I know… that it has been more than 2 months since I last wrote in this humble blog of mine. For the countless times, I had broken my promise to write consistently, at least once per month. But, my dear readers… trust me…. I have some really good reasons for not blogging once per month as I had promised.
Reason No 1: My Macbook screen was cracked and broken a few days after I posted my last blog post in August. And I took my sweet time repairing my Macbook screen because the repair cost was too expensive for me, especially since I had just spent a lot of money to pay for my CASC exam. I just couldn’t afford to repair my Macbook screen just yet. (Very good reason, no?)
Reason No 2: Exam! (Enough said. LOL)
My CASC exam was held on the 18th of October 2019 in Hong Kong. I am not exaggerating when I say it was the hardest exam of my life. At the end of the exam I felt like crying bloody tears. There were 16 CASC stations altogether and we were allocated 7 minutes to perform the task in any particular station. My problem with CASC was that I always felt like I didn’t have enough time to perform the task to my heart satisfaction. So, there would be times when I covered enough depth… but not the range that was required to pass the task. That was what happened during my first CASC attempt. My study partners were always telling me “You tak payah tanya dah yang lain-lain tu. Cukup criteria for diagnosis, move on. Tak payah tanya everything. Banyak lagi nak tanya….past psychiatric history, family history, risk assessment, coping, drug and alcohol. Kalau tanya detail sangat, yang lain-lain tak sempat. ”
Okay, but that is my problem. I whiningly told my friends “Susahlah. Aku rasa tak puas kalau aku tak tanya bagi habis semua symptoms for that diagnosis even if symptoms yang aku dah dapat tu dah cukup untuk diagnose. Tapi mungkin dia ada more symptoms yang aku tak cover lagi, right?” I would still feel like I might have missed something. That was the OCPD part of me that was ugh!! really troublesome for me. I just didn’t have enough time to cover the task for each station to my heart satisfaction.
There was a time when I had to give myself a serious pep talk. “Afiza, this is not about your heart satisfaction. This is about the examiner’s satisfaction! Please get this into your head! Just because you have covered the depth that is required to make the diagnosis, you still wouldn’t pass if you didn’t cover the range of the marking scheme. Range and depth! Not depth alone! 7 minutes is all you have and you cannot be too detailed on just one thing. Prioritize! Come on!”
CASC is so different compared to Part A and Part B. In Part A and Part B, I could still indulge my OCPD-ness to a certain extent. For example, for each question in Part A and Part B… even if I already knew that the answer was E, in my head I would still go through my own method of reasoning regarding why A, B, C and D were not correct. I just had to check and double check each answer even when the correct answer was quite obvious already in the first glance. I did all that because… yup, I have some OCPD traits that just could not be ignored at times. LOL.
But CASC was a whole new ball game. I had to learn to think quickly and to not ruminate. I had to learn to cover just enough in depth and then quickly move on so that I could cover the breadth/range of the task. It took hard, intensive practice for me to overcome and suppress my obsessive tendency but Alhamdulillah… as the exam date was geting near, I was able to overcome the urge to dwell on one thing in too great a depth. But ah… it was hard. I am the ruminating type. When something doesn’t make sense or when a story just doesn’t have enough details to it, well… it bothered me. (Which kind of explains why even as a child, I had a lot of questions about anything that was taught to me especially in learning the religion. The same obsessive ruminating trait that was so bad in exam, was the same trait that allowed me to discover the beauty of having real faith and real conviction in my religion. Because I questioned stuff, I now understand Islam better and it was the best thing that could ever happen to me especially when I was in my early 20s. So yeah… I don’t always regret having this OCPD trait. But I must admit it can be troublesome in certain situations… such as in exams. LOL).
There was one time when I was so frustrated while studying for CASC that I felt like giving up. Seriously… CASC is the worst exam for many of us. The financial burden was huge! Some people had to borrow their parents’ money to take CASC exam one more time because they had already run out of all their savings courtesy of previous payments of past CASC attempts.
Some of the candidates were already consultants or specialists in their own countries… but they took this MRCPSYCH & CASC so that they could work in the UK. They were so much more senior than us…. what chance do we have in competing with these people?
There were also times when I felt angry at myself for not passing CASC the first time. Doctors are always hard on themselves when they don’t pass exams, you know. Because the experience of failure is so rare and far in between. Most doctors are top students their whole lives. When they got into medical school, then they realized that there were so many other people who were just as good and clever as them, if not better. Then they would feel overwhelmed by the competition. And if they actually fail, they would feel like the stupidest person on earth. Even though failing your professional exam is quite common, it is still a bitter experience for any doctor to have to undergo.
Alhamdulillah, Allah created me with an ability to self-motivate. I am a very optimistic person, in general. And for that, I thank my parents very much. My father always encouraged repeated efforts in order to gain success. The concept of putting in an effort was very prominent in my upbringing. “Kena usaha! Sampai dapat!”. And until now, I internalize that concept. And it is a very motivating concept. Because my dear readers, Allah sees your effort. And I believe it wholeheartedly and behave accordingly. I don’t believe that my effort guarantees anything. I just believe that effort is required to qualify for God’s help. And I need His help in everything that I do. And therefore I have to make myself qualified for His help. So I put in my effort, hoping it would be enough.
And it is true that it is in the remembrance of Allah that the heart finds rest. It is really difficult to feel bitter about not passing an exam when I know that Allah has blessed me in every other aspect of my life so mercifully… that it would be very stupidly ungrateful of me to indulge in endless self-pity. I was afraid that Allah would punish me for being an ungrateful slave. Very difficult to pity myself after that. LOL.
One of the ways I calm myself is by reading and writing, which is something that I am sure you guys already know about me. I love reading stories and seerah. I also love composing poems of religious themes because I think they are motivating, uplifting, always relevant…. well, Islamic poems are evergreen, no? Because Islam will always be relevant in our daily lives as Muslims.
So I wrote a poem to remind me to be a grateful slave of Allah. To always be mindful that I also have another test to pass. The test of patience and fortitude and the test of NOT despairing of Allah’s mercy. And the outcome of this test would only be revealed in the hereafter which makes it far more important to me than passing CASC would ever be in this world. It doesn’t even begin!! to compare!
So I moulded my thinking accordingly and asked Allah to forgive me. I wrote the poem below around 3 weeks before my CASC exam in order to gather my thoughts properly. It was the most therapeutic thing I had done in a long time. The title of my poem is Remember.
Once upon a time, I stretched my arms faithfully upward Supplicating in silent soulful solitude Hoping You would deign to look downward And grant Your slave in prayer stood All the wishes and dreams of her heart to fly to heavens, a brand new start.
But the hand of fate was full of pain Dreams of mine went down the drain I wondered why my prayers were in vain When You have the power to grant my gain.
Did I not to You faithfully worship? That You had so forsaken me Have I not for You a love so deep? That You entirely shunned me Have You withdrawn from me Your favour? To bleed my heart all over.
But immediately I felt a twinge of shame What You must think of me, I’d take the blame As I imagined the response You exclaim To this ungrateful slave that I became.
Remember Ya Ibadi, When you prayed to me with outstretched hand For things you thought I wouldn’t grant Instead I bestowed you a better one Gratefulness for Me you displayed scant.
Remember Ya Ibadi, Sins You committed I’d overlooked Without you begging My pardon Still your soul-cleansing I undertook All that you lost I then returned.
Remember Ya Ibadi, All the promises to Me that you broke Hoping it would be of little concern Still your heart purification I undertook Your will and resolve I then hardened.
Remember Ya Ibadi, Good things happened you didn’t ask how Glorious miracles you asked to allow They happened without your bargaining vow How could you forget all my blessings now?
Remember Ya Ibadi, Did you suppose things happened in coincidence? Did you not see the purpose in all happenstance? Should everything go your way in every instance? What do you suppose your reason of existence?
I remember now, Ya Ilahi, And fervently I promise to do better Pardon this slave, in need of Your favour Forgive my sins past, present and future Have mercy on my soul now till the hereafter Only to You I place my worries, my fear I accept Your decrees, doubts burst asunder Whatever transpires, to My Lord I surrender.
-Afiza Azmee- 29/09/2019 6.00 pm
Allah, the Most Gracious, the Most Merciful, has bestowed upon me his blessing once again.
Alhamdulillah. Alhamdulillah. Alhamdulillah. A wave of happiness and gratitude filled my heart so overwhelmingly that my eyes teared up as I informed my parents the happy news. That I have passed my CASC exam.
I imagine that once upon a time when Allah had created the story of my life in the Luh Mahfuz, He had probably written “Today, Afiza will be filled with happiness for passing her CASC exam.”
The month of August is the month of Independence for Malaysians. And therefore I thought it would be nice to share with you guys how I view the concept of freedom and independence and why I believe that they are not the same but are very much related to one another.
This is just my own point of view and everyone is free to think differently. Those who have followed my blog since I was in medical school would understand how frequently I write about freedom. How preferentially I choose which fictions to buy based on the plot revolving on freedom. I value it very much. I believe that being relatively independent (and therefore, more free compared to those who are relatively dependent) is mandatory if you want to be a good person or a good Muslim. I believe that it is a religious obligation and a religious principle for you to keep yourself as independent as possible because without independence, you can be oppressed, coerced, thwarted from doing the right thing because you have no other choice.
My General Philosophy On Freedom
What is independence to you?
I might be the odd one out here but I don’t really think that independence is the end goal that we should aim for. Independence is only a TOOL…. and it is a relative one too! Because we are always dependent on something or someone, one way or another. We are dependent on the oxygen we breathe to stay alive, aren’t we? (haha I know that is an extreme example, lol). As a Muslim, we believe that we are always dependent on The Almighty for our every sustenance. We are also dependent on our family and friends for social and emotional support. No man is an island, right? We are all inter-dependent. We also learned about organisms interdependence in the food-chain chapter of our Standard 4 Science subject, didn’t we? (well, during my time, at least. Nowadays, the kids might be learning it in the kindy!).
I like the word freedom better in describing our end-goal in life. We can be inter-dependent while still being free to make our own decision and chart our own course in life. Just because I am dependent on you in certain aspect of my life, it doesn’t mean that I cannot have my own will and choose my own actions. You can disapprove my decision and hence choose to withdraw aid/resource/support from me, and I am sure I will be affected to a certain extent… but there are OTHER aspects of my life that has nothing to do with you whatsoever and therefore it wouldn’t be fair for you to dictate to me what I should do that doesn’t affect you just because I am dependent on you in one particular aspect only. I can choose to depend on other people as well to give me what you are not willing to give. So, go ahead, condemn me, threaten to withdraw aid/support…. I will just find a more compatible entity to be inter-dependent with.
But in order to boldly state that sentiment to ANYONE, we must be inter-dependent ‘just enough’ and no further. In other words, we should not be dependent on others for survival matters… but only for matters of comfort. So that if people try to get us to do their unjust bidding, we can just say “Look buddy, don’t overstep your boundaries with me. What makes you think you are so important that I cannot just walk away and find my resources elsewhere? It’s not like I need you to survive, ok?”
That is freedom! Irrespective of how dependent we are on anyone! Freedom is a mindset and our end-goal.
And any free, sovereign country should be able to say that to any other country who might be trying to manipulate us just because we are dependent on them on certain things. Our official foreign policy is based on the principle of neutrality and maintaining peaceful relations with all countries, regardless of their political system. During the time of cold war between the Soviet Unions and the US, we did not favour one political system over the other. And that is the only wise stand that a small, non-powerful but proud and sovereign country can have. Neither can use us against the other. We form our own independent opinion based on issues and how it affects our own interest. In certain issues (like the support of the US for Israel’s terrorism towards the Palestinians) we will condemn the US and Israel. But at the same time, in championing democracy and human rights, we will support the Western countries. We can warn Philippine to beware of China’s debt-trap while at the same time support China in its trade-war against the US by not banning Huawei in our country. See how great it is when we do not limit ourselves to a sense of false loyalty (to any organization or party) but instead, we choose our stand CAREFULLY by analyzing on issues!
Freedom or free-will is the concept being debated back and forth among theologians too. Some have posed the questions of “Do humans have free will… or has everything been pre-determined by God?” Very interesting debate. You can check it out on You Tube.
In Islam we believe that we’re free to choose our actions but God has the ultimate control over the outcome of those actions. According to the teaching of Islam, Allah has given humans free will to make choices in their lives but only God has foreknowledge of our destiny.
See? Freedom is our birthright given by God. Whereas independence is just a tool to reach freedom. No one is truly independent! But free? Yes… we are truly free!
“Come on, are you saying everyone is TRULY FREE? We have the law to abide by and we have our own culture that we are bound to. Violate them at your own peril.” some might point out.
Yes! I really am saying that we are free! It is our birthright, guaranteed by God. We are free to make our own choices. And we are also free to face the consequences of our choices. If it means going to jail and losing our physical freedom, then yes, you are free to make the choice that might lead to that. Just because you are afraid of the possible consequences and therefore refrain from doing any particular action, it doesn’t mean you are not free. It just means that you have weighed the risks and benefits of your actions and choose not to do certain actions because you are not willing to pay the price for it. But if you REALLY want to do those actions regardless of the consequences, can anyone stop you? No!
So, you DO have free will!
But because we are dependent on our surroundings and our society, we exercise our free will cautiously by weighing the risks and benefits of our actions.
For example, when someone said that they were not willing to fight the ex-PM Najib while BN was in power back then (or not willing to fight their HO-molesting or HO-assaulting boss, for those working in MOH), “because their hands were tied and they were not free to fight against him who is more powerful”, what they were REALLY saying was “Look, I know I am free to fight and go against anyone. Not like anyone can stop me if I am REALLY determined to do it. But I have weighed the risks and benefits of fighting my boss and I don’t think I can do it. My job and my livelihood is dependent on him. So, I am sorry.”
(Well, weren’t you sorry when Najib lose the election? Weren’t you sorry when your HO-assaulting boss got sacked from MOH? Now, you are saying that you, the enablers of immorality, had nothing to do with what your boss did? You had your chance to do something about it. You were not REALLY that un-free. You just weighed the risks and benefits and decided not to fight for your principles, didn’t you?)
This is why….. the more dependent you are, the more cautiously you exercise your free-will. This is why if you value your freedom, you will be hesitant (and in my case, paranoid hahah) about being too dependent, if you can help it. There are times when you cannot help it. Recognize why and make plans for the future so that you won’t be placed in a similar situation.
Financial Independence & Freedom
In the past, your inability to pay your own debts can cause you to be enslaved, did you know that? This is called debt-bondage or debt-slavery. This is SO SCARY because debt bondage could be passed from one generation to the next. If you were unlucky enough to be born from parents who were debt-enslaved, you have been dealt a terrible hand by fate. You were born physically enslaved (but hopefully, you are free in your mind. No one can enslave your mind if you don’t allow it! And you must NOT allow it! Freedom is a mindset too, remember?)
Similarly, we heard phrases in our modern era like “enslaved by debt”. Think about this!
Think about a person who is juggling his house mortgage, his car loans, and all the items he bought via instalments… things that he bought because he wanted a certain level of lifestyle that he used to be able to live without! Wouldn’t the thought of debts weigh heavily in his mind every single day, robbing him of happiness and contentment in his life? Wouldn’t he lose his passion for working if he found himself having to do a lot of overtime (or locum works, in the case of doctors) in order to pay his debts? Would he dare to firmly state his opinion even if it is different from the popular opinion of his colleagues or his superiors if he has to always be careful because he wouldn’t dare to jeopardize his current job in any way, shape or form?
“Aku kerja sebab aku perlu duit. Kalau aku cakap banyak, orang tak suka kat aku pula. Nanti aku nak pi kerja pun jadi tak syok. Nak berhenti kerja pun tak boleh juga sebab aku banyak hutang ni. So buat ja lah macam biasa. Boss molest pekerja ke, assault pekerja ke, pandai-pandai lah mangsa bela diri sendiri. Kalau boss songlap duit syarikat dan cakap itu derma from Saudi Arabia pun… what to do? Apa aku boleh buat? Bukan tanggungjawab aku.”
Hmm… this is the mentality of someone who is NOT financially-free. Just come to work, do the most minimal you can get away with, no need to uphold anything of human principles and values and at the end of your shift… just go home. Sad, isn’t it?
And whether or not you are financially-free has nothing to do with the objective state of your income. A cleaner can have financial freedom by living within his/her means whereas a CEO might have to file for bankruptcy! Whether or not you can attain financial freedom has A LOT to do with your ability to maintain your lifestyle according to your income!
If I have X amount of money, I am going to make sure my mortgage, my car loan, and my lifestyle is less than X-amount every month! That I have enough savings for a rainy day! I am not going to upgrade my lifestyle every time I get a hike in my salary. I am not the sort of person who would have multiple houses or multiple cars just because I can afford it. One house to live in and one car to get me from one place to another is enough for me.
The rest of the money will be used for the sake of increasing my independence. I finance and service my independence, regularly. Because the more independent I am (even though as I said, no one can be truly independent) the more liberally (and the less cautiously) I can exercise my free will.
Freedom is expensive. It is knowing that if things happened, you have money to tide you over until you can find the next job. It is knowing that if things happened, you have money to sue people and take legal actions. It is knowing that if either of your parents or your child are not well, you can take unpaid leave to care for them because you have enough savings to do so or maybe you can hire a nurse to care for them while you continue working (instead of IRRESPONSIBLY taking multiple ELs and causing trouble to your colleagues… or not settling the issues that crop up in your marriage causing you to take multiple MCs from psychiatry department by using your psychiatric diagnosis to not come to work! And you cannot settle your marriage problems because you don’t have money to hire a lawyer to fight for you for proper divorce settlements! So your marriage will continue to be the perpetuating factor to your depression because you JUST CANNOT SETTLE YOUR PROBLEMS! And you continue using your diagnosis to irresponsibly MIA from work!)
But how can you hire a nurse to care for your sick family members while continuing to go to work if you have multiple mortgages and loans? Your financial freedom is gone because you have become accustomed to a certain lifestyle that NO ONE force you to maintain yourself at.
The more materials you have, the more care and time needed to invest on them! Instead of the materials making your life comfortable, they are making your life more difficult. It always annoys me when I have to pay my ‘cukai pintu/cukai tanah/car insurance’ because I would start thinking that these are the money I won’t need to spend if I don’t own these materials. Lagi besar periuk, lagi besar keraknya, isn’t it? It always annoys me when I have to spend time cleaning my house because I feel like the time spent cleaning my house can be used for reading fiction! (Hahha… forgive me and my stereotypical, repetitive routine of fiction reading!) I used to live well with just having one room when I was a student at the uni and I didn’t remember my life back then as lacking anything in particular! But because I now have a house, I have to invest even more time and money for these materials that in the end, I could actually live just as well with less! What’s wrong with just renting a studio? Less cleaning time, less maintenance expenses! What’s wrong with just using public transport (especially if you are living in a Western country where public transport is amazingly reliable)? Why not use the extra money that you save for not having these materials by travelling and improving your mind and your view of the world?
This is the basis of the Japanese Zen-concept of minimalism and simplicity. (Mary Kondo, anyone? LOL!)
In Islam, we have the concept of ‘bersederhana’ or wasatiyyah which means best, middle, centered, balanced. It refers to the “middle way” or “moderation”, a justly balanced way of life, avoiding extremes and experiencing things in moderation. (But, of course we all have different needs. What is moderate to you, might be too much for me or vice versa. You know best what kind of lifestyle suits you better. But what I am saying is… be sensible. Don’t go overboard with materialism.)
So when my parents suggested that I changed my car because they felt like it was time to kind-of upgrade hahha, I just told them “The only reason I am going to change my car would be because the car can no longer be used or for some other practical or safety reason. As long as the car can safely and comfortably bring me from point A to point B, I am okay to use the same one.”
Likewise, I am not interested to invest money in properties. To me, if I have an urgent need of money, what would usually happen is I am going to have to sell the plot of land or the house at a cheaper price, won’t I? Because my financial need is urgent, how can I wait for better offers? And I might not even have finished paying the bank for those plot of land or house, in the first place! So whatever cheap offers I have to settle at, a large chunk of it still need to be used to pay the bank first before I can use the money urgently! Too much leceh-ness and paperwork and procedures! I hate it!
Compare that to investing in gold! Acquiring gold is a straightforward process. Just walk into any gold/jewelry shop and pay for them and I am done! Minimal paperworks and no complicated procedures! I can also get money stat whenever I need it by pawning them off! I might as well invest in gold jewelries which I can also use to accessorize my outfit haha. So practical, isn’t it? I just love, love, love simple things like that!
When it comes to financial aspect of things, my aim is to stay liquid! I don’t want to be tied up in assets that are going to use up more of my money and time to care for them. Because I use my money to buy me independence… as the road to freedom (of speech, of action, of movement)! Not to buy materials which I don’t need and which also troubles me with all their maintenance and up-keep and taxes!
This is my financial freedom philosophy. I know some people would think about it differently. Some people straight-out advocate for property investments! But not me. This financial freedom philosophy works for me for now. You can even call it my over-valued ideas. I am paranoid, even, about losing my freedom! Perhaps I was influenced by the books that I read… the struggles that other people had written about breaking away from oppression. I pray to God, I will not be placed in such a situation.
Whenever I talk about financial freedom, I would reflexively think about the doa below that I repeat every time I perform my prayer. Notice that ‘being heavily in debt’ and ‘being overpowered by other men’ are being grouped together! Amazing, isn’t it!? Once you are in debt, you are VERY VULNERABLE to being overpowered! If you value your freedom above extravagant lifestyle, you will NOT put yourself unnecessarily in a position of being in heavy debts!
In terms of the state of the country, remember how everyone was worried about China debt-trap? Makes sense, isn’t it…how debt can restrict your freedom! A lot of countries have fallen trap to China debt and some even said that Malaysia was also at the brink of it during the time of Najib! Some are not even sure if we have truly been saved from it, anyway!
My take home message is: FEAR DEBT! You can lose your principle and your very soul because of debts! Don’t do it to yourself, I beg you.
Other Factors Can Restrict Freedom Too…
Other than financial debt, there are other ways that your freedom can be restricted. Your freedom can be restricted by forming bad relationships that you then become stuck with, for example. But unlike financial debts, this can be easily managed by having some willpower and by coming up with strategies to modify the behaviour of the people around you so that you can have some breathing space.
People have also gotten into financial problems by forming bad relationships and lost their money due to having to finance a ‘biawak hidup’ in their lives. Some of these biawak hidups are drug-addicts who exploit their partners financially. But if you have a concept of how your freedom is highly related to sound financial independence, you wouldn’t have tolerated this biawak hidup for long because you want to protect your freedom. Right?
There are times when I despair at the fate of women who do not know how to look out for themselves especially when our religion is so protective of our rights as a woman. But we are all adults here. You have free-will and you have a choice to leave your biawak hidup. If you make a choice of sticking with your biawak hidup, you know the consequences for it which would include being in debt! There are times when I feel like maybe this is a lesson to those women. “Allah gave you freedom or free-will. To make the right choice when you had to make it! Then you made the wrong choice…. against ALL REASON! So Allah withdrew your freedom by putting you in debt. And when you think about it, it wasn’t Allah that had put you in debt and thus restricting your freedom! YOU had chosen to stick to your biawak hidup… and then your biawak hidup exploited you financially. Your debt now is YOUR choice…. don’t you blame fate or God.”
I put more emphasis on debt (rather than any other factors that can also restrict your freedom) because being in debt is the highest threat to freedom (and thus, reflected in the doa I posted above). If you are financially-free, other things (including bad relationships) can be easily managed. If you cannot manage it despite having financial freedom, you might have issues with problem-solving or getting enough willpower to get things done (like ending your no-good relationship). Don’t worry. This is where our psychiatrist and clinical psychologists can help you. We can give you some really good problem-solving advice and skills.
Come and visit our clinic and we will, Insya-Allah, help you! But gosh… please help yourself, first! Please help us to help you.
Last but not least….
Happy Freedom Day, everyone! Merdeka! Merdeka! Merdeka! May Allah bless our country with peace and prosperity for many more years to come. Amiin, Ya Rabb! Until next time, my dear readers. Take care and may Allah bless all of us!
Seriously guys… it wasn’t exactly a newsflash that MOH is understaffed, under-budget, over-worked and basically functioning sub-optimally due to all of those reasons. The same issues have been plaguing MOH since I started working in 2011 (and also long before that, I am sure). And naturally, with the way our economy is doing, the state of hospitals and health facilities in MOH has been progressively worsening since then.
And what a surprise (NOT!) that THIS time, it isn’t the mengada-mengada, manjalitis Millennials who are saying these things. These things come from the professional opinion of our country’s National Audit Department! When they say it, they have credibilities. People started sharing the news (which is not exactly news) all over the social media, flooding my newsfeed with their own take and opinions on the news. But when the junior doctors say it…. well, we can brush them off as manja dan mengada-ngada, kan? (Okay, I better stop the direction in which my composition is currently heading. Haha. I have promised myself that I am done championing the issue of junior doctors. I am already a senior now and I have my own issues that I care about to fight for. But old habit dies hard, LOL! I have always believed that as a group, we are only as strong as the weakest link. And therefore, we must empower our junior doctors so that they can be as, ehem, great as us the seniors. But heck, the juniors can learn to fight their own issues especially if they believe they are right. I have my own stuff as a senior doctor that I am unsatisfied about! LOL.)
If you look at the comments section, you will notice some of the commentators saying something to the effect of “Dahlah memang tak cukup staff. Yang ada pun, bukan semua functioning! Ada yang bermasalah… asyik EL, MIA dan ada yang mempunyai masalah peribadi hutang dengan Along sampai Along mai cari kat tempat kerja and mengamuk kat sana. Exit policy buat perhiasan agaknya!” (Love your comment, there!)
Another LOVELY comment:
“Aku tak tau la susah mana sangat exit policy tu tapi yg aku tau ada ex-staff klinik aku ada kes polis pun masih kekal lagi kerja dekat PKD aku tapi dibayar gaji hari. Depa sanggup buat laporan berjela2 utk tatatertib and bayar gaji hari tapi tak sanggup nak buat laporan utk pecat org. depa punya “busy” tu macam tiap2 bulan ada kes pecat org“
Another comment which I personally LOVE :
“Bukan saja masalah tak cukup pekerja… tapi ada yg tak function. Ada yg kerja cincai, salai-balai, tak bersungguh buat kerja, lembap…. dan ada yg jahat terhadap pesakit!Kalau aku jadi org admin dah lama aku buang dan terminate org2 bermasalah mcm ni. Kalau nak kerja, buat cara nak kerja. Berdisiplin mai kerja, dress appropriately pakai uniform kerja, professional layan pesakit dan PAP! Jgn sampai benda basic routine pun nak kena ketuk every day and nak kena cakap byk2 kali. Org2 yg baloq liat macam ni memang tak layak kerja dgn KKM. Ramai lagi menunggu masuk kerja. Inilah waktunya yg paling sesuai untuk kita terminate pekerja2 lembab dan membebankan jabatan. Sebab berlungguk lagi menunggu nak dapat kerja!”
Soooo many of my friends had the same view as above! We REALLY vented out while sharing the news in the social media.(Seriously, we cannot stop millennial doctors using social media anymore! One day the millennials will become the leaders and saying things in social media will no longer be taboo! Instead, it will become the mainstream. Trust me… you can see the trend already.)
We are FED UP of the admin people not doing something concrete to these toxic, cancerous, pathetic excuse of a human being who are degrading the morale of the rest of our MOH staff by their despicable (sometimes criminal) behaviour! Not just to their own colleagues but sometimes even to the patients! (I won’t say much if you are bad to your colleagues. Kawan-kawan sekerja kau tu memang deserve your bad behaviour sebab depa tak pandai nak defend diri sendiri dan lawan kau balik sedangkan diorang mampu nak buat kalau diorang betul-betul nak! They deserve the headache of dealing with your problematic behaviour and your unnecessary EL/MIA/laziness if they do not have the spine and are TOO MUCH OF A COWARD to report against you. But if you are UNJUST to my vulnerable, defenceless, involuntarily warded patients, I will personally make it my life mission to deliver your punishment even if I have to charge you through the legal channel. I swear it! I have even warned my own staff that if I EVER see them using ‘ubat kampung’ on my patients, I will go after them myself! Because my patients are vulnerable and they are MY responsibility. I WILL GO AGAINST YOU if I see your unethical or criminal behaviour WITH MY OWN EYES. The responsibility is mine to report on you if I see your ‘ubat kampung’ with my own eyes! If I can’t get you through the admin channel, I will get you through the legal channel! I don’t care whether the charge will stick or not… but police report WILL be done against you if any form of punishment failed to be delivered using the hospital admin channel. Whether or not the charge will stick… is the job of the police and the DPP. But making the report is MY responsibility and MY prerogative and IT WILL BE DONE if the admin people fail to give a suitable reprimand and punishment against you.)
So the admin people, please listen to the plight and woes of your clinical colleagues. Please take action against the person who has had multiple, repetitive complaints being lodged against him. (one complaint may be due to personal issues! But if multiple behavioural issues with multiple complaints?? Takkan nak brush off lagi?) Because even if we may not say things in front of you, we will certainly vent in the social media by hiding behind the sharing of ‘current issues’. Hahah. And the public will come to know all about it.
One week ago, again my Facebook newsfeed was exploded by the scandalous news that a private psychiatrist had allegedly sexually harassed his own patient. To be fair, we need to know both sides of the story before we come to any sort of judgment.
But, I was disheartened by some of the comments that I read in Facebook regarding this case.
Even doctors had said something to the effect of “Psychiatrists pun sama macam pesakit depa.” And another one had said “Psychiatrists pun ada mental health issues,”(What? You think Cardiologist cannot get heart disease? Oncologists cannot get cancer? Wake up to the real world, genius!)
Have you guys heard of the term ‘courtesy stigma’, first defined by the sociologist Erving Goffman in 1963?
Courtesy stigma is basically ‘stigma by association’ in which the stigma is extended to the people who are close to the stigmatized group. For example, family members of mentally ill patients are often affected by courtesy stigma. “Kakak dia ada Schizophrenia. Tak payah lah kawan dengan dia.” or “Padanlah dia suka marah-marah. Ayah dia pun bipolar. Like father, like son.”(even if the person has an absolutely valid reason to be angry at you, you will somehow relate it to the person’s mentally ill family member.)
And courtesy stigma also affects psychiatry doctors. Trust me, we in psychiatry know this VERY WELL. Some of our own doctor-friends will say things like, “Psychiatrist boleh faham patient mental sebab depa pun mental.” and disguised their offensive sentence as a joke.
Well, I am having none of that! None of my friends will ever dare say things like that to me because I call out on it STAT! Right there and then I will challenge their statement and shred their reasoning to pieces. And they learn to behave well with me next time. See? I am a staunch believer and practitioner of behaviour modification. Your bad behaviour will be called out and punished stat! I don’t put up with crap. Welll… not for long, at least!
So, I wrote my own comment in the Facebook thread by saying:
When a prominent ortho surgeon was accused of multiple counts of sexual harrassment, we do not generalize all ortho surgeons “gatal” the lot of them.
Anyone can behave unethically and despicably. And we shouldn’t overgeneralize a group over any misdeed done by a few in that group.
Please don’t say nonsensical things like “psychiatrist are also like their patients” or that “some psychiatrist have mental health issues”.
A lot of doctors have mental health issues across all fields. Some have anger management issues as well, making life hell for their subordinates. Some were depressed while undergoing their master programs. We in psychiatry have seen all of them. We know mental health issues are prevalent in any field.
Some of the other doctors have spouses or children who are affected by mental health issues…. because their parents are only concerned about being good doctors rather than being a good parent/daughter/son/sister and they delegate the job of caring for their own family to others.
Anaesthetists also have a higher rate of suicide. What funny jokes can we crack about that? Access to lethal means of suicide is a known risk factor for anyone who is depressed. But depression or other mental health illness can happen to anyone.
Stop this stigmatization and overgeneralization. Cognitive errors are so unpalatable when they come from doctors who are supposed to have an enlightened mind.
I was gratified to see that many had liked my comment even though I wasn’t expecting them to. Having a lot of people read this comment of mine and liking it means that people understood and supported what I had written. So at that particular time, I have at least educated some people into not stigmatizing us. Small steps… but everything big starts with something small, right? I have done my part. I have spoken up. In some other place and some other time, another person will speak up over the same issue and do their own part in reducing courtesy stigma. Slowly and surely the stigma will be reduced by these collective small steps. In fact, it is already reducing! The number of junior doctors queuing up in the waiting list to become Psychiatry MO is quite high, these days!
In fact, I was informed by one of my readers that my blog is one of their point of reference when they are trying to research on psychiatry career pathways! So, if my blog has done nothing else, it has at least promoted the field of psychiatry to some junior doctors. The popular campaign by RCPSYCH to #ChoosePsychiatry is also gaining momentum in the other side of the world.
The number of junior doctors choosing to train in psychiatry is at an all-time high, according to the latest statistics.
New figures from Health Education England reveal a 92 per cent uptake in England, Scotland and Wales, with 446 of 483 available places taken by junior doctors wanting to specialise in mental health.
This compares with a 69 per cent fill rate in 2017, when only 337 accepted one of the 491 places on offer.
The dramatic increase follows the Royal College of Psychiatrists’ #ChoosePsychiatry campaign, which launched in 2017, and has worked to increase the number of junior doctors choosing psychiatry as their speciality.
The figures also reveal a significant improvement since 2018, when 480 junior doctors accepted one of the 613 places on offer – a 78 per cent fill rate.
Record levels of investment in mental health services by the government and the NHS has helped increased public awareness to unprecedented levels, making psychiatry a more attractive career path.
Dr Kate Lovett, dean of the Royal College of Psychiatrists, said: “Psychiatry is an incredibly rewarding career and these figures are exciting news for patients as well as the specialism.
“The College’s #ChoosePsychiatry campaign has helped drive this dramatic rise in junior doctors choosing psychiatry as their career path.
ETHICS & LEGALITY IN PSYCHIATRY
As psychiatry doctors, ethics is one of our core subjects and is supposed to be our strength and our specialty! It is REALLY sad if we are the ones who cannot practice it properly. When ethical issues involving psychiatrists appear in the social media, it is especially disillusioning and disappointing.
We used to think that doctors are generally kind, helpful and ethical. But these days, that impression can no longer be taken for granted. Remember the case of the prominent Ortho surgeon who had sexually harassed his housemen? We all had wondered regarding how his criminal behaviour could be ongoing for so long? Aren’t MOST DOCTORS ethical? So, why do MOST OF THEM become the ENABLERS of criminal behaviour? We started to wonder and cast blame when the shit hit the fan.
“Kenapa specialists lain pun tak bersuara?”
“Kenapa tak ada siapa buat police report?”
“Kenapa Pengarah Hospital tak buat apa-apa sedangkan dah banyak complaints?”
I am sure, AT THAT TIME, they would answer things like, “Nak ambil tindakan kena cukup bukti.” OR, “He is too powerful. Dah buat report police pun tak boleh nak buat apa.” OR “HOs sendiri and victims pun tak berani nak ke depan buat laporan kat dia. Budak-budak Master pun bawah dia juga… nanti depa takut tak pass master.”
They justified their inactions and silenced their conscience!
Suddenly, ONE FINE DAY, it took only ONE PERSON to decide to contact the mainstream media (THE STAR) to give her side of the story. Maybe she was thinking, “To the hell cukup bukti ka dak! Yang pasti, aku nak benda ni keluar juga!” Sebab once dah keluar, barulah siasatan akan berjalan untuk cukupkan bukti! Masalahnya bila benda dok hushed up tak keluar-keluar sampai ke sudah… sampai bila bukti nak cukup?
So things that used to be swept under the carpet (BERTAHUN-TAHUN berlalu tapi TAK PERNAH CUKUP BUKTI sebab tak pernah siapa pun teringin nak siasat habis-habisan dan ambil tindakan) tiba–tiba senang ja terbongkar dan siasatan boleh berjalan.
Bila keluar berita yang “pakar-pakar Orthopaedic di hospital tersebut akan dipindahkan” (mungkin sebab pakar-pakar tersebut dilihat seperti membenarkan dan membiarkan penganiyaan berlaku) tiba-tiba ada yang mahu complain pula! “Kenapa kami kena pindah? Sedangkan kami tak terlibat! Kami tak bersalah! Kami tak tau pun kejadian sexual harassment tu semua!”
Amazing! Orang di hospital lain pun boleh tau pasal your notorious HOD…. macam mana kau di hospital tu boleh tak tau? What wilful ignorance is this?
You deserve the punishment of being transferred out! When you are neutral and not taking sides in the face of oppression, you are actually a co-conspirator to the act! Your silence in a situation of injustice means you are siding with the side of the oppressor! To quote Finaz Yunus, (the host of Analisis in TV Al–Hijrah) we have to “BE TRUTHFUL! Not Neutral!” and this is ESPECIALLY important in the case of human rights!
So, in my opinion, you deserve to be punished (mobilized and transferred out of the hospital) if you had known what had happened and yet you had silenced your own conscience and let the heinous crime persist indefinitely!
So the take home message is: Bukti memang takkan cukup AT FIRST. Tapi, tugas siapa untuk cari bukti once orang dah complain? Tugas KITA lah! Tugas admin! Tugas polis! Tugas DPP!
Kalau admin malas buat kerja dan nak brush off complaints by saying things like “Ada cukup bukti tak? Dia ni dah counselling belum? Korang dah pernah minta explanation letter kat dia ke belum? Dah pernah bagi warning letter ke belum? Dah pernah pergi kursus-kursus untuk pekerja bermasalah ke belum? Bla bla bla..Dia ni dah lalui this procedure and that procedure ke? Kalau benda2 ni tak buat lagi, tak boleh ambil tindakan lagi!” Aduh! Sampai menyusahkan pula pakar-pakar yang dah lodge complaints…. and the problematic worker will continue his problematic behaviour till kingdom come! Well, orang lain mungkin akan give up or just internalize learned helplessness in dealing with problematic staff. Tapi kalau aku kat tempat orang yang complain, aku takkan diam! Orang yang setakat ada problem EL/MIA bolehlah nak suruh counselling ke and whatnots…. tapi kalau kesalahan menyalahi undang-undang dan ada kes polis dan sebagainya (like being accused of sexual harrassment/rape/assault)… aku akan laksanakan gantung kerja dulu sementara siasatan penuh dijalankan! Once you are cleared, you can come back to work! But this is a HEAVY accusation, and you should be suspended until you are cleared!
In psychiatry, every single thing we do from patient admission, to medication, chemical restraint, physical restraint and seclusion/isolation are governed by the Mental Health Act! We are bound by the law in our clinical practice.
But it is no secret that mentally ill patients are very vulnerable to being abused by our own staff or by the police officers who had made the arrest. Sometimes they are abused to their deaths as in the case of the article above. And this can happen anywhere, especially in the third world countries where patients’ rights are not that well-advocated.
It is our responsibility as a psychiatry doctor to make sure that our staffs are ethical and follow the law in how they handle our patients. Mentally ill patients have their own rights. If they cannot speak up for themselves, we must look out for them!
One of my friends had said that she had heard some talks of how “ada staff masuk cell dalam wad purposefully untuk pukul patient.” in one of the hospitals she used to work at. I won’t be at all surprised if some of our staff might have unnecessarily roughened up or abused our patients.
But, that is CRIMINAL BEHAVIOUR, okay! And if I see such a behaviour with my own eyes, I will give them hell!
I personally had sternly warned my own staff, “Kalau saya nampak siapa-siapa pukul pesakit tak pasal-pasal, saya akan report! Saya akan siasat! Saya akan ambil tindakan undang-undang kalau admin tak nak buat tindakan tatatertib dan orang lain tak nak buat apa-apa! Kalau pesakit unmanageable, inform saya. Kita boleh bagi ubat, atau sedation, boleh chemical restraint atau physical restraint. Tak perlu nak kasar dengan diorang pun! Tapi macam mana kita nak bagi sedation kalau korang tak report? Dan macam mana korang nak report kalau korang tak monitor patient betul-betul? So kalau patient buat perangai, jangan nak lepas geram kat diorang kalau korang yang tak buat kerja monitor patient. Kalau korang monitor betul-betul dan inform MOs betul-betul, dah lama doctors bagi intervention tanpa perlu nak kasar-kasar! Kalau pesakit aggressive sekali pun, pergi mana breakaway technique yang dah belajar tu? Pesakit aggressive sebab dia sakit. Yang kita tak sakit ni, apa alasan kita nak aggressive?”
I make myself clear and my stand is rock-solid, unshakeable! If things happen behind my back, I might not be able to punish you because I do not know about it. But if I, myself, is a witness to your criminal behaviour against my patient, I will go all out to make sure you get your just dessert by the admin. And if the admin brushes off my concerns, I will use a legal channel to punish you! I will do it because I have the freedom and the means to do it! And most importantly, I have the WILLPOWER to do it!
Some people think that, it is necessary to hush things up untuk ‘jaga nama hospital’. Silap besar! What happened to Hospital Sungai Buloh once the conduct of the notorious Ortho surgeon became well-known, huh?!
The truth has a way of coming out! Instead of being known as “the admin who had done nothing when multiple complaints had been lodged”, be the admin who had done something worthy of your position by lodging your own complaints against him to the DG and MMC! Say to the DG and MMC “I have concerns about this specialist. I receive reports from HOs that he has been sexually harrassing them.” You MUST do your part. The outcome of your complaint is a secondary consideration! But you must do your part, first!
My principle is clear: I don’t owe my loyalty or my allegiance to any department, hospital or ministry. I owe my loyalty and my allegiance to the truth only. I owe my obedience to God, religion and my own personal principles, FIRST! Anything else is always secondary! Kalau kau salah, kau salah! My report against you had nothing to do with where I work at! I want my department and my hospital to be known as “jabatan/hospital yang akan jaga etika terhadap pesakit dan sanggup report staff sendiri kalau staff memang salah” rather than being known for lack of ethics or under the carpet dirt-sweeper! Because I believe that IN THE END, the truth will come out someday, somehow, someway… because the sunnahtullah is like that! And my lacking in action today will be the shame of me one day. I am accountable for what I see, what I hear and what I do about it. Even if the outcome might not be what I want and the perpetrator might go free, I have done what I should in my own capacity within my own limitations and that’s all that matters!
THE LEGAL CHANNEL IS ALWAYS THE RIGHT CHANNEL
We always tell our staffs not to use the social media and we encourage them to complain using the right channel (which is usually incompetent and slow and broken). Kalau admin tak buat tindakan sepatutnya through the right channel, then we should go through the legal channel! (The legal channel is ALWAYS the right channel, anyway). Imagine what will happen once the legal channel is taken? Well, of course media akan hidu and things will become viral anyway. So remember, the legal channel is always an option! It is YOUR RIGHTS as a Malaysian citizen. And your job does not bind you from taking legal actions against anyone who had broken the law. The hospital admin CANNOT punish you for taking a legal action when they themselves fail to deliver a fair outcome out of your complaints.
And the bonus is, the legal channel can also be the viral channel. Imagine the headlines, “Houseman lodged a police report against nightmare specialist” Haha!
Remember this incident, guys? It was only last year! The HO took a legal channel (which is always the right channel, as a Malaysian citizen) and the issue became viral!
So, my recommendation to any victim of injustice is this: It’s okay if you cannot use the social media since it is not allowed for you to do it. If you are asked to use the right channel, go ahead and use it as your first line action. But if your admin FAILS to give you justice, you must go through the legal channel. And trust me, the legal channel will be the viral channel, anyway! Because the media will pick it up! So, yup… you get what you want at last!
Unfortunately, most people will not want to go through the hassle of taking any legal action, especially if the criminal behaviour is directed towards others rather than themselves. Well luckily, I am not most people. Once I am angry enough, I will fight to the end. If my warning is not heeded by my staff, I will strike on my own if the admin is too slow in doing their job. I will take a legal action. I am not used to learned helplessness and I will never make myself get used to it when it comes to dealing with dysfunctional staff with criminal-like behaviour.
Before I end this post, I want to ask my dear readers to ponder the concept of justice and redha. Because trust me, even so-called religious people get confused at times!
My dear readers,
In our daily interactions with others in the society, the standard that is outlined by Allah for us is JUSTICE! That’s why in Islam we have judges and the justice system (Syariah: Hudud, Kisas, Takzir etc). It is not the place of ANYONE to tell you “Redha sajalah anak you kena bunuh. Kalau you marah pun, bukan boleh dapat balik anak you. Tak payah nak siasat, panjang-panjang cerita! Maafkan saja pembunuh tu. Redha kan dapat pahala! Redha kan Islamik.”
NO! NO! NO!
Instead, in our daily interaction with OTHERS – with our fellow human beings – we must always be mindful of justice because that is THE STANDARD that Allah had DEMANDED of us! You should instead say, “Allah had enjoined us to be just! Allah will punish us for failing to do justice! It is our responsibility to see it delivered no matter what!”
However, in our relationship with Allah, the STANDARD is redha! You should not question Allah, “Why are You not fair to me? Why do You let my son be murdered! Is this fair of You to allow him to be killed when my son is a religious Muslim and a good person?”
No! No! No!
Instead, in our relationship with Allah, we must always be mindful of redha! “Ya Allah, apa saja yang terjadi, aku redha! I submit to your wisdom.”
Redha and justice are NOT contradictory concept! You can be “redha anak dah tak ada kena bunuh” even as you demand that justice be done for your murdered son. Your demand for the justice system to deliver justice for you has NOTHING to do with how redha you are with what God has fated for you.
Justice is your standard with fellow human beings and with the administrative system in this dunya! Redha is your standard in your personal relationship with Allah! They are two separate (but related) concepts!
(Not delivering justice is BELOW standard. Demanding justice is THE STANDARD… and it is THE MINIMUM STANDARD expected of us by God. Choosing to forgive your oppressor is ABOVE standard. But you cannot make any inference regarding level of redha, faham tak? You might choose to forgive your oppressor, but deep inside, you are still NOT redha about what Allah has fated for you! Yes… that can happen, ok? You can trick other non-educated civilians into forgiving crime by manipulating the concept of Redha while ignoring the concept of Justice, but you cannot trick me! Because when I tak puas hati, I read up! I know my stuff! Manipulate me at your own peril.)
Please be clear about this. And try to lead your life according to THE STANDARD (of Justice and Redha). Even as you may not do it perfectly hundred percent of the time. At least, TRY!
Until next time, my dear readers! Much love and may Allah bless all of us.
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 changethe 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 maketheir 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 haveto. 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 andyour 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!
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 isthis: 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.
“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 controltheir 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.
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.
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.
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 caseyou 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.
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 andtheir 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.
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 theirCBT/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 tothe 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 ontime.” 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 andsolve 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.
Last month, I had reada biography of The Legendary Muhammad Ali written by Alan Goldsteinand 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 andfame, 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!
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 Guidelinesand 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.
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,”
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 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!”
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.
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 onthe 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!
Muhammad Ali’s name on the wall of the Walk of Fame.
The name of the rest of the other celebrities were placed on the ground.
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.
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!
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 inthe 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.
I reiterate that I am not bashing the master system. Ithink 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!
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.
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.
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?”
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!!)
Ifthey 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!)
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.)
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.
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.
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.
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.
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 areader can experienceis 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!