Life's uncertainties

"Where do you see yourself in 10 years?"

That is a common question asked in an interview. Ask any business student, he may say something along the lines of "starting my own company" to "working in a big firm".

Ask any medical student in Malaysia, you may not get any answer. Why is that so? I guess it is because the future is really uncertain for us, with the incoming "storm"

The future for me is even more uncertain. I do not know exactly where I am going to be 1 year later, what more 10 years later. I may be anywhere within a few kilometers from my current home, to thousands of kilometers from my current home. I may be in my current timezone, to a totally opposite timezone.

And with these uncertainties, comes fear. Fear of the unknown is indeed one of the commonest fear we have. We fear a new working environment, we fear when opening our exam results, and also we fear the midnight tap at our room door when nobody was supposed to be home.

Fear is what keeps us in our comfort bubble.

But along with fear, comes excitement.

And with excitement, comes life.

A question that I have been pondering for quite a while, that I want to leave you with : If you know that you have to write a book about yourself at the end of your life, your autobiography, will there be any changes you would make to your current life plan?

The Jugular Venous Pressure

"Lookout for the raised JVP to help you in diagnosing conditions such as the CHF"

My professors and lecturers would tell me that.

But honestly, I never did appreciate the "raised JVP" well enough, ever. Many times, I will just pretend that I am able to see the JVP, and I would say whether it is raised or not in relation to the patient's history and other physical signs.

I wonder if there'd be a huge variation, in what I perceive as the JVP, and what my colleagues perceive as the JVP, and what senior doctors would perceive as the JVP.

Would I ever trust my estimation of the JVP to make a life-changing decision on patient management? 

I doubt so.

Board Games

One new hobby I have recently is playing board games.

No, it ain't "BORED" games, though sometimes it can get a little boring.

One of the reasons why I like playing board games with my friends is because it is like developing a strategy, solving a puzzle or going through an adventure, together (or against each other).

Here are some of the board games which I recently purchased :

Betrayal at the House on the Hill, Settler's of Catan and Pandemic

Allow me to introduce my little buddies to you.

Betrayal at the House is a role-playing game where we are all stuck in this haunted house, and have to explore it. The peak of the game is when one of the players become a "traitor". Each time the storyline is different. On one scenario, the traitor turns into a madman and becomes in command of a group of zombies. The players on the other hand, will have to trap the zombies in special rooms.

Settler's of Catan is a game based on building and trading resources on an island. The fun part of this game is when players start to cry out "wood for sheep! wood for sheep! give me the baa baa black sheep please!".

Pandemic is a game where all the players have to team up together to "eradicate" diseases. I guess this really is a WHO game, where outbreaks occur at various cities, and your task is to fly all over the world, trying to cure the disease.

Another 2 board games I have is Bang! and Saboteur. Both really fun, having an element of "Trust me i am your friend!" and later on "Haha, gotcha!".

Expectations of us

Recently, I have been watching (or re-watching) medical dramas and documentaries. And one thing I noticed common among Grey's Anatomy and Boston Med.

The level of competency and confidence of their interns are superb. And by no way is Boston Med a fictional program.

(for those of you who do not know Boston Med, it is a documentary about the lives of doctors in Mass Gen, the Harvard Medical School's hospital)

As I enter the final year of my medical education, I do ask myself a lot of times :

Am I ready?

Well, I guess I am able to spit out some short answers in the paper exam, and I am able to identify some images in my picture exam. However, can I really be confident when it comes to handling a patient in a real life scenario?

When I watch those shows, one thing I try to identify is when I graduate 1 year later, am I going to be able to be as competent and confident as those interns in the shows?

I guess I really need to catch up in this game of playing doctor.

The first thing I need to learn is that many times, the next best step to do after a history and physical may not be an investigation, but rather a "treatment". And many times, the response to the treatment itself may be the indirect "investigation".

I need to learn to ask myself, "If I were the doctor, what would I do? And then what? And then what?" for all the patients that I come across in my final year.

Step 2 Clinical Skills

End of last April, I took my Step 2 Clinical Skills in Philadelphia.

I have received a few questions on how is the exam conducted.

So here is what you should expect :

The exam is conducted in a test center. Basically, this place runs the Step 2 CS 5 days a week, 2 times a day.

All the patients in the exam are Simulated Patients. Basically, they are professional actors who have been trained for just 1 purpose = to simulate an actual patient, and to have a scoring sheet imbedded in their minds.

The exam consist of 12 patient encounters (stations), with each station lasting 25 minutes.

15 minutes to go into the room, take a focused history and a focused physical exam, as well as brief the patient on his/her disease and your plan for her disease, and then provide some basic counseling.

Then you will exit the room, head to the table located outside the room, and start writing/typing your patient notes for the next 10 minutes.

So your encounter goes somewhat like this :

PA : "You may now begin your encounter"

J reads the paper on the door, which has the patient's chief complaint, vital signs etc.

Knock Knock.

J : Good morning Mr W, I'm Dr J and I will be your doctor for today. How can I help you?

(after taking the history)

J : Thank you Mr W, I will now begin to examine you. (wash hands)

(after physical)

J : Thank you Mr W. Let me tell you what I think. Based on your history and physical exam, your abdominal pain is likely to be due _______. Other possibilities include ________. However, I will need to run a couple of test, being taking a picture of your chest, taking some blood for some lab investigations, _____, ______. Do you have any questions so far?

J : And as for your smoking habit.. (starts mini patient counseling)

J : Do you have any questions?

There may be 1 "though" question posed by the SP per station.

Mr W : Doctor, my wife told me about a herbal treatment of this disease. Will that work?

J : Herbal treatment have been suggested for many diseases. However, their safety and effectiveness may not be always clear cut. Let me know the name of the herbal treatment, and I will check its potential role for you when I see you later. Is that alright?
(just enjoy the role playing aspect, you can role-play almost anything. Just imagine that you are in the actual hospital setting)


Do note the patient will be the one giving the score for the clinical encounter, based on your questions, physical exam, empathy etc. They work there 5 days a week, and are exceptional at simulating a patient and having a checklist in their minds for your score.

Your patient note that you write later will be marked by an actual doctor.

All rooms have a video camera taping your clinical encounter.

The exam does not require heavy clinical knowledge.

The part where most international students fail to do well at is the "empathy and counseling" section. The OSCE back home focusses a lot on knowledge and skill, but not much on patient interaction (unless its a patient history taking station or patient counseling station). I am speaking based on a 5 or 10 minute physical exam OSCE station, where we have the examiner siting in a corner, and our findings are reported to the examiner. Most of the time, we are so focused on performing the perfect physical exam, and then discussing the case with the examiner, and the patient will just lie there, sometimes even going to sleep.

Instead, in the Step 2 CS, the patient is the "star" of the show, where we directly "report" our findings to the patient.

"Mr W, I find that you have reddish spots on your hands and yellowing of your skin" (all patient's make up)

You can check you an orientation video of the Step 2 CS via this link : http://www.usmle.org/Orientation/2011/menu.html