Randomly JYSim

New Year Yuan

2012-01-23T18:07:00.000+08:00

I'm not a resolution person. Firstly I am dead afraid of criticisms upon failing my resolutions; and secondly they almost always fail to materialize, as observed by the following clip from Wong Fu Productions.
However this year, I need a few of God's helping hands in some of my personal pursuits. In Buddhism we make a wish (or bargain) with Buddha called yuan. In return, we promise to do something good like converting vegan for a month or memorizing a certain sutra by heart. It's like striking a deal with God whereby He grants you something good and you reciprocate with something similar. It is quite common among Buddhists and Hindus. Thaipusam is a festival where Hindus make offerings in return to God's goodness for the past year.
First of all, as we'd be starting our intern year come June, I hope to land myself in a rotation that allows me to return home for Chinese New Year celebrations. As many overseas students would agree, being absent from home during Chinese New Year is a sad burden to bear. I understand that my role in future requires me to dedicate duty over friends and family, but seeing my future of reunions bleak, I sincerely hope we'd be able to get together more often, at least for next year.
As such, I made a yuan. I promised to memorize the Heart Sutra if I manage to get my desired rotation. It is important not to hold any grudges against God in case your yuan does not materialize because Buddhism regards its best disciples to have no worldly desires or pursuits. In short, a devout Buddhist does not have to make any yuan because he feels comfortable being in any situation or environment. Making yuans are for needy, shortcut-seeking, half-hearted Buddhists like me.
Secondly, my closest friends will notice I was plagued by some irritatingly stubborn acne that won't go away no matter what I tried. The good thing is the worse of the acne is over now and I am managing it with sufficient sleep, a healthy diet, tea tree oil, and Chinese medications from my all-encompassing sinseh.
So my second yuan with Buddha yesterday is that I would be a vegan on Mondays in exchange for a clear, healthy complexion.
We'll see during the following year if my yuans are to be come true.
Finally, Happy Chinese New Year and may this year bring health, wealth, and happiness to all!

Major Traffic Congestion

2012-01-20T16:14:00.000+08:00

It is part of Malaysia, just like the snail-paced internet speed, crazy traffic signage, and selfish drivers. There will always be major road congestions during the festive seasons, and this year it's no exception. As such, I scheduled all my appointments to be 2 days before or after Chinese New Year, and cancel those anticipated to be held under the baking sun with standstill traffic everywhere. It's a great excuse to avoid seeing awkward old friends and going on an unnecessary shopping spree. I'm sorry but everywhere is so congested.
But if we look at the root of the problem, a 5 kilometer crawl is usually caused by a single vehicle or crazy traffic light. For the past week I observed:

An auntie waiting for her roadside hawker in her car, completely aloof to 5 kilometers of congestion behind
Uncle taukeh switching lanes every 4 seconds on the expressway, completely aloof to heavy vehicles that would crush his Benz with a failed brake or a moment's lapse of attention
Parking idiots with half their SUV jutting out from the indicated space, and 5 kilometers of congestion behind trying to avoid his 50,000 dollars bumper
Young intern late to a meeting, double parking onto my car in a dead-end street
Parents of a very prominent school (ahem! PCGHS, ahem!) triple parking waiting for their princesses to be dismissed from school

And not forgetting parking idiots occupying 2 spaces with their tiny car, an example below:

It's the festive season and we're all trying to stay sane and afloat with the new clothes and excessive eating. So please do your part by driving and parking responsibly. Remember, you don't want to be showered with bad karma and nagging on the first day of Chinese New Year!

Happy Holidays!

2012-01-13T22:19:00.001+08:00

Just realized I've been working with hardly a break this year. Even summer I was "working" while in New York.This year's winter break song is a "Need You Now" cover by rising star Charlie Puth and Emily Luther.

"When will you be available for Mr. Liu?"

2012-01-01T18:28:00.001+08:00

"Hi. Am I speaking to Mr. Liu? Son of Liu XY?"
"Yes, this is."
"This is medical student Sim working under Dr. Yu. I'm calling from Tzu Chi Hospital in Hualien. Are you free to talk right now?"
"Right. Yes, please go on."
"As you know, your father Mr. Liu was admitted to our hospital a few days ago due to generalized eczema with possible skin infection. He had been living alone and was brought to emergency by a distant relative of his, who visits him every morning while in the hospital."
"Yes. I last visited him a day before hospitalization and he seems OK."
"His skin condition had been bothering him since February. As he has no obvious means of caring for himself, we cannot discharge him back to living alone. We consulted social services and they recommend us to contact you as you're his closest correspondent. So we were wondering if you will be free to visit him soon to facilitate our discharge plans."
"Right. You see, I just found out he is my father a few years ago. He had a few wives when he was young, had never fulfilled his obligation as father, and now is totally dependent on me for his living. I have a job here that I can't simply take off. My wife is unhappy that I'm financially supporting him, so bringing him home is totally out of the question."
"I understand. I was briefed by our social services as well. We could, however, try to apply him into a nursing home nearby."
"Social services told me that as well. But I cannot support him living in a nursing home. I wonder if Dr. Yu can issue him some disability certification so that he can have free nursing home care?"
"Apart from his skin condition, Mr. Liu is, unfortunately, or fortunately, free of any chronic or disabling diseases. I understand the financial situation Mr. Liu, but I don't think it's possible."
"Right."
"I will ask Dr. Yu for you and see what he feels about this."
"Thanks."
"Anyway, it would help us tremendously if you could visit to sort this out together with us. I still recommend that you come as soon as possible. Is this weekend good for you?"
"Look, I just visited him last Sunday like I did once every month. I have a family to support and, like I said, cannot leave simply like that!"
"I understand your situation Mr. Liu."
"Can't you bother the relative he's with?"
"I'm afraid you're legally his son, which makes your decision more valid than hers."
"OK."
"So we will keep in close contact these few days to arrange for Mr. Liu's discharge. I hope it's OK we call you up very often as you are not physically present to make decisions or sign papers. I would once again, strongly recommend that you visit, at least one day, next week."
"I will try."

To Eat A Crab

2011-12-22T23:09:00.003+08:00

I can very clearly remember when I had my first crab. I was kindergarten-age and suffering from constant nosebleeds. My parents were very troubled by that and like all Chinese parents, we saw a dozen people suggesting hundreds of methods - eating raw lotus roots is among one of many. Somehow a smart person suggested eating a freshly steamed crab as a way to stop nosebleeds.
So I was picked up by my parents, probably from my sitter's. And there was this cage with a strange, dark crustacean in the front seat. I thought we have a new pet and was all excited about giving it a name. Until Dad (or Mum?) told me it is to be eaten.

Back home I studied the animal. It was the nearest and least-adulterated creature compared to illustrated animals in children's storybooks. Its claws were tied so that it does not pinch and escape, sideways. I asked how are we going to eat it when everything visible on the crab seems rock solid? To this Mum shoved me away from the kitchen and prepared the ritual to sacrifice the innocent crab for her son's cessation of future nosebleeds.
Then I heard unusual clickety-clacks from our wok, lid-covered and on full flames. Later the crab, still whole, now Sunkist orange with hues of blood red, appeared lifeless on the table. There and then I understood it had been steamed to death in the wok. With my primitive kindergarten mind I imagined if its last moments were comfortable, like being in a hot tub, or scary, like the Holocausts in the gas chambers. Vegetarianism is still 20 years away so I am not in any way saddened or disturbed. It is now that I feel sorry for the crab, who might have lived to bear offsprings.
Dad and I shared the crab. I ate mostly the claws, horrified by the anatomical contents inside the shell. I did, however, toyed with the lungs, recalling 10 years later the cell-thin blood-gas barrier to my first crab.
I still have occasional nosebleeds, to which the taste of raw lotus roots and steamed mud crabs waffled up the brain. Eventually my parents gave up on trying and just bought plenty of tissue papers around. And they became almost vegan I heard.

My Love for Airplanes

2011-12-11T19:57:00.001+08:00

The typical scenario starts like this: I enter the room / office / waiting lounge to meet the parent and my patient. Boys will either have model airplanes, trains, or cars; girls, dolls? After the introduction I will ask Mum if little guy is into planes / trains / cars. I always knew the answer - model planes / trains / cars are to boys as Barbies are to girls.
It didn't strike me as obvious until recently when I reflect upon my love for airplanes and aviation. I think I found the reason why. Guys' enthusiasm toward transportation is deep-rooted in our nomadic genes - our early relationship with nature when males hunt and fight wars in faraway places, necessitating a skill to select modes of transport. Before technology, we had the knights, camel riders across Sahara, and the Siberian huskies. Now, we had land rovers, bullet trains, and numerous Boeings and Airbuses.
I am an aircraft guy. You tell me 3 key information - how many engines the aircraft has, whether the wings have winglets, the arch of the tail - I can tell you the model of the aircraft. I'm those guys who stare at planes like perverts who stare at prostitutes. So you can imagine the happiest day during my vacation is when we are at the airport.
To me, an aircraft symbolizes freedom. To see a 200-tonne aircraft take off powered by four relatively tiny engines around the wings - the deafening roar as it soars across thin air, breaking borders and connecting continents. The people within, safely cocooned in their seats, waking up to exotic destinations as St Petersburg, Sao Paolo, Tel Aviv - some names we can't even pronounce properly. It's more than a technological marvel when you recall the first controlled flight by the Wright brothers took off a mere 108 years ago.

Thanks to rocketing jet fuel prices, sleek aerodynamics and minimalist interiors are in trend nowadays. However, aircraft design had gone through decades of revolution to arrive at its generic today. The lift of an aircraft comes from continuous movement of air through its wings. In short, an aircraft has to keep moving forward to stay aloft - and I think it's true for human beings as well to keep moving forward.
The power of flight enriched our lives tremendously - sun-kissed oranges from California, Norwegian salmon, Darjeeling tea, freshly harvested the day before, arrive at our tables during dinnertime. Airplanes made our world a little smaller, and us a lot more adventurous. Quoting a British Airways ad "transforming strange names from tall tales into pictures of postcards home."
Finally, though some argue against the romance of travel (in a steamship), airplanes made traveling so much faster and connected the world with endless possibilities. Before, a trip from London to Sydney takes about 3 months. Now it can be completed in less than 24 hours. It gave us our southern summer when the northern hemisphere is covered in hail; flew us to ski resorts during summer vacation; and brought closer distant families separated by borders and time zones. It opened our eyes and indigenized the foreign.
And that's my boyish love for aircrafts. Whenever some loveless person asks me to explain why I'm so insane about it, I can't express it in a few words within their attention span. It is more than a crush, it is genetically embedded within adventurous guys like me.
I end this with an excellent BA ad depicting my love.

Cranberry Juice and Herbicides

2011-12-03T19:37:00.001+08:00

Been in nephrology for 2 weeks now slowly adjusting to life in internal medicine as a whole. We had another TMAC (Taiwan Medical Accreditation Council) evaluation this week so things were hectic with lots of spruced up decors and model answers.
On the whole I enjoyed nephrology thanks to being empowered to give orders and perform tests under supervision. Depending on your chief and his level of confidence, capable and credible medical students are allowed to order tests and prescribe medications under supervision. Although this is widely practiced in the States, care is still very centralized around the attendings and residents in Taiwan. Medical students are usually just the "observer" and "note taker" shadowing during rounds and morning reports.
Being empowered means we are considered a team player during rounds - making decisions, determining severity, and planning treatment. This means you have to see your patients before round begins, update on their previous tests, and have an impression in mind by the time the attending calls.
Just to to emphasize how far we've come over 1 year - we were struggling with our hospital's crash-prone system, remembering to press save every lucid moment, and suffering writers' cramps on patients' notes. Now we simply breeze through pages of chart, extracting information like a vacuum cleaner, and synthesizing impression and plans with very little help.
One heritage I brought back from New York is how important patient education is. For too long Taiwanese hospitals emphasized only inpatient care, with dismal patient-doctor mutual understanding and long-term discharge plans. Eventually they snowballed into the burden called the National Health Insurance and aimless doctor shopping.
Being medical student I'm not as busy as my residents. So I endure to teach every one of my patients something they possibly don't know - I encourage patients with urinary tract infections to drink cranberry juice, and patients with postoperative ileus (abdominal distention and discomfort after surgery) to chew gum. They might sound surprising to you, but the aforementioned examples had been proven via large scale studies to be cheap and effective. ~~This gives me a superior feeling over my patients.~~ The truth is, why stay in hospital for a condition you could handle at home? I wouldn't want to stay in hospital even if my private insurance pays me - it's filthy, noisy, gloomy, and absolutely boring being a patient in hospital.
Nephrology also handles cases of suicide via ingestion of toxic compounds. I had a patient who drank a cupful of herbicide after a fight with his brother. We later found out their parents had passed leaving them a huge piece of land. My patient, being unemployed and poor previously, will inherit a quarter of the land. This makes him ineligible for government assistance of NT$12000 (USD400) per month. He has no family, friends, or any means of supporting himself.
As we slowly got him to talk, we realized medicine is powerless against psychosocial loopholes. This is when the social workers come in. Within hours they arranged for a full-time carer, settled the family issues and got him relocated to a long-term care facility. Although they still haven't got rid of the remaining herbicide at home and his government stipend (which he insists on receiving), I think they did a great job given the complexity and multiple parties involved.
There is so much medicine can do. But there are more that fell through the sieve of medicine, like curing cancer, psychiatric problems, and caring for people who are socially challenged. Where modern science couldn't provide for now, we are at least responsible in educating patients on sustainable medical habits and comforting those in need of non-medical assistance. Quoting Dr. Trudeau as my ending - to cure sometimes, to relief often, to comfort always.

Handwriting

2011-11-27T21:28:00.001+08:00

As most Chinese believes, a person's handwriting reflects your personality. That, however, isn't applicable in medical school or hospital charts. If it wasn't for computerized charts, we would still be deciphering Martian and Plutonian on every hospital charts. And grammatical errors are extremely common among Taiwanese medical professionals too.

However, once in a while when the patient presents with a dozen problems that will kill the computer charting system, we still handwrite our notes. That's when...

I know what type my attending or resident is.

High Fives and Tongue Blades

2011-11-17T20:23:00.001+08:00

I love working in pediatrics because (healthy) children (generally) enjoy another's company. Unlike cunning adults who stare (rudely) when you poke and probe their diseased parts, children either wail, or transfix in confusion held firmly by Mum.

So floor rounds every morning became the sole agony of pediatric patients. We will force their mouth open with a weird tasting tongue blade, sometimes accidentally evoking a gag reflex; their ears probed with an otoscope; noses swabbed for flu virus (if indicated); and for patients with ambiguous genitalia, their private parts exhibited to half a dozen medical students. But what's cool about children is that by the time we leave, they will happily wave us goodbye, shower us with goodbye kisses (amidst tears from just now), and give us multiple high fives. This routine is so well tested it is like a computer program installed into every toddler by the time they get admitted - like how dog trainers tell their pets to "sit" or "shake hands".

Most toddlers are full of virtuous moral values they learn fresh from kindergarten. This makes them ~~easily deceived~~ very cooperative during examinations. For example, before a throat swab which is potentially painful and uncomfortable, I exclaimed "what a big guy you are! You must be very brave. The bravest in class, isn't it?"

Big guy is beaming with pride and trying to conceal his blushes at the same time.

"Now, I hate to do this but this will make you better faster. I will put this thing (the swab) into your nose for a while. I know you are the bravest in class and that you won't fight or cry. It's going to hurt a little but I know you're the bestest! OK?"

"Yes! I'm the bravest in class!"

*Starts poking his nose gently*

Big guy tries to look brave but still can't stand it.

5 seconds into the procedure he's screaming and fighting. But by then I've got a swab and scurrying away to send the probe for exam while he complained in between large sobs to his mother "he's too rough lah!"

Nevertheless, no matter how loudly they swear they hate you, they will still kiss you goodbye and high five your hands when they recover enough - which is very quickly in pediatrics. Exceptions include irresponsible parents who use doctors as a threat, like "if you don't behave I will ask the doctor to give you a shot!" Remember: doctor-phobia will only increase both our difficulties the next time your child is sick. So always tell them doctors are the bestest persons on earth and they are bravest - that throat swabs or tongue blades are nothing. Also, keep up the good work on high fives and goodbye kisses!

Aspiring Pediatrician

2011-11-10T23:10:00.001+08:00

I guess I am influenced by many of my pediatricians to start loving pediatrics. Back in childhood my pediatric cardiologist shares the same surname as me and is a distant relative. Despite working in Penang General Hospital, his clinic visits were ample in quality time and fun to go to. To me pediatricians always have the extra patience to pacify a crying child, explain the umpteenth time a condition to the parent, and have fun in the meantime playing peek-a-boo with the thoughtless toddler. For some reason I yearn to have that patience and confidence and the responsibility of thinking the future of a child depends on me.

Four weeks in NewYork-Presbyterian Hospital opened my eyes to the scope of pediatrics. Breaking the traditional boundaries of common cold and chickenpox, the breadth of every subspecialty in pediatrics is beyond my greedy mind. Adolescence is also a branch in pediatrics that is commonly neglected, and I enjoyed my 2 weeks giving HEADSSS assessments and educating young adults on safe sex, contraception and healthy diets. I see a new light in my daily clinical routine - that advocacy, anticipatory guidance and patient education are just as important, even though not as well paid.

I'm among those fortunate enough not to be irritated by a child crying, capable enough to zip through PEs without breaking the threshold of irritable falsetto screams, and not ashamed of making a fool of myself pacifying an angry child. That should be enough to qualify me for a residency in pediatrics.

Anyway, this will not be an easy process. As with all other medical specialties, the call nights and intensive residency programs will milk all you're worth before they admit you as their equal. And I'm not sure if I can reiterate my passion today 5 years ahead. Maybe I'll end up a Broadway actor or travel book writer, or escape the realms of clinical medicine in pursuit of research. However, it's just good to find something you love and pursuit it for all its worth.

Death Be Not Proud

2011-10-31T20:14:00.003+08:00

I submitted this essay for publication in JAMA's A Piece of My Mind but was rejected. So I figure I'll publish it myself!

My Asian parentage in a conservative country meant that talking about death is much of a taboo as of drugs or sex. From childhood, we learned to ask no more questions when Mum or Dad says “I’m attending a funeral today.” Even when my paternal uncle passed, we drove back bantering all the way, embalmed and sealed his coffin, and buried him along with all our words.

When I enter medical school, I know death is an issue we all have to encounter in our careers. After all, medicine is to life and death as tailors are to fabrics. However, we are youthful flaming torches, the pillars of society; leaders of the future. Death seems the distant if not unimaginable end, yet. To us, life is limitless and we are omnipotent.

It wasn’t until my third year of medical school that I come face to face with death. “Silent mentors” we call it – cadavers willingly donated to our university to better medical education and lecture us (silently) on death. For the first time death was discussed openly, along with endless stories behind each selfless sacrifice and breaking social constraints. The traditional Chinese believes it is of utmost importance that you return dust to dust in physical completeness, lest you return handicapped should karma dictates another cycle of mortal suffering on Earth. These silent mentors are pioneers in their league – consenting medical students they never knew or talked to stripping them bare to the bone; occasionally having to confront protesting family members amidst their own terminal disease. Their goals simple – “I’d rather you make countless mistakes on my lifeless body than one single mistake on a living, pulsating patient.” Apart from anatomical knowledge, I promised myself a grandiose goal of learning about death, of overcoming the fear of it. I read Pauline Chen's “Final Exam: A Surgeon's Reflection on Mortality” and was touched by the closeness of death, anatomy and afterlife. I was prepared for the next step.

That semester, we literally lived in Anatomy Hall. Burdened by self expectations and the daily minute of silence before dissection, “death studies” eventually got tossed under the drawer. Our hot-blooded omnipotence in fall eventually waned into survival instincts by mid-winter and a great sense of relief by end of term. I ended up second in anatomy but still on the starting point about death - still feared, unspeakable and unapproachable.

During Chinese New Year the following year, I picked up a copy of the local newspaper on boarding my flight home. “All Bodies Found” it said. Shockingly, five students and a young teacher drowned in a boating incident in my hometown. They are my high school juniors, some of them I know distantly. The idea of such an abrupt end to six youthful spirits is deeply traumatic. The nation mourns as my Alma mater flew her flag at half mast, agonized parents find solace in pale chrysanthemum and roses lining school desks, and I wept every day reading the papers. Mum was surprised why his son suddenly became so emotional. Partly I was crying for the bereaved, the other part was for my unsettled understanding of death.

Prof. Huang auscultated me in numerous positions with both his stethoscopes. Surrounded by a dozen classmates in our heart sound class, I became my own patient because I couldn’t find another. I have congenital perimembranous ventricular septal defect. Prof. Huang looked at me sternly and declared, “you will have to get surgery someday, possibly before 40. Or else you will die from heart failure.” I took it lightheartedly. I twittered “time to unearth grandpa’s golden ingots this weekend!” But my end is already in sight.

Way too late, I started pondering the meaning of life in order to understand death. Why live if every one, everything, is destined to die one day? Why leave an impact if we’re bound to be forgotten? Why the aimless pursuits of material comforts, fame, glory, and recognition, if we will be gone and these worldly possessions recycled? Death still strikes the most fragile spot - I littered a tableful of Kleenex during September 11th anniversary; I sat tearing in front of a hospital computer on Steve Jobs’ passing.

Two weeks after the world mourned for Mr. Jobs, Apple posted a memorial page for tributes dedicated to the great man. Watching heartfelt words flash through a minimalistic clean interface, I think I found solace in my fears and answers to my questions. We fear and resist death because we are still so ready to live. As Buddhists believe, still tangled by mortal triviality disqualifying us for eternal tranquility. In other words, do your best, follow your heart and intuition, and leave the rest to faith. Leaving no regrets at the end of the day, literally, as we never know when is our last. Then we are truly, sincerely, fearless of death.

In fact, death makes living more precious. Knowing that all of us will eventually become part of history, we strive to leave legacies. Some bring up wonderful children, a partial imprint of their future; some design life-changing devices; some live forever in the hearts of others.

With hindsight, I recounted the story of my silent mentor. Extremely sensitive to pain, she left us with the notion that she would feel more worthwhile suffering the scalpel than that of rotting or cremation. At least it serves to educate five aspiring medical doctors. She had seen beyond her mortal self, willing to leave behind a declining but still useful carbon shell for us medical students. She lives forever in our hearts.

We never really leave the world without traces. Every humanly interaction, every patient we talked to and educated, every family we comforted, every tweet or Facebook update, had in a tiny way shaped the world for the better. Learning that my days are numbered (without surgery) helps me appreciate more the simple joys of everyday life - running on a crisp winter morning, eating pancakes with raisins and overflowing syrup, getting the full text of an article I really wanted on PubMed (you never know with our hospital). I may not live to have children, write textbooks, or be surgeon general, but I lived in my parents’, classmates’ and the few patients’ hearts I cared for. For some littlest amount of time they depended on me and I didn’t fail them. That is sacrifice I am capable of.

So I read through Mr. Job’s memorial tribute with elation and relief. Pondering whether to write an email thanking him for enlightenment, living today as if it is the last. No regrets.

Goodbye Surgery

2011-10-23T21:22:00.001+08:00

3 months of surgical rotation is officially over! Although not as tough as what we're facing next year, surgery is not my forte and hence I'm only glad it's over for me. Had good and bad times but it was enjoyable overall.
Pediatrics is next and I'm looking forward to it. This time in Xindian, a far cry from backwater Hualien. Also a lot of interesting events lately. Will keep you guys updated when I have the time (and mood). Right now just chilling off, enjoy the weather, and have lots of fun in Taipei.

"One Day"

2011-10-09T21:25:00.002+08:00

I made a promise to return to Malaysia "one day" - with no specific date in mind as yet. To my babysitter and distant relatives, they define "one day" as upon graduation; to Mum and Dad, we talked about this countless times and I expressed my desire to complete my training here.
Previously I've quoted the reason for not returning being the Malaysian Medical Council not recognizing my university's degree. When I grill myself deeper, I realize I was just being lazy not wanting to take the exams (even if I'm qualified to), not wanting to work in the "deplorable working conditions" of Malaysian hospitals - afraid of leaving the comfort zone.
I assume a lot of Malaysian students studying overseas feel the same - deep in one's heart the desire to stay and do great things is always fighting against the call for home. Our parents, like millions others, are tough liars on the phone - "don't worry, stay there, work hard, don't come back," but deep inside they are yearning for the next reunion. If Taiwanese customs allow sambal belacan, they'll make it pronto and FedEx it over.

We never heard from those very few who chose to head home. All we heard was from those who stayed, and seemingly never regretted the decision. I'm sure there are interesting and rewarding experiences waiting at home. And it is these little efforts that bring about change for the better.
I've got a set path in my mind and talked to my parents about the future many times now. I can't live up to everyone's expectations so there must be compromise. Being me, this "set path" is very likely to follow its course and end up almost like how I expected. As we mature we tend to lose our spirit of adventure. I hope I don't and it gets me someplace totally unexpected. As Mr. Jobs said:

Don't be trapped by dogma – which is living with the results of other people's thinking. Don't let the noise of others' opinions drown out your own inner voice. And, most important, have the courage to follow your heart and intuition. They somehow already know what you truly want to become. Everything else is secondary.

So be it working back home "one day" or staying put here, I promise to follow my heart and intuition, love what I do, and step out of the comfort zone. It pains me that I couldn't produce a definite "one day" for the ones I love back home, yet, but this is my life.

If Tomorrow Be Afterlife

2011-10-03T23:05:00.000+08:00

In my previous post, I mentioned I sang to my SICU patient, who subsequently passed after I left. This was the song I found on Youtube. Roughly translated it means "If Tomorrow Be Afterlife" performed by the choir of National Taiwan University.
I will provide a rough translation of the lyrics for non-Chinese readers:

Life passes between breaths

With the end in sight, are your expectations fulfilled?

Our mortal body exhausts itself day by day

When time is up, is your heart back at home?

Scenes after scenes of unfamiliarity;

What exactly are we seeking? How do we rejoin a broken string of pearls?

How do we sing a fallen song?

If tomorrow be afterlife, how would you spend today? [repeat]

I defend life with every warmth I possess, like the waves leaving behind traces

I guard well-being with intelligence, may the wheel (of life) be brightened

Much as I hope to strengthen his will to survive, the last two stanza serves as a reminder for me, as part of a medical team, to "defend life with every warmth I possess" and "guard well-being with intelligence." With God's will let us be.

My Turn At Being Ill

2011-09-30T21:42:00.001+08:00

We always emphasize efficiency, in daily handovers and rounds - name, age, chief complaint or diagnosis, current management. What we neglect is a whole experience of being ill hidden behind the 4 bullets delivered in less than 2 minutes. And medical education experts had been cracking our heads trying to instill a sense of empathy and all-rounded care since as long as I can remember.

I had a terrible flu last week, taking 2 days off work and lying at home waiting for episodes after episodes of fevers, chills, and pounding headaches. 10 years ago Mum and Dad would towel me and cook potato soup, now they are 2000 miles away enjoying boeuf bourguignon while I sweat and starve in my deathbed.

On Monday evening I decided to go see a physician. The problem is, I don't have a primary physician - we simply don't follow this system in doctor-shopping Taiwan. In my semi-consciousness I rode along a street hoping to find any signs of a doctor. I spotted an ENT clinic soon and went in.

After 20 minutes my USMLE-accredited Iowa-fellowed ENT specialist is ready to see me. I gave him the 2-minute stint: my friends had flu, I went out with them, woke up Sunday and dang! "Oooh, your tonsils are very swollen," "Veeeeery baaaad nose," he said, while stuffing cotton buds doused in steroids into my nostrils. I repeatedly told him I'm allergic to Naproxen, a potent antipyretic. I eyed his "Basic Pharmacology" sitting beside the table. He sent me out (to refer to alternative drugs, I think).

When I saw him again he was dictating his treatment plans - something I'm not allergic to for fever, cough syrup, clindamycin for possible pneumococcus infection etc. Thanks to my National Health Insurance, all that and consultation costs barely NT$100 (USD3). While I was feeling sad for my USMLE-accredited Iowa-fellowed specialist, I happily carried a bag of multicolored pills home...

Only to discover they package it all together so I wouldn't know which pill is for what purpose. To ensure I take the adequate dose of antibiotics, I have to swallow the entire pack of 5 pills 4 times a day, even if I don't have fever, coughs, or dizziness. What medical wastage!

I took Tuesday off, half of Wednesday off, and felt well enough for work Thursday. Between lucid intervals of watching Air Crash Investigations and cooking my own version of chicken soup, I received numerous phone calls. As my number is linked to the hospital paging system, any calls from the hospital phone is displayed as a 6-digit number. This I answer with a raspy voice sounding as if I'm intubated and in a coma (you never know nurse practitioners - they LOVE assigning patients at 5.28pm). Friends' calls I answer sounding pitiful. Then my ENT specialist called - just to remind me how difficult it is to run your own clinic in Taiwan - even have to make follow-up calls to your patients.

I made my bout of flu sounds fun but it actually isn't. Some things you just have to experience it yourself before you empathize. Nevertheless, for the price of less than a meal, I wouldn't complain too much.

Surgeon Sacrifice

2011-09-17T00:03:00.001+08:00

I once came across a notion that the sexiest profession are masked - dentists, surgeons, burglars? Never figuring out why, but I would strongly agree surgeons being a difficult person to work with. Generally, they are stubborn, defiant, ill-tempered, and hence definitely not, sexy.
Nevertheless, one-third of my rotation consists of surgery. Except in the event that I become director of medical education tomorrow and successfully abolish rotations consisting of surgery, I have no choice but to endure the politics and showbiz of surgery - the scrubbing in, the smell of povidone-iodine, the stick-to-everything OP-sites, and every surgeon's obsession - sterile techniques.
I dread my week in General Surgery. I'm scheduled into surgical oncology and insiders will know they are famed for day-long exotic-named surgeries - Hassab's, Whipple, Bilroth - and the magnum opus of every oncology surgeon - transplants. Much as I admire the great work of bringing life back to the dead with a switch of organs, I cannot imagine myself standing on a 2 x 2 foot plank for 36 hours with no food or water. I'm not that noble yet.
With Murphy's law working on me this week, my attending Dr. Lee scheduled a Whipple procedure today. I was foretold two days before and dreaded the arrival of Friday - usually my laziest. I made sure I get enough sleep, ate double breakfast and drank enough water to last the entire day before entering the OR. Clerks like me are not required to scrub in, but as an observer it is common courtesy to ask permission to leave. I have no guts to speak throughout the entire procedure. Dr. Lee was swift and precise in action. My instincts told me if I broke the silence with questions such as "can I go for lunch?" he'd fling a scalpel at me. Rumors had it that he did exactly that back in his young hot-blooded years, earning him the nickname "flying dagger Lee."

So I stood there obediently as the clock ticks till 2pm. Then the resident was sent to another OR to help out and I was asked to scrub in. When I was just a casual observer I have the liberty of leaving whenever I wanted. Now I'm stuck! My mind protested but I still obediently doused my arms with sterilizer and don the hideous blue gown.
It was interesting observing an extensive procedure. It's quite rare and almost extinct nowadays, an assistant told me. As my inner protests died down with hypoglycemia and leg cramps, I started noticing the undivided commitment of Dr. Lee to his surgery. 6 hours into the procedure and we're struggling with a stuck vein. I was thinking of how to scratch my nose without using my (sterile) hands, while Dr. Lee was faithfully freeing millimeter after millimeter of tumorous pancreatic tissue. Navigating the punch-sized surgical field with utmost tenderness and stopping every 2 minutes to kill an active bleeder. There was a moment when the bleeding became almost uncontrollable. Panicking, the assistant started throwing orders but Dr. Lee calmly instructed everyone to perform and quickly stopped the bleeding.
As the surgery comes to the final steps, the assistant casually asked how much it the NHI pays for a Whipple and he replied about NT$40,000 (USD1200), minus surgical consumables. After the hospital cuts off a share of the profits, a surgeon will probably be left no more over NT$20K (USD700) for 8-hours of suspense and undivided attention. That money may seem a large amount for some, but a lot of less demanding and risky procedures are definitely better paid.
At the end of the day it boils down to sacrifice. The NHI dictates monetary returns of each and every standardized procedure, but most of the time they don't take into account the process of one. A simple hemorrhoidectomy is equal in monetary terms to a liver resection, for example. But the latter definitely requires more tedious workup and care during surgery. For the same amount of money these doctors are discounting their stress hormones and mental concentration. It may not be fair, but they had done it and earned patients' respect over the years. My guess is they do it anyway for sacrifice's sake. Somebody has to do it. And I deeply respect them for this.

Hanging by a Thread

2011-09-09T23:07:00.004+08:00

I spent my previous two weeks at the SICU caring for one single patient. One. I never got the chance to talk to him, ask him how he felt, or personally wish him happy mid-autumn. Every day I looked at his vital signs, check his labs, listen to his heart and lungs, and dress his wounds. I had never spoken a word to my patient who is "intubated, sedated, in no acute distress."
This is something of a norm in the SICU. Patients usually arrive at their most critical state, requiring decisive actions delivered promptly. This is where things we take for granted become life and death. Too much water, for example, will flood the lungs and suffocate the patient. Every calorie matters to a patient who is critically ill. Even the bed angle affects breathing and intra-abdominal pressure - my patient got his too high and ruptured his surgical wound requiring an extra visit to the OR.
Most patients come and go. The average SICU stay at our hospital is 5.4 days. Mine is approaching his first full calendar month next week. As the clock ticks, his chances of leaving the SICU diminishes. This is a place plagued with superbugs and virulent hospital germs. And what's a better medium for growth than a stationary, defenseless, paralyzed patient on a bed surrounded by bodily fluids?
When we have employed the strongest antibiotics and the strictest regiments, life or death is back to God. An emotional place to be in - talking to families about DNR (do not resuscitate) orders, end of life care, and singing happy birthday to a 61-year old not expected to live through his birthday. Even though most never respond, I talk to my patient, sing to him, and wished him happy mid-autumn while attending to him every day. If he manages to pull through, I hope he can vaguely remember some medical student who swabbed his wounds, electrified his hands for the train-of-four test, and taps his brows every day.

Le Gourmet

2011-08-27T21:20:00.000+08:00

Our new dorm apartment comes with a little kitchen and induction cooker. This is great for me nearly broke from New York. I've often heard cooking your own meal is a fraction of the money you fork out eating out - even in eat out-friendly Taiwan, food is getting pricier and restaurant operators more stingy with gravy and pickles.
I drew up a 2-year home-cooked meal plan. Then I doubted if cooking myself is actually cheaper because you have to buy kitchen utensils. They don't just lie there waiting to be used like back at home. Then comes the ingredients. If you're cooking is winter melon soup, it doesn't just consists of winter melon. There are a million other things - pork ribs, red dates, wolfberries....All of them adds up to an unfriendly amount by the checkout counter.
I decided to test the waters first with a simple green bean and barley. It's a very common dessert in Taiwan costing about 30 NTD per bowl. It's as simple as boiling both ingredients until they're tender - totally no fuss. After I happily went to shower and studied a little, the benign handful of green beans and barley had expanded twenty thousand times to occupy the entire cooking pot. The 1L of water is completely gone, and the concoction resembles a porridge texture. That night and 2 days after, we ate slightly burnt green bean and partially-cooked barley. The dessert managed to convince my roommates they won't eat anything I cook in future, which is just fine by me as I'll have the lion's share.

This is NOT what I ended up with.

Defiant, I tried bitter gourd soup with pork ribs during the weekend. I went to a supermarket for the ingredients to avoid being questioned by nosey market hawkers about my intentions of buying the least popular vegetable. Hiding my face with a newspaper at checkout, I drove home in lightning speed so as not to bump into anyone on the way. We live in a small community, so news spread quickly. Once the green bean and barley failure spreads, everyone will make a ridicule out of my cooking. I definitely won't let it happen, lest the occupants of the apartment wait for me on cooking days with a fire extinguisher.
Choosing a HUGE pot this time, I added plenty of water and made sure my poultry are blanched before putting them into boiling water. This is to prevent surface fat of the game from dissolving too quickly in your soup producing a cloudy, foul aftertaste. Professionally, I cut up the melon, making sure I made a lot of noise so my flatmates heard.
I checked on the pot 3 times every minute, making sure it has enough water and suffusing it with love and care so it will turn out winning a le cordon bleu. Soon the entire apartment was filled with the aroma of red dates and refreshing scent of cooked bitter gourd. I went two floors above and below to trace the smell and it is still there! Great! I'm getting best chef on graduation! No fire extinguishers waiting for me!
I went to another apartment to borrow some salt. Not that I have none, I just wanted to make sure people know I'm cooking, and a great success at doing it. I sprinkled the precious chemical in and scooped up a teaspoon to taste. After all the scents it tasted bland to my disappointment.
Now it's time to consult the parents. I spent an hour listening to Mum and Dad's 50 year experience. You should cook it under low heat, you should double boil it, you should buy a slow-cooker instead. I didn't argue that I'm broke from New York and a slow-cooker will drive me into debt. I took their suggestions into the 2-Year Home Cooking Plan (2YHCP). They also suggested I buy my fresh greens from a local market, since supermarkets tend to process and transport cheap goods from faraway places. The problem is, going to a market means exposing myself to all kinds of ridicule. Oh dear.
After securing a mask and thick-rimmed sunglasses, I wondered into a market today. Surrounded by millions of vegetables which names I don't know, and ten thousand parts of pork and beef, I vainly pretend I know my ingredients by heart.
"How much is the radish?" I asked, trying not to provoke any suspicion.
"What are you using it for?"
"Soup." Sounding cool, like 007 James Bond.
"We have local radish and Japanese radish. This costs 20 per 600gm and the other 25."
In 2 seconds I have to make a decision that will drastically alter my soup. Local or Japanese? Local or Japanese? I guess the more expensive radish will taste better. But then the naturalist inside me kicked in. An imported radish emits more carbon. And Japanese food tastes totally bland. So I'm going for the local.
Then comes the pork section.
"Eerm...I'm cooking soup."
The aunty peeked suspiciously. "What soup?"
"Radish."
"So?"
What does she mean by so? I want something that will give me flavor in my soup. Is she even qualified to sell pork?
Sensing my inexperience amidst my guise, she sneered. "I'll give you the ribs. It has some meat that will taste really nice after you cook it long enough." Then started hacking up some unidentified part of a pig carcass. As I turned to leave, adjusting my sunglasses, I overheard her laughing with her colleagues. Guess they were conjuring images of an exploding kitchen and someone helplessly cooking a radish.
Back home, I Googled and Wikipedia-ed ways to cook radish soup. I managed to secure two leftover carrots from my senior who's spending the following month in Taipei. With pitch precision this time, I measured every cut and angle and dropped everything in with exemplary tenderness. Conceiving a theory that too-frequent lid-opening spoils the taste, I make myself go to the gym to channel the obsession onto dumbbells and treadmills.
Then I realize if I put too little water in the pot. My two other deep sleeper flatmates are asleep. If the pot boils dry and burst into an inferno they'd be roasted alive. I ran home half-expecting to see parched ground surrounded by firefighters. The building is still intact. Thank God.
Uncovering the lid, I was greeted by semi-translucent radishes and brilliant red carrots floating on an appetizing creamy broth. When two of my flatmates came to "tax" me, I knew I regained my status as top chef.

I added some noodles to fill in carbs for dinner.

After slurping the soup till its last drop, enjoying the savory success, I upped 2YHCP to include a Christmas pudding this winter. Who says guys can't cook?

Airway Management

2011-08-22T21:03:00.002+08:00

I'm part of the medical team. Being a medical student in a medical team means you get to try out stuff under the eagle eyes of your superiors, and get blamed when things don't turn out as expected. You're expected to know all of them - endotracheal intubation, arterial lines, central venous catheterization - the moment you wear your white coat. Much in the way a baby bird is pushed from the nest by his mother and suddenly grasps the majesty of flight. The kicker is that my superiors never knew I learned all these "skills" in a 2-hour session spread over 4 weeks.
So during my first week in anesthesiology, everybody expects medical students to magically know how to intubate patients and make them fall asleep with a snap. I'm sorry, sir. The last time I studied anesthesiology was last year - the 2 volumes of Miller's Anesthesiology all crammed into 2 days of 8-hour lectures. It's a miracle I can vaguely recall propofol is the "milk of amnesia" and laughing gas is no longer in trend for anesthesiologists.
Nevertheless, it is always the student's fault - you should have studied before you come, you should have got ample practice, you should do one million other things other than eat and sleep. They never reflect upon themselves the crazy timetables and a gazillion things crammed into 50-minute sessions - back in their time anesthesiology was a full-semester course with coursework and mid-terms; now it's a 16-hour marathon and finals.
Being responsible medical student and part of the medical team, I practiced and played catch up. After countless practice (on a mannequin with broken lips from all the abrasion of the laryngoscope), I grasped the instinctive "feel" of the deepest portion of the throat - the laborious pivoting a mass of soft tissue called tongue northward before exposing the holy vocal cord, like casting the Patronus charm if you just concentrate hard enough.
After a weekend of aimless wondering around my new room and eating tasteless self-cooked meals, I'm all ready to intubate my first patient on Monday. As the nurse handed over the endotracheal tube, casting a if-he-fails-I'm-killing-you glare at my attending, my hands were all cramped from 3 minutes of masking the patient weighing 108kg. Pretending I've been doing this for 20 out of 23 years of my life, I pushed against the forehead in an attempt to extend the patient's neck.
"First step wrong!" My attending barked. As I extended the blade to "isolate" the tongue, making ignorable mistakes along the way, all hell broke loose among the stadium of spectators around me. "Have you seen the vocal cord?" "Don't press too hard against the teeth, you'll break it!" "Now careful! I said CAREFUL!" "Don't touch the tubes with your contaminated hands!" "Remember, first thing to do in an emergency - call for help!"
After what felt like a century navigating the gulp-sized oropharynx, I indicated the opening is in sight. With everyone holding their breath turning purple, I proclaimed "it's in!"
The nurse snatches the stethoscope from my neck and listens suspiciously to every nook and cranny of the patient's lungs. My attending kept watch on the CO2 monitor and bagged the patient while I prayed so hard that I'd hit home run. When the flat yellow line started rising, I knew my tube went to the right place instead of the esophagus. Now it's the nurse's turn to see if I went too deep and only intubate one, instead of both lungs.
"Equal and clear," she said, throwing a if-you-screw-this-up-I'm-killing-you glance at me.

As my attending praised me for my successful first intubation, I pretended to be cool and took dozens of ID stickers to gloat on my patient care list. I filled the columns with headlines such as "first endotracheal intubation - a wild success!" Then strolling up and down the 20 ORs waiting for my next victim.

Holding Your Baby

2011-08-13T11:11:00.002+08:00

Time is vital during a Cesarean section. The clock counting down towards delivery when the newborn's shrill cry will pierce the tense atmosphere in the OR. Anything in between the baby, still not ready to come out, and the outside world will prolong this latent time and have detrimental effects on the baby's future.
I scrubbed in and stood opposite to my Attending. With swift and precise moves of 20 years he attached the vacuum extractor to the newborn's head as I connected the rubber tubing to the edge of the cusp. In 3 seconds the baby is out of maternal warmth. The shoulder, however, stubbornly stuck to the smallish incision - the skill ruler of an Obstetrician nowadays. As the baby hesitated to take in his first breath, we struggled with the shoulders, pulling in every direction until finally it dislodged and slipped off the tense incision.
I held the minute-old male newborn in my left arm. His face shrewd, not happy being awakened prematurely from the comforts of the womb. As his cries became more majestic in quality his body of lifeless grey turned pink with vigor. Apgar scoring - appearance, pulse, grimace, activity, and respiration. I would give him a 8 for his first minute and possibly 9 or 10 for his fifth. He's already off to a good start.
As I admired the beautiful newborn and generously wished him good luck for the future, a hive of activity is happening a few inches away - the umbilical cord is being clamped and cut, the umbilical vein punctured and blood drawn, the uterus exposed to be sutured, and the baby room nurse now takes the baby over from my hands. Baby boy is starting a journey of his own after 38 weeks of maternal affection and over-the-womb Mozart.
After he is cleaned, fingerprints taken, and dressed, baby boy will see Mum for the very first time. Experienced mothers will start talking to them, calling names and stroking their cheeks. This joyous occasion is short-lived, however. Matron nurse will take him back to the baby room for the next 3 days. Where he will only see Mum during mealtimes.
Then the OR will return to its pre-newborn stillness with a PGY suturing the incisions monitored by the Attending. Mum may eventually fall into a contented slumber, while other nurses record the baby's weight, height, Apgar scores, and gender. Only occasionally when we remember to congratulate the mother before leaving for another surgery next door.
But the baby's face and cries I can't stop recalling even into the night. The youngest baby boy in Taiwan for 2 minutes, weighing 3450gm, so kicking with life - it was during these moments that you recall God's wonder and glory. That we might live in Mars or fly to another universe, yet we are still primitively human when it comes to the basic reproduction. Nothing has very much changed during the previous 100 years. And nothing revolutionary will possibly emerge. We're still humble beings of God.

New York New York: Etched in My Mind

2011-08-05T19:47:00.001+08:00

I'm back in Taipei and had resumed my clerkship for 5 days now. Gradually tuning my body clock 12 hours ahead and getting used to rice, tea, and cabbage. Any conversation with me usually begins and ends with New York, its people, the huge meals, and exciting urban life. As life on this side goes back on track, so does the one on the other. There are certain qualities and images that I will remember about New York, and also a few people I'd like to thank for this trip.
New York taught me how to slow things down and do it properly. Strange enough for a bustling metropolis and capital of the world, it's in New York that I learned listening to others. Sensing what they want from you, convey what you can do, and carry on. Doing things fast doesn't mean doing it right, and this is what I must learn especially when work starts to rain in future.

Relax. Listen to others.

Take time off for solitude and reflection. We don't need to be around people all day.

Don't hesitate doing what's right because others are judging you.

In other words, follow your heart and just have fun when you have the opportunity.

Life's too short to think twice about something, sometimes.

And slow down to really look at something or someone.

We're very grateful the past month for Prof. and Mrs. Ku. Prof. Ku was my Dad's teacher back in NTNU, I got to know him just before he retires back to his family in New York. Mrs. Ku showered us with exemplary Taiwanese-American hospitality, driving us to dinners, across Brooklyn Bridge, and even to the airport. Her bubbly character made us feel at home the second day in New York, and subsequently consistently pestered us with phone calls for trips and fancy restaurants. July in New York would otherwise be dull without her presence.

This is Ginger, daughter of Uncle George, CEO of Tzu Chi New York. She works at the DaAi TV office at where we lived, hosts USA 360 degrees every month (a pre-recorded English program on DaAi TV), and our housekeeper during the day. I'm keeping this photo at the deepest crevice of my computer to blackmail her when she becomes famous, which will be really soon.

With jet-lag waking us at 3am Taipei time and shutting us down 7pm, I can't help reliving the past month in between sleep and consciousness. As much as I advocate change and voice for it, I can't help believing it'll last up to the end of the year. Nevertheless, I will attempt to persevere with the lessons I learned 8000 miles away, try to stay true to myself in face of stereotypy.

New York New York: Sim's Little Architecture Adventure

2011-08-02T07:23:00.000+08:00

I imagine New York would be a happy place for architecture students - the gothic baroqueness of Chrysler Building to the Greek-and-Roman inspired Rockefeller Center. For people with nil architecture knowledge like me, we just gawk in amazement and take photographs of everything. However, Manhattan being a more crowded place than most other parts of the world, a lot of these intricate designs or decorations won't fit into a camera lens on street level. What I got were mainly cliché at its extreme and some accidental stumble in an unlikely neighborhood, no intermediates in between.
Same thing with the arts, I invite you to sample New York's architecture by eyes and not through a camera lens. Starting to appreciate lines, colors, and space now that I'm stuck in Taipei's thousand hues of grey and grimy facade.

My tour starts at Wall Street, where the subway station is noticeably less gritty compared to others.

The intersection between Broadway and Wall Street is where the nation's most expensive real estate lies, currently occupied by Bank of New York. The "wall" for Wall Street originates from the Dutch, which built wooden barriers along this southerly end to defend New Amsterdam back then. Little do they know the humble wooden walls would translate to the most prestigious financial center less than a century later.

Touristy me.

New York Stock Exchange (NYSE), where as many dreams were made for as many broken. The coincidental stars and stripes is, to me, embodied the American dream in this place of unimaginable wealth and overnight bankruptcy. Interestingly, when I Googled NYSE, "stealing democracy, one billion dollars at a time" mindlessly popped up...

Federal Hall is just opposite NYSE with George Washington guarding the main entrance. Bailouts anyone?

Look for your own skyscraper shot along the way

Continue along Broadway and you'll be greeted by the new building at WTC. Due completion by early September 2011, the temporary memorial site and St. Paul's Chapel is worth a visit, just to pay respect to the 2977 souls who innocently passed and the day that changed everything.

A stone's throw away at City Hall, an exhibition of contemporary structure blends in surrounding classicism, including...

Tweed Courthouse, funded by the corrupt "Boss" Tweed constructed between 1861-72.

And Municipal Building, where Mayor Bloomberg works.

Just east of City Hall, the 19th century Brooklyn Bridge, once the longest suspension bridge in the world at nearly 2km, is the hallmark of optimism and hope, inspiring Kerouac, Marianne Moore and Bloom, which immortalizes the bridge with its explosive opening of "To Brooklyn Bridge":

"O harp and altar, of the fury fused,
(How could mere toil align thy choiring strings!)
Terrific threshold of the prophet's pledge,
Prayer of pariah, and the lover's cry,--
Again the traffic lights that skim thy swift
Unfractioned idiom, immaculate sigh of stars,
Beading thy path--condense eternity:
And we have seen night lifted in thine arms."

The United States Court House and a very important engraved message - the true administration of justice is the firmest pillar of good government.

City Council and State of New York along the way to...

Chinatown - where newly-arrived Chinese immigrants lived along the Italians at Little Italy, just a few blocks away.

SoHo - once the place to be for free and artsy souls. Now lined with high-end galleries and retail.

NYU has no campus. Or literally, a collection of inconsistent building blocks all marked by the violet torch.

My other favorite aside Strand Books, Shakespeare & Co. Needless to say they have a vast collection of plays by Mr. Shakes, and second-hand books at bargain prices too!

My host kept on telling me how NYU is not a university in truth but an urban campus. I didn't quite take it to heart until she showed me around Columbia.

Occupying the northwest corner of Manhattan, Columbia indeed has a breathtaking campus and Alma Mater sitting in front of her library.

Back to our final stops of the architecture tour. Radio City Music Hall is one of the many gems of the Rockefeller family that had become synonymous with performing arts in the US and around the world.

Rockefeller Center. "If you come during Christmas, there will be a HUGE Christmas tree at the center of the square and Josh Groban singing underneath it," my host said. There and then I decided to return in Christmas even if I fail medical school and had to smuggle myself in the cargo section of the airplane.

Finally, if you still have the energy to walk up north, Bethesda Fountain in Central Park is celebrated in "Angles in America" as a symbol of eternal health. Regardless, it is the first public art project awarded to a lady, and a true marvel of a sculpture with the serene face and wings just about to take flight.

New York New York: Adolescent Medicine

2011-07-30T09:10:00.004+08:00

I'm telling you something very personal - I had a horrible time as an adolescent. What typical adolescents do I missed all, except the endless tuition classes, science projects, and striving for As in school. I was a total alien during sports, hanging out at the cool spots, and relationships. Somehow when I saw Adolescent Medicine is being offered, I wanted in. Images of a friendly doctor talking to the vain teenager about issues too embarrassed for parents and too personal for friends conjured in my mind. Somehow I wished I had one of those doctors back then.
I'm well pass adolescence now. But my blank experience didn't help when it comes to talking to American adolescence who seem to have everything in the world.
Dr. Chang and Dr. Ipp are like twin sisters managing the adolescent medicine program at NewYork-Presbyterian. They were chatty, fun, and just the sort of person I would pour my secrets to if I were an adolescent. Dr. Chang also manages a special service program on Monday afternoons which sees children from problematic families. I am humbled by the amount of patience and confidentiality she gave her patients, and the generosity she showed me by showering me with details and reading materials.

As for American adolescents, my experience with them are far away from Hollywood stereotypes of arrogance or self-bloated possessive personality. Many of them are even shy and, like Asian teenagers, blush and turn wood when we talked about sex or illicit drugs.
Teenagers here enjoy a lot of confidentiality - physicians are not allowed to disclose information even to their parents without permission provided under special circumstances. The difference in culture, attitude towards casual encounters and school are all new to me. While I read up night after night on contraception and minor's rights, I went to an eating disorder ward at Westchester, New York, and was surprised by how open-minded families are toward their child with psychiatric disease - Mum and Dad were readily talking about how the perfectionist daughter grew obsessive with calories and their future plans and confidence that everything would turn out fine. It tears me to see ill adolescents, but the family and hospital staff support here is overwhelming.
Both Dr. Ipp and Dr. Chang are very accommodating towards medical students. Dr. Chang never failed to praise anyone for their littlest effort, with "exactly!" and "excellent!" all the time; Dr. Ipp thanked us after each session and always provided feedback and motherly advice. Both to me were like older sisters in medicine which set the benchmark of how I will treat my students in future (that is, if I manage to graduate).
I'm at the end of my clerkship at NewYork-Presbyterian Hospital. The one month seemed as surreal as first stepping on American soil. Hospital environment is so familiar yet different - the morning reports, noon conference, friendly residents and medical students, attendings I shall all miss dearly. Most of all, I shall miss the multicultural, often unpredictable, but always interesting patients. Spending more time with patients and being thorough and dedicated toward their care is my goal after this elective. We might not have the American environment for training physicians, but care and attitude towards patients we can achieve.

New York New York: Arts and Parks

2011-07-28T11:43:00.006+08:00

As with all major cities in the Anglosphere, New York has many great museums offering a wide palate of art tastes as well as patches of green from as small as the neighborhood playground to Central Park. Having the entire month at my disposal I had my fair share of crowding for pay-as-you-wish museum entrances and lounging in the park. One thing I would really love to do is to picnic at the park - books, shade, and home-cooked casseroles. But somehow the significant half never showed up and I'm too cowardly to picnic alone, so the dream still remains a dream.

Central Park is smack in the middle of Manhattan, an oasis of greenery, natural landscape, and water amidst the hustle and bustle of sprawling skyscrapers around it. Squirrels hop around while tourists and Manhattanites seek refuge from the big apple outside.

Central Park Zoo is smallish and charges $12 for general admissions. However, it has sea lions and penguins, guaranteed to drive the little ones crazy.

Shooting a movie in Central Park. Someday if you see me wondering aimlessly at the background of some Hollywood movie, you know it's shot at Central Park on summer of 2011.

Flushing Meadows Corona Park is one subway station away from where we live. It has an awesome steel globe and was host to the 39/40 and 64/65 World Fair (a.k.a World Expo).

Hudson River Park at southwestern Manhattan, as mentioned previously, is sunny and very gay.

Washington Square has a faux Arc d'Triumph. And being just beside NYU, a very chic place to hang out.

Central atrium of Museum of Modern Arts (MoMa). The theme for summer is urban living, portrayed by little squares of individual "windows" forming together a collage of colorful yet harmonious landscape.

MoMA offers free Friday evenings. Definitely grab anything free in capitalist America. For me, finding inner peace is easier with museums than churches or temples. Art is more than colors and brush strokes, it is a form of expression - telling the story of an instant state of mind to an entire generation using a medium so diverse from photography to calligraphy.

The con of a free-for-all is the amount of people. I'm fine with people if they behave properly and have some simple courtesy (such as not walking in front of you when you're viewing an art piece). However, most of (us) don't. And they like taking pictures of famous pictures, which is understandable. Since showing off is every human's nature - oh, I went to MoMA and saw Starry Night. But you know what? Most of the time the picture just get stashed into your Facebook album and forgotten 2 months later. So please don't hog the space around Starry Night and let others take a good look at it. You can get your photograph at the museum store for $1. And they usually do a better job than your DSLR.

I'm really curious about the psychology behind photographing the famous works. We all know our camera has flaws, yet we never stop snapping them, knowing very well the colors and composition will be way off compared to the original. Is it our nature to preserve beauty? Our desire to own beauty? If we can't have the original, why not have a photograph of it? Shamefully I did that too during my trip to France - aimlessly wasting my pixel space taking inferior pictures of art I don't even know.

What I later learned is that art exists in your heart and not your eyes. Art is what you feel and how you react when your senses are bombarded by colors, textures, light, emotions - not simply what you see and interpret from a photograph. You can look at the greatest piece of art and not feel a thing - then that is not art to you. Similarly, you can stare at the most common objects and get a torrent of emotions.

If you get what I said, repeat after me: I will not aimlessly take photographs of art in museums anymore, because it's stupid, useless, and impede other's opportunity of appreciating them.

Metropolitan Museum of Arts (The Met) admits everyone by donation at any time. That means you could go in by just donating $1 even though the suggested donation is $12 for students. Extended opening hours on Fridays and Saturdays make it a nice place to spend the entire day if you're not tired of walking.

The problem with mega museums, such as The Met or the Louvre, is that their collection is so vast you can never ever see them all. To avoid feeling unsatisfied about not seeing as much as you planned, lower your expectations - choose only one or two "specialties" you wanted to see, say Nineteenth century Europe or Egyptian arts. When you arrive, don't get distracted and concentrate on your quest. If you're still feeling up to it after you're done, explore the other sections. If you wonder aimlessly like you did photographing canvases in MoMA, you get tired quickly, saw what you don't really like, and go home leaving having no impression of any specific pieces.

Since the admission is only $1, you can come back anytime again and again. That's the cool thing about The Met.

Smaller museums are nice if you, like me, can't get rid of the "must see everything" mindset. Guggenheim Museum is on my top list for its spiral architecture, pedestrian-friendly galleries, and vast exhibition spaces. Admission is by donation every Saturday from 5.45pm to closing.

Neue Galerie for German and Austrian Art gives free admission first Friday of every month from 6pm onwards. The collection is smallish but the interiors are authentically Austrian-Hungary and for psychology students, there's a 19th century Freud chair you can laze on all day.

Frick's Collection (or Museum) is actually the old residence of Henry Clay Frick, industrialist, financier, and art patron. Though much hated among his industrial colleagues, he had an enviable collection of furniture, porcelain, statues, and paintings. Many Johannes Vermeer and Rembrandt are housed here in rooms untouched since early 1900's. Admission is by donation every Sunday from 11am to 1pm, and includes a free audio guide. If you have all day, stay for the free sketch trial from 1 to 4pm, where you might just unearth the next Picasso in you.

The Frick's Garden

Much as we believe arts and parks are two vital components of any global city, Asian cities are still lagging behind. I believe art is as important as religion - in fact art originated as a medium of expression and praise for religion - that must be nurtured, promoted, and freely available. Though museum admissions (during normal hours) costs around a meal for one, more so unaffordable after the conversion, free or admission by donation hours are certainly the right way to promote social awareness and art sensitivity. There is art cells in each and every one of us. Discovering and unearthing it will only do good in the sense of better appreciation, expression and communication of emotions and feelings. Art is definitely not for art school students only, and especially for heavily scientific people like myself, art is a way of doing things mindlessly - taking an uncalculated step against all my logic and reasoning.

Boston Weekend Part 2

2011-07-24T22:29:00.002+08:00

Boston is a compact little city where you can navigate easily on foot. For time-constrained travelers you definitely don't want to miss the freedom trail, where you can trace America's revolutionary birth and cover most of Boston's key Colonial sites.

The trail starts at Boston Common, America's oldest public park. Directly across it is State House with its golden dome, designed by Charles Bulfinch. The State House sits directly on John Hancock's previous residence.

And this is the old man's grave at Granary Burying Ground. Famed for his huge signature, looks like he likes his tombstone large too.

Next we proceed to King's Chapel, the first Church of England in Boston.

On Washington Street your historical landmarks are surrounded by skyscrapers of the mega-banks from the surrounding Financial District and government offices from Government Center.

Old South Meeting House is the cradle of the American Revolution. Here the revolutionists debated on the English parliament's decision of taxing the American colonies even though they are not represented in London; the Boston Tea Party, debates about the Boston Massacre and after independence, the issues surrounding the American Civil War were debated within the reverent halls.

Margaret Sanger, a public health nurse, was the foremother of birth control and contraception, two issues unthinkable lest a taboo back in the 18th century. As a protest against the oppression against women, she covered her mouth with a piece of fabric.

Interesting enough, a stone's throw down the road, Old State House is where the Brits ruled with orders from King George III. It housed Boston's earliest senate and Governor Hutchinson's office. During the turbulent years before the revolution, the addition of a visitor's pew to witness every senate meeting propelled Bostonians and eventually America to their fight for independence.

Faneuil Hall is a public market since Colonial times. Today it serves as a meal-stop for people walking the freedom trail. Cheap pizzas and seafood.

Lonely Planet especially recommended Durgin-Park for its Colonial fare. So much for Yankee pot roast, the pizza is still occupying the belly space. I had an Indian baked pudding and it tasted...colonial.

After lunch it's all parks and public spaces. This is a simple memorial dedicated to military officers who lost their lives in the war at Afghanistan and Iran.

I found out much later that the freedom trail is marked by red indicating direction. This is cross a bridge to USS Constitution. As you can see the sky was completely naked and we were basking under solar bursts. I later regretted my choice to cross the Charles River because I'm not a ship person and the ship was nothing very interesting either.

USS Constitution, nicknamed Old Ironsides because British cannonballs bounced off harmlessly off its sides during a battle at sea. Needless to say the Majesty's ship sank in no time (that's why they are so proud of it).

We later took a 4pm bus back to New York. The trip to Boston a weekend memory by the time we reached home at Flushing at 10. However, we really missed the slower pace and cleaner subways of Boston. The public spaces, red-brick buildings and historical artifacts that taught us an important (albeit expensive) chapter on American history. As much as I doubt my history getting A1 in SPM, I don't think Malaysian students learn enough, especially on the anglosphere and Middle Kingdom. Hey Ministry of Education, the world doesn't revolve around Prophet Muhammad and his dozen of wives...

Boston Weekend Part 1

2011-07-23T11:48:00.000+08:00

Boston was where the American independence and identity was built. The Boston Massacre and Boston Tea Party which subsequently led the American Revolution and reading of the Declaration of Independence 250 years ago. This is the place to learn your share American history, that is, if you didn't back in high school (we wasted 10 chapters on Islamic history instead).
To save time, Jun Cheng and I booked a Saturday morning JetBlue flight from JFK to Boston. It was a daring move back then as we didn't even know where we will be staying or how long the commune to JFK would be. However, since the flight cut down traveling time by a considerable 3 hours, giving us a comfortable morning at Boston, and it was only marginally more expensive than a bus ticket, we went for it.
Saturday morning, we woke up at 5am for the 7.30 flight. Thinking we had ample time and persistently naive to the fact that JFK is the busiest North American gateway, we were shocked to discover the E subway was 30 minutes late. Then a huge, spiraling queue greeted us on our mad dash into Terminal 5. Needless to say we missed the 7.30. However, with JetBlue being a big player in both JFK and Boston, we were rebooked (with grimace) on the 9am flight. I only realize how lucky we were on that unlucky morning - we were given a decent seat on the next available flight, which was already very full, with no extra costs. This being United States of America, airline passengers have no rights whatsoever. So we boarded the plane hailing Mary and chanting Allah. We landed at Boston Logan Int'l Airport after a free drink, some cashew nuts, watching CNN and laughing ourselves silly with the crew's tongue-in-cheek announcement.

JetBlue is quickly becoming my favorite airline.

We went straight to Cambridge, home to Harvard and MIT across the Charles River. We narrowly missed the 11.15 Harvard tour organized by their student union, so we had brunch and did all the touristy stuff while waiting for the 2pm tour.

Harvard territory. This is the Graduate School of Arts.

The Harvard Co-op is where you get your Harvard sweatshirts and T-shirts for show-off. They also sell a large collection of literati publications and bestselling titles.

Our Harvard tour guide is a senior-year anthropology student from Canada. By the time she toured us she is pink and hoarse from all the talking and baking under a cloudless sky. So you see, a Harvard education doesn't guarantee easy employment at all.

When this library was built, the donor specified not a single brick could be moved after completion of construction. This was back in the era of Titanic and steamship companies. Since then the book collection expanded beyond these walls and where do they go? 6 floors below and 1 acre across. So we are essentially trampling on the library collection up here. The library is so hard to navigate you can get a free map inside. I wonder if those brainy Harvard students actually get lost in there and starve to death in the labyrinth of books?

Hall of Science, an oddball architecture among the brick reds of Harvard property.

Harvard Hall, once a library housing John Harvard's precious collection of books. Finally burned down with 1 remaining stolen copy when a student forgot to extinguish the candles. So you see, Harvard students aren't that smart after all...

This is not a church but a common prayer area and dining hall for freshmen. Stained glass windows designed and made by Tiffany & Co.

Statue of John Harvard, or statue of three errors. I'll let you guys wikipedia to find out yourself. Anyway, despite the shameful errors, he is the third most photographed statue after Lady Liberty and Mr. Lincoln.

The one-hour tour is essentially a brief tour of Harvard Yard, or the main residential area. Harvard has still many campuses around Boston and cross country. I really admire the huge naturally-shaded green public spaces they have at American universities. Why can't we have something similar instead of having to stay at the indoor library? Even more woeful, ours are closed Sunday mornings even though we have nothing to do with Jesus Christ or Mother Mary.

Coming up: Boston Part 2 - freedom trail, road to independence.

New York New York: Pediatric Hematology/Oncology

2011-07-21T10:24:00.002+08:00

It seems only proper I talk about my electives here just in case people get the wrong impression I'm here just all play and no work. I applied to 2 pediatric rotations in New York-Presbyterian Hospital, teaching university of Cornell and Columbia University - my first two weeks with pediatric hematology/oncology and second two with adolescent medicine. Don't ask me why these three - they are a combination of self-interest, unavailability of similar courses at where I trained, and location.

New York-Presbyterian Hospital (NYP) is one of the proud tri-instutitions, situated at Upper East Side, that forms the glamor of Weill Cornell Medical College, the other two being Memorial Sloan-Kettering Cancer Center (MSKCC) and Hospital for Special Surgery (HSS). Residents and fellows essentially share these three hospitals - you can see all their various name tags and badges showing the different typography and design around their necks.

This is what greets you when you enter 68th Street on the 6 line. If you think subway stations in Kuala Lumpur are filthy, this might redefine it.

Upper East Side or UES is a very affluent neighborhood. We have St. Patrick's Cathedral, Sotheby's, Frick's Museum, American Art Society, and Rockefeller University all within walking distance. All 3 hospitals occupy a large space from 72nd to 68th - 4 blocks essentially, overlooking Roosevelt Island. You'll know you're in hospital territory when you see people wearing blue or green scrubs walking around seeking food or coffee.

Being in an affluent neighborhood and in New York has its perks. NYP is one of very few hospitals in New York in the black, one of the top ten hospitals in the US, and one of the best children's hospital in the New York area. Next door MSKCC is famed for its cancer and transplant techniques, which unfortunately I have little interest in. HSS is known for its orthopedics.

As one walks through 68th street you'll first be greeted by MSKCC in its red brick facade. My Romanian colleague says it looked like a factory. I personally think it reminds me of Nazi Germany. MSKCC's interesting history dates back to Nixon's War on Cancer and our naive believes in the 70's that cancer, like common cold, could be "cured". I recommend reading Siddhartha Mukherjee's The Emperor of All Maladies: A Biography of Cancer.

Further eastward NYP greets you with its slogan "Amazing things are happening here". Unlike Taiwan, where hospital lobbies resemble a luxurious Shangri-la, it's a humble yet functional common space where thousands pass through each day under the names and portraits of affluent donors. Clinic and office spaces overlap considerably, ancient elevators zip up and down 30 floors, coffee pots and laundry, patient and clinicians, Rolls Royce and wheelchair all come and go.

My first rotation here working under Dr. Bussel

Given the multicultural background and global patients they receive, lingual communication becomes an important issue. The hospital provides free interpreter services to patients who cannot speak English. During my stay there I acted as a Chinese interpreter (with some medical knowledge), and had patients speaking Bengali, Spanish, Hebrew, and Polish.

Some may imagine hematology/oncology as a sad place with dying patients and despairing families. The inpatient might be so but definitely not the outpatients. Some children with chronic hematologic diseases are so well-managed they are a picture of perfect health. The only difference is they have to come every once in a while for some infusion or medications - spending as long as 6 hours in the solarium watching TV and eating free ice creams every Mondays, Wednesdays and Fridays.

The exam and interview rooms are equipped with basic sphygmomanometer, otoscope and ophthalmoscope, a (very slow) computer for the charts, and lots of room for family to walk about and talk about almost anything.

Medical care costs a bomb in the US, but it is also of very good quality. Doctors see an average of less than 7 patients each session (morning or afternoon), and so they get to spend up to 30 minutes with every patient. Besides addressing their medical issues, some clinics are simultaneously attended by social workers, physical therapists, and dietitians - integrating wholesome care into a single session.

Dr. Mitchell

I witness the integrated clinics of hemophiliacs with Dr. Mitchell. It was an eye-opening experience attending a pre-clinic round - where everyone is briefed on the 4 patients coming in tomorrow, the nurse-social worker-fellow-physical therapist-attending sequence interviewing patients, and a debriefing round at the end of the day. Essentially, the patient gets an update about his medical condition, a social worker addressing his everyday issues, a therapist to help him cope with pain or disability, and finally the attending physician summing it up for him and helping in making decisions. For the medical team, we get a complete history and ernest communication with all the meetings, and needless to say, a better understanding of the patient's non-medical conditions - which plays an important role in adherence to therapy and drug compliance.
This week I'm starting adolescent medicine, working with teens with obesity, pregnancy, eating disorders, and HIV/AIDS. Similarly it overturned my previous assumption that teenagers are uncommunicable, reserved, and difficult; they turned out to be bubbly, chatty, and open-minded. We'll talk more about that next time.

New York New York: Out of the Cliché

2011-07-15T11:11:00.003+08:00

Let's do something more in-depth for the weekend before I head to Boston. I haven't found a suitable adjective for New York yet, and so much for its cultural diversity and mixed bag of everything, this post would be a little of everything too.

To start, St. Paul's Chapel is Manhattan's oldest chapel to date. Most remembered for being the humble structure that stood steadily beside the World Trade Centers when they crumbled on Sept. 11, 2001. It became an impromptu shelter for firefighters, policemen and volunteers following immediate rescue and months of cleaning up. The chapel that serves also as an exhibition hall displays heart-wrenching memorabilia following the attacks.

The grills surrounding the collapsed WTC became an instant message wall. At first anxious families posted photos of the missing. Then as hope diminishes, visitors from around the world added their own something just to remind America and the world that they care. Hats, teddy bears, flags, message cards, name tags...Until there was no more space to add they have to replace the grills.

The pews, heavily scratched by firefighters' boots when they took a nap with boots on (they get called back to scene very frequently), were preserved. Inside and out, supporters filled the pews with words of encouragement. Masseurs provided free massage services, the church provided spiritual and moral support, and millions of New Yorkers first took part in volunteering on that very day.

The Bell of Hope was a gift from city of London after the attacks. It symbolizes hope after terror and that good will always prevail. Since its cast, it has rung for similar victims of London, Madrid, Moscow, Mumbai, Virginia Tech, and all 9/11 anniversaries. "Cast in Adversity" it says, nay to terror and fear.

So this year being the 10th anniversary of the attacks, New York is completely dressed up for the future. A new mass transit station, park, and memorial will replace the previous towers. "Tomorrow" is the theme here.

RIP to victims of the 9/11 attacks.

Winding further south will bring you to Ellis Island and Liberty Island. Lady Liberty stands on the latter, holding up a torch and a tabula ansata. She greets almost all immigrants from sea during the great influx period, a symbol of new life and endless possibilities. This is all too cliche. We'll do Ellis Island, where the immigrants, all excited and hoarse from shouting "America!" gets processed, interrogated, held up, inspected, and hopefully accepted into the land of the free.

Immigration museum on Ellis Island. This is built back when there was no visa system and passports were scroll-sized. You travel 14 days in a coffin-sized ship compartment across the Atlantic. Numb, cramped, tired, and seasick from your journey, your baggage gets tossed upon arrival into the lobby, you're told to leave them, get undressed, screened for trachoma, and asked a thousand questions.

The Hall of Registries, where doctors flip you upside down and interrogators asked about polygamy, communism, work, and relatives.

I see our park ranger bears some resemblance to the immigration officers back then.

And just an idea of how many immigrant arrivals in one year, NY processed 700,000+ in 1903 alone. That's almost 2,000 people per day, including Saturdays, Sundays, New Year and Christmas (I'm sorry I ruined the picture). San Francisco (where most Asians arrive), is pale in comparison.

Next stop: back to Manhattan, this Barnes & Noble and its 1881 Queen Anne-building is a charming bookstore at Union Square. That's where the purple NYU students hang out. It's both studious and fun inside - people reading, people sketching people reading, people having a drink looking at people sketching people reading...

So this is Union Square - chess, debates about Wikileaks, planned parenthood, salsa classes, and topless picnics all in one place.

Hell's Kitchen, according to my local guide, is the gayest area in town now. Replacing Chelsea as the rent goes up. The flea market is just in front, but this lady(?)'s shorts caught my attention.

After Hell's Kitchen we can head west to Hudson River Park for the gorgeous sunset

And to appreciate I.M. Pei's architectural works overlooking Chelsea Piers just before dusk

I'm running out of vocabulary and I can't tell you how bipolar I am while composing this one. I cried writing St. Paul's chapel, laughed myself silly at Union Square, and admire the 19th century adventure of immigration to a brave new world. This is New York, my friend. And I'm going to need my bipolar medications soon.

New York New York: Bagels and Coffee

2011-07-13T10:15:00.000+08:00

As Lonely Planet wrote, what's the fuss about bagels? It's just bread with a hole in the middle, right? I had mine back in Taiwan and thought it overpriced and disappointing. It is not until you sink your teeth into a genuine New York bagel that you get hooked to its crusty surface and chewy insides.

A genuine bagel (genuine: NOT the 7-11 types with damp squashy dough and unidentifiable fillings in it, or the overpriced store in front of National Taiwan University which made bagels like sponge cake) is made of just flour, water and salt. It is often still rolled by hand, boiled, then baked. Hence the crisp outside and densely chewy insides. They can be sliced in half, then spread with cream cheese or butter and occasionally topped with lox (brine-cured salmon). A well-done bagel should have a smooth, glistening, crispy outer skin with a resistantly compact and springy inside dough. It comes in a variety of flavors, and just so you know, sesame seed was the one selected to go to the Space Station.
On a sleepy morning, a bagel saturated with cream cheese gently wakes up the palate. Not as jaw-wrestling as a baguette or soggy as loaves (in Asia, generally), a well-baked bagel is somewhere in between. First the cheese melts in your mouth, then the dough (and whatever flavor of it) wafts through the nostrils, before you chew it to your heart's content, your stomach is yearning for a fresh new bite.
Coupled with hot coffee (+ 1 teaspoon sugar), that's my American breakfast at work.
I usually get mine free at morning reports - a conference of residents and medical students discussing basic clinical topics. However, being the exam season lately, I can have them at $1 (one-dAller) from the street food vendor or $1.19 + tax from the lobby bakery. Absolutely can't live without it. I'm stocking them up to bring back end of this month!

New York New York: One Day in Sentences

2011-07-11T10:41:00.002+08:00

Subway schedule change. Took the wrong direction. Swear. Empty beer bottles on train. Totally filthy. 86th Street. Guggenheim Museum. Dots and lines on white canvas. Picasso, Gauguin, Cezanne. No staircase, I like it! Neue Galerie for Austrian and German Arts. No water bottles, sir. But I just want to go to the cafe (for the to-die-for pastries, according to Lonely Planet). Throw bottle away, went in, saw line to be seated. Came out.
Took the M86 crossing Central Park. Subway to American Museum of Natural History. Very rude African American ticketing lady. Had to crane my neck to see a show. Birth of A Star, narrated by Whoopi Goldberg (is that why it's so expensive?). Meteorites, tectonic plates, dinosaur eggs (wonder how many people we can feed with a dinosaur egg omelette). Touristy museum stalls. Made in China. Overpriced food court. Artificial coloring and sugar. The Big Bang, narrated by Liam Neeson. If my parents brought me here when I was in Primary School I'd get a Nobel Prize now.
Subway to 42nd Street. Hell's Kitchen Flea Market. Dubbed the most comprehensive flea market in Manhattan. Baking under the merciless sun. Old telephones, (stolen?) Tiffany rings, $10 Levi jeans, Cultural Revolution posters, old Campbell soup advertisements. Found a Welch Allyn ophthalmoscope! Salesgirl obviously didn't know its value: costs NT$20000/RM2000 brand new. Chewed her off at $5. Not sure it's working. Will try out back home. $5 for an ophthalmoscope! My heart just flew across Brooklyn Bridge. Could not contain my joy. Salesgirl senses something suspicious. Leaves quickly.
Walk southwards along Hudson River Park. Capt. Sully ditched his aeroplane here after hitting geese in both engines. Gay couples. Topless gay couples. Gay couples with babies. Soon we will dominate the straight world!
Bus across to Union Square. NYU Territory. Very crowded Sunday evening. Strand Bookstore has 18 miles of used and new books. More like a graveyard of out-of-print and used books. Very interesting to unearth these treasures and pay just a fraction of their original value. I could spend all day in here. Couldn't find the book I wanted though. Picked up an out-of-print Becoming A Man by Paul Monette. I spent too much money today. Just across the street Barnes & Noble flagship store have 5 floors of new books housed in a Queen Anne style building dated back to 1881. I could stay here all day. Picked up another For All the Tea in China by Sarah Rose. I'm defaulting mortgage next month.
New York - everything you can think of between the two rivers. Only if you have all the cash. Nevertheless, it is still the place of excitement and expectations. Where everything starts afresh and anything is possible. To quote:

New York New York: A Touristy Weekend

2011-07-07T07:13:00.000+08:00

I'm letting the pictures do the talking this time.

Besides San Francisco

2011-07-03T22:15:00.001+08:00

This is SK's university, San Jose State.

Downtown San Jose in typical Californian weather. I would later appreciate the wide sidewalks and open spaces when I arrived in crowded Manhattan.

Thanks to Eva and Irene, crashed at their place for 3 days and learned a lot about American college life.

Palo Alto is home to Stanford University and Facebook.

Walked all the way to Stanford near dusk. Love the shadows cast by the westward sun.

The oval at Stanford University

The other day we went to Mountain View for Taiwanese fare, quite authentic I'd say but the noodles were generic.

Next up: New York!

San Francisco, California

2011-07-01T21:26:00.000+08:00

I told Soon Khen I wanted to see the San Francisco Gay Pride which was held on the day after my arrival. After my flight was delayed, I was not keen on going anymore fearing for jet-lag. However, we persisted and I found myself in crowds of very friendly and showy people 2 hours later. It was an eye-opening experience to us we were so immersed I found I only had 2 rather boring pictures of the pride that's not worthy of show.

Later we trailed up Chinatown SF, the oldest in North America

I hardly experience any culture shock in the US. Firstly thanks to all the Asian and Indian faces I see everywhere, and secondly thanks to Hollywood movies that sculptured US scenes and cultures so well in our heads even before I step foot on America. The different Chinese dialects they speak in Chinatown is very authentic you could confuse being in Taiwan, Hong Kong or even Malaysia.

This is a very prideful San Franciscan seagull on a WWII submarine, at Pier 39

Gorgeous people and weather defines the west coast

For dinner. I'd say Penang cuisine is slowly evolving into cult status. We have "Penang" in midtown Manhattan too.

On another less sunny day I visited SF again, this time alone. I wanted to ride across the Golden Gate Bridge initially. Acknowledging the cliche when I got the looks from Soon Khen and friends, I wanted to do it anyway because that's what tourists do. We just have to show off after the arduous 12-hour plane ride, something to proclaim I survived US Customes and Immigration!
However, it was raining cats and dogs when I arrived. And I didn't have any raincoat that will survive the bicycle ride. So I end up in the Ferry Building for lunch served by a gay waiter instead. And got my first free beer... (that's right SK)

All kinds of cheeses

Didn't manage the Golden Gate, but I did dine looking at Bay Bridge

Later spending my remaining hours at SFMoMA (Museum of Modern Arts). Window views were rather nice, the art too radical for my tastes.

Take Flight

2011-06-27T23:32:00.001+08:00

Checking my room for the utmost time, making sure I emptied every drawer and cabinet in my Taipei bedroom, I struggled to find space in my luggage. Earlier, my sister remarked "it's bursting." Seems like the "light" baggage I started in Hualien had accumulated to a massive 27kg when I haul it out of my room. One last look at my home for the past 14 days and I'm off.
As the bus pulls out of Taipei Bus Terminal A, I bid goodbye to Taipei. "Pulsating" is the word for it - a city bursting with people, traffic, business, and more people. As the very empty bus weaves westwards to Taipei Taoyuan International Airport, rain and gust showered us reminding us of the typhoon which just passed and my flight's delay thanks to it.
I took a rare descent at Terminal 2, relieved to find the place a far cry from the ghostly aging Terminal 1. However, the good dream soon turned sour at check-in. "There's been a further delay. Departure is now timed at 01:30am." "But why? Isn't the typhoon gone already?" "Late arrival of aircraft." She said. I looked at the flight display and true enough, all flights that day were on time except San Francisco. A typhoon wouldn't specifically pick a San Francisco-bound flight, but poor aircraft dispatch and treating it as a second-class destination will, as I found out later. Then she started bossing about my overweight luggage, demanding that I remove 5 kgs and destroying my plans to be light and cool onboard. I'd expect better treatment for a frequent flier on peak season student fare.
I then paid 5000 miles from my frequent flier program to access Dynasty Lounge. After being pampered by Malaysia Airlines with a buffet bar and endless dessert I'm spoiled for the down-to-earth Dynasty Lounge. It only offers noodles, cakes, sweet potato and drinks. So much for Taiwanese hospitality you see circulating around the globe on "Visit Taiwan" ads.
Anyway, my flight turned out to be a nightmare. The cabin was warn and tattered, it felt like they just rescued it from decommissioning and flew it in for an emergency evacuation flight. There were no PTVs, the seats were dated back in the 90's, and lights were flickering during taxi. At one point my fatigued eyes even imagined seeing cigarette smoke billowing out of the back cabin - smoking section. They don't exist after the 90's thanks to vigorous anti-smoking campaigns. I was stuck with two Vietnamese sisters who kept invading my space and even asking me to move a seat so that she could lie down completely. Things would have been better had not the delay, which messed up my arrival in San Francisco. I then regretted my choice for China Airlines. I paid almost NT$ 8k more, got a 2-hour delay at the airline's home base and then an outdated cabin, a far cry from what the China Airlines website promised.
Immersed by the cabin's heat and boredom, I flipped through the entertainment guide. Apparently China Airlines still operates this ghetto aircraft around the world. To San Francisco and Amsterdam on a regular basis. Interestingly they did not show any specifications of this aircraft on paper or electronically.
Fast forward to arrivals. The notorious American customs and immigration was a far cry from my friendly attendants at San Francisco International Airport. At one point even Customs Officer Ngo (his nametag) seems more friendly than the matron chief stewardess who asks passengers to "switch them off RIGHT NOW."
Once on American soil I called Soon Khen. The rest, they say, is history.

Leaving Taipei Tomorrow Evening

2011-06-24T21:40:00.000+08:00

After watching 127 Hours this March, I'm all for going public with my schedules so that in the event my arm got stuck under a 5-tonne rock, you busybodies at Facebook will recognize something's gone astray and come rescue me.

Jun 25 (tomorrow!): Taipei - San Francisco
Meeting Soon Khen and sleeping on an inflatable bed

Jun 28/9: San Jose - New York JFK
Red-eye eastbound flight on JetBlue.

Jun 30: Orientation at Weill-Cornell New York

July 5: Starts clerkship

It's almost 24 hours to my flight and everything seems surreal, feverish with excitement.

Le Baggage

2011-06-21T21:35:00.003+08:00

It's the season of global traveling again. Summer - endless days of sunshine and 10pm sunsets and not worrying about turning up late for work the following day - c'est la vie!
I don't call myself a frequent traveler but over all these years traveling alone and with companion, I observed several types of people and how they pack their baggage. They say a woman's handbag reflects her personality - same thing goes for the big bag too.

The tour-Europe-with-one-shirt-and-sandles type - think you're a light traveler? They redefined the word "light" by washing their one and only multipurpose (usually thin cotton and light-colored) shirt while in the shower, hang it to dry and sleep naked. Their most precious commodity is probably cash or credit card - buy anything you need when you're there. My female friend Fang Yu stunned me when she complained I had too much baggage during our Shanghai trip. I bet the airlines love these people because they have no checked baggage and only a palm-sized carry-on.
The typical backpacker - they procrastinate more when it comes to packing, but they like carrying everything on their backs (snails...) - they say it's easier when you have to run away from, say, a rhino. However, when you need to look for a specific item from the "shell", you have to turn everything inside out. And I doubt the weight is any good for petit Asian ladies all wanting to be Lin Chi Ling. You can spot these people hogging the queues at airline check-ins by spreading out their entire belongings looking for their passports, and occupy everybody else's overhead bins with them shells.
The lite-business packer - t'is George Clooney in Up In The Air. Something formal and several mix-and-matches but NEVER a checked baggage. It's hard not to love these people but in the event you're stuck in Timbuktu and needs an aspirin or amoxicillin, you might have to wait till the supply boat arrives next month.
The heavy-business packer - at least 2 pair of shoes - running and leather; at least 3 sets of ties - blue, red, grey; at least 2 decent shirts - white and light blue. All these adds up to a considerable bulk during check-in. Although they don't usually hit the weight ceiling, waiting for the carousel is indeed very time-consuming. Thaasophobic (fear of boredom) people like me usually pack 2 to 3 books during long-trips, too. Though the weight a burden, it killed hours while queuing up for the Shanghai Expo and all the way back to Kuala Lumpur in an IFE-less flight.
The new Papa - these are considerate family guys who would pack the extra magazines for the wife, the Tigger stuffed toy for the baby, and even bring you souvenirs when they're back. They would be hovering around the weight limit but check-in ladies usually melt when seeing a guy with toddler on holiday. Parents with toddlers get to sit at bulkhead too!
The Mama - when the airlines say 20kgs, they read 25.9. They have everything ready, just in case - extra blankets, instant noodles, rice-cooker (I'm not exaggerating), honey-lemon-ginger, tub of detergent - just in case. They also tend to be extra cautious with money, keeping them separately in 10 different compartments but forgetting 7 after they arrive. When traveling with them, spare the labor and take a taxi instead. Lugging their room all across cobblestoned Roman streets is never an idea of a holiday.

Good packing skills and foresight will ensure not only a smooth trip but also save you bucks. For example, get your basic drugs like painkillers and vitamin C in Malaysia (where it is really cheap) before leaving for, say, Europe, where everything needs a prescription. A handy water bottle will save you a lot buying bottled water, and is better for the environment too.
Finally, always remember the less you carry, the less carbon footprint you leave behind. Aircrafts need fuel to fly you and your luggage. Even though an extra 5kgs seemed trivial compared to a 150-tonne 747, if everybody travel light, fuel savings can be significant. After all, who needs the DSLR or notebook while on holiday? Give yourself a break and leave them behind!

Goodbye Clerk 1

2011-06-15T23:25:00.000+08:00

Today I had my last exam. Well, probably, my last exam - all right, my self-proclaimed last exam. It's actually my last exam for Year 5 or Clerk 1. As corrected by my classmate - we have so much more exams to take, this is hardly of any significance. However, this is my last written exam before I'm set for the USA!
Lots of happenings during the past 2 weeks.

First of all, my deposit for Cornell got lost and found. Thank you so much to Ms. Dianne Young, my clerkship coordinator at Cornell, for her perseverance.
Then the New York Tzu Chi chapter found us accommodation. Thank you so much Mr. Scott Huang, CEO of Tzu Chi New York, that we won't have to sleep on the streets during our one month there.
I'm currently doing my 2-week clerkship in Obs/Gyn at XinDian Tzu Chi Hospital. Have to modify my course by bringing forward the rotation (which starts in July) now so that I can have a full month in Cornell. Thanks to all the ladies in our School of Medicine for their negotiating skills and endless paperwork. Thank you so much Mr. Hsu, our dean, for allowing us this privilege as well.
Thanks also to Ms. JJ from the Department of Clinical Medicine at XinDian Tzu Chi. She made my life difficult by asking me to collect 3 signatures for a day off (to take today's test back in Hualien). I appreciate her training my determination, which is nothing compared to months of negotiation for this trip.

This trip to the States had taken more than money and writing intention letters. It took days of staring-at-the-calender brainstorming, negotiating how I would do my clerkship in Taiwan so that I wouldn't miss Cornell's. It took up hours of telephone calls, waiting for approvals, signatures, e-mails, and the postman. Had not for all these kind-hearted men and women (including the hardworking postman), we would still be only on the planning stages. But no thanks to all the red tape we had to go through.

Overcoming Childhood Obesity in Med School

2011-05-29T21:31:00.001+08:00

When First Lady Michelle Obama stands out against childhood obesity, I'm skeptical. After all, how can you change a nation of McDonald's-eating TV-watching children to eat cucumbers and exercise 3 hours a day? I can totally understand it takes hours of sweltering near-syncope moments to cut a kilo but just an extra Cola to gain it back, it's inhumane, right? You have every right to feel angry just because society dictates slim people are beautiful and expects you to follow suit.

You see, I was once the obese, slow, dumb kid munching away at chocolate pies and watching television every weekend. Back when my classmates are playing football and training for six-packs I had a huge belly (38 inches at 17), and the tailor of my first suit finding it difficult to measure and fit me. However *drum rolls, screen flashes* when I got into medical school everything changed. *flashes following photographs*

I was normal and cute-looking little guy back then, no fat genes in our family as well - my youngest aunt and oldest uncle, god bless him.

Primary 2, still normal. Spot where I am?

I started to put on weight during my later primary school years. Sorry there being no photographs to display, but upon high school graduation I transmogrified into this:

Then I went into medical school...

First year of med school

As you can see the effects are quite profound already. I dropped from 38-inches to 35, lost almost 10 kgs during my first year.

Second year med school...

Can't exactly remember how much I weight then, but still within the seventies. Waistline down to 33/34 (I have my khaki bought in France as proof).

The most profound change I should say, is during my third year...

Broke the sixties, waistline plummeting toward 30, and some say I'm underweight.

Three years. 15 kilograms. Effortless.

The story continues...

Fourth year...

Fifth...

I'm currently hovering around the mid-sixties and wearing 30-inches, which makes some American brands unavailable to me, which is troublesome. All in all I lost approximately 20kgs in 5 years of medical school. I don't regularly exercise at school, just the occasional jog, swim, or gym. I don't starve myself, I eat heartily, and I live a rather regular lifestyle. So I figured it must be the textbooks, libraries, and endless reports and knowledge-cramming.

Medical school will do this to you. Mrs. Obama, please consider enrolling your obese American schoolchildren to med school, it'll do them good.

Surgery

2011-05-22T18:14:00.002+08:00

In a flash, our one-month rotation in surgery is coming to an end. Even before I started clinical clerkship, various people from all walks of life told me I'm just not made for surgery. I myself reinforced the idea during lectures - usually abandoning surgery for more brainy subjects like internal medicine, firstly because surgery is too masculine (an euphemism for straightforward), and involves more skills than knowledge. Secondly, I couldn't comprehend the rigid sifu-apprentice system so often associated with surgery, attenuated especially in East Asia thanks to Japanese surgical advances.
I started my rotation in orthopedics. Needless to say the backbreaking work and straightforward wheeling every fractures to the OR didn't live up to my expectations seen in House M.D. Exhausted, I started colorectal surgery with my fun-loving money-minded attending. He revealed to me a glamorous world of surgeons - weekend parties (with pharmaceutical companies), karaoke, and 8,000 dollars for a 30-minute hemorrhoidectomy.
Unlike internal medicine, surgeons invade their patients - cut them open, take something out, close the wound up. It's medicine at its barbaric form, tracing from Babylonian times. Surgeons care very little about making the right diagnosis, they are paranoid about sterile techniques, wound healing, nutrition, and surgery duration. Very much like comparing the pride of masculinity, they love comparing how good they are with a certain procedure, and derives pleasure from publicly humiliating their colleagues. That makes the field itself choked with testosterone, sweat, and blood.

Plastic surgery then changed my mind. As good as the name sounds, they deal with things superficially. Perhaps the most suitable knowledge for a clerk without brains nor skills are superficial wound dressing and skin grafting. Much as I like to admit plastic surgeons do much more complicated things than liposuction and breast enlargement, many young aspiring surgeons are tempted into this field for superficial procedures as follows:

Much as I despise surgeons for their straightforwardness and lacking in thinking process, I must admit that surgery is the most straightforward and fastest way to solve the patient's problems. That is, if we discount the risks of surgery and anesthesia. It's the most elemental form of medicine, very historic, but still advancing rapidly despite many older surgeons complaining internists eating into their pie with catheterization and stents. Nevertheless, I still think it's not a field for me, the heat, testosterone, backbreaking hours and that. Surgeons generally live ten years shorter than their non-medical counterparts, have more than one wife, and retires with Parkinson's disease. That contradicts with my ideal retirement at 50 living in Maldives with my beagle (and lifetime partner?).

Last Summer Holiday

2011-05-10T21:27:00.005+08:00

Readers of my blog will note I'm not the type to waste good holidays. For example, I will never spend weekends cleaning the house just for the joy of a sparkling new house. Much as I declare I'm introverted, my character justifies itself an outgoing personality.

The spark for this journey starts in 2008, when I was living joie de vivre, my 3 year senior was doing his summer electives in Weill-Cornell New York. He was the first in our school to win this new scholarship. I knew I would like to go because the US is a new country on a new continent. Nothing more.

Subsequent basic and clinical sciences exposed us to the threads of medicine. As the Taiwanese medical system is modeled after the US, our practice is dictated by guidelines and trials from the home of the brave. Expensive diagnostic testings and aggressive treatment is the thumb of American medicine, and when I reflect on my childhood, conservative watchful waiting seemed to be our rule back in British Commonwealth. We debated on the pros and cons, cost-benefit effects, patients' preference, insurance system, and whether it is ethical, but reached no obvious conclusion.
As I try searching for less costlier answers other than "head and brain CT" when the teacher asks how should head trauma patients be managed, admiration and disgust for the author from Washington University in St. Louis or Massachusetts General Hospital battled each other. It wasn't until President Obama fought with bone and tooth to pass universal health care when I felt acknowledged that my inner conflicts were not personal. But it's never easy to go back to basic physical examination when CTs and MRIs are so easily accessible. The Americans are trying, the Taiwanese, canopied under National Health Insurance, still practices it today.
Next, American medical students are, to me, a species of another kind. It takes twice the time for Americans to complete their training compared to, say, Malaysian or British doctors. The fees is astronomical, the student aging, and there's no turning back. It wouldn't do justice if I simply said I would like to hear what they're thinking doing medical school ("are you crazy? This is medical school!"), but that desire gradually piled up as I got exposed to call nights, scut work, and unreasonable "training" methods.

Enough of grave issues, this is my last summer and I'm spending it in New York!
Growing up with my fair share of Hollywood movies and sitcoms, it's a city where everybody drinks after work and ends up in a foreign bed the next morning; hails a cab when you're avoiding someone; parties on rooftops; fell in love overnight; and rise from rags to riches. It has filled our imagination and defined Americana in our generation, and I couldn't imagine anywhere else to spend my last one-month summer there.
So, thanks to Mum and Dad, my sister, my babysitter (the endless praying and chanting for my smooth success), my aunt, cousin, and so many others providing tips on applying an American visa (only the electric chair seconds the agony), I shall return you guys with my (hopefully) interesting posts this summer, and a better physician in future, with God's blessing. Stay tuned!

"The Doctor Respects My Beliefs"

2011-04-30T21:26:00.001+08:00

My colorectal surgeon attending is a jovial forty-something Sagittarius who laughs at his own jokes and takes us to pubs after work (I only followed once, Mum). "I think she's a little neurotic, can we do surgery on patients like these?" I asked. "Constipation. How the womenfolk is willing to do for passing motion and looking 1 inch slimmer..." he replied, stifling his giggles and walking away.
The patient - a 25-year old woman with history of chronic constipation since childhood. Lacking her daily toilet visits, she felt compromised so much to quit university to look for a solution. She tried everything, she said, and it ruined her body - "like being thrown down from a cliff and have your body smashed," to quote her exact words. "My body is a machine barely functioning," she mumbled, staring into the air. If any consolation is to be sought, she is the definition for beauty for Taiwanese - snow white skin, clear complexion, almond-shaped eyes, slightly puckered lips. Hopes of small talk, however, was dashed with her matron mother standing guard 24/7.
"Yes doctor, we tried everything and they just don't work. Now she sneezes at the slightest wind and doesn't eat anything."
"You don't eat?" I asked, alarmed.
"I only take some sugar water and protein drinks. I think if I don't pass, I shouldn't eat,"
It is no wonder she doesn't pass motion. Because she doesn't eat at all!
"I wanted to ask about DNR, doctor."
"What about it?" Impatient after 50-minutes of "my body is smashed" and "I'm allergic to mint, alcohol, bad aura, and handphones."
"I don't want my body to be cremated too quickly if anything happens to me. I read an article and it says most people who died of oversedation will eventually wake up. Bodies of morphine overdose victims were usually found different from their original buried position."
A chill climbs up my spine. "There's nothing to worry about for your operation tomorrow. The anesthesiologist will do everything they can to NOT let you into oversedation, and we will take appropriate measures in the event that really occurs, which chances are very very slim."
After another 20-minutes of DNR and keeping my body fresh if I die, I am released from her ward full with suspicion that she, is indeed paranoid. She will have her large intestines removed the following day, a surgery that will end her nightmare of passing stool once every 30 days. But I doubt she will ever be satisfied with the surgical outcome and side effects - diarrhea, intestinal stenosis, anesthetic nausea, vomiting etc.
I flip open my Mini-CEX booklet for a score card. We have to complete one sheet every week, and she is my only patient this. I skim through the basic skills for scoring.

Humanistic qualities / professionalism / patient's perceptions
Item no. 4: the doctor respects my beliefs
from: Hauck FR, et al. Family Med 1990

I certainly don't qualify on that, I said to myself. I personally think her constipation has more of a psychogenic or psychiatric component in it - think about it, her over-protective mother, her obsession about passing stool, and her not eating - where will the stools come from?
And I do not respect her or her family's decision to seek alternative treatment, later complaining that they "ruined" her body, and expect us to magically correct everything with surgery or drugs. I have a strong urge to suggest they go see a psychologist, but we have to be so careful nowadays even suggesting a pregnancy test is demoralizing enough for the patient to say hello to medical lawyers. Medicine has become a service sector, where "the customer is always right".
I am not saying that I object to doctors respecting to patient's beliefs, but limits must be set. We are humans, too, and bending too much might just drive us crazy in this crazy enough environment.

Questo Piccolo Grande Amore

2011-04-20T23:58:00.000+08:00

A filler for the time being, it's a classic Italian rock song, managed to find it last year from a pile of old CDs.

Meeting My 50-Year Senior In Internal Medicine

2011-04-09T22:06:00.000+08:00

My rotation at Internal Medicine starts smack after Chinese New Year. Still in holiday mood, I paced into our CV ward on Wednesday morning (they gave us 2 extra holidays). Just after we got a taste of Internal Medicine, visiting professor Paul Chang came and just about overturned everything we perceive.
We were 'briefed' about his straightforward attitude and minimalist approach in case reporting. Every oral presentation must start with his golden format - Mr. X, a n-year old office worker, was admitted due to intermittent abdominal pain for 3 days. Not a word more or less.
On Monday afternoon a bald old man walked into Classroom 602. We were to sit in a circle and not switch places until he can remember all of us. I was at his 7 o'clock position, which means no skipping classes for me for the next 6 weeks. We get to know each other during the following 2 hours, very much awed by his globetrotting experience - born in China, escaped the communists and completed high school in Penang Chung Ling, first degree at Santo Tomas, the Philippines, medical school at National Taiwan University, training in the States, and a missionary doctor for 2 years in Hong Kong, where he learned how to eat and cook. This old man must have one heart full of guts to be working in so many places, I thought.

He is here to teach us "wisdom", not knowledge. He also emphasized that medical education should be cooperative, not competitive, which I agree wholeheartedly. He changed our perception that medicine is noble, life-saving and glamorous, to one that is humble, flexible, and ultimately, a problem-solving task. "Not a word less" he insists in our oral presentations. We once slid into a 30-minute jabber just because I used 'madam' instead of 'miss' for my female patient - there's no 'madam' in American English was my lesson that sleepy afternoon.
As we slowly caught the gist of his format - we were taught to ignore some very tempting information, ask trick questions, and reporting only the most relevant tests - we learned to enjoy medicine. Internal medicine transmogrified from the mountainous pile of textbooks into series of quizzes, gambles, and logics. I learned not to be afraid of knowledge, because I have a lifetime to learn them. I am more confident in skipping useless lectures now, because all they do is narrating the textbook. "Use your time wisely," Prof. Chang said.
We also learned how medicine could be related to social issues, history, and even art. For example, we learn amyotrophic lateral sclerosis (ALS) by studying Stephen Hawking, Hodgkin's disease by the history of Guy's Hospital, hemophilia and the history of European monarchies.
A doctor should act like one is also Prof. Chang's motto. Under his tutelage we observed how to talk to patients and colleagues, dress like a professional, walk like one, and enriching our life outside hospital. We were told not to buy textbooks if we have no intention of pursuing the specialty (so long, surgery textbook!), and to compensate your weaknesses with your strengths - like not doing surgery if you cannot stand for hours on end.
Our last day is also Prof. Chang's at Internal Med. Seated together during our usual afternoon meetings, I felt confident as I have all my directions mapped in front of me. I shall not learn 'fancy knowledge' without my fundamental knowledge, and there's no hurry for that, too. I flipped through my schedule to see if I will see him again during my next rotation, completely forgetting the agonizing and sleepy afternoons listening to his jibber-jabber about madam, miss and misses, and the endless nights rehearsing my 2-minute oral presentations.
What I am most proud of, though, is that he is my 50-year senior from Chung Ling. We share the same roots, and if he can do it, I probably can, too!

Unwrapping My Baby

2011-04-03T21:47:00.000+08:00

My PC has been with me for 5 years now, approaching the average lifespan of a Windows-operated computer. Even though the specifications are still sufficient for today's standards and I'm more than happy with the performance - I don't play any games, heavy duty downloads, or crazy rigging - I can live comfortably with only a DSL cable, my future lifestyle of migratory hospital hopping and need for mobile connectivity means a laptop is a need for me. It has to be a near-PC replacement, light, compact, and last till I'm 30. Given that most Macs outlive PCs, and I can be granted a computer life free of virus infections and not responding windows, I decided to wait for the MacBook Pro update (rumored to be due anytime since last December).
On February 24 Apple finally revised its MacBook Pro line. I placed an order and waited for Taiwanese Authorities to clear its electromagnetism certification. One month later it flew from Shanghai to Taipei, got stuck at customs, and a series of barrage meant to make life of forwarding companies easier, I was finally handed my new baby on last Tuesday evening.

Made and assembled in China.

Apple's minimalist design

Back

The standard MacBook packaging

Apple's unibody aluminium case, made from "environmental-friendly materials" - a beautiful euphemism for recycled Coca Cola cans

My only complain about the sleek and minimalist design is that it has only 2 USB ports

The black keys

And bouncing to life...

Given that I've been using Dad and my sister's MacBook previously, getting used to my baby only takes several minutes. I won't start a debate here on Windows vs. Apple, but sometimes we can just save ourselves all the trouble - antivirus programs, scanning every incoming USB, mouse, speakers, webcam, legal softwares. I hear you say some top-end laptops sell at prices lower than Apple's, but nothing beats its all-rounded performance and chic design at the end! Oops, there goes the no debate policy.

I Live For Weekends

2011-03-24T23:29:00.000+08:00

Low cost apartments at Hualien in a post-drizzling afternoon

Carrot juice and my favorite club sandwich (not pictured) at CM. Waiting time is usually 30 minutes and I nearly died of hunger every time I frequent on late Saturday afternoon.

Taking a long walk in misty weather, the dampness soaking deep into our bones. Somehow I was reminded of the English countryside even though I never step foot in UK.

Then having tea at dinnertime, just for the sake of having tea.

My friend suffering stomach ache later.

Of Hepatic Encephalopathy

2011-03-13T09:37:00.001+08:00

He is a frequent ward resident, another admission just after a discharge two days ago. The reason: alcoholic liver cirrhosis so bad he has intractable ascites, permanent jaundice, and so malnourished he could be mistaken for a 15-year old had not for his hot-temper and know-it-all attitude.
"Let's do a basic physical examination," I said after completing history taking. He was admitted the week before my rotation in General Medicine starts, so another interview is essential even though it may be pergatory for him.
"Another PE?" He asked, not pleased.
"Yup, I promise it'll be quick."
Several nights later he developed stomach ache. From my daily conversations with him he seem to blame the pain to my abdominal percussion and palpation. He became colder and reluctant in replying questions and was irritable to all staff.
"He's not talking to me anymore. I guess he blames me for the pain," I told my PGY senior.Patient is uncooperative and refused to be examined due to sleepiness - I wrote in his progress note on Thursday evening.
Friday dawns on us an illness more severe than anger. He became stuporous, drowsy, and disoriented. Hepatic encephalopathy - accummulation of toxic substance supposed to be metabolized by the liver to affect cognitive processes, was impressed. His liver functions are so decompensated as little as a constipation flares up the syndrome. Patients are typically disoriented, detached, and solemn. We didn't identify the tremor or asterixis in the early stages, only his not heeding us we presume as snobbishness and blame.
After increased laxative use and enema he recovered to his usual self. My Saturday round with him was functional but not pleasant - he doesn't smile (who would if you're almost losing your liver?), and was depressed because his family is absent for 2 days.
They are the most challenging cases in medicine - their illness inflicted upon themselves by alcohol or substance abuse, their thinking we could cure them simply with a pill, and the disappointment when the truth isn't so. I didn't learn how to handle such cases, not yet at least for this week. But I learned how sometimes our patient's littlest reactions may be a prodrome of some more serious disorder.

Skies Are Blue

2011-03-07T23:02:00.000+08:00

Somewhere over the rainbow, skies are blue.
And the dreams that you dare to dream,
really do come true.

General Appearance

2011-02-20T20:18:00.002+08:00

A physical examination is one of two skills one has to master as a clerk. The first component of a physical examination is general appearance, where we evaluate and judge the patient for signs of chronic illness or disability. Its importance emphasized by Sir William Osler:

The art of the practice of medicine is to be learned only by experience, tis not an inheritance; it cannot be revealed. Learn to see, learn to hear, learn to feel, learn to smell and know that by practice alone can you become expert.

Judgemental as it may be, it does provides vital information for certain diseases. For example, a slowly healing ulcer may indicate poorly controlled diabetes; a patient who cannot recall what you asked a few moments ago may lead us to diagnose dementia.
So much for not generalizing or stereotyping, "general appearance" is actually quite close an epitome to it. What I learned this week was, despite what we were taught to judge patients by general appearance, we should withhold labeling them until we really get to know them better.
It was a busy Thursday evening when Mdm. TJ arrived in our ward. She suffered a mild heart attack and was transferred from a smaller hospital from Taitung because MacKay Hospital Taitung was full. Pending a coronary arteriogram to determine her severity, I quickly reviewed her information and important questions to ask during history taking - any dyspnea, chest pain, tightness, palpitations; what was she doing during the episode, risk factors etc. A few clicks and flip of old charts revealed the 68-year old having hypertension, diabetes, and end-stage renal disease. She smoked, drank, and chewed betel nut. In the world of medicine we usually refer these patients in a sinister way - often implying or projecting the idea that such patients are tough, does not care for their health, and difficult to manage.
When I walked into her single room, she was laying 75 degrees in sitting position looking utterly distressed. She was breathless and couldn't lie lower, and demanded sleeping pills because she usually takes them. She couldn't understand my questions and I couldn't understand her description either. We basically skimmed through our interview with help from her niece.
Sitted in front of the computer the following day, I wrote "an obese, chronic ill-looking, irritable woman older than actual age." I have no intent of discrimination, but the way I expressed the sentence made my patient sound pitiful, plagued with disease and riddled with problems.
She was to prove my first impression wrong with every subsequent visit. I see different sets of people taking care of her every day over the week, and as she gets better she talked to me about switching to a 4-bedded ward.
"But it's much noisier there. Are you sure you'll be able to sleep well?" I asked.
"I know. But I don't want to burden my children to pay for my medical fees."
"Oh, that's my mother! Always trying to think on our behalf instead of hers!" Her daughter, standing beside her, exclaimed.
Later that day her daughter told me in private that she never took a penny from her children. She lived on her own savings and the little income she made with her fruits and vegetables.
Meanwhile, worried about her problem with diabetes I asked her if she had had any diet consultation before and whether she took her drugs regularly (usually they don't). I was completely taken aback when she told me how much calorie is in a tofu block and she can only eat half every day.
"You should also be careful about tea as well because you have chronic renal failure," I said.
"Of course, I only drink water nowadays."
I couldn't hide surprise showing up on my face.
A few days later she recovered into a cheerful, bubbly woman who'd smile when we visited her every day. I would try my Taiwanese Hokkien with her and she would laugh at my futile scramble of vocabulary. Her initial "general appearance" was totally off what she really was.
Stealing some time off lunch break I hurried into her room before discharge. She was happily eating her last hospital meal (nothing happy about hospital meals by the way), and thanked us for our care. I wished her good health and learned an important lesson that week.

What's In An Upgrade

2011-02-12T23:57:00.003+08:00

There's nothing more financially discriminatory on Earth than when entering an aircraft. Regardless of color or creed, those willing and able to lash out a few thousand bucks get to turn left while those looking to curb every cent turns right. Therein lies an entire world of difference - 6 crew man a cabin of 200 passengers behind the partition on the right; 8 crew to an exclusive cabin of 35 on the left. Meals come in iPhone-sized boxes on the right; a full 4-course meal on porcelain and silverware served by a chef au bord on the left. While the 200 people on the back of the aircraft have to tolerate wailing babies and vomiting old folks; the exclusive 35 in front gets attended to on the most trivial of matters, like filling up a landing form.
On the dawn of the new year, I decided to end this discrimination against me for once. Forced to return on the 5th day of Chinese New Year with cattle class fares skyrocketing through my credit card limit, it's time to put my 20,000 Enrich miles accumulated with teeth and bone to good use. After a call to Malaysia Airlines and a visit to their town office, I was 'upgraded'.

You can't imagine the endless perks airlines provide for their premium passengers - town pick-up, priority check-in and boarding, special lounge area, and for First Class, a ride on Porche Panamera. Now we understand why some snobbish prince is willing to fork out the price of a small apartment for a coach in an claustrophobic flying aluminium tube - privacy and personal attention we 'commoners' are unable to appreciate in our daily unroyal life.

Saying goodbye to Penang on my last afternoon

Upon landing in KLIA, I flashed my Business Class boarding pass and get admitted promptly into the Satellite Golden Lounge with a "enjoy your stay with us!" from the concierge. I'm starting to feel la première associated with high living. In economy class you won't even get a second look from the ground staff when they scan your boarding pass.
Picture is the Golden Lounge of London Heathrow, I apologize for not taking any at KLIA.

This is the first class lounge, of which I can only admire through photographs.

The business class lounge is toned with navy blue and shades of wooden brown modeled in the style of old British train coaches. There were several TVs playing business channels for business executives who can't take their eyes off global finance and foreign exchange rates.

Bottomless drinks and food is enough to satisfy me. A noodle bar is here for made-to-order noodles from all of Asia, and a self-service wine bar for the bankrupting taukeh.

My 3rd meal of the day at 11am. This was followed by chicken rice with roasted pipa chicken, sardine puff, white wine, cakes, creme caramel, cheeses, and tomato juice. I had to constantly remind myself not to overstuff my stomach because there would be more food onboard. No wonder: studies show income is directly correlated with chronic diseases in developing countries. They do nothing but eat and watch TV!

Soon we're ready for departure. Upon boarding and (drum rolls...) turning left, a brightly groomed stewardess fully embalming the Malaysian hospitality spirit greeted one by name and showed you personally to your seat. "Any drinks for you, sir?" "More pillows, sir?" "Cold towels, sir?" "Newspapers, sir? We have (start chanting a series of international papers)."

The commotion did not died down like cattle class when we started taxiing. As soon as you lay down your used towel a stewardess gracefully walks over and stows it away. Fresh orchids and jasmine were placed in the lavatories, fully stocked with Aigner toiletries. A few seats back in a place without human rights called economy, you'd be lucky if the person before you clean the basin before he leaves. In business, a.k.a. Golden Club Class for MAS, I reckon a stewardess is present onboard just to clean lavatories.

A glance at my fellow passengers reveal they are either born with a silver spoon in their mouths or hardworking businessmen who started from scratch. A family of 4 - mum, dad, son, grandma, was on my right, Daddy quarreling with Mummy about spending too much time shopping. In my family we usually quarrel about who should use the car or have the new cell phone; my neighbour passenger had clumsily dumped his Blackberry, iPhone and iPad on the seat panel, precariously hanging on the edges occupied by his 39-inch belly. A lady was sitting alone clutching her LV handbag, and talked to no one at all during the entire flight.

After takeoff the drink cart came. Pretending to know all the drinks I ordered a Heineken. An entire can was promptly served in an elegant glass with coaster and napkins. Behind me the matron-stewardess scowls and say "if I give you the entire can, there wouldn't be any for other passengers, would it?" (On another note, I ALWAYS get an entire can in Economy on MAS).

Then comes mealtime. My business class menu invites me to dine, not just eat.

Malaysian satay is Malaysia Airlines' signature dish which two rivals down south try to emulate and glorify. Though not a fan of satay, I have to sarcastically admit that the best satay I had was at 37,000 feet up in the air. Large chunks of tender, moist chicken and lamb grilled to perfection - crispness and juiciness melting simultaneously in your mouthful of smooth peppery-sweet palate smothering with the right amount of fat. The salmon and salad was pale, in comparison

Then comes the main course, or 'the main event' which Singapore Airlines dubs. I chose the cod while my neighbour chose the chicken. A steward serves up our plates, warm straight from a plate-warmer in the galley. I took my time to appreciate the artwork of the dish, taking photographes and admiring it from every angle, while my neighbour busily wallops down his nasi ayam. Meanwhile in you-know-where, yellowed vegetables, dried chunks of unidentifiable meat and burnt rice are being served.

I am all for dessert. I'm a firm believer than a meal can be compromised of anything else other than dessert. I am rather disappointed when 'fresh fruit' actually means 3 pieces of careless cuts. This is no different from back there. The Haagen-Dazs ice cream somewhat made up for it, while the blueberry cheesecake is sublime.

There were several choices of wines, spirits, and champange as well but I decided to abstain just in case I go out of control and behave un-business class-like in my hard-earned business class trip.

After the entire affair, I started to play with my seat, which can recline up to 171 degrees, unlike only 1.7 degrees back in economy (on AirAsia). I could definitely sleep soundly in this position had the flight been longer. Memories of sleepless nights in a cramped seat with an obese seatmate creep into my mind as I write this. Ever since that trip on China Airlines, I vowed to not behave nicely and asked straightaway "can I have an empty seat beside me?" every time during check-in. A tip to share: utilize the empty seat beside you to the max - lift the arm rest, sit slightly slanted and you could actually recline a whole lot more. The table beside can be used for your paraphernalia or bottomless drinks (press the call button without shame). And you also get extra pillows and blankets without having to ask!
After a movie, How I Met Your Mother, and Glee on a screen twice larger than back there, it's time to descend. Besides the cruising part of the flight, taking-off and landing is actually pretty much the same as back there. Even the Pope has to wait for clearance to land and get stuck up when there's no gate to dock the aircraft.
Bidding goodbye to my seat after 4.5 hours costing 20K miles.

A moment to reflect:

Golden Club Class, a term which conjures a past era of official British colonial exclusivity and elegance exuding power or wealth is a good name for a business class product - Air France uses L'Espace Affaires, Continental Airlines Businessfirst, and Etihad Airways Pearl Zone.

Even though these names and products are a symbol of civility and the learned, the passengers riding on them aren't necessarily so. We've heard stories of premium passengers harrassing, extorting, bullying cabin crew, and my experience with the quarreling family and food-walloping neighbour certainly proves this. Hence, even though a majority of us can only afford you-know-where, we could still fly fully dignified knowing those in front aren't as happy or excited as us stepping into an aeroplane everytime.

Happy Lehbit* Year

2011-02-04T11:34:00.000+08:00

*"rabbit": way of pronunciation for some lazy tongues of Malaysian Chinese

My 22-Year Affair with Institut Jantung Negara

2011-01-28T18:37:00.000+08:00

For acquaintances, I have a congenital heart condition which requires me to pay an annual pilgrimage to Institut Jantung Negara (National Heart Institute) in Kuala Lumpur. Usually we would then start talking about the "congenital heart condition", but today I'd like to pay tribute to the humble medical center which is an epitome of Malaysian healthcare.

Back in primary school, the annual visit to Kuala Lumpur was a welcoming break away from school. Daddy would usually accompany me take the night bus down to KL, staying one night at my uncle's house at Puchong, and start the following day damn early to avoid the infamous traffic gridlock. My parents lived in an era of bureaucratic medical care - they cluster a year's worth of questions to be asked within the 15-minute intercourse with a pediatric heart specialist. My first physician was, as far as I can remember, Dr. Hasri Samion, who still works there from my last visit.
The typical routine when our number was called include the doctor asking trivial daily questions - "Wow, we have an overweight boy here..." (back then thanks to a kitchen appliance called the refrigerator I cannot stop eating), "how's he doing in school?" etc. A cardiac echo would follow, and I remember the strange feeling of lukewarm gel and the incessant pressing of the echo probe on my ribs. The machine would emit squishy-squashy sounds, which Dr. Samion says is the sound my heart makes. I knew that was abnormal, since normal hearts don't make sounds like that.
Then the ask-all-you-can Q&A session begins. "Does he require surgery?" "Any hope of the defect closing in future?" "What should we take note of in future?" etc. My doctor, from his encounter with countless patients previously, provided quick, definite, and no-terms-for-argument answers that brought our interview to an end as quickly as possible. Thank you and we're out.
After I got into medical school, I would attend these annual pilgrimages myself. From the old single-storey block with 70's blue walls, it's now a sprawling glass-and-aluminium structure with airy lobbies and LCD screens everywhere. Like other Malaysian private hospitals drawn into the lucrative 'medical tourism' field, the decor reminds of stylish hotel lounges, even the canteen is like an Ikea restaurant. Services are world-class, with a concierge and receptionists that would personally show you the way.

The doctors changed too over the years. After Dr. Samion, I've been attended by a vivacious Malay lady, an African woman whose voice is hardly audible, and a Middle-Eastern man with a goatee this year. They developed a modus operandi over the years - shake hands, how're you, echo, no surgery, see you next year. Except this year, Dr. Goatee says I'd do well returning 3 years later. "I should've graduated by then," I said (implying I wouldn't have time for the follow-up). "We'll see about that," Dr. Goatee replied.
Much as I love the service, the canteen nasi lemak, and the friendly staff, chances are that I would fail to turn up for my follow-up 3 years later. It's a sign of the passing of time, parting with a place that witnessed both our growing up. With all my (defective) heart, I wish IJN excellence in quality, and that I have the opportunity to contribute back home.

The First Eight Weeks

2011-01-16T23:12:00.000+08:00

Has its highs and lows, total exhaustion and insomniac excitements; and most important of all, was a totally new learning experience for me.
A bookworm back at school, the clinical setting was a complete stranger. We had many practises with standardized patients, seniors, and ward nurses prior to meeting our first patient, but actually meeting one is still like walking on the moon. Should I introduce my full name or just my last name? Should I reveal my identity as a medical student, intern, or just the general "doctor under Dr. What'shisname"? How should I ask about sexual history? Reason of abortion(s)? All these we ran through our minds again and again while dragging our feet to the ward.
My first history-taking in Pediatrics would be a total disaster had my senior not covered me up when I went into daydreaming mode. The second was better, but I still had episodes of "brainfreeze", my resident complaints.
Soon the routine sets in, I would grab a piece of paper, fold it into 8 equal columns, stick the uppermost corner with the patient's chart sticker, and preview his / her history. "Hello, my name is Sim Jun Yi, I'm a medical student assigned to your care." I would start like that, making eye contact and a friendly smile. I learned the importance of "relevancy" much emphasized by our Pediatrics teacher. Obs/Gyn taught us to bring along a female whenever we go, least our patient decide to accuse us of sexual harrassment when only a handsome male intern and an obese pregnant mother is in the room. Wear a mask, bring a pen-light, stethoscope, tongue blade, and we're almost ready.

Cooperation has to be earned from patients, the principle is similar to all walks of services unlike airlines or even bakeries and hair salons where they think they can bind you with a loyalty card. If my patients are easy-going, cheerful, or in the mood for more talking, I would attempt to trend into deeper waters. "Forgive me Mrs. Whoever, the following questions may sound offending but I may need to chart it down for future references. I hope you don't mind." We always try not to sound judgmental so that patients have the confidence in confiding with us. Mostly it's just empty talk anyway.
Then comes chart writing, another pivotal aspect of a clerk's job. Our teachers always say whether or not we produce good charts determine how the quality of care is given, on paper. My previous experience constructing complex sentences in English comes into good use - the dull pain at the lower abdomen was associated with intermittent cramping episodes and constipation, not radiating, cyclic, nor colicky. Information obtained from a series of questions we recite by abbreviations all squashed into a single sentence meant to pinpoint a specific diagnosis. We found out later there are many other indications for admission, such as nausea, vomiting or one episode of prolonged menstruation that I might easily take care at home with some sleep. How medical care is carried out is still beyond our learning I suppose.
These eight weeks had taught us the approach of medical care instead of the content. And I think it's equally important compared to shelves of internal medicine or pathology. The problem is, there is no book to dictate how you should pacify a screaming child while listening to his lungs or see his tonsils when he absolutely refuses to open his mouth ("look, a squirrel!"). Or how to handle a lady with schizophrenia who underwent surgery but wounds were too contaminated to be closed on the first week - she formulated a theory involving Russian KGBs working with aliens to steal her kidneys for clean, renewable energy - ok, I made that up myself.
So here we are, a bunch of young, shiny, well-dressed lads and ladies (in leather shoes and high stockings) pacing around wards asking questions in its most immature way, answering "I'll report that to the attending," to your every request, and whose visit every morning and evening finds you at your most inconvenient time. Forgive us, but please bare with us - it's for our good and ensuring the future medical quality.

Weekends with Near-Death Experiences

2011-01-02T15:59:00.000+08:00

Hospital life, like office life, is excruciatingly boring. After all, most human beings only live for the weekends. Being single and available makes weekends even more boring if you have nothing planned. However, thanks to my roommate, a spirited adventurer gifted with the ability to tone down descriptions of danger, we went on two separate hikes of his. The first nearly sees all of us drowned while the second nearly took my sister's life.

Adventure 1: The 'family grade' upriver hike
Prior to beginning that morning, my roommate reassured us that the hike would at most take 3 hours (ending by noon), and we could all wear slippers and conquer the place like Genghis Khan taking eastern Europe.

We began from the coast where the terrain was smooth and easy to navigate. Water's cold though, but still tolerable in November.

Had some fun along the way playing with nature's creations.

Then the perilous parts slowly emerge - note how we were struggling with our slippers!

Will we come back alive and whole?

Just after 1.30pm and our n-th query about the waterfall, we were greeted by this lake. It is impossible to go through it from the sides, and we couldn't get a visual of the bottom.

Instead of being defeated by nature, we started clearing the outflow of the lake. Our goal - to flush all the water out of the lake and we could easily walk across like Moses did to the Red Sea.

We moved rocks, branches, soil, crabs, frogs, more rocks enough to build a house, and more branches. By 4pm, the water receded by a mere 3 feet.

At last, Mr. Indiana Jones decided to call it a day and we all get to go home safe and alive!

Adventure 2: My anemic sister and the endless stairway
My sister had iron-deficiency anemia, that, compounded by the fact that she hardly get any exercise (climbing the stairs is not an exercise) and how she hates iron tablets, makes her the most vulnerable person should a tsunami hits. I completely forgotten that when she visited me, and we were off that morning to hike a little mountain.
The hike, the tour pamphlet says, could be covered in 40 minutes. We finished it in 3 hours.

The endless little breaks every 5 steps.

Our Princess of Kilimanjaro, note wearing boots somemore!

Well, this is the fruitation of our 3-hour hike.

And my sister barely made it up her train home since we got delayed so much!

Christmas

2010-12-24T23:09:00.000+08:00

I hope I can post very soon. Hang on and have a great Christmas!

Life as Clerk 1

2010-12-12T23:58:00.000+08:00

Fifth year medical students are called 'Clerk 1' in the hospital. True to the name, we spend most of our working hours doing clerical work - writing all kinds of notes, filling up boxes in our clerkship passport, writing case reports, planning case discussions. Those with limited medical vocabulary or poor mastery of English grammar will suffer from miscommunication in note writing. We also learn to filter information - fever with a history of animal contact: goes in chart; diarrhea, and a fight in class the day before: ignore - much as we know some trivial piece of information may be a key to a different diagnosis, current medical education dictates every patient is at best given one diagnosis and all other unrelated information goes elsewhere.
Life typically begins at 8 with a one-hour morning meeting hosted by the chief resident. A case will be presented with information and knowledge shared among colleagues. Senior physicians will provide guidance to unsolved problems while children like us write everything down like reporters interviewing the president. At 9 attending physicians (or visiting staff, VS in Taiwan) start their outpatient rounds while residents (Rs) begin their long hard day taking care of ward patients. An R gets up to 15 ward patients; interns (seventh year med. student) up to 5, while clerks get a maximum of 2 beds only. Before our VS come visit we should complete surveying all patients under our care - vital signs, conditions the day before, latest lab results, patient's complaints and expectations.
In our smallish hospital, a VS has 1 R, 1 intern, and at most 2 clerks to abuse. That adds up to a max of 25 beds per day. A typical ward round goes like this:

VS: Good morning, this is eerm...

Intern: [patient's name], admitted for fever up to 39 Celcius yesterday.

VS: Feeling better?

Intern: No fever after admission. Urine analysis shows some bacteria and white blood cells, so [antibiotic name] will be used empirically.

VS: Ok, how about other systems? You surveyed? [to patient] any cough? vomiting? diarrhea? dyspnea? abdominal pain?

Patient: Wh...what? Can you...repeat?

VS: Guess not. Any arrangement for a renal sonograph?

Intern: Yes, probably later.

VS: Good, tell me the results as soon as it's out. [to clerks] Why should we do renal sonography?

Clerk: To...to eerm...

VS: Go home and study, tell me about it tomorrow! [to patient] Any questions?

Patient: When can I go home?

VS: As soon as we confirmed your kidney and bladder is ok and you don't have fever for two consecutive days. You will still need to blah-blah.....

We doctors generally have very short attention span. Attendings order workups, drugs, and tests along the way, dictating them like reciting out of the Bible. Rs write them down in illegible writings on the blue patient charts. Clerks and interns follow closely behind listening to heart and lung sounds, performing simple physical examinations on the way.
Then it's time for some mini-lectures, the least mentally taxing part of our day. In the hospital it's not rude to have your mobile phone on full volume, even during lectures. So we're constantly interrupted by a library of ringtones and endless pestering on the phone.
Lunch time is usually 2 hours from 12:00 - 14:00, but being the lowest-ranked, it's the only time we have full access to the chart computers without being interrupted. I usually take a quick lunch, nap (add some reading Time magazine there), and do all my clerical work before station bounce back into activity at 14:00.
Depending on schedule we might have more lessons in the afternoon, a new patient, or idle time until our 17:30 meeting. It's basically a repetition of morning meeting except this time we discuss patient conditions and new patients we approached during this 8 hours. The chief R will do some teaching and reminders. Then we're off. Except if...
You're on night duty today. One would have to stay till 22:00 on a night duty, usually there just being an observer. For me I will present myself to the OPD or ER for the night and see what's happening there. Patience will reward some interesting cases like a child with hyperventilation, or one who swallowed a screw. However, usually it's a series of asthma (very typical during winter).
Then the cycle starts again at 8 tomorrow morning. Everything else goes into the weekends - laundry, movies, buying groceries etc.
So the next time your doctor mistreats you, think twice before lodging a complain - we might just had had a long day. Give us a second chance to prove ourselves!

Pediatrics: Happiest Place in Hospital

2010-12-06T23:42:00.003+08:00

Whether or not you have some knowledge of music, human beings are designed to be aware of baby cries. After all it's one of our primitive reflexes - to recognize another vulnerable human being in danger. In pediatrics we are surrounded by baby crying all day all night - infants who don't know how to speak express their anguish, despair, and call for help through various crying patterns; and it is worse if someone he knows is there. Children who know one or two words (around 1 year old) cry while uttering Mama or Papa, and you know they're just pretending to cry when there's no tears - crocodile tears. So that makes one of the fun lists in pediatrics.
Second fun thing - when they are not crying, children and infants make good company. There are a dozen cool reflexes one could indulge with them - Moro's reflex and the parachute reflex being the coolest of all. And just for medical students only, the Babinski sign is VERY obvious on infants - once you observed it on babies you won't want to see it again in neurology. I personally think children are good patients because they are so straightforward. They have no hidden feelings - making faces in front of them will send them into giggles, while an otoscope or pen light will send them straight into tears. Needless to say syringes and vaccines - don't let them even see you or else they'll remember you for life - childhood traumatic events.

Third fun thing, even though they throw a havoc when swallowing medicine, or fun faster than the Olympic gold medalist when a synringe was flashed in front of their visual field (I actually saw one the other day, took 3 nurses and his mum to surround him and carry him a la hunted down game back to ward), they are a symbol of the future - of hope. When pediatric patients got discharged it's always a blessing - we wish them all the best, they have a future ahead of them. Unlike, say, oncology, nephrology, or endocrinology - a discharged patient only means more work in the future. And believe it or not, no matter how you bullied and abused your patients, they will still bid goodbye to you when you wave your hand to them - the age of innocence and ignorance.

Of course there are sad cases as well - 10-month old boy who just suddenly turned black - sudden infant death syndrome - a reminder to all of us that science and medicine is not invincible just yet. The art of talking to patients, revealing reality and harsh information while making sure they're really listening, is something like kung-fu. I gradually come to know medicine is not the cold hard science, but a living spirit and a form of art that indirectly shapes humanity and the community. No wonder we called it a "practice" - lifelong learning.
2 weeks more in pediatrics - hope I can complete all my work before rotation ends, and make lots of new friends and lots of knowledge that stays.

Stop. Look. Go.

2010-11-21T22:35:00.000+08:00

I apologize for such an idle November, once again it's either my ADHD had gone from bad to worse or the piling workload. This time it's both. Time seems to seive through my fingertips for the past few weeks. While I'm getting used to the 9-to-4 lesson schedules, I was also busy preparing for a pathology presentation which was done for yesterday at the beautiful main campus of National Taiwan University.
I also took my TOEFL exams this weekend, wishing to apply for a one-month exchange stint to the US later next summer. But we'll talk about that next time.
The significance of this weekend is that it's my last weekend before I start clinical clerkship - working in a hospital. Approaching and handling real patients. Up till now everything we studied were oriented around textbooks, guidelines, and standard patients (hired actors portraying patients). To really have a patient in my hands would be a real challenge. Most professors and doctors say you really learn medical knowledge when you see your first patient. We'll see about that tomorrow.

Anyway, this weekend was very enjoyable to me, managed to catch up with a medical student old friend, found some good second-hand books in a bookstore (but lacked the cash to buy), slept on a sofa, and drank beer. My day at the pathology conference was eye-opening as well - chat with several pathologists - human and vets about future careers, flying aeroplanes, and visiting New York.
Time and again there happens to be signs that tell me to slow down and enjoy the moment. To savor time as it slips by unconsciously, regardless of productivity or efficiency.
As I go into clinical I hope I do that to my patients - have more time for them, and learn from every possible moment with them. I hope I'm up to the challenge, while still maintaining a certain amount of life quality. Stop. Look around. And keep going.
And pray hard this blog won't get neglected for too long again!

The Final Piece of the Puzzle

2010-11-10T23:41:00.000+08:00

I went to Taipei last week to attend a conference on hospice and palliative care. For those unfamiliar with medical care, palliative care is defined by Wikipedia as "any form of medical care or treatment that concentrates on reducing the severity of disease symptoms, rather than striving to halt, delay, or reverse progression of the disease itself or provide a cure." It may sound radical at first sight, but if you take a macroscopic look at our current medical system, you're bound to be disappointed by limited treatment regimens, unknown disease etiology, and aimless aggressive treatment, especially in cancer.
When we've done pondering what we can't do in medicine, we start thinking about what we can do for these terminal patients. To quote a 15th century anonymous statement on medical care - to cure sometimes, to relieve often, to comfort always - this is our work. This is the first and great commandment. And the second is like unto it - Thou shalt treat thy patient as thou wouldst thyself be treated. When we really go grassroot to ask terminal patients what means the most to them, we knew by heart most would want to spend it at home surrounded by family and friends. Yet current medical care do not permit this. We see death as a medical failure, and doctors try their very best to prevent death from happening. As majority of medical students say when entering med. school "I am going to save lives."

The truth is, death is an all but natural process. We may delay it with current medical technology but we can never avert it. Death is part of the four living cycles in Buddhism, and just like giving birth or getting married, it only happens once.
During the conference we were lectured about the history of hospice and palliative care in Asia Pacific, apparently Singapore, Taiwan, and Malaysia are quite forward when it comes to facing death. We were exposed to how and why it is very important to discuss the issue of imminent death with our patients even if their still alive and talking - techniques such as "will you be surprised if this would be the last year of your life?" is a good way in assessing if patients are ready or open-minded to discuss this morbid issue. Approach death in a honorable way, respect our patients' wishes, and fulfill it when the time arrives.
It is shocking that although 80% of patients wish to pass at home, only 30% get to do so. Our lecturer from Birmingham described to us how an average English man dies - even when he has agreed to DNR (do not resuscitate order), when he falls or faints the care home operator or a family member will immediately summon an ambulance and rocket straight to the hospital. Most of the time patients die on the way or in ER, so called "trolley deaths". If vital ideas and communication had occured beforehand the patient might die a more digified and peaceful death.

We also learned about hope. What does hope mean to you? For healthy living adults it may be something impossible to achieve. For a terminally ill patient it may be as simple as getting engaged or baptised, make peace with all enemies. Needless to say it is utmostly important to communicate these and attempt them for the patient. This is the essence of palliative care.
I may not be in the appropriate age to think about death yet, but I believe as we're at an age where our grandparents, parents or even some of our older friends are leaving, we must face this fact - would you like to be treated the way the deceased was treated? Would you be lying on a hospital bed hooked with dozens of tubes and moaning in pain, or would you pass comfortably in your room, your wallpaper, and the people who cherished your company or you come to appreciate during the final days of your life?
Providing hospice and palliative care to all is the future goal all governments must attempt. Medical care comprises of perinatal care, gynecologic and obstetrics care, pediatrics care, chronic diseases, psychological, and even gerontology. It's only natural end-of-life care becomes part of it.

We Have No Opportunity Here

2010-10-31T21:42:00.003+08:00

Will Malaysians of our generation able to live, work, and contribute to a pleural Malaysian society we studied about in school?

Who wouldn't want to contribute to the place that nurtured us? But sadly, we have no opportunity here.

Or do we? In the very near future?

Datsun

2010-10-25T00:00:00.002+08:00

Our first family car is a Datsun. I can still vaguely remember the white metal cabin and the charcoal-black plastic door handle, the grey plastic lining in the passenger cabin, and the sound of engine groaning against the slopes. It had very powerful air-conditioning, something we sorely miss when the Proton Iswara replaced it.
What I really missed is the lovely evenings - family dinners, movies, or a wedding dinner perhaps, that we children are permitted to go (newlyweds nowadays think inviting children along is a nuisance). If the function stretch beyond bedtime I would usually fall asleep in the car, rocked by the sudden jerks of brakes and acceleration. When we arrived home Dad would carry me in his arms into bed. I just loved the feeling of being ferried through air in Dad's arms and landing in our snuggish bed - even though it was only a mattress on the floor back then. Usually the next thing I know would be waking up to sunshine the following morning.
Daddy wasn't muscular, and he had a weak spine - one thing I found myself inheriting. So as I spurted in height and weight (weight much more than height back then) Mum would refrain Dad from carrying me, roughly nudged me awake, and make me brush my teeth before going to bed. Gradually I begun to lose my ability to fall asleep in a car, or any mode of transport now. Later in high school we never woke up to sunshine but the alarm clock or Mum (or even our maid's) incessant threats of being late (even though I am usually the first few to arrive in school). Soon I'll wake to telephone calls asking me to attend to critically ill patients.
Even though we have 3 cars now (only 2 drivers at home), I still miss our white Datsun and I wonder why.

See The Future

2010-10-17T23:37:00.001+08:00

I am the future, we are the future. If everything goes according to plan, I will become a physician. I will be part of the Taiwanese healthcare system, trying to serve my patients in between a rigid national health insurance and patient-friendly medical policies. Expectations and demands are high, patients will be picky, will be hard to convince, and harder to explain to once mistakes were made. Will I be happy? Perhaps, perhaps not.
Seeing we are the future, shouldering the burden of healthcare for the next 30 years or so, medical education nowadays must be comprehensive, innovative, cutting-edge, emphasizes teamwork, and encourages self- and lifelong learning. Wow, this sounds really nice on paper - something a Health Minister or Prime Minister can blabber out easily in propagandist fashion pleasing journalists and the general public. However, the havoc it wreak in medical institution is beyond imagination.
Lessons, more lessons, lessons in different forms - lectures, mini-lectures, discussions, PBL sessions, SPCs, CPCs, chef du clinic, M&Ms, OSCEs, online conferences, sheet reflections. Then comes the training - communication skills, written consent, clinical procedures, everything must be evidence-based, choose the best option for your patient, quality of life.
I might not actually start clinical clerkship yet, but after 4 years of swimming in books I expected clinical years to be more "hands-on". Profs may teach a procedure the hundredth time but a single hands-on practice beats mundane recitation. Yup, I hear you arguing about complication risks and screwing up the patient - not that it doesn't happen with skilled professionals. Human lives are worth more than the chance to practise a skill, but book recitation gets us just there - the rest we must delve in on our own, with guidelines.

There also seem to be a predilection to cram every single medical knowledge into 50-minute sessions and feed them to medical students a la Toulouse geese for foie gras. We are supposed to be *ahem* the creme de la creme. We studied our way into medical school, and the education board thinks we can't study these knowledge on our own? In fact, majority of these knowledge being treatment guidelines, are prone to change in the future. Why do we have to spend 2 months in a windowless classroom listening to boring teachers teaching knowledge they themselves find boring? For some classroom sessions may reinforce confidence before actually approaching the patient, but, forgive me for being harsh - so does repetitive practising and self-study. I prefer to eat on my own than to be fed.

I get angered the most when our teachers, or our board, speak on quality of life. I do not disagree on the fact that modern healthcare should be more patient-oriented with the patient's priority and wishes as prime consideration. However, how can we speak about quality of life and implement it in future when physicians and medical students now have none of it? Currently, an average first-year physician has to be on-call every other 3 days - that means aside the routine 8 to 5 clocking, one has to stay back from 5 to 8 the following day attending to sudden or emergent needs of in-hospital patients. Medical students may have less on-calls but more homework. While students of other faculties are having weekly Friday parties, Saturday shopping and Sunday couch-surfing, the future physician can only "occasionally" enjoy such luxuries. We spend minimal time with family and friends to save up for studies and sleep. We may look and feel geeky not because we wanted to, but because our environment made us. We're constantly sleep-deprived and work-drowned but we still need to appear composed in front of profs, confident and in the know in front of patients, and smarter in front of colleagues or classmates. Quality of life? Forget about it. We're more than glad only to survive till the weekend.
I may appear a socialist or even a communist with this post, but know that I am not opposed to the current swift changes in medical education. Change is good, change makes us more competent and sculpts a better society. We may be physicians in the future, but we will also definitely become a patient not long after. I feverishly hope what on paper will materialize, but not at such rapid pace when the entire system is not sufficiently prepared. It's akin to rushing the second storey when the first isn't even complete. While change is good, change is also slow - it took America 147 years for its first African American president (after the liberation of slaves by Lincoln). There is no need to rush.

Choir Nostalgia

2010-10-12T23:44:00.000+08:00

Having fun is what choir is all about!

Journey to the Middle Kingdom: Xitang and Shanghai at Night

2010-10-06T00:20:00.002+08:00

With heavy hearts we left Suzhou on a brilliant afternoon taking the local express bus to Xitang, another little town south of Shanghai.
It was drizzling when we arrived. As usual, petty traders of all forms and functions were there - umbrella sellers, trishaw riders, tour operators, 'hotel' managers etc. With all deliberation, we weaved through all them good-natured samaritans and walked to the...

Gates of Xitang.

What's so special about Xitang is that it's a smallish water town, like a miniscule Milan with Oriental touches. They even have gondolas, but all manned by folks in their 60s to 70s. Some gondolas are even motorized - the Chinese innovation.

I Liked the tranquil feel exuded by this century-old town, especially when we arrived late afternoon during a light shower.

We had an early dinner overlooking one of the canals.

Then out to photograph the sunset at Xitang. My compact digital camera seems to love China, snapping shots I never expect this 3-year old 7-megapixel Panasonic is capable of (disclaimer: some iPhoto edits were done on these pictures).

The following morning we woke up at 6am to photograph dawn. From this you can see that we're obviously late.

Very late, in fact...

The town is rather photogenic - microscopically it's quite dirty actually - centuries of dust consolidated in gaps between tiles and bricks, and your chef cooking the plat du jour just beside the river which they wash their clothes and mop their floors.

But, well...

After that we head back to Shanghai. For me it was the last day of my trip while for my "new" partner (did I tell you I changed partners during the trip?) they're just about to begin their Expo adventure.

We met a Shanghai in bad mood - after-work traffic congestion, and a typhoon just passed by the coasts of the city pouring water upon us. We managed to sneak to the antique street to find it all closed...

Then to YuYuan for dinner, photographed during an intermittent lapse of downpour.

After that rain literally barraged on us. The streets were transformed instantly into monsoon rivulets and here comes the petty umbrella sellers again. We hailed 10 cabs, all of them occupied. And we refused the unlicenced ones. After our shoes are completely soaked, we decided it's the same walking back and standing there. It was 4 blocks away.
Back at my hotel I was worried about my flight next morning - if it got delayed I might not catch my flight back to Taipei. While I hung up all my clothes and shoes to dry, without hope against the weak air-conditioning, I waited for the airline to call me.
Fortunately only Dad called to ask if I was having fun.

I insisted on taking a walk on The Bund, Shanghai's most prominent waterfront and the site of countless historical events in modern China. And thank god I dragged my partner there. The place was absolutely breathtaking. And thank God it rained before - crowds were much less and I love the reflection on the floor~

The opposite shore and HuangPu River reflecting all the neon and LEDs.

The trip to The Bund is a grand finale to my journey. I walked back listening to the radio broadcasting about "Modern Chinese Socialism" and all the country's optimism crammed into the next day's paper. China is indeed the next in-thing and future place to be, no doubt about that. We may hold prejudices against its people, its government, its undemocratic system, and perhaps the red tape, but sooner or later we would have to work with it. China is destined to be the next economic giant.
While Mainland Chinese still fares behind in creativity, innovation, and critical thinking (expecially in politics), they retribute these qualities with hard work, perseverence, and the Chinese spirit of never giving up even we overseas Chinese are proud of ourselves. We may live better lives or had better education, but are we as competitive as them in, say, 5 years ahead? We would be flung far behind by these tireless Mainland Chinese if we still assume ourselves to being the superior.
With that in mind I end my final trilogy of Journey to the Middle Kingdom.

My flight back to Kuala Lumpur departed on time and arrived a little early.

Journey to the Middle Kingdom: Suzhou

2010-09-30T00:16:00.000+08:00

After 3 days in the World Expo site, I'm ready for a less crowded China. Suzhou is one of the many peripheral cities of Shanghai and is famed for its Chinese Gardens, adored by the old-time scholars from dynasty to dynasty. Suzhou sees herself in various literary works like Cao Xueqin's Dream of the Red Chamber and a dilapidated poet's famous verse (in order not to exhibit my inferior Chinese mastery I will not provide a translation):

月落烏啼霜滿天

江楓漁火對愁眠

姑蘇城外寒山寺

夜半鐘聲到客船

Anyway, Suzhou has a combination of great gardens, less crowded public spaces and picturesque landscape - which in socialist China adds up to some degree of shunning and adoration from the people.

Taking the train there - socialism dictates there would be no "economy class" or "first class", rather, we have "hard seats", "soft seats" etc. This is hard seat. It's a good thing I'm in here only for 2 hours.

QuZheng Garden is a UNESCO World Heritage Site

An exemplary work of Chinese landscaping. Lotus ponds blossoming for summer.

We Chinese love geometrics, that's why we're good in math.

This is the famous poem describing the melancholic poet riding his sampan down the river overseeing HanShan Temple.

The river he sailed eastwards (all rivers in China flows east).

HanShan Temple, infiltrated by superstition and us Chinese.

Next we visited HuQiu or Tiger Mountain. Which this Leaning Tower of the East is based. This tower is approximately 1000 years old, and still standing naturally despite the 4 degree slant.

Again, parks and gardens in HuQiu

Sword-practising pond - imagine Shaolin-style kung fu masters practising their fencing (and wall climbing) skills here a millennium ago.

Suzhou Museum is designed by I. M. Pei, same architect as the Louvre.

Loved the geomancy and clean zen feel.

A Chinese scholar in olden times is not unlike the English baron or lords. Here's an example of their taste and style. All with a very zen feel.

A window.

Journey to the Middle Kingdom: World Expo

2010-09-21T00:34:00.000+08:00

My first trip to China was back in 2003, when change was around every Mainland Chinese's mouth and the dragon, after being held in captivity under Maoist rule, is ready to dominate the world scene again.
My first impression was not good - the knick-knack sellers, petty touts, trishaw riders and every other Mainland Chinese who would go an extra mile to squeeze another dollar from your pockets. Mum and Dad was extremely nervous while I was having fun climbing the Great Wall covered in frost; they grumbled as the tour guide literally concord through the Forbidden City, while my sister and I scalded our tongues and bloated our bellies eating Made-in-China food.
So I made a vow to avoid China in my future travels, that is, even though it's the origin of my ancestry and roots of my culture. However, my classmate talked me into visiting the World Expo in Shanghai. "What is world expo?" I naively asked my classmate.
To sum up, it's a materialistic muscle flexing by each and every country on planet Earth showcasing their biggest and greatest. I hesitated for a few weeks because this journey would cost me my future MacBook Pro. My scholarship is already taken to its maximum allowable limit and I still have 3 more years to go until I graduate. So I talked to Dad about money, discussed with several of my classmates who are interested, and drew out a plan that would cost the least while maximize my time in the Middle Kingdom.
My first part will be a 26-photo report on the World Expo, the second will be of Suzhou, the third on Xitang and Shanghai the Bund at night.

Part I: World Expo

The design of the queue areas are meant to treat each and every visitor like cattle.

You practically S your way through thousands of people on several feet of ground before you get into the Expo Park.

Our first pavillion - Brazil - nothing interesting.

Second pavilion - Central and South America - boring. And by now we're tired by all the queuing and crowd jostling.

The exterior of Slovenia was very interesting, though we didn't queue for it.

By nightfall we were queuing for Russia, a 2.5 hour queue. As it was our first day we assumed anything above 2 hours is considered "exhausting". Japan proved us wrong the following day.

We managed to sneak into Belgium-EU Pavilion before closing time at 21.30.

I really liked this pillar where all EU member countrymen greet you in their own language and interact with one another.

The following day, my partner decided to buy an Expo bench from one of the many Expo tauts. This flimsy plastic cost 10RMB.

The cattle herd entering Expo Site at 9.30.

I figured since I can't go to Israel (Malaysians can't), I might as well visit Israel in Shanghai. It turned out to be a rewarding visit.

Queuing for one of the permanent exhibits in the Expo Site. Expo 2010's theme is showcased here. Looks like queuing is becoming a trendy feature in "better cities" and "better lives".

Queuing for Japan pavilion - 5 hours, the flight time from Taipei to Kuala Lumpur.

Japan pavilion is also one of my favorites - robot playing the violin, wall-sized LCD screens and a Japanese opera. It's both fortunate and unfortunate that photographing isn't allowed, though that didn't stop the Mainlanders from flashing away their brand new digitals.

UK Pavilion at night. I love UK the most.

The seed cathedral

My final day at World Expo began with waking up at 5am to queue for reservation tickets for China Pavilion. I felt like a refugee waiting for rescue teams - eating my miniscule breakfast in my 1-foot by 1-foot space.

After 4 hours of agonizing wait, running 50 meters marathons and crowding with ten thousand Mainland Chinese, we got this credit-card sized reservation tickets. "Why are we doing this?" I asked my partner. "Because we're here only once!"

Then we ran 3km to Germany Pavilion to cut the morning queues. Forgive me for this picture, because the one I took while queuing was subpar, having to replace it with this one I took on the first night.

France pavilion which I have no opportunity to visit.

Germany features Balancity - city of harmony and balance, which I quite liked. They end the visit with a 20-minute interactive energy ball.

After that my last pavilion - China.

清明上河圖 or Scenery of Upstream during Ching Ming (ancestor prayer day) is a big feature. Sophisticated animation made the 100-meter ancient painting alive.

Land of Hope features China's aspiration to becoming a green nation. Though I have to say much of it is for show only.

I have to say I disliked the Chinese pavilion because it's grossly overrated and basically exhibits are kind of showy without real practical value. They didn't much control the crowd thus complicating the entire experience. When it comes to queue cutting and rushing for places us 'foreign Chinese' will never beat them on speed nor spacial utilization.
My 3 days in the World Expo was fun, lethally tiring, and opened my eyes to how Mainland China and Chinese is progressing in terms of culture, technology, and sustainable resource management. I will not comment further as it involves personal interpretation of events, but do feel free to discuss with me via commenting or when we have the opportunity to meet.
Next up: the garden city - Suzhou.

Shanghai, Penang, Taipei, Hualien

2010-09-13T23:41:00.001+08:00

What!? He's trying to buzz through his trip to Shanghai and jump straight back to the mundane schooling life of his! You think we'll buy that?
Allow me to defend myself. First of all, I would very much like to blog about Shanghai. However, finding myself in a packing whirlwind upon my return, I packed and sulked away one day, I'm riding on a plane back to Taiwan, this time with my sister tagging along. The following day Dad and Mum came as well and the entire Sim family is trotting on Taiwanese soil speaking Malaysian Chinese. While I juggled with anesthesiology and orthopedics 8 hours in the day, they were touring the beautiful mountains and seas of Hualien. Then my roommate terrorized my computer and it went into E1B1M1 coma for 4 days - ordered the terrorist to send it to my dealer to find out the RAM is loosened but the computer is otherwise intact.
So back on cyberspace yesterday, and we had our 6-hour clinical clerkship introductory course today. Preparing for Inter-Medical School Physiology Quiz in Universiti Malaya late September, a pathology conference mid-November, and the real clinical clerkship after that. You dare ask me to blog!?
Anyway, I promise I'll try my best to find time for posts. It's one of my hobbies and probably the last I can have time to afford once life at hospital begins. Starting at the lowest rank in the food chain, and being the nice guy that I am, I'm sure to be gobbled up and bullied by nurses, technicians, colleagues, seniors, patients, and even the washing women. So you're sure to find more interesting posts about these in the coming months.
So, brace yourselves for hospital lives, an autumn with lots of traveling, and God permitting, an interesting summer next year.
You guys want reports on Shanghai?

Sunday Morning in Penang

2010-08-26T17:28:00.000+08:00

We actually wanted to go hiking, up Muka Head and ending at the Lighthouse. But rain started *drizzling* when we were in Tanjung Bungah so we decided to spend it more laid-back.

Having dim sum at 9 in the morning, our driver Zhi Ming.

With nothing in mind we text Chien Gay to see if he's home. He is! So we headed to Chew Jetty. Parked our car at Lebuh Acheh to admire all the pre-war houses there.

When terrain suddenly change from land to timber and water, you're unmistakably in one of Penang's most famous sites - the Clan Jetties. Chew is the most well-maintained of all the jetties.

Chean Gay's house so happened to be in a scene of a recent Malaysian production "Ice Kacang Puppy Love". We went inside for some chit-chat and 2 hours just flew past.
Land in Penang is getting so expensive I'd buy myself a wooden house on seawater when I grow up!

Nearing lunch time, we left Chean Gay's house to hunt for food. Mr. Kuat suggested Amelie beside Cheah Kongsi, which we visited and was full.

So next we went to Prangin Mall (any mall is the most convenient place for food). We discovered excellent views up on the 6th floor parking space. All 5 of us stood there for a well 15 minutes taking photographs.

After lots of food and talking we went home. I went to my babysitter's house for another round of feasting later the evening. A weekend of food and fun.

Lingua Kopitiam Malaysiana: Kopi and Teh

2010-08-24T22:31:00.001+08:00

Let's start with the bread and butter of the kopitiam - coffee, or kopi in Malay and Hokkien, ka feh in Cantonese.
Malaysian coffee, unlike its western counterparts, is usually roasted in margarine until charcoal black. After your skillful kopitiam tauke (barista) made it into your cuppa it's usually ink black. It tastes sourish bitter with a little hint of charcoal. Traditional kopitiam will have porcelain cups and saucers like the one below.

Your standard kopi is usually served hot with sweetened condensed milk. Variations of kopi are as follows (for convenience's sake English will be in blue, Hokkien in red and Malay in green):
Iced coffee: kopi peng, kopi ais. They will serve you a large glass with 8 portions ice and 2 portions coffee. That's why we have...
Iced coffee, less ice: kopi peng ss'eng jioh, kopi kurang ais. If your kopitiam waiter happen to be a foreign worker forget the less ice option. It's too complicated for them.
Lukewarm coffee: kopi so'om, kopi suam. Not pipping hot but just nice for a good gulp.
Thick coffee: kopi kao, kopi kao. Double espresso.
Coffee with no condensed milk, sweetened with sugar: kopi-or, kopi-or. Or means black. Americano.
Coffee with evaporated milk: kopi si, kopi si. Somehow there's a perception that evaporated milk is less unhealthy compared to condensed milk.
Plain black coffee: kopi-or mai liao, kopi kosong. Mai liao means nothing, kosong means zero. Americano when Starbucks run out of sugar.
Coffee less sweetened: kopi kiam t'eng, kopi kurang manis. If you're in an Indian establishment please repeat the kurang (less) at least 3 times.
Thanks to aggressive marketing and probably very little competition back then, Nescafe is widely popular in Malaysia. The instant coffee brand has now evolved into a synonym for coffee, so you may also substitute 'kopi' with 'Nescafe' when ordering.

Now we can proceed to the teas. This is where our ethnicity comes into play - Indians usually drink black tea (Ceylon most of the time); while Chinese drink a wide range of oolong, green, white and black teas. However, the kopitiam serves only Lipton or Boh teh for everyday consumption.
Generally ordering instructions are similar as coffee. Flavors range from the Mamak (Indian Muslim) thick teh tarik to the Chinese bland teh-or.
Your standard teh is usually served hot with sweetened condensed milk. In a Mamak stall expect your barista to "pull" your tea to cool it a little before serving, with a thick foam on top of your beverage. Variations of teh are as follows:
Iced tea: teh peng, teh ais. They will serve you a large glass with 8 portions ice and 2 portions tea. The characteristic color of teh ais is what Malaysians refer to flood waters. That's why we have...
Iced tea, less ice: teh peng ss'eng jioh, teh kurang ais.
Lukewarm tea: teh so'om, teh suam. Not pipping hot but just nice for a good gulp.
No such technology to make your tea double in concentration, so we skip teh kao.
Tea with no condensed milk, sweetened with sugar: teh-or, teh-or. Or means black. No milk.

Tea with evaporated milk: teh si, teh si. Somehow there's a perception that evaporated milk is less unhealthy compared to condensed milk. For me I liked this option because one would not get intoxicated by the taste of condensed milk after your second sip.
Plain tea: teh-or mai liao, teh kosong. Mai liao means nothing, kosong means zero. Tea during sugar strike.
Tea less sweetened: teh kiam t'eng, teh kurang manis. Advice as above.
If you're still unsure of how these jumble of languages are pronounced, pay attention to the waiter or waitresses shouting your order to the baristas. They have the best pronunciation of Lingua Kopitiam (foreign workers excluded).
So the next time you find yourself in a kopitiam, please sit back and enjoy the hive of activities. The shop may be 100 years old, fumed with char koay teow smog and blackened by charcoal of grilling satay, but it's still the best place to have a cuppa!

Lingua Kopitiam Malaysiana: Prologue

2010-08-20T16:45:00.000+08:00

Back at a time when Starbucks was unheard of, before we have Old Town (in brand new malls), and chain outlets that sell exactly the same food all across the country, there was an even larger consortium of food outlets that tailor its services to local communities in small kampungs and large cities alike. Its name, kopitiam, is a true representation of the 1Malaysia spirit - a combination of Malay (kopi for coffee) and Hokkien (tiam for shop).

If you think a kopitiam sells only coffee ala-Starbucks, then be prepared to be surprised by the versatility of the kopitiam tauke. For breakfast they cater a wide range of continental items that set the standards for these chain outlets in shopping malls to replicate - soft-boiled eggs with a dash of soy sauce, charcoal-grilled toast with thick butter and kaya, sweet tea or coffee that kick start your day.
Back when the person taking your orders or making your coffee isn't some foreign worker who understand only the first half of the order, the tauke takes great care in your drink. That's why we have an entire list of vocabulary that we leash out for drinks. It's even more complicated than "How Would You Like Your Drink" in Starbucks - we have instructions for hot/cold/lukewarm/chilled but less ice, we have instructions for the different level of sweetness (especially so if you're in an Indian kopitiam), we have options for milk as well - condensed milk or evaporated milk, and we have a whole range of genuine though diluted fruit juices.
The kopitiam culture defines who we are as Malaysian - our love for good food, our boisterous talking (that we even bring into Michelin-starred restaurants) and our laid-back lifestyle.
It is with this in mind that I decided to compile a list of Lingua Kopitiam in line for Malaysia's 53rd birthday. Afterall, 53 is my lucky number, and one can never get the oomph from the teh tarik served in Starbucks (if they ever come up with one).

Touring My Own Country

2010-08-17T23:28:00.000+08:00

Medical Licensing Examination, Step 1

2010-08-13T23:39:00.001+08:00

The United States has a cool name for it, USMLE or United States Medical Licensing Examination. I wished Taiwan has something as cool, but they just simply call it Medical Board Exam, or 醫師國考. Unlike its American twin it's much simpler with only 2 steps. Step 1 consists of basic medical sciences in 2 separate papers: paper 1 for anatomy, histology, microbiology, immunology, parasitology, biostatistics and public health; paper 2 is physiology, pharmacology, pathology and biochemistry. Step 2 concerns clinical knowledge with 4 papers roughly divided according to the Big 4 - internal med., surgery, pediatrics, and gynecology/obstetrician, with several canapes in between such as radiology, urology, rehabilitation medicine etc. It's not a fun exam but one has to pass it to begin your physician license.

The major challenge for me is taking the test in Chinese. The last time I had any major exams in Chinese was in Primary 6, and even though I'm Chinese educated my brain is, sadly, programmed in 26 alphabets. I learned all my basic medical sciences in English too.
With the language fear haunting me, and my decision spending 2 weeks in Medcamp, I started preparing for the exam as early as my winter break. It may sound boring but I started with anatomy and physiology - which I didn't regret because it laid foundations to all my subsequent studies. As the semester progresses into summer I found less and less time for my exam preparations until it got abandoned altogether before my finals. I didn't do well for my semester this time round.
After an insane Medcamp, the countdown starts - 2 weeks. Groups of us huddled around our PBL classrooms and begun our tedious 14-hour workday. If exams are the killer of fun in education, then studying is the electric chair, or the guillotine. My study drive eroded slowly as the exams draw nearer - afternoon breaks got longer, napping time gets longer, and then comes tea time, chocolate time, walkabout time, surfing time, and daydreaming time. I think I might have attention deficit disorder because at the end of 2 weeks I can't even sit without nudging for 30 seconds.
The sympathetic nervous system kicks in, stress levels skyrockets, and REM sleep (or restful sleep) got shorter. Everybody turns on their "exam mode" - not talking anymore, taking showers at 3am, wearing singlet and shorts to school, not eating, or eating the same food over and over.
Like most other examinations past-year questions became the golden standard, the Systeme Internationale. Those who obtain a pass loses motivation to study further; those who fail are too broken in spirit to continue further.
Then we seek spiritual support - from whatever religion and spiritual source there is. I personally paid my visits to Jesus Christ of a Taipei Presbyterian Church, a Taoist temple, great Buddha, our silent mentor, and the Goddess of Hell (sounds creepy eh? In Buddhism she's actually a very noble Goddess).
With the blink of an eye 31st July is here. I was jerked awake at 5am to see all 3 of my roommates grilling their books under the lamplight. I had 2 straight nights of very light sleep and was feeling groggy. I summed up all the stress hormones I had in my body, top it up with black coffee, and headed to the examination center - a high school about 3km away.
The Taiwanese summer and the smallish classrooms that were our exam centers don't make the experience a pleasant one. I was melting from the heat, suffocated by the humidity, and starving - because I dare not eat too much in fear of sleepiness - I have a problem with sugar spikes and neurons shutting down, so I had a cinnamon bun for lunch and went back watching others with their carbs and proteins.
As quickly as it started it ended. My instincts tell me I shouldn't have problems passing, but my brain kept dissecting and analyzing questions. It's useless to sleep with a disobedient mind, and my roommates were already in celebratory mood - 2 of them being sleepless for at least 3 days, I can't really tell.
That evening after packing up for home and washing my jeans and hoodie (a task ignored for 3 months), I slept the deepest sleep ever. In my dreams I became dean of medical school, abolished all kinds of exams, and students gave me a standing ovation.

Ticket to Johannesburg

2010-08-10T22:01:00.000+08:00

Everything began on a boring weekend afternoon, when we were still killing ourselves preparing for the Taiwanese Medical Licensing Examination, Step 1. As per my usual self I took a very long afternoon break - surfing the net in the library packed with 'holiday makers' during summer break - and just by chance I decided to check out Malaysia Airlines' website to see if there's anything new.
"Wow, how come my name is up there?" was my first thought upon seeing my name on the winner's list. It took 5 seconds for reality to wash ashore my stalled mind - I'm on the winner's list! And what's more, I won first prize!

Call me pessimistic but I've never had any luck at any such stuff - at lucky draws I usually end up with the table gift, I never ever once won in anything related to luck - not even when I called in RedFM to talk to a Malaysian writer when they promised a book - "You've read the book Mr. Sim? Then we'll leave it to the next caller! Bye!"
So I was skeptical about this for the rest of the day. It's also partly Malaysia Airlines' fault because I haven't received any notification whatsoever. Usually the winners are notified first before their names get published isn't it?
Luckily there's something called Twitter where I can easily chirp to anyone anytime. I tweeted MAS and got a reply almost instantly. Telling me they'll deal with me on Monday when everyone's at work. And I spend that night daydreaming how I would spend my free ticket at some country I don't even know how to pronounce - is it "Jho-hannes-burg" or "Yo-hannes-burg" by the way?
Anyway Monday came, and by lunch time I got an e-mail from someone called Jaime confirming my win and telling me to hang on till Wednesday. In the meantime I gathered what I had to learn about the South African capital - its sister cities encompasses London and New York, so I was impressed. Whenever I mentioned I won a ticket there to my Taiwanese friends they're either very excited because they think it's in Europe (let's face it, Johannesburg does sound European), or they'll shrug and ask where's that?
Nobody really shares my excitement, but I am not THAT excited to begin with. Mum says crime is rampant there while Dad asks if they can change the destination to somewhere nicer. SleeplessInKL suggested a side trip to Cape Town, while Dad's Taiwanese friend started describing how her experience was a decade ago. My already wavering excitement is quickly extinguished by lack of money and fear of losing my life.

Wednesday came and I received a soft copy of the letter attached above. Then another wave of reality washes up the shores of my mind - ticket validity is only 6 months, and the date they issued this letter was 26 July 2010. Which means the last day I can use my ticket will be on the 26 of January 2011.
This won't work for me because my winter vacation starts on 24 January and I'll be back in Malaysia on the 25th, which translates to only one day of me flying to Johannesburg if at all. Then there's another rule which states that any portion of the unused ticket lapses after 26 January - which means if I really do fly to JoBurg I'll have to swim back or hitchhike on the human trafficking boat.
Traveling this summer is a no-no for me because I've my Shanghai trip lined up, and all cash milked for the New York of the East. I obviously can't go to both New Yorks (East and African) in one summer - Dad would mortgage me away for the house loan. And I will have to ride on a human trafficking boat to Papua and sold as child labor.
Back to the point, I wrote up to Mr. Jaime Wong (self assumed to be masculine, how silly) and asked about the possibility of extending the validity. Jaime turned out to be a she, so I got rejected - non-negotiable, non-transferable, and non-exchangeable for cash. I guess my fate hasn't changed after all - still no luck at luck after all these years.
I'm keeping the letter as a momento of how luck brushed past me, by hair's breadth. In the meantime I pray for some winds of change, either on MAS' side or mine, that would allow me to board the flight bound for Johannesburg!

Observations Of Another Sort

2010-08-04T20:32:00.000+08:00

My Taiwanese friends consider me a frequent flier. I travel home twice yearly, I know my way around nooks and crannies to land myself a cheap ticket home, most of the time. Going home was my only will to live through my finals back in freshmen year. The feeling slowly evolved into excitement at the end of terms, and lapses now into just another part of the summer holidays. I guess I'm growing up.

Anyway, as the years go by the routine of traveling scrapes away any excitement left of traveling. The routine sets in, the unexpected slowly becomes the expected, and fatigue closes in. Sometimes the familiarity gives a little comfort - comfort of being home - but this too slowly gets eroded away with time. Much as I yearn to be home with my parents and sister, I gradually find life at school inseparable. Much as I detest the lack of everything in Hualien, I find myself wanting nothing when I'm surrounded by retail outlets in Taipei. The airports I frequent the most - Taipei Taoyuan and Kuala Lumpur are like the back of my fingertips I can easily navigate through them. Spot me sipping coffee at one of the best secluded spots and arriving at the gate right on smack of time for boarding. I glee at this familiarity but am worried the excitement is slowly evaporating - is this mid-life crisis?
Much as everything is becoming routine for me, sometimes the smallest actions of others will simply light up our very routine day. Take for example, the stewardesses was dictating meal options to me this morning - fish with egg fried rice, chicken with pasta or nasi lemak? Without hesitating I answered the latter, and perhaps with too much enthusiasm. She flashed a smile and asked how long have I been away. I mentally counted the months and said "it's been six months!" She laughed.
This is why I find Malaysia interesting. It's a country with unhurried people - people who are willing to sideline things just to bring his attention to your problems, people with their relaxing demeanor who will put you at ease even when you lost your credit card (sometimes interpreted as inefficient). Malaysia is a reminder of slowing down and smile to me, that I shall carry in heart.
Have plenty to blog about this summer, most still spinning in my mind, but will be out of town again tomorrow. See if DiGi Internet is as good as they advertised then!

T'is Cometh Summer

2010-08-01T11:46:00.000+08:00

Licensing exam ended yesterday. Screwed up pathology, hope I can still pass.
Got a haircut.
Packed.
Going to Taipei in 30 mins. time.
Back in Penang on the 4th.
And lots of traveling this summer.
Will post more when I'm less in a hurry. See you guys and enjoy the remaining summer!

Stories

2010-07-27T23:21:00.001+08:00

I have to admit I love stories as a kid. I think both my babysitter and my kindergarten teacher can bear witness to my loving for stories - I am least noisy and a troublemaker whenever it is storytelling time. I can finish the "Collection of 365 Stories" (meant to last for 1 year) in 2 days' time, back when I was in primary school; and listened to 7 days' worth of cassettes in an afternoon, sleeping on my belly while flipping through the read-along book.
I don't think it has anything to do with my reading skills - my reading speed was below average, and I am always too lazy to look up words I don't know. It has to do with my hunger for stories - the plot, the characters, the suspense and the resolution. Back then children stories were simple-minded and peppered with moral values, be it filial piety, being nice to strangers (still applicable nowadays?), sharing among friends or such. I knew children story writers would reach one of these some way or another, but how they get there is what I loved most. It wasn't until much later when I read Gogol or Chekhov I started to realize plot twisting was cool, and unchildish.

Anyway, with hospital clerkship less than 3 months away, I realize story listening is a very important aspect in physician's practice. Patients may come and go with the same disease, but the process of getting ill is usually the essence in medical care.
Take an example, a granny is repeatedly being admitted for fractures. A doctor who doesn't like story listening will repeatedly treat her fractures and send her home; a doctor with a good sense of curiosity and loves story listening delve into her problem and, say, find out she lives in an apartment with no elevator, and that granny, living alone, walks up and down 4 floors everyday 3 times daily. In the morning she carries a day's worth of groceries and food, the afternoon enough cash for her mahjong session, and in the evening the day's worth of garbage to throw away. If this doesn't translate to weak bones and frequent falls, nothing else does. Subsequent correspondence will solve the problem to its roots.
I believe many among us go to see doctors because we have a story to tell. I'm one amongst those labeled by doctors as 'the talkative, difficult type' - the last time I got scrub typhus, I went through the entire process of how I contracted the disease to how unsuspecting I was, thinking it was just common cold. And how my pathology professor said I have a 10% chance of dying if untreated to how I come to the hospital and gone to the wrong department. Of course, my doctor, also vice-chair of Tzu Chi General Hospital, stopped me by my 30th second.
I agree that most of the time the patients talk too much - their pets, their neighbors, husbands who cheated on them, children who don't listen anymore - which is why they come see a doctor. Modern research indicates even if patients were allowed to talk without interruption, the most they can go on talking when doc feels frustrated is 30 seconds to a minute. So that's not too bad afterall.
What this translates to a common layperson is this: talk less, listen more. You actually gain more by listening instead of yakking away gossips or how hard your life is. And when your doctor stops you, send him this link.

This Feels Like Summer

2010-07-21T00:05:00.000+08:00

I'm Yours by Jason Mraz

So I won't hesitate no more.
No more, it cannot wait. I'm sure.
There's no need to complicate our time.
It's sure, this is our fate. I'm yours...