The Mulu Pinnacles Challange 2020

Ever since the last post on my first 10k race, I have become rather obsessed with fitness. I have managed to finish two races this year, namely the Twincity Marathon 12k challenge (1:25:41) and the KK City Borneo Half Marathon (2:14:52). My consistent training was paying off. I was really looking forward to improve my time in the next races. Unfortunately, the COVID-19 pandemic brought all of these into a halt. Literally, the whole world went into lockdown. We were not even allowed to go out for a run. It was then I tried Zumba, Yoga, Strength-Flexibility-Mobility exercises, all done virtually. I found them really fun. More than anything else, amidst the social isolation, I looked forward to seeing the familiar faces in the virtual class working out together. However, the virtual classes were discontinued after the lockdown ended. And I went back to running, only this time, without a particular race as a goal. 

The idea of climbing the Mulu Pinnacles was planted by a friend. Having visited the Mulu caves 5 years ago, I have known of the Pinnacles, but I have never thought of climbing it. All the websites detailing the hike had grave warning like: ‘must possess above average fitness’, ‘not for beginner’, ‘high risk activity’, ‘difficult even for the experienced climbers’ – in other words, not me. I was unsure why my friend thought that I was indeed fit enough to do it. But on the other hand, this was actually the best time for the trip, as Sarawak had restricted entry into the state at the time to control the spread of Covid-19. It was cheap to visit at that time and we would have the whole place to ourselves, without the usual crowd of foreign travellers. In the end, I agreed. It served as the goal of my training. 

Training began in June. I would do between 3 to 6 runs a week, to build up and maintain my endurance. I tried to incorporate at least one hill session per week. I always run the BDA slope, which was 500m in length and 50m in elevation, then going downhill as recovery, and repeated 5 times. Hill sessions were always hardcore. I could feel the lactic acid burning at every muscle fibres over the legs and sometimes even running up my arms. I looked forward at reviewing my heart rate pattern after each hill session. 

We were fortunate to have a tour package had everything included (airfare, board, meal, registration fees, guide fees, entrance fees, boat fees) and we had little to worry about but to prepare our personal items. I indulged in shopping for my outdoor gears, my favourite item being the shiny navy blue 50L North Face backpack, purchased at a heavily discounted price. The day came when I said goodbye to work, then drove to Miri Airport in early morning to meet up with my three companions. And off we went to Mulu via a little plane. The plane took off 30 minutes earlier than scheduled. The first day was pretty relaxing. A boat ride brought us to Kuala Litut, then we had to trek 9km through a forest trail to the Camp 5. It was the first time in my adult life, trekking through a forest for this distance carrying a fully loaded backpack. It was quite an enjoyable trek, until it started raining. I stopped sightseeing, put on my raincoat and picked up the paces. It was only near the end of the trail that I realized that I have left my friends far behind. I stopped a few times to wait for them, took out my phone to record a few photos and videos, but the insects started to attack, so I pushed on. 

I arrived to find myself soaked inside out. I washed off the mud and pulled the leaches off my feet. I thought I would be squeamish, but it wasn’t too difficult after all. It was the first time in my life being bitten by leaches. I found out that I have put the waterproof bag cover the wrong way, and as a result, almost everything inside my bag was either wet or damp. I was especially sad to find my phone soaked and could no longer start. That was a bummer as I wanted to have a GPS recording of the climb to the Pinnacles. 

We settled into the camp easily. There was a group of middle age uncles who had just finished their Pinnacles climb early on in the day. They were obviously seasoned climbers. Even so, three of them did not manage to reach the peak. They were telling us the difficulty of the trail, in what way it was dangerous compared to the many other mountains that they have summited. We kept pressing on with so many questions. Yet, the more answers we get, the more anxious we became. After dinner, our guide with his assistant and the park ranger came to brief us about the climb. There was time limit for each of the three checkpoints, failing which we would be asked to turn back. Inclination would be steep (nothing less than 50%), and there would be sections of rock climbing and rope climbing. Should it rain, the climb would be cancelled for safety reason. Each of us was seriously questioning ourselves, especially me, who had never hiked before. We told ourselves to be prepared to give up if we really could not manage. Safety first, we just need to return in one piece. We went to bed early, but none of us could really fall asleep. The sound of the river and the forest were just a little too loud and disturbing for me. 

We woke up early the next morning and set off at 6:30am. We had to reach the first checkpoint in 1 hour, and I found this the most difficult. Actually, this part of the trail is comparatively the easiest to climb. However, pace needed to be fast, and it made one breathless. I could only keep up as we made several short breaks while waiting for my friends to catch up. After the first checkpoint, the terrain became more difficult and involved more technical climbing. The rocks are just there, and you need to figure out where you would put your hands and legs to push yourself up. It was challenging, but extremely enjoyable! It reminded me of my childhood days when I used to climb up my father’s big bookshelf spanning the entire upstairs living room like a spider man. The climb did not require that much of upper body strength than I previously thought. All of us managed to reach all the checkpoints in good time and eventually arrived at the Pinnacles. We were rewarded by a spectacular view! I would never forget my first glance at the majestic structures. What an incredible creation of nature. We spent half an hour absorbing the breathtaking scenery. 

Then, in a matter of minutes, the sky turned cloudy, and we worried that it might start to rain soon. I was the first to hurry my friends to pack up and start descending. It was at the beginning of the descent through the ladder sections that it started raining. Ladder section was the scariest, as one miscalculated move, one would fall from a height of several floors. The rain had made it more difficult as the rocks we relied on for grip had become more slippery. I was worried, but I just told myself to focus, one step at a time, forget about the rain, and get this section over and done with as soon as possible. Focus and concentrate were the key words here. Before long, the ladder section was over, the rain stopped, and my guide and I breathed a sigh of relief. 

That was the only part of the descent that I found relatively easy. The rest of the decent, especially from halfway point onwards, was a struggle. Words of the seasoned climbers and the guide who warned that ‘descending a mountain would always be more difficult than ascending a mountain’ came back ringing repeatedly in the head. I did not believe it when it was said to me on the day before the climb. Never in my life had I find descending an activity that require any effort. This time, I could truly understand what this means. I never thought the day would come when I could not balance on one leg to land the other leg on a lower ground. My thigh muscles were giving way. I had to use my arms to support myself through almost every single step. It felt never ending. I was ahead of my group at the beginning. However later on, not only did they caught up, I eventually slowed everyone else down. But I have to say there is no shame to be slow if it meant safety. I knocked my legs and feet against many rocks and nearly sprained my ankles a few times along the way, but no real harm done. We finally arrived back at camp safely just before sunset at 5:30pm. 

I did not sleep well on the night after the climb. Each time I close my eyes, I see more big stones to pass in order to descend the mountain. I spent the next few days walking sideways like a crab. I dreaded the sight of any stairs. It took one week for the soreness at the quadriceps to subside. We spent the last night at Marriott Mulu. It was rather a sad sight to see the beautiful resort so empty, our group being the only guest at the time. 

This trip was a very memorable one. I am so happy to get to know this group of friends. Only one of them was an old friend, the other two were new friends. We clicked so well right from the start. There was never a dull moment. We helped out each other in many ways throughout the trip. We were also lucky to be assigned to our guide, who was clearly competent and extremely helpful, looked after us well from the very beginning till the end of the trip. The muscle soreness was the only regrettable annoyance from the climb. 

I have to thank all of my travel companion for making this trip such an unforgettable one. I never thought I could ever climb the Pinnacles. This experience has taught me to have more belief in myself, taking on boulder steps out of my comfort zone. For even if I fail, what does it matter? 

First 10k run

This has been an unexpected achievement for me this year. Ever since I started working in Malaysia 9 years ago, exercise had not been a part of my life. Life as a doctor in training is physically and mentally demanding, and often in my mind, there was no room for anything else other than work. But something changed last year. I passed my postgraduate exams and my job scope changed into one of a clinical specialist in a smaller general hospital. That allowed for much more time to venture into a life outside medicine. I tried to get back into violin but the interest did not sustain. I was watching some videos on gymnastics and cheerleading, and I wished I was able to do some of those tumble passes. I also watched Paskal the Movie, and I wished I had the strength and endurance of those navy men and women, until I checked out their recruitment info and found out that I would not even have passed the physical test for recruit training. My younger sister, Annie, in the mean time, was looking super fit being a Zumba instructor, and I must admit that I really admired her toned body. Although I was not fat, my weight was edging towards the unhealthy BMI already, and I thought this was a good time to try loose some weight. Another wise sister, Cheng, gave me words of wisdom too: we often do not prioritise our body as we do not see it imminently important, but in fact it should be (in the category of not urgent, but important). I tried a few workout: Yoga, Barre, Pilate, short workout for ladies (arms/abs/core/gluts/full body). Then I tried running, first around the housing area, but the stray dogs scared me, so I switched to treadmill. Once on the treadmill, I started to pay attention to the stats - time, speed, distance, and before I knew it, the competitive self in me brought me back to the gym day after day, so I can outrun myself (how silly, now I put it out like this!). I started to keep a log of my workout. 

I also bought myself a fitness tracker to push my workout to the peak zone to enhance my performance. I was becoming serious, reading up on various articles and watching feature videos on metabolism and weight loss, building strength and muscle, nutrition and really what it means to be fit and strong. 

After a few months of running, I finally gained enough confidence to sign up for my first ever 10k run. I ran with two friends. We arrived early. Seeing a few other runners doing their professional  warm up moves made me nervous. But, after the flag off, I zoned into my comfortable pace and started to enjoy the experience. There were a few short uncomfortable moments of uphill slopes and painful muscle stitch. I would give myself an intensity score of 7/10 for this race. The run felt easy, and before long, I was approaching the finishing line. After the race, I was so happy, first and forth most, for completing a run of this distance, the longest distance yet for me, for the first time in my life. I set myself a modest goal of 1h 30 min, but in fact, I did much better! The the aftermath of the 'runner's high' is real: I could not fall sleep that night due to the overwhelming euphoria! 

This accomplishment has given the insecure me the much needed confidence boost to take on more physical challenges. I hope I have not started this journey too late. I look forward to playing around with the various modalities of workouts out there and setting myself more fitness goals next year.

Miss little boss

I was reading your blog. You didn’t tell me that you have been updating your blog! I really enjoyed reading your thoughts. I didn’t know you are such a deep person.

You are not the easiest person to have an idle chat. Even on the most trivial subject, you often end up becoming overly emotional by standard of a normal human. When emotion dominates, there is no way a reasoned conversation can continue, and I would never grasp your actual thought process. Through the stories that you have shared, I have come to realise that it has not been easy for you either. Some of the issues that you were talking about, for example being excluded by a popular group of friends in upper high school, were experiences of my past and many others, and had been settled (forgiven and forgotten) a long time ago. Yes, I did dismiss you when I shouldn’t have. Why? I don’t want to admit it but yes, it had to do with you being the youngest. Perhaps I thought such issues would become non-issue with time and maturity, just like it had been for me. I did not understand what a torment it could be for a young person still figuring out.

I sense insecurity. I see you are in constant need of external validation to assert your confidence. Is that so? Do you see that coming to an end? Do you want this to end? Hands down I cannot fathom this. I have never felt I need to look or present myself a certain way for others to make me feel good. If others are not happy with the way I want to be, go ahead and shun me out, I couldn’t care less. I only wish everyday, to do my part, to be as good a daughter and a doctor as I can be.

It is interesting that you do not feel you have accomplished enough. If it has not been obvious enough to you, let me reassure you that you are an outstanding young lady of your age. You are extremely passionate in the cause you believe in. You manage to get our family into environmental-aware mode (and trust me, it is not easy to change something so fundamental among our family members). Although I cannot share your passion with animals (I am allergic to dog dander), I now have a new level of respect for them and their rights. You are definitely a leader. Against all odds, you have successfully organised the Life of Stray event day. Sure, it wasn’t perfect, but it has definitely made an impact to all who were involved. Great job on the stage play, Cheng and I were super proud to have been the sisters of the heroine of the night, I am sure mum and dad felt the same. You have many talents. And when you are working on something that you are not so gifted in, you are diligent and persistent till you achieve your goal. You are the sort of young people I want my children to aspire to be. When I look at you, I see a prominently figured and naturally confident person. If I am looking for positive energy, I would look to your direction. You are kind, and you value friendship and relationship, something that I still do not think a priority.

Perhaps I can offer a useful suggestion. Do you really want to be like the prime minister and change the world? Rethink your role in the world. For me, that was my turning point. There after, I was more or less calm and content. Seeing that both of us have this bipolar tendency – ie when we are on a high we become extremely excited and energetic, and when the inevitable anticlimax comes, we are dragged into darkness and depression. It is not healthy to have such swings. I would say keep your feelings in check, try not to become overly invested. On the other hand, a downfall is not the end of the world. Too extreme of anything is bad, even if it is the best thing in the world, because when the balance tips over, you will be hit hard. I have read this is in dharma books before. Why should we not laugh and sing out heart out over the pleasurable moments in life. Before I didn’t understand, now I do. Balance it out. You are a clever girl. You will figure it out.

Do forgive me. I have been one of those who have failed to give you acknowledgement when you needed it most. I strive to be a better person each day. This is important and I must thank you for the reminder.

The dip

This is the emotion I feared the most. I was feeling over the moon over a month ago as I was finishing my PHDW rotation. I was performing well, exceeding expectation and building reputation across the board, ace-ing the procedures, having good relationship with the nurses and my bosses. Being aware of the bipolar tendency in me, I knew that the feeling was too good to last. I expected this to come, the inevitable dip.

This is it. I am in the hole. I cannot perform. One year and a half completely out of neonates and I have lost all the sharpness and sensitivities related to babies. I know I used to be good. Using my past self as the standard that I should reach now, which I am no where near, I am my biggest critique. I am disorganised, slow and hesitant, I doubt my own management plan, I attempt procedures expecting to fail, I let other people make myself feel inadequate, I cannot get over every small mistakes that I make everyday. It is dark over here. But I hope other people are seeing the tough, stoic face that I intended to put up. 

It does not help that several babies have died under my care in the short one month that I have started. The babies actually died, not one, but several. That must tell something about myself as the doctor. 

It does not help to feel I have to step up and impress at every occasion, now that the bosses are aware that I have signed up for the clinical exam, which would mean that I feel myself to be ready to perform as a specialist. 

I hope this is transient. I am trying to improve everyday. It is just if this dark cloud goes away, I can be a little more constructive in this arduous process.

.

Pre-empt

In the business of child health, a mentor once taught us that we must always be ahead of the babies and children. From the moment they come in, we should already be able to anticipate the course of the illness, complication and recovery, and pre-emptively sort them out. We do not wait until the problem arises, then go into a panic mode and make rushed decisions. 

In the district hospital that I used to work in, this ethos is well understood by the whole team. From the outset, if the doctor or nurse who first saw the child have any concern, whether it is a diagnostic dilemma or that the child did not look so good, we would talk to each other about it. We may alert the parents and the rest of the team about the concern or put on extra monitoring in a place easily noticed, and make sure that a senior personnel is to see the child before nightfall. When I first started in Paediatrics, I was an anxious ball and would become agitated over every tiny anomaly which I did not expect to find. But I am grateful that even as a junior member of the team, my concerns were usually taken seriously. Hence we are able to prevent lots of unanticipated problems. 

This is very different in the adult wards, especially the medical wards. It is extremely common to have several deaths in a day, more than half of those were unexpected, resulting in several 'crash calls' in a day (or night). 'Crash call' is a panic button that summons a team of doctors and nurses to come immediately, and is to be pushed only when a patient deteriorates critically suddenly. 'Crash call' in the UK hospitals are quite well run because the members of the team have been exposed to different scenarios simulated beforehand in training. But, over here, it is more like a circus of confused people arriving, no leader, no effective communication, only grumble and criticism at this most inappropriate timing. Needless to say, the patient outcome is usually poor. 

One of my colleague who used to work in the adult medical department, had recently join Paediatrics, and was asked to present on a case of a child who deteriorated during the early hours in the morning during his oncall duty. 

'The child was admitted at 3pm, with a chief complain of fever, altered behaviour for 3 days and 1 episode of seizure which lasted for 20 minutes'. On arrival his GCS was 11 out of 15 but haemodynamically stable. He was reviewed by the specialist at 5pm and started on antibiotic and anticonvulsive treatment. Night review was done at 7pm and the child's condition was the same. At 4am the staff nurse was called by the mum as the child had suddenly became unresponsive. On my review, the GCS was 3 out of 15, hypotensive and bradycardic. He was intubated and sent to ICU.'

The boss was clearly unhappy. 

'In medicine, there is no such thing as 'suddenly collapsed', 'suddenly deteriorated', 'suddenly became unresponsive'. I do not want to ever hear those words again. The child was last seen at 7pm, What happened between 7pm and 4am? The child was at the acute bed with continuous monitoring. What did the observation show? What was the level of consciousness in the interim?'

My colleague were unable to answer. GCS was not recorded and observations were not documented clearly during the interval 9 hours. For the child to deteriorate to the point at 4am, there would have been some signs that the body was compensating, and all the members of staff on duty that night have failed to pick them up. From this example, we all got the message and went on to improve patient care by working on this very basic principle of medicine for every single child that came through the doors.

I requested for transfer to this tertiary referral centre to further my training in Paediatrics. To my dismay, such basics are even more poorly done here. There is a systemic problem of too many staff, too many teams, too many leaders, too many egoistic heads, as well as a system of office politics and culture that have been ingrained in this institute for many decades that are not easily corrected. The Paediatrics department is huge and the sub-departments who are supposed to provide support are not always easy to talk to. I see more of the bad habits of adult medicine surfacing, for example kicking patients like a ball from one sub-specialty to another, or from one ward to another, to avoid the responsibility of being the primary team. Every workplace has its strengths and weaknesses, and it is working with the systemic limitation that upsets me because I cannot give the best to my patients.

However, as another of my mentor who has worked in this dinosaur institute for many years said: 'Aim to save one patient at a time'. I am a tiny minion and I have conceded that I cannot change the system. So I am using the principles of good practice that I have learnt to look after the few patients I see. And so far, I have been able to prevent a few patients from failling into the state of 'suddenly collapse' by starting antibiotics early, fluid resuscitating early, starting inotropes early, referring to ICU early. 

One of the parents once told me he would like his son to be admitted to ICU because he felt the doctors there are better. In his son's previous hospital stay, he had experienced watching the ICU doctors rushing to the ward in an emergency, intubating the child, performing chest compressions, inserting various lines to save the child. He felt that the ward doctors were inferior as these jobs are not their routine. This is the trouble with people watching too many dramas on TV, who sensationalises this heroic image of being a doctor. 

Please. Every doctor is able to help in any emergency situation, but to what extent? If only one can feel what a doctor feels during those surprise 'patient collapsed' situation: rushing to the scene, internally your heart is palpitating away, you feel a little dizzy from hyperventilating, your hands become cold and your brain starts to freeze; externally it is a havoc, no one knows what is going on, who is who in the team, who is this patient, where equipments are kept and who has done what. Besides, once a patient succumbs to the point needing CPR, much irreversible damage has been done. The patient stands little chance being treated in this extremely uncontrolled environment. It improves though, the profession has started to realise the importance of teamwork and effective communication in such high stake scenarios (but this awareness has yet arrive here, I am afraid).

Who you really want is a doctor who is able to prevent you from falling into that state. Problems are always easier to tackle when recognised earlier. There is completely no need for 5 doctors rushing to stick huge needles all over the patient instituting invasive treatment when one injection of antibiotic given 5 hours ago could have prevented all these. 

An unknown hero is the real hero. But a good doctors do not care, he or she just want to be able to sleep well at night. 

Do the basics well. Being able to pre-empt problems is one of them. 

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A disability is not a disability to a child

One of the most amazing insights that I have gained working with child is seeing how this group of little creatures adapt to misfortune.

Parents are often upset when they learn of a disability in their child. A child born without his right arm, a girl with a spinal deformity making her never being able to walk, one who has hereditary cancer of the eyes that defines her blind. Even the doctors and the nurses cannot help feeling pitiful for the kid. How is this child going to survive life, in this cruel, unforgiving world? We foresee the mountains of difficulties. The child would be looked at and treated differently. Kesian, kesian... This must have been the expression most commonly surround this child from the time he arrive in this world.

Fortunately, the child being born ignorant does not comprehend such expression. He does not realise that how others see him matter. He does not understand that it is a deficit to be born without a limb, or a sense. He simply go about exploring the world with whatever resource he has with him, and make a sense of this world. And he would find journey of exploration as enjoyable as his counterpart born 'perfect'.

S was my first teacher. He is now 18 years old. The senior paediatric orthopaedic surgeon of the team had known him since he was born and keeps a photo record of his case from the time he was a neonate till now. He showed us pictures of his legs auto-amputated from the knees while he was still in the mother's womb. As a result, his leg prosthesis have been part and parcel of his life since. Yet, there is nothing to feel sorry about for him. He is as lively as any other boys, who would sometimes test the patience of the the adults, just to see where is the line drawn. When I was attached to the team, this boy was admitted for infected wounds on his knees. He has been told to get off his prosthesis for a few months in order for the wounds to heal, but how would he go about doing Taekwondo (a black belt holder), going out with his girlfriends and training with his police cadet corp in school without his prosthesis? So the wound deepened and he was admitted. In the ward, we were able to take away his prosthesis to rest him forcefully. That was the plan, but it didn't work. Often I cannot find him on his bed, or even in his ward. He would often be on the wheelchair, roaming the corridors and in the other wards trying to chat up the other patients making friends. I once caught him in the men's toilet, holding on to the plastic bars frame of the toilet doors doing pull ups! When I met his mother once, out of routine, I asked her if S has been registered an OKU (as a disabled person). To my surprise, the answer was no, eventhough there is no doubt that a double amputee qualifies for the label. It is not because of the fear of stigma or anything complicated like that. The mum genuinely did not feel that S is an OKU, being him as he is doing normal this that boys of his age do.

This boy made me believe that there is no need to feel pitiful for children with disability, in contrary to what I have been taught. Remember those moral lessons in school, that compelled the students to have a 'sikap belas kasihan' to blind people? I am a sure a professional film crew can easily cook up a sob story about S along with all the melancholic sound effect to accompany the story of this unfortunate boy who was born without his legs. We have all seen it. But the reality is not like this. The difficulties they face in adulthood arises from such societal conditioning that we are subjected to. If we all treat S like how his mother treat him, i.e. a normal person who will try and manage with whatever resources that is available to him, there would not be any difference between us and them.

Later on in my career, I have had to meet parents of children born with problems. A child without a limb, a blind and mute baby as a result of a congenital infection, a child with very limited sight due to his extreme premature birth, a boy with speech delay who portrays features of autism, a child would cannot read and most likely has dyslexia, a child with cleft lip and palate etc. Parents to newborn with such problems are often very worried and upset, but I am always able to confidently convince them that it is a manageable situation, that it is not the end of the world. As the child grow up into toddlerhood, it is very satisfying to see parents bringing in their child to clinic in a relaxed state, sometimes chasing after their child telling them off for being naughty, in other word treating them like any other children. These special children know their children so well and takes pride in any strength their children display, and I am always delighted to learn about this side of them.

Cognitive disability is sometimes less easy to adapt compared to physical disability, just because of our education system which caters too narrowly for the most academically able group. I dare say of all the 'normal' children, at least half are not be able to fully benefit from our education system, in the sense that the system does not bring out the best potential of each child. I have often received referral from schools who want their student to be signed off as an OKU (with cognitive problem or learning disability) because they cannot keep up in the mainstream school. In the form, the doctor is suppose to recommend appropriate education placement for the child. I am often perplexed that I should be filling up this component. I am reluctant to label any child OKU just because they are non-specifically slower in learning compared to their peers, bearing in mind that I am not particularly a bright student myself. The teachers and psychologists are supposed to be the ones who are the expert in this field, not a doctor. I cannot simply choose and tick a box putting a label to a child after one clinic session. I often spend these sessions discussing with parents the actual aspects that is problematic about the child (in contrast to what the school thinks), the aim of education specifically for this child, how to ensure he can lead an independent adulthood. I teach them to rely less on the system and put more effort to help themselves.

A disability in a child is not a curse. It does not bother a child and it should not bother us. Every individual is unique in their own way and we should allow each to develop into their full potential in their own way. I thank all the special children and their family whom I have the privilege to work with in all these years, dispelling the dogma drilled into me, and teaching me a unique kind of resilience I did not know exist.

Becoming robot

This blog has been abandoned for a while. It is not that I don’t want to write anymore. I know a few of my colleagues have stumbled upon this blog and I don’t want to make my private thought public especially at my work place. But, I am now at the point of ‘TAK TAHAN LAGI’ and desperately need an avenue to vent.

I have been working here in this district hospital for a year and a half now. In the first few months, it was immensely enjoyable. The learning curve was very steep. I would come to work early and leave late to help around, get that extra bit of practice or to see the interesting patients. My colleagues would make silly joke all the time and made me laugh everyday to the point my cheek and belly hurt from exhaustion. The experience was so good that I declined an offer for a paediatric medical officer post from my old teaching hospital.

Now, it is just the opposite. I feel unmotivated. I feel work is routine. Every morning when I wake up, I contemplate faking an illness to be absent from work.

My upbringing, education and training made me expect a high standard of myself. It is not good enough to do just enough, it has to be better than that. Similarly, I expect my teachers to be better than me. I am trained to always keep an open mind, always ask why, always to look at an issue from different perspectives.

The problem with training in this hospital now is that the specialists in charge of the wards are new specialists, fresh from passing the exams, having been medical officers just like me a few months ago, sent here for a stint of gazettement. Hence I do not find their rounds as worthy for my training as compared to, say, a ward round with my previous consultant who was near retirement age. I do feel arrogant writing this, and I have tried to think of it another way. But there is no other way of putting it. This is how I truly feel.

The feeling is exactly the same like when I was a house officer having to do round with a junior medical officer, who did not having the experience to make any meaningful decision, whose basic knowledge was shaky at best and not only was unable to teach my anything useful, I found myself having to fill in gaps in their inadequacy. With this type of medical officers, I found that registrars and specialists often like to hear from me or convey their management plans to me directly, without going through the medical officer. That made life a lot easier for me without having to go through an intermediary.

In Malaysia, this is considered close to unacceptable. Respect for the people older than us, people who are considered our senior, people who are more experienced, had been drilled into every Malaysian kids by the time they finish school. My mere thought of the kind mentioned above would have me labeled as someone disrespectful. Biadap, they call it in Malay.

Of course, most housemen in Malaysia are not like me. Most are obedient and do not judge their medical officers like me. Most just follow order, get the job done, and that’s good enough. And that work routine carries on when one becomes a medical officer, who follows orders, who doesn’t judge their specialists.

Once mastering the basics after a few months at work, I began to think about our current medical practice, to read up more broadly. And I became more unsettled with a few things on the way we work. I started to ask questions. It wasn’t received well. They were often met with silence when I discussed them with my colleagues, and when brought up to the boss, occasionally ended with heated argument. 

It frustrates me very much when I am forced to practice medicine in such old fashion way. When I asked why, I get vague answers. I am not stuck up. If there is a plausible explanation, I can accept it. The logic around here probably makes as much sense as the logic of witchcraft. I don’t know. Maybe I have not enough grey matter to understand. Maybe there are extenuating circumstances why we cannot follow the standard practice and in accordance to the best available evidence.

I am critical of the way we manage things here. I feel things could have been better. But no one else would speak up. Sometimes I feel I am leading a rebellion, trying to convince my colleague of a different point of view from what the bosses think. And they do not take it well. They all asked me to tone down, not speak up. ‘Just follow, no need to think.’ I was told, and my soul would be at peace. She was too kind in her words. Another had harsher words: ‘She thinks she is smarter than the specialist.’

Paediatrics appealed to me because I feel paediatricians are proper clinicians. During housemanship time, I was most unimpressed with doctors from adult specialties, whom after only a quick cursory interview and examination, often order a battery of tests and imaging without much consideration or justification. In contrast, I liked what I saw in paeds. Answers were often found in a thorough history and examination. In teaching rounds, professors often encourage us to make accurate, confident diagnosis, to fine tune management. Yes, the child has been having fever for 3 days, but if it is a viral fever, there is no need for antibiotic. In those days, there cannot be such a thing as ‘antibiotic just to cover’. They pay attention to teach us clinical judgments – how to differentiate a viral vs bacterial pneumonia and the likes. And they pay attention to explanation and education to the parents. I believe this is how medicine should be practiced.

But it is not the case here in this district hospital. Not to say that histories and examinations were bad, but I just do not understand why it is so different. I cannot count how many children we ‘empirically treat as pulmonary TB’ without much as a shadow of lymph node on chest x-ray. There has been even more children, maybe in the thousands, subjected to antibiotics they do not need for viral illnesses. There has been too many unnecessary lumbar punctures evidence by the overwhelming negative results (I have never seen a culture positive CSF). Sometimes even myself as a junior medical officer, am able to tell with confidence that a fever is viral in nature, hence do not need antibiotic, only to have my decision overruled by the specialist later, adding antibiotic with the reason ‘just to cover’. Our head of department wants us to be safe, by over-treating rather than be perfect. I disagree. Every x-ray is radiation, every ultrasound takes up time (and every negative ultrasound makes the radiologist think less of us in paeds), every drop of blood is precious in a little human, and every poke is a trauma to the little one’s childhood. Overuse of antibiotic breeds resistant organisms. Over-investigation and overtreatment increase anxiety in the parents. If we are going to overtreat everyone, what is the use of learning clinical medicine? We only need to take a single sentence presenting complain, take a look make sure nothing obviously wrong, then proceed to all investigations, wack some antibiotic 'to cover', like how they do it for the poor adults. I am not learning much clinical acumen here as you probably can tell. Hence, I feel my time is up here in this district hospital. This is a shame. The myriads of disease presentation here is amazing and I could have seen the best of medicine here.

During university days, I used to run workshop convincing other students to join my cause for the right of refugees, fighting the policy makers, with a motto of never taking no for an answer. Here, nobody feels righteousness is something worth fighting for. In this lonely battle, I have lost confidence and motivation. I am tempted to give in, to quit thinking, to be comfortable and just follow like a robot.