The Pulse 2017

A PUBLICATION OF THE T&T MEDICAL STUDENTS’ ASSOCIATION (Nov 2017)

Student Life

Beyond Office Hours

Mental Health

Father & Son

& much more!!

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THE PULSE What’s Inside?

T&T Medical Students’ Association

Dean’s message

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Greetings from the President

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A message from the TTMA president

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Cimone Ramcharan

A message from the Editor

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Patrick Edward Chin-Kong

On reading and medical school

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Sneha Rao

An appointment with the psychiatrist

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Mateus Fernandes

Clinical rotations

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Father & Son & Alzheimer’s

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Planting seeds

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Beyond office hours

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CONTACT US

A roller coaster ride

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Email: ttmsapulse@gmail.com

Robotic surgery

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The Doctor-doctor relationship

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Oath taking — MBBS Class of 2017

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THE PULSE TEAM Taureef Mohammed (Editor) Nicole Maharaj

Sherry Ann Padarath Keeron Tull Hugh Jacob

Tel: 769-1865/742-7534 Facebook: Trinidad & Tobago Medical Students’ Association

MBBS Class of 2017

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EMBRACE THE

FUTURE I would like to commend the president Class of 2019 (and of course Taureef for not giving up on me!) for leading her team once again successfully toward yet another enlightening publication. It is good to see personal experiences of students as they pursue medicine—this will give courage to others for the future. But it is exactly the future that I want to address today.

We recently had a symposium entitled “Nanomedicine—A glimpse into the future of medicine. An exploration of the purpose, potential & passion for nanomedicine in the Caribbean context.” This symposium was important for two reasons. Firstly the Faculty of Medical Sciences, UWI, St Augustine (FMS) does not have an established leadership in this area and secondly FMS assembled a faculty of leaders in the field from universities with outstanding leadership in this field including the famous Harvard University, Johns Hopkins and Oklahoma universities. In so doing FMS gave access to the latest information in this field to the wider community and its student and staff.

More importantly, the symposium was about the future...but in an odd way also about the past. You see 1996 was an important year for nanomedicine for two reasons. Firstly it was seven years after 1989 (The first mention of nanites in Star Trek!) but it was also the year that Richard E. Smalley received his Nobel Prize in Chemistry. Smalley is known

to have made a famous statement and a prediction for the future: "Human health has always been determined on the nanometer scale; this is where the structure and properties of the machines of life work in every one of the cells in every living thing. The practical impact of nanoscience on human health will be huge." He went on to

“The practical impact of nanoscience on human health will be huge."

— Richard E Smalley found The Rice University Center for Nanoscale Science and Technology (CNST) which was renamed after his death in 2005, "The Richard E. Smalley Institute for Nanoscale Science and Technology".

I am confident in assuring you, my future colleagues, that nanomedicine is going to be the key science of the 21st century. Although the production and use of nano-sized particles have taken place in several different ways in the past, nanomedicine emerged as a modern interdisciplinary science only in the last decade of the twentieth century. Nanomedicine has applications in diagnosis and treatment of many diseases especially cancer but regenerative medicine is now emerging as the most exciting area for application of nanomedicine—in fact it

PROFESSOR TERENCE SEEMUNGAL would be true to say that it is revolutionising regenerative medicine.

I want to encourage each and every one of you to remember this as you move forward in your career and to seek to gain entry into this field where ever possible.

Terence Seemungal Professor of Medicine and Dean, FMS

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GREETINGS FROM THE PRESIDENT

Greetings students! Welcome to another academic year. I especially want to welcome the newest addition to our family, the Class of 2022! Congratulations, you have worked hard and you have been accepted into the prestigious Faculty of Medical Sciences. Of course, medical school is not easy but we are all here to help you and guide you.

The T&T Medical Students Association (TTMSA) is a representative body for medical students. We are a non-governmental organisation based at the Faculty of Medical Sciences, UWI. It is a completely student-run organisation that is actively involved in medical education and service initiatives in communities across T&T, as well as coordinating extra and cocurricular events for medical students.

We are so excited to have you join the family! However, our activities are never limited to any specific school or class year group so we welcome participation from all students. I encourage you to work hard but leave time for extra activities as well. There are many groups at Mt. Hope that provide something for everyone. These extra activities have numerous benefits including keeping us healthy (socially, mentally, physically, spiritually and emotionally). The TTMSA offers many avenues for participation. This year, the Guild of Students, St Augustine, introduced exciting news with regard to participation in school activities—it can now be added to your transcript!

In terms of advice to the new students: I urge you to push past your limits. You all did well in high school, but the reality is that everyone else in

“Your character is what will set you apart from the rest.” this faculty did too! It can be very easy to fall behind if you procrastinate (take it from me). Don’t do it! Do your best to learn the work well so that you can be great clinical students and excellent physicians. I can assure you that the TTMSA family and faculty members are here for you every step of the way.

Make the most of all your classes, labs and skills sessions. They are all there to help you grasp concepts in a practical way. Overall, I humbly beseech you to be compassionate, empathetic and respectful students—practice makes permanent. Your character is what will set you apart from the rest.

Our duty is to our patients; it’s not one to take lightly.

Furthermore, we have recently become involved with organisations that will help propel your clinical thinking and give you opportunities that previous medical students didn’t have! Over the school break, TTMSA was accepted into the International Federation of Medical Students’ Association (IFMSA) and we have joined the Caribbean Chapter of the American College of Physicians (ACP) by forming our own Internal Medicine Interest Group (IMIG). IFMSA has six standing committees: Public Health; Sexual and Reproductive Health including HIV/AIDS; Medical Education; Human Rights & Peace; Professional Exchanges and Research Exchanges.

Each subcommittee will be planning exciting ventures throughout the academic year.

For our IMIG, our activities will be geared towards preparing you for the clinical years as early as you start medical school. We want you to be better than we were and provide you with resources that will continually help you to succeed.

I want to remind you that you are blessed, lucky and privileged to be attending medical school. It is a far cry for many and you have been given this great opportunity; do your best to honour it.

I pray that God blesses you in this new journey.

Meagan Mohammed President TTMSA

TTMSA EXECUTIVE 2016-2017 President: Meagan Mohammed, Vice President: Jonathan Edwards, Treasurer: Adabelle Romany, Secretary: Alyssa Singh, Assistant Secretary: Marika Seenath, PRO: Naomi Scott, and respective year representatives.

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What an interesting year it has been, since my last missive to this newsletter. We’ve celebrated our 55th year of independence as a country; we beat the USA in football (ok still didn’t allow us to qualify for World Cup, but beating them felt goood) and the WI cricket team won the first test against England in ages.

We have seen two hurricanes blow past our beloved twin isles to wreak havoc on our regional sister isles, while the rains before and after caused mass flooding in the east and south of our islands. The Faculty of Medical Sciences, UWI, hosted the first nanomedicine conference, and we’re beginning the discussion about antimicrobial resistance locally—bodes well for the future of CMEs, and the focus of the Ministry seems to be veering back to basics: primary care and NCDs. It’s also been an interesting time to be a doctor in T&T, for the first time in our country’s history, an intern was fired by the Ministry of Health for purportedly lying. But on closer inspection, the issue was darker than what was represented in the media—the intern lied because of the pressure of being bullied consistently by a senior member of the team. You see, medical professionalism is not something we can take for granted—professional bullying and sexual harassment in the workplace is very, very real. The 2017 WMA Hippocratic Oath (which I urge you all to read) reflects the changes within the fraternity, seen internationally, with reference to the relationships between physicians and patients; teachers, colleagues and students; and the requirement for physicians “to attend to their own health and wellbeing and

DR STACEY CHAMELY

“Diversify who you are as a person, and do not just be defined as a doctor.” abilities” to be able to provide the best that we can for those in our care.

The rate of national unemployment is rising, and doctors, like other public servants, have, again for the first time, found themselves in the unenviable position of not having their contracts renewed resulting in over 150 of our house officers not having jobs in the public sector. Over 70 interns had to have a deferred start to their internship because there weren’t places for them to train and no budget appropriated for their service. Some of these HOs have been offered hospital locum positions in the interim, and the interns have all been accommodated—but we

know that for the next five years at least while the attrition rates in UWI remain unchanged, this trend is going to continue.

So what does this mean for you as medical students? Should you be concerned? University days are meant to be the best of your lives. Five years where you work hard and play hard as well. Some of the friends you make during your time at Mt. Hope, you will have for life, and those are the people who you will work with for a large part of your career—they become your ‘work family’ and will directly impact on your happiness and work life balance. Having a job when you graduate wasn’t something you actively had to be concerned with...until now!

So while your future as a member of this proud medical fraternity is bright, you as medical students must not be complacent. Whether you continue at the UWI and work locally or have to leave to work and do your post -graduate training abroad, study...study hard, and do well in exams and your rotations. Consider from now, how to ensure you have a robust curriculum vitae which includes research, publications and philanthropy. Get involved – UWI Blood, TTMSA, MEDS, Art Society, Rotaract Mt Hope, IVCF, and Concerts for Charity (I could go on).

Diversify who you are as a person, and do not just be defined as a doctor. Doctors may not think that they are all born leaders, but all doctors have a duty to be leaders.

Stacey Chamely T&TMA President 2016 - 2018

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Forget everything else, including the grade. As university students our purpose ought to be bigger than a letter. As Dr. Farid Youssef points out, university is about discovering yourself, your identity, your passions, your strengths and weaknesses, your purpose, your story.

In writing your medical school story—which The Pulse is really fascinated about, by the way—the most important question is, do you really love medicine? Not like, but love.

There are only three possible endings to your story: either you will love medicine, you will love something else, or you will be unsure about what you love—whether the story takes five years, five years and six months, six years is irrelevant.

Some people, like Prof S Teelucksingh, were born with an innate love for medicine. “It was medicine or nothing,” he said in a 2012 interview with The Pulse. However, as a medical student, shell-shocked by the volume of work, Prof doubted himself. That he loved medicine was a consolation, and, I guess, the fact he attended Presentation College.

Others, like the late Michael Crichton, author of Jurassic Park and creator of the popular TV series ER, found their calling elsewhere and happily jumped off the I-want-to-helphumanity train. A graduate of Harvard medical school, Crichton never practised medicine, choosing instead to

pursue a passion in writing and filmmaking.

The last ending—being unsure about what you love—is tough. The best advice comes from Open, the autobiography of eight-time Grand Slam champion Andre Agassi. Agassi hated tennis but it was all he knew; he had no choice but to be good at it. Although he was a rebel on the court with his denim shorts, mullet, and hot mouth, he consistently strove for excellence. Eventually he figured himself out, married fellow tennis star Steffi Graf, and with the money he made from his albatross opened the Andre Agassi College Preparatory Academy in Las Vegas for at-risk children.

The point is all three endings have the potential to be happy endings—it is what you make of it. So be true to yourself and remember VS Naipaul’s words: “The only lies for which we are truly punished are those that we tell ourselves.”

So I ask again: do you really love medicine?

Best wishes, Taureef Mohammed Editor (2013-2017)

“There are only three possible endings to your story: either you will love medicine, you will love something else, or you will be unsure about what you love.”

Do you have an opinion on anything related to medical school? We would like to know. Write a letter to the editor and send it via e-mail to: ttmsapulse@gmail.com

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rom Clinically Oriented Anatomy in first year, to the Oxford Handbook of Clinical Medicine in the fourthyear Internal Medicine clerkship, every medical student can safely say, “I read.” But on starting medical school it begs the question, how many non- medical books have you read? My answer is best expressed in the words of C.S Lewis: “You can never get a cup of tea large enough or a book long enough to suit me”—my only amendment being, once it is not medically related.

As a fourth-year medical student, it is challenging to balance time between studying and getting in leisure activities. While perusing the mechanisms of action of drugs or reading on small bowel obstruction for the umpteenth time can be interesting, it can also prove frustrating.

Dropping it all for a few minutes with a favourite novel or an ingenious plot is a welcomed form of relaxation away from the foreboding of interminable exams and OSCEs. Reading has always been a hobby and stress reliever that gives me an opportunity to expand my mind beyond medicine. I have always

believed that while the role of medical student takes up the majority of one’s time, there are other areas in life other than academia, and these should be nurtured and indulged as well. Books have allowed me to be engrossed in themes and perspectives relevant to modern day society, widening my understanding of the world outside of medicine and expanding my way of thinking.

“Books have allowed me to be engrossed in themes and perspectives relevant to modern day society, widening my understanding of the world outside of medicine and expanding my way of thinking.”

One such book is Khaled Hosseini’s A Thousand Splendid Suns which, though fictional, highlighted the themes of femininity, poverty and the uncertain vision for a war-torn country— very contemporary issues. Other favourites

include Life of Pi by Yann Martel, Outliers by Malcolm Gladwell and Paulo Coelho’s The Alchemist. The general theme of all surrounded personal growth through adversity, and the belief that your work will render fruitful if you are consistent. Such themes strike a chord with the frustrated, tired student mere weeks before an exam—that is currently every medical student. These books have motivated me on days when I can no longer keep up, and a few minutes rereading my favourite excerpts—one example, from The Alchemist, “The secret of life, though, is to fall seven times and to get up eight times,” —give me that instant reminder and the fuel I need to press on. On less intense days, however, newly bought releases and even classics such as The Lord of the Rings and The Adventures of Sherlock Holmes make for an enjoyable trip down memory lane, a light and familiar read, revisiting the tales I so loved as a young selfacclaimed bookworm.

So here is to the hobby that keeps me sane in a fast-paced programme—the stress reliever, mental stimulator and motivator that allows me to live innumerable lives through a myriad of pages.

Hopefully, it can give to you the enjoyment and the motivation it has given me.

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Crime and Punishment (1866) by Fyodor Dostoyevsky: “It is about a university student who kills a pawn broker, who made money off desperate students in financial trouble, but then felt guilty and became depressed. Behaviour always has consequences.”

— Prof Gerard Hutchinson

My Sister’s Keeper (2003)

by Jodi Picoult: “Gifted to me by my English teacher Ms. N. Hosein, the book explores the moral conflict 13-year-old Anna Fitzgerald faces as she contests her parents for medical emancipation. She was conceived via IVF to be a compatible donor to her sister, Kate, who had leukaemia. The fictional story is intriguing as it explores themes including the price of medical advancement, how one copes with having a child diagnosed with cancer and the impact of illness on the family.”

—Sherry Ann Padarath

The Kite Runner (2003) by Khaled Hosseini: “The Kite Runner tells the heart wrenching tale of an unlikely friendship between two boys. One, the son of a wealthy merchant, the other the son of a servant. It explores how kinship and friendship deeply influenced the life of the favoured protagonist and how the guilt of one event led to the premature end of his friendship with his servant.

However, as the protagonist silently struggles with the guilt of his betrayal for years, he is finally faced with an opportunity for true redemption.” —Fazida Khan

Jonathan Livingston Seagull (1970) by Richard Bach: “One of my favourite books, it is an allegorical tale about a seagull learning about life and flight and speaks to self-perfection. It shows that there is more to living than meets the eye. He followed his heart, made his own rules and had the pleasure of doing some things well by flying higher and faster than he ever dreamt.”

—Prof Zulaika Ali

The Citadel (1937) by AJ Cronin: “Dr Premchand Ratan recommended this book to me.

It is the story of a doctor seeking contentment. After a series of fortunate and unfortunate events he finds contentment in doing what he loves day after day, having sound ethical values, and appreciating his friends—not in the highfalutin way of life that some people wrongly associate with being a doctor.”

—Taureef Mohammed

The Alchemist (1988) by Paul Coelho: “This book is different every time you read it. I’ve read it seven times after stumbling upon it in a beach house in Tobago. I find myself reaching for this novel when I feel lost in life and each time, I take something new and inspirational away.

The book takes us on a journey with a shepherd as he discovers his personal legend and somewhere along you just may figure out yours.”

—Cimone Ramcharan

Long Walk to Freedom (1994)

by Nelson Mandela: “Long Walk to Freedom chronicles Nelson Mandela's life from a boy in rural South Africa through his years in prison and his eventual release. The reason I recommend the book is rather than simply focusing on the posture of Mandela we all see at the end of the journey the book chronicles his process of personal transformation. Mandela journeys from an advocate of force to achieve institutional change to eventually recognising the importance of personal responsibility, forgiveness and national healing.”

— Dr Farid Youssef

When Breath Becomes Air (2016) by Paul Kalanithi: “The book is the riveting autobiographical tale of a neurosurgery resident who develops terminal cancer just as he is about to finally graduate. He gives his perspective on life while facing death and his experiences as a physician turned patient.”

—Nicole Maharaj

The Autobiography of Malcolm X (1965) by Malcolm X with Alex Haley: “I ended up reading this book after noticing that it was on the recommended reading lists of several people I look up to. It tells the story of the famous American civil rights activist’s life from early childhood straight up to a few weeks before his assassination in 1965. Though our own personal circumstances may be different from Malcolm’s, the book contains lessons on personal growth and on fighting for what we believe in, which can certainly be applicable to all of us.”

—Irfaan Ali

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BY: SNEHA RAO & NICOLE MAHARAJ

M

ental health problems affect everybody, including medical students, doctors, nurses and other healthcare professionals.

As medical students, we have entered a profession that pushes us to the limit mentally and physically.

Are we at a higher risk of succumbing to a mental illness? How could we prevent it? When should we seek help? What should we do if one of our colleagues shows signs of a mental illness?

Sneha Rao and Nicole Maharaj made an appointment with Prof Hutchinson to get some answers.

Q

How many students do you think suffer from mental illness?

A

I don’t know if there is a good answer to that question. Mental illness in the society will be reflected in the medical student population but of course many do not seek help. I would say based on surveys that have been

done, and quite a few have been done on medical students, depression and anxiety, which are the most diagnosed, the ones that people have sought help for, would range between 20-30% of the entire population.

Do you think that there is a difference in the number of people diagnosed with mental health issues in our campus at Mt. Hope compared to the main campus in St. Augustine?

There are particular challenges to being a medical student. It is a high pressure type course. It is also one in which your progress is very public so people know when you have not progressed with your peers. Then there is the issue of pressure—parental, family or peer—and getting into the course due to this pressure rather than really wanting to do it. So when the challenges get excessive they tend to respond with symptoms of depression and anxiety.

So from that point of view, yes.

From the studies on campus, the faculty with the greatest number of students having problems is Science and Technology. But certainly, the Medical

Sciences faculty gets flagged a fair amount in terms of depression and anxiety.

What year of medical school do most students present with mental health issues?

I think there are two peaks, between years two and three and another around years four and five. The year five peak is largely due to exams, challenges associated with either preparing for exams or having fears about their ability to succeed. Years two and three, I am not sure what the drivers are but I would guess it is the transitioning process. First year students are still adjusting and coming off the high of being in university and then years two and three when that has settled down, you are faced with the tasks ahead of you and coming to grips with what being in medical school means.

What percentage do you think do not seek help due to the stigma attached or due to any other reason?

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It is difficult to say. Internationally about 60% of people with mental illness do not seek help. We have not done any population surveys here to establish that breakdown. But based on what information we have, it would probably be within the same range.

Usually most people don't come because, other than the stigma, they attribute the illness to spiritual and supernatural causes and even due the umbrella term 'stress'. So we see them after they've tried to deal with those things and failed.

What signs or symptoms should push a student to seek help?

I would say the greatest measure is impairment of functioning—if you recognise that you cannot study as well as you normally are able to or fulfill your clerkship responsibilities or engage in life in the way you are normally accustomed to.

A meta-analysis which covered over 120,000 students in 47 countries found: 

  

27.2% of medical students had depression or depressive symptoms 11.1% contemplated suicide 15.7% sought psychiatric treatment Take home: overall prevalence of depressive symptoms among medical students was higher than that reported in the general population, which underscores the need for effective preventive efforts and increased access to care for medical students.

Rotenstein LS, Ramos MA, Torre M, Segal JB, Peluso MJ, Guille C, Sen S, Mata DA. Prevalence of Depression, Depressive Symptoms, and Suicidal Ideation Among Medical StudentsA Systematic Review and Meta -Analysis. JAMA. 2016;316(21):2214–2236.

What do you think students can do to support their peers who are undergoing a mental illness?

I think the first step is to provide unconditional, non-judgmental support and try to let them know that you are there for them and that you have noticed whatever you have noticed and that you would help them be prepared to navigate toward a solution. This

“...the first step is to provide unconditional, non -judgmental support and try to let them know that you are there for them.” might be for example saying 'This is getting a bit serious so I think you should go and see somebody and if you want I'll come with you,’ or even make the appointment for them if they don't want to do it themselves.

Sometimes people are very depressed and they do not have the energy or the motivation to do those things even. Things like bullying and teasing the victim should be discouraged and if you know anyone doing that, they should be discouraged. I think that the big word here is support.

To provide the victim support in whatever way you are able to and whatever way the person is willing to allow you to.

So if students are undergoing a stressful situation how do you think they can prevent a maladaptive response to it?

By understanding the situation, why it is stressful to them at that time, recognising that the situation is becoming problematic and determining, 'What do I need to do to address it?’

Then if that is not possible or it is clear that it is not something that you can do for yourself, seeking help from some

provider

is

advised.

How can medical students prevent themselves from getting a mental health illness?

Understanding and being aware of what your vulnerabilities are or what your weaknesses are, what your challenges are in terms of personal relationships and your ability to manage difficult situations, and then having things in place to address those issues for example, having a good support system and being aware of the symptoms so if you are experiencing them you can seek help early before they are exacerbated.

Also engaging in wellness. These are things that most medical students must be aware of such as eating well, exercising, having some form of stress outlet, and finding time for things like yoga, meditation or prayer. Those preventative things have all been found to be useful. Also, managing your time properly or as properly as you can.

How many students have you seen recover from mental illness and how many have relapses?

The idea of recovery and relapse is a controversial one. Again it depends on the seriousness of the problem, the psychosocial circumstances that the person happens to be in and the level of support that they have. All those factors vary in each individual. I would say that most students do well enough to sustain themselves post-graduation as doctors and function fairly effectively. There have been a few who have not recovered and they would have had to not practice or had to practice very sporadically. But the majority are able to function pretty well.

What do you think about the subject of mental health being taboo and how do you think we can break the stigma?

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I think it's the understanding.

People need to understand that the brain is an organ just like the liver or the kidney and when there is dysfunction in it, the expression of that dysfunction is behaviour versus physical symptoms that you may be able to feel or say. I think this is a big dimension of it.

It's appreciating the brain as a physical structure that influences and is the source of all that you think, do and feel. When the average person thinks of mental illness, they think of the layman expression, a "mad man," not recognising that this is by far the exception in terms of people who develop mental illness problems. There is the common misconception that these people are violent and unpredictable. This again is an exception and a very small exception as well.

Also recognising that a lot of mental health symptoms occur in physical disease. The presence of strange behaviour doesn't mean somebody is mentally ill but it could mean they have some physical condition. It comes back to understanding that mental illness does not equal madness and that it is caused by what happens in your brain in the same way that anybody could develop diabetes if they don't attend to their lifestyle risk factors. Anybody can develop renal failure if they don't take their antihypertensives and their anti-diabetics.

In the same way, people can develop a mental illness if they do not take care of their brain.

What services are available for students who have a mental health issue and would like to seek help?

There are two routes, one is going to the counsellor directly—there is a counselling unit that the university provides on main campus—and the other is going to a primary care doctor

who may then refer. The counselling service provides psychological help but if it is thought that the person needs psychiatric help they are referred to Mt Hope or even the service we provide at NCRHA. Many students go straight to pri-

“People need to understand that the brain is an organ just like the liver or the kidney and when there is dysfunction in it, the expression of that dysfunction is behavior.” vate services which are affordable through insurance policies. Within the public system, most university students will be associated with El Dorado Road Clinic, Arima Health Facility, and also the Chaguanas Health Centre which has a psychiatric clinic on a Thursday.

Of course, some students have come directly to the NCRHA faculty maybe because they are already here.

The academic staff tries not to encourage direct contact or first call contact because of the conflict of interest particularly with the fourth and fifth years who we will have to teach and examine at some point.

If you had a few words to give medical students, medical doctors or anyone in the medical fraternity, experiencing mental health issues, what would you say to them?

There are three big tips: 1) Be aware of the symptoms and be able to appreciate when they do occur, 2) Seek help as early as possible and 3) Establish a social support system that allows for you to have support when you need it.

T&T

SUICIDE

LIFELINE

(available 24/7): Tel: 645 2800/ 800-5588/ 220-3636 E-mail: life@lifelinett.com

UWI Student Counselling and Psychological Services Opening hours: Mondays to Fridays (except public holidays) During semesters: 8.30am to 8pm During vacation: 8.30am to 4.30pm Telephone: 662 2002 (ext 2491) Email: counsellor@sta.uwi.edu Location: Health Service Unit (HSU), between the Learning Resource Centre (LRC) and Trinity Hall at St Augustine main campus.

FAMILIES IN ACTION: 628-2333/ 622-6952 There are three BIG tips: 1) Be aware of the symptoms.

2) Seek help as early as possible.

3) Establish a social support system.

(Prof Hutchinson)

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N

ow before I start, let me pose a question to you: have you ever seriously considered being a GP? Unfortunately this question is just rhetorical but think about it.

So why oh why did I choose to write about Public Health and Family Medicine? There’s wide consensus on it being the easiest rotation and students use it to prepare for surgery. But because of that, many students unfortunately miss the whole point of this rotation. I almost did. I entered the rotation fully expecting a vacation. I had planned to study nothing until the last week, attend the bare minimum of classes and relax. But thankfully I didn’t and at the end of six weeks I had a newfound respect for the work GPs do.

So classes upon classes. That’s defining about this rotation. We had no ward work, little responsibilities, loads of classes. The classes were on a range of issues from ethics to common medical problems in primary care to group presentations. It was definitely an adjustment from the blood and sweat of medicine at POSGH. There was a significant aspect of course work in this rotation. We had to spend at least 24 hours in total at a health centre and/or GP office and wrote 11 reflections on cases we encountered. At first I saw this as a chore but I soon saw it as a privilege.

I quickly realised that I knew quite a lot about tertiary care but I knew very little about primary care.

Ask me anything about an MI and I’ll rattle out the presentation, ECG changes, treatment. Ask me about muscular chest pain and, boy, I might

“The biggest lesson I learnt was to appreciate the role of a GP in healthcare. As medical students and in the medical profession generally, we tend to trivialise being a GP and joke about it.” have an MI. It really struck me that in tertiary care most complaints are followed by a barrage of tests. I eventually understood that the patients in tertiary care had often been filtered out so every chest pain in a hospital was more likely to be an MI but in primary care, every chest pain was more likely something that’s not an MI. What

really struck me were the different skill sets needed and spectrum of ailments in Primary and Tertiary Care.

The biggest lesson I learnt was to appreciate the role of a GP in healthcare.

As medical students and in the medical profession generally, we tend to trivialise being a GP and joke about it. We say if we don’t get hired after internship we’ll just open up a GP office. It may not be as glamorous a job as being an Interventional Cardiologist who does stents all day, but if a patient, let’s call him, TJ, needed a stent, he already has had significant morbidity. Most likely he can’t walk very far without being winded. He might have had to change jobs due to his condition. And now his cardiologist is just providing tertiary care to improve his quality of life.

Now if TJ had a GP he trusted, he’d have visited him more often. The doctor would have picked up on TJ’s risk factors for cardiovascular disease. He would have counselled TJ on lifestyle changes such as exercise and dietary changes. TJ would have shed some pounds and controlled his cholesterol.

Then TJ would have gone on to beat Donald Trump in the elections and we’d all be happy as TJ would have really made America great again. All because TJ visited his GP. Now, there are many many more lessons I learnt in family medicine but if I tell you them, I’d be robbing you of the opportunity to discover them yourself.

So all I have to say is keep an open mind. You will learn a lot more than you think. At the end of it, ask yourself the same question I asked at the start: have you ever seriously considered being a GP?

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S

urgery, the rotation that triggered sympathetic looks from senior colleagues every time I asked for advice on how to approach it.

Soon, I would learn that their expressions were warranted.

It was one of my most exciting yet gruelling rotations—my very first clinical experience as a fourth-year student. From taking bloods, to putting in IVs, to arduously clerking new patients, it was all new. It was an extraordinary experience, spending time in the operating theatre, marvelling at surgeons in their element, and even scrubbing in a few times to be part of the action.

I remember my very first day.

Newly oriented. Intrigued. I had started at EWMSC and my designated unit was on call and busy with clinic that day. I could genuinely say it was the longest day I ever had. By the time they dismissed us for the night, it felt like a week had passed. I was enervated. That night, a scary thought crept into my mind: was I supposed to look forward to such days? Here I was terrified, and for the first time I contemplated what I got myself into.

Luckily, it was only a transient thought. By the end of the first week, I soon understood what was expected of me as a student and therefore tried to be as involved as I could on the wards.

Though the days continued to be long and tiresome, I adjusted and eventually it didn’t matter as much.

By the second month, which was at SFGH, the labour had intensified.

Nevertheless, I was eager to be working under Prof Dan and was up to the challenge. The days were lengthy. One was expected to read on what had been

“At first, you never know how you'd make it through, but somehow you do.” encountered for the day. However, as much as I read, nothing fully prepared me for the unrelenting grilling by the house officers and the infamous 'shame' rounds with Prof Dan where no-one remained unscathed.

Despite those challenges, observing the bedside refashioning of a stoma, bonding with patients and assisting in debridements were moments I cherished. However, my favourite memory had to be the day I finally scrubbed in for my first surgery, a below knee amputation (BKA). How ecstatic I was just at the thought of being under the lights! So you can imagine how astonished I was when the surgeon asked me if I was ready to amputate the leg. I wouldn't lie. I thought she was joking at first but she wasn’t. It took a

while to cut through the bone but I did it! And it was undoubtedly worth it! I even got to put in a vertical mattress suture! It was certainly an incredible moment.

Although the transition from the classroom to the wards was an abrupt and overwhelming one, I eventually found my footing and confidence. At first, you never know how you'd make it through, but somehow you do. Saving textbooks to my phone helped a great deal, especially when it came to time management. It meant that I could have sneaked in a read between walking to and from wards or while waiting on lab results, classes, or the next theatre case.

The surgery clerkship, like all clerkships in medical school, also reinforced the importance of cooperation and teamwork. My teammates, although I barely knew them, motivated me to work assiduously. Sometimes we don't always get to work with our “friends” but when it comes to teamwork, it's essential to be with those who are as equally driven as you as this helps create an optimal learning environment. So, always try to encourage and test one another, help out a colleague who you think might be struggling with something. I assure you, you will also benefit. You never really learn something until you teach it.

In retrospect, I wish I had utilised my time more efficiently, whether by reading more or trying to perfect my clinical skills. I also wish I had invested in more comfortable footwear.

Trust me, you can probably skip leg day at the gym for these two months.

Ward rounds got you covered!

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W

hile walking into Mount Hope Women’s Hospital for orientation day on Monday morning I felt unsure of what to expect. Surgery rotation had just finished. The mind was still recalling exam questions and demanding more sleep.

Obstetrics and Gynaecology proved to be very challenging yet rewarding. The rotation was split between San Fernando General Hospital (SFGH) and Port of Spain General Hospital (POSGH). At SFGH most of the time was spent in the gynaecology and labour wards while at POSGH in the antenatal wards. Most of the teaching my group acquired was from our registrars Dr. Subramanyam and Dr. K. Jurawan. They both took time from their busy schedules to teach us and ask challenging questions. Many times I left these discussions learning something new and realising how much more I had to learn.

The most enjoyable task was getting to carry out physical examinations on the mothers at the antenatal clinic.

To see how those moms’ faces lit up at the sound of their babies heart beat was blissful.

Then there were the moments that pulled at the heart. Seeing a mother being counselled after the death of her premature baby. Having a patient with a history of Polycystic Ovarian Syndrome smile though she just had a miscarriage and it was her first pregnancy.

All her life she believed becoming pregnant was impossible but now she and her spouse had hope. Families were being made on one ward and in

another mummies were saying goodbye to babies who never took their first breath but were loved.

Having done surgery before I felt confident that I could make it through any on-call session. This rotation definitely proved me wrong. Thankfully, I was amongst an awesome group that encouraged one other. Lunch breaks taken at half twelve or two o’ clock were a welcomed relief. There in the humble student room at POSGH we spent a few minutes laughing and discussing interesting conditions seen throughout the day.

This rotation reinforced the importance of group work, proper communication in a work environment and caring for your patient (even though she is squeezing your fingers so hard they are turning blue.) As a young woman this Obstetrics and Gynaecology rotation also puts life in perspective as I saw the sacrifices required when having a family. It goes without saying this rotation definitely made me more appreciative of all mothers, especially my own.

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“

Daddy! We’re in the middle of the highway!” I screamed as dad suddenly mashed brakes on our usual route to school. He had a confused look on his face. It seemed as though he was seeing the road for the very first time. I was scared. Just dad and I were in the car. As they whooshed by, the other drivers blew their horns and shouted insults. “Pull to the side please,” I said, nervously. It was clear to me that something was wrong. This was one of the first signs of Alzheimer’s. My dad will never be the same and it was downhill from here. I was 14 years old at that time.

It has been 10 years since my dad was diagnosed with Alzheimer’s disease. My brothers and I sought medical attention after witnessing a string of unusual activities. We knew this was not our dad. After the highway incident and several other similar events, it became clearer and clearer.

He had started to wake me on Saturdays and Sundays to attend school. Soon after eating he would ask me whether he ate or not. He’d buy newspapers twice for the day and he frequently misplaced his keys and wallet. We were often blamed or accused of taking these items. His paranoia grew. On evenings, he checked the gate over and over to ensure it was locked.

Within the space of one hour, he would check the gate about 10 times. A memory I’ll never forget: dad drove to buy newspapers, parked the car at the junction and walked home. He asked us about his car repeatedly, suspecting that someone stole it. My brother and I walked to the end of the road and to our dismay, we saw the car parked up, not in any normal car park, but on a gravel heap. “Dad needs to see a doctor,” we thought.

He was diagnosed by a neurologist who then referred him to a psychiatrist. A few years later he was banned from driving. Fortunately my brothers and I got our permits around the same time. However, this did not go down well with him and he would ask us, sometimes becoming very angry, for the keys. We knew this was a recipe for disaster and we tried to coax him out of it. At times, he got aggressive but we knew this was not our father. It was signs of the disease which was overtaking his memory and personality.

Alzheimer’s is a degenerative disease of the brain. My father is currently unaware of his children’s names and ages and sometimes unable to recall if he’s married and has kids. Sometimes he thinks I’m his nephew and 10 years old. He has typical “sun downing” symptoms: in the evening he becomes excessively paranoid. He continuously asks if everyone’s home every two minutes, checks the lock on the gate, and sometimes becomes paranoid that the house will burn down.

Sometimes he looks at the road as cars pass by and asks “What are all those

Mr. Deonarine Basdeo in his younger years lights?” He’s unable to tell the difference between morning and evening. At nights he’ll wake up midnight, scared, thinking he’s alone and wondering where he is. On these occasions we calm him down and assure him that he’s safe.

Thus far there is no cure for Alzheimer’s disease. Medication is available to slow the deterioration. These include NMDA receptor antagonists and acetylcholinesterase inhibitors, such as donepezil (Aricept). Dad has been on Aricept for the last couple years. However his condition has continued to deteriorate at an alarming rate.

Dad was always known to be a pleasant person, always smiling and never rowdy. Nevertheless as a principal, he was stern with his students. He was one of the first villagers in Piparo to own a motor vehicle, which had functioned as the village school bus.

Page 17

As a figurehead in Piparo, he took up the responsibility to lobby for a reliable supply of pipe-borne water, electricity, street lights, and proper roads. Passionate about his East Indian roots, he travelled to India in the 1970s to find his family who we correspond with up to this day. It is a pity that this disease has robbed him of these precious memories and achievements. To him they simply never occurred.

Being the last of four children, I have slept with my father since the age of two. Growing up, the love between my father and his children grew immensely. Every day he dropped us to school and picked us up. He ensured we did our homework and took great pride in doing this. Education was of utmost importance and he encouraged and supported us all the way. He always had a love for cricket and some evenings he would play cricket with us.

If you saw dad bat and bowl, you would have thought he was 20! He made sure that all of us looked at cricket especially when West Indies was playing. Whenever my brothers or I had a cricket match or attended cricket practice he was there support-

Mr. Basdeo enjoying the newspaper at home. ing us 100 per cent from the very start till the end. He gave us tips and was proud of us. I saw that as the purpose of my life: to make my father proud.

The onset of his disease shook me like a bolt of lightning. As I lay next to him in bed, it was shocking to see him get up lost and confused. This began when I was 14 years old. Not only did it hurt but sometimes brought tears to my eyes to see my father, once a

healthy happy man now lost in his own home. I felt as though I lost my father who was there with me all the way.

The pain I felt should not be experienced by any other. This had a major influence on my career choice of medicine. Furthermore I felt as though my purpose of making him proud was lost.

In this state he’s unable to recall my name much less for my academic achievements.

“It is a pity that this disease has robbed him of these precious memories and achievements. To him they simply never occurred.’’

While attending secondary school, my siblings and I decided we’ll have to help mom as much as we can.

A heavy weight was now on her shoulders playing the role of mother and father. Financially things became difficult as my brothers and sister started university. My siblings and I did odd jobs to support one another. At times I stayed away from school to help my brother in the garden. This encouraged me to work towards a scholarship.

With the help of God this was accomplished and I was accepted into medical school.

Beginning medical school was a new era in my life. I rented in St Augustine and felt very guilty for being away from my dad. As embarrassing as it sounds, it felt strange not having dad next to me at night. I dreamt him on many occasions. One of these dreams I vividly remember: dad had passed away and was on the floor with everyone crying around him. I had just arrived and heard the bad news. I was in disbelief. I stood there as my body felt cold. I then felt a warm hand on my shoulder and heard dad’s voice: “Why are they crying son, I’m right here and will always be here.” I took this as a message that God sent for me to comfort me.

I know my dad is sick and unable to recall if he has kids, but his spirit will always be there with me. He wants me to help people just as he did when he was a teacher, a principal, a role model in his village. Being his son I’m

motivated to do this for him. I’ll be the best doctor I can be, help as many people as possible and put as many smiles on as many faces as I can. I try to make my dad smile and laugh as much as I can. It’s the least I can do when I’m around. Looking at his picture, especially when I’m away from home motivates me to study and give my all. My father is currently 81 years old and may be in his final years but I appreciate every second with him. When God is ready for him, and he passes away physically, his soul will be looking down from heaven and he’ll be proud to call me his son.

MORE INFO  Dementia is not a natural part of ageing and it doesn’t just affect older people.  It's not just about losing your memory.  People can still live well with dementia. Non-pharmacological treatment include cognitive stimulation like word puzzles or discussing current affairs; life story work, sharing memories and experiences with a carer to create a ‘life story book’; keeping as active as possible – physically, mentally and socially (The Alzheimer’s Society UK)

FOR SUPPORT: The Alzheimer’s Association of T&T Tel: 225-8764 E-mail: alztrinbago@gmail.com Website: www.alztrinbago.org Facebook: Alzheimer’s Association of Trinidad and Tobago

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P

rof Zulaika Ali loves to plant. Lilies, ixoras, anthuriums, heliconias and orchids, nurtured by her paediatric-trained hands, decorate her Petit Valley home. As a neonatologist and leader in her field, Prof Ali scattered seeds far beyond her home garden. Today the fruits of her labour abound: thousands of children now adults who benefitted from her care, doctors who trained under her tutelage, institutions that serve the region.

With an unwavering passion and indefatigable spirit, Prof Ali continues to nurture these plants, doing so for well over 30 years.

Nurturing children was second nature to Prof Ali, the second of 11 children.

“Having to help care for my siblings as each one of them came into this world made looking after children a sort of natural fit,” she said during an interview at her Mt Hope office.

In 1974, after completing undergraduate studies at Mona, Jamaica, Prof Ali returned home to do her internship. “It was during internship at Port-of-Spain General Hospital (POSGH) I decided on paediatrics. I preferred to deal with children more than adults. When children are ill they’re genuinely ill.”

So not too long after completing a gruelling internship, the young doctor

BY: TAUREEF MOHAMMED from El Socorro returned to Mona to study for the Diploma in Child Health (DCH) and Doctor of Medicine (DM) in Child Health. “The external examiner for the DM, Prof Neville Butler from the University of Bristol, was very impressed with my work and offered me a scholarship to train in neonatology/ perinatology at Bristol.” After spending about 18 months in the hilly, sunny English city, she returned to Trinidad in late1980 as a newly minted neonatologist ready to pursue her lifework.

“The Government was developing women’s health at that time and Mt Hope Women’s Hospital (MHWH) was built, initially for family planning, but it was converted to an obstetric hospital with a newborn nursery and later included gynaecology.

“In 1981 I was appointed a lecturer in neonatology by the UWI and an honorary consultant at the MHWH.” Here Prof Ali would plant her first seed: the Neonatal Intensive Care Unit (NICU), the first of its kind in the country.

“They had minimal items of equipment which were also outdated. I found out where the Government stored their medical supplies in Chaguaramas and collected basic things like measuring tapes, stethoscopes, thermometers etc to start a neonatal service. With the help of head nurse Mrs Ramkissoon we took what was needed, placed the items in my car trunk and brought them to MHWH.

“The Unit was assigned two nurses, the head nurse and an assistant. I obtained a list of the names of nurses who had some neonatal and paediatric training and persuaded the Ministry of Health to transfer them to the NICU. We managed to get about eight nurses and were able to run three nursing shifts.”

On June 16, 1981, with one consultant, two house officers, a handful of nurses, and basic equipment, the NICU opened its doors.

Prof Ali prepared working manuals on policy and procedures and basic care of the newborn. The service would steadily expand over the next

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twenty years, providing more and more advanced care as well as hope to distressed parents. At the unit’s entrance, a noticeboard, almost the size of a blackboard, plastered with thank you cards, family pictures, and newspaper articles, is proof that this seed has borne fruits.

A children’s hospital is born As an intern Prof Ali had worked on wards 42 and 43—paediatric wards at the time—at POSGH for some months. The Eric Williams Medical Sciences Complex (EWMSC) and the Children’s Hospital (CH) did not exist at the time.

“The first paediatric clinical service at the CH was a walk-in clinic and I assisted in writing the proposal for developing and implementing services at that hospital. Originally it was a fee for service until the Government decided to provide services at the EWMSC free of charge.

“I was also a member of the commissioning team that was responsible for the transfer of paediatric patients from the POSGH to the CH.” Over the next decade, the CH would gradually widen its scope from a hospital that provided general paediatric care to one with a range of specialties like developmental paediatrics, haematology, cardiology, oncology and gastroenterology, capturing the spectrum of problems that children in T&T presented with.

Beyond our shores

“My first experience as a new intern was treating a newborn with neonatal tetanus and that was an eye -opener.”

“We had very busy wards. The most common problems were gastroenteritis and severe dehydration followed by respiratory problems. My first experience as a new intern was treating a newborn with neonatal tetanus and that was an eyeopener. And generally there were a lot of other infectious diseases like measles, mumps, rubella.”

A young, motivated, passionate doctor who just did what she loved, Prof Ali had no idea at the time that she would assist in transplanting paediatrics from the two wards in the Central Block of POSGH to a CH.

By the start of the new millennium, paediatrics in T&T had made significant strides. However, some children were still falling through the safety net.

“When I was at NICU, there were a lot of babies born with chronic congenital abnormalities such as congenital heart disease, anomalies of the bowel and genitourinary tract like bladder and cloacal dystrophy which we could not treat”.

“We had difficulties to get funding for patients and parents who could not afford to travel abroad for consultations. So I had contacts with SickKids Hospital (SKH) and wrote a proposal for using telemedicine for consultations.

“After a couple of years of back and forth, the Herbie Fund, which only supports one-off surgeries for children, agreed to provide funding f o r t h e p u rc h a s e o f v i d eo conferencing equipment and eventually we got local sponsors to cover the other expenses.”

The UWI Telehealth Programme (UTP) was launched in 2004 and is a collaboration between UWI’s Child Health Unit, the Government of T&T, SKH and the Herbie Fund, Toronto, Canada, and local corporate sponsors.

The programme provides consultation between local doctors and specialists at SKH utilising real time videoconferencing at no cost to the families.

“Once a patient is accepted, the clini-

cal details are sent to SKH for review.

We then set up a clinical consultation via the telehealth facility. The patient, parents and referring doctors must be present so the doctors from abroad can talk to them.

“If surgery is required SKH starts to organise with the Herbie Fund for financial support and arrangements are made for the parents and patient to travel to SKH, Canada.”

The UTP has pride of place on the third floor of the administrative wing of the CH. Since its inception, the programme has helped over 200 families access advanced, state-of-the-art healthcare. It has also provided an enriching learning environment for healthcare professionals in both T&T and Canada.

The innovative programme can boast of a success rate of 100%. But more important than percentages, children with congenital problems—like Brittany Ramai who was born with congenital heart disease and couldn’t walk a few feet without becoming short of breath—can run and play like normal children.

Brittany with her dad, Jitendra Ramai

The Academic Prof Ali’s commitment to paediatrics in the public health system did not prevent her from fulfilling her university duties. As a senior lecturer and Head of Department, she was integral to the introduction of the Objective Structured Clinical Examinations (OSCE) across all campuses in 2000. She was also part of the team which saw the ex-

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pansion of the medical sciences faculty to Nassau, Bahamas which, she pointed out, started as an offshoot of St Augustine.

While leading the university to greater heights, Prof Ali still had time for the bread and butter of academics: teaching and research.

“When I came back to Trinidad, most of my research was on newborn problems. One significant work was identifying that newborn babies were not all dying from intracranial haemorrhage but from Group B Streptococcal (GBS) infection. Recognizing GBS as a killer and the importance of hand washing with the requisite available consumables to prevent nosocomial infection were important public health interventions.”

She added: “Another one was when we had the outbreak of Congenital Rubella in 1988-1989 and I reported on a number of cases. I wrote a paper with the virologist from CAREC (Caribbean Epidemiological Centre, now CARPHA) and based on this the health ministry started to give Rubella vaccines to young adults of reproductive age and eventually started MMR vaccination in children.”

Thorns along the way Although it may appear that Prof Ali’s career flourished like her colourful home garden, it was by no means a bed of roses.

“Paediatrics suffer from the fact that children don’t have voting rights so they sort of get put on the back burner.”

“Paediatrics suffer from the fact that children don’t have voting rights so they sort of get put on the back burner,” she said.

And being a woman in a maledominated field did not help. “It was tough,” she admitted. Prof had some

advice for upcoming women in the medical field: “Stay focused and when you know that what you want is being infringed upon stand your ground.”

However, with teamwork, Prof Ali said, no battle is insurmountable.

“Everything is teamwork. Without this, things will fall apart. You have to be honest with your peers and colleagues so if things begin to fall apart you huddle and discuss to find a solution.”

Prof Ali’s contribution to medicine in T&T and the region cannot be overestimated. Besides paediatrics, she has also made significant contributions to raising the awareness of HIV/AIDS and currently runs a fully online parttime postgraduate programme entitled, “UWI Diploma in the Management of HIV Infection”.

As a lecturer, she continues to nurture these plants. Like those in her home garden, they continue to bloom, enriching the lives of those who come in contact with them.

So what is our role as students and young doctors? Equipping ourselves with the tools to take care of this garden and plant seeds of our own seems to be the most logical thing to do.

Call 769-1865 / 742-7534

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BY: SHERRY ANN PADARATH & IRFAAN ALI

D

r. Farid Youssef is a neuroscientist, psychologist and a senior lecturer in the Department of Pre-Clinical Sciences. If you’ve ever had Dr. Youssef as a lecturer, then, aside from his infectious chuckle, you probably also noticed the dynamism in his delivery of topics, how he engages his students in the learning process and how much of an effort he puts into, not just lecturing to, but educating his students. It therefore is no surprise that he was awarded the Vice Chancellor’s Excellence Award for Teaching in 2016. I mean, he’s even got his own YouTube channel—that’s got to count for something, right?

Q:

Can you tell us a little

about yourself?

A:

I was born in Egypt, my

dad is Egyptian and my mom is British. But I left Egypt when I was about one year old. I lived in the UK for a couple of years then came to Trinidad in the mid 70s, and my family has been here ever since.

I grew up in Trinidad in St. Augustine. Both my parents were lecturers at the UWI; my mom was a linguist and my dad was in agriculture.

So I’m the child who continued the

family tradition of working as a lecturer in the university.

During your primary and secondary schooling, did you always see yourself going into Medicine?

I did very well in school generally. I attended Hillview College and having completed A’ levels, I wasn’t too clear about what exactly I wanted to do. The opportunity presented itself to study medicine here at Mt Hope.

The school had just opened. I was part of the second class. So I kind of fell into it.

I completed my medical degree and practiced for a little bit but never really enjoyed clinical medicine. Pretty soon, I decided I didn’t want to do clinical medicine. I ended up doing a PhD in physiology/neurophysiology.

Even when I was doing medicine, the two things I was most interested in were psychiatry and orthopaedics. Psychiatry because I always had an interest in the brain and the mind and orthopaedics because I always played a lot of sports.

Could you tell us about your post-graduate education?

I did a PhD in Neuroscience at Mt Hope and a masters in Psychology at the University of Liverpool recently.

My masters looked at burnout and stress in medical students at Mt Hope and my PhD looked at long potentiation and how it changes the sensitivity of the brain to certain neurotransmitters.

Could you give us an idea of what medical school was like during that time?

We were the second class, so everything was still new. It’s different from today, because there was only one class above us and our class was small, about seventy people.

At that time, I saw university— and I still do now—as not just an opportunity to learn, though that’s your

“I saw university...as not just an opportunity to learn, though that’s your primary responsibility, but it was an opportunity to discover who you are and understand and formalise the shaping of your identity.” primary responsibility, but it was an opportunity to discover who you are and understand and formalise the shaping of your identity. So I guess that’s part of what was going on with me during university.

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see how it affects things like memory and executive cortical processing.

I have an interest also in the neuroscience of decision making: what are the mechanisms by which we make decisions? Particularly in decisions related to prosocial behaviour, things like empathy and altruism. We’ve also done research into professionalism and its application in medical students.

Dr Youssef and his medical school colleagues in Maastrict, Holland.

What was the most difficult part of your medical training?

I remember in medical school a challenge I had was that everyone wanted to talk about medicine. Though this is good, everything we do takes place within the context of normal life.

It is useful to have broader interests.

This will help you to better understand the world in which you are living in and the people you are going to serve.

What about clinical medicine did you not enjoy?

I guess, at the time, being young, I didn’t see myself spending the rest of my life in a hospital and I think I was much more drawn to teaching and research. Not that anything was wrong with spending your life in the hospital, I just didn’t see it for myself.

But you did work as a clinician for some time?

Only for a few months.

So after internship, just a few months?

No, I didn’t even finish my internship. I made that decision pretty quickly.

What are your current research interests?

In T&T, we don’t have huge amounts of funding for research so you tend to have multiple streams. Currently I’m involved in a an interesting project with some PhD students looking at the effects of obesity on cognition. I think everybody knows that obesity has a lot of metabolic effects, so we know it will affect the heart and blood vessels and lead to kidney problems, etc. But only now there’s emerging more and more data that says it affects cognition. So we’re looking to

What are the pros and cons of being a lecturer/researcher?

I enjoy lecturing and interacting with students because I think about it as an opportunity to help provide perspective for students. It is not only about training people to be doctors but training people to be good doctors.

That involves not just the competence of making a diagnosis but the so called “soft skills,” which entails care, compassion, and empathy.

I strongly feel that we as lecturers have a responsibility to be role models and put forth an example of what it means to be a professional and a good doctor.

As for the cons, most challenges come from interacting with people but if we all try to be reasonable professionals and try to see things from other people’s perspective, you find that we can overcome a lot of those things.

Is there a link between your interests in neuroscience and your interests in the course Professionalism, Ethics, and Communication in Health (PECH)? Can you describe this link to us?

Over the last 20 years, there has been a big revolution in neuroscience in which some people argue that everything about you is due to changes taking place in the brain. I don’t actually believe that but I do think a lot of behaviours can be explained by things occurring in the brain. We just don’t understand it. For example, large parts of our brains are designed to function in relationships with one another— humans are social animals. When we

Page 23

appreciate this, we can then ask ourselves, ‘Do I want to train my brain in a way that does or does not promote this?’

A simple way to understand this is that when you do something good, you get a feeling of well-being due to the changes in brain chemistry. I think when people recognise that so-called “soft skills” have underlying biology, they are more willing to accept them.

What advice can you give to students who find it difficult to apply the lessons from PECH to the real world?

Sometimes in a classroom setting there is a tendency to project the ideal.

This is important so that we know what we are aiming for. In terms of having to deal with real world situations, the core aspects of professionalism will come forward. This gets expressed in the way that you interact with your patients and colleagues. These are fundamental aspects of one's character and you should not allow anything to erode this. Yes, there may be bad days where you may get short tempered and make a mistake but you can apologise. Ultimately it comes down to deciding what type of person you want to be.

Is there anything about the current batch of students you don't like?

It’s not that I don’t like things about students. The education system encourages competitiveness. Being in medical school means that you have learnt how to do well in this system.

“There is all this talent and ability and it is as though you don’t touch it because you are so focused on passing exams. The society then suffers as thinking becomes very narrow and we lose creativity, innovation and the ability to think of things from a different perspective.”

There is a focus on passing exams more than truly understanding the lessons being taught.

At the end of the day, you all are training to become medical professionals. There is all this talent and ability and it is as though you don’t touch it because you are so focused on passing exams. The society then suffers as thinking becomes very narrow and we lose creativity, innovation and the ability to think of things from a different perspective. Students are so anxious about passing exams that they forget about their competence. It should be

competence first and then passing exams will come naturally.

Outside of medicine and physiology, tell us about your other interests.

I am very involved in leadership development. The aim is to promote value-based leadership. This is very relevant to all levels of society including our faculty and at a national level.

Aside from this, sport has always been a part of my life. I do the UWI Half Marathon every year and I recently resumed playing tennis. I also manage the medical sciences football team. I am also interested in sports psychology as athletes also need to develop their cognitive skills to perform and excel.

Share with us a little about you family.

I am married and have three children. My eldest is a boy and he is 13 and we also have two girls, aged 12 and 10. There is always a lot of excitement and activity within the home (laughter).

Do you have any advice for the current students?

Trust the process, in the sense that if you are diligent, you will have a good result. Remember that lesson about angry birds and trajectory.

Page 24

I

nternship, an experience like no other, impossible to fully comprehend until you have dived in yourself. Exhilarating, frustrating, stressful, and rewarding—contradictory words that still do not encompass the past year.

Imagine a rollercoaster: fast paced, hair - raising, full of ups and downs and you and your fellow co-interns are along for the ride.

The first day of internship was exciting and nerve wracking. I was accepted to Port-of-Spain General Hospital and started in Internal Medicine.

Being on call on my first day, I felt like a fish out of water, having been thrust into so much responsibility. From 6.30 am till midnight, there was always something that demanded urgent attention. There was no let up. After clerking six patients, there would be seven more waiting to be seen. On that first call I received possibly the most useful advice from my registrar: “Always carry a coke and a pack of nuts in your pocket when you’re on call. You have to care for yourself first if you want to care for patients to the best of your ability.”

I also started internship with some personal goals, like shedding the extra exam pounds. I was determined to always use the stairs and eat healthier.

However by the end of the first week, the daunting reality of climbing five

“Never remain stagnant...do something with your time.” flights of stairs multiple times a day set in and the elevator sometimes became my best friend. Pies from the cafeteria also unwillingly became a lifesaver.

Day by day the horizon brightened as I settled into a steady rhythm. Usually I arrived around 6.30 am to “SOAP” (subjective, objective, assessment, plan) patients, followed by ward rounds with the seniors. After this we tackled the ward work which mainly involved ordering medication, changing dressings and of course taking blood.

How many times we interns were called

mosquitoes and vampires! In the afternoon we reviewed the patients and by then the day was usually over.

As time passed, colleagues turned into friends and lifelines. Quality friendships were now judged by those who remained after hours to help you with ward work after a particularly hectic day.

There were many memorable moments. The best parts were when a patient took the time to thank you.

“You see that one, you have a real good doctor there” or for a patient to say, “Thanks doc, I didn’t even feel when you take that blood” was enough to make my day. Being included as part of the team was great. Whether it was being asked my opinion during post call rounds, having ward breakfasts with the nurses or the seniors treating us interns to a lime, these moments made all the difference.

Of course, internship being a roller coaster, the ups were coupled with lows. Losing a patient, especially the long stay ones who you’ve grown accustomed to chatting with, was a very somber experience. Perhaps the most frustrating thing about internship was the system itself. Most facilities are severely overworked. It is extremely frustrating to have a patient recently diagnosed with breast cancer, unable to get immediate treatment because the appointment for the CT scan

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is one month away and two, the report takes another month to procure.

Countless times interns and students had to wheel patients to radiology themselves. As interns it was our job to “chase” the official report—chase being a euphemism for harassing the radiology staff daily until we acquired it. The only thing one can do in such a situation is try one’s best and take it in stride.

My advice is to make the most of the year because it is like no other. It’s so easy to treat it simply as a job: go to work, come back home, watch television and then knock out. But then you look back, only to realise that you wasted the entire year by simply existing. I tried to learn and do as much things as I could. And trust me, once you express interest, everyone is willing to teach. It is an exhilarating moment when you first do a lumbar puncture, intubate a patient, close for a surgeon, do an episiotomy or put on a backslab.

It is also important to separate yourself from the job and enjoy other outlets in your life. For me this included liming with friends and family, escaping to Maracas and Tobago whenever I got the chance and learning sign language.

Before I knew it internship was over. The period after internship for some of us, means an extended vacation. During this time, I encourage you to fulfill your dreams and enjoy the time off as most of you have worked nonstop for the past fifteen years.

However, never remain stagnant.

Whether it be writing foreign entry exams, being mentored in a specialty you are interested in, or giving back to your community, do something with your time.

I miss the people, my now lifelong friends and fellow doctors, the nurses who were always willing to give their two cents on a matter and the patients who had a joke or story to share. Most of all, I miss the hustle and bustle of it all and making a difference in people’s lives.

As interviews for a house officer position came trickling in (an overstatement), I had noticed a trend. The interviewers all want to know: “What was your most memorable experience as an intern?” And so I posed this same question to some of my colleagues: “This man literally brought tears to my eyes, when his mom died from a massive MI. In the end, he thanked us instead of blaming us because I had taken the time to talk to him before.”

“A man with bilateral above knee amputation asked me what it is like to walk while I was pushing him in a wheelchair—changed my perspective on life.”

“The shoot out in 2015 at POSGH when you were hearing gunshots and we were all on a lock down.”

“A young boy with HIV/AIDS and in renal failure asked if doctors could do magic to save him. He passed away a few days later.”

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L

ike all good journeys, mine began as a flurry of long emails. Still, it was a thrill to converse with an attending in Robotic Surgery at New York. The day after my Psychiatry clerkship exam, I was off to St Johns Riverside Hospital, New York where Dr. Jonathan Arad would be my mentor for the next month. A mentor in a rapidly emerging field, yet still in its infancy. A hospital with first class facilities, and the highest standards of technology. A foreign student in the city that never sleeps, about to indulge in the next level of surgical techniques.

Needless to say, I was overly excited.

The first week was the hardest, having to adapt to their system, and learning the rules of the hospital. Every patient note was digital. Medications and the plan could be adjusted with a few clicks. This made rounds entirely patient focused and efficient, without any thought of paperwork. The system was also a lot less liberal with medical students than in T&T. Students always had to be supervised and could only touch a patient with senior guidance, as opposed to the wards at home where students were allowed to examine and perform basic procedures under minimal supervision.

On my first theatre day, I became acquainted with the da Vinci Surgical System. The da Vinci, named after Leonardo da Vinci for his interest in anatomy, used four interchangeable arms and access ports, all controlled remotely by one surgeon who was

“I certainly returned home with a deeper appreciation for the privilege granted to us by our patients in T&T to examine and interact with them.” completely engaged in a threedimensional view of the patient’s body. This allowed enhanced magnification and visibility, and articulation through any angle without difficulty.

This paradigm shift in surgery trumps traditional laparoscopy, easily reaching places that were otherwise impossible or awkward to access.

While observing the robot perform a cholecystectomy (removal of the gallbladder), Dr. Arad paused and looked at me. “Do you wanna have a look?” he offered, as I stepped up to the console nervously. The 360-degree view was simply amazing, as if I was sitting

on the gallbladder marvelling at the biliary tree. The future of surgery is here—at a cost of 2 million US dollars.

Over the next month, I became more familiar with this neoteric approach to surgery. The theory was the same, but methods differed. Before surgery, we had a “time in” where a scrub nurse read aloud pertinent patient details, after which all doctors had to verbally acknowledge before touching a scalpel. During the operation, every swab and material had a printed bar code that was scanned out rather than counted. And before patients were discharged, they completed a mandatory satisfaction form assessing every aspect of their care for feedback and quality control.

“The 360-degree view was simply amazing, as if I was sitting on the gallbladder marvelling at the biliary tree.”

Living on your own in New York may seem daunting, but luckily I met Dr. Ibesh, a Syrian doctor who studied at Cairo University in Egypt. He did an externship with Dr Arad during my stay, and shared his unique experience in the journey of obtaining a US residency while being a foreign medical graduate. I also met students from England and Pakistan, who were doing electives at Mount Sinai. Along with my fellow UWI colleagues Mitra and Ranisha, we explored the city, lounged

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in star drizzled rooftops, and even adventured off to SixFlags in New Jersey, all in my strictly “champagne papi" Kia Soul rental. Driving in the city is a story best left untold.

In closing, Robotic Surgery is a new, quickly emerging field that has set the bar in minimally invasive surgery in developed countries. I encourage all students with an interest in surgery to consider Robotic Surgery for your elective.

Upon reflection, the most striking difference was the role of a medical student at St Johns where the wards were for observing and the plentiful classroom sessions for learning. I certainly returned home with a deeper appreciation for the privilege granted to us by our patients in T&T to examine and interact with them.

Indeed, here in T&T, the ward is our textbook.

Mateus, Ranisha, and Mitra with their colleagues in NYC

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BY: CIMONE RAMCHARAN If we’re not in the hospitals we’re in the libraries, and the few times we crawl out to socialise chances are they are with the same group we are studying with. No wonder 40 per cent of physicians marry other doctors—yes I looked it up!

I interviewed three doctors who are in doctor-doctor relationships to get an idea of what it’s like: Dr Kenneth Charles, lecturer and consultant in Hematology, married to Dr Desirée Murray who is also a UWI lecturer in Ophthalmology; Dr Daynish Maraj, consultant in Anaesthetics and Intensive Care, married to fellow anaesthetist Dr Indira Ragbirsingh; Dr Kevin Sarran, a general surgery resident, who is married to Dr Candice Charles, a recent MBBS graduate.

Dr Charles met Dr Murray when he was a Presentation Collage student and she attended St Joseph Convent in San Fernando. They began courting in 1990 and seven years later got married.

Both got accepted to hospitals in England to specialise but were cities apart.

For eight years they lived apart. Dr Charles fondly remembers the times when he took a train for an hour to visit her ever so often. When I inquired about how they made time for each other he said, “It just happens.” On prying I realised Dr Murray was the planner but he did admit, “Most times plans fall through and life just happens.” He said being away from her while studying was a blessing and

curse. “I got time to focus solely on my profession but missed the woman I loved.”

In 2006, having returned to Trinidad as consultants, they had their daughter. He said raising a daughter when they were both consultants turned out to be less stressful—no late call nights, no long post calls. In closing, Dr Charles advised, “Choose your profession carefully because it will be the source of your happiness as your career is with you for life and your life partner will follow.”

Drs Maraj and Ragbirsingh began medical school together. They were a riding side of the three musketeers along with his best friend. As medical school went along, they were in the same rotations, studied together and helped each other. After graduating they interned at different hospitals and eventually started the anaesthesia postgraduate programme together. They make time for each other outside of the hospital, escape for vacations about three times per year and work out together regularly.

I enquired about future plans for children and he responded with a chuckle saying that part hasn’t yet been planned. As ICU tends to warp your view by seeing the worst outcome of situations, Dr Maraj said they try not to speak about work at home and it’s generally off limits. When I asked him about the benefits of having a wife in the same profession he said, “It’s nice

to have someone who understands your crazy schedule and understands your style of life.”

Kevin and Candice have been together for almost 13 years, but married for five, and have two children. He met Candice through a mutual friend and it was love since then. Being a surgery resident, his schedule is unpredictable. But they have mastered being spontaneous. They seem to face the same problems all med couples do: when to find time for each other! But he said having someone who understood his days brought a comfort and ease to the relationship.

Kevin said finding the perfect balance was crucial. “Your profession was there before you and would be there after you,” he said. “You are always going to be on call, post call or getting ready for call—forget about it sometimes (not to be negligent, but don’t let it be all you think about) and spend quality time with each other and your family.”

In the end, it seems to boil down to one thing: medicine is a world on its own and finding and settling down with someone who also lives in that world makes life a lot easier. We’ve also seen how different couples manage life differently, whether you chose to schedule time together or be spontaneous, its essential to make time for each other.

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A

pleasant good evening to all, it is indeed a pleasure, and a great honour to have been given the opportunity to deliver the valedictorian’s address this evening.

My heartfelt congratulations go out to all my fellow interns on reaching this important milestone in our journey.

Today is truly ours and a day to be thankful. A day in which we reminisce upon and celebrate our perseverance, sweat, sleepless nights, and yes, even tears that went into the hard work that has brought us success.

Today is the day we all have been waiting for, from the first day we walked into this amphitheatre five years ago all with bright eyes and full of energy. Now we can finally give thanks and say we made it!

I’d like to take a trip down memory lane. Days in the anatomy lab, with the smell of formalin and Dr Odekunle discussing the “heart” and his leaving a stack of micrographs for us, to know that a few of those pictures were coming for spotter. Prof Nayak always ensuring we understood everything in biochemistry, “any doubt?” The days of PBL, where most of us would tell ourselves we’d start early, but we all knew we waited till the night before.

Skills lab was a joy, where we started feeling that we were finally getting into the medicine, learning examinations and technical skills. Who could forget Communication Skills, where every three weeks when you finally thought you had a break from exams, you had an act to put on, whether it be breaking bad news, acting out a multidisciplinary communication scene, we started to question if we were doing a drama course. The days of PDQ in year

PATRICK CHIN-KONG MBBS CLASS OF 2017 VALEDICTORIAN

three, where coming down to the week of the examination, everyone tried to pick the lecturers for hints.

Onto our clinical years, the guys with the brand new white shirts, or shirt jacks, and the girls with their new white jackets tailored to their fit and the gold pin with our names. We were excited to start going onto the wards as medical students, where there were less classroom sessions. This was when we learned to live on the wards, and that each patient was a page and each ward was a different chapter of our textbooks. Even though the famous “L” factor that Dr. Harnaryan always told us about was strong with us, we tried to conquer it. We got a sample of what our lives are going to be like as doctors, attending clinics, ward rounds, calls, following up our patients and even assisting in the ward work to help

the interns out and gain experience for ourselves.

Who can forget our faculty events such as the TTMSA Annual Fun Day that brought us closer each year, and Class of 2017 we shall forever be remembered as Code Blue; MEDS play where everyone came out in their full Indian wear for the event, and who could forget Nurse Pusungee’s quote from 2015’s play, “Always chase after your dreams, when you catch it, grab it and pelt it further and run after it again,” and the Art Society’s famous galas, and all other events held by the various clubs at the Faculty of Medical Sciences.

We have much to be thankful for.

Firstly, we want to thank God. For without him, we won’t be here today and made it this far.

Secondly, here at the UWI, St. Augustine Campus we have received a great education thanks to our fine administration and lecturers. We are prepared to move on and to take on whatever challenges come next in our lives.

We would like to thank you, the lecturers of clinical and pre and para-clinical departments for guiding, mentoring and assisting us along the way to achieve this milestone event. Tremendous thanks go out to the administrative staff who always worked assiduously behind the scenes to help us through it all.

We the graduates are greatly indebted to our families. These past five years have presented us with a lot of trials and tribulations and it is good to know that we had our families in our corner, supporting us along the way.

Always ensuring we had food to eat, clean clothes, and a roof over our head.

Thank you! thank you! thank you!

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We are also thankful to our patients. They have given us the opportunity for us to take histories from them and especially, to examine them when OSCE was around the corner, when we all mastered the art of introducing ourselves as medical students.

Finally, we are thankful for one other. The friendships that we have made here will last a lifetime. In the same way, we have supported and helped one other succeed in these years at UWI, I hope we will continue to provide support and encouragement for one another in future endeavours. We can’t forget our friends who didn’t

make it. It saddens us they are not here to celebrate this day, and we will certainly assist in every little way and give them the encouragement to get back up. Special thanks to my Group A family and friends in other groups and the higher years—without your support and encouragement, as group leader and class representative over the past two years, I won’t have made it this far without you all, thank you.

As we go forth into our medical career as interns on July 1, 2017, the date Dr. Motilal constantly reminds us of in his classes, as my group knows I like to give reminders, remember it’s

hool is edical sc ect of m to p as e, v g fi in four and challeng udy The most gement! In years own ward and st n a o y n ls m a o e g ad g m time ma I and settin st my time manage y using a planner to study. My mo b schedule n topics I needed iving my finals o ce st each day mo ment was re efinitely my mo ble as d ose w S B me mora B ed all th as so M v e s. li lt re su as MBBS re perience so I w ing paid off. I w h it dy ex stressful less hours of stu e this mo ment w d ar almost en I was able to sh friends. at nd happy th , close fa mily a er my moth

April 7, 20 15 was my fo and it was also the da urth year orientation yw the brightes t and most hen I was graced by beautiful so ever had th e pleasure ul that I ha of ve found acqu aintance an meeting. This new d I would the same su soon be pu rgical unit t on at light, brav e this foreig SFGH and with her n it. For the next two ye landscape, conqueri ng ars our bo strengthen nd would an shield toge d taking up the battl e axe and ther again, conquer M That day w BBS as ing hope to the start of something finals. the rest of new, addmy days.

just another beginning of our medical careers, what we have learnt throughout our five years of training, to be kind to our patients, colleagues and seniors, the patient in front of us, is important and the ethics of health care—autonomy, beneficence, justice and non-maleficence. I would like us all to remember this quote by William Osler, “The good physician treats the disease; the great physician treats the patient who has the disease.”

Thank you and congratulations again Class of 2017!

Fourth ye interacti ar is a big tran s n new set g with patients ition to being a o alism, a f challenges a extensively. T working stude his ro nt, n experie d workplace re und communic brings a who nc le la a and lea e in which yo tionships. It w tion, professio rn u n il you. Th ing from those spend a lot of l be a humblin tim e g who are learn in amount of kn more ex e listening to ow m informa edical school ledge that on perienced than e ti is is supp fire hose on has been d huge. Taking ose escribe in that a d to . da My mo If you’re not st mem careful, s trying to dri mount of o n it rable ex hospita k out o will blo la fa p presenta t 2:30am to vie erience was go w you away. ing bac tion. w a surg k ery for to the my gra nd roun ds

First le medic t me debun k a cal lite l school is a myth: the th r parts a ature you h e work, the hardest asp ec a r v over th e non-med ve to learn. ast amoun t of ic t Wron g! The of mediing, fin e fear of pu al. Strange ,r b d h challe ing food a lic speaking ight? Amo ardest ng t n , it and ging part fo 12am in the self-directe getting it r d plann will be yo me was tim hospital, th learnin u e of my g, always r greatest a e manage m most lly ex e b horseb est me mor pect the un . But with nt. Perfect ies all ex ack rid ing. E here was r pected bec that ealisin njoy! a g my use one dream of

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nical t the cli ent in first time. I m o m e le t th b s r a o r o f o m m g CPR as is. The ost me My m as performin fragile life ool for me w w h w o c s ing s h e l e b a s year y ic li a d tl f me penstan me re made ing aspect o on. I was co success I ex I g ti e n ly e ta th k ll p a d ic a u ch an ad how q ations nstant the co ith new situ depended on re don't be o w f n e o d face rotati tions. Ther rt zone and l a d in a rience to new situ your comfo tions. It wil . f a r d o u te te t f it p s u a a e o r e e ad ew and th pt to n to mov afraid quickly ada dical school e learn to u through m o help y

As a student, you are plunged into a world of death and disease that we use science to package into neat diagnoses to be studied. Some do it as a job, fixing a problem, belonging to a bed number. Some see it as a calling, easing the transition from sick to healthy beyond just the medicine. Learning to treat your paperwork as patients, and not the other way around, developing empathy, living through the fears, hopes, relief, grief and uncertainty with your patients, these cannot be taught by a textbook. It's not the best job, but maybe the best calling.

My m 4 and ost memo ra sure t 5 experien ble mome o all the d ces. I enjo nts were m acting if y y The c and build ferent hos ed getting year pitals ing ra linica exponicati pport and i l year n o s w When n skills I truly test ith patie tern o e ts. n d t a c t l e ho kin le thise and g g to patie arnt in ye se commu n a e r t to k t and n now s you lear one. ot jus t n h e to e t ther patien e med t as a mpaical i whol llness e .

My m wou ost me l m play d have orable . It w to be m fron my oment as l t and me. I d ike a m taking p in med o i e I proc made n cided I vie play art in th cal scho e e It is ss. Med ot only wanted ing out yearly ol f t b mem the time ical sch riends b o be pa rilliant MEDS r l o indi ories an spent w ol is no ut a clos t of the y in vidu actio ith f d e t o f m a n stud mily al. I ake rien ly ab n t t d e fies nts to t is some he large s that w out aca in the ry. I d your s t i h e t l l m i im ng e t can i ever role in rears hu I woul pact on cho in y a. d ur our imag the m mili you g t a e y edic ine. al fi , matur new m s an eld g it e reate y and so dical r tha l n yo idiu

The most challenging aspect of medical school in my opinion is proper time management. Being on the wards at crazy hours, and knowing all the patients and doing ward work, while being expected to know all the theory, while also being expected to be well rested enough to function daily at a high level, proves to be extremely difficult, if not impossible.

The most memorable moment for me would have to be meeting the people on the first few days of first year, who would eventually become like an adopted family—the “code blue" family.