Malaysian Public Schools

It has been two weeks since our move back to Kelantan. Another important transition year, moving from my hometown PJ to Kubang Kerian for the second time in my life, at the same time, having my eldest child start form 1, while my youngest girl started primary school, and middle son continue with his primary school, and of course not to forget, the little baby to deal with.

Now that the 'dust has settled', I finally have some time to sit, write and reflect.

High Performance Schools

My two children who are still in primary school have enrolled in one of the best primary schools in town. What does that mean? 84 students obtained 5A's in last years UPSR (compared to the school my kids attended in PJ where only 29 students got 5A's and 25 students 4A's). This school is labelled 'high performance' (sekolah berprestasi tinggi/SBT) and the outward appearance of the school is not disappointing.

Reflections:

1) So it does boil down to exam results because at the end of the day, that is what matters (is it?), at least for our current education system. Cant blame the system either because what else can be measured and compared so easily other than exam results? How about how the children eventually do in life later on? Obviously, this will require research and funds and hence we are limited some what to measuring and comparing that which is easily measured and compared.

2) The buildings appear new or well-maintained, painted nicely with many murals on the walls. I attended a talk for the Dual Language Program last week (during the first week of school) and was very impressed with the 'Bilik Gerakan' or meeting room that was used in comparison to the facilities of the school in PJ. The meeting room was clean and well organised, furniture appeared relatively new, it was also well decorated and there were pictures of linkages with other schools abroad.

On my way out, I also took some pictures of the gardens, being impressed with the landscaping.

Having said that, myself, being part of academia for many years, I understand that having impressive facilities and quality education are not necessarily things that come in hand to hand (one does not necessarily imply the other), and I am glad that I have this insider perspective. However, my experience has been limited only to higher education institutions in Malaysia. I do not know whether the same can be said of primary and secondary schools in Malaysia.

I heard that schools with special titles like 'high performance' (SBT) and 'cluster' obtained massive amounts of funding (RM700k per school and RM700 per child for primary school, RM1k per child for secondary school) as a reward for their achievements and so that they are able to maintain the results.

While I agree that good results must be rewarded, I sincerely hope that the competition is made on a level playing field and that rewarding some schools does not take away from funds that could in theory be used to help other 'more deserving' schools. 

Let us consider two students who attend public primary school, one is from a well endowed family and the other from a low income family. Which child deserves more help?

Here is a website with list of all the high performance schools in Malaysia:

http://www.moe.gov.my/my/sekolah-berprestasi-tinggi


What do I mean by a level playing field?

The student selection
The way public school system is Malaysia (and most other countries where I have read about the schooling system) works is, to attend a particular primary school, one must show evidence of nearby residence. Proof such as electricity bill or water bill is sufficient to justify. Having an older sibling in a particular primary school will also make it easier for the younger brother or sister to attend the same place.

In other words, the children who attend a school in Taman Tun Dr Ismail, for example, will be from a different socioeconomic background compared to those who attend a school in Kampung Tunku, Petaling Jaya. Why? Because the cost of homes in TTDI and Kg Tunku can be very different. And hence the children of certain schools will be pre-selected because of this.

(When I was looking for a school for my first child, at that time we were living in KL, I came across these high performance primary schools:
Sekolah Kebangsaan Taman Tun Dr Ismail
Sekolah Kebangsaan Bukit Damansara
Aren't these two areas considered 'posh' for Klang Valley standards?)

I have to remind myself to look up the list of all schools which are high performance and compare them geographically average household income wise with schools which are not.

Yes, in theory, public primary schools in Malaysia have to accept all students if they live nearby within the catchment area. There are no other 'barriers to entry'. But bear in mind how important neighbourhoods are in forming the student pool for any particular school.

Conclusion: Although no formal barrier entry exists other than proof of residence, the actual location of the school indirectly acts as a barrier depending on the 'price of property of the neighbourhoods nearby the school'.

These concepts: high performance and cluster schools are relatively new, in that they did not exist when I was a child. Both the primary school and secondary girls school I attended are now high performance schools (and they both had good reputations back in the 1980s and 1990s).

It was agreed between my husband and I that should we make the move to KB, my husband would be in charge of the children's transport to and fro from school. The reason being because, when we were living in PJ, I was the person in charge as it was my own hometown. Fair and square.

The Toilets in Public Schools

One afternoon, my hubby was caught up with work and I had to pick up my child from school. One huge difference compared to the school in PJ is that parents vehicles (for example motorbikes) are allowed within the school compound and so are parents. I walked into the compound and went inside to wait at the reading area, which is a nice shaded area with chairs, tables and books. As we sat down and awaited the strong smell of urine hit me. I initially thought it came from the reading area. Later when we got up and walked about did I realise it was from the children's toilets.

The Dual Language Program

I was invited to attend a talk about the DLP. From what I gather, the headmistress described that maths and science will be thought in both English and Bahasa Malaysia. The exam (UPSR) will be in both languages and children will have the option to answer using both languages. It is a pilot project, in that only a selected number of schools (totaling around 300 nationwide) will be participating and the government is spending RM38.5 million for this project (that brings about RM100,000 per school). Apart from language being thought in English, there will be reference books from Oxford used (but teachers are not from Oxford, just the books).

For standard one, the two top classes are selected for the DLP and they require a minimum of 15 students for one class. Lacking of numbers will mean no program.

Personally, I think it is a good idea to teach maths and science in English. I really do. There may even be enough evidence of an advantage to want to teach maths in mandarin. But the problem is, do we have enough resources, human resources that are trained and equipped to do so? I'm not sure. Let's hope the money is well invested and not poured down the drain.

Which School to Choose?

This is probably the most important question. The answer is never straight forward.

Let's change it a bit to question which area I feel more authority to answer. Let's say a person had a medical condition and was looking for the best treatment, and I get these sort of questions all the time...someone's kid broke their so and so bone, where should they go, someone suspects their kid has autism, where to go next and so on.

There are several factors to consider:
1) Whether the person would like treatment in a private or government setting
2) Where they are located geographically
To put it simply, how much resources are available and what options are there...

How people respond to treatment though, is very individual. In an ideal world, medical therapy would be tailored exactly according to individual needs. In ideal world, so would the education system.

The headmaster of my children's school in PJ said we must not compare one school to another as schools are 'individual', each has its merits, and the same principle applies to children, we must not compare one student to another.

Most people are limited in terms of where they live.





Baby has awaken...to be continued

Harvey Simulation Training

Today I attended another session for Harvey training for trainers. Prof Scalese aka Ross was an entertaining and enthusiastic teacher from Miami, the centre for simulation in medicine.

I remember having to travel all the way to Singapore 5 years ago. I enjoy travelling but not when I am nursing and that day I still remember hubby sending me off to KLIA in the when it was still dark (he goes to HKL roughly 7am, so we would have left home before that).

Then, waiting for flight and travelling to NUS, luckily traffic wasn't that bad in comparison to rush hour in KL. I remember the simulation unit in NUS was quite large, one whole floor. The staff were friendly. I cant remember much about the demonstration, but again we had a very mixed group ranging from lab technicians to medical lecturers, same as today's crowd from cardiologists to nurses, all the way from Thailand and Indonesia. I lucked out, only heard about the workshop a few days ago.

When I joined USM, I was impressed with the huge Clinical Skills Centre they have there because I dont remember using one as a student. The only remote thing I remember to using simulation as a student was performing a per vaginal exam and inserting a speculum in a mannequin, and using manneqins for basic life support, paediatric life support and advanced cardiac life support during training after graduation.

Then I joined Taylors and was very impressed with Harvey. I remember the murmur clinic we attended during final year, it was one cold morning where they gathered about 30-40 patients in an outpatient clinic, and all us 100 or so medical students went around listening to all the murmurs, taking on average maybe 3-5 minutes per patient and we were done by lunch time.

I have never heard so many different murmurs in so many different patients in one day, the rest of my life so far. It was a very intense session, and I'm sure more beneficial than not having any at all. But my point is, murmurs are not easy, even after many years of practice. So Harvey is a brilliant idea. You can listen as long as you want, whenever (depending on the opening hours of the clinical skills unit) you want, and keep practising as much as you need until you are confident. I wish my medical school had a Harvey when I was a student. Another point I'd like to make is that murmurs, although not that common in clinical practice, is extremely common in internal medical exams, both at the undergraduate and postgraduate level because patients are usually well, and the physical signs are usually stable, the ideal exam patient.

Harvey is also the ideal exam patient, and more ideal that patients themselves as Harvey does not get tired and doesn't mind being poked and prodded. One setback is you may require more than one unit if your OSCE has more than one cycle. Sometimes, it may also overheat. So remember to let it cool during the break.

I learnt today that Harvey is named after a cardiologist by a doctor who created Harvey, whose name is Gordon. Dr Gordon was so impressed with Dr Harvey, who basically uses bedside skills and a stethoscope to make diagnoses equivalent to what other doctors would need an echo to do.

Upcoming developments for Harvey: they will soon release more diseases (currently there are only 30) between 10-20 more and will also feature a faster heart rate of 90 beats per minute (currently Harvey's rate is 60 beats per minute).

No, they are not planning to have an Asian version, nor a female version, nor a paediatric version of Harvey. And the reason Harvey is big is that they need the space for all the contraptions that make it work.

Points for students:
Do not eat or drink near Harvey.
Do not use a pen near Harvey (use only pencils). Ink will stain and become a permanent tattoo.
Do not press too hard on the arterial pulses or you might obliterate it (I think this is the same for real patients).
You can palpate the jugular venous pulse in Harvey but it is not palpable in real patients (this is due to the mechanics of how the pulse is formed)

Other points for students:
Revise the JVP double flicker or complex wave components.
Understand why a and v waves are formed.
Describe why cannon v waves are formed.
Apex beat/PMI - why is it felt and what are the reasons the wave or impulse could be slow-rising.
Other abnormalities of the pulse such as parvus at tardus, bisferiens
Causes of displaced apex beat
The effects of increased preload - hypertrophy, increased afterload - dilatation

I was disappointed that the session did not start 9am as planned as I arrived 15 minutes earlier. Prof Scalese was there even earlier. We started 9.15am because we had to wait for people who were late.
 

UPSR 2016

First of all I must say I am grateful that my eldest son sat for UPSR this year, and that my second son will be setting for UPSR in 2017. The 2016 batch will be the first. I just attended a session at my kids school this morning where the teachers took time of on a Saturday to describe the details of the new exam format.

It is helpful to know the format of the UPSR 2015 exam and then look at what has changed. In general, the main changes are:
1) There are more subjective questions in all four subjects Bahasa Malaysia, English, Maths and Science.
2) These subjective type of questions require 'higher order thinking' (kemahiran berfikir aras tinggi KBAT) which the aim is avoid mere memorisation and regurgitation of facts to pass the exam. Instead, students will need to apply what they have learnt in order to answer the questions correctly.
3) The English paper will be divided into two papers and two separate grades, so next year the aim will no longer be 5A's, it will be 6A's.

There were notes provided for the session and the teachers also recommended:
1) downloading and looking at the questions at the Lembaga Peperiksaan 
2) buying books so that students can start practising answering now during the holidays, however, the teachers also said that book publishers have not started to print books yet as there are some uncertainties regarding the format of the questions.

When reading this post, I have used:
Italic fonts for Bahasa Malaysia
Brackets ( ) to compare with previous format
Bold to denote the different papers

BM Pemahaman

Masa diberi 1 jam 15minit

The main difference will be addition of subjective type of questions "objektif pelbagai bentuk" and "respons terhad".

There are two parts to the paper, bahagian A dan bahagian B. 

Bahagian A ada 20 soalan, markah 20. Bahagian B ada 5 soalan, markah 30. Jumlah markah = 50.

(Mengikut format lama, BM pemahaman ada 40 soalan objektif).

Bagi soalan subjektif respons terbuka;

Jawapan 1 markah adalah jawapan satu perkataan, jika ejaan salah contohnya Baik dieja BaiK, markah adalah kosong

Jawapan 2 markah adalah jawapan yang memerlukan ayat lengkap, ejaan tidak sepenting jawapan 1 markah.

Jawapan 3 markah adalah jawapan yang memerlukan pelajar berfikir (hello? Maybe my attention lapsed while writing the notes).

BM Penulisan
Kertas penulisan pula ada tiga bahagian, A, B dan C.

Bahagian A (10 markah, 15 minit)

Gambar diberi dan pelajar harus membuat ayat penuh berdasarkan gambar yang diberi. Ayat penuh bermaksud mempunyai subjek dan predikat.

(Berbanding 2015 penekanan adalah kepada penggunaan kata kerja).

Bahagian B (15 markah, 25 minit)

Memberi ulasan, contohnya kebaikan dan keburukan berdasarkan sesuatu maklumat yang diberi, contoh soalan adalah piramid pemakanan dan pelajar harus memberi pendapat mereka tentang piramid tersebut.

(Format 2015 ialah menulis tentang nilai murni yang terdapat dalam perenggan yang diberi).

Bahagian B boleh dikatakan lebih senang dari format terdahulu.

Bahagian C (25 markah, 35 minit)

Karangan, 2 soalan diberi dan pelajar boleh memilih salah satu. Panjang 80-120 perkataan.

Masa diberi 1 jam 15minit

Pendapat Guru-guru mengenai penukaran format BM:

Seorang dari guru yang hadir baru sahaja mengikuti kursus kecemerlangan bersama En Mat Arifin, penggubal soalan.

The question samples are not exhaustive. 

UPSR baru mirip PT3, tak boleh spot soalan.

Kita tak tahu bentuk soalan yang akan keluar.

Bentuk soalan adalah tidak muktamad. 

Untuk menjawab soalan KBAT pelajar perlu banyak membaca (doh!)

English
There will now be two separate paper and grades. The reason behind this move was vaguely explained...something to do with empowering English Language to a higher level, or rather, the students acquisition of such.

English Comprehension/Bahasa Inggeris Pemahaman

Section A is 20 marks
Section B is 30 marks
Time given 1 hour 15 minutes
Mixture of objective and subjective questions (previously 40 objective questions/MCQ, 40 marks)

Bahasa Inggeris Penulisan
Has 3 sections, A, B and C.
Section A 10 marks
Section B 15 marks
Section C 25 marks (compared to 15 marks previously) 2 questions, answer one only.

Time given 1 hour 15 minutes

The term 'holistic' was used, in that the paper will be looked at as a whole as opposed to separate parts in forming the overall marks.

Sains
Seperti biasa ada kertas 1 dan kertas 2, markah dijumlahkan sebagai satu gred. 
Kertas 1 ada 40 soalan objektif (berbanding 30 sebelum ini)
Kertas 2 ada 8 soalan (dahulu 5 soalan) dan 40 soalan kecil/breakdown
Tempoh adalah 1 jam untuk kedua-dua kertas

Ada soalan2 objektif jenis yang terdapat dalam buku IQ, mengikut pendapat cikgu sains. Thus it might be a good idea to buy some of the IQ books for practice.

Dalam kertas 1 terdapat soalan jenis aplikasi yang memerlukan KBAT, contoh soalan fakta dan aplikasi ialah penggunaan bekas makanan dari polistirena yang tidak digalakkan dan pelajar ditanya mengapa.

Komen guru mengenai kertas sains 2016 adalah (berbanding 2015, the type of questions that can be asked is limited, contohnya salji, dan unta yang tidak terdapat di Malaysia, tidak boleh ditanya tetapi sekarang boleh). Pendek kata, apa sahaja soalan boleh ditanya. Contohnya proses pengaratan, soalan lazimnya berbentuk paku yang direndam didalam air, dan terdapat lapisan minyak diatas. Untuk berkarat memerlukan air dan udara. Soalannya mungkin, jika paku dan air dibawa ke angkasa lepas, mungkinkah proses pengaratan berlaku? Jawapannya tidak, kerana tidak terdapat udara di angkasa lepas.

Please go to the following links and download the sample questions:
http://www.moe.gov.my/my/pemberitahuan-view?page=1&id=4967

tbc

The Best Place to Get A Facial Done In PJ

A few weeks ago I was undecided on whether to have a facial or not. It had been two years since my last facial. I skip these things when I'm pregnant. It was 5 months into my new job and with a fourth baby on board, things were not looking great for my skin despite using a pretty expensive anti-aging cream which made me look (or was supposed to make me look 15 years younger), true, at the very beginning I was often mistaken as a medical student. Now that I've pretty much done away with the white coat, that case of mistaken identity happens less often.

So out of the blue, baby happened to be settled and the other kids were reasonably content, I dashed out to of the house with the objective of getting a facial done. I headed for one of the shops in the shoplot of this well known international skincare brand, thinking that this usual outlet was pretty quiet and chances of getting a facial done here are pretty good without an appointment. "We close at 6pm" said one of the girls with a pretty face at the counter. It was 5.30pm. My hopes were dashed. The initial excitement of getting prime parking just opposite the entrance quashed. I asked for a business card and was told that I need to make an appointment. No walk-ins please.

I looked at the card and tried calling for the same brand shop but in a favourite nearby (sort off) mall. That was even worse. Weekday facials need 1 day advance booking and weekend facials at least 3 days in advance to secure an appointment. Appointments don't really work for me because baby is unpredictable.

So then I remembered seeing a sign for facial at another shopping mall. I wouldn't call it a favourite shopping mall, because it is rather old, but parking is free and is has some advantages compared to favourite shopping mall no1. I looked at the clock and decided to try my luck.

I walked in and yes, the lady at the counter was very happy to give me a facial without an appointment! Great! My kind of facial.

The decor was a bit worn out but it was clean. There was no locker or place to keep my belongings, I just placed them next to me on the couch. There was no need to change into other clothing like the 'place that I usually went for facials but could not give me a facial without an appointment'. So I was a bit apprehensive.

The lady looked at my skin and said it looked dry and tired. She made some recommendations and I went with whatever it was. At the end of the 1 hour plus session, I felt great. The products were locally made. The owner of the shop was a Kelantanese. I felt the pressure applied for massage was a bit too much, but I didn't complain. The next morning I stood at the mirror and I could appreciate the difference in my skin.

I remember initially thinking that I was not going to bother with facials. I mounted my exercise bike and decided to look up "why we need to do facials" on my phone, and lo and behold one read one website which said something to the same effect "We need to have facials because daily skincare, like brushing your teeth, which must be done daily, can never have the same effect as deep cleansing that the dentist can give for your teeth".Reading that made me jump off the bike, change into outside clothing and quickly dash out in search of a facial, walk in.

Yesterday, a few weeks later, I arrived at favourite shopping mall no2 sort off, earlier than planned for an appointment. So I decided to have a quick facial. I met with the owner (recognised her Kelantanese accent, and she had beautiful skin), and went straight in. What I like is that the lady gave me a good "about 20-30 minutes express facial", at my request. I don't think 'the usual place where I had gotten most of my facials before this' would be able to cater to such demands. And so, I am very happy to recommend this shop as the place to go for facials.

Long Case and Short Case

One main difference between the American and British medical education system is the use of long case and short cases in the exam. I still remember my final medical exam, the long and short cases that is. I wouldn't recall much about the written examinations, except that there were essays, with some options, and MCQ's.

For most medical students, preparing for written exams should not be a great hurdle because majority would have developed a way of preparing for such. A huge part of preparing for MCQ type of exam is to practice doing questions. For the majority of people, the challenge is time. So during practice it would be smart to time oneself. Regular practice is needed and the momentum should increase nearing the exam, so that the candidate can 'peak' their performance during exam time. (Somewhat similar to training for a half marathon).

So if the NBME is two months away, and there are about 1400 questions in the question bank, average questions to be done daily is 1400/60 = 23.3 questions per day, do or die. If it is a real pain, in the first 2-3 days start with 5 questions per day then slowly build up momentum to achieve 25 questions per day and maintain this till the last week prior to exam, where you can up to 30 questions/day.

For essay type of questions, what we used to do was look at all the past year questions available, to have an idea of the type of questions and what had been asked in the past. Sometimes, there is a pattern, allowing some kind of 'prediction' and sometimes there isn't. That is irrelevant. Looking at the past year questions will allow one to focus on areas that could potentially come out in future exams. Never do anything blindly. Never study without first understanding how you will be assessed.

My general advice to medical students on how to operate on a daily basis is:
1) Spend time on the wards seeing patients, clerking patients, examining patients, don't read your books on the wards. You need to read but spend your time on the wards wisely. You can read later at home.
2) On the wards; work in pairs or groups of three, with colleagues whom you respect and are of relatively equal standing. Take turns to take history, do the physical exam, and present to each other. Practice, practice, practice. Then ask questions pretending to be the examiner. When you get a chance to present to a doctor, use it. It is a golden opportunity for feedback and how you can improve. Some students have the ability to speak fluently without preparation, you have an advantage, but talking nonsense fluently will not get you the marks you need. If you are the introverted type like me, you will need more practice on the presentation part, so present to your dog, cat, fridge, mirror, friend, anyone willing or otherwise to listen.
3) When you get home after the day is done with ward work and teaching, it would be best to sleep first (after meals, praying, shower etc) before studying. Some people love to study at night, others during the early morning hours. Find what works best for you. The main message is don't study when you're tired. You will not be very productive. Rest first and then study. The hours spent studying too should increase as you near the exam. What to study? Apart from doing exam questions, I also read around the cases I have seen during the daytime at the ward, plus the themes in the exam questions. Time is a limitation for most people, so I would discourage just reading text or textbooks for the sake of completion. Targeted learning and meaningful learning will allow the type of learning that relies lest on memorization and would last longer.

During the weekends, there are additional hours where one can spend doing other things like socialising, shopping for groceries, household chores, recreation, exercise and unwind. But do maintain the momentum of practising exam questions and studying. You can even make up for days lost during the week.

The long case

There are in general different understand and interpretation of what a long case is. The British system, which is what Malaysians follow, would usually involve a carefully selected patient who has a suitable history and some positive physical examination findings, often one who is not acutely ill, but rather with chronic, stable signs, and is able to give the history him/herself. Sometimes, especially when there are many students taking the exam at the same time, there may be a shortage of these 'ideal long case' type of patients, and less then ideal cases may be used. Less then ideal may mean that the patient is unable to give a detailed history, or there is a lack of history, or the presentation may be atypical for the particular condition, or the patient has no clear diagnosis after a barrage of tests which all comeback negative....so yes, there is an element of luck and the solution to reducing this 'unfairness' is the OSCE exam, where each candidate will be examined on the same patient, using several patients in many different stations.

The long case is easier than the short case because you will be given about 45 minutes to take a history and do a relevant physical examination without the presence of any observer, usually behind closed curtains. The unofficial advice to the student is, at the very beginning, to get the patient 'on their side' by explaining the importance of the exam to the student, that the exam does not in any way impact patient management, and to please do not contradict what the student says in front of the examiners later. In other words, build rapport. It is also useful to ask the diagnosis first, and work backwards, though this may not always work if the patient is unaware or unable to communicate.

The candidate is usually given empty pieces of paper and maybe a board to write on. It is a good idea to jot down the headings for example presenting complaint, history of presenting illness etc at the very beginning so that you do not miss anything, and leave large amount of spaces so you can add in information should you forget something and later remember during the process. You must also watch the time very closely and aim to finish the history and physical 10 minutes earlier so that you can arrange your notes, come up with a differential, and anticipate questions regarding management before the examiner walks in.

The examiners (usually there's two but there might be there is an observer wants to join in) would ask if you are ready at around 45 minutes - 1 hour. The earlier candidates may have less time than later candidates during the day, as the exam continues, this is just the normal process. After presenting, the history, physical examination findings, differential and management, the examiners will usually ask you to demonstrate any of the physical examination findings and then discuss management. They may give feedback regarding your performance or they may choose not to. At undergraduate level, the examiners usually give leading questions if one is straying away from the correct path/answer. The examiners will usually have a detailed note of the patients history and physical examination findings, plus the diagnosis, and they may have a checklist to ease the assessment process.

The Short Cases

The short cases are a bit more tricky and the purpose of it is to assess your interaction with the patient, but more importantly, your skill at performing the physical examination and ability to discern between what is normal and what isn't. One average, a student may see three or four cases for the internal medicine part of the exam. Most of the time, as many as 10 or more patients will be placed in an area (maybe one ward prepared just for the exam) behind separate curtains or in separate rooms. You are not allowed to ask any questions other than "may I examine your......?" or " do you have any pain anywhere in your tummy?" before you start palpation.

You are expected to use your powers of observation to pick up things that will aid in the diagnosis, without obtaining the history, or using entirely the physical examination, to work out a diagnosis or differential, and then discuss the pathophysiology, possible etiology or management.

You must follow exactly the instructions given, which will be very specific for example, examine the respiratory system, look at the hands, look at the face, examine the praecordium, look at the fundus etc.

You may clarify if you are not sure what to examine, again, the examiner would lead the student if they are at lost or diverge from the correct answer.

It is best to give a running commentary while examining, and present as you find, although this may backfire if your findings are later found to be conflicting.

It is very impressive to examine efficiently, present the findings with the likely diagnosis or differential and then include a management plan. As long as your answer is correct. Usually, if the examiner doesn't interject, that means you are on the right path.

Do not spend minutes doing a part of the exam that could be done a few seconds. This can be very irritating to watch. Do not hesitate moving from one part of the exam to the next. Do not mumble when presenting your findings. Be confident, and this naturally comes with practice. Be confident, even if you are wrong, at least you sound good.

Make sure you know how to work the beds and how other apparatus works, this 'shows' that you have spent adequate time on the wards and can only be learned through experience.

Examples of Long Cases

I was the last candidate that day for the medicine long cases. In Trinity College Dublin, my alma mater, the long case for medicine is combined with psychiatry. So a student has a one in five chance to get a psychiatry for the long case. While I enjoyed psychiatry as a medical student, I cringed at the thought of getting one for the finals. Luckily, I did not get such a case.

Instead, the patient was a very pleasant, youngish middle aged lady who was newly diagnosed with leukemia. I cant remember which one. There wasn't much to report in the history. She had felt unwell and went to her GP. The GP did some routine blood tests and picked up the cancer. She did have hepatosplenomegaly. As I had explained earlier, had there been other more suitable patients on the ward, this patient would probably be a more suitable candidate for the short cases.

By the time the examiners came, they seemed rather tired and sort off 'fazed out' during the presentation. Thankfully, it was brief. The focus of the history though, was on the social part because anyone with newly diagnosed cancer will have a lot of issues to look at, can the patient continue working, how would they manage with chemotherapy, is there someone at home who can help take care of them when they are ill, etc. So if you don't have a lot of stuff to report, make sure you do a detailed social history (also if the case warrants it, for example a patient who is blind but has ischaemic heart disease, or a patient with diabetes who needs insulin but is unable to inject themselves due to rheumatoid arthritis).

I was asked to demonstrate my findings (hepatosplenomegaly) and then discuss the general principles behind the management of leukemias (and the different types), but not in great detail as specialists are not allowed to examine their own area of expertise, for example a gastroenterologist must not be an examiner for a case of crohns disease and a chest physician should not be the examiner for a COPD patient.

My husband got a patient with a stroke, another excellent case for the medical finals. The were only pure motor findings so the working diagnosis was lacunar infarct. The patient had difficulty hearing so my husband had to practically shout throughout the history and physical examination.

Other long cases for medicine include heart failure, multiple sclerosis, COPD complicated by cor pulmonale, lung cancer, cirrhosis....

One student recollected getting a patient for the long case who was unable to give any history at all due to a mixture of dementia and probably dysphasia. The student proceeded to do a mini mental state examination and a physical exam. During the presentation, the student emphasised the need to look for old medical notes and to obtain a collateral history. He passed.

It's funny that I can't seem to recall my surgical long case. My husband got a patient with Crohns disease with multiple surgical interventions, who was not aware if the diagnosis.

For paediatrics, I was introduced to a 10-12 year old boy who I was told should be able to give the history by himself. They were right. I was disappointed that the parents were not there, but that disappointment went away within the first few minutes when I realised that the patient was a 'professional' patient. It was pretty obvious this was not the first time he was included in the medical exams. He had stage 4 clubbing due cystic fibrosis. Admitted with pneumonia. All paediatric long cases must have their height and weight plotted on the centiles. Failure to thrive is as important a sign to pick as unintentional weight loss is in adults.

In the obstetric and gynaecology finals, each student will either get an obs or a gynae patient for the long case. There were no short cases, instead they had a viva, which is a live voice exam with two examiners immediately after the long case. If the long case was obs, mine was a lady post lower segment caesarean section, she was lovely but I cant recall any other detail about the case, then the oral exam would focus on gynae. I remember being asked about vaginal prolapse and chlamydia infection. It still amazes me that I can recall the event to that amount of detail more than a decade later. Talk about the effect of stress and memory formation.

Examples of Short Cases

If there is a patient with a murmur, no doubt they will be invited to participate in the exam. Make sure you are comfortable examining the praecordium and anterior chest of female patients. I find a lot of students dwindle at this, even the ladies. After examining and presenting the findings, you will be asked what type of lesion you think it is, and what the possible causes are. Instead of giving lists, it is more impressive if you can taylor it to the particular patient you just saw. "Given the young age of this patient, the most likely cause of the x murmur is infective endocarditis" is better than saying "The causes of x murmur include bla bla bla...". You may be asked about management.

Other favourite short cases include pleural effusion. Stony dull to percussion. What are the causes? Make sure you answer by dividing into exudates and transudates.

Rheumatoid arthritis hands. "Examine this patients hands".

Lymphadenopathy for example in the cervical area. What is the differential diagnosis?

Ptosis, bilateral in a patient with myasthenia gravis. Instruction was 'examine this patients eyes'.

For the surgical finals I remember seeing a lady with a new mastectomy scar. I was asked to describe what I saw, give the diagnosis and then was asked what I wanted to do next. I replied I would like to examine the remaining breast and the axillae.

I was taken to see a patient with a urostomy bag. I was asked where suitable sites for stoma bags would be (away from the umbilicus, bony prominence etc, apparently this is a favourite question), and whether the piece of gut used was retro or antero-peristalsis.

In the paediatrics short case I had a toddler who was screaming from beginning to the end of the brief exam. I believe the baby was upset even beforehand so it was not me that made the baby cry, but uncomfortable for me to continue with all the racket. I did ask the examiners whether I should continue and they said yes. The child had bilateral stumps at the ulnar side of the MCP joint, due to surgically removed 6th digits. I was asked what I would like to examine next, I replied the feet. I was asked "what one question would you ask the mother?"

For internal medicine, Baliga 100 Cases remains a favourite book and Stryders Short Cases for the MRCP will give examples that is meant for postgraduate exam but can be applied at the undergraduate level too.

Hope this helps.

Looking for a Photo Shop in PJ After Hours? I Recommend the one in Jalan SS5B/4

A few days ago I was at ends wit. The deadline for the submission of teaching permit was around the corner because of the accreditation and guess what, I forgot that I had to submit three passport sized photo's. Months earlier I had brought my certificates and letters from previous employers stating that I had experience teaching in a higher learning institution. But I forgot the pictures.

So I went out after 8pm because I wanted Baby to sleep first. The first photo shop nearby was already closed about 10 past eight. Just as well, the road was a very narrow slip and parking was not easy. This is near Jalan 222. So I remembered going to a shop in Section 14 maybe 20 years ago, near Joo Hua, to get passport pic taken. Headed that direction immediately. It was around 8.30pm when I got there, section 14 you have to go around the McDonalds because of the one-way streets. Traffic is always kind of crazy in that area with people double parking as the norm. Sadly, second store was also closed.

Then I remembered some 4 years ago now, I went to a photograph shop in Kelana Jaya. My second son had missed his graduation photo session at the kindy and the teacher had given me the gown plus hat and scroll, and I had to take him on my own to the store for his picture taken. If not, there would be no graduation picture for kindy (horrors). At that time I was busy with my previous full time job and three kids, so having to do something extra was a chore, an unfortunate chore back then. My son had taken ill during the original photo session. As soon as he was well, we went to the shop for his moment. There was no waze back then so it took some time to find the place.

It those desperate moments, the memory of the photo shop came back. It was 8.40pm and time wasn't on my side. I decided to try anyway. Nothing to lose. I googled for photo shop PJ half way there and an address in section 14 came up instead. I decided to forgot about that and continue to Kelana Jaya.

The moment I arrived, the shop had its doors open with lights still on but they had drawn the covers partially. I parked quickly (there were ample parking spaces) and clocked had ticked 9pm. I made a dash for it and asked as soon as I entered the shop whether they could do passport photos. A lady answered, is it for passport she enquired and I said not really, its just for teaching permit which required 3 photos with blue background. The lady was happy to help and said that they were almost closed. With the CD it would cost RM15. Yay!

I sat down at the back of the shop after some adjustment of lights and seating and had two shots taken. Ok lah. No make up. The natural look. Lack of sleep because of baby and work. I like it, sort of.

It only took a few minutes and I was out of there, one satisfied customer.

Accreditation

It has been a stressful week at work. Why? Accreditation. The only people in the world who do not hate accreditation is probably the auditors. I have heard that auditors too, do not necessarily enjoy their work.

I have worked in a government organisation when I first encountered an experience with being evaluated for Quality Assurance. The funny thing was, always in retrospect, that my boss at that time, and most of my working colleagues, were completely clueless as to the process. The leaders themselves were in the dark because the previous leaders had left without fully explaining the situation. So we just waited for the arrival of the internal auditors and 'prepared to be slaughtered'.

Thinking back I am reminded of what the whole process is about. In one word, it is about documentation. Everything that we do must be documented so that it can be evaluated by someone from the outside.

Yes, documentation is very important in medicine. Everything that happens to a patient during the course of a hospital stay or interaction as an patient in the community must be written or entered in a computerised electronic health care system. Why? For the records, so that when another doctor or health care professional attends to the same patient, they have accessed to the whole story, not just from the patients perspective but also from the doctors perspective. And, I guess more importantly, should anything go wrong, God forbid, there are records of what had happened so that such mistakes (if proven to be) could be avoided in future, or the records could prove that despite everything was carried out in the normal expected way, the patients deterioration was outside the control of the treating physician.

That worked well in the practice of medicine. I've written countless of entries into countless of medical charts, both electronic and hand-written, both in hospital and in the community. It seemed logical and the right thing to do. But in academia? Why? Who would want to read it anyway? It turns out that yes, every single organisation needs to document their operations and the academia industry is no exception.

At the department level, department meetings, and other standard operating procedures must be detailed in the relevant files. The funny thing is (ok, maybe its not that funny), is whatever you decide to write in the SOPs, must be followed through. So if you can't, then dont write it down. So the documents are not goals but rather reflects what is done in reality. And if it does not concur with reality then it is something that must be changed (either the documents or the reality).

For the academia world, curriculum is everything. Ok its not everything but it is very important. One of the first things the auditors will look at. From my experience in a previous institution, a person was hired to prepared the entire syllabus and who showed this to the auditors who were not even interested to flip through the hundreds of pages of medical school curriculum. Instead, I am told, they are looking for very specific things.

It seems the curriculum, timetable and lecture samples are the highlights from an individual level. From the customer perspective they look at contact hours, time spent on wards, ratio of lecturers to students, then of course there is the assessment. They also look at the logistics, are there enough lecture halls and facilities for students, the library, the anatomy lab, the pathology specimens, the hospital and wards available, and human resources, they scrutinize the staff hired, are they suitably qualified to what they are meant to do, are they being paid enough to prevent high staff turnover and so on.

My second experience with accreditation was a good one, they identified areas which require improvement, which I think regardless of how good an institution is, no one or thing is perfect expect God, so there will always be room for improvement. Then, they gave the green light that the institution was given accreditation for a number of years before they will return again for a routine review.

The scariest thing that can happen is if an institution does not get accreditation. That means there are severe deficiencies that make it not up to mark of standards that is acceptable for the organisation benchmark. The organisation is then left to make repairs and then subject itself to another round of accreditation.