Sometimes, it is.

First father-daughter hair braiding!

Post-bathing ritual called 'Wrapped like Sausage'...
wrapped up my daughter from neck to toes with towel
She will start counting from 1 to 10 or go from A to Z

As she reached 10 or Z, I will lift her up high above my head

Lift off!!!

Skills training always starts with side by side tutelage.

Wife did my daughter's left, I did the right side.

Feedback: a bit loose at the beginning.
(Note: 'a bit' was added)

Zoom in on my side.

One-day-old braidman.

Upclose on my wife's side.

An experienced braidmaster since young.

Photography | Antenatal, Postnatal

Inside others' hearts...

Choose wisely

This is a pimped post from KevinMD:

An OB/GYN perspective on Choosing Wisely

MARGARET POLANECZKY, MD | CONDITIONS | MARCH 18, 2013

From ACOG comes five new cautions, part of the American Board of Internal Medicine Foundation’s Choosing Wisely campaign, to eliminate wasteful and unnecessary medical interventions that can actually cause harm. All the recommendations are evidence-based and have broad consensus.

1. Don’t schedule elective, non-medically indicated inductions of labor or cesarean deliveries before 39 weeks 0 days gestational age. Delivery prior to 39 weeks 0 days has been shown to be associated with an increased risk of learning disabilities and a potential increase in morbidity and mortality. There are clear medical indications for delivery prior to 39 weeks 0 days based on maternal and/or fetal conditions. A mature fetal lung test, in the absence of appropriate clinical criteria, is not an indication for delivery.

I agree. However, while,”medically necessary” is generally agreed upon, there will always be cases that fall outside the agreed upon parameters, and we need to respect physician judgement, patent autonomy and informed consent.  But when the parameters are exceeded, there should be documentation as to what the medical reasoning is and that the patient is well informed.

2. Don’t schedule elective, non-medically indicated inductions of labor between 39 weeks 0 days and 41 weeks 0 days unless the cervix is deemed favorable.  Ideally, labor should start on its own initiative whenever possible. Higher cesarean delivery rates result from inductions of labor when the cervix is unfavorable. Health care practitioners should discuss the risks and benefits with their patients before considering inductions of labor without medical indications.

I agree.  Again, there needs to be room for physician judgement and informed choice. Not every pregnancy can be as accurately dated as we’d like, even though it may seem obvious using the retrospectoscope, so we need to be reasonable with this and the first recommendation to allow for a realistic range of error.

3. Don’t perform routine annual cervical cytology screening (Pap tests) in women 30–65 years of age. In average-risk women, annual cervical cytology screening has been shown to offer no advantage over screening performed at 3-year intervals. However, a well-woman visit should occur annually for patients with their health care practitioner to discuss concerns and problems, and have appropriate screening with consideration of a pelvic examination.

I sort of agree. I have to admit that I am still having a little trouble with this one. I once diagnosed a very very tiny, early invasive cancer in a woman who had no history of abnormal paps and whose last pap was just a year prior. Not that anecdotes make for good healthcare.  I am using HPV testing to assist in the decision to back off on annual screens (If the test is negative, you can go 3-5 years between paps.) The recommendation has made me much more comfortable in reassuring patients, many of whom express guilt at being “late for my annual”, that they have not done themselves any harm. (Currently writing an upcoming post on the demise of the annual exam…)

4. Don’t treat patients who have mild dysplasia of less than two years in duration.  Mild dysplasia (Cervical Intraepithelial Neoplasia [CIN 1]) is associated with the presence of the human papillomavirus (HPV), which does not require treatment in average-risk women. Most women with CIN 1 on biopsy have a transient HPV infection that will usually clear in less than 12 months and, therefore, does not require treatment.

I agree. I have already been doing this for some time now in almost all patients, the exception being the occasional women with no recent new partners who is past childbearing, has visible lesions on colposcopy and would prefer treatment to follow up.

5. Don’t screen for ovarian cancer in asymptomatic women at average risk. In population studies, there is only fair evidence that screening of asymptomatic women with serum CA-125 level and/or transvaginal ultrasound can detect ovarian cancer at an earlier stage than it can be detected in the absence of screening. Because of the low prevalence of ovarian cancer and the invasive nature of the interventions required after a positive screening test, the potential harms of screening outweigh the potential benefits.

I strongly agree. I’ve been trying to do this for a long time, and fighting my patients all the way on this one. I hope that the publicity around it will lead to less requests for routine ovarian cancer screening.

The Choosing Wisely campaign is joined by nine medical societies, each of whom has identified 5 areas where wiser choices can lead to better health outcomes – and probably significant cost savings.  It’s a reasoned approach to the spiraling costs of healthcare.

Unfortunately, in some cases, not performing a test requires more time on the doctor’s part in educating the patient as to why that test is unnecessary. Trust me on this – it takes 5 times as long to talk a patient out of a CA125 screening test for ovarian cancer than it does to order one.

Margaret Polaneczky is an obstetrician-gynecologist who blogs at The Blog That Ate Manhattan.

Raised my hand

Those with answers, please raise your hand

I AM a houseman in one of the main training hospitals in Ipoh.

The Government has already issued a directive earlier about the implementation of the shift training system, whereby a houseman’s working hours is fixed at 60 hours per week in every hospital.

Why is it that some departments comply with the Government’s directive while others don’t?

The same reason why your university who passed you in final exam did not comply to the Ministry's standard in producing a good doctor, but instead lean on their political or royal connection and produced more calculative doctors who are more interested to count the hours they had poured into service rather than the quality of care that they had provided. 

I am working 86 hours in week one, 84 hours in week two, 82 hours in week three and 60 hours in week four of a month.

Why is it that some administrators at the hospital are not able to understand what the Government has already made clear?

Fyi, our government expired on 9 March 2013. If you care to read while you calculating your hours of service. We're probably waiting for a new government who will eff us less or continue to get more effing from the return of the current regime.

Is it because there is no penalty for those hospitals who refuse to comply with the Government’s directive?

Nope. There is no penalty for being righteously right about preparing the correct method/regime of training for our future doctors and not blindly follow baseless directive. It is called evidence-based medicine.

Are they so sure that housemen are very terrified young professionals who are too scared to voice their opinions?

You can voice your opinions all you want. Your opinion does not heal patients. Your opinion does not shame the 'older' professionals. If you're truly terrified, go see a psychiatrist. If you're not, you're a shame to yourself and your family - but I am willing to help you. I understand your fear and lack of confidence. 

Are the superior officers so affected by their old way of training that they refuse to see that the younger generation of housemen are capable of being good doctors in the near future, even with shift systems?

Nope, most had embraced it quite well. In fact, it is you and your fellow 'young professionals' who refused even to attempt to try even the slightest taste of how medicine was years ago where there's no limit in providing care. You take holiday or break, the disease/germ/bacteria/virus does not take holiday. Simple as that.

How can the current housemen be undermined before we even have a chance to prove ourselves?

How can we undermine you if you don't allow us to? You're confabulating. Read: Psychiatrist.
Maybe we'll come up with House Officer Olympics end of this year, just so you can prove yourself and earn a medal. I suggest Branula insertion relay, Blood bank sprint and Complaint letter to newspaper marathon. 

Do you think a houseman would not want to be an excellent doctor after taking the effort to earn his degree after five or more gruelling years at medical school, with such a high cost and with financial loans to pay?

Talk is cheap. Now, write is cheap, too. You want to, but you're too busy counting the hours of your service. I repeat, shame on you. Yes, you. 

I have so many questions in my mind but my last question will be: If anyone is able to answer my questions, will you please raise your hand?

I raised mine.

A MERE HOUSEMAN

Batu Caves, Selangor

P.S. My answer in Pink.

P.S.S. Please click on the ad on the upper right corner to support my movement on Anti-Calculative HOs.

Has our government expired?

The real expiry date:

Ministry of Health's Statement of the Year!

This letter from the Ministry is currently being circulated in the cyberspace.

Most of doctors who read it was in shock, anger and mainly vulgarities played a huge role mainly.

My best friend in the similar current apprenticeship as I am doubted this letter and thought it is a photoshopped letter.

Who could blame him for the content of the letter is totally absurd and goes way of the tangent of logic.

For the people outside medical field, let me put it into a simple language of the message being sent in this letter.

1. The Ministry have totally filled up the posts of Medical Officers up to 95% with some States fully occupied and some overfilled (possibly it's KL or Selangor).
Commentary: If this is so, it simply means the government has run out of doctor's post and house officer's post should be converted to temporary post.
2. The Medical Officers should play more active role in clerking and examining the patients.
Commentary: This is an overstatement because in our current state of house officers, most medical officers re-clerk and countercheck most of the clerking and examination.

3. House Officers should be fully undergo the shift system and they are to be trained, and NOT to provide service ( Not extra pair of hands, as well)
Commentary: House officers are being downgraded to Final Year Medical Students or less. Heck, I started clerking even when I was in med school and assisted as first assistant in few Surgical Ops. The most intrigueing part is why the FUCK is the Ministry paying every house officers around RM 5K each PER MONTH from the rakyat's money if they are not providing service or extra pair of hands, but to be trained. I thought it should be the other way round where one pays for the training.

Considering an UNDER-estimation of around 1000 house officers now, RM 5 millions every month are being drained out of Rakyat's money just so House Officers (luckily not majority of them) can lepak and called it 'training'.

Luckily at this moment, at ground level, such absurdity is not being implemented, but I am sooooooo ashamed to be part of such an important establishment which came up with such a shallow juvenile formal statement.

When I told my barber about it, my barber laughed her ass off.

"I don't think I can be trained to be a barber without holding up a scissor or a razor."

Simple logic which even the Ministry failed to grasp.

If this is implemented at the ground level, my Plan B would be to go apply for house officer's post in my current department, get extended indefinitely and spend 'my training hours' to study for external papers or do some research.

Sounds like a good plan?

Top 3 Excuses in Crisis of Lahad Datu

The chain of events in Lahad Datu are still forming a long spam of news on my FB's newsfeed, starting from the cup of coffee served by our Police

to their violence disobedience and disregard to our law

to the unfortunate deaths of the police officers

to our retaliation with the help of armed forces (with AirAsia’s help)

to the ‘ceasefire’ they offered

to the current persecution of the villainous figures.

 

 

And the spam continues.

Frankly-speaking, this is not a war or a battle.

This is simply an organized crime with massive weaponry, masquerading as Sulu nationalism, mainly to secure a part of the land of Sabah for their leader, unlikely to be the Sultan of Sulu. That leader or the leading perpetrator is still invisible to our national intelligence agency, mainly because this agency has little intelligence to begin with.

At his current state of health, Sultan of Sulu would rather spend his kingdom’s money to go China, get a kidney transplant and take him out of the dialysis routine, than to blow them all on bombs (no pun intended), rocket launchers and heavy machine guns.

Over the years, borders of Sabah had been left open without any worries mainly because any crisis that started there will unlikely to create chaos or escalate to the centre peninsular where centre of economy and governance are.

Secondly, it’s basically more of a fluid region rather thana hard state.

Thirdly, project I.C., besides serving the political triumph of Uncle M, it also manage to pacify the people that they are being very much welcomed into this hard state.

But the rules of the game change when heavy weapons came out into the picture.

Yet, our Defense Minister twittered the most unbecoming statement, belittling a group of people with heavy weapons.

If the similar situation was in Putrajaya, would those thugs be given the window for negotiation?

The death of police officers could have been prevented if enough intelligence was being collected beforehand.

Instead of allowing media to report it and our nation’s top leader to come up with the major strike which inevitably happened, they continued to dumb down the less internet-savvy civilians about the sentinel events that had taken place.  

Conclusion is the top leaders do not give a damn about Sabah or its people.  Mainly because how most Sabahans will vote in the next GE would not change, even if you load them with lots of goodies or a crisis like this exploded in their face.

And the top 3 excuses for their apathetic attitude on this crisis are:

1. We don’t want to cause any panic.
   What we don’t know cause more panic. How many of us, who are not in Sabah, near Lahad Datu, are actually shitting bricks when we know about the ‘invasion’.  Public panic is a pathetic excuse.
2. We don’t want to reveal our police’s and army’s strength and strategy to the enemy.
   You mean from our radio and newspaper, the enemy can find out all those top secret stuff? I must read and listen more to mainstream news. Another pathetic excuse.
3. It’s Anwar’s fault, anyway.
   Instead of focusing on the crisis, politicking takes priority. No wonder, the Russia’s meteor and the recent MU’s loss was Anwar’s fault as well.

 

Penang's Street Art Tour

Prepared by  Elaine Yap

Relaxin

http://www.realage.com/parenting-pregnancy/relaxin-and-pregnancy

Is your dream drowning in reality?

Life has been hell of a bitch to me.

 

Yes, it is a matter of perspective, I guess.

 

Wifey kept telling me to work hard and harder to be a success.

 

I had reassured her that I am already a success.

 

I have healthy loving parents.

I have a lovely and supportive wife.

I have two marvellous kids.

I have a steady and at times, noble job

I have supportive superiors who are enjoyable to work with.

I have great friends around me, some more superficial than others.

And I am healthy.

 

Nope, not this kind of dream.

 

Nevertheless, complacence should not be a barrier for my perseverance to climb to a higher heights in my life.

 

I have a dream and that dream should be never-ending, just like Ang Lee's.

 

Ang Lee: A Never-Ending Dream

"In 1978, as I applied to study film at the University of Illinois, my father vehemently objected. He quoted me a statistic: ‘Eve...ry year, 50,000 performers compete for 200 available roles on Broadway.’ Against his advice, I boarded a flight to the U.S. This strained our relationship. In the two decades following, we exchanged less than a hundred phrases in conversation

Some years later, when I graduated film school, I came to comprehend my father’s concern. It was nearly unheard of for a Chinese newcomer to make it in the American film industry. Beginning in 1983, I struggled through six years of agonizing, hopeless uncertainty. Much of the time, I was helping film crews with their equipment or working as editor’s assistant, among other miscellaneous duties. My most painful experience involved shopping a screenplay at more than thirty different production companies, and being met with harsh rejection each time.

That year, I turned 30. There’s an old Chinese saying: ‘At 30, one stands firm.’ Yet, I couldn’t even support myself. What could I do? Keep waiting, or give up my movie-making dream? My wife gave me invaluable support.

My wife was my college classmate. She was a biology major, and after graduation, went to work for a small pharmaceutical research lab. Her income was terribly modest. At the time, we already had our elder son, Haan, to raise. To appease my own feelings of guilt, I took on all housework – cooking, cleaning, taking care of our son – in addition to reading, reviewing films and writing scripts. Every evening after preparing dinner, I would sit on the front steps with Haan, telling him stories as we waited for his mother – the heroic huntress – to come home with our sustenance (income).

This kind of life felt rather undignified for a man. At one point, my in-laws gave their daughter (my wife) a sum of money, intended as start-up capital for me to open a Chinese restaurant – hoping that a business would help support my family. But my wife refused the money. When I found out about this exchange, I stayed up several nights and finally decided: This dream of mine is not meant to be. I must face reality.

Afterward (and with a heavy heart), I enrolled in a computer course at a nearby community college. At a time when employment trumped all other considerations, it seemed that only a knowledge of computers could quickly make me employable. For the days that followed, I descended into malaise. My wife, noticing my unusual demeanor, discovered a schedule of classes tucked in my bag. She made no comment that night.

The next morning, right before she got in her car to head off to work, my wife turned back and – standing there on our front steps – said, ‘Ang, don’t forget your dream.’

And that dream of mine – drowned by demands of reality – came back to life. As my wife drove off, I took the class schedule out of my bag and slowly, deliberately tore it to pieces. And tossed it in the trash.

Sometime after, I obtained funding for my screenplay, and began to shoot my own films. And after that, a few of my films started to win international awards. Recalling earlier times, my wife confessed, ‘I’ve always believed that you only need one gift. Your gift is making films. There are so many people studying computers already, they don’t need an Ang Lee to do that. If you want that golden statue, you have to commit to the dream.’

And today, I’ve finally won that golden statue. I think my own perseverance and my wife’s immeasurable sacrifice have finally met their reward. And I am now more assured than ever before: I must continue making films.

You see, I have this never-ending dream."

(Following Ang Lee’s second Best Directing win at the Academy Awards last night, this beautiful essay resurfaced. Here is my translation of Ang Lee’s words, written in 2006 (post-Oscar win). Please credit the translation to Irene Shih. thank you!)