Couple Random Thoughts - March 11 2012

1) Since the Share Sheet feature in future OS X Mountain Lion includes Vimeo and not Youtube, I'm considering returning there for my video hosting needs.

2) The takeaway note from the recent hospital lecture in conjunction with World Kidney Day: you can't expect to receive if you're not willing to give. The Malaysian organ donor rates are really appalling such that the majority of recipients get their surgeries in China/India. I agree that we need an opt out instead of the opt in system in place currently.

3) The worst thing about being in the strength sports (powerlifting/strongman/Oly lifting/bodybuiling)? Your thigh size determines your pant size, not your waist. The belt *is* mandatory.

4) It's cool to have passed the anaest/ICU posting assessment without studying at all (the exam came as a surprise). Maybe I should return here. After all, being an intensivist is one of my interests along with (paradoxically) sports medicine/rehab.

Strength Training... As a Houseman.

This post is obviously inspired by Fendi's worries of not being able to train as a houseman. After 1 year of housemanship, these are my thoughts:


1) Let's face it, the most important step to being able to train as a houseman is to be at the right hospital so that you can choose the right gym.

Rules of thumb:

• You need to be near a gym with good operating hours. For example, during weekdays I train at Celebrity Fitness, Lot 10 (closes at midnight during weekdays). This is a big point as it allows me to sleep first before going to the gym, should I choose to train in between EOD's (!).
• The gym must be good enough so that you don't have to wait too long to use the equipment you want.
• The hospital shouldn't have EOD's as the rule. Having a hospital with stable on call schedules is best. For example, I train better during medical with 10 calls spread evenly throughout the month than during O&G with the same 10 calls but with EOD's and greater breaks between calls. If you can coordinate your calls with your leader, do so. As you'll be able to adapt calls to your liking for training.
• Find out gyms near areas you'll be traveling on off weekends. A good session in a per entry gym is a good session.
• The point is: getting a hospital suitable for you to train after work is doable, and the onus is on you.

2) Another issue is timing of training. Unless if you are working in surgery HKL with 3 calls a month, you are not training 4 times a week; 3 might be possible if you are single. 

Since medical posting, I have maintained a fairly regular schedule of training on post-post-call days. I was very lucky in medical as I was able to negotiate a very good on call schedule; I did not have EOD's ever in medical except during the Chinese New Year (and that was a passive EOD call; oh wait I'm too Jonah).

In O&G however, I was stuck with EOD's. This requires more precise planning in advance. On some days I'd train in between the EOD's with sleep before sessions, especially if the break after the EOD was only 2 days. On some occasions I'd train post call (of the 2nd EOD) followed by an EOD session at the gym if there was a 3 day break. You need to know your schedule.

3) Seeing the 2 points above, there's a conclusion to be made: you need to choose the right program. 

If you were a seriously body-building type of strength athlete you'll have serious problems: Your optimal program is always 4-a-week, which is not attainable. And forget 6-a-week body part splits. You'll have to change to a 3-a-week with an upper-lower split with high intensity during the training. Hitting one body part twice a week on 1 week, then once a week on the next week is the idea. 

Another idea is to go straight to full-body routines. For a bodybuilding program, it should work well if you're still a beginner. I'm not familiar though with bodybuilding programs that aren't in the traditional body-part split model. But I think looking up Chad Waterbury/Alwyn Cosgrove for interesting full-body routines might give clues.

And if you're more into powerlifting like me, the solution is very simple: Jim Wendler's 5/3/1 is king; devised by a lifter who wants to do more in life. And you can modify it to a 2 a week schedule and make great progress. This is an example of my 2/week, 2 week per round, 6-week training cycle:

Day 1 week 1:

Deadlift - 5/3/1 week would be 154.4 kg x 5 (+4) (just deadlifted 138.6 x 8 few days ago)

Reverse lunges, front squat grip - 5 x 10 x 52 kg

Lat pulldown, supinated grip - 5 x 10 x 47 kg

Out in 1.5 hours; it's changing the plates on the deadlift that take a lot of time training alone.

Day 2 week 1:

Bench press - 5/3/1 week would be 85.9 kg x 5 (+4) (just benched 77 kg x 10 today)

Penlay rows - 1 x 8, 4 x 7 x 61 kg

Standing DB press - 1 x 10, 4 x 9 x 30 lb

Warm up till done in 1 hour.

Day 1 week 2:

Low bar back squat - 5/3/1 week would be 131.1 kg x 5 (+4) (last cycle ended with 129 kg x 6)

Romanian deadlifts - 5 x 10 x 63 kg

Face pulls - 5 x 10 x 7 lb each side (pitiful, I know)

Warm up till done in 1 hour 15 minutes.

Day 2 week 2:

Military press - 5/3/1 week would be 59.1 kg x 5 (+4) (last cycle ended with 59 kg x 6)

Pullups - 2 x 3, 5 x 2, 3 x 1 (not awesome, but I'm 94 kg with a 34 BMI)

Pushups - 3 x 10

All are done in superset fashion. Warm up till done in about 1 hour, depending on how crowed the pullup station is.

As I'm still a beginner, such a program is sufficient for me to get stronger, with getting bigger as an interesting bonus.

3) Exercise selection is extremely important.

This is why body part splits are not so smart; too little bang for your buck. What builds more muscle: lying leg curls vs deadlifts? Pullups vs (stupid) pullovers?

But you can't choose exercises that are too challenging for your soft tissue nor your brain. A previous problem I had was that my deadlift days are too CNS heavy: deadlifts followed by squats followed by good mornings. It was common that I'd skip good mornings, or end up vomiting on the way out of the gym, and feel like a piece of shit at work the next day.

Not that I did not include isolated core work in my routines. The sole reason is that I want to save time. Hence why I do no supported work other than the lat pulldowns; all exercises are to involve the core when possible. Maybe I'll add them one day on bench days; assuming that my free time increases as an MO/specialist (I doubt it).

4) How about supplements?

Frankly, the supplement you'll most need is caffeine! I do not use protein power, stopped creatine after noticing that it actually had some not-so-nice effect for men with hormones, and never tried anything else than fish oil (which I tend to forget to take, but you should take it regularly even if you don't train). Eat a shit ton of real food and save some cash. If you weigh 100 kg's with 10% body fat, or a powerlifter with lifts of say, 200 kg/150 kg/230 kg, pretend I'm not talking to you.

5) Recovery will be an issue.

You are a doctor. Recovery will always be an issue. Hence a few rules you need to accept:

1. Your training schedule is never optimal.
2. You might train post-call
3. You'll feel like shit even on good days of rest (but feeling shitty is relative)

This is why you need to accept that going to a gym for fat loss during HO days is probably not a good idea. Just focus on overall mass/performance and you might make yourself happy with small progress. I actually halve the progressions for my squat and press for subsequent cycles to deal with long term fatigue and slow strength progress.

Notice how I did not mention cardio yet. It's because of this: sleep is more important than cardio for fat loss as a medical professional. Lower your overall stress hormones by getting enough sleep, whatever that is for a medical professional with on calls. Train for the stimulus to increase mass/strength.

I might amend this further down the end. When HKL goes into shift work for HO's, a lot in this post might be irrelevant. But if you've questions, I'll answer and probably edit/add some points I've forgotten in the main post. 

In the meantime, here's some inspiration:

And what you can do as a houseman:

Things to Aim for in 2011

Training:
1) I want to reach that theoretical 100 kg bench. And since I already can and have deadlifted 140 kg for a single, I'm now aiming for at least 180 estimated 1RM. Since I'm not training to compete, I'll stick with the basic Jim Wendler 5/3/1 "2 a week" template without focusing on singles; as long as the estimated 1RM reaches the goals, I'm happy. I've already recovered from the temporary hiatus from training due to starting housemanship and training at full speed (considering the circumstances). Here's where I'm at now, with the estimated 1RM and previous best (right before starting housemanship):
Deadlift - 123 kg x 9 (159 kg, best 166)
Bench - 68 kg x 10 (90 kg, best 94)
Squat - 117 kg x 5 (136 kg, best 140)
Press - 52 kg x 6 (62 kg, best 63)

2) Keep the weight down, without the expense of losing strength. This is a bit difficult as I'm training 2/week. If I've more time, I'll do more resistance-type of cardio. Dietary restriction will only be secondary. As long as I'm not bloated up I'm happy. But...

3) Being heavy inhibits my pullups. I want to get stronger at pullups again. Currently I'm training my back in every lifting session. But that won't do much if my weight remains at 90. Last session, I could only 2 7 sets of 2. Pitiful. But hey, that's at a BMI of what, 34?

Career:
I want to further set my sights on the path that suits me. In general, this is how I am as a doctor:
1) I hate history taking
2) I don't hate examinations
3) I love difficult procedures, and am relatively good at them. I always get "referrals" from colleagues for difficult lines, difficult ABG's or blood taking. I'll do those over boring reviews. If you can memorize your cases, and monitor them well enough, writing everything down again and again with small changes is dead boring.
4) I love resuscitations, making sense of investigations results stat, and tense moments.

So far the 2 career paths I'm keen for are surgery and anesthesiology/critical care. Mr Zainal (HOD) has already said (via MO's I know) that I'd be welcome back once I finish my housemanship. Prof Faisal (UPM) has also said that I'd have his full support to enter UPM as a trainee lecturer in surgery. But I want to taste the anaesth posting first if I can.

Another issue is whether I want to stay in KL/return to IIUM Kuantan. My first choice would be Kuantan; but since my wife has a good career development path by staying in HKL, the obvious choice would be to stay within the Klang Valley.

Exams? I'm seriously considering to take the MRCS part 1 this year, and maybe even the MRCP part 1 even thought I hate medical; after all, a strong medical background is needed regardless of your clinical specialty later on.

Life:
Aim for a nice balance between training/work/family/personal stuff. Duh? I still want to read my comics, and I wonder if Rhye will produce a Rhye's and Fall of Civilization version for Civ V...

I know that resuming life as a Wesnoth online player is more or less impossible. But watching the developments as a silent_obs (hint to the MP community) is fun, especially as regards to the tremendous art development going on.

When my late father asked me to enter boarding school, I initially refused on the grounds that I don't want to become a robot living with a fixed schedule. As a doctor, I refuse to be limited by my long hours.

Valedictory Speech, Full Version

I've just finished my training session for the upcoming convocation with the IIUM Senate Committee. They said that it had good content and a good flow, but was far too long for the 10 minute limit. I'm posting it up, as I feel that the summarized version will never be as good. Note that I've not yet finished it, as the Arabicized stuff wasn't done yet, and the BM needs a lot of corrections. Done in like 2 hours before the training session, haha (!). We doctors do lack time you know (you know the typical doctor excuses).

Assalamualaikum and good afternoon to all.

It is a great pleasure and honor for me to speak in front of an accomplished audience. For today I am speaking not to an ordinary group of graduates; today I am speaking to a group whom can now be called professionals. I must take this opportunity to first thank my parents, my other family members and friends, my teachers of past and present, and as a doctor, my patients. Without all of them, I would not be as successful as I am today, nor selected to speak to address such a special group of graduates. For who I am today is a product of all those I mentioned above.

For you are a special kind of audience. You are an audience of whom standards are not just set by your teachers; the standards of your proficiency of practice is also set by your senior professionals, who have set high standards upon themselves. To graduate as a doctor, an allied health professional, or a lawyer means that there is no question regarding your qualification.

I still remember 7 years ago, when all of us were a group of students who had just finished the SPM examination, and were just about to begin a new phase as students in the Matriculation Center. At that moment many of the faces I saw were a mixture of excitement and anxiousness. We thought that SPM was hard. Would we survive the next 5-7 years of education? An education that is more specialized, yet harder. Nevertheless at the time there was always those moments of youthfulness. Late nights, last-minute studies, and of course the obligatory sleeping in class. This was the same regardless of the course undertaken by the students. Even Medicine.

Now fast forward to the moments right before the graduation. At that time you can also see the same mixture of excitement and anxiousness. But now it was for a different reason: We were preparing for the professional exams. An exam where you are judged not just by your regular teachers; but judged by professionals who are going to see you for the first time, and probably the last time. And this is what I mean to speak to a special group of graduates. You are graduates who are trusted not just by your own lecturers, but also by other professionals who have never met you before; who are convinced by your knowledge and skills the only time they saw you. You have achieved success, surely to be envied by others.

Kejayaan itu adalah sesuatu yang patut diraikan. Ini adalah kerana sesuatu kejayaan akan membawa kepada kejayaan yang seterusnya. Akan tetapi kejayaan kamu pada hari ini adalah hasil campuran pelbagai elemen. Ia bukan sahaja hasil daripada titik peluh usaha tuan-tuan dan puan-puan graduan. Kejayaan kamu pada hari ini juga adalah hasil daripada pengorbanan tenaga dan wang ibu bapa dan ahli keluarga kamu, daripada pengorbanan guru-guru, dorongan dan kerjasama rakan-rakan, sama ada rakan sepelajaran mahupun yang bukan, dan yang penting untuk diingati, para pesakit, pelanggan, dan sejarah atau pengalaman orang lain seperti kes-kes mahkamah yang terdahulu. Oleh itu, adalah penting buat diri saya bagi mengambil kesempatan ini bagi mengucapkan penghargaan terbesar bagi mendiang bapa saya sendiri di atas pentas ini, bagi Allahyharham Prof Madya Ayub bin Mohd Yatim yang meninggal ketika bulan Ramadhan al-Mubarak yang lepas.

It is only fitting to pay tribute to my father, who has given unlimited support in my endeavors to achieve excellence in IIUM. It was a rarity for him to ever say no to giving financial support for my efforts in buying all of However, my late father fell ill during my final year of studies with stroke, making life extremely hard for my family as a whole. He then was afflicted with a heart infection, which required heart surgery - on the day of my final professional exams. And yet my family and I persevered, and I passed my exams which I personally viewed as with flying colors considering the circumstances surrounding the end of my undergraduate life. But 1 month ago, ironically on the first day I was on call, my father passed away due to complications of his illnesses. It instantly had made the hardship of work, and the rigors of studying before that, pale in its emotional stress. The scolding of senior doctors and specialists, and the fatigue of long hours at work, felt tolerable with the death of my father.

The emotional burden of personal family illness, yet with the coincidence of becoming a successful graduate has taught me one thing, something that I wish to impress on you today: your success as a graduate today is to be cherished, but its elements are never to be forgotten. The success you achieve will thus protect you from arrogance, and keep you humbled.

And your humbleness in remembering your roots will keep our parents safe once they leave us, which they will. It is with this humbleness that we will remember to pray for them. To pray that they will be rewarded with Paradise, and saved from Hell. As the prophet once said, “One does not bring but 3 things to the Hereafter: beneficial knowledge, charity, and prayers of a good son.” But before we go further, I would like to remind everyone of a verse in the Qur’an”... I want to create a khalifah on earth...” To fulfill the principles mentioned in the above verse, we muslims must rediscover what it takes to become political and professional leaders. And the effort must be exemplified by none other than the IIUM graduates themselves.

It is important for IIUM graduates to not only be humble as I have mentioned above. IIUM graduates are bred in its system to be more than mere certification holders. We have to, and are educated to, to be more than followers. We have to be leaders. And the leadership displayed by IIUM graduates is not limited to our muslim ummah only, but also to the general public, or in terms of lofty standards befitting an IIUM graduate, leadership of present mankind itself. And better yet, the principles required to lead the ummah in the 21st century are easily derived from the Triple I-CE vision introduced by IIUM, that is internationalization, integration, islamicization and comprehensive excellence. By living the principles above, doctors, allied health professionals, and lawyers from IIUM will not be mere professionals; we will be professionals with leadership, who will unite the muslim populace and lead the world via the various avenues, whether it be academics, practice, or politics.

Internationalization is an important principle to be upheld if we are to achieve our ambition of being khalifah on earth. Muslims in the modern era are now segregated by nationalities and race. In the political sense, muslims are characterized by divisions, infighting, selfishness. And in the professional sense, muslim professionals are slow to not only develop, but to adapt new revised and better standards as regards to our professional development. Instead, we have left it to our Western colleagues, of whom the majority are non-muslim, to develop new ideas, practices, and guidelines which have increased the quality of the work of their profession.

In a different aspect, muslims now still stuck by sometimes questionable traditions. We have refused to see outside of our bubble, thinking that we are superior simply because of our religious faith as being muslim, or by misguided notions that some aspects of culture and tradition have their roots in religion when they are not.

Muslim professionals must be the spearhead of efforts to finally bring muslims to the forefront of the international arena. Muslim doctors, allied health professionals, and even lawyers must learn to be at the forefront of research and development, and to quickly explore new avenues of ideas that may help us improve the standard of healthcare care and legal systems. We should not hesitate to seek knowledge from non-muslims if it means improving ourselves. After all, best practice is best practice. And we must make example of muslim professionals who are among the leaders in their fields, but ply their trade in the western world, and thriving in it.

Muslims professionals from IIUM must also be at the forefront of efforts to educate the general public and modernize its thinking. The muslim professionals should make effort to educate the general public, to teach them than modern development does not have to, and should not lead astray from religious principles. Muslim professionals must teach the public to differentiate culture and religion; the latter is permanent, the former can and must change according to its suitability in modern practice. Muslim professionals from IIUM should be exactly that: excellent professionals, and faithful muslims. We must equal the accomplishments of the various muslim professionals of whom their names we keep on hearing as regards to the Islamic Golden Era.

To become a leader in the modern era, it is not enough to simply be a doctor, an allied health specialist, or a lawyer. The certificate that we have received today, despite of its significance, is not enough to allow us to lead the muslim world and the general ummah as a whole. We must seek out further knowledge, more than the knowledge of our practicing field. And all of this various knowledge needs to be united into one. Muslim professionals from IIUM must live the principle of integration.

A good example of this is seen in medical education. For clinicians of the modern era, it is not enough for them to simply be a highly qualified clinician in practice, or to simply be a Masters holder in a specialist field. Clinicians must now be proficient at research to become leaders of their field, that is to become research clinicians, to search for better practices and develop better technologies. To do so the clinicians must not just deepen the depth of their knowledge; these clinicians now have to broaden the scope of knowledge to the basic sciences of mathematics, the truly basic medical sciences: biology, chemistry and physics. But mastery of these fields is not sufficient; the knowledge must be turned into one, that is integrated.

Integration can also be seen in another light: that is integration of the general ummah. Muslims, exemplified by muslim professionals from IIUM, must be the example of integrating the ummah as a whole. In IIUM, we are blessed with a mixture of muslims originating from various countries. We even have non-muslims studying in this garden of knowledge and virtue. Our experiences and abilities to integrate with various peoples must be extrapolated to leading the muslim professionals and muslim populace as a whole, and then on to becoming political leaders of integration for the general mankind. Muslims professionals from IIUM must be at the forefront of education and goodwill to peoples of other faiths.

Muslim professionals from IIUM must not shun themselves and segregate into their own group. Instead, we must reach out to peoples of other faiths. We should provide service and education to muslims and non-muslims alike. And the responsibility is double-fold for us: to provide as a professional, and to provide as a muslim. During our practice is an excellent opportunity to preach regarding Islam to our clients and patients. And this preaching may not be direct; the character that we portray may sometimes be enough preaching in itself.

Integration and internationalization are interrelated with the next principle of Islamicization. IIUM graduates are ingrained with the principle that all worldly and religious knowledge is interrelated with each other. Secularization is the exact opposite of the what is taught in IIUM. Muslim professionals must change the current practice of their fields to reflect on basic Islamic principles. A good example of this is the field of shariah law, which combines the principles of modern law with basic Islamic rules and regulations into one field, which is already established by lawyers and led by IIUM. Other good examples are the halal food business and Islamic banking. And there are many avenues for muslim health care professionals to contribute to health care. The most obvious of this is medical ethics which I want to talk about.

Medical ethics is currently led by the Western world, based on mostly ethics based on human thinking, which can be wrong. And the western world is itself segmented, with those who believe and those who do not believe in divine concepts. This is where muslims have a great avenue to contribute. This is because Islamic principles of the world and law are based on permanent concepts: the revelation via the Holy Qur’an and teachings based on the Hadith of our beloved prophet Muhammad s.a.w. Because of this, medical ethics based on Islamic teachings would thus have more permanence and acceptance, as basic Islamic principles are true regardless of the passage of time. By improving our practice by integrating fields of professional practice with religious teachings, we will be following in the footsteps of the Golden Era researchers who pursued knowledge of Graeco-Roman origin and related it with Islamic principles to develop new fields of knowledge for which the muslims were the leaders and not mere followers.

To live by the previous 3 principles stated earlier, muslim professionals from IIUM would be living by another principle of IIUM needed to lead the muslim ummah and mankind in general for 21st century and beyond: comprehensive excellence. For to be leaders in an age with increasing populace, increasing political dynamics, increasing numbers of specialized academical and professional fields, and increasing technological advances, there is no other way other than to make effort to be the best: to be the best doctor, the best husband, the best father, the best son, the best neighbor and the best leader. This is because your deficiency in one area may ultimately hinder your role in another. And if you are deficient even slightly in a very competitive era, your leadership role will be taken by another. It sounds hard; no mission ever is easy.

But IIUM has taught you well. You have been taught to become excellent professionals in your field. You have been taught to become excellent muslims, who integrate knowledge of the islamic teachings and modern fields to develop knowledge more than the sum of its parts. You are taught to become one who integrates with the populace and others of your profession. You are taught to become one who seeks to be excellent in all aspects of life. You are a professional, an IIUM graduate.

Now go and make us proud.

Thank you. Assalamualaikum wbt.

Thoughts (July 24 2010)

1. It's back to reality pretty soon. But then again, the post exams was never a holiday for me. No honeymoon, no traveling, none of the stuff people do before starting work as a houseman. Every day, it was 4-7 hours of driving. If you think driving is not tiring by itself even though it burns no calories and chronically breaks people's backs, I'd love to have you as a personal driver.

I had to survive on pretty high doses of caffeine. There were several times when I had to just sleep in the car because of severe fatigue. Once my wife and I had dinner at 1.30 AM with work on the next day (I cooked of course, she was already fried from work and slept until food was ready). The day was spent helping my mother with errands/Abah's health issues. The only thing keeping me sane was the progress in the gym, which I could only go at night and ended up with coming home late, exacerbating my caffeine super-dependence. For references, to survive the induction I drank almost 6 cups/day of coffee/tea. That equaled 2 strong cups of coffee from Dunkin Donuts every day. I also kept my typically high levels of reading during the holidays, which at least kept my mind a little bit sharp. No studying though.

The recently ended induction program for housemen was supposed to be a holiday. But then I ended up as the participant leader. Luckily, other than an incident of a "lost" laptop and handling money-collecting duties, it wasn't too hard. But the chance for a mental break was lost. And housemanship starts next week.

I really envy the people who have been having fun during the holidays.

2. Next week I'll start work at HKL. Will it be that hard? I'm really not sure, after feeling exhausted already before starting work. Maybe it'll be the same level of tiring life as now, but in different ways. After all, I did say that the medical exams were harder and more stressful than the akad nikah (wedding vows).

What's really getting into me is the need to find a house. It's no longer feasible to go to KL every day from Bangi, especially if the aim is to reach there by 7 AM. The preferred places are Sentul/Ampang/Cheras as there are LRT stations there. A sleepy houseman is a dangerous houseman. But Sentul is super expensive, and the other two are jam centers on days that we drive. Other choices are Keramat & Gombak, but those options mean that driving is the only option to work. But as it stands, going to work from Bangi has been hell for both of us.

3. Will need to find another gym when I move. I'll make sure I get a lift, even during housemanship. But nothing will be as cheap as Kaki Gym/TLS/Try My Gym in KL. And it's utopian to get as many sessions as I could before, even during the peak of Abah's ills, when I did two a week, combing days into long sessions, sparing the weekends. Being strong has been quite useful and I don't want it to go away.

4. I'm a bit torn as regards to my future. My plan has been to go to a government clinic after housemanship, followed by pursuing studies in sports medicine. But there are several issues. With whom do I want to work? KKM, MSN, or MoHE? Do I want to be attached to a sport, or in a clinic setting? When the time comes, do I want to open what I have in mind: a comprehensive physical/sports rehab clinic, catering for sports and general public needs? I really would like answers.

But if all that fails, emergency medicine and internal medicine are fallbacks.

5. Lastly, Abah is back in the wards, this time for overwarfarinization, bleeding gums, INR of 8. Unsure of the cause though. Sigh.

Random Thoughts (July 13 2010)

1) I wonder if soft tissue work (in the atheltic sphere speak) is used in the world of physiotherapy for treatment of spasms/contractures. This might be especially powerful in the management of cerebral palsy, as there is a potential of > 10 years of spastic paresis.

For a general theory of the "scientific" basis (sports medicine is more observational and theory than experimentation), have a read of Mike Robertson's self-myofascial release manual.

Case in point:

I have regularly used self myofascial release on Abah to help with his spasms and maintain his elbow/wrist flexibility. Abah tends to get nasty spasm episodes with even slight passive elbow/wrist/finger extension or distress. To help with this, I "gently" massage in a cross-fiber direction his bicep insertion (for elbow) or finger tendons proximal to the carpal tunnel (for the wrist/hand); this allows for the elbow to extend without even exerting any force to extend them! And as I massage further, the extension is increased. I even use this method to do the regular physiotherapy while he is not experiencing spasms; the hypertonia is reduced greatly.

To understand this better, try this experiment:

Lie down and test your shoulder anterior flexion flexibility (by reaching your arms back in a forward direction ala windmill fashion); when your lumbar spine hyperextends or your arm "hangs in the air", you have reached your limit. Then, use a tennis ball and roll it along your lattisimus dorsi insertion (sides of arm, near the armpit) and retest. You'll find that you can reach farther back without the lumbar hyperextension.

I find (from my own severely limited observation) that most mobility modalities used in physiotherapy of patients employ only passive movement and static stretching. Ironically both induce spasms in people with hypertonia/spasticity.

2) If you want to think about starting but always asking about quitting as well, get the hell out.

For the Juniors

The drama in my life ceases to stop, and at some point or another, you just accept it. An abnormal day is a normal day. Luckily, lifting and recently cooking has kept me sane. After marriage, I have no idea whether life will normal as others'. Yes, I've told her I will keep lifting (but certainly not in a 4-a week schedule, rather a 3/2 a week schedule once work starts and the schedule permits).

Anyways, one of the juniors asked me, what's my secret. After being asked the question, I initially wanted to record myself talking and uploading it as it's easier. But the internet connection sucks balls, so a long lengthy post is what's for offer.

But to understand how I did what I did, you must understand my situation. A background.

I have been active all of my life, physically and in extracurricular activities, though entering UIA made me more sedentary until the discovery of strength training. I was in MSC until 4th year as President. I debated during matric + MEDCY VP and later President too. I once dabbled in program compiling, and for a short while the Mac compiler for the Wesnoth game (recommended), and a bit longer among the moderators (still an MP server moderator). I love learning about other things than medicine. I'll leave school stuff out.

At the same time, I'm a perfectionist. I always wanted to be the best of what I think I can be. This is not the same as being first, in which I compare myself with others. I only compare myself with myself. And so, if I want to invest in something, I'll 1) want to beat all others, 2) once others are beaten, I want to beat myself. 2) comes after 1). This means that even if I was no 1 compared to others, if I didn't reach my standards, it meant that there was still room for improvement.

During the final year, my father suffered from clinically migraine paralysis, radiologically lacunar stroke. A few months afterwards, he suffered a watershed infarct secondary to left ICA thrombosis. He still hasn't recovered from the Broca aphasia and hemiparesis, and now suffered Gram negative infective endocarditis of the aortic valve requiring valve replacement. Radiologically there were new infarcts. He has not yet been discharged, and developed new onset fever with bacteremia. My wedding was supposed to be on this Saturday. It'll have to go on I guess. My mother still has not started working, our general life and finances are in disarray, and other stuff probably with no need of mentioning. The almost constant progress in my lifting keeps me mentally fit, relatively.

I returned home almost every week since the first episode of stroke, whether it was to help out or to prepare for the wedding. My father's op was done at the practically the same time as my clinicals. The initial op planned had a higher risk of dying on the operating table. And added to that, my long case was not revised at all before the exams, and I never saw the case, until the exams.

And my exams were never normal too. My ped's patient had multiple problems. The surgical patient lied, and had a language barrier too. My psy patient ran away. My IM patient was someone I knew 100 percent since admission, with an atypical presentation (bias). My O&G was a "contradictory" presentation. I never saw hemophilia until my Pro.

I'm not going to spend time telling you about the exams exactly, but how to prepare for that. It's how to go through the exams, and call your mother straight away "I passed" before the results came out. Even with my way of life then I told the junior, "I came to the exam not to just pass".

Preparation

It starts now. You need your basics, identify the ones that will last you throughout school, and never forget it.

What you use in BMS will be used in 3rd year, and what you use then will be used in final year. But not all of it. Identify them. Remember them.

Medicine is in some ways about memory. Use it. That means treating information as though you might not read it again. Punish yourself to make sure you never forget important information/values. I survived despite being someone who can't count in his head. If the -7 serial test was the ultimate test, I'd be a permanent Psy patient.

Medicine is about associations, cause and effects, and is not black and white. Cultivate your imagination, be willing to dissect the conditions of patients and relate.

A textbook is thick. A patient's file is thinner. The patient tells more than the file.

You can only read so much with focus. You can listen and discuss much more.

You are only as fast as you can find your information. The internet helps. Knowing how to use it helps even more.

The exams may go the advanced issues, but basics are never ignored.

Mr Hafiz: "You don't need to see any case, you only need to know it."

Timing

Should you go on full throttle very early? Probably not. Even I did not start on "full gear" until the final posting was over. But that's why memory is important.

It's okay to choose whatever method to revise topics, but remember 1 thing: does it help you remember it the next time you have to use it? What we chose was a "always study all postings" method without any particular phases. But early on we stressed more on Ortho.

MCQ's are a student's best friend. But memorizing T/F is rubbish. You should be understanding the spirit behind the questions. I never write T/F on my MCQ's. If you don't know why reread this post. MCQ's always tell you what you don't know. There's more to learn in an MCQ stem than a PMP case.

How to divide time? What we did was to answer MCQ's in the morning, read in the afternoon, discuss and short cases at night. I lifted in the afternoon.

Clerking

Remember: Complaint, course, cause, complications, current status. Start now.

Remember: Patients are not like textbooks. Throw away your scripts. Learn the art of clerking. Start now. With experience, you will learn to pick up what the extras are on a "case-by-case" basis. Some questions you ask patients may make you look silly, and hence are silly to ask.

Patients are people, and hence if they are in distressed, just gather the info you need and move on. No need to do a full cardiac exam on a patient with right sided failure when you just want to appreciate the P2 sound. Others want to examine him/her too. Saves time as well.

Be brave yet respectful. Think of when you will start working as well. I learned to insert cannulas into, um, myself.

You will have to cover wards, not patients. Learn to clerk without writing, and learn to present without reading. Start now.

Ward presentations are different from exam presentations.

Addendum:

Start learning by doing "full" clerking. But learn the shortcuts before the final exam. It might save you. And it's all you'll be doing when working. Clerk to diagnose within 10 minutes of seeing the patient. Dr Haji: "You don't need 30 minutes to diagnose your patient do you?"

Addendum 2:

For ward presentations, remember: presentation, diagnoses, problems, management, current status.

Friends

You are teachers to each other. Be critical of each other. Not to compete, but that's how you cooperate. Teach.

You are as slow as your slowest friend. It's your job to make sure he/she picks up the pace. Teach.

You remember what you teach. Make sure everyone gets a chance to yes, teach. The listener-only friend loses out as he only listens, while the rest loses out in terms of effort.

Sanity

Medicine is not everything. Learn other things. Many other things. I continued to read other stuff even during exams.

Physical health is important. No talk, all action. The fat slob sweating is a lot "healthier" than the skinny nerd.

Have avenues to relieve stress. Endorphins are useful.

Lifting was useful because:

1) The focus needed is more than during exams. A barbell falling on your neck hurts more than the scowl of an examiner. So you train your brain. Exams feel "easy" on the brain.

2) Endorphins.

3) Activity.

Just do something.

Arguments are not useful. Stay away from them, and get them away. Sacrifices, temporary, may be needed during the peri-exam period.

The effort-results curve is sigmoidal. If your aim is to be sane, understand this curve. To be in the middle, aim for 52. Always. Start now. Once comfortable, raise the bar and become crazy like me.

Exam

20 minutes history, 20 minutes PE, 20 minutes everything else. Halve that for your ward time.

Reorganize your thoughts.

Remember your summary, differentials, investigations, management. Start now (in clinical years).

What is the spirit behind the lecturers' questions? Steer them. Be "safe".

The exam is between you, patient and examiner. You can control yourself. Be prepared for the unexpected.

Bismillah before, Alhamdulillah after.

Anything Else?

Go ahead and ask, I'll answer as I can. Preparing for exam only questions of course.

The Professional Exam

Thank you to all the lecturers, staff, patients, seniors and juniors (my teaching subjects, a source of study), study group mates (Abe, Aiman, Ammaar, Coax, Hafiz, Nadhir, and even Zaim for a short while), batch-mates. Thank you for tolerating my extroverted, cynical, nasty, narcissistic and mean tendencies.

Looking back, I am still sad that the memories of SPM haunted me again, consistently scoring among the top, but failed to deliver on the big day (1 B, in BM). And considering how hard I tried to achieve it, more than my SPM efforts, it hurt even more. Considering the potential I knew I had, the result was an underachievement, a failure of sorts in the objective point of view. Even as I type I am still having periodic episodes of tears welling up.

How I hate the effort-results curve (my imagination, and it's sigmoidal in shape). To get a higher result, you need extraordinary effort after a certain level. And when you fail to achieve the objective, you feel as though all of that effort was just, "lost".

Long story short, it wasn't composure that failed me in the clinicals, but my mental stamina. My mental energy ran out at the wrong time.

Long case - Hemophilia B. Never seen 1 in my life prior to Pro. I clerked according to logic.

Short cases - Twin pregnancy, acromegaly, ACL tear. Those who remember my luck with the Lachman test might be interested to know that again, I failed to notice a really obvious positive Lachman test while lecturers already saw it. Just like in year 4 revision. Only when I repeated the test did I notice it, a complete tear.

But subjectively, it was probably not a failure. None of the study group members had to re-sit their exams. Truthfully, when I heard every one of those names mentioned, I smiled in my heart.

And I did well for the Pro considering that Abah fell sick since the 3rd posting with stroke. Almost every week since December if I remember correctly I went back home during the weekends. It was extremely tiring, regardless of whether I travelled by bus or car. 70% of my knowledge of internal medicine was based on my year 3 knowledge, as there was a lack of time to read. Teaching juniors helped tremendously.

And right before the exams, Abah would again be readmitted, with an aortic valve replacement during my clinicals. The original planned surgery was to include an ascending aortic replacement with coronary reimplantation, and cardiac bypass; I only knew that the simplest was to be done well after the exams. And yet I remained composed enough, I blocked out any worries about Abah and focused on the exams. I did well enough that I called Umi right after the exams to tell her I passed before waiting for the results, the confident being I am. I knew a distinction was out of reach, but yet I remained hopeful until yesterday noon. I haven't told her yet the exact results. But Abah is now alert.

Inspired by the performance of Liyana Mazli, Mastura and Fatin of the previous batch, I tried to emulate their excellence. During that year I was disheartened by the fact that I was not considered for Ortho distinction due to failing an easy PMP on sports injury which I was confused by the manner of the questions. I vowed to keep myself average and sane, until the AGD, listening to the posting awards. I wanted to be at par with them. Since then I worked hard, getting distinctions in the first 2 postings, and good marks in the latter 3

Alas, the handicap I had probably hindered me, but to me this was probably an excuse. But yet I hope that Umi and Abah would be proud of their son, excelling in difficult physical, emotional and mental circumstances, although the true definition of excellence would have been the D. I cannot thank them enough, Umi for teaching me the alphabet at 3, and nurturing my competitive self, never settling for mediocrity. Is there any mother that scolds her child for not getting a distinction when it was in reach? She was the one who cared for Abah since his illness, and told me to focus on studying and performing. And for Abah, who never stopped helping me financially in living comfortably to excel, and for teaching me to work hard, even when you are a bright person. And thanks to my fiancee as well, who had to tolerate me ignoring her for weeks focusing on the exams. I've done what I could, but I guess second best is the highest I can ever achieve, until proven otherwise.

With that, thank you. Alhamdulillah. The pain may persist for months, but at least the "educational" ride is over. Now into the world as a working doctor, a different animal.

P.S. Mr Hafiz on me never seeing a hemophilia patient, "You don't need to see cases, you only need to know it!" I hope that he was proud seeing me present and discuss a case I have never seen outside of a textbook.

Thoughts, Training (May 16, 2010)

Thoughts (It's been a while):

1) The LPT stretch from Gambang to Kuantan is dangerous in the presence of rain: T-Rex was skidding almost every 3-5 minutes.

2) An interesting quote from Harry Selkow to me:

"The quickest way to get strong is to be the weakest guy in the gym." I've learned to create my own ways to avoid a "jaguh kampung (big fish in a small pond)" mentality. For example, I always look at lift videos in the Internet, not really to humble me, but to motivate me.

MJ used to lie to the media that opponents smack talked with him, and admitted that he lied when he retired, with the intent of firing himself up.

3) An even more interesting quote from Michael Jordan when he was told to emphasize teamwork:

"There's no "I" in team, but there's an "I" in win."

4) People need to have a winning mentality. Standards must be individualized. You don't tell Federer to be grateful whenever he became second best to Nadal; hey at least he got into the finals. You don't tell the same to LeBron James when the Cavs just lost to the Celtics. When your potential is much more, why settle for less?

When I told Umi that I was close to getting a D for O&G, her response was to actually scold me (and my fiancee) for going back every weekend!

5) I've been feeling that I am very lax in preparing for the Professional Exam this Friday. Not spending much time studying, and more relaxing. No pressure for the most part.

This reminds me of SPM, a time in which Abah and I got into a very heated (understatement) argument, and a time in which I was even more hot-headed than I am now. Abah was pressuring me to study while I was home in between papers. I wanted to relax and take my time to read in the middle of a stressful exam period. The trigger was when he kept pestering me to come back after prayers while I was talking with friends. Hm...

6) Speaking of Abah, he and Umi are currently back to the general ward. Atrial fibrillation secondary to CAP. The neurologist said that there's probably new recent stroke(s), although there's no functional signs other than generalized lethargy. I guess the echo tomorrow is for that. Thanks for the wishes from everyone.

7) I'm finding that everyone loves my massaging skills. Maybe I should learn Active Release Technique (ART) or Graston (gasp!).

8) Hm, I can no longer borrow Abah's pants: my thighs have become too big.

9) I don't understand why casual gym goers waste their money with single joint, isolation exercises and getting no visible changes after even 1 year. Unless you can bench 100 kg (I can't), squat 140 kg (not tested yet), or deadlift 140 kg (yes), you have no idea imitating routines of people who spend at least 2 hours every day for 6 days a week with the help of assistance and are already fucking strong in the first place.

Sure, it's your choice, but money and time is precious for those of whom going to the gym isn't no 1 in their lives.

Training:

Since I'll be getting married soon (27 June, Bangi Golf resort - bookmark that date, invites will be sent out when they're ready), I'm going to start fat loss. It's time to dial in the diet 100%. I'm aiming for (generally) normal strength training via 5/3/1 3 days a week, with heavy conditioning on the same days + one. Every other day except 1 day per week will be filled in with general "light" conditioning, probably with Turkish get-ups.

Diet will be carb cycling. Previously I still took carbs on off days. Now it'll be carbs in morning and pre-training only on days with heavy conditioning, and no digestible carbs on off days. The aim is 1-2 kilos a week.

Soon I will also be going back to Bangi, with no lifting partners. At that time I'll have to reduce again my lifting maxes for the bench, which is my weakest lift relatively.

In the mean time, I did have a good deadlift session last week: 131 kg kg for 7 reps.

Thoughts, Training Log Until March 21 2010

I haven't written in a while; not enough time.

Thoughts:

1) Living in the fast lane, stress can either bounce off of you like a slab of concrete, or deliver blast through you, like a slab of concrete. Usually for me it was more of the former, but yesterday it as certainly like the latter, due to multiple stressors finally getting into me.

I need to keep my legendary temper in check: I think I punched the wall almost 10 times yesterday, hard enough to make people notice. The skin at my knuckles aren't hyperpigmented because of hemochromatosis, you know.

2) My aunt got operated for a "ruptured" appendicitis, but the operation was laparoscopic, so it shouldn't have been too bad. Get a good rest Umi Dah.

3) So far I'm finding that I need to do a lot more to get myself ready for Pro, especially now that the date has been pushed forward. And I can't enter the wards to boot. But with the current schedule and stress levels, I'm not sure how I'll manage to fill the hours in. With my current "intellectual abilities" I'm guessing that just 1 hour to study O&G and another to study for Pro consistently every day would suffice. Another would be to study 1 1/2 hours for Pro (which I've not started on my own yet, only group study), and depend 100% on bedside teachings and other "classes" (including on call sessions with 3rd years) to prepare for O&G (which was exactly what I did for internal medicine, and still got me no 2 in the group). We'll see which path I follow, which depends a lot on how well I cope with the stress.

But I want another distinction, for O&G and Pro. I want the money from the MMA award (though I haven't registered as an MMA member. 1K will help out a lot, especially with the internal drama in the family (not just Abah's illness).

4) Speaking of Abah, he has been talking a lot more, which is good. This morning he also started trying to regularly walk without his walking stick. But there's a lot more training required especially regarding his speech, and dealing with his upper limb spasms while doing ROM exercises are very difficult: too soft and you won't be able to extend the elbows & fingers at all, and too hard and Abah will be in pain. But he's laughing more, and interacting better with guests, who are still coming non-stop during the weekends.

Thanks for the support.

5) Next week is Naufal's wedding, the wedding of a person I can truly refer to as a best friend. Congratulations. Hopefully I'll be able to come over, unlike the so many I've missed lately.

6) Some people have it so easy: you'd God damned better be grateful.

Training (writer's block setting in):

The b-ball underground tourney is less than a month away, and what is hopefully going to be a special day is another 3 months away. It's probably time to reel in the diet, get a good more cardio in, and hopefully still increase if not maintain strength while shedding some fat. People don't care how healthy you actually are, just as long as you meet others' interpretations.

Videos are up on my Youtube page. But one thing is for certain: my pullup strength sucks, and I'm very unhappy about it.