Curriculum

After reading one of our teachers' blog, I couldn't disagree on what he said.

Having gone through the medical year three curriculum, what I feel is that we were having the third pre-clinical year, rather than the first clinical year. I expected we should have received more training on clinical than basic science. Nevertheless, they are fundamental to clinical medicine, but they cannot be over-emphasized. While I was in my pre-clinical years, I thought clinical years will be challenging, in the way that there would be always exciting things happened around me. Yes, exciting things really happened, while we were reciting things.

At the beginning of year three, Prof. JS said, "A student nurse knows more than you." This is of course! In contrast to nursing curriculum, we have far much less to learn in practical skills. For the theoretical side, I must say their lecture notes are or less similar to ours, in terms of quantity and quality. I was deeply impressed by one of the student nurses in a non-university based nursing school, when she could fluently tell me the five etiologies of hyperthyroidism, and clinical presentations of Cushing's syndrome, knowing the complications of TURP, and management of hyperkalaemia. Our future nurses are having similar level of knowledge as us, what next to compare, is our practical skills.

Yet, we focus on physical examination skills targeting various organ-systems, but it is not enough. Say, student nurses have sessions on "How to assist a sterile procedure", "How to scrub up in an operation theatre" or "How to insert a Foley catheter / Ryles' tube" in a simulated laboratory before really coming into practice. For us, merely none of them. Surgeons were shocked when they learnt about that scrubbing up was not taught in our newly furnished skill laboratory. All these were learn totally and only from bedside. I can imagine how the crocodiles replied "Well, we expect students to go more to wards and operation theatre, in order to expose themselves to more procedures, and learn though these process."

Damn, I know. Going back to the last entry, 又要羊兒好，又要羊兒不吃草. The problem is, we have no time to expose ourselves to clinical environment. The root of problem is those regular summative assessments (SA), with two of these holding monthly, taking us away from wards and theatres. In the past, the MB was done in days, with these four major subjects were examined at the last of a year, and to the best of my knowledge, there is nothing like summative assessment.

From our seniors and teachers, students were fond to attach at night, following house officers admitting cases, sitting in the out-patient clinics. I also noticed that there were "blue progress sheets" on wards for medical students to put down their notes into patients' case history. These were not our draft paper, as I once came across a senior nursing officer briefing her subordinates, "These blue sheets are for medical students to put down their notes into the case history (to bullshit on blue sheets?) . However, it is rarely done nowadays."

Teachers, I can realise that you would like to dilute the pressure of studying MB, by cutting it short and diffusing it into regular assessments instead. However, two problems arise:

• The MB is really too short for differentiating students. I must say, I did not deserve a distinction viva and some of us did not deserve a fail.
• Those regular assessments are our trammels (緊箍咒), inhibiting us from devoting ourselves to clinical medicine wholeheartedly.

There were many opinions saying that many medical students today stay away from wards. Yes, this is true. But please! Please look into the problem behind. The reason was not we are too lazy, we are actually too hardworking. With an examination ahead, one may treat it as "no big deal", but most of us did strive for merely a pass. Ya, a pass only, may be a bad pass. Two more problems concerning the summative assessment per se:-

• The topic was too board with too few MCQs.
• The result was released in grades relative to our classmates, not the marks we scored.

It is impossible to study everything hard, except some bright students, while most of us are not. You may think less is better, but you know percentage right? We can easily fail ourselves in just half a dozen of MCQs. More often, those MCQs dig on minute things that was rarely seen or hardly correlated to the goal of lectures. While the grades can reflect your position in class, this would only induce competition, more probably a vicious one. I agree that competition does enhance improvement, but couldn't those examinations be reflecting how much knowledge I had learnt, not how high I got by stepping onto the heads of my classmates. To cope with this unchangeable reality, we have not methods but to skip wards, in order to gain more time for study.

Writing case reports is one way of assessing students, but it is not the best way. Most of the time we were "referencing" from the sample case report, or the case notes; and I can see some teachers did not really read through my report, having it returned to me with simply a score on it. I learn nothing from writing. In addition to bedside teaching and tutorial, we have nothing else to do. We may choose to attend operating theatre or outpatient clinics, but what hinders us has been discussed. Besides, we are isolated from the day-to-day ward duties or activities, nobody wants us or welcomes us. We are so unimportant. Therefore, we leave, as we, hardworking loyal lambs, have to utilise our time best to study for those summative assessment.

"若要羊兒好，讓羊兒吃草。" If the crocodiles really want to improve the number of students stay in wards, please:-

• Abolish those summative assessment. Since SA is the root of problem, but it is impossible.
• Increase the number of MCQs. So as to cover a boarder topic and get harder to fail.
• Give results in the marks we scored, plus or minus relative position in class.

To increase the attractiveness of staying in wards, BEFORE alleviating the pressure on regular examination, please DO NOT add the following into our clinical teaching:-

• Every student have to take up two to three patients in his ward.
• He is responsible to see his patients at least once daily, and present the progress, or be it less formal, discuss, his cases with the case MO.
• He should write progress notes daily with those blue sheets, which has to be co-signed by MO.
• He may also write about management plan. If possible, his plan may directly taken into action.
• He may choose to perform or assist procedures (blood taking, pleural tap, lumber puncture) of his patients.
• Follow his patient to operating theatre, endoscopy centre, or radiology department. I bet many of us haven't seen how a CT is being done.
• On-call to 9 p.m. once biweekly.

Well. May be I have talked too much. Time to shut up.

End

Lambs kept in custody before crossing the river. (Jimmy Leung)

Everything has finished finally. I took a deep breath by the time I dragged my tired body out of the examination hall. In fact, the Surgical OSCE was not that difficult, only my nervousness had affected my own performance.

Here I have to thank the old, no, (some crocodiles will ask me how old is old) experienced nurses, irrespective of their ranks, enrolled, registered, or officers, at the out-patient clinics who assisted the examination. Before the start of examination, the lambs were escorted to the designated rooms, standing like a log outside the door, looked agitated, with fine hand tremors and sweating palms. Unlike the cunning crocodile who took a photo of the restless lambs, saying "Don't fall down during the examination, you will only be dragged aside" (whether it is a humiliation or humour, depends on you); the nurses, on the other hand, knowing that the lambs were nervous enough, tried to comfort us by saying "Boys and girls, this is only a minor examination in your life." "Come on, you good boys will be free to summer holiday one hour later!"

We had a label sheet with us during the examination, and we had to give one sticker, with our name and number, to the crocodile inside, or stick it onto an answer sheet once we entered a room. The most shitty thing happened when I found my little label sheet was not in my pocket at the resting station, probably left in the previous room! I waved my hand towards the nurses and a mother-like enrolled nurse attended me. I told her my situation in few words, and without hesitation, she made my label sheet back to me in few seconds. The nurse, probably treating me as one of her children, kept on reminding me to put it back to pocket after taking one sticker. I thank her for not only taking back the labels for me, and also her lesson made me a bit relieved when I was that tense.

The lambs were escorted back into quarantine after examination to avoid any contact with those who haven't sit the exam. No mobile phones communication was possible as they were stripped by the crocodiles. No computers were allowed either as messages may spread through the Internet. Bored enough, we found our own way of making fun, besides discussing the questions and performance, we played around with the little sticker left behind on our hands. Two hours later, the sheeps were freed and started their summer holiday.

----------This is a breaking line----------

Sad enough, some of us were still held within the mouth of crocodiles. Virtually all sheeps attending the pull up viva failed to escape. The more unfortunate ones received the bad news just minutes before handing in their mobile phones at the registration counter, which directly affected their performance at surgical OSCE. You know what, if one failed viva and OSCE at the same time, there will be no chance to take the supplementary examination, i.e. straight repeat.

To most of us, it is quite the end of term; to some of us, it would be the end of world.

If a pull-up viva does not mean to pull anybody up, what is the point of holding a viva? I know nothing about the marks or the marking scheme, may be some of us really deserve a fail anyway after the viva as the marks are too low, so why don't fail them straightly then? Human beings are still human beings, there are always bias. If a distinction viva candidate is allowed to choose what he is most familiar with, why can't a pull up viva candidate do so? You may say, oh, it's because he had failed. Come on, why don't you give him a chance to show his power, in certain areas, at least?

You failed him finally, because he cannot answer the pharmacodynamics of warfarin, the pathogenesis of typhoid fever, or name all sorts of breast cancer under the sun, which are, considered basics of medicine? You may argue, knowing nothing about warfarin will lead to coagulopathy; ignoring typhoid will lead to public outbreak; confusing benign and malignant lumps in the breast may lead to unnecessary mastectomy which is disastrous. Men, we are training house officers, not specialogist. Please, let him defend himself. I am sure that he knows when should we talk blood for INR, how to manage a patient diagnosed to have typhoid, and how to approach a breast lump by triple assessment. More than that, he must be confident in telling you what are the ten causes of arrhythmia, what to do if a patient has hypernatraemia or hypocalcaemia, and makes at least five differential diagnosis of acute abdominal pain and relevant investigations.

If you are so fond of those -logies, please drop two of your fascias in your year three curriculum. One is "Integrated Medical Science", another one is "Junior Medical & Surgical Clerkship". First of all, I see nothing integrated. The examination, I must say, is solely set on the basis of -logies, to distinguish brilliant lambs in that -logy, to invite them to vivas and giving them prizes. Secondly, there is nothing in those clinical clerkships can apply. Nothing about signs and symptoms, possible aetiology? A few. Investigations? A little. Differential diagnosis? One. I am sure that if I rely totally on my dear Yellow Bus, what I get will be a fail, but your notes, is mostly impractical in my future! How can you persuade students that going to wards is better than studying in library? The examination questions, if not far from, then it is not close, to the reality.

I am not surprised to see some really smart guys sweeping medals in those subjects, they deserve the honour. But what made me frustrated is, we don't actually understand what the Tower expected us to learn. The crocodiles must have my question replied in a bureaucratic tone, "Well, we fed our lambs with the best grass, they are herded in the most spacious field," with a hesitation, "Therefore, we expect them to be masters in all subjects, as well as a compassionate, confident, and professional medical doctor."

There is an old Chinese saying, I modified it a bit, "又要「羊」兒好，又要「羊」兒不吃草". Despite the fact that you are taking in the top 1% of lambs in this town, you cannot deny that all of them are just identical. Each of them has its own mind, memory and feeling. They already spent three years' time in the Tower, burning oils, burning all sorts of textbooks and notes, and, their lives. One had already burnt out last December. Taxpayers have invested a million on each of us, and each of us have invested our springtime to strive as loyal lambs. Although the Tower have to safeguard the quality of her lambs produced, please kindly put your foot into others' shoes and think twice, before ruining our future.

We are little, but not weak.

Some of us being snapped, is because they lost their way in finding a safe crossing point of the river. I have to revise my saying, those being put to the pull up viva, are not those run slowly. It is only they are unfortunate enough to discover the stepping stone. We are naive, and our heart is fragile. Well, heartbreaking can be a way of training, and I understand that it is inevitable in our growth. May some nice crocodile in the Tower, please, once again, think of their goal of education? How many 赤子之心 you want to break before we graduate? Actually, what does your highness expect us to do? Basic science, or clinical? Not both, please.

p.s. I Hope this won't make me the next sheep to be slaughtered.

Viva

This is to my very surprise that I was invited to a viva voce. For those who know nothing about Latin, it can be literally translated to "a living voice", meaning "an oral examination", which is very frequently employed in academica for candidates to defend their thesis.

In the Great White Tower, only two kinds of sheeps are eligible for the viva, those run ahead, and those at the back. The crocodiles would like to know, though the viva, have a better idea of their preys, that how fast and slow those sheeps can run.

There are four parts in the examination papers. Only by chance and luck and the grace of God or whatever, I accidentally squeezed myself into the sheeps in the front at one of the four parts, and, being picked up by our nice crocodiles. When I first saw the viva list, I was very glad that I was not in the list of failure. When I felt relieved and scroll the list down lightly, I was very shocked to found my name in the last line of the last page.

Nevertheless, I have to emphasize that I hate that part most. Very, very, very. I don't know what the bullshit those bastards (yes, our dear crocodiles) are talking about. When I have finished the examination, I shouted loudly outside the examination hall "Damn crocodile who and who go to hell!" and that who and who crocodile picked me up three days later in his letters patent.

From that day, no more sheeps will trust me that I hate that subject most, but actually I do. I am not telling lies to cheat others and ease others' tension on revision, on the other hand read through all the textbooks on that subject twice. No. No. Never.

When I saw my name on the letters, although it is an honour to receive a viva in this way, I am not too happy at all. The only thing in my mind is that "Oh my God, I have to attend one more damn examination at the risk of being tortured by those crocodiles!" Only minutes later, my friends keep on sending me their hearty congratulations. Thousands of thanks!

I have to confess that I was not intended to strive for this honour, and this is really unexpected. All of my aim is to attend no viva at all. I truly believe that some of the genius and/or hardworking sheeps next to me deserve this honour more. This is a bonus for me, I have to say.

Before leaving for the examination room, I met a friend who was garrisoning the Great White Tower at the library, while I was busy flipping through Robbins in the last minutes. I expressed my nervousness to her, being so worried that I will spoil the honour given to me in case I perform badly in the distinction viva. She then gave me a metaphor, 'Say, you were one of the shortlisted candidates for Best Director in Oscar, and you lost finally. Do you feel shameful or not?' 'Not really.' I hesistated for a while, 'Still, I am lucky enough to be shortlisted.' 'Keep this in your mind and proceed to the viva.'

Thanks to the genius who told me my fate half a minute beforehand - there were only two nice crocodiles to confront.
Their first question was, 'How do you feel?'
'Nervous, of course,' I replied, 'This is my first time to have a viva examination'
'Hmm, I can see that you are quite tense, just sit back and relax.'
'It is very unexpected. My panel results are actually quite, so-so, or sometimes, poor.'
'Well, forget about that, those things are just for fun.' the crocodile gave me his classical cunning smile, 'We are looking for students that are good at our subject.'

Damn I hate your shitty subject most.

I was allowed to choose which topic I wanted to discuss with them, and I chose Gastroenterology and Central Nervous System. Well, they think that I shall never defeat them in any subject, so just let me choose the ones I think I was good at and shoot me down right there - the best humiliating method.
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Alien language follows:-
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The question began with polyps. A crocodile from the other side of the globe asked me on how many types of benign and malignant polyps do I know of, followed by Familial Adenomatous Polyposis (FAP). Then I came across a tricky point that, for patients with FAP, the chance for a single polyp to turn malignant is higher, the same, or lower than those without it. The answer is - chance for each polyp is the same, only the number of polyp is more than a hundred time different. He was also interested in FAP related syndromes that named Gardner and Turcot, and whether FAP can be cured if total colectomy is performed. I could only say that it cannot be cured and can appear somewhere else, but guessed one of the two alternative sites wrongly. I was asked on the screening of FAP, which he was looking for the locus 5q21 and gene name APC. The topic ended with to Gastro-Intestinal Stromal Tumour (GIST), what I remember for it was the expensive tyrosine kinase inhibitor, Glivec, and, my helpless face when I was asked the resistance mechanism of the tumour to it.

The local crocodile began with 'What is the commonest brain cancer in adults?' This was a notoriously tricky question, just like 'What is the commonest liver/bone cancer', the answer should be metastasis, metastasis, and metastasis, unless specified otherwise. 'Primary brain tumour, I mean.' 'Astrocytoma.' 'Which one?' 'Glioblastoma multiforme' 'How does it kill patient?'

'Infiltrating the brainstem, cardiorespiratory centre, blah blah blah.'
'Not exactly.'
'Tonsillar herniation, press on brainstem, blah blah blah.'
'No. What leads to tonsillar herniation?'
'Increase in intra-cranial pressure.'
'Yes, what are the signs and symptoms?'
'Headache, nausea and vomiting. Anisocoria, focal neurological deficit like hemiplegia.'
'No...what is the global changes?' I was frowned at.
'Coma!'
'Excellent.' I received the classical cunning smile again.
Finally I got his mind after hanging around the garden for so long.

Then the topic was switched to 'tell me the secondary causes of kidney disease'.
Common things come first, hypertension, diabetes mellitus, systemic lupus erythematosus...
'Can you think of any deposition into kidney?'
'Amyloidosis!'
'What is the causes of amyloidosis?' When he asked, I got a sense of digging my own grave.

'Tumour!'
'Yes! What tumour can cause amyloidosis?'

Shit! I really dug my own grave.

'Any kind of tumour that can produce lots of protein?' The crocodile tried to help me when he saw my hesitancy.
'Err...may I guess, it is multiple myeloma?'
'Ha! Come on, you actually know more than your confidence!' A cunning smiling face appeared in front of me again.
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Alien language ends here.
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The examination ended when a photo was taken on three of us, with my back facing the camera. I came out of the examination room without any lacerations, contrutions or bruises. No crocodile biting marks, of course.

When I returned dorm, seeing the gang of fellows aggregated in my room, I can strongly feel our brotherhood. To my deepest sadness, one of my friends was caught by the crocodiles for not running fast enough. I disclosed this bad news to him on phone while he was out and I was reading the letter, dare not to tell him my name was also on the other page of it. He had been living with me for the whole year, and we studied together days and nights before the exam.

I can produce no reason why one of us was invited to the distinction viva and the other one was on the pull up viva. I can speak for him that he is not a lazy, nor a stupid sheep. He studied the same notes that I am studying. I am stronger than him in some areas and he have more knowledge in other areas than I do. I must say that we are essentially at the same level.

The only reason I can attribute to is that the questions are not well set to let him show his power, and, what is in my mind is that, though this viva, he will have a chance to defend himself in front of the panels of examiners, that he deserves a pass.

May I quote some Chinese proverb for myself, and both of us.

For me:-

"人無千日好，花無百日紅。求學如逆水行舟，不進則退。"

For both of us:-

"勝不驕，敗不餒。"

I have to be humble at all time, and may God help my dear friend, who is now sitting at the viva examination room, in front of a dozen of examiners, and send him wisdom and calm, to pass with every success.