This week went by especially quickly; unfortunately it was only a week, as it was a thoroughly stimulating one at hospital on medical oncology. Despite my little-boy-like desire to fiddle with my hands and perform procedures, medical oncology was a very thought-provoking and meaningful experience. In the sense of listening to patients, getting an idea of their issues and concerns, and feeling how they would change through the course of their illness is really fascinating. The humans’ ability to hope; cope with stress, emotions, the pondering of life, reasons behind it and more. I feel, there may be more like this to come with palliative medicine, which I look forward to. Not to see the suffering, but to see the steps taken towards hope and reconciliation with whatever they had to do before the end of life. It’s impressive and really elating.

Indeed, every individual will take a different amount of time, have a different approach to coping with a terminal illness – it appears to be more so if the patient is under the age of 60. Also, new cancer diagnosis after presentation with what appeared to them to be minor symptoms, tend to hit the hardest. We are told the emotional responses include, shock, disbelief, fear, anxiety, guilt, sadness, grief, anger, and more – as described on That is a lot at once. And for me at this stage unimaginable. For grief, there is a Kübler-Ross model (it includes some of the other emotional responses as a part of grief) that comes in five stages: denial, anger, bargaining, depression, and acceptance. It may be a useful tool when it comes down to understanding what patients are going through, but as we already know, each patient is an individual and will expereince things differently, nevertheless these studies are useful for the teaching of how to deal with a certain situation – despite it only being a small degree. There are various other theoretical models, each of which with their own limitations. What can we as clinicians do about them? I suppose a baseline understanding of each of these theories is the start, remembering to take a thorough history from the patient would be important as well, so as to know their individual stance and point of view. When discussing the prognosis with a patient, be PREPARED – in the literal sense of the word and also as an acronym properly put together in a journal article in the MJA.1 P: prepare for the discussion, R: relate to the person, E: elicit patient and caregiver preferences, P: provide information, A: acknowledge emotions and concerns, R: realistic hope (to be fostered), E: encourage questions, D: document. Being prepared goes hand in hand with knowing how to best make the patient feel comfortable, and besides carrying out oneself professionally, discussing what is generally important to most people and tackling what is identified as the main issue for the patient is also very important.2 We often pride ourselves in thinking we know what is best (in every sense of the word), I think it happens far too frequently when doctors overstep their roles as healthcare providers to sometimes forcing their opinions down the throats of their patients (for the lack of a nicer way to put it), I suppose returning to my previous reflection, remembering that human interaction between humans, would be one way to keep things natural and sincerely – hopefully.

To ask a why question about death and dying could take this reflection down a much longer path, that I, myself have not completely explored clearly, and opens a whole other can of worms. I hope will be discussed in coming journals, maybe along with my palliative care week.

Essentially my main reflection on this week was what can we do better as clinicians who work with sick and dying patients… It may be more evident in oncology, but it also cannot be denied that all of us, will eventually die. And death does not have to be something we fear, maybe even something we strive toward (or prepare for). I suppose being open minded and having a big heart would be a start, especially as clinicians, the patients come to us at their most vulnerable, and the immense amount of trust they place in our hands, the very least we can do, is to respect that and acknowledge the deep privilege it is to have that relationship with them; to be with them at that critical point in life. That is just the beginning.


  1. Clayton JM, Hancock KM, Butow PN, et al. Clinical practice guidelines for communicating prognosis and end-of-life issues with adults in the advanced stages of a life-limiting illness, and their caregivers. Med J Aust. 2007; 186: S77, S9, S83-108.
  2. Schofield PE, Butow PN, Thompson JF, Tattersall MHN, Beeney LJ and Dunn SM. Psychological responses of patients receiving a diagnosis of cancer. Annals of Oncology. 2003; 14: 48-56.


“Sarabeth is scared to death… to hear what the doctor will say…”

Recently, I was obliged to produce written/typed reflections of each passing week, and I found it to be a rather positive experience. I have decided to share my thoughts online – and hopefully this will resume on a monthly basis.

Plack’s article and community research.

Reading Plack’s article was a good opportunity to discover what is needed in order to get this journal writing underway. In and of itself, it put forward some very interesting points – about reflection and the perception of facts rather than the facts themselves. Plack put forward certain mechanisms that can be followed when it comes to reflecting, and writing questions, in hopes that all these experiences are not wasted as we let bygones be bygones. I consider myself to be reflective, since high school I used to question and ponder the reasons as to why we learn what we are learning, is it of any importance to the life we live, how do we know what we are taught is true – is it even true for its time in this ever evolving world that we reside in. Nevertheless, Plack’s proposal of reflecting for the sake of experiential growth in the clinical setting, for progress of medical education was definitely a valuable read. It can already be identified that there are many many views on reflection, and not only those limited few as mentioned in the article, it is, as it appears to be, a cycle of reflecting and acting, maybe until consciousness is lost.

As to be expected of an educational endeavour, I will do my best to keep in line with the goal of Personal & Professional Development (PPD), and try not to delve too deeply into the unnecessary. I apologise in advance if I do slip up.

From all this, I am curious, I think I have a tendency to be a content dependent reflector – and is that an adequate way of reflecting, now knowing that there is a time dependent form and Bloom’s taxonomy, which I think sounds fantastic if it can be naturally be put into practice. I think it will be difficult to change, but it may be possible if strived for enough. Will it be a problem I suppose being more likely to reflect on a situation in such a structured manner? Just a thought that will probably need further study and investigation.

As for an actual reflection on the week. I am currently on my community research rotation, starting medical oncology next week. I found myself taking on the role of ‘researcher’ seriously, I think I was able to come across as professional and genuine in my approach to subjects / potential volunteers, that being said, (possibly a struggle many professions face) is that putting on the role of a profession had easily covered up my ‘true-er’ being, which is human. I think this became most apparent when two members of the community had declined to participate in the simple questionnaire that had the potential to improve the standard of care for their children. Immediately negative thoughts and judgements were rushing into my head, I am quite ashamed to admit. What was the problem with reacting that way, how can I prevent situations like that from arising again, and why had I reacted that way. Also, what reason would the person have for refusing this survey, and if it was even a valid question to be asking – had I come across in a negative manner? On hindsight, I think it is inevitable that not everyone will be able to fully comprehend or even understand what the survey is about regardless of how informative a sheet they receive or how much it was explained over such a short period of time. It may even be that they do comprehend it and simply chose not to – not necessarily out of malice, but simply out of having a private life, which they would like to have remain in such a manner. On my part, I think realising that we are human first in all that we do, it is much easier to understand that when you say ‘no’, you would simply want it to be taken as such. So life goes on, but with applying this to medical practice, I think even as a medical student, and with all the scientific curiosities, it is easy to forget that we are human first and caring for other humans, not just an interesting specimen.

Given that a basic medical degree is generally a five year stint, hopefully, after these five years i will still remember what i was singing five years before then – and remember the love we had for our fellow humans when we first chose to be in the medical field.

Plack MM and Greenberg L. The reflective practitioner: reaching for excellence in practice. Pediatrics. 2005; 116: 1546-52.


Dharmaraj Karthikesan's Blog

I met a young doctor who used to work under me recently. I had just completed my night rounds in the hospital and I was leaving for home.

And then I saw him. He was unkempt, exhausted and appeared famished. Worst of all, he looked like a man who has totally given up on being a doctor. He appeared hesitant when I asked him what was wrong,but I could not just leave him there.

After much persuasion and insistence on my part he agreed to join me for a late supper. While he ravaged through his first proper meal of the day, he finally opened up. He has started working for the past week in a new speciality. Though the hours are longer, it was not an issue. He was well aware of the sacrifices he was expected to make.

However, the degradation, humiliation and constant harassment have finally taken…

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Realistically racist

It took me at least 20 years to realise I was a racist. Or at least to realise the extent of my racism, in the past it was always running under the guise of what was culturally accepted or lawful – almost. If anyone was racist, it was against me.

16 years in the country I identify with as home – maybe even a part of the racial majority, I pretty much grew up thinking racism was not a big deal. Even when I was a racial minority after moving out from home – racism was only a big deal when it was against me – never realising how racist I was myself for assuming that every racial slur or mistreatment I received was simply because I obviously did not belong. Only upon returning home – well, to the country I called home, and to find myself assimilating the mindset of the locals – to which anyone who didn’t look like they belong was an alien. Despite all that travelling and cultural exchanges, I never really gave it much thought.

Racism in Australia as indicated in the article is something I truly myself must admit I know nothing about. I have tried to understand, and have asked countless questions, some of which produce a textbook historical indifferent answer, some anger – saying it is now ‘white discrimination’ because of indigenous ‘perks’, and varying degrees of ignorance. I must admit, history is not my forté and I can quite literally say I know nothing, even much of which I was forced to learn in school has since been put out of my mind. (maybe another day I will write something about being force-fed information – it does not seem to work in the long run). Kinda reminds me of a song… (linked)

Keeping on track, the article ( by Charlie Pickering is a gentle reminder that even towards the end of 2013, our beloved citizens of Australia, at least those he talked to, are oblivious to the massive issues we face with racism. White or non-white. Orientals are pretty damn racist themselves if you want to add them to the equation and you have the Sub-continentals who may or may not essentially hate themselves if they have the chance to all come together. And so-on-and-so-forth…

I think ‘this’ discord amongst humans could go on forever.

The thing that really struck me about the article was the Pickering’s statement: “I know that attitudes of white racial superiority weren’t just attitudes, they were structural planks of our legal framework. Prejudice wasn’t just a kind of bigoted ignorance, it was the law.”

Maybe I just did not quite think about it along those lines before, but it is so true.

In medical ethics we are constantly debating what purpose the law serves it if neither protects the innocent nor brings the guilty to justice – it simply presents the most convincing party as the champion of social integrity. Essentially if we allow ourselves to be fooled, we will be able to believe that we are indeed deserving. And that all but sounded too familiar. What do we deserve in this life?

Do we truly believe that we deserve to be greater than the aboriginals? Do we think that because our mighty ancestors have brought wealth to Australia we deserve to rule her first people?

Where is all this wealth from anyway? Can we be worth more as human beings because of our heritage?

Apparently we can. (for now.)

If can assume I to know anything…

So listening to The Killers – Human

I was thinking about asylum seekers and refugees in Australia… and the moderately new operation sovereign borders (link intended) and also how these changes have come about:

In the wake of the sad state of humanity, we actually do see acts of sympathy, and maybe even empathy, with the recent bush fires around Australia. For those who have lost their homes to the flames, and struggle once again to rebuild their lives, I feel your pain. But do we all? Australia suffers when their citizens suffer, we share their pain in having to start over from practically nothing.

Do asylum seekers and refugees not have to endure the same pain? Did they not leave their homes to be raided or sacked by civil war and unrest? Do they not suffer the same way people who have lost their homes to the fire suffer? If not more…?

Does Australia care?

Recalling the song: “are we human…?”

or are we dancer… dancing…

being comfortable with our lives and moving on… without a worry…?

Onto the second day of the week, in my second year, second semester of medicine, and I figured, this blog needs a post. This will be the second post, if you count the relatively useless “Welcome to” one.

Procrastinating lots over work is a pretty bad idea, but I figured this is a good opportunity for me to work on my flow of language. Reading lots of random articles on the internet has been a good way to waste the day almost, or a not so good way, rather…

Here goes, so healthcare is finding it necessary to implement “aviation-styled” check-lists to reduce the number of holes in their “swiss-cheese” through which patients slip through these cracks of doom, and eventually end up either worse than they first came in, or dead — either of which is a very much unwanted outcome (hopefully! considering this is healthcare). So what we ideally have in mind is to heal the world. Pity he had to go down that way…

Working on a template myself as a researcher on how to improve patient outcomes in oncology, it has actually occurred to me how massive this is. Although moderately straightforward enough for it to be entrusted to a student.

Running out of fuel here. Shall go and study more public health before I comment. Maybe I should also make a tiny complaint about Zimmerman, considering people are still pro-garden-testing his acquittal – i mean come on! He shot someone dead! Whether he meant to or not, when do you give the law to the citizen and say, do whatever you want? It is not someone’s right to impose on another’s right, is it? Let me know.

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