owl’s (long-overdue) update….

Vieux Lyon (Old Lyon)

It has been two weeks since I returned to Melbourne, and it has been many months since I last updated this blog! Gosh, the last post was during my first clinical rotation early this year, and now I am already into the sixth rotation, and 11 weeks from completing my course! Many things have happened over the last 6 months or so, from doing my overseas elective rotation, to travelling, to job applications and interviews etc (I am sure most of you guys would have known about them from my facebook status). Anyway, I will try to highlight some of the interesting events in the coming posts. Also, as I come towards the end of my medical degree, hopefully I will also have some time to write some reflective pieces on my past 6 years in medical school…

 

Of multiple admissions…

And today, this same patient was admitted AGAIN, for the third time over the past 5 weeks, and with the same presentation – non-infective exacerbation of COPD -_-”

I first saw this patient during  the first week of my general medicine rotation. With a background history of schizoaffective disorder, the registrar already foresee this patient returning due to poor compliance and apathy. Hence, the team requested psychiatric review; psychiatric team decided that no further psych review required. COPD nurse and social worker input were requested; patient simply refused social workers assistance. And so patient was discharged, and to be followed-up by local GP.

In about two weeks time, the patient was admitted again. He just came back from having a cigarette when the registrar was about to see him during ward round -_-” Imagine a patient coming in with exacerbation of COPD, and yet still managed to walk down to the yard for a cigarette!? The registrar was a little pissed off, and decided to discharged him on that day itself since he did not appear to be medically sick at all! GP follow-up was arranged in a week time.

Four days later (i.e.today), the patient was re-admitted AGAIN! He reported shortness of breath (again), took TWO PUFFS of ventolin, and decided to call the ambulance!  And he was about to go for a cigarette (again), when the medical team was just about to review him. And when asked why didn’t he try taking more ventolin before calling the ambulance, he claimed that too much ventolin is not good for him! -_-” The registrar decided to discharge him today (again)! This time the COPD nurse was to be visit him in a few days time, to make sure he does not come back to the hospital (again)!

Ah, god knows when will he be coming back again. And wasting the hospital resources!

Update: patient was re-admitted again on the night of discharge. This time, he reported having 6 puffs of ventolin before calling the ambulance -_-”

 

Happy Chinese New Year

 

Public Health Genetics – a Breast Cancer Perspective

Note: The following is my abstract for presentation at the 30th World Congress of Internal Medicine in March 2010 in Melbourne, as Victoria state finalist for John Snow Public Health Scholarship.

With the rapid expansion of knowledge in the realm of genomics, there is no doubt that we are moving towards an era of personalized medicine, with more individualized disease prevention strategies and therapeutic options. Hence, the intricate interplay between molecular genetics and public health is being increasingly recognized, and this will be discoursed in the context of one of the commonest diseases – breast cancer.

Our knowledge about breast cancer genetic factors these days is generated through different genetic epidemiological study approaches, from genetic linkage studies, to candidate gene case-control studies and genome-wide association studies (GWAS). This led to the identification of breast cancer genetic factors of different penetrances and prevalences (Turnbull & Rahman, 2008).

Enlightening as they are, novel molecular discoveries confer minimal benefits unless they are translated into practical use. However, with emphasis on evidence-based medicine these days, there is a whole layer of complexity involved in the bench-to-bedside translation, which can be a protracted process. Hence, of the many breast cancer associated genetic factors known to-date, only a handful is widely available for genetic testing.

And while breast cancer genetic testing is becoming increasingly common, due to the high cost involved and limited public funding available in Australia, not all individuals who are concerned about inherited breast cancer risk are offered genetic testing. To ensure cost-effectiveness and equity of access to genetic testing services, various models, such as BRCAPRO and BOADICEA, have been introduced to facilitate selective genetic testing on individuals most likely to be affected by genetic mutations.

Also, as we advance towards more personalized medicine, cancer control will adopt a fresh new attitude. It appears that it is no longer appropriate to view cancer prevention as a ‘one-size-fits-all’ public health effort and apply the same prevention strategies to the population at large. With better understanding of genetic basis of breast cancer and hopefully more accurate cancer risk prediction, it seems inevitable that there will be a gradual shift towards more individualized cancer prevention strategies, based on one’s unique genetic make-up, and this is going to have a huge implication in the improvement of resources allocation (Pharoah et al, 2008).

In short, public health genetics is an emerging field of great importance, involving integration of genomic knowledge into public health research, policy and practice for disease prevention and management.

 

Of the short-sighted scholarship sponsor II

In response to some queries on how I managed to convince the Public Service Department (PSD, i.e. my previous shortsighted scholarship sponsor) to approve my application to pursue the BMedSc year, I supposed it is time for me to clarify the actual situation.

After hesitating for a few years, I have to make a decision whether to pursue the intercalated year of research by the end of 2008, as 2009 will be the last possible opportunity for me if I am interested (p/s: the faculty has since allowed students to undertake BMedSc after end of final year).

I wrote in to PSD seeking approval to undertake the year of research, citing my interest in research and past laboratory experience over the summers. I also highlighted the importance of research training for future medical practitioners, including the fact that The University of Melbourne (and some other Australia and UK universities) medical course even make it compulsory for undergraduate medical students to undertake the additional year of medical science research. I also explained to them very briefly on my potential project, and get my supervisor to write in a supporting letter as well.

Unfortunately, my application was turned down. The one and only reason given is that the ‘honors-equivalent year of research is not essential for medical students’! [direct quote from the reject letter from PSD in Malay: ‘…JPA memutuskan tidak membenarkan pelajar-pelajar di luar negara utk mengikut penyelidikan di peringkat honours memandangkan penyelidikan berkenaan bukan satu keperluan bagi pelajar tajaan bidang Perubatan.’]. What a fatuous excuse is that!

Anyway, I put in an appeal letter, written in the most polite manner possible. Obviously, there is no point talking to these ignorant officers about the importance of research again. So, this time I emphasized on the fact that I will only be deferring one year of medical school, during which I will be paying all the expenses for the year on my own (i.e. no additional financial burden on PSD), and will resume my final year of medical school upon completion of my research year. Unfortunately, I received a negative response again, with no explanation given. It really puzzles and frustrates me that PSD allowed medical students who have failed to repeat an entire year of study (still fully sponsored) whereas my request to defer only a year for research was rejected!

I was downright disappointed with how they handled my request. After much deliberation, and with support from my family, I made one of the biggest and boldest decisions I have ever made. I put in a request for termination of my sponsorship, in order to pursue what is best for me. After all, the reason for attending university is to amass knowledge and pursue one’s interest. Why should I sacrifice my education opportunity and give up my interest just because of the imprudent decision by a group of improvident officers/ decision-makers? It was proven to be the right decision. My BMedSc year turned out to be the most fruitful year ever in my university life! Anyway, There was no news from PSD after that, until about 10-11 months later (i.e. recently). I received a letter demanding repayment of all the expenses involved over the last few years of the sponsorship within 2 months, which I duly comply with (I will leave you to calculate the sum of money involved) .

With the PSD contract legally terminated, while I will be financially constricted, one of the obvious advantages is that I am no longer legally obliged to return to Malaysia IMMEDIATELY upon completion of my studies. In fact at this point in time, I have decided to stay on in Australia at least for my specialty training. With all these hoo-has going on (almost annually) about PSD scholars not returning, I am fully aware that there will always be people out there with that holier-than-thou attitude. Well, I will leave them to continue standing on the higher moral ground, and to judge me however they like (ungrateful, traitor etc?). However, I still do acknowledge that the taxpayers have provided me with an ‘interest free loan’ for my studies over the last four years without which I wouldn’t be here in the first place. So, someday, someday down the track, I shall contribute to you, the taxpayers of Malaysia, in one way or another.

p/s: It is unfortunate that the taxpayers’ money for the education of the future generations continues to be poorly managed and unjustly distributed by these witless government agencies/ departments.

 

Year 2009 in Review

This is not really a deep ruminative reflection, but more of a record of the highlights of 2009, so that many years down the track, I could recall on things I have done or achieved during the year.

Academic

Academic wise, there is no doubt that 2009 has been the most fruitful and fulfilling year in my university life thus far. I have no regret deferring the final year of medical school and going against the scholarship sponsor’s directive to pursue BMedSc research (well, maybe I should write on/ clarify how I defied the scholarship sponsor’s witless order in the next post). In fact I would have regretted if I have not undertake this year of research! After flirting with the possibility of a research career over the last few summers, I have gotten both my feet thoroughly wet in the field following one year of rigorous research, and I have become confident of a future in research. From the tedious DNA extraction to high throughput genotyping, from managing the massive dataset to advanced statistical analysis, I have learnt a lot throughout the year. I am also tremendously grateful to my supervisors for providing me with so much exposure to the real world of medical research. Thanks to their guidance and support, I have presented at two conferences i.e. annual meeting of kConFab and the Australian and New Zealand Familial Cancer Clinics (oral presentation) and Asia Pacific Cancer Conference (poster presentation). It was also an honour to be selected as Young Investigator Award winner at the Asia Pacific Cancer Conference. That’s not all! I have another abstract accepted for presentation at Lorne Cancer Conference in February 2010, and as the Victoria state finalist for John Snow Scholarship, I will be giving an oral presentation on public health genetics at the World Congress of Internal Medicine in March 2010! I was thrilled, but at the same time felt a little overwhelmed and daunted, by the vast amount of opportunities presented in front of me! During the year, I also got to know and established contacts with various passionate academics/ researchers/ clinicians, including Alex from Dana Farber, Soo Hwang from CARIF, Dr Lee from UKM and Dato Wahid from Malaysia Oncology Society, all of whom had offered valuable advice and pointers, as I started mapping out my own career pathway.

Travelling

Academic aside, 2009 is also the most ‘productive’ year in terms of travelling. Seriously, I think I have not travelled this much in my entire life than I had this year! Apart from the short break back home to Malaysia, and the brief visit to Singapore, I have been to two new countries (US and Japan) within this year! Visited US in the middle of the year, and covered most of the major cities on the east coast, from Chapel Hill (catch up with Eric), Washington DC, New York City and all the way up north to Boston. Then another 3-4 weeks in Salt Lake City, and short stay at Los Angeles. Later in November, spent another 10 days solo backpacking in Japan (almost entirely sponsored:P)! Even back in Malaysia, I stepped feet on the Borneo Island for the very first time, as I flew across the South China Sea to attend my sister’s (Dr OWL-I) graduation ceremony.

Running

While I participated in significantly less runs this year compared to 2008, I have achieved my best time ever in all the three runs! I clocked 1:25:49 in the 14.1km Run for the Kids, 0:57 in the 10km Deseret News Pioneer Day Run (in Utah, ran with David, my US-based BMedSc supervisor) and 2:07:20 in Melbourne Half Marathon. So, having already completed a number of half marathons, I supposed it’s time to get into a full marathon in 2010. Will definitely be registering for Melbourne Marathon in October this year. So some serious training will be on the way and hopefully will be able to complete the run within a decent time!

Bushwalking

Achieved one of my New Year resolutions i.e. to learn new things/ skills. Gotten into a new outdoors activity – bushwalking (Aussie terms for hiking). I was no Boy Scouts or cadets back in primary or high school; so basically, I have no idea what so ever about camping! As a complete beginner, I then decided to join the Melbourne University Mountaineering Club. I started off hiring gears from the club, and over the course of the year, I have spent considerable amount of money buying gears such as boots, hiking pack, sleeping bag, sleeping mat etc. It was really gratifying to have learnt new skills, such as pitching tents, along the way as I went on more overnight bushwalking trips. My navigation skill is still very crappy though. Am also really glad to have explored a lot of new places in outback Victoria (and Australia), which I haven’t never thought of going since I came to Australia five years ago. Have been to Mount Howitt and Mount Feathertop (2^nd highest peak in Victoria) in the Alpine National Park, Little Desert National Park, Wilson Promontory National Park, and Flinders Rangers (in South Australia) among others.

Photography:

Another new expensive hobby for the year – photography. Gotten my first DSLR camera early of the year, and started getting into more serious photography. While I am far from a professional or even semi-professional, I am quite satisfied with my work so far!

Volunteering

Another thing I like about my BMedSc year is the flexibility of time. I am not bound to attend ward round at 7am, PBL at 1pm, bedside tute at 5pm etc. That flexibility has allowed me to continue volunteering with the Australian Red Cross on a more regular basis, through their emergency service section and youth wing (YConnect). While I have been volunteering sporadically as first aider over the last couple of years, I managed to commit to an average of two event-postings per month throughout the year (except when I was overseas). And with YConnect, I started off as homework club tutor at Fitzroy Primary during the second term, and later decided to take up the role as the convenor as well as tutor during the last term. I find that helping the under-privileged immigrant kids with their homework (though only one hour per week) was indeed a rewarding experience. At times some of the kids were difficult to deal with though. I think it is pretty unlikely that I will be able to continue volunteering at homework club in 2010 due to the more rigid schedule as I return to final year medical school. However, I do hope to find some time to continue volunteering regularly as first aider.

The only regret of the year is that I have NOT read any new books this year! What a shame still haven’t finished Dreams of My Father (by Barack Obama), which I started back in December 2008!

And so that’s my 2009! I would say it is one of the most awesome years ever! Hopefully 2010 will match if not beat the ‘awesomeness’ of 2009!

 

Happy New Year 2010

Melbourne fireworks in the rain, after a sweltering 38 degree in the afternoon! (image credit: herald sun)

 

Journey to Japan IV

Day 8-9

I woke up rather late on Day 8. After packing up and checking out, I headed to my next destination – Hakone, a small town southwest of Tokyo, famous for its onsen (hotspring). It was a rather long journey, taking me about two hours to get from Shinjuku station to Hakone-Yumoto Station. I then checked in to the ryokan (traditional Japanese inn) straight away, which is located on top of the hill right next to the train station. Ah… after staying in dormitory-style hostel for the past week, this is the first time I have a room for myself! It’s not that expensive anyway (about 5000yen for the night, compared to 3000yen/night at the hostels). And it’s a traditional Japanese room (washitso), with sliding door, tatami mat flooring and Futon (Japanese-style bedding)! Oh, and the ryokan has its own onsen as well! That’s what I call a true Japanese experience! The only bad thing is that there’s no internet access in the ryokan. Anyway, by the time I get settled, it’s already past three in the afternoon. I had late lunch and had a walk around the small town, thronged with tourists. Again, it got dark really early, and I went back to the ryokan and have some rest.

Later at night, I went for Japanese-style bath i.e. naked bath in the onsen! Since this is my first experience in onsen, I did read up on some of the common etiquette observed in the onsen before hand, so, no, I didn’t jump straight into the onsen with my swimsuit and splashing water all over! I was hoping that there was no one around at that time (which was why I went pretty late at night), but unfortunately, there were still a group of young men there. After removing (all) my clothes in the changing room, shyly, I walked past the group of men who were soaking in the onsen (covered only with the small piece of cloth that I was provided!) to the bathing station. For hygiene purposes, it is important to get washed at the bathing station, equipped with stools, water buckets, and toiletries, before going into the onsen. I took my time applying the soap and scrubbing (very) slowly, hoping that the group of men would leave before I go into the onsen. Ha, and they did leave soon, so I have the whole onsen for myself! And since I have the whole onsen for myself at that time, I set up my tripod and camera (that I brought along) at the side of the onsen, and ran in and out of the onsen to take photos (I know this sounds ‘wrong’ but hey, I am not the only one taking photos there! The previous group of young men was also taking photos, among themselves in the onsen!) After the 20-minute soak in the onsen, I felt very much refreshed, and had a really good sleep for the night. I enjoyed the onsen bath so much that I went for another early morning bath the following day before checking out (huh, luckily there was no one around as well! )

I left my luggage at the ryokan reception after checking out, and went on to explore the outer region in Hakone. Basically I did one loop around part of the Fuji-Hakone-Izu National Park, on different mode of transportations. From Hakone-Yumoto train station, I took the Hakone Tozan train to Gora, then the cable car to Souzan, followed by the ropeway/ gondola lift to Owakudani (The Great Boiling Valley), a scenic active volcanic valley. Smokes can still be seen coming out of the vents, and there was a strong sulphurous smell in the area. This valley is famous for Kuro-tamago, eggs that blackened upon boiling in the hot spring (apparently due to the sulphur), and legend has it that eating one Kuro-tamago prolongs one’s life by seven years! Haha, however, the maximum you can eat is two and a half eggs for an extra 17.5 years! Apart from offering quite a nice view of Mount Fuji (I was lucky to get a clear view of Mount Fuji at that time), Owakudani also has also a number of hiking trails, and I went on one, which leads to the peak of Mount Kamiyama. Along the way, I met a French couple, Olivier and Caroline, as we tried to navigate our way up to the mountain. Obviously, most of the signs in Japanese were not helpful at all, but luckily we met an old Japanese hiker, who was kind enough to show us the way and gave us his map. After the 2-3hour hike, we returned to Owakudani station for a quick lunch. Olivier, Caroline and I then decided to travel together for the rest of the day. From Owakudani station, we took the ropeway to the next station, Togendai, where we boarded the Disney-esque pirate ship, sailing across Lake Ashi to Hakone-machi. We then have a walk around the Cedar Avenue and the old Tokaido-Hakone checkpoint. Not too impressive though. At the end of the day, it’s time to part. After exchanging contacts with Olivier and Caroline, I took a bus back to Hakone-Yumoto train station. Had a quick dinner near the train station, picked up my backpack from the ryokan, and headed to my final destination – Yokohama.

Day 10

Yokohama is located somewhere mid-way between Hakone and Tokyo city. It was already late at night when I arrived at Yokohama. Checked in at yet another Hostelling International branch. It was raining the following morning, and I would have love to sleep in for the whole day, but argh, have to check out by 11am. Left my backpack at the reception, and went out to explore Yokohama in the middle of the rain. Covered a few places, including the waterfront, immigration museum, and the Chinatown (largest Chinatown in Japan). Did not spend much time in the city, as I had to leave for Narita airport around 4-ish in the afternoon to catch the 8pm flight back to Down Under.

And so, my 10-day visit to Japan comes to an end. Overall, an educational, enriching and exciting experience!

-the end-

 

Journey to Japan III

Day 5 – 7

Took a break from holidaying for the next three days to attend the 20^th Asia Pacific Cancer Conference in Tsukuba Science City (about 60km northeast of Tokyo). As I couldn’t find any budget accommodation in Tsukuba, I ended up staying in Tokyo (Tokyo Hostel) and commuted to Tsukuba daily (about 45-minute train ride on Tsukuba Express).

I would say that the three-day conference was quite educational, and highlighted some of the unique contribution of Asian research studies to the field of medical research. One, which was highlighted a number of times throughout the conference, was the finding from IPASS (IRESSA Pan Asia Study). It was the first study to show that EGFR mutation status was a strong predictive marker for response to gefitinib/ IRESSA for treatment of non-small cell lung carcinoma (NSCLC), when researchers investigated the reason behind the better treatment response to IRESSA in non-smoker Asian women with NSCLC. However, while developed countries such as Japan and Korea are leading in terms of scientific research, most of the third world countries in Asia Pacific region are trailing way behind, and they do not even have facilities for decent clinical practice, let alone funding for research. There was also a lot of emphasis on the need for establishing comprehensive cancer registry, with assistance from International Union Against Cancer (UICC), in the third world countries. This is one of the first step to developing good framework for cancer control, since cancer epidemiology in different countries, even in the Asia Pacific region, are not the same. One good example is the much lower incidence of cervical cancers in developed countries with well-organized pap smear screening program compared to the higher incidence in third world countries such as India. The last day of the conference was largely presentation by each cancer-specific working groups. However, it can be seen that, with huge disparity in health systems in different countries throughout Asia, it’s indeed difficult to come out with a consensus statement of best clinical practice for management of each cancer.

Also, as a Malaysian student studying overseas, with little exposure of the actual medical and research development back in Malaysia, I reckon attendance at this sort of conferences has been a great opportunity to meet and get to know fellow Malaysians working in the field. After meeting Soo Hwang (Head of CARIF) at the Familial Cancer Conference back in August, this is the second time I came across fellow Malaysian clinicians/ researchers at an international conference.  In fact, there was quite a large group of delegates from Malaysia at this conference. It was a pleasure to meet Dr Lee Boon Cheok, a urologist and Dr Shamsul Azhar, an epidemiologist, both from UKM. They talked to me about how they have to juggle between clinical practice and meeting the research requirement set by the university, as well as difficulties in securing funding for research, and even for attending conferences. I was later introduced to Dato Dr Mohamed Ibrahim Wahid, president of Malaysia Oncology Society, who is also a radiation oncologist in private practice. I had a good chat with him and he offered valuable advice as to choosing the right career pathway (i.e. radiation oncology vs. medical oncology) to meet the demands and suit the clinical settings in Malaysia (if I were to return to Malaysia some days down the track).

Academic stuff aside I have to say that I was also very well fed throughout the three days. We had bento box lunch everyday, and the welcome reception (on the first night) and closing reception (on the second night) were simply awesome. Kept stuffing myself with the fresh nigiri sushi, teriyaki chicken and tempura prawn. Ah, what a luxury! What makes those food taste even nicer was the fact that as a student, my registration for the conference is free (which otherwise costs 30,000yen)! As the three-day conference came to an end, I looked forward to the last few days of my journey in Japan!

p/s: Oh, and did I also mention that I received 50,000yen for the Young Investigator Award! Coupled with the AUD600 travel grant from the medical faculty, my entire trip to Japan cost me only about AUD200 out of pocket!

pp/s: The Japanese academics speak pretty bad English!

… to be continued…

 

Journey to Japan II

Day 3

p/s: Oh, did I mention what happened at the end of day 2? While resting and surfing the Internet in the common room in the evening, this middle-aged Chinese lady who was also staying in the hostel approached me and chatted with me, and soon we started conversing in Mandarin when she knew that I speak Mandarin. She then started talking about her visit to Hokkaido and Kyoto (apparently she was a visiting research fellow from Wuhan in Hokkaido University). Coincidentally her travel plan for the next day was similar to mine (i.e covering Asakusa and Ueno region); hence she insisted that we travel together the next day. While it was nice meeting new people while travelling, personally, I would have preferred travelling alone, as that would allow me the flexibility of spending as much (or as little) time as I like, taking photos along the way. Anyway, I succumb to her persuasion, and reluctantly agreed. And so, my Day 3 in Tokyo was spent travelling with this newly met stranger.

Early morning the next day, we hired a bike each and headed north to Asakusa region. As we arrived at Sensoji temple, we couldn’t find any parking spots for the bikes. Upon asking one of the policemen on patrol (asking = pointing to the bike, and saying ‘’parking’‘ slowly in English), we were directed to an underground parking area one block away. I was utterly impressed by the massive and rather organized underground bicycle-park. We paid 100yen each for the whole day parking. Anyway, back to the temple. Apart from being the oldest temple in Tokyo city, one of the major attractions of the temple is its main entrance, Kaminarimon (Thunder Gate) with a massive lantern. This gate opens to a walkway of about 200m lined with souvenirs stores on both side, which then leads to another massive gate, the Hozomon (Treasure House Gate).

Later, we headed towards the west to Ueno Park, which housed quite a number of tourist attractions, such as Tokyo National Museum, National Science Museum, Ueno Zoo among others. While I was not too keen on visiting the National Museum of Western Arts in Tokyo, I was somehow being coaxed by the travelling partner into spending a couple of hours in the museum (argh, that’s the other down side of travelling with strangers). On the way to our next and final destination of the day, the University of Tokyo, we passed by the Shinobazu pond and the Bentendo Temple (in the middle of the pond), which was quite a scenic park. We had a walk around the University of Tokyo campus, and took photos at some of its famous landmarks including the Red Gate (Akamon) and the Sanshiro Pond. At the end of the day, we  dropped by one of the restaurants for dinner, before heading back to the hostel. Later in the evening, I decided that I haven’t had enough of photos of Sensoji Temple, and so I cycled all the way back to the temple (about 15 minutes ride away) for more shots (this time on my own of course!).

Day 4

As forecasted, it rained the whole day. Luckily I have covered most outdoor tourist attractions around Tokyo over the last few days. So, I decided to walk just few blocks down the road to Akihabara electric town (it’s not entire indoor though). There were indeed lots of electrical stores. After busy surveying and comparing the prices of few gadgets (digital compact camera for Violet, and maybe new lens for myself) at different stores and calculating the currency conversion, I decided not to get any of those in the end, as the prices do not differ much compared to that in Australia. However I did get some souvenirs from the duty free stores. Later in the evening I collected my backpack from Sumidagawa Hostelling International, and headed to another backpackers hostel, the Tokyo Hostel near Minowa station, where I stayed for the next four nights.

…to be continued…