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.

My Studying Resources and Methods

This is something inspired by a recent "conversation" on Facebook, so I thought I'd share my methods. In no way is it the best way, but it has worked for me since 2nd year (the year I had mobile internet, beginning with DiGi).

My reading is always in order of importance (for diseases):

1) Internet - emedicine.com, wikipedia if all I want to know is a summary. The main problem with emed is that the information is not standardized as an educational resource, so you have to correlate with what you see in the basic text books/wards.

2) Text books - Read for the basic info, but I'm reading less and less of them. Unless if it's Nelson Peads.

3) Student's presentations - Very rarely. I feel that they're more imperfect than emedicine.

For BMS:

1) Text books - Getting the good books is the key.

2) Internet

For examinations/investigations:

1) Internet

2) Text books

Additional reading for examinations is supplemental anyways. The most important source is the clinical teachings.

The basis of my studying is "spontaneous" research, followed by attempts to memorize everything into long-term memory.

This explains my method of studying: I read MCQs and perform "research" based on them. I also don't mark whether they're T/F. This behavorial training forces me to remember stuff. The only thing I know is whether or not I've researched a particular q or not. If I don't remember it, I'll look it up again, hoping that I'll remember it this time. Usually, I'll either remember the particular information, or the particular resource I referenced.

I also love case scenarios, and approach-based learning. This is because

1) you can cover many topics in one go

2) you simplify your line of thought to consider your most important and most common differential diagnoses when seeing patients.

Disadvantages of my methods of study:

1) Time. There's a lack of time to make notes. I have not consistently made notes since the middle of 3rd year. To compensate, I save all of my internet resources in my computer. What is from written resources (like textbooks), I try to type the notes in my computer. Obviously, this is next to impossible to optimally use with anatomy/physiology.

2) There are no notes to bring with you, anywhere. My laptop is my notes. Luckily, I do have backup. And probably less than 5% of that is in my head.

3) There are times when I do have time to make the notes. Another problem arises: RSI. Nothings beats the ergonomics of writing versus typing, even if you're a trained touch typist like me, using among the best manufactured keyboards in the industry.

4) Sometimes you miss the simplicity of the important info in textbooks by becoming too engrossed in the complexity of the more informative resources.

Advantages of This Method of Studying:

1) You get more reading.

2) Approach based medicine is not covered in most textbooks, but may be researched via the web.

3) By studying via MCQ, you can cover a ton of topics within a few weeks time. This is because you can perform lightning revisions for "easy" topics, and intensive revision for topics you know you don't know. This is best appreciated in a group study setting. For example, for last year's Comm Health & Family Medicine, my study group only managed to start studying on Friday, with exams on Monday, due to on-going work that did not end until Thursday. No matter, as we all comfortably passed. This method in a group setting was further refined during the next two postings of 4th year.

There are a few prerequisites of studying like I do:

1) You have a knack of remembering things on the first reading/discussion. Or at least you think you do. Actually you can, as housemen can remember patients without looking at the notes.

2) You can digest multiple resources into one. The internet can provide quick information, but resources like emedicine is too complex and does not take into account local practices. You have to be able to correlate internet reading with textbook reading, and local epidemiology and practices.

3) Having a strong imagination helps too, as sometimes you need to make those mind-maps in your head, or at most, on a whiteboard (to be erased).

There you go. Not applicable to everyone, but maybe something is useful in there.

Random Thoughts too Big for Facebook

Oh the School Days:

Passed by SMSS while driving back home from HUKM, but didn't pay a visit despite being relatively free for the day. But then again, that happens every day passing by SMKSI sending my sister to school. Anyways, SMSS looks better from outside than when I studies there; all of the buildings including the hostels look like they were newly painted, at most 1 year ago. It certainly reminds me of the fact that our childhood experiences shape very much our principles in approaching life, and is underestimated. But reading the Sham: How the Self-Help Movement Made America Helpless book, which I'm still not finished yet, certainly teaches another lesson: that doesn't condone negative actions that you do, at least most of them.

Anyways on reflection, I always though that my best years in school was in the span of 5th - 6th grade while in the states. Only 2nd place is the IIUM Matriculation years, when I won the overall best student award; frankly, the debating experience is the most fulfilling during those years. In Matric, you didn't have to study, as one day before a paper will do, so learning itself wasn't a challenge (too much). And despite the (in my eyes) highly regarded MEDCY during that time, the mental challenge of debating brought me a lot of mental development in a period characterized by memorizing and throwing up info (not necessarily knowledge) in exams. Sorry Madam Nur Rinah if you read this!

5th grade was the year in which I finally removed my demons of 4th grade, in which all 6 six-weeks was characterized by 2nd honors (all A's except 1 B). I finally got a first honor in my second six weeks of 5th grade after getting second honors, and it continued all until before I returned by to Malaysia (I had second honors in my 2nd six weeks in 6th grade though, but all A's in the assessment of 3rd six weeks). During this while I was enrolled in the TAG (talented and gifted program) for 5th and 6th grade, which allowed me to do many extra things in school, among them, studying marine biology, a subject I still love until today. Compare that with the grind of "top student studying" in Malaysia. There may be many things wrong with the American education system, but making education fun for the top students isn't one of them.

I still remembered the time in Form 5, when an English teacher started backbiting me in front of other students because I refused to enter an extra class for top students (obviously a step to ensure A's in the school, not helping the less fortunate students). It was optional anyways. I've always wondered how'd it be if I brought that subject up in her face as I got the highest grade (can't remember the grading system) for the 1119 English subject, something she said I wouldn't get. Sorta like in standard 6, when the Student Affairs teacher of SKSS asked why I didn't bother to pick up my UPSR results (all A's). Funnily enough, it was him who recommended that I be enrolled in what was considered among the lower of classes in standard 6.

Regarding that, I think the system of streamlining students into "good and bad" classes is for the most part, stupid. Unless if 80% of your students are thugs, there's no need for it. Interaction breeds experience, and experience breeds learning. And the Malaysian education system fails miserably to instill creativity. Thank God for debating as it saved my brain.

On My Obsession with the Shoulder Joint, as My Friend Has Impingement Syndrome:

Another thing passed my mind while driving: the shoulder joint, and the various things you can do almost any time to protect it's health. And the main issue with rotator cuff impingement, probably the most common, and certainly among debilitating among injuries in the public and athletes, is that it is usually caused by scapulothoracic joint dysfunction, i.e. the inability for the scapula to rotate upwards when doing overhead work (like getting that cup out of the cupboard). Added with poor thoracic mobility (too much kyphosis, lack of abdominal breathing), and the supraspinatus is just waiting to be injured. Mike Boyle's article gives a good overview on requirements to maintain shoulder health.

But there are a few exercises which I actually love, based on a few principles outlined here (by Bill Hartman and Mike Robertson):

Observe how 3 muscles together produce upward rotation of the scapula, ensuring safety of overhead movements. Along with scapular pushups (also referred to as the pushup plus) and wall slides, my favorite to be done is the overhead shrug, all shown in the above linked article. The reason is that for the most part, you can do it at home, and you do not need weights (a boon for the general public); proper motor mechanics is the key, instilled by habit.

But for those who are already symptomatic, there are still ways to incorporate such "exercises" into your activities of daily living, keeping you safe when forced to perform risky movements anyways. Or you can exercise at some opportunistic times, like say, while in a traffic jam (not while turning the corner of course).

1) Perform all overhead activities as though you are trying to perform an overhead shrug. The easiest way to do so is to shrug --> overhead movement. Another way to do this is by partially performing the overhead task, followed by active shrugging before finishing lifting the arm overhead. The basic theme here is to ensure that your body always "remembers" to have that upward rotation when lifting overhead.

2) Incorporate shrugs while driving. Shrugging in itself may not help with impingement, as activation of the rhomboids during normal shrugs may prevent upward rotation. Shrugging with the arms elevated help prevent this. So hold onto your steering wheel, and do those shrugs, which mimic the overhead shrug with a barbell/scaption + shrug with a dumbbell.

3) Incorporate scapular "rows" while driving. The whole point here is to imagine pulling your scapula downwards and back, to make both of them meet. You don't want to pull your scapula upwards, in order to remove the rhomboids out, stressing the movement on the upper and lower traps.

(video viewable in original post)

Incorporate points 1, 2, and 3, along with easy to perform anywhere scapular pushups (for specific serratus anterior activation) to prevent problems, or fix them before you need surgery. Remember, rotator cuff impingement is not an automatic spell for surgery!

Ah, My Achin' Back

I've just returned from my SMSS batch reunion held in PD for 1 night 1 day. The RM150 price was a bit steep (for accommodation mostly anyway), but the experience of meeting friends you've been split from for many years certainly pays for itself.

Good thing I've resumed heavy workouts before going; I'm probably as weak as car left in the sea for 50 years.

Now it's back to Wesnoth work I guess. Heh.