MRCPSYCH, The Road Less Traveled

A few days ago, a couple of medical graduates who are currently waiting for their housemanship posting had asked me to brief them about the MRCPSYCH program and how it compares with the Master program.

In my conversation with them, I addressed a lot of issues regarding the specialty training in Malaysia and the issues surrounding our training. The stigma, the challenges, the difficulties, the hard work.

This post is inspired by my interaction with them.

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The thing is, my behaviour has always been consistent. I have always spoken up about the same kind of issue, over and over again. 

I don’t agree for anyone to persecute a whole group just because they are ignorant or biased in their views. I don’t agree for anyone to persecute a whole group out of a mistake done by a few people in that group. I don’t agree for anyone to badmouth a whole group for incompetencies committed by some in that group. Because racism and Assobiyah is a sin in my religion!

If we are Muslims, we surely can relate. When Bali bombing happened in 2005, many Muslims in Australia felt the heat. Islamophobia and hate-related crimes increased. It was not surprising to encounter some rednecks shouting at us “Go back to your country, you turban-head!”

My experience in Australia shaped me so much, to the point that I have perfected a very sharp vision of how not to overgeneralize a whole group for some idiotic things committed by some of the people in that group.

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When I was a HO, I felt so angry when I heard some of the consultants in the hospital talked badly about Russian grads or Indonesian grads or Ukraine grads. I was an Australian grad, and therefore I was spared the stigma. But even then, it was said “Overseas grad are not as good as local grads. They are not good at setting brannulas. They are not exposed to procedures as much!” Pffft! But one month into your first posting, ANY HO can set the brannula regardless of where they grad! One month into medical posting, ANYONE can do procedures for Peritoneal Dialysis and short lines and long lines. So, what exactly is the big deal here?

So when I was a junior MO, I wrote a long blog post defending the Russian grad. (It can be read H.E.R.E.) I wrote that, contrary to people’s belief about the Russian grads (that Russian grads had achieved bad SPM results and should not have been qualified to go to a medical school) those who were government-sponsored to Russia were actually the cream of the cream in our SPM batch. They went to Russia based on their trial results! It was the government policy AT THAT TIME, to send brilliant people to Russia. I went to Australia based on my SPM result… not my trial! So these government-sponsored Russian grads were actually excellent students.

A lot of the Russian grads (some of them my friends) had widely shared the post. It became viral in no time. I was quite surprised.

And now, we have had many specialists and even consultants in various fields who were Russian grads. In fact, there are still many MOs who are currently doing their master training who are Russian graduates and they are just as good as the local grads or the UK/Ireland/Australia/NZ grads.

See? All your skepticism and your ‘budget bagus’ statement and yes, your arrogance!! have been proven wrong! Any incompetency, attitude problem or lack-of-knowledge in a Russian grad, they are personal to that particular person! You are not being fair when you overgeneralize the whole group! Yes, you had PERSECUTED the whole group just because they were weak and disadvantaged

When there were so MUCH brouhaha about how HOs in the shift system would never be as good as us who were doing our housemanship in the on-call system, I had been very consistent in defending the HOs in the shift system! Even though I was a HO during the on-call system, I NEVER act like I have a crystal ball to see the future and automatically KNOW that none of them will be just as good as me.  I defended the shift system many times! Because I don’t,  and NEVER WILL condone anyone to persecute a whole group or a whole system for any mistake or attitude issues done by some people in that group or in that system! How can you be so small-minded and so certain that the whole group in that system will never be a good doctor just because they have a different training than you! I have many friends doing internship in Australia, UK, New Zealand and Ireland… all of them are good doctors now even though the shift system is implemented there. In fact, the irony is, we send our undergrads to learn to become a doctor in those countries who have been doing the shift system for decades! And then we have the cheek to bash the shift system?!

In my department now, we already have MOs who did their housemanship when the shift system was already implemented. And they are just as great a doctor like the rest of us seniors! In fact, banyak lagi senior yang baloq liat compared to them! Again, all your ‘budget bagus’ statement that this shift-system will produce bad MOs have been proven wrong! Any bad MOs prevalent in the environment stems from their own personal issue and again, it is ridiculous to persecute a whole group based on mistakes done by some in that group!

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External Pathway Vs Master Pathway

There have even been a lot of ‘budget hebat, aku paling terer’ statement when it comes to bragging about systems in specialty training.

Nowadays, there are already many specialists and consultants who were the product of MRCP, and thus they received less criticism than us MRCPSYCH. But still, you can hear people saying things like “MRCP is not as good as master”.

But the reality is, there are NOW many consultants who are the products of MRCP, some of them are cardiologist, respiratory physician and gastroenterologist ALL OVER THE WORLD. When you say they are not as good as the physicians in the Master pathway, what exactly do you mean? On what basis do you say that? Is the Master qualification recognized all over the world outside Malaysia like MRCP? No! Do you have an objective scale in which to measure how better the Master pathway is compared to the MRCP? No! Or are you just giving an emotional statement just because you disagree with the MRCP physician’s management? Or maybe you have had an inter-departmental issue or disagreement that would have existed anyway regardless of whether the physician is an MRCP product or a Master product?

This is what is happening with MRCPSYCH too. Unlike MRCP, we are only just recognized in Malaysia around 2013/2014. So everyone is having an adjustment disorder about the whole thing. And of course the most logical thing to do – in their opinion – is to bash the MRCPSYCH system and comparing them with the master system in an unfavourable manner, despite the fact that the MRCPSYCH system is recognized the whole world over!

Now, my question is, how sure are you that MRCPSYCH system which is world-recognized will never produce good psychiatrist like the master system? Do you perhaps use a better and different book than us? Do you use special Malaysian-made books that cater specifically to Malaysians psychiatric diseases? (Or do you, in fact, use UK-based books and some of our MRCPSYCH notes too, hmm?) Do you perhaps have a larger amount of greater professors and lecturers compared to the rest of the world? Do you read different journals than us? Or do the people doing the master pathway are somehow less forgetful, more diligent, more up-to-date in anything compared to the MRCPSYCH students? I mean, WHAT?

Oh yeah… maybe the master students were more ehem, GUIDED by lecturers compared to us who were so-called ‘study sendiri-sendiri.’ But then I have checked with several master students too… not just in psychiatry but also in other fields…. they were always told “La ni kita adult learning ya. Bukan semua kena spoon feed. Kena belajar sendiri and tahu apa nak belajar.”

Hahah. So what is the difference, then? Kau belajar sendiri, aku pun belajar sendiri! And nowadays, how many percentage of your time are spent at the uni, especially if you are an out-campus student and also doing various rotations all over KKM facilities? The same KKM facilities that we the MRCPSYCH students use!

Oh yeah… master students have to do thesis! MRCPSYCH tak payah.

So what? I am not going to be a researcher. I am going to be a clinician! You choose master, you deal with YOUR requirement. I choose MRCPSYCH, I deal with MY requirement and the requirement set up by KKM. I pay using my own money to train in MRCPSYCH pathway. If you want MY requirement to be the same as YOURS, then maybe the amount of financial support by the government to MRCPSYCH candidates should be the same too. Everything should be the same then! Tak payah nak buat two different pathways if you guys are so KIASU to question why MRCPSYCH candidates don’t have to do any thesis. My question is, why didn’t you choose MRCPSYCH if you had cared so much regarding how we don’t have to do any thesis? Does doing the Master thesis help you being a better clinician? How much difference does it make? I want to know. And if you think doing this thesis makes you into a MUCH BETTER clinician than the MRCPSYCH candidates, then you shouldn’t feel so bad that you get to do it. Shouldn’t you want what is best for your adult learning despite what other people are doing in another pathway? 

One last point about doing thesis! It would be UNFAIR and VERY UNJUST for anyone to suggest that the MRCPSYCH candidates should do a thesis, just like the Master candidates. When you are doing a master program…. OF COURSE you have to do a thesis! All master students in OTHER FIELDS also have to do a thesis to be eligible to get a MASTER DEGREE! That’s why nama benda ni MASTER PROGRAM! Whereas, MRCPSYCH is a MEMBERSHIP program! We don’t get a MASTER degree despite the fact that our syllabus are the same with the master program. If we ever want to pursue a PhD in the future, we have to get a master degree first before we can do a Phd! But for you guys who are already doing the MASTER Degree, if ever one day you want to do a PhD, you can straight away do it because you already have a Master Degree! Get it? Faham tak beza Master dengan membership program? Semua Master degree kena buat thesis, regardless of their fields… faham tak? How is that FAIR and JUST for you to suggest for us to do a thesis when we are PAYING OUR OWN WAY for an exclusive world-recognized membership program and NOT for a master degree? Semua nak sama rata… tiba-tiba at the end of the day, korang dapat master degree tapi kami pula dapat membership of Royal College of Psychiatrist? Nak sama rata celah mana?? (Gosh, aku  tak faham how some people utilize their minds! So weird how they want everything to be fair … as long as in the end, it STILL favours them!)

So, if you are a smart person who JUST KNEW DEEP IN YOUR HEART that you don’t want to do a PhD in the future and you don’t want to become a lecturer or a researcher and you just want to be a CLINICIAN, you would have chosen the MRCPSYCH program! Simple decision making, isn’t it? Tapi kalau kau nak jadi CLINICIAN tapi nak juga ambil Master Degree, that’s YOUR choice! Mungkin kau rasa Master Degree lebih hebat, lebih seronok, lebih banyak pengalaman…. for whatever reason… that is YOUR choice! Jangan nak suruh kami pun nak kena buat thesis! Siapa suruh kau pilih Master?? Lepas tu nak jealous dengan kami pula? Kemudian at the end of the day kita sama-sama buat thesis, tapi kau dapat Master Degree, kami dapat Membership! Banyak cantik! Fair sangat lah tu? How biased is that!

In many parts of the world, most doctors only do a Membership program rather than a Master program because as a doctor and a clinician, that is already ENOUGH. Malaysia should have its own Membership Program for post-graduate training without having to go through the Master system. Maybe this is something we should start looking into! UK has it (RCPsych UK), Ireland has it (RCPsych Ireland). In Australia and New Zealand, they have a regional membership program called The Royal College Of Australia and New Zealand and their candidates also don’t have to do any thesis! Semua orang yang buat membership program, memang tak payah buat thesis! Faham tak? Please get this into your head.

If we have our own local membership program, only then it is fair for you to do some comparison between MRCPSYCH and the local membership program. Candidates can even decide to do BOTH the local membership program as well as the MRCPSYCH program just to get an extra international recognition. (Maybe we can set up a Royal College of Psychiatrist of Malaysia? Or maybe we can collaborate with regional countries and make it into an ASEAN College of Psychiatrist or something. Tak payah dah KKM nak bayar duit kepada universiti untuk train specialists! Besides, most of  the KKM facilities are being used for master training, anyway kan?) Let’s just keep the master program for those who want to become trainee lecturers. Of course trainee lecturers have to do a Master program (and therefore a thesis) if they want to become a lecturer or a researcher or an academician.

Look, at the end of the day, all of us have a choice! We choose according to our own views about what is beneficial for us and how it would fit our commitment and lifestyle. You had a choice too. Once you have made your choice, you really should stop questioning regarding how greener the other side is.

And before I forget, please remember that people who live in a glass house shouldn’t be too quick to cast stones.  The Master system is also very vulnerable to criticism. At least, I TRUST the integrity of the MRCPSYCH pathway. I mean, we NEVER heard any incidence of someone getting hold of leaked questions. We NEVER heard other candidates complaining about how they were disadvantaged because  they did not know about the leaked questions until after the exam… because that kind of thing just does not happen. There is a reason why MRCPSYCH is world-recognized. Because we adhere to a very strict exam guidelines standard and  procedures. Can we say the same about the Master system? Think about it before you say anything disparaging about another system. There are good and weak points in BOTH systems. You are welcome to point out the weakness in my system, but you too must be ready to hear your weakness being pointed out in return. Fair, ok?

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Now, let me be very clear why I chose MRCPSYCH over Master.

It does not have much to do with the fact that MRCPSYCH is recognized all over the world, even though that is a really good aspect of doing MRCPSYCH! I don’t think that having a world-standard recognition automatically makes MRCPSYCH better than the master system (yup, unlike some people, I don’t feel the need to belittle other system. I think belittling others is a sign of insecurity! But if you belittle mine FIRST, I will certainly retaliate. So jangan nak jolok sarang tebuan unless you are prepared to be stung. Because I will sting you!) Like I said, we use the same books, the same syllabus, the same DSM-5 and the same ICD-10. MRCPSYCH is not better than the master system or vice versa. Please be CLEAR on this!

The reason I chose MRCPSYCH is because I am already used to the freedom and the ‘adult learning’ in the western system! I am free to explore knowledge and form my own opinion without having to navigate politics in the uni. I don’t like those things! I am very outspoken too. I don’t think I can tolerate the Malaysian mentality that outspoken-ness is equal to arrogance (Not all Malaysians are like this, and not all workplace have mentality like this. Even my workplace is generally nice and supportive. I need to put this disclaimer so that no one ends up with their feelings unnecessarily hurt).

I avoid any type of environment that would try to regulate or institutionalize my thinking and my ability to speak up about anything that is wrong or unjust. That is THE ONLY REAL reason I chose MRCPSYCH over Master.

I have heard some disturbing stories about the master system (not necessarily in psychiatry but in other fields as well. I don’t think this is the norm in the master system… but it can and does happen). My friend had told me regarding one student who was quite outspoken regarding her dissatisfaction in the master system, and because of that, she was barred from taking an exam. I asked my friend “Perhaps, she has an attitude problem? Was she always late or did not perform her responsibility well? Was she MIA? Maybe she didn’t finish her assignment?”

My friend said, “No, she was just more vocal about what she found wrong about the master system. So she made a few enemies. She had no knowledge issues. When she takes her exam in the next sem, she passed with just one attempt… she is quite intelligent actually.”

I was bewildered by that story. How can you bar someone from taking an exam just because she speaks up against the system? How dare you! I told my friend “Kalau aku kat tempat kawan kau, I will sue the uni! And I will send complaint letters to many people in KKM! See me in court!”

My friend laughed, “Lagi teruk dia kena nanti. Kami semua ‘yes boss’ ja la,”

There was also another story regarding how ‘adult’ the learning really is. You just did everything and you had to pay for it too. “Kami yang organize kursus. Kami yang dok organize lecturer mana nak bagi talk. Kami yang kena jadi MC, kami yang kena jadi usher… tapi kami pun kena bayar RM500 untuk kursus tu, Padahal kami yang organize. Ramai orang tak puas hati… tapi senyap jalah.”

Wow… how, ehem, unique is that arrangement? In the Western country, the trainees would have raised hell if they are treated that way! Instead of barring the students from having exams, they would be scrambling around doing damage control to their reputation. When you pay for something, you are the service-user or the participant of that course! Somebody else should be organizing it! Not you… who had PAID for it! There is an emphasis for getting the value of your money when you are doing any transaction in the Western country! That is just a simple concept of fair dealing!

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screenshot 2019-01-17 12.25.49
My Facebook Status on October 12, the day when  Dato’ Azman came to HSB for a session with MOs.

Another issue in the Master system is regarding what happens if you want to quit your master program. I had raised this issue myself when Dato Azman came to HSB even though this has nothing to do with me and more relevant to the master students (So jangan ingat aku asyik tulis saja. Bila ada peluang nak cakap dengan orang atasan, I do it, okay! I just need to feel annoyed enough and then I can REALLY speak.) And Dato Azman was quite nice in listening to all the issues I had raised. I applaud his patience in giving us, the MOs, a fair and transparent platform to speak up.

Another friend of mine who was doing a master program in another field had told me that if she wants to quit her master program, she has to pay RM250,000 to the government.  I was aghast!

“Takkan sampai RM 250,000 kau spend untuk belajar kat uni for these few years?!”

My friend told me, “Dia cakap sebab kita ambil tempat orang lain. So dia nak penalize kita dengan RM250,000 tu. Padahal satu semester RM 8000 saja. Kalau lapan semester baru 64,000.”

I shook my head in disbelief. RM64,000 vs RM 250,000. That is almost QUADRUPLE the amount that you actually used to do your master. How can they justify penalising people QUADRUPLE the actual amount of money used? In my head, I went “This is even worse than usury! Riba kot! Even worse than hutang dengan Along! Just because the master pathway had the MONOPOLY in the business of specialty training, it doesn’t make it right for them to impose unjust deals and rules!” (That is why monopoly is bad in any sector. It encourages unethical abuse of power and the consumers have no rooms for negotiations of their rights because they have NO OTHER ALTERNATIVE!)

So on the day of the meeting with Dato’ Azman, I went down to where the mic was and I said, “Many people are interested in  the master program. But you made it so unattractive to us with oppressive deals. When I am doing MRCPSYCH, I know what I would be getting for everything that I have paid. When I pay RM1300, I get the course notes. If I want to join online classes/tutorials, I can pay for it and I get classes/ tutorials. When I want to do mock exams, I pay for it and I get to do mock exams. When I want to do my actual exam, I pay for it and I get my exam. If I fail the exam, I just need to fork out MORE MONEY to pay for another attempt and I will get another attempt. There is no ‘penalty’ whatsoever. The system is so much more transparent, money-wise. I get what I pay for and I KNOW what I am paying for! No one feel cheated or short-changed! So…how can we justify QUADRUPLING the amount of the actual money used just for the sake of penalty?”

Seriously, I was quite outspoken in that meeting. I mean, think about it! Why don’t you penalize the person by asking her to pay another RM64,000 on top of what the person already owed the government? Which means, get the person to pay RM128,000 (RM 64,000 for her own study + RM 64,000 Penalty for the place of others that she had taken = RM 128,000)  That is more reasonable, isn’t it? (but still unfair. In contrast with the MRCPSYCH system, you only pay for what you want or for what you use. It is fair and transparent!)

We call ourselves as Muslims and Malaysia is a so-called Muslim country! And yet in ANY ‘urusan Muammalat’, the Western non-muslims are more fair and more just and more transparent in all their dealings and transactions! That is the truth! And that’s why when I see intelligent, fair-minded Muslims, my heart softens towards them because they remind me of Australia, the place where I had learned to become more mild-mannered after I was impressed by their intellect and their patience and their fair dealings. In their system, they are MUCH MORE Islamic than us! (Bila balik Malaysia, my disposition has suffered a relapse. Hahah. Hopefully, with the new PH government, the environment in our institutions will change accordingly and my manner will become mild again. LOL)

I told Dato Azman, “I am actually doing the external pathway… but I am just speaking up on behalf of my master student friends scattered all across the fields. What is the RM250,000 money for? They learned mostly by themselves just like us in the external pathway… what is the money paid for then?”

Dato Azman raised his eyebrows “They learned by themselves?” He sounded surprised. And Thank God, there were a few MOs (I didn’t know which of them in the audience) had shouted yes! (Hahha. Thanks guys, whoever you guys are, for the support! I needed it at that time! You guys rock!)

I went on to say, “When we were doing our undergrad study, RM250,000 might be a somewhat justified amount for us to pay back. We got a lot of lectures every week, we got tutorials, we got quizzes every month! We could roughly see where the huge amount of money was spent! But with ‘adult learning’, I do not understand what is the RM250,000 penalty for.”

Dato’ Azman had noted what I had said and he said he would think about it and look into it. I hope, he really does. He also gave his email address and he said we are welcome to write to him directly for any issue. He was quite nice actually despite having to hear a lot of issues and complaints by many MOs that afternoon. Some MRCP candidates had also spoken up and supported what I said regarding our issues in the external pathway. MRCP candidates and the MRCPSYCH candidates kind of conquered the mic that afternoon. Hahaha.  But Kudos to Dato’ Azman for remaining calm. (Actually there were so many other issues I had gone to the mic for but not all of them are relevant to this post. Aku antara orang yang paling kerap guna microphone on that day. And seriously, Dato’ Azman was very patient in handling my questions. Tabik spring!).

I think, this is what leadership is about. Listen and respond.

The era of autocracy is outdated and should have been long gone! Dialogue is in! When someone criticizes your system, you don’t bar them from exams! Instead, you engage them in an intellectual discourse and settle your differences. You remain objective and fair towards them. Be matured! We are all adults here! But once you use autocracy in a cruel and unjust manner, you will one day encounter a student who may fight you back and will never stop fighting until she/he wins against the system! The probability is such that when you use the same method over and over again ENOUGH TIMES, one day you will encounter an EXCEPTION to the norm. When that time comes, you would wish you have never used autocracy against the student and had used intellectual discourse instead. Because trust me, some students may have the courage to fight you all the way to the court. Just imagine the kind of damage it would do to the reputation of the system. It is already happening in housemanship  and now our housemanship training has gotten a terrrible name already. So, please use the method of engagement rather than autocracy in anything you do. Because in this generation, the current maxim is “Be fair or Beware”.

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Some people had also said “Bila ada external pathway ni, kita tak boleh nak control who are the candidates that become our future psychiatrists. Who knows…orang tu ada attitude problem ke… mungkin diorang tak sesuai nak jadi psychiatrist. Kalau dalam master program, kita boleh stop dia jadi psychiatrist from the very beginning kalau kita rasa dia  tak sesuai.”

Wow…. this is SO Malaysian! Do you think NONE of the master graduates had ever had any attitude problem? I can name a few, too! But do I go around saying “See? What kind of bad psychiatrists the master program is producing? And look at the products of master program in other specialties! Some of them molested HOs. Wow… such a splendid ‘attitude screening system’ you have in the master program, huh?And with those who didn’t molest HOs, they simply remained silent out of sheer selfishness and cowardice! What kind of specialists are the master program producing!? Look at how institutionalized their thinking is that they would ignore any wrongdoing just because it comes from someone of a higher hierarchy than them… perhaps because they are so used to it in the master system. Asyik senyum and cakap, ‘yes boss’ or ‘yes, prof” all the time!” Did I say any of that? Ada ke aku keluarkan kata-kata overgeneralization macam tu? Ada aku generalize semua master products as cowards based on that notorious incident? Tak, kan?! Because I am fair in my thinking and my judgment! I don’t over generalize people. In psychiatry, over-generalization is a cognitive distortion, ok? 

Should there be any issues with the attitude of your future specialists, you deal with them when they come along! Just like in anything in the world, you intervene when there are issues! You shouldn’t PRE-EMPTIVELY discriminate the whole group with your snide remarks based on your bigoted, discriminatory unfounded fears! But now, what  we did was the EXACT OPPOSITE! (klasik perangai orang Malaysia! Suka buat benda tak logik!) When there are serious issues with your specialists, you remain quiet and silent because you “nak jaga nama jabatan!”. Bila specialist dah ada isu, kita pula pi buat senyap! Sampai HO pun boleh kena molest for MANY YEARS! (Tapi ada hati nak condemn the external pathway sebab kita tak boleh nak, ehem, ‘pre-emptively screen their attitude’! Wow! Amazing reasoning! Boleh tak kalau ada isu, deal with it then and there?! It is a more logical approach, isn’t it? Tak payah nak kalut risau pasal the future, sedangkan benda yang kita boleh intervene STAT, kita tergamak buat senyap for MANY YEARS! What is that?! How dodgy is our priority!)

If an MRCPSYCH candidate does not perform well in the department, you can talk directly to the candidate and tell the person to improve. The candidate’s particular issues should not be generalized to the whole system! If a specialist asks an MRCPSYCH candiate something that she/he doesn’t know… maybe it is the candidate’s personal lack-of-knowledge and incompetency issues. It doesn’t mean the whole MRCPSYCH candidates are not good. Likewise, I have seen quite a few Master candidates who are not that good… some of them are already a specialist and they can still be confused about certain aspects of patient management. To me, that is just human! I do not generalize that to the whole Master program, do I? We read, we take exams, and then we have a tendency to forget a large chunk of it! That’s why we have CMEs! So that we can refresh our knowledge, get it?

So, when you come up with a statement, please be fair! You might get away with it when your audience are not as out-spoken as me or if they always feel the need to kowtow to people and please the authority. But I am not like that. That is just my personality.

personality

I reiterate that I am not bashing the master system. I  think they produce very good psychiatrists, in general. But my personality, my principle against unjust contract, my aversion to oppression, and my personal inclination, had made me choose the external pathway, instead! It is MY personal choice. And you can openly judge me for it… don’t worry, I will just argue against your points. If you can openly judge my choice, I can openly judge your choice too! It will be fun! But if I speak and answer you back in a way that might hurt your feelings, don’t think I am arrogant. You had it coming. And I am the sort of person who fight ALL THE WAY once I am angry enough!

I have always spoken up against the persecution of any underdog. My behaviour is CONSISTENT. If MRCPSYCH is considered the underdog program, heck, I don’t mind speaking up about it. I have spoken up (written up) for others before… and so, believe me, I have no problems speaking up or writing up for myself.

I will continue to do it until MRCPSYCH is as established as MRCP and any issue will then become redundant background noise! 

***

“Don’t worry, Afiza. Kalau depa dok buat payah, kita pi ja la kat Singapore ke Brunei ke…UK pun boleh. Terus jadi orang sana. Gaji pun lagi banyak. System pun lagi bagus.” Said my friend.

That is true. But it will be sad for Malaysia isn’t it? I understand now how the ‘brain drain’ phenomena befalls Malaysia. People get upset by some bureaucratic red tape and they just pack up and leave! And Thank God, that option is always available for MRCPSYCH candidate

Yup…. with MRCPSYCH, I retain my freedom. Free to speak up. Free to move out. Free to address my concerns and the concerns of my colleagues. I will not exchange that freedom for anything in the world. And if people ask me why I choose MRCPSYCH, this is why!

If you have different values than me, you do you! Live and let live! But if you try to belittle my pathway in front of me just because we have different priorities in life and different lifestyles, get ready for my rebuttals. Because I will give them! This is my promise!

Disclaimer:

This is my personal blog and my personal opinion on Malaysian specialty training. It does not reflect the opinion of anyone in KKM or in my department. Please also refer to my blog disclaimer on the bottom right side of the page. My blog has been around since 2009 and it has always been dedicated to me recording about my life as a medical student then, and my life as a doctor now. I have always been very outspoken about things even when I was a houseman. My blog is a place for sharing of life experiences, life-philosophy, world-view and opinions as well as for advocacy of the causes I believe in. So, if you disagree with me, I encourage you to have your own blog and advocate for your own point of view. I also encourage you to leave a comment if you disagree with me and we can debate the matter. This is a free country that respects the rule-of-law since Pakatan Harapan won the General Election last year. Which means, everyone can have their own point of view and advocate for what they believe in. Any assumption, presumption, speculation or hurt feelings that result from what I had written are the responsibility of the readers themselves and they are accountable for it in its entirety. 

My Problem With Anything Vague

The question I always have in psychiatry relates to the psychodynamic area of psychiatry.

“If something is unconscious to the patient, then how can you be reasonably sure that THAT is the reason for how she is feeling at the moment? You are just the therapist. If it is unconscious EVEN to the patient who had experienced it herself, then how do you know that you are right when you point out, oh, the childhood experience of this and that are the reasons for what the patient is feeling now?”

I kind of feel unsettled by the vagueness of it all.

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I think many people who are involved in psychiatry DO have similar questions about psychodynamic stuff like this. But perhaps, unlike me, they don’t really feel the need to vocalize their confusions (or maybe they are not confused about it. Maybe I am alone in this bothersome affliction. Oh well…). 

I never get a satisfactory answer.

Or maybe… my benchmark for what is a satisfactory answer is higher than most. I was like that since I was a child. I would ask the same question to my parents repeatedly until I was satisfied. Of course, as I grew into adulthood, I learned to suppress my questions and pretend that I am satisfied with an answer… just to cut the interaction short. I suppressed my dissatisfaction at the answer that I received so that I could simply leave the discussion. And then I went back home, forever googling. Hahaha.

There are times, when I wonder, why should I bother being so open about my dissatisfaction? Orang lain belajar, jawab exam dan lupakan! Tak payah nak ruminate or question something that is already in the syllabus!

But questioning is how I learn! Debate, discourse, arguments… that’s how I learn. I need to know. Not with ABSOLUTE certainty; just with reasonable certainty that are backed up by scientific evidence.

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I have to admit that my arguments can be very tiresome. Don’t take it personally, ok. That’s just my learning style. Convince me! Break my argument! Then, I will learn where I went wrong. If you cannot rebut me, then I will go away believing I am right.

When I was a teenager, I even questioned the so-called religious stories that were fed to me and my friends. And trust me, among traditional Malay community, questioning anything that sounds religious is taboo. They can jump to conclusion “Your faith is weak! Questioning something religious… you should make taubah and say astaghfirullah. It is the Satan whispering evil doubts to you.”

Kesian kat syaitan. Tak pasal-pasal dapat nama! When it is actually THEIR respresentation of religion that is faulty!

I had asked my naqibah, “Is that religious for her to ‘cungkil’ her eyes just because a man was attracted to her eyes? She had covered her aurat, even wore a purdah. But just because a man, who could not control his own self, was attracted to her eyes, she was supposed to ‘cungkil’ them out to demonstrate to us of her piety? Aku tak faham! How is that religious?”

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In one narration, this woman ended being dead! And this story has been propagated as the story of a pious woman that all women must aspire to become! And only MUCH later did I find out that, it’s a fake story!! And this story is still circulating in dubious blogs and among ustaz/ustazah who could not be bothered to check their references.

I was 18 at that time, doing my IB studies in KMB. I was just a teenager; albeit a curious one. When adults (like ustazah who endorsed the content of the ‘talk’) do not even question the ‘religious’ story, what authority did I have to even question it?

But question it, I did. 

I couldn’t help myself. It was deeply ingrained in my psyche to express my discontent at things that do not make sense.

I was SURE many students MUST have had similar thoughts, but they didn’t feel the need to voice them out. Kita dengar, kita balik, kita lupakan. That was the maxim!

And I used to be like that too. Religion was a mere ritual, separated from any logical understanding whatsoever. I prayed, I fasted… I was good enough, I thought. That was enough, surely! I would have been just like other teenagers….EXCEPT…. at that time, I was dealing with the death of my ex-classmate. I was interested to know – more than I ever did before – about religion, about philosophy, about life after death.

And they fed me these illogical stories?! (I knew it was not intentional on their part. They believed the story themselves! To them they were speaking the truth. But shouldn’t they have cross-checked their references before they gave talks to others. If I were the one being asked to include such a nonsensical story in my religious talk, I would probably ask about the authenticity of the story and investigate the sources until I was satisfied enough! You nak bagi talk, you prepare betul-betullah, kan!!)

If  they had known, how MUCH such fake stories would SHAKE!!! the foundation of someone’s faith, especially in the context of someone who was grieving and was searching for the TRUTH, they would NEVER think that their fake Israilyat stories were harmless and were just for  “Pengajaran saja. Bukan maksudnya kena cungkil mata. Kita nak tunjukkan potret seorang wanita yang berakhlak mulia.” Ugh!!

I was incredulous and very upset when I heard such an answer! What the hell, berakhlak mulia pi cungkil mata tak pasal-pasal? (In psychiatry, that is like deliberate self-harm! And we use the term deliberate self harm even for someone who simply cut their wrists. But this is cungkil mata, okay! Imagine if we have a non-muslim psychiatrist hearing this story, he would NEVER be interested in Islam kan! He would say Islam endorses deliberate self-harm! This is why the Prophet (PBUH) made it so CLEAR, that ‘sesiapa yang berdusta atas namaku, dia telah menempah tempatnya di neraka’. That is a huge warning, you know! Some people could not imagine how stories like this can turn intelligent people away from the religion! They could not imagine that …because in the first place, they were not deep thinkers! So why would they ever question anything, right? They assume everyone is as simple minded as them! And anyone who question them is just not religious enough!)

Glad INTJ argues

****

Let’s create a made-up scenario here to demonstrate how easily we can be wrong in our assumptions.

Let’s say… an imaginary psychiatrist, who is not well-trained in psychodynamic, finds out that when I was 11 years old, Ustazah S at my primary school was upset at me for secretly reading the school magazine in her class while she was teaching. This imaginary psychiatrist also finds out that Ustazah S had scolded me fiercely and took my magazine away from me and then she hurled the magazine out of the classroom door until it fell all the way to the ground floor of the building. (I was just flipping through that school magazine in her class because I couldn’t wait to find out whether my short story was placed in the ‘karya murid’ section.  Hahha. My fault for being unable to delay my gratification, I admit. But she didn’t have to throw my magazine down the building, right? Marah aku sudah cukupkan?! Tak payah lah nak rosakkan majalah sekolah aku, right? Hahha. I was ready to admit my mistake for reading the school magazine in her class. But when she threw my magazine all the way from the 3rd floor down to the school garden, I could feel my anger flare almost instantaneously. Instead of looking downward to demonstrate my remorse, I looked up and stared back into her eyes and refused to look away. It was a staring match I was determined to win. Hahah. She became upset and scolded me even more. “Kenapa jegil mata kat Ustazah? Tak puas hati!?” I remained silent but I held her gaze still. In my heart, I went “Memanglah aku tak puas hati! Kau baling buku aku kot! Kalau rosak, kau nak ganti ke?!” Haha. Seriously, I loved all my books! At that age, I had to collect my school money to buy myself any book and magazine that took my fancy. Every single book was precious to me at that time. So, of course I was angry! Ustazah S decided that I should stand at the corner of the class for the rest of the period because of my insolence for staring at her eyes. I defiantly held her gaze while walking to the corner of the classroom. In the end,  I won the staring match. LOL. Until now, my hilarious siblings who knew the story would take one look at me and said, “Weh…mata kak ngah dah mencerlang tu. Dia dah marah tu. Lariiii!” hahah.)

stubborn INTJ

 

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Hahah. I am not this bad. I don’t think I have a sinister smile.  LOL

The psychiatrist who finds out of my history with Ustazah S would probably say, thinking that he is applying his psychodynamic skill, “Hmm…maybe this is why you are hypercritical towards religious figures? Because of this ustazah? Maybe this is why you always like to question religious stories? Maybe this is why you don’t like anyone who speaks  like ustaz or ustazah? Because of what happened to you in your childhood with this ustazah….”

I would probably go…. “This psychiatrist is so ridiculous. He just didn’t get it! Such a faulty psychoanalysis!”

This imaginary psychiatrist is ignoring every other thing that was relevant to my behaviour in KMB when I questioned that ‘cungkil mata’ story. He is ignoring the fact that in the first place, the religious story was fake! When I questioned it, my question was right. I did not question it because the speaker reminded me of my childhood Ustazah S! I questioned it because I wanted to know whether the story was valid… because it sounded so dodgy, okay?! He is also ignoring the fact that, there ARE religious figures that I actually like especially those who are logical and sensible. So how does my terrible childhood experience with Ustazah S can explain my ability to like certain type of religious figures? Surely my sentiment and my dislike towards anyone is more logical than just being solely influenced by my brief childhood experience with Ustazah S. Human beings – when they are not psychotic, at least – are logical creatures!

This psychiatrist, if he jumps to such conclusion, is not being thorough in his assessment! For example, he might also be ignoring the fact that as teenagers, our formal operational stage was on the way to its peak! (Google Piaget Theory of Cognitive Development, guys!) Our logical sense was at its peak when we are at the teenage stage, especially when all our lives, we are surrounded by intelligent cohort from our previous school and all of them study science! Of course, we would question something as stupid as the ‘cungkil mata’! And do not forget the context of me dealing with the death of my friend. The urgency of me wanting to know existential, philosophical stuff like this was at its most passionate at that time. 

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Piaget Theory of Cognitive Development

 

When you put all those into context, the childhood Ustazah S really is not that significant to explain my abrasive manner in questioning religious authority, is it? 

So, my point is, not everything is about your terrible childhood, right? Childhood experience cannot explain everything that you are feeling or going through now! People who you have met and disliked in the past do not necessarily have such power over you that you would illogically and instantly dislike anyone who you meet in the future that reminds you of them!

I don’t believe that psychodynamic is that simple!

Oversimplifying things like this is an error in judgment!  We would be underestimating the power of our brain to learn from other non-childhood experiences. Our brains are always continuously learning, adapting, and assimilating our mental schemas (Piaget’s theory again) until we reach a cognitive equilibrium! And this process goes on for the rest of our lives.

You are not defined by your childhood alone. You don’t stop learning and adapting and accommodating… and you don’t always get stuck in a rut just because of your terrible childhood experiences. Our brain is so much better than that when it comes to adaptation!

Give our brains some credit!

I created that ‘imaginary psychiatrist scenario’ simply as an example of how easy it is to jump to conclusion and construct a connection which is NEVER actually there. And trust me, in those who practice psychiatry, sometimes they DO have the tendency to make assumptions, thinking that they are applying their psychodynamic theory that they learned VERY superficially during their Master days.

Heck, one case protocol….does NOT a psychodynamic expert make!

And yes, sometimes making assumption is necessary to help you direct your thoughts in formulating your case… but you MUST verify it! Otherwise, your assumption is pointless in the general scheme of things; your assumption would be worthless to the case and at worse, it only makes you come across as judgmental to the patient. 

If you have learned psychodynamic and you think assumption and interpretation can be made lightly, you don’t understand it enough! You don’t respect its grey complexity enough! And therefore, you should not be applying it haphazardly! I don’t like psychodynamic, but I have a lot of respect for it sampai aku tak berani pun nak guna that approach and pandai-pandai buat assumption pasal orang. Because I understood how very easy it is for me to be wrong when something is as vague and as unscientific as this! Psyhodynamic is an art…. more than it is a science. Some people are good and talented at this art… but for those who are not good at it, they shouldn’t even bother to make assumptions ‘tak semena-mena’, thinking that they are simply applying their psychodyanamic, ehem, ‘skill’.

I prefer the straightforward approach. If I observe something about the patient that I do not find the real origin for, I will clarify it with the patient. The patient deserves the chance to either confirm your assumption or deny it! You owe your patient that much. You owe it to your patient to make an effort to come to a correct understanding of their position!

“Afiza, for those who are well-trained in psychodynamic, I am sure they won’t simply jump to conclusion based on flimsy observation.  Psychiatrists who are trained in psychodynamic would take everything into context lah! Macam yang you nak dan macam yang you cakap tu!”said a friend of mine with whom I discussed the matter over. 

“Okay, kalau macam tu, we as psychiatry doctors should be trained very well first in psychodynamic.We should first KNOW which type of cases and which type of patient warrant psychodynamic approach. Kalau kita just psychiatry doctors biasa yang tak expert in psychodynamic, kita tak boleh pandai-pandai buat assumption kan? Some patients are intelligent, you know! And they might take it personally when we cannot connect the dots properly and simply repeatedly go back to her childhood yang mungkin langsung tak signifikan! Lepas tu bila dia annoyed dengan kita, kita cakap dia ada transference dengan kita pula! Padahal mungkin dia memang ada valid reason nak annoyed dengan kita!”

My problem is: I don’t like vague things! And psychodynamic feels vague to me. I will never be good at it, I humbly admit. And that’s why I just bought a book on psychodynamic. I want to settle these doubts in my mind once and for all. 

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I just bought this book via Book Depository. It cost me RM232. I wanna cry!

***

I am just an MO. So if I said something or expressed my criticism towards a certain concept or worldview in psychiatry, I am just not credible enough, right? Not everyone is like INTP/INTJ who respects someone NOT based on position, but based on what you have to say. Some people need the stamp of titles and authority to push them to reevaluate their thoughts.

INTJ and authority

Kalau HO/MO cakap tak betul atau tak dipersetujui oleh orang atasan, mesti akan dikritik. Kalau specialist cakap, tak betul pun kita akan senyap. That kind of ‘yes boss’ attitude is prevalent everywhere and I have kind of adapted to that and have stopped expecting Malaysians to be less of a coward who can actually be honest with what they really think and just speak them out. (There is a lot of psychodynamic in this paragraph, and if you are the psychodynamic type you might be able to see it… But rather than going back to my non-existent childhood trauma, you can just go back to my first posting as a HO. Haha. See? Not everything is about childhood! My attitude towards authority began slowly as part of my INTP/INTJ personality but it escalated to this point after my first posting. Our brain is not so weak that they are stuck in childhood forever. Some people do get stuck with their unresolved childhood conflict… but some people get upset due to some recent things they genuinely and validly SHOULD be angry about. So, verify, verify and verify! Verify your assumptions with your patients!)

Imagine my delight when I read the book written by Jeffrey A. Lieberman (the former president of American Psychiatric Association) earlier this year, and he concurred with what I had always believed about psychodynamic. I don’t generally read a lot of non-fiction (I have been trying to increase my habit of reading them over the years) but this is one non-fiction book I actually enjoyed and I found it very relevant to my career.

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Well, Dr. Lieberman who was also one of the people involved in constructing DSM III which was a MUCH more systematic DSM than the previous two DSM…. well, he criticized psychodynamic quite heavily himself in this book.

Dr. Lieberman went through the history of psychodynamic and psychoanalysis in his book. He explained the history of how it came all the way from Europe to be practiced in the US, and how it then affected the psychiatry practice in the US.  He said that, initially Freud’s psychodynamic had brought respect to the psychiatry field until they feel they owed a lot to Freud/psychodynamic in general…. but as the sciences became more influential, as biological and behavioural approach took center stage, others started being openly critical towards this approach, and slowly but surely they departed from this approach.

I love this book! I have been having the same thoughts about the imprecise and unscientific nature of psychodynamic approach for so long (since I got into the psychiatry department) that when I stumbled across this book, I felt like “Yes! Finally there is someone who call a spade a spade. Finally, someone influential had written a book that concurred with my thoughts.” (I am sure there are others who have probably written the same thing over the years, but none that I have personally read myself. So yeah, I was pleasantly surprised when I read this book. I was so impressed by Dr. Lieberman’s book, so much so, that after I returned this book to my friend who had lent it to me, I went online and purchased it for myself so that I could have the copy of the book for my own keeping. So this book flew all  the way across the vast seas for me. I recommend this book for everyone interested in psychiatry!)

One of the best feeling that a  reader can experience  is when we read the written thoughts of someone else we have never met and yet…we can feel… “You and I could have been good friends if we are not separated by time and space. You explain my thoughts so precisely in a way that I would never be able to do. I would love to meet you.” (I feel that way towards Charlotte Bronte, Anne Bronte, Jules Verne and Jane Austen. And many many more authors. I have had hopeless crushes on book characters for so many times that I have lost count on how many different ways my heart is divided. Haha.)

***

I am not saying that psychodynamic approach should not be practiced. Some of the theories are actually understandable (id, ego, superego is one example of psychodynamic aspect that I can understand…well, sort of. Fruedian slips do make sense in a way. Free associations can be useful in therapy, I suppose. The negative therapeutic reaction described in psychoanalysis is comprehensible enough.)

I am saying that when it comes to making assumption about our patients (or about other people in general), we have to keep in mind that psychodynamic is not precisely accurate. There is a high chance that we are wrong in connecting the dots especially when we are not trained! I repeat, “when we are not trained!”

If we want to practice it, we should do it properly.

Further your training in psychodynamic if you like it so much. Do it right. Don’t just make assumptions in every case you see thinking you are applying your psychodynamic approach, and at the same time you never even make the effort to actually verify what you assume about the patient. Because people who really know what psychodynamic is about would find our casual manner of doing it as quite haphazard and an insult to the REAL way psychoanalysis is supposed to be done.

I am sure that psychodynamic psychiatrist would inwardly cringe when they hear their colleagues jump to conclusion improperly and would feel “this people would give this approach a bad name; more bad name than it already has.”

Some assumptions are not psychodynamic. Some assumptions are just nonsensical baloney. And we in psychiatry should know that. If we want psychiatry to gain some semblance of elite status in medical field, we can start by being serious and methodical in how we come up with our thoughts about our patient.

My take home message is this: If you want to practice psychodynamic, you do it right and do it properly. Intelligent people can hear what you say and they can break your assumption to smithereens when they are annoyed by your jumping to conclusion and they will walk away thinking psychiatry is full of baloney. Is that what we want? For intelligent people to feel psychiatry is bogus? Just because we are psychiatry doctors and are ‘supposedly’ an expert in human behaviour and motivation, it does NOT mean that we are correct in our assumptions all the time. It does NOT mean that we can make assumptions based on flimsy anecdotes when we are not properly trained. And then, we go around giving excuses “oh, this is psychodynamic approach.” *shakes head* Aku rasa psychodynamic psychiatrist pun akan bengang! Be fair to the patient…. be fair to the reputation of psychiatry. Be fair to yourself! 

The Association of Time & Respect

My exam is in 5 months time. I am freaking out!

My mom was telling me how 5 months was plenty of time to get ready for ANY exam. “Tapi kalau asyik kalut baca buku cerita, kalau ada masa setahun pun takkan sempat, Kak Ngah,” LOL *sarcasm detected*  

It’s not like I don’t know how precious time really is. I do know it. Allah Himself had sworn by Time in Surah Al-Asr.

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But knowing something is not enough to move me into acting on it. Because… how else can I explain my inability to stop wasting my oh-so-precious time and just study consistently from now on (and stop buying anymore fiction)?

Knowing something is just not enough prodding for me to resist the lure… especially when the temptation (in the form of book reviews by Goodreads/Amazon/BookDepository) proves too hot to resist? Once upon a time, when online shopping was unheard of, I could resist book reviews easily because there was just no other alternative. A Kedahan like me could only rely on Popular to supply me with new releases of books and what Popular didn’t sell, I wouldn’t be able to buy. Temptation was manageable then. (We don’t have MPH, Konokuniya or Borders in Alor Setar and thus Popular monopolizes the Alor Setar’s scenery of book selling industry until now. But alas, Popular has never been exactly great at updating their stocks of recent book releases.)

These days, temptation is impossible to brush off. I just bought myself a book by Mathew Reilly, The Three Secret Cities, via online shopping when I could not find the book in Popular despite the fact that it has been released since November. (I TOLD you Popular is SLOW!) So feeling exasperated by the long unfruitful waiting, I decided to go online-shopping to take care of the itch. Now, I am patiently waiting for the book to arrive on my doorstep.

Which means that when the book arrives, I won’t be studying, LOL. Yup, wasting my precious study time, I admit. But it’s not like I can concentrate on my studies anyway when I know the book is somewhere inside my house still awaiting my touch. Might as well I just get rid of the temptation and hopefully, I can then focus on my study… Amen.

***

But my time is MINE to waste it in any way I like. If my time were to be wasted anyway, I might as well be the one who DECIDE what I am going to waste it on. And since I am going to waste it regardless, I might as well waste it doing something enjoyable, right? (like reading fiction, hahah) Logic, si?

However, I resent having my time wasted by others, especially in cases when I have no say nor control on how it should be wasted on. I am not gonna tolerate having my time wasted by ANYONE unless I absolutely have no choice about it for some obscure reason.

For example, I tolerate people wasting my time by being late when they first show me how to hike a new track. Because I need them at that point. But once I have mastered the track and have stopped depending on people to show me the way, I prefer to go hiking by myself. I find it troublesome to wait for them when they are late… and I am not going to. If you are late, I will go without you. Next time, I won’t go hiking with you anymore unless you can prove to me that you are not going to make me wait. The reason I always try to make myself independent and self-sufficient as soon as possible is because my time is precious and it is MINE to waste it in however way I choose. I am not gonna waste it WAITING on people. If I were to waste it, I wanna waste it reading fiction, ok?

And so it goes, that I almost always hike by myself. Occasionally, when my friends ask me whether they can join me hiking, I make it compulsory for them to be on time. I will wait for them up to 10 minutes if they are not on time, and then that’s it! I will go without them and I am okay with that. I am okay doing things alone. If you are not okay to hike alone like I am, you follow MY time.

All my close friends know this about me. If they are close to me, chances are they are a punctual person, themselves. Even when they are not naturally a punctual person… at least when they have planned an activity with me, they made themselves punctual for me if they are my friends. Because they know, I can do most activities myself and I have no problem doing things myself. They are the ones who usually feel awkward doing things alone and ask me for company, so they have to abide by my rules. I can eat alone, walk alone, shop alone, … I don’t mind it. What I do mind, is waiting on people when I could have done something else with that time. 

Does that sound cold-blooded and inconsiderate? “You must do things my way because you are the one who need me and I don’t need you as much. So you must follow my rule if you are going to depend on me in doing this activity.” Hahha. Yeah, when put it that way, it does sound cold-blooded, isn’t it? And so insensitive, right? But I am just being honest, here.

In my opinion, for you to keep me waiting when YOU KNOW I must have been waiting, you are PURPOSEFULLY disrespecting me. In MY view, YOU are the insensitive one, here! Not me. I made the effort to see you on time even though I don’t really need you… because I respect you and I honour my obligation and my promise that I have made towards you to arrive at a specific particular place at a specific particular time. But you didn’t make an effort to arrive on time to see me even though you were the one who were asking for my company? (In my mind, I will be like, “Damn… I could have read a few more chapters of my latest fiction in my comfortable bed rather than waiting for you. What makes you think you are more enjoyable than my novel that I will be willingly waiting for you without feeling angry when you fail to be on time? Don’t you know that there are not many people whose company I enjoy more than my books?”) When you fail to be on time (+/- 10 mins are still acceptable; I have learned to tolerate that much) in my opinion, I am no longer obligated to be sensitive towards you and I will make my displeasure known. My cold-bloodedness… well, you earned it. You will be lucky if I ever agree to make any plans with you again. 

One of my friends (the nicest one hahah), said, “Afiza, relationship requires compromise. You have to meet people half way. Not everything must be done your way.”

I was like, “Oh? You mean, if my way is the punctual way, which is the right way… and the other person’s way is the non-punctual way, which is the wrong way… I must compromise MY right way for HER wrong way?”

“Is there always a wrong way or right way of doing things…. that’s dichotomous, isn’t it? What I am saying is, you must meet people half-way.”

I laughed. “Half way? You mean, if I am punctual… and that person is always 2 hours late… we must meet each other half-way by being one hour late instead?” *sarcasm detected* (and to answer her question… yes in certain things, there ARE the right way and the wrong way of doing things. If you think your way is more right than mine, engage my intellect by debating the matter with me and make me see. I will change my view if I am convinced. I am willing to change to follow the right way. See? I am willing to learn… to do things the right way or the more efficient way. Not because it is YOUR way or MY way…. but because it is the right way. When it comes to time, being punctual is OBVIOUSLY the right way. Otherwise, why bother specifying the time in doing anything?!)

My friend shrugged after hearing my answer. She knew I have made up my mind and there was nothing she could say that would change it. Yes… when it comes to being punctual, my mind is made up! The debate is closed! 

In my opinion, unless you are facing an emergency situation, there is NO JUSTIFICATION for you to be non-punctual! There is NO JUSTIFICATION for you to keep people waiting especially WHEN YOU KNOW that person is waiting! And if it happens multiple times, well, I am not going to tolerate it and my mind will conclude that “Obviously, there are discrepancies in our habits and attitude towards time, and therefore we cannot be friends. I value my time more than I value any relationship with a disorganized person.”

***

So when do I tolerate people not being punctual?

Obviously, I will tolerate them when I STILL need them (like in the case of people showing me the right track for hiking). To me, that is just simple strategy on my part. Since I need you, I will have no choice but to tolerate your annoying habits. But once I have mastered the skills that you have and is fully able to be independent, I will no longer tolerate your bad habits. I am not being disloyal… trust me, I would have been really honest about my dissatisfaction regarding your bad habits… but if you persist in doing them despite my clear communication of dissatisfaction, what else am I supposed to do? Eventually, after my obvious dissatisfaction is being brushed off, I will take that as a sign of disrespect and I am just going to have to say “Look, it’s been nice learning things from you… Thank you so much. But for now, I am just going to say good bye and do my own things for awhile…. well, unless you are willing to be on time when we next go for a hike. Otherwise, I will see you around, yeah? No hard feelings, ok!”

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That’s why I appreciate people who are on time! 

I don’t abandon my friends lightly. I do care about them. But the least they can do to show that they care about me in return…. is by being punctual. That’s all I ask (and of course, other than that, I also want them to have general good principles that align with mine. I am not going to be friends with murderers, thieves, psychopath, work-slackers…. well, you get the idea. Hahah) Luckily for me, my friends are mostly punctual. (Like I said, if they are not punctual as a habit, we would not have come to the stage of being friends in the first place. I would have abandoned them when we were at the stage of being acquaintances.). But even friends are allowed to have lapses and make mistakes. Tertidur, terlupa, unforeseeable emergency that crops up… those are understandable rare occurrences when my friends are late. I can tolerate that. These are the friends I keep… and they will enter my ‘inner circle’. To them, I will be loyal and supportive and transparent in my thoughts and my feelings. So, I am not that cold-blooded, am I? I do know how to be loyal and supportive and ehem, ‘nice’, but I am not like that for just anyone.

In fact, why should I?

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And trust me, NO ONE should be loyal and supportive and nice to EVERYONE. Who got the time, man? Why do you want to waste your resources like that? Be selective in whom you should be loyal/supportive/ nice to! Be that way with family and real friends who respect your principles and your boundaries! Invest your time where it is most beneficial to you. We don’t know how much TIME we have left on this earth and we should spend them wisely with people that matter. And with the rest of the others, just be generally polite and professional, abiding by the rules of social conduct (which includes being punctual) and fairness (which includes being honest) but not more than that. Don’t drain yourself with unnecessary obligations that will take away your resources. And believe me, your time is your resources. 

Time is not just gold and money. Time is LIFE!

 

***

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I also tolerate unpunctuality from superiors. Why? Because in order to complete our professional activities, subordinates need superiors. So, of course I will tolerate unpunctuality from them. Well, for awhile, at least. But again, eventually, I would make my dissatisfaction known.

When I was doing one of my clinical attachments in one particular hospital, I arrived to my first meeting with my supervisor 20 minutes late because in the letter I had received, I was told that I was supposed to report to Unit Sumber Manusia first. I didn’t know that it was customary to see the supervisor first before going to the Unit Sumber Manusia. How was I supposed to know the custom of a place I had never been to before? (Anyway, if that’s customary, it should be clearly communicated in the letter, shouldn’t it?). My supervisor told me “I am a punctual person, please try to be on time.” I was also quick to reply, “I came half an hour early and had reported to Unit Sumber Manusia as instructed by the letter given to me. I didn’t know I was supposed to see you first.” I hoped, I had made it clear that I was just as upset by the lack of proper planning and the bad communication that had taken place. I am always quite sorry when I am late… but NOT when I am late through no fault of mine! I am not willing to take a blame that is not mine to take.

I like structure, planned schedule, and having a timeline. To me, that’s professional work ethic. I can understand that sometimes the roster might be tight and superiors can be late in arriving on time especially if they have to cover multiple wards or workloads from their colleagues who are on leave. But if schedules are planned, and rosters are not that tight and many people are available, there is NO JUSTIFICATION for you to keep your subordinates waiting.

As an MO, I am in the middle position of being someone’s superior and also someone’s subordinate. So, I can totally identify with the difficulties of being either of them. Superiors have their own limitations and so do subordinates. But come on, having limitations when you are a subordinate is always going to be more difficult than having limitations when you are a superior. Because by the very definition of subordinate, he/she will always be dependent on his/her superior for decision making. The subordinate is always subject to the superior’s dictation and instruction. And that’s why I make it a point to not make my HOs wait without telling them what to expect. When I do think I might arrive late, I whatsapp them beforehand to let them know that I am going to be late and I will tell them what I want them to do in the mean time. Because I believe, it is MY responsibility to tell them what to do when I am not around for the activity that I should be doing with them. It is not their responsibility to have to check with me whether or not I will actually arrive especially when it involves an activity that has been routinely scheduled! When something is routine, there is already a tacit and implied understanding that I should be there. Any failure on my part to arrive to a routinely scheduled activity means that it is automatically my fault if I fail to inform them about it. I do NOT think that superiors have any rights to keep their subordinates waiting any more than it is okay for subordinates to keep their superiors waiting.

Respect is the key point here.

We should respect our subordinates just as we should respect our superiors. We should also respect our patient’s time waiting for us to come and review them! Should we not be available to conduct our professional activity in the clinic or in the ward, it is our obligation to passover the matter to our colleagues of the same rank. If rosters are tight and there is no one else in our own rank we could passover our obligation to, we can tell our subordinates to go ahead and run the activity on our behalves. Of course, it is not ideal but if circumstances cannot be helped and we trust our subordinates to run the activity on our behalves, that must be clearly communicated. It is not okay to let our subordinates to wonder to themselves about what to do and whether or not we will ever arrive and whether or not they should just go ahead and run it themselves. If we want them to start any activity first without us, tell that to them. If we want them to wait for us anyway even though we are going to be late, tell them clearly so that they can apologize to the waiting patients and persuade the patients to wait for our arrival.

It shows respect and decency. You don’t have to be someone’s close friends to respect his or her time. You just have to be an overall decent person.

And that explains why I will not tolerate people who are not punctual. I respect people’s time even when they are not my friends. So, for anyone not to respect my time or other people’s time, well, that is bewildering to me and I will take it personally. 

But I was told that “Afiza, hang kena baik sangka. We are a product of our environment and upbringing. Not everyone was raised to be obsessed about punctuality.”

Okay, I do give people chances to redeem themselves. I will tell them that I am not happy about them not being on time. But if they do it again despite my explicit communication of dissatisfaction (and trust me, most of my communication is explicit anyway), then I no longer have any obligation to ‘baik sangka’. My obligation to clarify the matter is done and whatever ‘sangkaan’ I have about you is accurate from that point onwards.

And that’s that.

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My staff nurse told me one day “Dr. Afiza jalan laju sangat. Awat kalut sangat ni? Dok ligan apa?”

My colleague replied something like this, “Dr. Afiza hanya jalan lemah-lembut bila dia tengah tak sihat. So kena bagi dia tak sihat selalu kalau nak tengok dia ayu.” I was having URTI at that time and was feeling generally lethargic. So, they were teasing me about my slower walk and how I look more demure when my face was less expressive than usual. Haha.

Yes, I do walk fast. My nickname when I was in high school was Fifi Ferrari. (Created after the like of Maria Mercedes, a popular Mexican soap opera at that time. Haha. I had really creative friends, back then!). It’s because I value my time. I don’t know how people get bored because I always have things to do. Upon waking up, I have to pray, get ready to go to work. From the parking lot, I have to rush to punch in. And then, I have to go to my ward and review my patient. And then, I have to go to my clinic and start my clinic. The routine is already established. There are always THINGS to do that it doesn’t make any sense for people to walk sedately as  though they are aimlessly wondering what is their next task for the day. It always annoys me when I have to slow down my pace whenever the people in front of me are walking slowly. In my mind, I would be like “Ni nak berjalan ke nak jalan-jalan? Ni tempat orang kerja, bukan tempat melancong tengok permandangan nak jalan slow-slow.” Hahha. (Okay, I know this is just my personal pet peeve. Everyone is entitled to their own pace of doing things. If you want to walk slow, that’s your rights to do so. I am just venting out that I couldn’t stand walking behind someone who walk slowly and aimlessly.)

When would I be walking sedately? Well, maybe when I am walking at the beach….or when I am on a holiday and trying to soak in the beautiful scenery of a new place. Yes, I can walk slowly then. Because my PURPOSE at that time is to enjoy my holiday and learn a new culture and absorb the beauty of the new surrounding… and therefore I act accordingly and walk slowly to fit the PURPOSE of my activity.  Another time I would walk slowly is maybe when I am walking with friends who are slower than me. Or when I have just arrived at a new place and not yet sure where places are and need to stop and read the signs to know where I should be heading. But once I am familiar with the place and with the routine in that place, I like to get things done in the day as fast as possible.

At my clinic, my routine is established. From the moment I go out of my car in the parking lot to head to the punch card machine to punch in… until I punch out at 5.00 p.m, I always have things to do. Whether it is to see my patients in the ward, start the clinic, or go for lunch and start the p.m clinic or go for a departmental CME…Why should I dilly-dally, walking sedately and aimlessly when I already KNOW what things to do one after another?  Doesn’t it make more sense to get your task done as quickly as possible and settle everything one by one so that you get to relax as soon as possible?

Again… it’s about time. I cannot even tolerate wasting it by slow walking. That is the reason I always wear pants to work and very rarely do I wear baju kurung. I couldn’t walk fast in baju kurung. Lagi awal aku siap kerja, lagi awal aku boleh study, lagi awal aku boleh relax, lagi awal aku boleh baca buku cerita, get it? Hahha. As simple as that.

So you want to see me relaxed and not kalut? See me while I am reading my fiction or when I am sleeping. I am at my most relaxed then.

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