these was just enough to get us through the journey, without having to buy a lot more on the way. We forgot to bring gloves, so I bought a pair for about £1 in Cusco.

We managed to packed all these into 1 big luggage (25kg) and 1 rug sack. And we're all ready to go!

Monday, July 24, 2017

An Elective in Cuba and Peru: The Preparation

Hello! I am currently in Cusco, Peru, starting the 6th week of my elective. I've decided to write this series of blog posts, instead of just my elective report, to allow more space where I can express myself in greater details, and to share my experience to whoever/future medical students who may appreciate this. 

For those of you who are not very medical profession-inclined, a medical elective is something (very fortunate) medical students do towards the end of their 5/6-years of medical school. During the electives weeks, we are allowed to go, literally, anywhere in the world, where there are medical professionals willing to give us supervisions during our practice. The main purpose is for us to see the world, instead of just hiding in our mountain of books and to learn about other health care systems and medical practices around the world. I think it's a particularly important part of opening our minds, especially for the medical students who have been studying and living in their own country for their whole lives. 

Our goals for our elective

The preparation for this medical elective started about 2 years ago when we first started our 4th year. Kevin and I decided to do our electives together and instead of going back to Malaysia or Singapore (where most Malaysians and Singaporeans would prefer to go for their electives), we decided we would like to do something different, something 'once-in-a-lifetime' because after all, when we start working next year, when will we have 2-months long holiday to do whatever we want again? So instead of choosing where we can learn 'proper first world medicine' eg in Australia, UK or US, we tailored our elective so we could experience cultures and healthcare systems which would be wildly different from what we have experienced. And maybe for once, put ourselves out of our comfort zone. As for proper medicine, that can wait... we have at least 40 years of working life ahead! :p 

Where should we go?

'The world is your oyster!' we were told once during our elective preparation session in clinical school. We will have plenty of opportunities in the future to go to places in Asia, US, UK and Australia, whether for medical practice purposes or research purposes. To be able to complete our elective in prestigious universities in the US (eg Harvard, Stanford, Yale, John Hopkins) would be great for our knowledge and CV, however, when we checked the elective prices for those universities, our eyes popped. Is the price worth it? What will we gain from paying that ridiculous amount of 'registration fee'? 

So we decided to park 'US elective' aside. And we were left with mainly Latin America, Africa and the Middle East. I have been hoping to see Machu Picchu and Kevin loved Latin America when he first came here a few years ago. So Latin America it is! 

Peru was the top of our list. But spending 8 weeks in 1 country seems a bit dull to us, so we've decided to choose another country for half of our elective. Our main alternatives were Bolivia and Cuba. And somehow, charmed by the photos of 'Capitolio' and the old American cars of Cuba on google, we've decided to go for Cuba.

I took this. Not from Google. Proud of that. 

Ok, so our touristy interests aside, these are the things you should consider when choosing an elective destination:
  • Safety - in general, and in clinical practice
  • Costs
  • Availability of supervisions in specialty of your choice
  • Language
A good starting point on what to consider for your elective - the MDU's booklet

Contacting our hosts

When we did our research on which hospital to go, we had no idea on which hospital actually caters/welcome elective students. Besides, some hosts were notoriously bad in replying to emails. Fortunately, we found 2 very brilliant, organised and responsive organisations that provide elective packages which met our interests: 
  • For Cuba - Cuba Medical Electives, which has sadly closed now. However, you're encouraged to search for other hospitals in Cuba from Atillo
  • Medics Away - who also provides elective packages to many other countries in the world. 
With their help, we managed to secure places in hospitals of our preferred destinations without much fuss. I will talk more about hospital, accommodation, food and tourist attractions in detail in another post. 

Many people opted to organise their elective independently. While feasible for developed countries and countries which you've already known the hosts, it may be a bit hard to know exactly what is suitable. We've tried another Peruvian elective company, Mundo Verde, before Medics Away. However, after spending 1 year trying to arrange our elective and not getting any response from them 2 months before our elective, we've decided to switch to Medics Away. Fortunately, Medics Away is very very responsive and made arrangements for our whole elective within 1 week's time. 

Language classes

Important when you are trying to understand what your patients are talking about!! 
Most parts of Central and South America speak Spanish. I knew zero (really!) Spanish before year 4. I was fortunate as I was able to take a Beginner's Spanish course, with a slight medical twist, as part of my student selective component (SSC) in my clinical school. After the course, I've decided to learn Spanish on my own by doing grammar books and watching medical Spanish series (Centro Medico). I was nowhere near as good as Kevin, who did 4-5 years of Spanish course, of course. And I knew I will have a hard time following what's going on in the hospitals, but I had to learn! Just imagine, after these 2-months of elective, I will be able to understand a whole new language! 

There are several Central American countries which speak English eg Trinidad and Tobago and Belize. These are popular choices among my peers. Otherwise, you're always welcome to visit Malaysia or Singapore! We speak English and we are quite 'exotic' too! (lol) 

Funding

I shall not dwell much on this as there are plenty of ways to earn your way to your dream elective. From bursaries and grants of Royal Colleges and specialty societies to University Grants, you can easily search for fundings from google. I was fortunate enough to be able to pay my whole elective from my savings and Kevin's college paid for most of his trip. 
I will talk about our specific budget in each country in the other blog posts. 

Flight 

This is a major cost to consider when planning your elective and best booked early. We booked our flight 8 months in advance and managed to spend only approx. £900 per person (London-> Havana-> Cusco -> Lima -> London), with 30kg luggage allowance. 

Vaccination 

This also another major factor/cost to consider. We visited our University's Occupational Health to disucss about this 6 months before our trip as they tend to get really really busy as summer approaches. I spent about £250 getting vaccinations for Rabies and Yellow Fever, and prophylactic tablets for Malaria. The Rabies jabs come in 3-doses and require at least 1 month to complete, and it lasts for 10 years once completed. As for the Yellow Fever vaccination, it supposes to cover your whole life. 



That's it for the advance preparation we had. I will talk about our Ultimate Packing List next! 

Saturday, June 3, 2017

Ethics in Medicine: Termination of Pregnancy

ethics
ˈɛθɪks/
noun
  1. 1.
    moral principles that govern a person's behaviour or the conducting of an activity.



Recently, as part of our 'Ethics and Law' course in clinical school, we have to attend seminars talking about ethically controversial issues. They have been 'bearable', I mean, we attended it as part of a tick-box exercise so we can pass medical school. But the latest 2 sessions have been quite interesting. 

The last 2 sessions were about the Reproductive rights of human and Abortion laws. eg. Should pre-implantation genetic testing be allowed? Is it eugenics? Should IVF be allowed in the NHS on public funds? Who has the right to have unlimited rounds of IVF? Is childlessness an illness that needs to be dealt with by medical professionals? It stirred quite fierce debates among my group. We talked about topics like 'is it absolutely ridiculous that we allow people to terminate unborn babies who have congenital defects?', 'Is any form of contraception or procedures related to human reproductive actually killing a life?' It was definitely very eye-opening, especially the moments when some of my quietest colleagues stood up and spoke strongly for their stance. 

The point of these sessions was not to come to a conclusion. There will never be a conclusion. (That's partly why I dislike these seminars...) If there were a right answer, we wouldn't need to have these debates anymore and things will be done. The point is to just to think about it...

But...I felt very detached and unmotivated to debate about any of these things. I mean...I felt like, it's part of my job, I shouldn't impose my moral judgement on any of my patients. I should do my best to help them from a medical point of view, regardless of what I personally think. With that string of thoughts, I found it pointless to have a debate because...I will do it if that's what my job requires me to do and as long as I am not harming a person. 

'But what is a person?' 
A fetus has no thoughts, no voice and can't say no, even if you try to kill it. Because there isn't a proper definition of 'a person', everyone has a different definition of their own. My view of a person is when the fetus starts having a heartbeat. But that's what I think, not what the patient think. And when in a consultation, what my personal definition is, doesn't matter. Clinically, if the pregnancy is severely harming the person in front of me - a mother, a wife, a woman who is trying very hard to keep her life in one piece and prevent her world from crashing down - I will do my best to relieve that woman's pain. 

'Aren't you a Christian? How can you support something which kills life?' 
I am a Christian, and I try my best to be what my Lord tells me to be in my everyday life. To be loving to everyone, to be kind, to be patient, to be forgiving, to not worry and to fully trust in Him in whatever lies ahead of me. I used to in my mind, judged those people who had a termination, sneered in my mind how heartless these people are. I used to in my mind, judged those parents who chose terminate a pregnancy because there's a serious congenital defect in the unborn baby....until the day I attended the Termination of Pregnancy clinic as part of my O&G attachment. 
I sat in front of these ladies. Every single one of them, feared for their future, scared of what will happen to their body and felt guilty about their past. Even those who had a termination before. Not a single patient was happy when they came into the clinic because 'yay, I can finally get rid of this thing growing inside of me.' 

I chatted to the Consultant who ran the clinic after that session.
'How long have you been doing this?'
'More than a decade.'
'Do you feel bad doing it while all your colleagues shy away from it?'
'Where will these ladies go if I don't do it?'

Sure, as a doctor, I can turn them away under the 'Conscientious Objection' because 'this is killing a life!' But hey, they come to you because you are the only person whom they can turn to, who can help them in a safe manner and who will not judge them. If you judge them as well, they will have nowhere else to go. Perhaps, they will resort to illegal termination or even, suicide. So is that more loving?

Patients have their own stories and their own reasons for having a termination. Doctors have their own stories and their own reasons to object a termination as well. Regardless of what I personally think, I will (hopefully) be their doctor and their colleagues, not their judge.

p/s: If you object TOP, please let me know what would you do to help these ladies if you were in my shoes. 

Wednesday, April 19, 2017

A change in the blog name

No more 'the white coat' because...I have never actually worn a white coat as a medical student. The only time I remembered wearing anything close to a white coat was in the dissection room or in the biochemistry lab during my first year. I have been wanting to change that title since I first used it, but couldn't find any particular name which can accurately describe my journey as a medical student (and hopefully a doctor in the near future) and is constantly there - till my clinical years, I found out that, coffee (or 'kopi' in Malay), my dear faithful friend, has been there all these while, through the years. I have no plan to cut this addition of mine yet (for the fear of a migraine I will be rewarded for abandoning a faithful friend).

Besides, my documents, sign-off sheets and books seem to be constantly being stained with coffee. And I always get this disgusted looks from consultants and nurses when they see my documents...

'Can you sign me off for this skill please?' (Before they opened their mouth) 'Oh, don't worry, that's just some coffee stains.' not blood, not faeces, not urine, not what you think it is... Or is it? 

Coffee addiction seems to be the only a socially celebrated acceptable addiction. Well, at least in the clinics and wards. Even if I missed my coffee in the morning, when I am in the hospital, the nurses would always be so kind to offer me a free cup. And I, being a humble, lowest of the low, medical student, feel obliged to accept the offer. 
'Yes please.' followed by a sweet, sweet smile. 

There was once I forgot to drink my morning cuppa before I met up with my Endocrinology project supervisor at 8am. It was the most awkward meeting ever as she, a consultant, a prominent figure in the world of endocrinology, who came to the hospital at 8am to meet me, tried to be friendly and initiated the conversation, but was responded with responses like this throughout the 1-hour meeting. 

'So how's everything?'
Eyes half opened. 'Mmm..ok.'
'Are you ok?'
'Mmm...yea..'

You can imagine how guilty I was after that. Thank God she's still willing to talk to me. 

Coffee stains? No. I am not sloppy. This is what you'll get even if I have 1 spillage for every 1000 cups of coffee I drink. Blame chance.