The last moment

My life is actually quite busy when i am not working, contrary to my expectation. It is relaxing, but busy. Busy as I need to reorganise my routine with the arrival of our daughter, Amatullah Husna. Busy as I need to sort out many things (procrastination is never good!) including locum job, letters and certificates, registration with MMC, returning expert program (for 2 tax free cars) and etc. That does not include shipping, packing up stuff to bring home and shopping.

I recently as well read few blogs, written buy young cancer patients who are at their terminal stage, meaning there is not much options to offer anymore. How they organise themselves to deal with the remainder of their lives. How can they make the biggest impact to the people around them so that their present lives would be remembered and contribute to their benefit in the hereafter.

To compare these two is like heaven and earth. No way you can compare somebody who is actively dying, and somebody who is leaving one place for good, although we are all passively dying. But just imagine if this is our last few weeks on earth. What will we do?

If I could make a comparison, now I am busy preparing for my MMC registration, my tax free cars and looking for a house in Malaysia - ie busy preparing for my next phase of my life. Have i make sure that I am 'registered' as a Muslim, have I checked that my aqidah/belief is the correct one? Allah promises us that He will prepare for us a house in the middle of paradise if we have good manners.

Instead of preparing to go home just after I have finished working (read retired), I should have started a long a long time ago. My GPT scheme was completed 2 years ago, but still i have books to be signed. It doesn't seems that I can can complete it. So I have to make up for it my going to the hospitals asking for signatures. In the hereafter, if I would not be able to make up all the things that I procrastinated in this world apart from paying them with my good deeds. So I have to make sure that I ask for forgiveness with those whom I might have wronged. I might not be able to find them anymore once I move on to a new place. Imagine the work I have to do if I don't deal with this issue there and then? It will be an awful job to find somebody, especially somebody you try to avoid becuase you knew you have wronged them in one way or another. I have to make sure that I pay back whatever money that I owe - so I beg for those who read this article, to clarify matters with me if there are things that is still outstanding in your views!!

In one of the blog that i read, what strikes me is that one of them has started to actively give talks to other people. Instead of thinking what do I want to do to myself in the last moments that I have, he was thinking 'how can I help other people so they can make full use of their life'. And that is what we are supposed to do. So for me, it is wrong to say that we should not think of death as our lives would not be productive. Thinking about death makes us want to live this current life to the fullest.

As somebody who believe in afterlife, it does not make sense when we spend a lot of time for this world (me included) while knowing it is the hereafter we are going to live forever. By making sure others benefit from our living, in return we will get reward for guiding others, Insya-Allah.

To the next phase of my life...
@Peace

envy

I went to a course recently and I met somebody who I knew from my students years. I knew that she was one of the best, if not the best to say the least - at that time. And even after 5 years, she did not fail me at all. She rose higher than my expectation. Even others who were participating in the same course noticed her 'talent'. Every instructor who taught us will complement her. The good thing is, she remained humble (externally), just like 5 years ago. Internally, I am sure she would feel proud of herself. Would anybody not feel proud with all the praises? Even I would like people to say something like that to me.

And that's it. I actually felt envy (in a mild way). Envy to have the praises. Why people were not noticing me? Was I not as good as her? ( obviously not!! :)) Masya-Allah. I usually don't care whether people look at me or not, but i guess the nature of the course is to please the instructor. Your intention became just exactly that - to please the instructor.

Imagine what can happen in our day to day lives if our aim is limited to becoming a consultant quickly, or get awarded for our excellent presentation or skills, or praised for our jobs? What will happen if that aim is not being satisfied and somebody actually stand in between? Would our reactions be that we want this no matter what, we want this thing even at the expense of that person? Or we continue praising our competitor so that we will look good (at least externally) to his eyes and hoping that he will praise us and help us in the future?

Islam taught us not to be envy, except for something good. And that something good are limited to 2 things - somebody who was given the quran and he recites it day and night (or in another wording, someone who was given knowledge and teach to others), and somebody who was given wealth and he spends it in the cause of truth (Bukhari). We envy these two groups in the hope that we can be like him.

Competition is not considered blamesworthy in Islam, especially when it can increase productivity and actually praiseworthy when it was done for righteuosness. It becomes bad when the thinking behind it was a win-lose situation - it is either you or me. And the intention, it has to be for the sake of Allah. To be specific for the course that i attended, it should be that I attended the course so I can pass the course as best as I can. This I will use to save lives of other people, as Allah has said that saving one live equal to saving the whole humanity (quran). NOT for the praise of the instructors. The more people excell the course, Insya-Allah the more lives will be saved.

O Allah, purify our intention and protect us from evil eye.

@Peace

Mastering Adverse Outcome

Approximately 10% of medical encounter resulted in adverse outcome. If this is applied to aviation industry, it means 50 plane will crash at Dublin airport on daily basis!

How do they maintain the high standard of care?

So, how did the aviation industry tackle the scenario? Pilot used to be employed from army, hence the smart uniform and discipline that they still right now - although there is no relationship anymore with defence forces. As we know in army, they rely very much on not questioning the order of the superior. However, the aviation industry challenged this type of culture by normalising respectful assertive communication across the profession. What this means is that co-pilot are free to communicate his worries to the captain assertively, and this has become the norm in the industry. This is very far from what we have been practiign in medicine.

To break the norm is always proven difficult. How can you say to your consultant that you think what he did was not appropriate? In the MPS workshop recently, the presenter adviced on a formula, the square root of n. That is apparently the formula to change the culture/habit of a place. Lets say there are 100 angry people in the workplace. Base on this theory, it only requires10 people to start making changes (ie to be nice), then others will follow suit. I tried to googled it, but could not find any further information on this (eg: study/origin etc).

Confronting an adverse effect from our intervention is a daunting experience. It does not necessarily mean that we are at fault, but it will certainly throw a lot of guilty feeling deep inside. Did I not do enough to prevent this from happening? Could I foresee this coming? Different people then will take different steps. Some will of course apologise but unfortunately some will blame others. We all have gone through the feeling when something like that happened to us, I am pretty sure of that. The culture of blame and shame should have long gone. That will hinder a proper investigation to be carried out. Once we know what was wrong, then we can proceed to explain it to the patient involved and perhaps prevent it from happening to other people. remember the story of how an intern mistakenly gave KCl instead of normal saline solution, and the heart stop beating? The outcome from this was that there should be no KCl next to saline to reduce this probability. KCl is not available to everybody except for certain few, and rigorous label checking at every point of treatment.

In the workshop that I attended, one thing that caught my attention was the discussion on how the doctor was coping when we are involved in adverse events. As usual, there was a video session with a doctor who has little clue on how to communicate properly. Of course our task was to learn on what not to do. But it was interesting to observe how we (who are supposed to observe professional integrity) quickly jump into accusation and our pre-made conculsion on how bad the doctor is. Are we that quick as well in passing comments in real life about our own colleague?

Throughout the workshop, the take home message was that patients who were involved in the adverse event should be informed of what was happening, and we as a doctor should feel sorry of what was happening to them (sympathy). This obviously has provoked a lengthy discussion. There was an argument that by saying sorry, we are admitting liability and that will not look good in the court of law. If we are worried about this, then the advice is to sympathise with the outcome (say: I am sorry that this is happening to you/saya bersimpati atas apa yang berlaku pada pakcik) instead of indicating that we are sorry that it was our mistakes that it happened. Document what we say properly so that the next person will know whether was it a sorry for mistake and just for sympathy. This is also the position of MPS and HSE - that the patients should understand fully on what is happening, and they should not be kept in the dark.

It is not the same as when we have car accident. Lawyers and our insurance company will ceratinly advice us not to admit that we are at fault. Apart from exchanging details, let them sorted out who are at fault over the accident. This defensive culture has creeped up into the medical community. many studies have shown that by being open and transparrent with the patient, the litigation rates are supprisingly on the way down (Kraman & Hamm 1999, Liebman 2005, Quinn 2008).

One thing I believe we should be practicing even on individual level is to help our fellow doctors/nurses in dealing with death of our pateints. One of the doctors in the course told a story of hers, how traumatic it was for her (as a junior doctor) to encouter death of a patient for the first time. One time there was a person who unfortunately involved in a fire. He got nearly 100% burn all over his body. He did not feel the pain as it was a 3rd degree burn, but everybody knew that he is not going to survive. He said at that time that he will be out in 2 months to work againn, and he was still lucid. 3 days later, he died. After the incident happen, all the nurses who were involve din dealing with the patient waere called up into a room and were de-briefed of what was hapepnign etc. The doctors? They were told that they were many cards waiting to be seen (in A&E). the very least we can do is to approach our fellow doctor and say to him, is there anything you want to tell me? Are you ok? How are you coping?

One technique that we learnt on how to deal with adverse events was to apply A.S.S.I.S.T technique.

A Acknowledge (that there has been a problem)
S Sorry (that this is happening)
S Story (in patients own word, what was happening?)
I Inquire (what answer the patients look for? Request permission to provide further info)
S Solution (request permission to propose some lan and to agrre on them)
T Travel (to have follow up)

It has been great to take some time off to attend these lectures. I wish I could attend the next in the series 'mastering professional interaction', but I don't think it will be avaialble in Malaysia or before i leave Ireland.

@Peace.

Mastering your risk

Statistically speaking:
- if you make a mistake, it is unlikely that you'll be sued. (as only 3% of actual negligence end up in court)
- if you are sued, it is unlikely that you have made a mistake.(as 2/3 of cases has no basis whatsoever)

I attended a workshop by MPS a week ago on how to reduce my risk of getting sued. Apparently, just by turning up for the class, statistically it has reduced my risk already. Isn't it good to know that?

Nowadays, practicing medicine is not the same as 10 years ago. We order more investigations while repeating the same mantra in our mind 'what if i did not do enough?' - and that drives more unnecessary investigations. It is all about how to save yourself, just in case we miss anything.

Throughout the workshop, there was a constant take-home message - litigation is a result of poor interpersonal relationship, either with the patients or even with our own healthcare workers. It is nothing to do with our competencies. Apparently, studies have shown that there is no clinical correlation between competency and how many times you are being sued.

Analogy of a mechanic

Imagine that your car broke down a day before you have something important to attend to. You have to give a speech in a major conference. It was a raining day (like in Ireland) and you are soaking wet. Your car started to play on you, you heard some noise coming from the engine. What could it be? Not knowing anything about cars, you conveniently arrived at a car garrage down the hill. It was filthy place, with oily stuff everywhere. After tiredly waiting for 10 minuets, you were attended by a receptionist who rudely asked what do i want at 4.30pm (while watching at her watch)? After explaning about my car, she looked at me up and down with disguise (probably because it is time to close the shop) and said they are busy tosay. It will be a while. After half an hour, a mechanic came out of nowhere and said he has fixed my car. €40 altogether and off i could go. I guess i could feel relieved by that, and happily drove my car home. The next day on the way to the conference, the engine started making noise again, and this time it worse than before. What would I think at that time? I've been ripped off by the idiot who knows nothing about car!!

Then another similar scenario whereby I arrive at the garrage and greeted by one nice lady who asked me how could she help? She offered me coffee and emphatised with me how awful it must be for my car to act up just a day before my big speech. She said unfortunately I have to wait as it is quite busy that day. half an hour later, a person called john turned up and explained to me what went wrong with my car. He said he has fixed it and it will cost me €40. He said as well that the same thing might happen again, and if it happens, I might need to change one part of the engine altogether. So I drove my car home happily and when my car started to make a louder noise the next day, how do I feel? Ooo, that mechanic was brilliant - he even predict that this might happen!! and I promote his garage to my close friends.

Looking at the scenario objectively, we cannot say the second person is a better mechanic than the first one, although the second person is definitely nicer. And that is how we are viewed and judged by the patients. Within that minutes of first time meeting a patient, he/she has already made a mental assessment of our 'performance' - with something as trivial as the way we shake hands, or whether we smile or not etc.

Being a patient

Being with my wife while she was admitted a few times towards the end of her pregnancy really made me realise how awful we treat our patients. I have to say overall, the care that we received was excellent. However, one time, we were worried whether the baby was kicking enough or not. After doing CTG etc, the nurse make a weird look while looking at the CTG. It went on and on for almost 1/2 hour. Everything crossed our mind, what did that mean? Was there something wrong? Even a doctor with some little knowledge of O&G could feel insecure, imagine a patient with no knowledge at all, being kept waiting for 1/2 hour (only!!) without knowing what was happening? Scary!! I must have done similar things to my patients many times. Result of scans, blood test etc, how soon did we convey to our patients that everything was ok?

I myself was onetime admitted to A&E for vertigo. Being taken care off by the nurses and doctors at that time actually felt really good. Somehow I felt I was in safe hand. They look after me well, communicate things clearly. No wonder why people would sometimes 'like' to be in the hospital.

Interpersonal skills

I used to like reading books on self-help, especially when I was as young as 13 years old. I remember picking up a small book belonged to my father - 'Know yourself through your handwriting' and read it with great interest. The interest is now not as powerful as before.

Some people might feel that these are superficial things only, and what really matters is what is inside. It is true to certain extent, especially when politician and actors have these skills at their disposal. However, if the skills help us in understanding our patients and people around us, why not? At least, we will be less likely to be sued.

I also think that most of our ulama should improve their interpersonal skills. When you read their fatwa, you don't feel that empathy that they suppose to show. I appreciate that they only want to please Allah alone, but they can please Allah while empathise with human beings. Did not we learnt from the prophet when a man asked the prophet whether he can commit fornication? instead of brushing him off which he can easily do, the prophet reasoned with him - that he would not want fornication to happen to his mother or his sister. Remember the man who passed urine in the mosque? or the people of Taif when they threw stones at the prophet? The prophet did not ask the companion or the angels to interfere but instead he said that these people did not know. He approach the issue in a different way.

What I have learnt

I have learnt that I am not supposed to discuss patient in public places anymore, and that includes facebook. We know this already but we cannot help but to follow the urges, especially when we don't like the patients.

I am not supposed to make ill comments about my other healthcare collegues, including other doctors, nurses and medical assistants. There are proper channels to follow, and from Islamic standpoint, that is called backbitting. However, I have responsibility to follow up on cases in which I think there is a grave medical error performed by my fellow collegue.

Everybody has expectation, and that include every patients that we consult. When the expectations are not met, dissappointment ensues. So, it is a must to know the expectation in order to satisfy the needs.

When we grow up the ladder of responsibility (from intern to consultant), most of us would write less and less - and we see this everyday. Probably we think that by doing less work with our hands, we will do more with our brain. That is just wrong. Up-to-date documentation is the main thing that will stand in the court of law. If we don't have our own piece to be on our side, what chance do we have? This is not the Day of Judgment when eveyrthing will recorded by angels with our own hands and feet becomes our witness. The judge and the jury are human beings who can be persuaded depending on available evidence.

Hope that will help to remind me in the future, Insya-Allah.
@Peace

Reasons to go home

KLCC, Malaysia

When i told others of our plan to go home for good (Insya-Allah), I'll be greeted in any of these few ways:
- "That is so nice. Where is your country? Are you looking forward to that?" etc. Obviously this response usually comes from non-malaysian, who does not really know what is the situation back in malaysia.
- "Why would you want to go back to Malaysia? Didn't you hear all the crazy things that happens to doctors in Malaysia?"

I guess, i don't have any particular tendency or urge to dwell too much on the debate which one is better. I just get on with it, and once i made my decision, let us hope for the best, Insya-Allah. Money is not the ultimate objective for me to stay in ireland. Of course to certain extent, it would help to have an extra income. But there are other reasons. There are people who want to stay here for their children educations, others want to finish their training up to the consultant level and others probably for political reasons.

For whatever reasons that we have, let us make sure that the time we spend in one place would not go wasted from the world viewpoint and moreover the hereafter. The correct intentions are so vital that everyone of us should examine every so often, even for those already in Malaysia.

Intention

If i begin with good intention of the reason for coming home, what would it be? Can i force myself to have these intentions? A man came to the prophet and asked, "A man fights for war booty, another fights for fame and a third fights for showing off, which of them fight in Allah's cause?" The prophet replied, "He who fights that Allah's word (ie Islam) should be superior, fights in Allah's cause. (Sahih Bukhari & Muslim).

We learnt from this simple hadith that any intention to elevate islam to its proper level is the way to go. It could be in many different ways. Money could come into picture, but with the correct intention so that we can help other people in need.

Value system

Different communities has different value system. I agree that we might not be 'culturally' advance compare to people of Western world, but I feel at ease talking to our own people and especially with people of the same belief system. It might be that people who stays abroad wants to propogate the teaching of Islam, but for me, I have been here for 10 years, what did I do for Islam? In my opinion, Insya-Allah I might do better in Malaysia.

It would be nice to discuss about religion in open space. I remember reading a blog of my friend. She ts an anesthetist who put people to sleep. She asked a patient to say shahadah before doing so, and the patient died later. This story might be really simple to you, but it sticks with me until now. I would not have the oppurtunity to say those things, and I really want to say it to people:
- Makcik, kita cuba sedaya upaya untuk berubat, tapi jangan lupa selalu doa okay. Allah sentiasa menerima doa hambanya. kalau bukan dgn cara yg kita nak, mungkin dia elakkan kita drp bala yg lebih besar.
- Jangan lupa ajak/tolong dia sembahyang walaupun dalam keadaan macam ni pakcik. Boleh tolong ambik wudhu. Sebelum dia tidur, ajar dia mengucap selalu yer pakcik.
- Dialysis ni umumnya tak membatalkan puasa pakcik. Pakcik boleh cuba puasa kalau pakcik larat. kalau pakcik nak tanya apa apa lagi, boleh saya tolong - kalau saya tahu.
- Tak perlulah marah marah, kita sama sama buat kerja doktor ni. Kalau saya salah, boleh tunjukkan cara mana yang lebih elok. kalau marah marah, itu cuma buat saya sakit hati dan tak akan belajar apa apa bende baru pun.

And so many more....

Family

Looking back at my life history, I actually spent more time outside my home than inside. I left home when I was 13. and till now still am away.

My mother died when I was working in Ireland. i have already missed the whole good deeds that i can do to my mother. Remember the hadith of being dutiful to a mother 3x more than a father. This means that I have to be dutiful to my father a lot more now. Ibn 'Abbas said, "If any Muslim obeys Allah regarding his parents, Allah will open two gates of the Garden for him. If there is only one parent, then one gate will be opened. If one of them is angry, then Allah will not be pleased with him until that parent is pleased with him." He was asked, "Even if they wrong him?" "Even if they wrong him" he replied. (Al-adab al-Mufrad). Ibn Abbas said that he did not know of any action better for bringing a person near to Allah than dutifulness to his mother.

What about the rest of our family members, old or new. I felt that it is part of my duty to 'practically' expand the already expanded family.I don't want to be known as an uncle whom they see only once a year. I want to be involve with them, teaching them something about this life that I have learnt. My kid will need to know who are her parents' family and friends. It is part of the sunnah to continue this tie of friendship with the friends of our parents.

O my brothers and sisters, Prophet has cursed the person whom while having their father and mother but still could not enter jannah, because they did not serve their parents well. And may Allah prevent us from the curse.

Things to change

But they are so many things that are not right yet in malaysia. Look at the salary or working condition for example. And how uneven the distribution of doctors. While in UM, we hear about extracorpuscular shockwave therapy for angina, something which i have to do a bit of reading as i haven't heard about it before - in other place we have doctors performing all sorts of procedure without proper supervision as there just not enough doctors there. Look at the attitude of people/doctors. the back bitting was so severe. That does not include the rape, baby dumping syndrome, the heat, balck magic etc.

Let us not forget, these things does not happen in Malaysia only. It happens here in Ireland as well. we hear almost every day people are bitching each other. In peripheral hospitals, the A&E system was so defective that other doctors make fun of them. Alcohol is everywhere and so difficult to go to restaurant where there is no alcohol on board. Islamic schools are scarce in number, and our teens are exposed to the danger of free sex, drugs and alcohol.

Most of us who is living abroad would like to go home one day. we can make a choice, whether we can be part of the team to build the health system to the level of our satisfaction, or we can join only when almost everything is in place. Of course there will never be a perfection in health system. While there are still plenty to do, I think i better get involve soon.

It is a bit like Naruto after few years training outside the village with Jiraiya. When the training finished, it is time to pass the knowledge to others. Not that I am saying I have sage power, but i do believe that I have the responsibility over other people in the village/country.

Other wordly things

Imagine shopping complex that close at 10pm, not at 6pm, with rows of shops and new gadgets in Low Yat, instead of Currys + PC World + Dixon. in which they are all from the same parent company. Warung that open till midnight, especially when you are tired after coming home from work and too lazy to cook, instead of delivery from Spice n Rice or Chiken Hut.

I have enough of Castles and Churches around Europe when I travel. I am longing to go Sabah & Sarawak with my family, or having a camping experience again like the good old days.

I want to attend formal religious education in the masjid, instead of listening to VCD of Dr Asri, or searching Youtube of Islamic lectures, or learning from books - which is not complete.

May Allah show us the proper way to a prosper hereafter, with whatever way we choose to live in this world. Ameen.

It is time to go home.
@Peace.