Values For A Balanced And Well-Ordered Life

When I was an IB student in KMB, part of the World Literature component that we had to study was the novel The Great Gastby, authored by an American novelist, F. Scott Fitzgerald.

Though at that time as a teenager I was not that enamoured with this magnum opus of F. Scott Fitzgerald, the FIRST TWO SENTENCES of this novel had stayed with me until now.

In my younger and more vulnerable years my father gave me some advice that I’ve been turning over in my mind ever since. 

“Whenever you feel like criticizing any one,” he told me, “just remember that all the people in this world haven’t had the advantages that you’ve had.”

We had to analyze the novel as a student. And I just kind of wrote in my literature analysis that we shouldn’t be judgmental towards other people because we don’t know what other people have gone through in their lives to cause them to behave a certain way now. By the way, I got an A for my literature analysis of The Great Gatsby at that time. But all I wrote in my essay was some wishy-washy namby-pamby crap that I feel embarrassed to be recalling now.

Trust me, I have changed my mind. I think the longer I am in psychiatry, the more objective I become about things that I read and what I should tolerate and not tolerate. Or maybe it is just the effect of me being older and wiser.

I believe that what happened to you in your past DO affect your life now…. but only up to a point. Whether or not you let the past haunt you, it is ON YOU. It is YOUR DECISION.

If I could go back in time and do the literature analysis all over again, I would probably change  the tune of my essay and write something like this instead: “We all have different life story. OF COURSE none of us will have the same kind of advantages and disadvantages. That’s just life. It doesn’t mean you can excuse yourself when you do something bad or maladaptive. Instead of wallowing in your disadvantages in life and comparing how other people’s lives are much more advantageous than yours, you should move forward and think about how you could make your life better, isn’t it? Mr. Gatsby deserved what he got in the end! He should have moved on a long time ago and stop pining for a married woman.”

Trust me, I have no sympathy for the great Mr. Gatsby.

***

As a psychiatry MO, I am going to be honest and admit that I have favourite cases and favourite patients. I mean, that is only natural. That’s why we have subspecialty, right? Because we don’t always like all types of cases even though we DO see and manage them all to the best of our ability.

And, let’s face it. We do have favourite patients, don’t we? We don’t discriminate our patients in terms of treatment and resources but there are certain patients we like to see MORE than others. That’s just human.

So, what sort of patients do I like? Well, I like patients who help themselves because it makes it all worthwhile. Because without the patients helping themselves, there is nothing much I can do to help them that would work long term. We can psychoeducate till kingdom come, or do daily home visits, or call them every day to update on their progress, or we can repeatedly give them compliant therapy…. over and over again…. but nothing will stick long term until they accept their illness, and make THAT VITAL DECISION to take the meds and perform all the non-pharmacological measures we tell them to do. My whole investment in effort and time to make  their mental health better depends LARGELY on the fact of whether or not they themselves will do what I have told them to do! I can do my best… but it won’t work if THEY don’t do their best. We are not going to be there for them 24/7. And we shouldn’t have to. Part of the responsibility should be shouldered by the patients themselves and their family members.

So yup… I do have favourite patient’s family members too. The more cooperative the family members are, the bigger the smile that I bestow towards them as a form of greeting at the start of the conversation. LOL.

It is kind of disheartening sometimes. When the reward for our hard work (seeing the progress of our patients is a reward) depends on the patients themselves taking that leap of change…. it can be disheartening because some of them just refuse to take that leap.

So when patients (or their family members) ask me about their prognosis or if they will ever get better, I said truthfully “You will get better. Not all conditions can be cured… but they do get better. But how much better you get depends on YOU.”

And that’s the problem. And that’s also the solution.

YOU are the solution. Regardless of your background! Regardless of your advantages and disadvantages in your past! Regardless of what had happened to you in the past and the present, YOU are the solution to your own problems. Make that decision to take your medication. Make that decision to not let your past determine your future. Make that decision to put some effort in doing all those lifestyle changes! Make that decision to do your CBT homework! Make that decision to feed your thoughts with positive self-affirmations as you were taught to do in your CBT sessions. Make that decision to practice that deep breathing exercise and the relaxation techniques taught to you. Do it for you!

Because I cannot do it for you.

***

What are the values you must internalize in order to move forward DESPITE your past and  your disadvantages?

Because trust me, if everyone can behave badly by citing random disappointing things that had happened in their lives as the cause of their depression/borderline personality/ antisocial personality/addiction, then everyone can get away with crimes because “oh, it is not my fault. I had a deprived and disadvantageous childhood, you know”.

“Oh, I murdered that guy because he reminded me of an ustaz in a Maahad Tahfiz who had sexually abused and sodomized me when I was younger! It’s not my fault. Don’t judge me if you don’t know my past.”

But when you are arrested by the police and subsequently sent to be evaluated in Hospital Bahagia Ulu Kinta, we will only determine whether or not you were of sound mind when you had committed that murder and whether or not you are fit to plead! Regardless of whatever bad past experiences you had, we are only going to be interested in the soundness of your mind! We are only interested to know whether you knew what you did was wrong and contrary to the law! That’s it! We might be interested in your past… but only up to a point. The court may take note that you used to have a disadvantageous childhood… but you will STILL be punished. It is only right for you to be punished. Your bad past will not suffice in the court of law to justify your crime!

Facts! Reality!

Regardless of whatever childhood adversities you have experienced, by the age of 18 you will be treated like an adult in the court of law! You would be assumed to have had the maturity of an adult and you are accountable for your own action. You cannot turn around and blame your parents when you are addicted to drugs… because your siblings who are NOT addicted to drugs ALSO have the same parents as you! The judge in court will not entertain wishy-washy, sappy sob story of an excuse like that! Even in Islam, we are accountable for our sins at the age of puberty! The reality should not be distorted to adjust to YOUR subjective experience! Instead, regardless of whatever bad experiences you have had, you must make the effort to adjust to the reality. If anyone can be excused based on ‘subjective’ experiences of childhood disadvantages, then that’s it! There should be no law and order. Everything must be grey and blurry, then!

Likewise, the reality is such that when you behave in a counter-productive manner or in a socially inappropriate manner, most people will reject you. Regardless of your past! People who are going to deal with you day in and day out are not going to care about how difficult your past was after a certain point! Their sympathy can only go so far. So the onus is on YOU to rise above your past and change your behaviour if you want to lead a fulfilling life. And we are here to help you do that. But you must be willing to put in some effort without always blaming others for every single thing that goes wrong in your life.

In Psychiatry, we also learn that there are certain risk factors that predispose someone to having depression or other mental illness. But some people do cope well with life despite having those risk factors! How come?

So my take home message is  this: Your past DO affect you… but ONLY up to a point! You are not totally helpless against your past! Because the rest of your life is determined by what you are going to do now in moving forward.

And you can turn over a new leaf by internalizing certain values in your life that I am going to enumerate below. Please take note that I am not disregarding or invalidating all your past experiences and all the injustices that had happened towards you. I am just giving you a way to move forward.

Effort

“Doktor, ingat senang ke nak usaha? Pesakit depressed memanglah tak larat nak exercise, nak buat behaviour activation semua. Bila doktor cakap kena usaha… macam stigmatizing. Ada doktor suruh pesakit kencing manis usaha supaya pancreas diorang keluarkan insulin? Tak kan…”

“No, I won’t tell type 1 diabetic patients to put in an effort to force their pancreas to produce insulin. However, I do tell them to put in an effort to take their insulin, to control  their diet, to exercise and keep a healthy lifestyle. And this is what I am telling you to do too. It is not stigmatizing. It is factual.” This was my answer to the patient (who also had some component of personality on top of her depression). Very matter-of-fact, very reality-based.

To be honest, I NEVER like the ‘mental illness stigma’ poster that compared depression with diabetes. It is so inaccurate, and we should stop saying “Jangan stigmatize pesakit depression. They cannot help their behaviour. They lack serotonin. Just like pancreas orang yang ada diabetes tak boleh keluarkan insulin, orang depressed pun tak boleh keluarkan serotonin. When you tell depressed people to put an effort, it is a stigma! You don’t tell diabetic patients to produce insulin, do you?”

Ugh! Gosh! I cringe inwardly whenever I hear misleading things like that.

I agree that we should not stigmatize mental illness! But I disagree about depressed patients not having to put in any effort in dealing with their depression! Asking people to put in some effort should not be construed as stigmatizing! In ANYTHING we do in life, effort is vital! In ANYTHING!  Stop trying to tie our hands from telling our patients to put in some effort! What do you want me to say then…. tak payah usaha langsung?

As a Muslim, Allah will not help us without us putting in our effort! To Muslims, that’s a fact! I am not going to distort reality just to align myself with the content of a bad poster. I am not going to distort facts just to appear FALSELY empathetic and sympathetic when the reality is different! If we cannot tell them to put in some effort, then how about asking them to go to occupational therapy? Doesn’t that require some effort? How about asking them to attend their CBT sessions or their psychotherapy? Doesn’t that require effort for them to do their homework?! How about asking them to practice deep breathing exercise and do some physical activities? Doesn’t that require effort?

The only condition that doesn’t require your effort is when you are in a state of coma! You don’t tell ICU patients to put in any effort, sure! But for the rest of us, the requirement for a good, healthy and balanced living is our effort. The faster you internalize this idea, the faster you will improve your life, Insya Allah.

So, please! Please stop promoting mental health awareness by comparing depression with diabetes! That’s like comparing apples and eggs. They are not even in the same category! (at least, comparing apples and oranges can fall under the category of fruits! But apples and eggs are two different categories altogether, get it?). For one thing, there is no component of the ‘mind’ in the Pancreas! There is no intertwining interpersonal conflicts and ongoing social stressors in the development of Type 1 Diabetes! So Type 1 Diabetes patients really cannot change anything much in the way they behave to help their condition. But this is not the case in depression! So, how is this a good and fair comparison? Neither the diabetic patients nor the depressed patients are treated fairly by this comparison.

And Wallahi, this comparison should cease to exist! (Adoi, penat! Too much emotion has been invested in writing about this alone, LOL. Pheww!) 

To quote Kevin MD: 

Diabetes is a disorder of insulin metabolism. Insulin is produced in the pancreas. The (depression-diabetes) analogies disregard the intimate intertwining of brain and mind. For the pancreas, there is no corresponding “mind” that exists in the realm of feelings and relationships.

I prefer to compare depression with having a fractured lower limb in terms of how effort would improve your outcome. “Katakanlah awak mengalami kemalangan jalan raya dan kepatahan kaki lalu tidak boleh berjalan.  Lalu, saya pun beri kepada awak tongkat untuk bantu awak jalan. Sudah tentu berjalan dengan tongkat dengan kaki yang patah lebih susah berbanding sebelum kaki awak patah. Tetapi tongkat itu serves its purpose untuk bantu awak bergerak walaupun memerlukan lebih banyak tenaga. Tapi jika awak masih duduk di kerusi dan tidak mahu berjalan walaupun sudah diberikan tongkat, maka tongkat itu langsung tak berguna! Bila awak duduk dan baring sahaja, ini akan membawa risiko mendapat bedsores dan secondary infection yang lebih teruk lagi. Apabila saya berikan awak tongkat dan suruh awak berusaha untuk berjalan, tak bermakna saya menidakkan kemalangan yang berlaku dan kesakitan yang awak alami kerana patah kaki. Tetapi saya bantu awak untuk move forward WALAUPUN ya, saya akui awak kemalangan dan ya, saya akui awak memang sakit dan patah kaki. But the tongkat is here, isn’t it? Are you gonna take it and walk or are you going to just sit down, not using the tongkat and instead repeatedly go back and forth questioning why the accident had happened to you? And why aku patah kaki dan orang lain tak patah kaki? Because think about it….How is that going to help you? Now… let’s get back to your depression. I am giving you your medication and I have scheduled CBT sessions for you with our clinical psychologist… will you take it? When I told you to put in some effort to do all these measures, to try to go to work… I am not denying your depression and I am not saying it is going to be easy! It is hard! Of course going to work while being depressed is ALWAYS going to be much harder than going to work without any depression… that goes without saying! However, now I have given you some medication, and you will be seeing our clinical psychologist for CBT sessions….these things are the tongkat! Yes, it is still harder to go to work compared to when you were not depressed… but now, going to work is becoming more achievable, isn’t it? Compared to when your depression was not treated at all, now even though it is STILL hard… it can be achieved right? Just like it is still painful for a man with a broken leg to walk with a crutch, but at least with the crutch, the man with a broken leg can now walk, isn’t it? Will you at least try first?”

Most patients who already have some spark of optimism inside them can relate with the ‘patah kaki’ analogy FAR BETTER than the diabetes analogy, in my experience.

Really… I am not a vague, wishy-washy person. I am always the ‘bottom line’ kind of person! I want to know the truth, the reality, the actions that I need to do and what is the possible outcome I can expect. And therefore, I don’t like to comfort people with half-truths. I do adjust my style of giving away the real truths to my patients depending on their personality and the appropriate context…. but I am not gonna give them empty words of comfort. I am not gonna tell them it is okay when it is NOT okay. I am gonna tell them, “What happened is not ideal but what are you gonna do about it? Let’s face it and deal with it! It will be hard but it can be done. I will help you… but again, it will only work if you help yourself because a lot of things require effort on your part!”

And most patients recognized the truth and they gravitate towards it! The sunnahtullah is such that deep inside, all of us want to know the truth. And when we give the truth to them, it builds trust because they know that this doctor is not lying and pretending to care about them! Sure, some of them don’t like to hear the truth and they might hate us for awhile. But the seed of doubts regarding their actions has been planted in their minds…. and eventually they will think and evaluate the matter again.

But patients who STILL persisted in playing the victim card (usually a personality component is involved here), will continue to deteriorate. And my heart sinks.

As a psychiatry doctor or a therapist, among the first thing we should do (after allowing them to ventilate and express their distress), is to get them to internalize the value of effort! We will not get anywhere if they still persist that they are victims of their past and therefore they will always be ill and flawed because their past can never be changed and therefore there is no use for them to put in any effort.

That is really such a tragic way to think about life. We must pull them out of that mindset before anything can ever change. But unfortunately, it is STILL their decision to change their mindset! At the end of the day, we can only do so much to help them. The ultimate outcome lies in their decision. 

 

Having A Growth Mindset

The opposite of having a growth mindset is having a fixed mindset. The worst thing that can happen to anyone is to have a fixed mindset. Having a fixed mindset would wreak havoc in your life because you have basically internalized learned helplessness. Learned helplessness is bad, folks! With learned helplessness, people can be driven to suicide because they believe nothing they do will ever change the situation and there is just no hope left. 

 

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Biologically, we learned about brain plasticity which is the ability of our brain to change through life with our experiences and our training! It correlates perfectly with the value of having a growth mindset.

From the psychological point of view, Piaget’s theory of cognitive development talks about how our mind and our mental schemas are always adapting and accommodating…. for the rest of our lives. So we are not always stuck in our bad childhood memories. Provided you put in some effort, you can overcome your disadvantages! 

While I do think that me hearing out your feelings and allowing you to ventilate your problems do help to de-stress you while you are facing your crisis, I am more interested to know what you are going to do about overcoming your limitations in life? That’s the BOTTOM LINE always.

With a growth mindset, you will have a positive and optimistic outlook in life because YOU JUST KNOW that whatever it is that is happening to you, you can master the steps that you need to take to overcome the challenges! You just need to grow your mind by expanding your horizon with new skills, new set of positive thoughts and new set of behaviours. When you have a growth mindset, you know you can learn and re-learn and un-learn your way into a better coping mechanism. 

You won’t say things like “Dah aku memang macam ni. Family aku dulu ajar aku macam ni. Memang dah tabiat aku. Memang aku tak boleh nak ubah… nak buat macam mana?”

I am not saying that it is easy to change your habits! A person with a growth mindset ALSO might be resistant to change because they are already comfortable with their own habits and personality. But when it is important for them to change and adapt (perhaps, there is something at work that they have to be in-charge of that requires a new set of behaviours and habits), they will make themselves change their habits and behaviours because they know that the only constant in life is change! And if they have to do it, then they have to do it!

So, will you continue to practice? Will you continue to study and acquire knowledge and skills for the betterment of your future? Will you be willing to put in some time and effort (goes back to effort, doesn’t it?) to do what has been taught to you during your CBT sessions so that your new skills slowly become second nature and would be automatically activated in the future with much less effort than what you have to put in now?

You will do it, when you have a growth mindset.

If you have a fixed mindset… don’t worry. This is the beauty of the concept of having a growth mindset. You can unlearn that fixed mindset NOW, and start to learn to have a growth mindset.

Having An Internal Locus Of Control

In psychiatry/psychology, locus of control is defined as the degree to which people believe that they have control over the outcome of events in their lives, as opposed to external forces beyond their control.

locus of control

If you have an internal locus of control, you believe that events that happen to you is the result of your own doing rather than the external forces outside your control. For example, when you have an internal locus of control, you would believe that you had passed your exam because you had studied hard and went to all the lectures and tutorials that were given at the uni and because you had prepared accordingly. You did not think it was the external factors beyond your control that had made you pass. You did not think that it was just luck or because other people were doing even worse than you or because the teachers like you better than your other classmates. You are less likely to conform to your surroundings when you have an internal locus of control.

If you have an external locus of control, you believe that you had no control over the events that had happened to you and there was nothing you could do to influence the turn of events. For example, you believe that you would never pass the exam because the subject was too hard and the lecturer did not like you. So there was nothing you could do to pass your exam. You believe that the result of your exam somehow depends on all other external factors except your own effort. Having an external locus of control makes you more likely to conform to expectations and environments because you want your life to progress smoothly.

In general, when it comes to motivation and drive, having an internal locus of control is much healthier than an external locus of control. 

However, having too much of anything is never good. Having a much too internal locus of control can also cause you to blame yourself and will make you feel unnecessarily responsible for something that you could never help. And that can also predispose you to depression. See the diagram below to see what I mean regarding imbalanced locus of control and why it would be bad to have too much of either.

locus

 

The key word here is balance and reality check! I have mentioned before that I like the truth! I like reality check! Those are the two words I use a lot with my patients. You are entitled to your feelings and you have a right to them because it is YOUR feelings…go ahead and have them. But at the end of the day, your feelings do not necessarily reflect the reality. And if adjustments need to be done, your feelings must be compromised to give way to the truth or the reality! You must start learning to feel the right thing! (yes it can be done!) Because your feelings, even though you have a right to them, are subjective. But the truth and the reality are the objective facts! It will make your life much easier and less turbulent if you can learn to feel the right thing. 

As Muslims, we know that things that happen to us are decreed by Allah. But because we don’t know the decrees of Allah yet (I don’t know whether I will pass my exam or not, for example) we are ORDERED by God to put in some effort to attain what we desire. So the locus of control is balanced here. You are neither too sad nor too happy about things that happen to you in this life. Because you know that whatever bad or good things that happen to you have already been decreed by God and eventually anything bad and good will simply run its course! It will pass! There will be a next challenge to conquer and then the next, and the next…. until you breathe your last air! Bad events hurt… but give it time. Put in some effort, work at it again! Continue! Persevere! Feed that internal locus of control.

And when a disappointing outcome arrives… recognize that some things are out of your own control but it does not nullify your effort at all. It’s just life!

For example, someone passing their viva is a combination of effort, studying and doa (internal locus of control) and examiner factor, your health issues during the time of exam, and the type of case  you get (external locus of control). That is the reality! Nothing in life is TOTALLY in your control. And nothing in life is TOTALLY under the control of the external forces. Perhaps, when you realize this fact, your feelings about anything will be in moderation.

324472-My-Heart-Is-At-Ease-Knowing-That-What-Was-Meant-For-Me-Will-Never-Miss-Me-And-That-Which-Misses-Me-Was-Never-Meant-For-Me

Read Up

I suggest that people take up reading as a hobby. Not because it is my hobby and I am very much in favour of that habit (haha… mungkin ada juga komponen biased sikit. Because I will always think that reading is superior to any other hobby hahah… so yup, ada biased sikit) but because it is the one good hobby that will benefit anyone regardless of gender, social status, and whatever past experiences you have had.

Even if you read commercial fiction like Harry Potter, you will feel like “Wow…. this kid could fight the evil Lord Voldemort by the virtue of his effort and perseverance. Setakat kena marah dengan consultant, that is nothing to be scared about. I will turn up to work and finish my housemanship regardless of how bad I kena marah. I can overcome this!” Hahha. Okay… that is an extreme example. After all, Harry Potter is a fictional character and most people don’t try to relate their lives with fictional characters to sooth their feelings. So, you might not think that reading Harry Potter can ever motivate a disillusioned houseman (though actually it works with a lot of ardent readers out there! It certainly works with me!)

But you can also read biography/autobiography of really inspiring people. Autobiography books are real-life events! In my last blog post, I talked about the biography of Muhammad Ali and how inspiring he was. If you are a Muslim, you can read the seerah of our Prophet and his companions (I have mentioned before that Umar Al-Khattab is my favourite superhero). Read about the history of Jerusalem and the oppression committed by Israel towards the Palestinian people who are still persevering and fighting for justice and freedom (Netanyahu is worse than Lord Voldemort, okay!). Read the biography of Mahatma Gandhi and Nelson Mandela and the sort of sacrifices they had to make for the sake of freedom and social justice.

I am not saying that reading protects you from depression or neuroticism. But it broadens your horizons, knowing that people are always struggling sometime, somewhere. You get to live the lives of many people through reading, and you get to find out how all these various people cope with their own mistakes and  their own troubles (After all, the best way to learn is to learn from other people’s mistakes and troubles…. rather than making the mistakes and having the troubles yourself, right?).

If you just read (the right material), you will have a better coping mechanism. It improves your logical thinking and your abstract reasoning which will make it easier for your therapist to work with you. Some of your CBT homework require some reading too. You are more likely to do it if you already love reading.

If you don’t like reading, don’t worry. Focus on getting a growth mindset, first… and then you will know that you can adapt your brain into loving to read… and it WILL benefit you.

For Muslims, it is no coincidence that the first verse that is revealed by Allah to our beloved Prophet Muhammad (PBUH) is to read! Iqra’, remember? Get some knowledge! Internalize the values that you read and use it as your guidance in making any decision! Our parents can only teach us so much… because they have only their own experiences to tell you about. Their way of doing things and their experiences may not be applicable to you. And so, we read in order to experience the lives of many people so that we can have a big arsenal of weapons to choose from whenever life strikes us hard. 

iqra
This is the first verse of the Quran that was revealed to our beloved Prophet Muhammad (PBUH)!

***

And as a therapist, sometimes we need to set up boundaries with our patients. We have to let them experience the consequences of their own behaviour. We should not be enabling and reenforcing their bad behaviour by always giving in to their demands for attention and validation when what they are doing are obviously wrong and maladaptive.

They have to stick to their appointments and learn to deal with the consequences of being late to their  CBT/Psychodynamic session. When they throw a tantrum, we should ignore them until they are willing to behave well and until they can state exactly what sort of problems they want to discuss with us in a rational and calm manner. Behave like an adult and we will treat you like an adult.

Some patients will manipulate their counsellors or their therapists or their doctors. It is important that we recognize that behaviour and not accidentally rewarding them.

A few years ago, I myself had terminated a therapeutic relationship with one patient when he had thrown a tantrum at the nursing counter in order to see me. My late HOD, Dato’ R, happened to be at the counter at that time and managed the situation by telling him that I was covering addiction clinic and he must see other doctors. The patient should have come during his allocated appointment time but he didn’t.  He had come earlier than his scheduled appointments so many times in the past and I had told him not to do it. I told him that he had to learn to deal with his feelings by the techniques that had been taught to him. And I told him that he should go to the ED for any emergency that crops up in between appointments. I was hoping that by making myself less accessible, he would learn to deal with his distress by himself using the techniques that had been taught. But he still didn’t.  A few days later, he came to  the clinic again (again, without an appointment) and I decided to see the patient one last time to terminate the therapeutic relationship. I told the patient that what he did at the nursing counter a few days ago was unacceptable and I think he should see other doctors. I was very firm. You must follow the rules, or bear the consequences. After I terminated the therapuetic relationship, he did not see any specific doctor since then and was placed in the general pool for any doctor to see. As far as I know, there is no issue since then.

One day, I happened to bump into him at the supermarket. He was polite and did not try to detain me when I said that I need to excuse myself to finish shopping. That was a huge improvement! A few weeks later he came to the clinic, and he had requested to see the doctors in room 2 (happened to be my consultation room on that day). The clerk at the counter was firm and said “But you didn’t follow appointment. Pergi bilik 5. Lepas ni kalau nak request doctor mana, datang on time.” And he abided by that instruction without insisting to see me in Room 2. Very good behaviour that he had displayed there! So, I have made a decision that if he ever comes on time later on and requests to see me, I will grant him his wish as a reward for his much improved behaviour.

I am very particular about time and sticking to agreed rules and negotiated terms. That is one of the ways I know that the therapy is working. I have an aversion to being manipulated and controlled. I don’t like it and I won’t allow it in my therapeutic relationship with my patients. On this, I am very firm. I don’t think it is healthy to be there for your patient 24/7.

At what point is your patient going to be able to learn to think for themselves and  solve their own problems if you are always there to be depended on whenever they are in crisis? Once we have agreed on the negotiated rules and terms, we must stick to it. Early in the treatment, there might be some adjustments and hiccups along the way. But by the time the adjustment period is over and the patient is still crossing all sorts of boundaries… then a serious talk must be conducted to establish what is okay and what is not okay in this therapeutic relationship. Any more crossing of boundaries is no longer healthy for either party and perhaps we should pass the case over to our colleague.

And that’s what I did.

Maybe as I grow older and mature into the profession, I might learn differently about what to expect and what to tolerate with regards to therapeutic relationship with my patients, but being controlled and manipulated and being forced to give in to that kind of behaviour will not be something I will passively tolerate. I don’t think that will ever change about me.

On the other hand, another patient of mine who had successfully internalized the values of effort, and having a growth mindset and having an internal locus of control (unfortunately she STILL hasn’t internalized the values of reading, haha) had successfully managed all her crises in the 3 months when I was not around in the clinic (because I was doing my forensic attachment in HBUK at that time). When she saw me shortly after I returned from HBUK, she had said “Doktor tau tak dalam masa 3 bulan ni banyak sangat benda jadi kat saya. Tapi saya boleh handle sendiri, doktor. Doktor tau tak saya dah berhenti kerja yang dulu. Waktu tu saya sangat stressed dan nak sangat jumpa doktor… tapi nurse kata doktor pergi attachment. So saya pun pendam sajalah and handle sendiri. Alhamdulillah, sekarang saya dah dapat kerja baru. Dan gaji saya lagi bagus dari kerja saya yang dulu.”

I was overjoyed that she could handle things for herself. I said to her something along the lines of “Bagus! Memanglah semua masalah kena handle sendiri. Kalau saya ada pun, apa saya boleh buat? It’s your job, it’s your life… you have to make your decision and stick to it and then put in the hard work. And then, there will be another challenge… and you will handle it again just like you have handled it in the past. These things will continue for the rest of our lives.  Memang awak boleh buat pun. Congratulations! Lepas ni bolehlah bagi appointment 3 bulan sekali pula.” I teased.

“Dua bulan dulu lah, doktor!” 

I laughed. “Saya tak ada tiga bulan hari tu, awak okay jer! Pernah dengar tak, necessity is the mother of invention? Bila benda dah jadi dan kita terpaksa handle sendiri, waktu tu lah kita discover our real abilities. The situation NECESSITATES us to grow! We must start creating opportunities for you to handle crises yourself in between appointments. You can do it! In fact, you have done it when I wasn’t around!”

I cannot wait until I can give her a four monthly appointment. Hahah. Yes, she is one of my favourite patients. Because she internalized those values I had listed above, she is much better now. So, I like seeing her because I feel like all the time spent in my session with her was not in vain. Not wasted. But eventually, it is our responsibility to make sure our patients can be confident to let us go. One day, I might have to move elsewhere, work in another state. I am not going to be there for them 24/7. It is an unrealistic expectation to be placed on any doctor or any therapist! And I refuse to do it for any of my patients. It is kinder in the long run that we maintain boundaries and make them self-sufficient. It is the kindest thing you can do to anyone…. to provide them with a fishing rod instead of a limited supply of fish of uncertain duration. That kind of uncertainty will create unconscious distress in them because they will always be wondering “Can I survive without my therapist?”

So, I have told her that next time, we are going to try for a 3 monthly appointment regardless of whether or not she feels ready. She just smiled… because she knew I always do what I said I would. Or maybe it was a smile of someone who is confident enough not to worry too much any more.

Why worry when everything has been written and all you have to do is to go through it and do your best until you breathe your final breath.

I leave you guys with one of my favourite songs by Sami Yusuf. This song teaches us that when it comes to dependency, there is only ONE entity that we REALLY cannot live without… and that’s the way it should be in this life. That’s the reality. All the dramas in your life should take a pause to acknowledge this fact once and for all. And trust me, you will be happier for it.

 

The Gudjonsson Suggestibility Scale & The Legendary Muhammad Ali

Muhammad Ali Book
The biography of Muhammad Ali, written by Alan Goldstein

#BookReview  #GudjonssonScale  #MuhammadAli

Dear readers,

Last month, I had read  a biography of The Legendary Muhammad Ali written by Alan Goldstein and Masya-Allah, I was blown away. It was a truly absorbing read and I finished reading the book in 3 days. Muhammad Ali’s life was nothing short of inspiring.

I knew that Muhammad Ali was this great boxing legend who “floated like a butterfly and stung like a bee” but in my opinion, his greatest achievement was not made in the boxing ring. There was no specific arena… no particular moment while fighting in  the ring… in which I could say “Yup, that’s it! That’s when he was at his best.”

It was just the way he led his life… the way he stayed true to what he believed regardless of what other people said about him. The way he had stuck to his gun regardless of the risks of losing his money and  fame, and even regardless of going to prison. That was some heavy-duty powerful faith there! How many people would rather be in prison rather than sacrificing their principles? These days, I assure you, not many!

float and sting

When people persecuted him for his staunch principles, he stood firm and fought back with witty words that spoke volume of his wisdom. I didn’t know before what was the big deal with Muhammad Ali. I only knew him as this great boxer who also happened to be a Muslim. To me, ah… ok fine, just another famous Muslim celebrity.(What can I say? I was never into boxing and Muhammad Ali was famous way before my time. Now, I am acutely embarrassed of my previous ignorance of this legendary persona!)

But after reading his biography, I was in awe.

I remember, whilst reading the book, that Muhammad Ali would have no problem with the Gudjonsson Scale if the test was administered to him. He would stick to his gun and to hell with what other people say to the contrary.

Want to know what I mean? Read on!

***

So what is the Gudjonsson Suggestibility Scale?  Well, this is not a very well-known test in psychiatry. When they are used, they are usually used in the forensic setting. It has been used in court cases in several jurisdictions but has been the subject of various criticisms.

I am not sure whether this scale was ever used in Malaysia. I certainly never came across it when I was doing my forensic posting.

But I had to study this scale when I was doing my Part A MRCPsych exam. I remember feeling slightly troubled when I thought of how my performance would be if the scale were administered to me.

According to Wikipedia, this scale was created in 1983 by Icelandic psychologist Gísli Hannes Guðjónsson. The Gudjonsson Suggestibility Scale consists of reading a story aloud to participants, who are then asked to recall as much as they can remember. Subsequently, participants are probed with 20 questions pertaining to the story, 15 of which are misleading. When the 20 questions have been answered, the participants are clearly and firmly given a negative feedback on their performance. Specifically, they are told that they have made a number of errors and that it is therefore necessary to repeat the questions to obtain more accurate answers. On the basis of participants answers to the misleading items, a total suggestibility score can be calculated.

I remember thinking, would I ever change my mind, even as I know that I was right, if the pressure towards me was administered just hard enough? Would I break? Or Would I bend? Would I stand straight or would I fall in heaps and pieces?

Imagine someone administering the Gudjonnsson Suggestibility Scale to you.

Let me walk you through the simplified version of the scenario (you can read the actual details on how the scale is administered in Wikipedia)

So an examiner reads you a story and after hearing the story to its conclusion, you are initially reasonably sure that you have understood the story correctly. The examiner then proceeds with asking you a few questions to test your comprehension. You are confident with all the answers you have given the first time. Then, the examiner asks you some of the questions again and again… the examiner acts as though he thinks your answers are not quite correct…. so….would you slightly alter your answers to accommodate the expectation of the examiner? If the examiner asks you repeatedly “Are you sure that was how the story goes? Are you sure? Is that REALLY what happened? Could you perhaps be mistaken?Is that REALLY how you understood the story?”…. would you then doubt yourself?

Or would you stick to your gun and say “I know what I heard. That’s how I understood the story. I could be wrong. But that was what I heard and what I understood. And I am not going to change my answers no matter how many times you question me. Period!”

Seriously, in my own experience, MOST people would accommodate expectations (subtle or non-subtle) regardless of how wrong the expectations might be or how right their answers initially were.

Heck, it happens to our politicians all the time. It takes someone with strong conviction like Tun M to oust Najib out of his political throne because everyone else around him were as fickle as the weather when it comes to speaking up for the truth and fighting for justice.

It happened to me when I was a junior doctor. It happened to many other of my colleagues. It happened to even specialists and consultants when they were dealing with their own superiors.

It happens in our ward rounds and teaching sessions ALL THE TIME. For example, you might KNOW that you have given the right answer to your specialist’s question…. but when your specialist tests you by deliberately questioning your answer (or maybe the specialist himself also did not know that you were actually correct), you would change your answer to accommodate the expectation of your specialist. And even if you don’t change your answer, you will still start to doubt yourself even as you give the same answer… but this time, your answer comes in a less convincing manner.

One of my close friends had answered correctly regarding what are the anti-depressants licensed for OCD. She rattled off “Escitalopram, Fluoxetine, Fluvoxamine, Paroxetine, Sertraline.” Her answer was correct and spot on! Of course she must have read it before doing her presentation and she should have been confident with her answer. But someone in the audience had questioned, “Are you sure Sertraline was licensed for OCD. I am not sure… but I think, Sertraline is not licensed for OCD, right?” And EVERYONE fell silent regardless of whether they are HOs, MOs, specialists or consultants. Maybe everyone was also not sure at that time and it was too easy to assume that someone who was brave enough to question the presenter must have been correct. 

But me and Dr. T…. we have this curiosity that is not easily satisfied. We used to read that Sertraline is licensed for OCD. Our Part A MRCPsych notes had a list of all meds and their licensed indication. And we kind of vaguely remembered that Sertraline is licensed for OCD but we were also not very sure when someone had questioned our friend’s answer.

By the time, me and Dr. T had finished extracting the information from the pdf version of Maudsley Guidelines and had confirmed that my friend’s list of answers were correct, the audience had moved on to a new topic of discussion.  And me and Dr. T didn’t feel like it was appropriate to point out to everyone that my friend’s answer was correct and the person who had questioned her was the one who was mistaken. I mean, people make mistakes and if we can let it go, we will let it go. But rest assured, if the CME gathering was still talking about the same topic, I would have offered the correct information for the benefit of everyone in the audience. My close friend deserves to have the credit of having given the correct answer. It is only fair for her to receive that recognition, in my opinion.

After my friend had finished her presentation, I went to her and said, “Mesti kau dah prepare sebelum present. Kau tahu kan jawapan kau betul. Just be firm and stick to your answers. Lepas ni, tak kisah siapa yang tanya…. specialist ke, consultant ke…. if we know what we know…. we stick to it!” (Bab mengajar orang suruh rebel, memang boleh bagi kat aku. Hahha)

She told me “Aku baca sekali lalu saja… takut aku tersalah.” This friend of mine is the nicest, the most humble and the least aggressive among my close circle. She is the angel to my devil. Hahha. So, I know she would willingly accept the appearance of being mistaken even when she was right. I am her exact opposite. And I think, Dr. T is also like me. When we believe we are right, we are going to question you regarding what made you question our facts in the first place? (As in, how dare you question me when you yourself are not sure! Now, face our wrath! Hahaha. Okay, just kidding.)

Look, it can happen to anyone. When an ‘authority’ questions you, you become uncertain of yourself. Most people are like that. As stubborn as I always am, even I used to be like that too when I was a HO or a junior MO.

Now, I am more certain and more confident of myself in general. Yes, I still doubt myself, but much less than I used to. If I don’t know, I will say I don’t know. BUT… If I know what I know, there is NOTHING you can say that will convince me that I was wrong. I accept only evidences and references. You must give me more than words before I will accept I was wrong. I had invested time and effort to read my academic materials to come to a conclusion of certain facts, and for you to say that I am wrong, you must give me enough reasoning and evidence for me to change my mind. I would love to learn the right thing…. but I am not suggestible. I might pretend to accept what you say just to keep the harmony… but I will not accept anybody’s dubious words at face value without doing my own research.  I will go back home and verify your answer until I am satisfied. 

But even I sometimes feel unsure whether or not I will ever be as staunch and resolute the way Muhammad Ali had been.

In his life, Muhammad Ali provoked his opponents with razor-sharp words that rhyme and comical one-liners that hurt. But what made him an iconic cultural figure was his quotes on achievement, social justice, religion and war. And what made him greatly impressive was his rock-solid stance in his principles.  

***

Why did I say Muhammad Ali would have passed the Gudjonsson Scale with flying colours?

Well, because he was the epitome of faith and belief in himself and in his religion that there is just no room for him to doubt himself on what was the right course of action. He knew what he knew and even if the whole country was against him, he would not budge.

muhammad-ali-motivational-message-and-quotes-4-638

He held firm to his principles and his belief NOT to fight in the Vietnam War waged by the Americans towards the Viet Cong. Because he was persistent in sticking to his belief, he was exiled from boxing, ostracized by his peers and fans, and stripped of his crown as the heavyweight champion of the world. He was pressured right, left and center. People called him as a coward for refusing to fight a war he did not believe in. He lost almost everything – money, fame and reputation – and he also had to face the risk of prison for refusing to go to war… but he remained firm in his decision.

Muhammad Ali had declared himself as a conscientious objector and refused induction into the U.S army, famously saying, “I ain’t got no quarrel with them Viet Cong,”. He also had said “No Viet Cong ever called me a nigger,”

vietnam war

 

He was also recorded to say, “Why should they ask me to put on a uniform and go ten thousand miles from home and drop bombs and bullets on brown people in Vietnam while so-called Negro people in Louisville are treated like dogs and denied simple human rights?”

I am free

I especially love Muhammad Ali’s beautiful words in defending his stance: “I believe in Allah and in peace. I know where I am going and I know the truth, and I don’t have to be what you want me to be. I am free to be what I want. You can’t condemn a man for wanting peace. If you do, you condemn peace itself. A rooster crows when he sees the light. I have seen the light and I’m crowing!”

Beautiful!

But his words had upset the US Government. So, the US government then tried to send him to prison. He was put on trial and sentenced to 5 years in jail and $10,000 fine.  He was also banned from travelling and was not allowed to participate in matches outside the US. To this, he had said, “They want to stop me working, not only in this country, but out of it”. He must have suffered greatly at that time but he pushed on. 

He was 3 years in exile from boxing. And he almost had to serve his prison sentences, but fortunately, the US Supreme Court later overturned his charges. Muhammad Ali praised God on hearing the news. “I’ve done my celebrating already. I said a prayer to Allah.” 

He added, “They did what they thought was right, and I did what I thought was right.” To him, it was as simple as that.

Muhammad Ali had no higher education. He came from a poor family. But when he spoke, it was full with conviction in his faith and belief system. 

After 3 years in exile, he then resumed his boxing career after the Supreme Court had overturned the charges. Amazingly, he returned to the ring stronger than ever, winning match after match, strengthening his reputation in leaps and bounds.

History later had proven him right. Vietnam War was an embarrassing failure to the US. The US had lost the war and its veterans returned home to taunts and abuse by their own countrymen who were frustrated by the cost of the war to the US economy and to the morale of the country. Influential Hollywood celebrities started to protest the war which Muhammad Ali had condemned much earlier from the very beginning. University students had begun to protest the prolonged war with pickets and demonstrations, cementing the fact that Muhammad Ali was right not to be enlisted even at the risk of being imprisoned.

The truth had prevailed and Muhammad Ali’s wisdom had shone crystal clear and bright.

See?

As I had said, even though he was this great boxing legend of the world, his most impressive achievement was not made in the boxing ring. It was in the way he stood up for what he believed as right, no matter what!

Years later, Muhammad Ali’s name on the Walk of Fame was placed on the wall, instead of on  the ground as in the case of the rest of the other famous celebrities. I am sure, his name was supposed to be on the ground initially… but knowing Muhammad Ali, he must have insisted that his name should be placed on the wall… or NOT AT ALL. And his wish was accommodated since his name is so great that it would be preposterous and ridiculous to leave his name out of the Walk of Fame. So finally, when his name was placed on  the Walk of Fame…it was on the wall, as he had wished, instead of on the ground like the rest of the others!

 

When asked regarding why he wanted his name to be placed on the wall, he had said, “Because I don’t want the name of Muhammad to be stepped on.”

This, my dear readers, is the greatness of Muhammad Ali. May Allah be pleased with him.

Ali
May Allah be pleased with you. Amin.

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.

***

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.

***

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!

***

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?

***

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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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”.

***

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.

****

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.

Is-Arguing-Your-Childs-Learning-Style
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

 

intj stare
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. 

piaget-adaptation
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! 

Core Project

Professor Brian Little argued that people are more than just a bunch of traits. There may be many people out there who have the exact same personality traits as you (maybe all of you tested as INTP in your MBTI personality test) but there is something about you that makes you unique (from the rest of other INTPs), regardless.

In psychiatry, we have many trait theories and of course my personal favourite is the MBTI personality theory. I always tested as either INTP or INTJ. 

But we also have other personality theories/tests. The common and easy one we usually learn in our Part A Psychiatry exam is the OCEAN personality theory.

O stands for Openness to Experience (how open are you about exploring new interests – being creative/flexible/ curious and adventurous. Personally, I rate my openness to experience as moderate. I am not creative and I am not that flexible. Once I have perfected my point of view and my principles, I rarely change my mind. But I am very curious in nature and that’s why I read on many genres and on various issues. And I am quite adventurous especially when it comes to outdoor activities. I like to travel and learn about new cultures. So, I think I am pretty open in certain things.)

C stands for conscientiousness (how organized, how thorough, how much planning you put in your work. How hardworking you are. I also feel I am moderate in this. I must care ENOUGH in order to give a good effort. I care about my studies and my work, so I am organized when it comes to those sort of things. But I can give up easily when it comes to doing things that I am just not interested in.)

E stands for extraversion. (Extroverts are those who are recharged by having social interaction. The more they interact, the more energy they have. Whereas, introverts are those who are recharged by having some alone time. The more they interact, the lower their energy level becomes. Introverts do enjoy social interaction with people they know well, but even so, they NEED some time alone in order to recharge before they can come back to interact some more. I am very, very introverted. Outside office hours, I really just want to be by myself and do my thing.)

A stands for agreeableness (how kind, how ‘nice’, how affectionate you are. I am not that agreeable. I am not universally nice. I am only selectively nice. If you do something that I feel is very irresponsible or cross a certain principle, I won’t mince words in how I let you know that you are a slacker and you better buck up now and meet the standard! But I think I am nice to my friends and my family….. but still…if they do something that I think is unacceptable, I will let them know….eventually.)

N stands for neuroticism (how tense/moody/ anxious you are. I think I can be quite neurotic… but again, only about things I really care about. Like exams. Hahha. Or when I am planning for something important, I get a bit tense…. ehem, or a lot tense. When things go awry or opposite to what I want, I cannot even hide my displeasure and it would show on my face… or show through my words. I guess I am moderate to high in neuroticism).

But remember, Brian Little said that we are more than our traits. What makes us unique, he said, is what we have undertaken as a core project in our life.

Brian Little used himself as an example when he said that we are more complex than just our traits. He said, that he is an extreme introvert. But because he is a professor and his personal project is TO PROFESS, therefore he has to act in an extrovert manner when he is teaching his students, be more jovial and more animated, so that his students will be interested in what he has to profess.

In his TED talk ‘Who Are You, Really? The Puzzle of Personality’, he said,

“How about the idiosyncratic you? As Elizabeth or as George… you may BOTH share your extraversion or your neuroticism. But are there some distinctively Elizabethan features of your behaviour or Georgian of your behaviour…. that makes us understand you better than just a bunch of traits… that makes us… love you. Not just because you are a certain type of person….. So what is it that makes us different? It’s the DOINGS that we have in our life. The personal projects. You may have a personal project right now, but nobody may know it.”

He continued to say that the personal project can be anything. It might be your mom. You might be an agreeable person. But you act disagreeably in order to remove the administrative barrier that keep your mom from getting the kind of treatment she needs at the hospital, for example.

He termed this ‘out of character’ event as adopting a ‘free trait’.

 

Take myself as an example: I am an introvert. I am not universally friendly and very slow to warm up to strangers. But if I am suddenly being placed in the position of asking for a sponsorship in order to organize a non-profit event, won’t I have to adopt a ‘free trait’ (out of character traits) and act like an extrovert with people I have never met before just because I need their sponsorship? Yes, right? That’s what I have to do, isn’t it?

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I will have to smile when I don’t really feel like it, and act like I don’t mind when you are not on time or when you don’t deliver your sponsorship on the day you said you would. I would have to be so conscientious in following up on things I never really care before. Normally, I won’t ask people for their help and I won’t bother to follow up on whether or not they can help if they can’t immediately say yes to my request. Because usually, I can always find other ways to accomplish the same thing without having to ask for help multiple times. But because I have to run a state-level event, I will have to act like asking people for money and sponsorship, and keep on messaging them to find out their answers are something I don’t feel embarrassed about. Like it is something I don’t hate doing. Like I do things like this all the time and I am not stressed about it.

When you are running an event, you have to be patient in dealing with many people. Person A complains to you about Person B. Then Person B complains to you about Person A. Then Person C complains to you about Person A and Person B. Or your boss tells you to change something (multiple times!) in the Program Booklet, so you then have to go to the booklet designer and apologize to him for troubling him again but can he please, please, please do the changes again, you beg. Or you are stuck in a war between 2 committees; BOTH insist that the job does not belong to their committee. So, you resist the temptation to be your usual character and say “I will do it myself lah kalau dah susah sangat” (you resist saying that because you know you can’t do it yourself, this time) and be patient and listen to their problems, ‘pujuk-pujuk’ /cajoling them with soft words, in order to get things done.

So in the above example, I adopt a ‘free trait’ (that of extraversion and agreeableness) in order to advance a personal project. Because I care about my work (and unfortunately sometimes it involves organizing events), I have to adopt ‘out of character’ trait to advance a personal project that I care about.

And I am not the only one who does this. Everyone behaves outside their character because of their personal project. And Brian Little said, that’s what makes you unique… that’s what makes you MORE than just a bunch of traits that you share with many people. It’s the things we DO and the core projects that we embark on (that necessitate us to behave in a counter-dispositional manner) that make us different from one another.

That’s why at the end of the day, our traits are our traits (something we in our own self know about ourself if we are self-aware) BUT where it counts most (in reality, when things must get done), we are what we repeatedly do. Or rather, we BECOME what we repeatedly do, even as we know that it is against our biogenic trait.

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I guess, that is the basis of attending occupational therapy and training,right? Why train if we can never change?

 

However!!! He also said, even though adopting ‘out of character’ free traits may enhance well-being when we become successful at the project we pursue, it can also COMPROMISE well-being because it challenges your autonomic nervous system (The fight or flight or freeze reaction! With me…. I tend to fight than flight or freeze.)

Indeed! Behaving out of character is stressful. Pretending to enjoy excessive social interaction is stressful. Forcing yourself to be okay about asking for help, managing conflicts between people, dealing with people you cannot stand, dealing with sudden multiple changes because there are too many heads and different ideas to follow…. are stressful. Prolonged excessive environmental stimuli is stressful to an introvert.

See? There is an EMOTIONAL COST to adopting ‘free traits’ behaviour when it is done in a prolonged and excessive manner. Continuous ‘free-traited’ behaviour means dealing with chronic stress. In which case, I suggest you find a different core project that most of the time complement your real personality.

Choose your core project wisely. Make the cost worth it.

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Oh My English!

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The above picture is a screenshot of my facebook status regarding the recent viralled article from The Star in which a worried Malaysian (presumably a parent) had implored the Ministry of Education (MOE) not to penalize the 2017 SPM candidates who had misinterpreted the question of their English essay exam.

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The article in The Star was an open letter titled ‘Error in Reading Exam Question’ in which someone using the pseudonym ‘A Worried Malaysian’ was saying that only a maximum of 3 marks should be deducted from the whole essay if a student had misinterpreted the question as asking them regarding moving to another part of the world, as opposed to another part of Malaysia. (Hmmm…. what is it about ‘another part of Malaysia’ did SPM candidates get confused about, I have no idea. The question is so precise to me! There is no room for confusion, I think.)

Below is a screenshot of the whole article from The Star. I am sorry it is a bit small but you can try to google it yourself.

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Basically, we could sum up the whole article by the first few sentences of her writing which says, and I quote:

THE English SPM 2017 Paper 1 was conducted on Tuesday. In the continuous writing section, which is worth 50 precious points, students were given five options to choose from. The first option reads: “If you had the opportunity to move to another part of Malaysia, where would you choose to live? Explain your choice.”

As an adult who read this question for the first time, I did not realise it was asking about a place to live within Malaysia. Likewise, many excellent SPM 2017 students who sat for this paper didn’t realise an inclusion criterion set by the question. Some wrote about living in Korea, Britain, Bali, Switzerland, Mecca, Madina, and etc.

SPM is an important examination for students in our country as it will decide the paths they will follow. For excellent kids who wrote about living outside of Malaysia, they have made a mistake in one of the most important examinations in their lives.

These kids have been in turmoil since they realised this horrendous mistake. Those who were aiming for an A+ in English are in extreme shock about this.

I think, it is a sad day indeed for English teachers all over Malaysia when their SPM candidates can misinterpret ‘another part of Malaysia’ with ‘another part of the world’. I cannot understand how such error could have occurred.

Even if (and it is a BIG if) the question is misleading or tricky (Gosh, it is not!!) , if I were the SPM candidate this year, I would have chosen another essay option to answer if I could not be sure whether this question was asking about ‘another part of Malaysia’ or ‘another part of the world’. (The more I write ‘another part of Malaysia’ and ‘another part of the world’, the more puzzled I become at how anyone can confuse these two! I mean seriously! Repeat it to yourself! Another part of Malaysia, another part of the world, another part of Malaysia, another part of the world…. say these over and over again and you will find yourself in a state of incredulity at how anyone can be confused of these two different meanings).

I thought it was absurd when the Worried Malaysian had said that ‘excellent’ students were the ones who had made an error in understanding the question. In my experience with my excellent friends back when I was doing my SPM, ‘excellent’ students usually don’t make simple errors. They only make complicated errors, and only when they are drunk, drugged or in a state of panic.

Excellent students are usually hypercritical at how they look at questions, and if they doubt their judgment, they would change the course of their strategy and choose another essay to answer.

So when I had said in my FB status, that if I were the English teacher, I would straightaway give the students grade B or below, I was not doing it out of cruelty or lack of compassion. If excellent students who would never have made such a simple error deserve an A, then these students deserve a B or below, right? You cannot give similar grade between those who make this error and those who don’t!

It won’t be fair, right?

***

 For those who don’t know, English essay is marked based on:

  1. -Content  – 20 marks
  2. -Language – 20 marks
  3. -Organisation (coherence)  – 10 marks

At least, that is what I was told by my fellow friends who are English teachers.

To me, who is a psychiatry doctor, content is very important. It forms part of our Mental State Examination that we perform on our patients. Based on your speech (in how you answer our question), we put a remark on whether the patient’s speech is relevant or is it circumstantial or tangential etc etc. (I won’t bore you with the technicalities of my daily work). In short, we psychiatry doctors really ponder your answers and we give them our own version of grading. (Not unlike English teachers, Lol.)

As a psychiatry doctor, your answer and your thought content are so important to me. That might explain why my knee jerk reaction to SPM candidates who don’t answer the question properly would be to straightaway give her a B or below (But I have known other people who are so good in English that they were even more strict regarding understanding simple phrase of ‘another part of Malaysia’ and these people simply wanna give these students 25 marks; half the full mark of 50. Lagi kejam dari aku kan? Haha. But it reflects how much people were disappointed that you can misinterpret something like this!) 

But I guess, to be really fair, we should mark the essay according to the marking scheme above; based on content, language and organisation.

I think if the content does not fulfil the requirement of the essay question, I would probably give 5 marks only. A nicer English teacher might give a 10 (half the full marks for content).

So basically, only marks from the content component would be deducted. If the student’s command in the English language is good, then hopefully other components (language and organisation) would make up for it.

I do feel sorry for any of the SPM candidates who had made such an error in reading the exam question, but I do disagree with the spirit in which the article by Worried Malaysian was written…. as though the students should only be lightly penalized for their mistake.

Penalty should be given according to the marking scheme; in this case the marks for the content component must reflect their poor comprehension of the essay question.

My worry is, some over-involved parents want to shield and protect their kids from various bumps in the road of life and the MOE then breaks under the pressure.

***

It would be a shame if the MOE decides to break under the pressure of many worried parents and decides to only ‘lightly’ penalize these ‘confused but excellent’ students. Our standard for getting an A in SPM English is already so low, that lowering it further would place our examination system at the realm of a hilarious joke.

Seriously!

When I was an SPM student, nothing made me more annoyed at seeing how other students whose command in English was not that good had obtained an A too.

But then, there were also people like Miss A (whose command in the English language is not only good, but almost Shakespearean in its literary!!) who might also be annoyed that I got an A. Hahha.

So I learned to be okay with that aspect of exam; that people of the same grade do not always have similar level of excellence, but at least, well enough to get an A.

But I am here to tell you, that the standard for getting an A is very low already.

I will give you an example of many different standards of  introductions to an essay and how all of them can get an A so easily.

  •  When I first met Rania in my first day of residential school, I knew she would be my best friend for the rest of my schooling days. There was an air of sophistication in the way she walked and talked that I couldn’t help myself from being utterly enthralled in her presence. I wanted to know more about her and emulate her style. When she told me that she was from Kuala Lumpur, I knew immediately that if I were to gain her level of confidence, poise and ‘worldliness’, I must become a city girl too, just like her. Since then, I have wanted to make my home in KL, far away from the charming rustication of Alor Star.  (I think this is good enough. Maybe this intro deserves an A minus. But certainly not an A plus! This girl is a kampung girl from Alor Star who is fascinated by her new friend and this girl thinks that she might become like her friend if she lives in the same place as her friend. Maybe, you can develop the story into how this girl later finds out that certain traits have nothing to do with where you were born or where you live. That certain traits you develop through experience or travel or through books that improve your mind. That the secret to her friend’s sophistication is her wisdom, and nothing else. Depending on the candidate’s creativity, this can develop into a good story. During my SPM year… this sort of intro is considered great and I got A1. But Miss A was even better than me, but she too got A1. I wonder if like me, she was upset by the ridiculousness of the marking system… But such is the exam standard in our country.)
  • Once upon a time, when I was a 10 year old child, my father brought my whole family to Pulau Langkawi for a delightful vacation where we spent almost 2 weeks in a chalet of Pantai Chenang. As a busy executive in the hectic city of Kuala Lumpur, there are times when I wish that I could be transported to an island like Pulau Langkawi, where the atmosphere is that of serene calmness. I think, I would be happy in a rural area. (I think, this is grade B. Well, B for boring.  This girl is a city girl, and she remembers her old vacation when she was a child and she wants to go back there while dealing with a hectic executive life in an urban area. Boring, kan? There is no hidden story; no layers to the obvious. But this is also at the level of A1 during my SPM.)
  •  “A mind that is stretched by new experience can never go back to its old dimension.” It was the famous Oliver Wendell Holmes Jr, the Associate Justice of the Supreme Court of  the US,  who had said that piece of elevated wisdom. And now more than ever, I found the quote reverberated deep within my heart. What is it about being human that we can never be still and satisfied? The soul wants to wander and the mind wants to rebel at anything mundane and repetitive. Now as a Judge myself at the ancient age of 60, after presiding over thousands of various criminal cases and making life-altering judgments and verdicts, I had to make the most important decision of my life. Where shall I spend these lonely years of retirement? Did I even have that long to live? My last heart attack was last week, and it began to dawn on me that I needed a place where my old, broken soul who had seen so much hatred and atrocities in life could heal once again. (Can you see how different this intro is from the rest? This candidate begins the intro with a quote… showing that this candidate is a person who reads a lot and actually memorize quotes. From the very first sentence of her essay, this candidate is already impressive to the examiner! Her very first sentence is already impactful, you see! The protagonist in  this essay is described as being elderly, and is thinking about moving somewhere else for his retirement. It makes the important decision of where to move very critical for him who has just suffered from a heart attack and might not have long to live. He is philosophical when he talks about the soul wanting to wander and not easily satisfied. We as the reader would also wonder why his soul is broken and needs healing and we want to continue reading to understand the reason! What I mean is … there are layers upon layers to the story. It is not a simple story of “I simply want to move somewhere because that is the essay question I am supposed to answer in this question”. Hahha. In short, this candidate is successful in grabbing the examiner’s attention. This candidate is an essayist par excellence! This is the level of Miss A, my friend in MRSM Langkawi who really deserves A+++ if other less impressive essays are given A+. ) 
  • If I can choose where to live in Malaysia, I would definitely choose to live in Kota Kinabalu. I have been there once before, and it was love at first sight.  (Straighforward. No layers! Nothing extraordinary. Grammatically correct because the sentence is a simple sentence, anyway. But yup… these kind of essays also got an A just as long as the language was good enough, not to have made some crazy errors. See how different all of them are but yet all 4 essays do get the same damn A! Sheesh) 

In order to write well, you have to read well. And the average Malaysians don’t read non-academic material! So we do not know how to set a proper standard when marking English essays. We think simple introduction to an essay should get an A already.

Well, it shouldn’t.

Essays should reflect your language sophistication! Because if you cannot be good in your writing (when you have the time to ponder about what to write) then how can you be good at your speech (when you have little time to ponder and simply need to think on your feet and respond)?

Language is not simply making sure other people get what we mean. When it is an essay, it is about getting your message across in the most beautiful way possible. Content is the core; but language and organization make it excellent.

***

And to the Worried Malaysian who thinks that SPM is very important, well… yes, it is. But it is not the be all and end all of everything.

Fair, is fair, is fair.

Everyone has to pay when they make mistakes in exams. Even for a careless mistake, we have to pay for it. In fact, most exams are all about catching you with your carelessness and stressing you with your lack of time management and tricking you with your comprehension of the questions etc etc. Exams ARE designed to trick you and stress you out! So, should everyone then be given compassion for any of those mistakes? Come on!

And in this particular context, what makes this mistake even worse is…. it was not even a trick question! So think logically; should they not be given marks accordingly, with compassion not being made an issue?

How are they going to learn if they never pay for their mistakes? Stop trying to shield your children from life’s disappointments.

Looking back, I am so glad that I was brought up in an era where tough parenting was the norm. No one mollycoddled us or packed us in a cotton wool away from harm and disappointment. We dealt with stuff!

Resilience is developed by dealing with stuff. By not running away from problems but facing them head on! Confidence is developed when you knew you had faced many challenges before and yet, here you are, having come this far! It reminds you that whatever current challenge you are facing now is just like other past challenges you had faced…. that they too will pass with the passage of time!

In my growing up years, my father was very strict but his strictness made sense. He ran the household almost in a military-like style. I had a schedule for every single hour of my days. Even during weekends and school holidays, I had a revision schedule. There were rest periods, of course, but only after I earned them by performing my academic tasks properly. (Rest periods are also scheduled! Haha)

Even my life as a student at a boarding school was not as rigorous as my life as a student in my own home. (To be honest, my life as a student in MRSM Langkawi was not tough in the sense of being a student, but tough in the sense of having to deal with the lack of privacy and the excessive noise and the intrusive friends.)

Just like any kiasu Asian parents (haha), my father too placed a lot of emphasis on academic performance. When we were children, he told us about how difficult it was for him to convince my grandfather to let him continue his education until the STPM level. He kept saying “Waktu ayah dulu, tok wan tak pernah ambil tau ayah punya pelajaran. Ayah nak kena tolong tok wan memotong getah lagi bila cuti sekolah. Nak sambung universiti pun tak boleh, sebab tak ada duit. Lepas dah kerja, baru boleh sambung belajar. Ayah dapat degree lepas umur dah  30 lebih. Sekarang kerja Kak Long dan Kak Ngah belajar saja. Takkan itu pun tak boleh? Kalau ada pelajaran yang lemah, usaha sampai boleh. Kalau tak usaha, sampai bila-bila pun takkan boleh.”

But despite his insistence that we do well in our exams, he would never shield us from the consequences of our own carelessness in exams. He was not that kiasu, see? He would never have written something like the Worried Malaysian had written. He would say, “Lain kali baca soalan elok-elok. Kalau dah silap, memang salah kita…nak buat macam mana. Kena hadap sajalah. Belajar daripada kesilapan. Silap sekarang tak apa lagi. Jangan silap waktu UPSR/PMR/SPM.”

When I discovered the horror of Add Maths as a 16 year old, I told my father that I would never be good in Add Maths. I was afraid that I would not get straight As this time. What made it worse was I could not even attend any outside tuition because I was studying in a residential school. So during the school holiday at the end of my Form 4, my father hired a private tutor for me to help with my Add Maths. For that one month of school holiday, it was NOT a holiday!

But then, when the school open for the new semester of Form 5, my Add Maths result showed a dramatic improvement that impressed my friends. And my SPM result showed the string of straight As I had always wanted for the very last of my National Level Exam.

I  think, our mother sometimes felt sorry for us because we only had one hour of play time per day. The time when my father was outstation was the best time in our childhood. All of us ‘raya hindu’ playing non-stop. My mother would turn a blind eye but would remind us that my father would expect to see our tasks properly done by the time he came home.

Whenever my sister and I came back home later than 7.00 pm after one hour of outside play, we would get a stroke of rattan because we broke the rules. (Afterwards, my Kak Long and I would enter our room and started the game of blaming each other for not minding the time… but after awhile, we simply laughed about it.) If you compare my life to the other kids in the neighbourhood back then, you might say that I didn’t get the same amount of play time like they had. And the other kids kind of pitied me for it. But then, they also didn’t get the same kind of academic results that I got. And I kind of pitied them back. Haha.

So, life is actually quite fair, don’t you think? Not totally fair; not absolutely fair. But QUITE fair.

Because every action has a reaction! Every action has its own consequence and following its own law.

Sebab semua perkara ada sunnahtullahnya. Usaha tu ada sunnahtullah dia. Disiplin tu ada sunnahtullah dia. Banyak main pun ada sunnahtullah dia. Buat silap pun ada sunnahtullah dia. (I should repeat these sentences to myself every day. If only I can get back my level of discipline in studying when I was a kid…I would not have to face the horror of my life while preparing for my Part B exam. My discipline had disappeared by the time I finished high school as my father no longer cared about what I did with my time. Haha)

So, when you make your decision, remember the sunnahtullah of your decision. MOE must remember that if they decide to NOT penalize this mistake properly, then it would open a Pandora box for every mistake not being penalized. Everything can then be argued on the basis of compassion rather than fairness. And everyone then forgets that this is a big national exam we are talking about! NATIONAL LEVEL Exam! National Level Exam should follow strict rules and regulations!

Otherwise, don’t organize an exam! It would be a waste of everyone’s time.

P/S: How are we ever going to get our education system respected and recognized if we always give leeways in the system in order to ‘help’ our candidates. I am sure everyone still remembers the ‘Soalan bocor UPSR 2014’ as one of the worst scandal in the MOE back then. Even at the level of UPSR, our integrity has much to be desired. 

Up to the level of master among professional doctors, leaked questions are common and this is like an open secret! Everybody knows it! And we are talking about professional doctors whom we should be able to trust as having the best level of moral and integrity in the society. But sadly, even at that level, we are just like naughty school kids who would grab whatever leeways or ‘help’ we can find. I have friends in other specialties as well who are doing Masters, and THEY too admit that they got hold of leaked questions.

We all know the credibility of ANY exam is non-existent if leaked question and ‘leeways’  and ‘help’ are not just possible, but very highly probable. No matter how good your system is, when it is not trustworthy, it loses all credibility. 

SPM exam was the last exam that I took using the Malaysian Education system. My IB diploma, medical degree and specialist exams are all International and I prefer it that way. Nowadays, we should think globally! 

So when anyone dares to question my MRCPsych credibility or the credibility of any of the external pathway (MRCP, MRCPCH, etc) to my face, as though I am taking shortcuts in my training, I will just smirk and say in my heart “At least, my exam is world-recognized and meets the rigorous standard of examination that is set by an organization that is recognized everywhere. And I have never heard of any leaked questions that would destroy the credibility of the exam system. Unlike yours!” Once upon a time, I would have said those rebuttal sentences back to their faces, instead of just in my heart. But nowadays, I take refuge in the Malay saying that “Bukit tak runtuh dengan anjing yang menyalak.”

I am not the sort of person who would go around belittling others. My self-esteem doesn’t require me putting other people down or making my unwelcome criticism known in order to hurt other people’s feelings (unless I was feeling provoked), the way some people had done towards me when they talked about MRCPsych as though it is not as good as the Master pathway. It is my principle to support anyone pursuing their education in whatever way they prefer, because that is better than simply sitting on your bottom, not progressing. But in the past, I did give people a counter attack when they tried to condemn my decision to pursue my study via the external pathway. In the past, I paid back taunt for taunt. I was quite fierce in my retaliation, too.

However, nowadays, it might be a sign of maturity that I can ignore people who have a need to belittle other people’s qualification when their own qualification is very, very questionable! With the existence of leaked questions that does not fulfil the moral requirement of integrity, that kind of exam system would NEVER be recognized. So now,  I can ignore their noise and regard it as the hallmark of a jealous and insecure person… and I move on. Yeay, mature me!

Glad INTJ argues