Let me preface this post by sharing that I’m not someone who drinks, particularly when I heard of the WHO consensus statement in 2023 that there is no level of alcohol that is safe for consumption (in contrast to the often echoed guidelines about how men and women should consume under two and one standard drink(s) daily). This is similar to how there is no level of cigarette smoking that is safe. Nevertheless, alcohol consumption is extremely prevalent, and is commonly viewed as a means by which people in society can socialise more easily.
Starting medical school has a way of turning everyday experiences into mini science lessons. Let me share with you some of the details of ethanol metabolism that I learnt about as I studied biochemistry previously.
1. The biochemistry of ethanol metabolism
Ethanol is metabolized primarily through two key enzymes in a two-step process that happens mostly in hepatocytes (liver cells). First, alcohol dehydrogenase (ADH) oxidizes ethanol into acetaldehyde. This step reduces NAD⁺ to NADH. Acetaldehyde is a highly toxic substance and a known carcinogen. Your body doesn’t let it hang around for long, though. Next, aldehyde dehydrogenase (ALDH), particularly the mitochondrial ALDH2, quickly converts acetaldehyde into acetate (acetic acid). Acetate is then turned into acetyl-CoA and fed into the citric acid cycle, eventually becoming CO₂ and water. Consider the following diagram (a screenshot from a review book that I used extensively during medical school):
This above pathway is why our bodies can clear alcohol at a relatively steady rate (about 7–10 grams per hour on average, or roughly one standard drink), but it also explains a lot of the damage. The buildup of NADH shifts the cell’s redox state, which can mess with other metabolic processes, contributing to things like hypoglycemia or AFLD (alcoholic fatty liver disease) in heavy drinkers.
The real “wow” moment for me was learning about disulfiram (not something I see in clinical practice in Singapore, but interesting to learn about it; it’s probably something used in the US). This drug is used in alcohol dependence treatment and works by irreversibly inhibiting ALDH. If you drink while on it, seurm acetaldehyde levels skyrocket, often 5–10 times higher than normal. The result of drinking while on disulfiram is a disulfiram-alcohol reaction: flushing, nausea, vomiting, palpitations, headache, and a general feeling of impending doom. It’s basically weaponizing the body’s own hangover chemistry as aversion therapy.
I was astonished at how elegantly (and brutally) it targets that single step in the pathway of ethanol metabolism. It’s a reminder of how finely tuned our metabolism is, and how a small backup in the pathway can make you feel utterly miserable.
2. The gritty etymology of “hangover”
The second lesson came from outside the textbook. I recently came back from a trip to Japan, and whilst resting in the hotel rooms in the evening during the trip, I would sometimes watch some educational videos to expand my general knowledge. On one of the evenings, I had watched a video about the typical life of the underprivileged in Victorian-era London. The real story of the story behind the term ‘hangover’ is darker and more human.
In Victorian-era London, extreme poverty meant many destitute or homeless people couldn’t afford proper lodging. Apparently, for four pennies, you could buy a space on a very humble bed (whose sheets would not have been changed for a long time), and rest while supine. One could use such a space for eight hours and attempt to get some rest. However, some of the underprivileged, with their limited funds, would spend one or two pennies getting some alcohol instead, in an attempt to drown out their sorrows with the effects of alcohol at least in the form of a temporary escape. As a result, they wouldn’t have the required four pennies to rent a bed for eight hours. The result is that they aren’t able to afford the four-penny bed where they can lie down supine. Instead, they would have to opt for cheaper accommodation to spend the night.
For a lower price of two pennies, they could pay for a “two-penny hangover” in certain rough shelters. Proprietors would stretch ropes across a room like clotheslines. People would lean or drape themselves over these ropes to sleep—literally hanging over them. In the morning, the ropes were cut or lowered, and everyone “hung over” would drop to the floor, often still feeling the effects of cheap alcohol from the night before.
The Victorian image is vivid and poignant. It captures both the literal “hanging over” and the lingering misery that follows a night of drinking. It’s a stark reminder that hangovers aren’t just a modern inconvenience. They’ve been part of human (and especially underprivileged) experience for a long time.
Medical school has this habit of making the mundane profound. The next time you go out drinking with colleagues and friends (if you do drink), do consider the biochemistry churning away in your liver. Perhaps also spare a thought for those poor souls draped over ropes in 19th-century London…
Recently, I chanced upon an online media post where one writer shared how the now-defunct Czechoslovak Government legally pillaged the life savings of its citizens overnight. Allow me to share that with you.
Imagine waking up to discover your life’s savings in a local bank like DBS, UOB and OCBC — every hard-earned Singapore dollar tucked away for the future — being reduced to a fraction of its value by government decree.
This nightmare became reality for millions in Czechoslovakia on May 31, 1953, when the communist regime executed a pretty brutal currency reform. To provide some context, “Czechoslovak” refers to the former country of Czechoslovakia, which existed from 1918 to 1993 and was formed from the territories of Bohemia, Moravia, and Slovakia after the dissolution of the Austro-Hungarian Empire.
For many, the scars of that betrayal never fully healed.
The Backdrop: Post-War Economic Chaos
After World War II, Czechoslovakia faced severe economic turmoil. Inflation soared, and the rationing system—meant to manage wartime scarcity—had left a crippling imbalance between consumer demand and supply. The government, struggling under centralized planning failures, saw a “solution” in radical monetary intervention: a currency reform designed to erase excess cash and reset the economy.
But there was a catch. The reform wasn’t just economic—it was a political weapon.
The Deceit: Lies Before the Storm
Just 14 days before the reform, President Antonín Zápotocký publicly assured citizens there would be no changes to the currency. It was a calculated lie. On May 31, the government dropped a bombshell: all existing banknotes would be devalued, effective immediately.
The plan was simple, ruthless, and devastating.
The Reform: Legalized Theft
The government imposed exchange rates that obliterated savings:
First 300 Kčs: Converted at 5 old korunas to 1 new koruna.
Savings above 300 Kčs: Converted at 50:1.
For example:
A family with 5,000 Kčs saved pretty much saw their life’s work reduced to 100 Kčs overnight.
Workers, pensioners, and farmers—people already struggling—lost decades of savings in a single stroke.
The state framed this as a “reset” to curb inflation. In reality, it was state-sanctioned theft, nullifying its obligations to citizens and consolidating control over the economy.
A Betrayal That Lingered
The writer’s grandfather was 20 years old when the reform hit. Like many young people, he didn’t have much saved. But what haunted him wasn’t the money—it was the betrayal. The government he’d been told to trust had lied, manipulated, and stolen from its own people.
“They turned us into beggars with the stroke of a pen,” that writer’s grandfather would say, his voice still sharp with anger 50 years later.
The People Fight Back
The public reaction was swift and furious. In cities like Plzeň, workers—the very class the communist regime claimed to uplift—flooded the streets in protest. Factories ground to a halt. Citizens demanded accountability.
The regime responded with force. Protesters were arrested, dissenters silenced, and the media censored. The message was clear: resistance would be crushed.
A Pyrrhic Victory
While the reform technically stabilized inflation, it came at a catastrophic cost:
Living standards plummeted as savings vanished.
Trust in the government collapsed, replaced by widespread cynicism.
The state’s credibility was bankrupt long before its economy recovered.
Historians now recognize the 1953 currency reform as one of the most draconian economic policies of the communist era—a stark symbol of centralized control’s brutality.
Distrust and the Rise of Bitcoin
For generations of Czechs and Slovaks, the 1953 reform left an indelible lesson: governments cannot be trusted with money.
Bitcoin’s decentralized, apolitical nature offers an antidote to the scars of the past. As that writer’s grandfather’s story shows, when a government can erase your savings overnight, the appeal of a currency no one can control becomes undeniable.
History’s Warning
The 1953 currency reform wasn’t just about economics—it was about power. It revealed how easily a regime can weaponize money to control its people. For Czech Bitcoiners, this history isn’t abstract. It’s a family story, a cautionary tale, and a rallying cry for financial sovereignty. As governments worldwide experiment with monetary policy, the ghosts of 1953 remind us: Without safeguards, the state’s pen can still become a thief’s tool.
After a typical Sunday morning at church today, I headed for lunch at the Wisma Atria foodrepublic food court before then making my way to Sim Lim Square to upgrade my newly bought ThinkPad E16 Gen 2 with some extra RAM.
Walking through Sim Lim’s narrow corridors lined with gadget-packed shops, I was reminded of why this place remains so essential for tech lovers in Singapore. Beyond being a treasure trove of electronics, SLS is also one of the few places where a bit of bargaining can help you score satisfying deals.
Sim Lim Square is steeped in history, with its doors opening in 1985. For nearly 40 years, it has been a gathering spot for everyone, from hobbyists and tech enthusiasts to bargain hunters and tourists looking for their first tech haul. Over the years, it has maintained its reputation as the go-to hub for everything tech. It’s a place where prices aren’t always fixed, and a bit of negotiation is often expected—if you know how to play your cards right.
A few days prior, I had also found myself wandering these same halls, eyeing a new HDD for my backup needs. With SSDs all the rage these days, HDDs often get overlooked. However, for long-term data storage, I still find HDDs more reliable. HDDs are also more affordable. My aim was a Western Digital My Passport 2 TB model, so I spent some time comparing prices from various shops in SLS.
Here’s what I found (just in case you’re interested in buying a hard drive too):
#02-66 was selling the 2TB WD My Passport for SGD 109
#03-90 had it priced higher, at SGD 159 (ridiculous, right? lol. I think this seems to support the notion that the mainstream shops on the lower levels tend to be frequented and patronised by noobs and folk who are not so ‘in-the-know’).
#04-70 offered it for a very competitive SGD 95
#05-46/47 priced it at SGD 98,
#05-48 gave SGD 98 as their fixed price on their price list; however, when I started walking away, they said that SGD 96 was their “best price”
#05-50 publicly listed the price as SGD 100; but the staff said, “for you, brother, I offer you SGD 99).
After scouting these options, I went for the shop on #04-70, which had the best deal at SGD 95. I frankly doubt that one can get a better deal for this. SGD 95 would be even cheaper than what one would find on Amazon, Lazada, or Shopee. If any of you are able to find a place in Singapore which sells this product for less than 95, let me know! I’d be really keen to learn where this place is.
Anyway, this kind of comparison gave me a good sense of how prices can vary between shops even for identical items and reinforced the value of a bit of patient research and price-checking. So, my experience with the HDD shopping gave me some insight into price ranges, and I adopted the same approach to my RAM shopping this afternoon.
When I went back today to buy two pieces of SODIMM DDR5-4800 MHz 32 GB RAM (see above) for my laptop, I found myself at Tradepac, which had listed these RAM sticks at a fixed price of SGD 118 each. I however wanted to get them for SGD 115 per piece.
So I initiated a friendly negotiation, suggesting SGD 115 per RAM stick, even offering to pay in cash. Cash payments, after all, are often more appealing to small businesses as they save on potential digital transaction fees. But the staff insisted his margins were too slim to accommodate my offer.
Then I mentioned a competing offer from Dynacore upstairs, who was selling the same RAM for SGD 116 per stick. Upon hearing this, the Tradepac staff started saying how prices fluctuate, and his competitor may have readjusted the price such that it was now higher than SGD 116.
Seeing that he still wouldn’t budge, I started to walk away. This little nudge did the trick—the shop owner quickly called his colleague over, exchanging a few words in an Indian language.
Then the Tradepac owner was like, “You can pay with cash, right? Ok ok ok, 115 per piece”. I happily took my new purchase (picture below), promptly got home to get the RAM sticks into my laptop myself (There was absolutely no way I was going to pay the service staff an additional SGD 20-70 for helping me put in the RAM when I had the expertise to just do it myself).
The appeal of cash in these negotiations can’t be understated. Many smaller shops in SLS work on tight profit margins and potentially face transaction fees on digital payments, so cash provides an immediate benefit. Plus, offering cash creates a sense of finality, a kind of instant transaction that can be quite persuasive, especially if you have a few blue ’50’ bills in your hand from the get go. It may signal that you are a serious buyer.
Shopping at SLS isn’t only about finding the right price but also about understanding the environment. Each shop has its own approach, and each negotiation can be different. There’s an art to bargaining here (something which I want to get even better at) — a mix of patience, respect, and a willingness to walk away if needed. Whether I’m after a Western Digital HDD or RAM for my laptop, knowing when to negotiate and when to accept a fair price makes all the difference. SLS, with its storied past and bustling tech scene, remains a place where you can find not only the latest gadgets but also the thrill of bargaining and the chance to pick up something new without breaking the bank.
For anyone with a bit of patience, an open mind, and cash in hand, there’s really no place quite like it.
It’s currently about a week and a half before the start of my final exams as a fourth-year med student. As part of my revision schedule, I’m revising some ophthalmology content this afternoon – yes, even on CNY Day 1. Sad, right? Officially, we’re only granted a 1-week study break and this week just happens to be preceded by a weekend which constitutes the first two days of CNY 2024.
Specifically, here I am reading about age-related macular degeneration, and here’s an interesting sentence I chanced upon: “Other risk factors include smoking, gender, …, and hypermetropia”. As I read this the above sentence, I couldn’t help but ponder on the term ‘hypermetropia’. I was much more familiar with ‘hyperopia’, and wondered if they were truly synonymous. Alternatively, were there subtle differences that I’m not aware of?
Historical Perspective and Donders’ Influence
The journey begins with the work of Donders, a pioneer whose contributions in the 19th century shaped our understanding of refractive errors. Donders introduced the term ‘hypermetropia’ to describe a condition where the eye’s optical power is insufficient for its length, causing light to focus behind the retina. This term, etymologically derived from Greek—’hyper’ (over), ‘metron’ (measure), and ‘ops’ (eye)—captures the essence of the condition with remarkable precision: an eye that measures beyond normal.
Donders’ differentiation between hypermetropia and myopia, as well as his distinction from presbyopia, was a monumental step forward. It was a clarification that allowed for a more accurate diagnosis and understanding of visual impairments, distinguishing between the effects of aging and inherent optical power discrepancies.
The Etymological Critique by Duke-Elder
Sir Stewart Duke-Elder (after whom the Duke-Elder Undergraduate Prize is named), a towering figure in the field of ophthalmology, later critiqued the term ‘hyperopia,’ advocating for the original ‘hypermetropia’ as etymologically sound. His argument was rooted, I suppose, in the desire for terminological precision that fully encapsulated the condition’s nature. The term ‘hyperopia’—whilst shorter and arguably simpler—lacks the explicit reference to ‘measure’ that ‘hypermetropia’ carries. Duke-Elder’s concern was that ‘hyperopia’ might misleadingly suggest an elongation of the eye itself, rather than a discrepancy in its focusing capability.
Modern Usage and the Persistence of Both Terms
Despite Duke-Elder’s criticisms, it seems that both terms have persisted in the ophthalmic community, with ‘hyperopia’ seemingly being the more popular one (at least based on Google’s Ngram viewer (see below), which reports that ‘hyperopia’ has been consistently the more popular of the two terms since the 1970s). This could be because it’s a shorter word.
Embracing Linguistic Diversity in Ophthalmology
The debate between ‘hypermetropia’ and ‘hyperopia’ is a testament to the rich linguistic heritage of the medical profession. Staying true to etymology is how clinical tutors are able to teach medical students that ‘Staphylococcus’ looks like a bunch or cluster of grapes under the microscope, while ‘Streptococcus’ can be seen looking like chains. It underscores the importance of language in framing our understanding of medicine.
More broadly, I would say that from this example, we are reminded of the giants upon whose shoulders the field of ophthalmology stands. Donders’ legacy, enriched by Duke-Elder’s critiques, offers more than just a lesson in etymology; it invites us to appreciate the depth and precision that language brings to the science of vision.
Thus, let us cherish the diversity of its language, understanding that whether we choose ‘hypermetropia’ or ‘hyperopia’, our goal remains the same: to enhance the clarity of sight and understanding.
In December 1980, a man stood atop a platform at Fullerton Square and delivered an important message at a rally amidst light rain. His determination resonated as he declared amidst the pitter-patter, “Whoever governs Singapore must have that iron in him. Or give it up. This is not a game of cards. This is your life and mine! I’ve spent a whole lifetime building this and as long as I’m in charge, nobody’s going to knock it down“. Singapore’s growth has been systematic and intentional, owing to the iron will of Mr. Lee.
As we contemplate the future without Mr. Lee’s direct influence, we must grapple with the implications of his legacy, and our vision for a Singapore that continues to prosper. In this post, I hope to delve into my understanding of Mr. Lee’s enduring influence and my aspiration for a Singapore that builds upon his foundational ideals, while evolving to meet the complexities of our changing world. With my family’s journey as a testament to Mr. Lee’s dream of a meritocratic society, I offer a perspective that intertwines personal experiences with national evolution, underscoring our shared destiny in a post-Lee Kuan Yew era.
UNDERSTANDING LEE KUAN YEW’S LEGACY
Born in 1997 into a family that epitomises the fruit of meritocracy, an ideal that Mr. Lee Kuan Yew held dear, I am a part of the generation that has grown up marvelling at the success of the nation he built. My paternal grandparents, who were emigrants from Hainan, lived humble lives. My grandfather was a ship’s chef, often away on lengthy overseas postings, resulting in an absence of a father figure for my father and his siblings. My grandmother, in contrast, worked as a servant for a British family during Singapore’s colonial days.
Yet, despite the odds, they raised my father to value education, and he became the first university graduate in his family, a source of immense pride for my grandparents. Today, I am a medical student at Singapore’s oldest medical school, whilst my middle brother is on an overseas military scholarship training to be a pilot with the Singapore Air Force, and my youngest brother is studying Electronic Engineering at NUS. To understand the legacy of Mr. Lee Kuan Yew, we must navigate the maze of his influence that has shaped Singapore’s economic and socio-political landscapes.
Economically, Mr. Lee was our Odysseus, guiding Singapore from a resource-starved agrarian economy to become a bustling cosmopolis and a pivotal node in the global financial network. His visionary investment in education and skills development, coupled with fostering a hospitable climate for enterprise, provided the bedrock for our vibrant knowledge economy. His pragmatism bore witness to the inception of the Housing and Development Board (HDB) and the Central Provident Fund (CPF). These social programs revolutionised living standards for the average Singaporean, providing affordable housing and financial security respectively, while promoting a sense of national ownership and unity.
Politically, Mr. Lee’s conviction in a corruption-free, meritocratic system was instrumental in cultivating effective governance and public trust. His steadfast commitment to racial and religious harmony helped foster an environment where diverse ethnic and religious groups peacefully coexist.
However, it is crucial to acknowledge that these achievements involved certain trade-offs. Mr. Lee’s vision of swift development occasionally found itself at odds with individual liberties, resulting in an authoritarian governance model. Critics suggest that his firm hand on law and order suppressed political dissent and curbed freedom of expression, casting a shadow over his legacy. Nevertheless, my family’s journey remains a testament to Mr. Lee’s tireless efforts at nation-building. The opportunity for my father to become a university graduate and for my siblings and me to pursue our ambitions reflects the successful implementation of at least one aspect of Mr. Lee’s vision.
A GENERATIONAL PERSPECTIVE: LEE’S INFLUENCE ON THE POST-1990 GENERATION
Mr. Lee’s legacy etches its influence into the collective consciousness of Singaporeans born after 1990. Notably, the year marks the end of Mr. Lee’s 32-year-long term as Singapore’s founding prime minister. We are the silent inheritors of the principles that propelled Singapore from a fledgling nation to a cosmopolitan city-state. This inheritance is evident in our relentless pursuit of excellence, a testament to Mr. Lee’s commitment to meritocracy. The tale of my family’s social mobility mirrors this conviction, as we strive to achieve our fullest potential within the meritocratic framework that Mr. Lee championed.
Mr. Lee’s enduring influence also extends into our societal fabric. His dedication to racial harmony has imbued us with an appreciation for multiculturalism, and such harmony was on full display during the 2010 Youth Olympic Games, an event that showcased our unity in diversity to the world. It was a moment of shared pride for my generation, seeing the synergy of diverse cultures that makes Singapore unique.
Moreover, Mr. Lee’s uncompromising stance against corruption is not just a principle but a lived reality that continues to inspire us to uphold integrity in our personal and professional pursuits. One striking incident that underscores this involves a botched bribery attempt by the United States Central Intelligence Agency (CIA). As documented in declassified documents, a CIA agent, in 1960, was caught trying to bribe a Singapore intelligence officer.
In response, the CIA audaciously offered then Prime Minister Lee Kuan Yew a sum of USD $3.3 million to cover up the matter. Displaying the steadfastness that defined his tenure, Mr. Lee categorically rejected the offer. Instead, he proposed that the U.S. provide formal economic aid to Singapore, redirecting the incident towards a constructive outcome that benefitted the nation.
Further demonstrating the integrity of his character, when the U.S. State Department and the ambassador to Malaysia attempted to deny the incident, Mr. Lee presented a formal letter of apology from then U.S. Secretary of State, as undeniable proof of the event. In a poignant television interview, Mr. Lee warned the Americans of the character of the people they were dealing with in Singapore. In his words, “You do not buy and sell this Government.”
This incident sent a powerful message to the world about Singapore’s incorruptibility and the nation’s refusal to compromise on integrity. Such occurrences have influenced our collective psyche, reinforcing our commitment to uphold these principles of integrity in our endeavours.
However, we are not merely the custodians of Mr. Lee’s legacy. We are also its innovators, faced with the responsibility of interpreting his principles in our rapidly evolving world. As we approach this crossroads, we envision a future that blends the resolute spirit of the past with an innovative ethos for the future, extending Mr. Lee’s legacy into the Singapore of tomorrow. Mr. Lee’s legacy, while revered, should not be seen as an immovable monolith, but rather as a foundation to be built upon.
SHAPING THE POST-LEE KUAN YEW SINGAPORE: EVALUATING THE LEGACY AND ENVISIONING THE FUTURE
Navigating the path forward necessitates upholding the legacy of integrity and meritocracy, fundamental pillars established by Mr. Lee. The 1960 CIA bribery incident serves as a stark reminder of the moral rectitude that Mr. Lee upheld. As an aspiring professional soon to join a field where the highest standards of integrity are expected, the significance of this is not lost on me.
Yet, preserving these principles does not entail rigidity; our approach must adapt to contemporary challenges. For instance, Mr. Lee’s advocacy for language stream schools was instrumental in fostering bilingualism and promoting social cohesion in its time. However, in today’s era of globalisation and digital interconnectivity, we need to foster an even more inclusive cross-cultural perspective.
The digital revolution, coupled with the emergence of ground-breaking technologies, calls for a re-evaluation of our economic model. Singapore, under the visionary leadership of Mr. Lee, has already positioned itself as a global hub for manufacturing and finance. However, the post-1990 generation now confronts a rapidly changing landscape shaped by technological disruptions. As we navigate this new era, it is imperative to foster innovation, nurture entrepreneurship, and leverage the potential of data and artificial intelligence.
Notably, the advent of cryptocurrencies, led by Bitcoin, revolutionized finance and blockchain technology, bringing attention, legitimacy, and paving the way for a vibrant cryptocurrency ecosystem. Similarly, the transformative advancements in artificial intelligence, including natural language processing and machine learning, are reshaping industries, and pushing the boundaries of what is possible. Language models such as ChatGPT have demonstrated the relative robustness of AI in human-computer interaction, transforming the way we communicate and access information.
In the face of these rapidly advancing technologies, one of Singapore’s fundamental principles of governance, ‘Anticipate change and stay relevant‘, becomes more important than ever. Singapore, as a resource-scarce nation, understands that its greatest resource is its people. By equipping its citizens with the skills and knowledge to thrive in the digital age, Singapore can continue to anticipate and embrace change, ensuring its relevance on the global stage. Embracing the principles of innovation, technological adaptation, and human capital development, Singapore can navigate the evolving landscape and maintain its position as a dynamic and resilient nation.
In a post-Lee Kuan Yew Singapore, I envisage a society that harmoniously synthesises our cherished heritage with the demands of a rapidly advancing world. We should harness economic prosperity with sustainability, let our cultural diversity reinforce social cohesion, and use our historical strengths as a springboard for future innovation.
As a future contributor to a profession steeped in trust, I am deeply committed to embodying Mr. Lee’s legacy within the healthcare sector. His principles of meritocracy and integrity are cornerstones on which I intend to build my practice. However, like Singapore itself, the healthcare industry must adapt and evolve. We face the demographic challenge of an ageing population, and the simultaneous excitement and uncertainty brought by medical technology breakthroughs, including predictive analytics and precision medicine.
Mr. Lee’s lifelong philosophy was one of learning from the past, being firmly grounded in the present, and constantly planning for the future. This philosophy encapsulates the balance we aim to achieve between preservation and evolution as we navigate the path of a post-Lee Kuan Yew Singapore.
CONCLUSION
As this voyage of a post reaches its final harbour, the towering figure of Mr. Lee Kuan Yew, a political Colossus, looms large in the panorama of my reflections. He has woven a tapestry of integrity, meritocracy, and pragmatism, whose threads have been central to Singapore’s nation-building narrative. His audacious defiance in the face of the CIA bribery incident remains a beacon of ethical conduct for us.
Yet, our role is not merely that of custodians of this legacy, but of shapers too, moulding it to our contemporary context. The advent of globalisation and technological innovation necessitates recalibrating our educational and economic models, from language stream schools to embracing the AI revolution.
I envisage a post-Lee Kuan Yew Singapore that cherishes its historical ethos but also strides fearlessly into a future built on sustainable prosperity, cultural unity, and technological innovation. As I stand on the cusp of my medical career, I will adhere to the time-honoured principles of my profession while also preparing for the inevitable challenges of an ageing society and the transformative potential of technologies like precision medicine.
Like Odysseus, we chart our course using the stars of our past as a guide, while the winds of our present challenges propel us towards the shores of our future destination.
Such is the essence of my vision for a post-Lee Kuan Yew Singapore.
Prior to my initial foray into the realm of serious resistance training, the closest encounter I had with physical exertion was during my two years as a full-time NSF in the Singapore Armed Forces. It has been more 5 years since I finished my two years as a full-time national serviceman though.
Fast forward to today – my life has taken a turn I never anticipated – a journey into the world of strength training. This was a journey sparked by a simple and innocent question which my youngest brother had posed to me on a fateful Saturday morning in early December 2022: “Do you want to go to the gym with me?“
I still remember how it was drizzling slightly and I was rather reluctant to accompany my brother to the gym. In retrospect, I’m so glad I felt somewhat adventurous and open-minded that day to the extent that I would agree to step outside my comfort zone. Perhaps the greatest factor in tipping the scale and convincing me to accompany my brother to the gym on that fateful Saturday morning was the realisation that I could achieve something similar to what he had done in terms of putting on muscle size/bulk. The reality was that his physique change was rather apparent over the few months that he had been going to the gym. Specifically, I noticed how his anterior deltoids had become more prominent. And I thought it looked great on him. I thought to myself: surely if I do what he does, I’m sure I could get something similar!
EVOLVING GOALS
When I took my first step into the gym, my goal was straightforward – to gain both muscle size and strength. Let’s talk about the goal of strength first. For the uninitiated, the standard 2.2-metre-long Olympic barbell weighs 20 kg, and a standard ‘plate’ is 20 kg. As such, a x-plate barbell would constitute the 20 kg barbell and x plates on each side of the barbell. As such, the 1/2/3/4 plate goal in the OHP, bench press, squat, and deadlift corresponds to 60 kg, 100 kg, 140 kg, and 180 kg respectively. This goal seemed (and of course, still seems) like a formidable challenge. Yet, multiple sources online claim it to be an achievable one for an average-weight male with no prior resistance training who has maintained a year of consistent training, proper nutrition, and ample recovery. Such milestones were concrete and defined. That’s the good thing about strength. The numbers are tangible and don’t lie. You can either lift it, or you can’t.
But with strength, I also had another captivating prospect – size. The idea of gaining size as a by-product of my strength training was enticing, because who wouldn’t want to look more jacked, right? I mentioned earlier how my youngest brother’s physique transformations were noticeable, and it was something I actively worked towards.
As much as some members of the fairer sex may not want to admit publicly, a muscular physique on the human body is something admirable by all. After all, is it not a testament to the person’s dedication, perseverance, and consistency? This is particularly so in an increasingly sedentary society where the prevalence of largely preventable metabolic diseases is rising, and even many individuals who are neither in the overweight or obese range for the BMI could be considered ‘skinny-fat’. It’s a shame that the limitations of BMI aren’t more widely known. Having even an acceptable ethnicity-adjusted BMI isn’t a carte blanche to just slack off and eat whatever one wants as long as one remains within the ‘acceptable range’. In fact, the vast majority of people who are in the ‘acceptable’ range stand to gain innumerable health benefits by starting a structured resistance-training programme with the purpose of gaining strength and functional muscle mass.
And just to clarify, I qualified the nouns “muscle mass” with “functional” for a reason. Gaining muscle mass isn’t just about the aesthetics (though this is admittedly the chief reason many guys go to the gym). There is a distinction (albeit a controversial and disputed one) between myofibrillar hypertrophy and sarcoplasmic hypertrophy, and the former is associated with substantial health benefits. Myofibrillar hypertrophy refers to the enlargement of the muscle fiber’s contractile components, i.e., the myofibrils. Unlike sarcoplasmic hypertrophy, which increases the muscle’s size mainly for aesthetic purposes, myofibrillar hypertrophy contributes significantly to the muscle’s functional capacity. Thus, while there is a place for aesthetics in the world of fitness, the focus on myofibrillar hypertrophy brings about a more holistic approach towards health and fitness. It emphasizes the role of functional muscle mass in enhancing our overall well-being, extending far beyond the confines of the gym.
On the topic of gain and loss of mass/size of muscle, I have increasingly not liked using the generic term ‘weight loss’. Weight loss can happen in a myriad of scenarios, and can be due to losing predominantly fat mass, losing predominantly muscle and fat mass, losing predominantly ‘water weight’, and even losing predominantly muscle mass. When most people say they want to ‘lose weight’, what they usually mean is that they want to lose fat, while minimising any muscle tissue loss (or perhaps even maintain or even facilitate muscle hypertrophy during the weight loss period).
The biggest mistake I made in hindsight when undergoing that aggressive fat loss journey was that I did so without paying serious attention to my daily protein intake and without doing any sort of structured resistance training whatsoever. This is because research has established that both adequate protein intake and an appropriate amount of resistance training helps preserve muscle mass.
So, that was exactly what I started off with when I began this structured 23-week-long strength-training journey on 26 December 2022. Compared to my June 2022 self, the December 2022 self was still skinny-fat – just with a lower body fat percentage. Sure, my BMI was finally very comfortably in the ‘acceptable’ range after that drastic cutting phase that I engaged in over the course of a few months, but in retrospect I was a sack of bones with barely any muscle. So what if one’s body fat is relatively low if one doesn’t have the accompanying amount of muscle mass? Such a physique just makes one look skinny and weak.
SURPRISING MILESTONES DURING THE 23 WEEKS
I was taken aback when I achieved the first of the 1/2/3/4 plate milestones within just 3.5 months of training – the 1-plate OHP. Traditionally, this is considered the toughest of the four goals to achieve due to the unforgiving nature of the overhead press. Imagine lifting 60 kg overhead – it’s no easy feat! However, this has become my favourite compound movement, and the joy I experienced upon achieving this goal on 13 April 2023 is indescribable. I remember shouting a resounding “Yes!” in the gym that day – April 13, 2023, a day that will forever remain etched in my memory.
Adherence to the training program, a diligent focus on nutrition, and prioritizing recovery have been the cornerstone of my success. My journey was marked by consistent training, bulking up my nutrition, and ensuring optimal recovery – even if I could not always achieve the recommended seven hours of sleep.
CONCLUSION
Looking back at my 23-week journey with Phrak’s variant of the GreySkull Linear Progression program, I see a transformation that has been as much about physical changes as it has been about personal growth. My goals have evolved from just gaining strength and size to a broader perspective – healthy aging and longevity. With this evolved perspective, I recently embarked on a new journey with Jim Wendler’s 5/3/1 program for beginners, which includes my self-initiated structured running training to complement my strength training. This holistic approach considers not only raw strength but also cardiopulmonary fitness, encompassing aerobic capacity and endurance.
Stay tuned as I continue my journey towards becoming the best version of myself, maintaining a balanced focus on strength, endurance, and overall health. Remember, life is about constant growth and improvement, and my journey is just one example of how that can manifest.
As a youth in Singapore and an aspiring future homeowner, I am pleased to read of the additional property cooling measures announced recently. However, despite these efforts, young Singaporeans continue to grapple with the challenging prospects of homeownership. It is not uncommon to hear people in-person and on online forums lamenting that HDB should take responsibility for buying back all resale flats at reasonable prices, ensuring only minimal profits for sellers to maintain maximal affordability. While profit-making may not align with the spirit of public housing, this quixotic proposal regrettably overlooks both human monetary incentives and fundamental economic and logistical constraints.
Selling HDB flats back to the board after the minimum occupancy period presents financial and logistical challenges. With billions of dollars in annual resale flat transactions, HDB would require substantial liquid assets. Furthermore, HDB would need to expand resources, handle increased transactions, and manage flat maintenance between buyers, leading to higher taxpayer-funded costs.
Possibly a more sustainable approach is implementing a hard cap on Cash Over Valuation (COV) for HDB resale flats. Setting a maximum limit on selling prices, accounting for depreciation, lease duration, and inflation, could create a controlled market. A fixed COV cap, like SGD 75,000 (though the fixed cap is probably best determined by policymakers with access to all relevant data) would prevent unreasonable pricing for potential buyers of HDB resale flats while allowing sellers a modest profit.
Understandably, this proposal may face opposition from existing property owners. As the number of current homeowners exceeds those seeking their first flat, it is natural for voting dynamics to be considered. While the principle of “Do what is right, not what is popular” (anyone else remembers this from the blue SS textbook we had to learn from in secondary school?) has guided Singapore’s governance, navigating the complexities of the property market remains a Sisyphean task. Ultimately, striking a balance between the needs of current and prospective homeowners will be crucial in determining the future of housing policy in Singapore.
In sum, implementing a hard cap on COV may offer a balanced approach, addressing the concerns of young Singaporeans without placing undue strain on resources. I implore policymakers to consider this alternative and not neglect the dreams and aspirations of our nation’s youth.
As an alumnus of Maris Stella High School and a current student at the National University of Singapore (NUS), I echo the sentiments of the opinion piece by Mr Sim Lim Onn (‘Grateful for big donation to NUS’, 13 April 2023). I vividly recall the TK Low Hall within the campus of Maris Stella High School, which would always be used for a myriad of activities, enhancing the school experience for Marists across all year levels.
Utilitarianism encourages maximising overall happiness and well-being. In this case, the advantages of using the donation by the Low Tuck Kwong Foundation to support leadership programmes for policymakers and scholars from Asia, as well as promoting research in green energy, could be deemed to outweigh the ethical concerns. It is vital to focus on the opportunity to train leaders who can advocate for sustainability practices and contribute to the global fight against climate change. Whilst it is important to scrutinise university funding sources, we also have a duty to acknowledge the positive outcomes that can arise from accepting donations linked to fossil fuels. By educating and empowering leaders dedicated to sustainability, we can be good stewards of our resources whilst on our quest to create a more environmentally responsible future.
The Necessity, Ethics, and Consequences of Restraints
Physical restraints can be necessary in medical settings to prevent disoriented or confused patients from inadvertently causing harm to themselves or others. However, it is crucial to differentiate between appropriate restraint use and excessive application. Hospital protocols should adhere to ethical guidelines, minimise restraint utilisation, and respect the dignity and autonomy of patients.
Ms Lim’s apprehension about her mother’s care is understandable, given the potential consequences of restraint use, such as prolonged immobilisation, muscle atrophy, pressure ulcers, and adverse psychological effects. These concerns underscore the importance of finding alternative approaches to ensure the well-being of our ageing population.
Exploring Alternatives and Encouraging Open Dialogue
Healthcare professionals continuously seek alternatives to physical restraints, such as multidisciplinary care plans, addressing reversible underlying causes of agitation, and using personalised environmental modifications and assistive devices. Family members play a crucial role in patient care by offering emotional support and advocating for their loved ones. Ms Lim’s decision to voice her concerns highlights the importance of open dialogue between hospitals, medical professionals, patients, and their families in addressing concerns and ensuring that everyone’s voice is heard.
Conclusion
Admittedly, the issue of physical restraints in elderly care is complex. As Singapore’s population ages, prioritising the well-being of our elderly patients becomes increasingly important. By embracing a holistic approach to patient care, we can minimise the use of physical restraints and ensure a more compassionate healthcare experience for our elderly patients.
The provocative title warrants meticulous examination.
Recently, I encountered a video containing that title, and it made me wonder: what could possibly justify such a bold statement? In an attempt to satiate my curiosity, I opted to watch the video to hear what the video creator had to say.
While I certainly didn’t attempt any slow and careful reading of Peter Singer’s controversial 15-page paper “Famine, Affluence, and Morality” that constituted the basis for the video’s title, I have indirectly learnt that the paper unveils a moral challenge. More than half a century after the publication of Singer’s paper, the paper remains a classic text in the study of ethics.
The paper invites reflection on one’s own privilege, echoing the myth of Narcissus (from which we get the word ‘narcissistic’ that has wended its way into psychiatric terminology, and unfortunately – common parlance too where it’s commonly inappropriately usedat the expense of actual patients suffering from narcissistic personality disorder), whose inability to recognise his reflection led to his downfall – a fall resulting in more than a mere benign splash in a body of water. In this blog post, I hope to briefly share what I learnt about Peter Singer’s work.
Singer’s argument
Singer presents a cogent argument that probes the moral obligations of those of us in relatively affluent societies towards those beleaguered by poverty and preventable diseases. The crux of his argument appears to be that providing help to those in need is incumbent upon us, particularly when doing so necessitates relatively minor sacrifices on our part.
To illustrate his point, Singer employs an allegory reminiscent of the Good Samaritan: if one were to encounter a child drowning in a pond, with the capacity to save the child at virtually no personal cost, a moral obligation to intervene would arise. Singer maintains that this principle should extend to assisting those in need, irrespective of geographical location.
Another example closer to home
To make this argument more relatable for those of us in this tiny city-state, consider yet another example.
While routinely strolling along Orchard Road on a swelteringly hot afternoon, you see a person suddenly fall to the ground and astutely recognise the clinical features of a potential heart attack (especially so if you’re a medical professional): excruciating crushing chest tightness, dyspnoea, a grimace, Levine’s sign, etc. All that jazz happens while his wife with whom he was previously walking comfortably just moments ago tells you rapidly that he has a personal history of longstanding hypertension, dyslipidaemia, and diabetes.
If you’re a bystander trained in basic first aid, you’d have the skills to help this person and potentially save their life. In this situation, most of us would concur that a moral obligation exists to intervene and help out. Singer’s argument extrapolates such a moral duty to encompass everyone in need, regardless of spatial or national boundaries.
The Moral Obligation to Help
Singer’s argument challenges us to rethink our moral obligations in an increasingly globalised world where, I would dare say, we have less of an excuse to disregard the predicament experienced by those who live far far away.
He asserts that geographical distance and nationality should not be factors in determining our responsibility to help others. Rather, our moral obligation stems from our ability to prevent suffering and death without compromising our own basic needs.
Component of Singer’s argument
Description
Moral Obligation
Individuals have a duty to help those suffering from extreme poverty and preventable diseases.
Geographical Distance
Distance should not factor into our moral responsibility to help others.
Nationality
Nationality should not determine our responsibility to help those in need.
Personal Sacrifice
We should be willing to make reasonable sacrifices to aid those suffering from preventable harm.
Table – Key Points in Singer’s Argument
Actionable Steps for All
One must begin by expanding one’s knowledge and remaining informed about global health inequalities and the challenges faced by developing countries and marginalised populations. This awareness serves as a solid foundation for taking meaningful action.
Next, it is crucial to engage in volunteer work and collaboration, seeking opportunities to contribute time and skills towards improving healthcare access and outcomes for underserved populations, both locally and internationally. Working together with others who share a similar passion can yield significant benefits for those in need. For medical students, there are often abundant opportunities in going on OCIPs (overseas community involvement projects).
Advocacy is another essential component in addressing global health disparities. By using one’s voice to promote policy changes that tackle the root causes of inequality, such as poverty and lack of access to education, one can contribute to creating a more equitable world. Using one’s voice could manifest in many ways: it could be starting your own CIP or OCIP, publishing a relevant journal article to raise awareness, having your views aired on national platforms such as The Straits Times forum.
Supporting effective charities is also an important step in making a tangible difference. When donating to charitable organisations, it is crucial to make informed choices by researching their effectiveness and impact. Singer himself relies on organisations like GiveWell, which evaluates and identifies the most effective charities to support. Think of it as a ‘meta-charity’.
Finally, reflecting on Singer’s argument, we should consider the personal sacrifices we may be willing to make to help those in need. This could include donating a percentage of one’s income, cutting back on nonessential spending, or dedicating a portion of one’s time to volunteering or advocacy work. By making a personal commitment to alleviate the suffering of others, one can actively participate in the collective effort to create a more just and compassionate world.
Tuberculosis (TB) remains a global health challenge, and its current treatment regimen, known as “directly observed therapy, short course” (DOTS), is ironically anything but short, and significant infrastructure is required to deliver and observe therapy. As such, researchers are constantly exploring shorter treatment regimens that can reduce the burden on healthcare systems and patients.
Recently, while on the NUS website, I chanced upon an article and learnt that a ground-breaking international study had been conducted by a research team from NUS YLLSoM, NUH, and Singapore Clinical Research Institute (SCRI), led by Professor Nicholas Paton.
The results of the study were published in the New England Journal of Medicine (NEJM) last month and revealed that a tubcerculosis (TB) treatment strategy with an initial 8-week treatment period followed by retreatment of a small minority who were not cured, showed the same efficacy level as the standard 6-month treatment, but halved the average total time on treatment.
The recent publication of the TRUNCATE-TB trial (the aforementioned trial led by Prof Paton’s team) results in NEJM offers us promising news on this front.
TRUNCATE-TB trial
The trial aimed to test a new two-month (8-week) treatment strategy for TB that responds well to drugs (specifically rifampin-sensitive TB). The study included 674 participants and compared the standard 24-week treatment with two experimental treatment plans. These experimental plans were evaluated after eight weeks to see if the disease persisted. Additionally, participants were closely monitored to check for disease relapse until week 96. The main goal was to measure the combination of death, ongoing treatment, or active disease at week 96.
Key findings of TRUNCATE-TB
Group
Primary Outcome Events
Adjusted Difference
97.5% CI
Control (Standard Treatment) – (i.e. 8 weeks of RHEZ, followed by 16 weeks of rifampin and isoniazid)
With these results, only the bedaquiline–linezolid intensified regimen was found to be noninferior to the standard treatment (c.f the rifampin-linezolid intensified regimen wasn’t deemed noninferior because the upper bound of the 97.5% CI for the incidence of primary outcome events was 13.2%, which was higher than 12%; for a strategy to be deemed noninferior according to the study protocol, the difference between the strategy group and the standard-treatment group in the risk of the primary outcome had to be less than 12%).
In the group which received the bedaquiline-linezolid intensified regimen, 85.7% of participants didn’t need treatment beyond eight weeks. On average, the total treatment time in this group was 84.8 days, which is less than half of the standard treatment group’s 180.2 days. However, an important thing to note is that as of the time of writing, bedaquiline is currently not registered as an approved drug in Singapore. It has been FDA-registered for more than a decade though, and is indicated in the management of MDR-TB (multidrug-resistant TB).
Although there were concerns about toxic effects and antibiotic resistance associated with the bedaquiline and linezolid regimen, the trial reported limited toxic effects, suggesting that earlier concerns might be overstated. There were two cases of acquired drug resistance in the bedaquiline–linezolid group, which does not raise substantial concerns in the context of the trial.
Potential Impact and Challenges
The two-month treatment strategy could greatly benefit patients, healthcare systems, and TB control efforts. However, challenges remain, such as the high level of treatment adherence andthorough patient assessments needed for the strategy, which may not be possible in many TB control programs.
Despite these challenges, the TRUNCATE-TB trial is a significant advancement in adaptive clinical trial design and offers an encouraging treatment strategy for drug-sensitive TB.
Adaptive clinical trial design allows for modifications during the trial based on the data being collected, such as dropping treatment arms or adjusting sample sizes. In the TRUNCATE-TB trial, the researchers used early stopping rules and modified entry criteria for higher-risk patients, among other adaptive strategies.
One of the adaptive strategies employed by the researchers was the use of early stopping rules for certain treatment groups. The trial initially had five treatment groups, and the plan was to drop two of these groups based on early stopping rules. However, none of the groups met those standards. As a result, the researchers decided to stop enrollment in two groups on the basis of logistical criteria, such as pill burden and regulatory concerns, in order topreserve statistical power for the remaining groups.
This approach allowed the researchers to focus on the remaining treatment groups, which were more promising and had fewer logistical challenges. By employing early stopping rules and adapting the trial design based on the data, the researchers could optimize the use of resources and increase the efficiency of the study. This flexibility is an important aspect of adaptive clinical trial design, allowing for improvements and modifications during the course of the trial.
Conclusion
For the longest time, as a medical student, pretty much all I’ve ever known about the medical management of TB is the standard RHEZ cocktail that can be used: (‘H’ and ‘Z’ here refer to isoniazid and pyrazinamide respectively) or RIPE (the letters of this acronym correspond to the first letter of common anti-TB drugs: rifampin, isoniazid, pyrazinamide, and ethambutol). The results of this TRUNCATE-TB seem to be yet another one of the many reminders that medical practice and the latest standard of care are constantly evolving, and that we need to keep up with the most important updates. As such, in some sense, I pity future generations of medical students, who will only have an increasing amount of content that they need to learn – the historical streptomycin, the standard RHEZ cocktail, and now: regimen-intensifying agents such as bedaquiline and linezolid.
In sum, the TRUNCATE-TB trial shows that a two-month treatment strategy with the bedaquiline–linezolid intensified regimen is noninferior to the standard six-month regimen for drug-sensitive TB. While there are challenges to implementing this strategy in real-world settings, the results offer a beacon of hope for reducing the impact of TB treatment on patients and healthcare systems not just on our little red dot, but in other TB-endemic countries.
Originally submitted on 2 March 2023for consideration for (and won) the Palliative Medicine Book Prize:
Prior to the palliative medicine posting, I was thrilled to learn that I would have in-person clinical exposure to palliative medicine, a privilege denied to many of my seniors due to COVID-19 restrictions. This experience was particularly poignant for me as my interest in medicine had been sparked by an experience I had more than a decade ago.
In 2010, my mother presented to our GP with a large firm RHC mass and was otherwise asymptomatic. As a never-smoker, never-drinker, and someone who ate healthily and exercised all her life, she had even finished a marathon as an adult! Appropriately, she was referred for an urgent CT Abdomen, and the scan results were concerning. Grappling with the first stage of the Kübler-Ross cycle, we opted for the biopsy, and even had the sample flown to three renowned labs worldwide, including Mayo Clinic. “There would be a higher chance of ruling out a false positive this way, right?”, we desperately thought.
The labs all independently reached the same conclusion – gallbladder carcinoma. Despite increasingly aggressive doses of bevacizumab, her condition eventually deteriorated with multilevel vertebral metastases. On her last visit to her oncologist, the doctor conveyed that there was nothing more he could do for her and that she should “get admitted to a hospice”.
I saw it all – the progressive alopecia which prompted her purchase of a black neck-length wig, and the recurrent emotional conversations between my parents. Her functional decline was so rapid and heart-wrenching. Her cachexia worsened steadily, and soon, her inability to converse became more pronounced. Eventually, she was granted a terminal discharge by Assisi and passed away in our home in April 2011. Through it all, my late mom had the privilege of receiving excellent palliative care from the doctors, nurses, and allied health professionals at Assisi. This effort by the multidisciplinary palliative care team provided the much-needed solace to make the journey as bearable as possible, and it is my wish that more people would be aware of what this nascent branch of medicine can offer to patients and their loved ones.
During my two-day hands-on experience, I had the opportunity to prepare fentanyl syringe packages for a patient at TTSH planned for terminal discharge. This experience gave me a glimpse of what goes on behind the scenes of the care associated with managing patients’ symptoms and helping them to achieve a peaceful and dignified death. I also witnessed a doctor formally document a patient’s death at DPH. After documenting the death, the doctor repositioned the patient into a more dignified posture. In Being Mortal, Gawande remarks that our “ultimate goal, after all, is not a good death but a good life to the very end.” Palliative medicine plays an essential role in this pursuit by providing patients with the support and care they need to live the remainder of their lives with dignity and respect.
As I reflect on my experiences, I am struck by how misconceptions from the part of both fellow healthcare professionals (e.g. getting the palliative care team on board too late to allow for a smoother transition) and patients and their caregivers all contribute to the suboptimal use of all that palliative care can actually offer. Many people erroneously believe that palliative care is only appropriate for patients who are actively dying from advanced cancer. However, the reality is that palliative care can benefit patients at any stage of a serious illness and can help manage symptoms, improve quality of life, and support patients and their families throughout their illness journey.
In conclusion, from this short yet meaningful four-day stint in palliative medicine, I now have an even greater understanding of the critical role that palliative care plays in improving the quality of life for seriously ill patients and their families. I hope to honour my mother’s memory by providing compassionate care to my patients in my future clinical practice. Regardless of whether I find myself specialising in palliative medicine, I hope to abide by the eloquent words of the late Paul Kalanithi in his best-selling autobiography:
“The physician’s duty is not to stave off death or return patients to their old lives, but to take into our arms a patient and family whose lives have disintegrated and work until they can stand back up and face, and make sense of, their own existence.“
As part of my thrice-weekly full-body strength training routine, I incorporate full back squats into two of my gym sessions, which currently fall on Tuesdays and Saturdays. On Thursdays, I focus on deadlifts to ensure even training of my lower limb muscles. Both exercises are important for balanced lower limb muscle development, with deadlifts targeting the posterior thigh muscles like the hamstrings, while squats emphasize the anterior thigh muscles such as the quadriceps femoris.
Despite people tending to find upper limb muscles (eg biceps, triceps, deltoids) more impressive in general, it’s important to not skip lower limb development! Only with appropriate lower limb development can proportionate overall muscular development be achieved. And that means doing exercises which works main lower limb muscle groups such as the quads, which is the focus of our blog post today.
Basic anatomy regarding the quadriceps
The quadriceps femoris muscle (also called the quadriceps, or simply ‘quads’) is a large muscle group on the front of the thigh that includes four prevailing muscles. The name ‘quadriceps femoris’ is literally Latin for “four-headed muscle of the femur.”
As the traditional etymology suggests, the quadriceps femoris muscle is subdivided into four separate muscles, known as “heads.” The rectus femoris muscle occupies the middle of the thigh and covers most of the other three quadriceps muscles. It originates on the ilium and is named for its straight course. The vastus lateralis muscle is on the lateral side of the femur, and the vastus medialis muscle is on the medial side of the femur. The vastus intermedius muscle lies between vastus lateralis and vastus medialis on the front of the femur, but deep to the rectus femoris muscle. Typically, it cannot be seen without dissection of the rectus femoris. Attached here is a illustration of the anterior thigh muscles from an edition Gray’s Anatomy.
However, research has suggested that the quadriceps femoris may actually be composed of five muscles, rather than four. This newly discovered muscle has been dubbed the “tensor vastus intermedius” (TVI), and its presence may have important implications for our understanding of the musculature of the lower limb.
The Discovery of the Tensor Vastus Intermedius
The existence of the TVI was first proposed in a 2016 study published in the journal Clinical Anatomy. The study entitled “A newly discovered muscle: The tensor of the vastus intermedius“, was conducted by a team of researchers (Grob et al.) from the University of Central Florida, who used dissection and histological analysis to examine the structure of the quadriceps femoris muscle.
The premise of their study was that they noted a tensor-like muscle between thevastus lateralis (VL) and the vastus intermedius (VI), and hence they wanted to clarify whether this intervening muscle was a variation of the VL or the VI, or a separate head of the extensor mechanism. This study demonstrated that the quadriceps femoris is architecturally different from previous descriptions: there is an additional muscle belly between the VI and VL, which cannot be clearly assigned to either the former or the latter. Distal exposure revealed that this muscle belly becomes its own aponeurosis, which continues distally as part of the quadriceps tendon, before of course finally inserting on to the medial aspect of the patella.
It is important to note that while Grob et al. proposed the name ‘tensor vastus intermedius’, the reality is that this specific muscle has been reported previously in the literature.
Implications for Anatomy and Physiology
The naming of the fifth muscle as the TVI, and hence giving rise to a ‘quinticeps femoris’ has important implications for our understanding of the musculature of the lower limb. For example, knowing that there are five muscles in the quadriceps femoris rather than four could potentially change the way that we approach surgical procedures that involve this muscle group. It could also shed light on the evolution of lower limb musculature in humans and other animals.
In addition, as I was trying to hint at from the title of this blog post, the discovery of the quinticeps femoris raises questions about the nomenclature of the qunticeps femoris muscle group. If there are in fact five muscles in this group, should we continue to refer to it as the “quadriceps”? Or would it be more accurate to call it the “quinticeps femoris”? This is a question that particularly pedantic anatomists and physiologists will need to grapple with in the coming years.
Half a decade after the study by Grob et al., a systematic review on the anatomy, morphology, and function of tensor of vastus intermedius (TVI) was published in 2021. Alas, the review sheds light on the lack of high-quality evidence on the muscle’s morphology and clinical significance. While the TVI is located between the vastus lateralis and vastus intermedius, there is insufficient high quality evidence for us to confidently state its functional and clinical importance. As more research on TVI morphology emerges, we will gain a better understanding of the role of the muscle and the overall function of the quinticeps femoris.
Conclusion
The discovery of the quinticeps femoris is a fascinating development in the field of anatomy and physiology. Whether or not we end up calling it the “quinticeps femoris,” or simply deciding to stick to the good old “quads”, it is clear that the newly discovered TVI (tensor vastus intermedius), one of the five muscle heads of the quinticeps femoris, is an important part of the human body, and one that we are only just beginning to understand.
The blog post which some have been requesting. Aptly, it is being published on New Year’s Eve. I hope this encourages and inspires you to consider realistic fitness and health goals, particularly if you’re one who sets New Year Resolutions.
For those just interested in the rough ‘before’/’after’ photos and only want an overview of the progress, head to the bottom of this post.
PRECIPITATING AND PREDISPOSING FACTORSFOR THE DECISION TO LOSE WEIGHT
Let’s go back to the beginning.
I enlisted on 5 January 2016, and ORD-ed in November 2017. I finished my BMT in March 2016, after which I was posted to 48 SAR 1st COY where I trained as a tank operator (specifically as a driver of the L2SG main battle tank, but I also underwent training operating the weapon systems of the main battle tank, and how to load the rounds).
Within my unit, I was always considered by many to be slightly above average (for my running, at least) in my physical fitness parameters. My company had around 50-60 servicemen and for the 2.4 km run component of the IPPT, I would normally be among the first five to complete the run.
In May 2016, I was required to take the IPPT shortly after being transferred to 48 SAR/1st COY. On this occasion, I achieved my all-time personal best for the 2.4 km run: 9 min 39 sec.
Fast forward to November 2017, when I completed my mandatory full-time NS. After a three-month break, I then commenced my medical studies in Australia in Feb 2018.
You see, back when I was studying in Australia, I pretty much lived independently. I had my own bedroom in a house which I shared with other occupants. I did my own groceries and had much greater freedom regarding my gastronomic choices. I was quite disciplined with what I bought – adhering to a diet that many would dismiss as boring. I would pretty much eat the same thing every day (eg muesli, full-cream milk, either salmon or steak, and a ton of eggs). I would pretty much never buy any snacks/dessert during my grocery runs.
As such, my weight had hovered between 61-62 kg for more than 2 years (I had studied in Australia for a grand total of slightly over three years: from Feb 2018 to May 2021).
When I first returned to Singapore due to the medical school transfer in AY21/22, I arrived in Singapore in end-May 2021. Largely due to a complex interplay of different reasons (e.g. reduced autonomy over the food I ate as I no longer settled my own groceries and chose what I wanted to eat at home, the constant ubiquity of highly processed food in my fridge at home, less flexibility over my eating hours due to a persistent family tradition of eating together for dinner as much as possible, larger-than-average portion sizes for home meals, easy access to fatty and oily foods from the coffee shop across the road), my weight dramatically increased as soon as I returned to the little red dot. Grappling with the transition in the different medical school learning environments, it was all too easy to rely on food as a constant stream of quanta of solace.
Since I returned to Singapore in end-May 2021 for good to continue my medical studies in YLLSoM, the exit permit I previously possessed that had hitherto exempted me from all annual reservist IPPT obligations officially become null and void. As such, when I birthday came around last November, I was informed by MINDEF that I ought to complete my IPPT within the fresh “window”. Such a window (time period) is personalised for every reservist personnel and commences whenever it is the serviceman’s birthday. Officially, at least for MINDEF, a person’s birthday is measured by when the person’s actual birthday passes, and not when the calendar year changes.
In June 2022, when I took the mandatory IPPT, the score that I obtained was 84, a mere 1 point from gold. By many people’s standards, passing the IPPT when it has been half a decade since the last IPPT attempt as an NSF is a fantastic result, let alone doing well enough for the monetary incentives. However, I wasn’t contented with a mere ‘pass with incentive’, or mere Silver. The result stang so much because I was so close to Gold (achieved at a minimum of 85 points).
It’s not a regular 1-point difference. The one-point difference was ultimately due to the fact that I had run 10:21 for the 2.4km run instead of the required 10:20 (given my combination of scores for the push-up and sit-ups stations) for the Gold Award. As such, for my first reservist IPPT attempt, I clinched a Silver award at 84 points. However, because I didn’t clinch the Gold award, I only received a $300 incentive (for Silver) instead of the typical $500 incentive (for Gold). Can you believe that?
Losing out on $200 due to a 1-second difference!!
Tragic, isn’t it?
This was certainly the precipitating factor for my decision to initiate my journey of intentional, sustainable weight loss with the aim of reducing total body fat percentage.
In retrospect, missing out on Gold wasn’t all too bad. After all, it was the wake-up call that I had to lose weight. To illustrate the effect of body weight on running speed, a cursory Google search would reveal that for each pound (about 0.45 kg) of body weight lost, you can run a mile by 1-2 seconds faster than that of your current speed on average for the same effort expended.
However, to give even more context, this miss on the Gold acting as the triggering factor occurred on a background of a progressive discomfort and uneasiness that I experienced over the fact that I was technically in the ‘overweight’ category (my peak recorded weight was 71.5 kg in Feb 2022; for an Asian of height 173 cm, this corresponds to a BMI of greater than 23.0, which means I’m overweight), a label which I did not like on myself (not only because I had never been overweight, but also because of the dire acute and chronic complications that generally being overweight had on my constitution). One thing that too many people in Singapore aren’t aware of is that Asians have a higher risk of cardiovascular complications at any given BMI compared to the typical Caucasian whose ethnicity constitutes the majority in influential countries such as the US, UK, Canada, Australia, or New Zealand.
Guess which ethnicity the World Health Organisation (WHO)’s BMI guidelines are catered towards?
Beyond BMI, the same can also be said of another anthropometric measurement: waist circumference.
A well-known limitation of BMI is that it doesn’t consider the varying contributions of the different components of one body’s weight (mass due to muscle, fat, water), and therefore should be interpreted with caution, particularly in pregnant individuals or individuals who have a unusually significant lean mass (e.g. bodybuilders). Compared to BMI, waist circumference is a better surrogate marker of one’s body fat distribution and one’s risk for cardiovascular disease. WHO’s guidelines for the waist circumference threshold for truncal obesity are: 102 cm and 90 cm in men and women respectively.
As with the example of BMI earlier, the 102/90 figures apply to the typical Caucasian and provides spurious reassurance to people of Asian ethnicity. The corresponding thresholds for truncal obesity in the population in Singapore, which have been previously determined from Asian-specific epidemiologic studies, are more conservative: 90 cm and 80 cm for men and women respectively. It certainly wasn’t reassuring to know that at one point, my waist circumference was 86 cm, just a mere 4 cm away from the abdominal obesity thresholdfor males.
The message was clear.
These personalised anthropometric measurements were of great concern and certainly necessitated prompt action.
As such, on 26 June 2022, I officially endeavoured to rectify my dietary habits and exercise habits (or lack thereof). The following sections will reveal how exactly how I went about doing this.
HOW EXACTLY THE PROCESS OF WEIGHT LOSS TRANSPIRED(INCLUDING MISTAKES TO AVOID)
As someone who was embarking on a process of weight loss for the first time, there was clearly room for improvement in terms of how I started the journey on Day 1. These were issues with the very start. Therefore, if you yourself want to lose weight while following the general trajectory I took, I highly suggest you address the following issues to have a smoother and more satisfying experience:
Not having a reliable weighing scale.
A reliable weighing scale is an important tool for tracking progress in a weight loss journey because it allows a person to accurately measure and monitor his weight. This information can be used to gauge the effectiveness of a weight loss plan and make any necessary adjustments. For example, if a person is following a calorie-controlled diet and exercising regularly but the scale is not showing any changes in weight, they may need to reassess their plan and make adjustments in order to see progress. On the other hand, if the scale is showing consistent weight loss, it can be a motivating factor that helps a person stay committed to their weight loss goals. With the manual mechanical scale that my family had for aeons, it was hard to track progress, particularly when one has doubts regarding the accuracy of the scale itself.
Not taking the steps to minimise interday variability in weight due to factors that are easily mitigated.
The most accurate way to track one’s weight day-to-day is to measure one’s weight on the electronic scale the first thing after waking up in the morning (after completely emptying one’s bladder and clearing one’s bowels, and before consuming any food or liquid whatsover), with all accessories, jewellery, garments, and undergarments removed.
Any deviation from what I have described in the paragraph above will most likely lead to an unncessary increase in interday variability in weight, which makes progress tracking more challenging than it needs to be.
Not using an app for weight and calorie tracking from the very start.
With an app such as LoseIt (which I only started using a few days after commencing the weight loss journey), I was able to have visual overview of my progress, and this motivated me to persist with what worked for me. A comprehensive outline of the benefits of using the app such as LoseIt to facilitate weight loss is beyond the scope of this blog post, but in essence, it aided me greatly. I tracked my calories, my macros, and received encouraging reminders of the milestones I had attained.
Not taking adequate ‘before’ photos.
I should be grateful that I at least have a photo of myself (taken on 26/6/22) that was taken around the time I decided to lose weight. It’s certainly better than nothing. There are many people who don’t even have a single photo around the time that they decide to start their weight loss journey, and this makes accurate comparison (via a before-after) challenging.
Nevertheless, if I could do things all over again, I would definitely take more photographs. Clearer photographs. Photographs of myself from the hips and up, and in the side, frontal, and back views. This way, the ‘before’/’after’ transformation would certainly be more inspiring and motivational.
Not tracking progress via photos at regular time intervals and consistent photo conditions.
It was only on 5/11/22 that I realised that the progress photos weren’t taken on regular intervals, and that it could be improved. As such, starting on 5/11/22 (Saturday), I would take a progress photo every Saturday using the front camera of my phone, with the photograph being in the dimensions of a square shape, with the visage being centered appropriately, with the lateral canthi of both eyes at the level of the 2/3 way up within the centre subsquare (when dividing the entire square photograph into nine equally-sized subsquares), and with the inferior border of the middle subsquare corresponding to the level of the subnasale. The facial expression is also kept consistent as much as possible (you can see a smile plastered on my face!).
Such standardisation as described in the above paragraph may appear excessive at first glance. However, when these photos are compiled into a specific album on one’s phone, it’s actually remarkable when one swipes left and right and instantly appreciates even subtle changes (made possible because the position of the face and all the relevant features are kept constant as much as possible!). In fact, outlining all these specifications for my progress photos is precisely what facilitates easy comparison between the progress photos that you’re about to see in the section below!
OVERVIEWOF WEIGHT LOSS JOURNEY+BEFORE/AFTER PHOTOS
In sum (particularly for those of you who just scrolled all the way down here to see the visual transformation), I made the decision to start losing weight on 26/6/22. On that day, a Sunday, I had gone to Tenya Orchard Central for lunch and had my ‘before’ photo taken.
On 1/7/22, I decided to ‘up’ my game by formally tracking the nutritional content of my meals and my weight, in order to better document my progress. However, the manual nonelectric scale I had at home was both imprecise and inaccurate. As such, I went to Decathalon Waterway Point to grab a simple and affordable electronic scale at about SGD 16 (cheaper than the ones from even retail pharmacies) a few days later. On 1/7/22, I also started tracking my calories on an app called LoseIt!. Starting on 5/11/22, I started taking progress photos at a consistent time interval (every Saturday).
Key milestones:
71.5kg (26/6/22 – date of ‘before’ progress photo) > 70.5 kg (1/7/22) >67.4 kg(1/8/22) > 64.6 kg (1/9/22) > 62.6 kg (1/10/22) > 62.1 kg (1/11/22) > 61.5 kg (12/11/22) > 62.6 kg (10/12/22 – date of ‘after’ progress photo).
Apart from cropping the individual photos to a square shape and putting the watermarks, these photos are unedited, and have not been tampered in any way.
THE EFFECT OF THE WEIGHT LOSS, AND LESSONS LEARNT
Following the weight loss, I became a totally different person from the person I was in June 2022 and the few months preceding it. Mobility was enhanced. Running felt more enjoyable. My sleep improved slightly. My mood and self-confidence has flourished, and life is simply more interesting and enjoyable. Life’s just easier when you’re healthier, fitter, and more attractive.
Despite attaining my weight loss goal, I continue tracking my weight every morning religiously, and also still track my macros, and calories to a reasonable extent as this is excellent way to remain conscious of what I’m consuming. These are great habits that I hope to sustain indefinitely. After all, for any fat loss to be permanent, there needs to be some permanent and lasting change in one’s lifestyle habits. Bad habits need to be eradicated. Good habits need to be established.
Oftentimes, people embark on ambitious ‘detox’ programmes or fad diets that last a few weeks only to do a complete 180 and return to their old ways after the temporary programme ends. Under such circumstances, it should thus be no surprise when one regains all the weight one lost during whatever temporary programme one was on.
It’s hilarious how along the way, many people (including quite a few fellow medical students, one nurse in NUH, one of the admin staff in NUS, one surgical resident) couldn’t help but point to me that I had lost weight (particularly people I hadn’t seen in a while). Those are some of the greatest encouraging reminders of what I have accomplished and never fail to write glee on my face. When other people notice and also feel compelled to explicitly tell you, that’s when you know that it’s significant. Of course, I’m sure there are also more who noticed but chose not to point it out for fear of committing a faux pas.
Overall, the weight loss journey has been quite humbling. Often, doctors tell patients to ‘lose weight’ as a first-line noninvasive approach for the management of a variety of chronic metabolic conditions (see my previous blog post where I explored the role of weight loss in the management of osteoarthritis). While this advice is generally sound, it’s too easy to rattle it out of habit and without any conscious regard for how challenging it can actually be. This may be discouraging for patients who have already heard this advice repeatedly but nevertheless find it very challenging to lose weight.
This personal journey that I undertook will certainly be paramount in helping me empathise with my future patients when advising them to lose weight.
Indeed, as supported by the various guidelines, sustainable weight loss with the goal of reducing total body fat is achieved by sustaining a net caloric deficit, while still ensuring adequate macronutrient intake and appropriate amounts of resistance training and cardiovascular activity. The highly personal weight loss journey has etched this cardinal rule of weight loss into my mind forever.
WHAT’S NEXT
After that glorious run of a cut, I made the transition to a brief period of eating at maintenance (i.e. having neither a net caloric surplus or deficit in order to maintain weight, with the proportion of lean muscle and body fat remaining the same during maintenance), followed by a controlled ‘bulk’ (i.e. striving for a slight caloric surplus accompanied by adequate daily protein intake (0.82 g/lb of body weight) to facilitate muscle hypertrophy).
I realised that if I wanted to get even fitter, healthier, stronger, and look even better, I had to incorporate consistent resistance training into my life. As such, on 6/12/22, I started checking out various gyms (aided by the guidance of my youngest brother who had already been consistently doing strength training for about four months) in the vicinity of my residence and soon realised some limitations. Many fairly basic gyms (particularly in most condominiums) lack barbells, which are required for the classic compound exercises: deadlifts, squats, bench press, and overhead press.
While chest press and shoulder press machines exist in virtually all gyms, they are suboptimal compared to barbells because they do not activate the required stabiliing muscles to the same extent. Additionally, the weight increment intervals on the machines are far larger, which makes tracking incremental linear progress via weights more challenging.
Fortunately, after some research, I managed to locate a reasonably priced gym near my residence that has barbells, and the relevant bench press stations and squat rack.
As such, on 26/12/22, I officially began a structured beginner’s strength training programme. Looking forward to reporting both visual and numerical progress/results in a year’s time. Stay tuned!
In contrast, for the sake of this blog post, I would like to share something which I feel is important and clinically relevant. I only learnt this after participating in a tutorial which I attended a few days ago. It was a didactic tutorial held on 23 Nov, Wednesday, and it was led by Emeritus Consultant A/Prof Low Boon Yong, an orthopaedic surgeon who works at Changi General Hospital (CGH), a hospital within the SingHealth cluster.
Just to provide some context, my fellow clinical groupmates and I are currently on our orthopaedic surgery posting (our third major clinical posting as part of the curriculum for third-year undergraduate medical students at NUS). The focus of the tutorial was that of essential knowledge pertaining to the hip that medical students are expected to possess. It was evident to me, at least, that A/Prof Low is indeed highly knowledgeable even as he briefly walked us through an extensive amount of background information prior to even broaching the hip per se. He shared with us the implications of human beings being bipedal, the advantages and disadvantages of being bipedal, a short segment on the Neanderthals, the mechanism of how losing 1 kg of body mass takes away 4 kg -equivalent of pressure from the lower limb joints, and a conceptual understanding on what constitutes an antalgic gait.
It is beyond the scope of this blog post to elaborate on everything that A/Prof Low covered. So, I will only be elaborating on what I deem to be the highlight of the tutorial. It is valuable knowledge and deserves to be shared.
All credit for the explanation of the mechanism of the stress/pressure offloading to A/Prof Low, and do kindly consider any error (if present) to be mine.
WHY EVEN CONSIDER THE EFFECT OF WEIGHT LOSS?
Before we even get to the mechanism as to why 1 kg of weight loss leads to a disproportionate reduction in equivalent pressure from one’s lower limb joints, it is necessary to discuss why we may even need to consider the effect of 1 kg of weight loss.
The reality is that intentional weight loss remains the cornerstone of the management of virtually all chronic metabolic diseases such as obesity, essential hypertension, dyslipidaemia, and diabetes mellitus (along with all its associated acute complications, chronic microvascular complications, and chronic macrovascular complications). Moreover, intentional weight loss remains one of the key strategies which many rely on to boost their level of physical attractiveness, an objective which is desirable by many in society.
The prevalence of obesity has been steadily increasing, and this constitutes a worrisome threat to the fiscal viability of healthcare systems around the globe. The obesity epidemic is thus perhaps more appropriately termed the obesity pandemic, as it doesn’t just affect developed countries such as the United States, the United Kingdom, or Australia, where highly processed foods, high fructose corn syrup, artificial sweeteners, excessively salty, fatty, and oily foods all abound.
Even our island home hasn’t been spared. According to a press release by MOH in 2014, “Singapore’s obesity prevalence increased 0.7 percentage point a year since 2004 to reach nearly 11% in 2010, only one percentage lower than the global average obesity prevalence of 12%.” I’m not sure what the latest figures are, but given that it’s 12 years on from 2010, I’m certain that the prevalence of obesity is greater than the already-dismal 11%.
For the past few decades, the obesity pandemic has not spared developing countries due to the far-reaching tentacles of globalisation. In fact, the affliction of the obesity pandemic in developing countries is often harsher due to the dearth of relevant health and food safety regulations, thus allowing unbridled capitalism to hold the reins of the industries of local sustenance.
With the unfettered proliferation of unhealthy diets across the globe, people are increasingly getting horizontally challenged (pardon that sad attempt to cruise along the euphemism treadmill). Obesity has numerous complications which ultimately contribute to a reduced quality of life for patients, and one such complication is the acceleration of the progression of osteoarthritis of the weight-bearing joints, which manifests clinically as progressively worsening mechanical pain.
Osteoarthritis may be defined as a disorder characterised by chronic progressive degeneration of articular cartilage within synovial joints, resulting in the loss of joint space that is often asymmetric, and the formation of subchondral cysts. Osteophytosis (the formation of new bone and cartilage at the joint margins), sclerosis of subchondral bone, and formation of new connective tissue in the form of capsular fibrosis all occur as part of the body’s attempt at counteracting the degenerative process.
Acceleration of osteoarthritis as a complication of obesity is unsurprising because as one might imagine: with an abnormally high body mass, there is a pathologically high amount of stress or pressure on weight-bearing joints such as the hips and knees, which increases the rate of the degeneration of these joints due to greater tendency and magnitude of the wear-and-tear associated with the articular surfaces grinding against each other.
It is thus no surprise that when we talk about the management of osteoarthritis, for which there are nonoperative options (further classified as nonpharmacological and pharmacological) and operative options, chief among the nonpharmacological options would be intentional and sustainable weight loss, which would reduce the rate of osteoarthritis progression.
Specifically for the typical patient (whether suffering from osteoarthritis or not) of Asian ethnicity in Singapore, this would ideally entail getting the BMI to <23.5 and ensuring that the waist circumference is also <80 cm (if female) and <90 cm (if male), as per local guidelines. Of course, what I’ve listed here is just general advice for educational purposes only. For appropriate management in your specific circumstances, please consult your doctor.
THE MECHANISM UNDERLYING A DISPROPORTIONATE REDUCTION IN EQUIVALENT PRESSURE FROM THE WEIGHT-BEARING JOINTS OF THE LOWER LIMBS IN WEIGHT LOSS
Now that we’ve discussed why people may even be interested in the idea of weight loss in the first place, let’s now explore the mechanism underlying a disproportionate reduction in equivalent pressure from the weight-bearing joints of the lower limb.
A/Prof Low used fundamental physics principles to illustrate how one could arrive at a factor of 4regarding the offloading of pressure from the weight-bearing hip joint (though a similar calculation could be modified and tailored to other weight-bearing joints of the lower limb) for each unit of weight loss.
Consider the principle of moments which is a staple of Newtonian mechanics in any physics syllabus, whether at the O-level, A-level, or even within an introductory physics module at university. The principle of moments may be defined as follows: “the resultant torques due to a number of forces applied about a point is equal to the sum of the contributing torques”.
From this definition, it follows that when an object is in rotational equilibrium, one can determine the relative magnitude of a particular force if the other variables are known. A/Prof Low shared with us how we can use this well-known physics principle to better understand the anatomy and mechanics of the human hip and the clinical implications of this.
As we all know, the hip can be thought of as a ball-and-socket joint, with the head of the femur constituting the ball of the hip joint, while the acetabulum constitutes the socket of the hip joint. Whilst a gross simplification of the actual mechanics within the human body, the following framework is nevertheless sufficiently robust for both clinicians and patients alike to conceptualise the positive effect that intentional and sustainable weight loss can have on weight-bearing joints:
Consider a vertical plane passing through the centre of mass of the femoral head to correspond to the position of an imaginary fulcrum.
The gluteus medius, the main abductor of the hip, attaches to the greater trochanter of the femur.
The vertical plane containing the ‘average’ origin (because after all, the actual origin of the gluteus medius is not a mere simple point, but rather, a relatively large region) of the gluteus medius can be taken to be approximately some perpendicular distance ‘a‘ from the femoral capital vertical plane.
Next consider another vertical plane which runs through the centre of mass of the patient, which would roughly correspond to the sagittal plane of the patient.
Based on standard anatomic proportions, when in the anatomic position, the perpendicular distance between this new vertical plane (i.e. the sagittal plane) and the femoral capital vertical plane is roughly ‘3a‘ (i.e. the perpendicular distance between the vertical plane containing the point of the patient’s centre of mass and the femoral capital vertical plane, is approximately three times the perpendicular distance between femoral capital vertical plane and the vertical plane containing the ‘average’ origin of the ipsilateral gluteus medius).
Do you see where I am going with this?
Let ‘F’ represent the weight of the patient.
Considering just the abovementioned force and distances, one can certainly mathematically determine the average force (or tension) present within a contracted gluteus medius when the patient is in balance.
Let T represent the tension within the contracted gluteus medius in the abovementioned system. Using the principle of moments, we can construct the following equation:
T (a) = F (3a)
Thus, T = 3F;
Going one step further, assuming the patient is in a state of not just rotational equilibrium (i.e. no net torque about the femoral head; constant angular momentum), but also translational equilibrium (i.e. no net force acting on the femoral head; constant momentum), we can use Newton’s third law to determine the force, Z, exerted on the femoral head.
By Newton’s third law, for the system to be in translational equilibrium, Z = T + F = 3F + F = 4F.
Z = 4F.
Incredible, isn’t it?
In fact, A/Prof Low used this relationship between the various forces and perpendicular distances to explain why the classic antalgic gait is the way it is. In an attempt to minimise the magnitude of the downward forces acting on the femoral head (which would of course be counteracted by the reactionary normal force due to Newton’s third law; note that a similar system/reasoning can be employed if the source of the antalgic gait is another part of the lower limb), the patient will ’tilt’ towards the unaffected side during the stance phase of the unaffected limb (see the second image given below, where the patient’s left lower limb is affected and presents with an antalgic gait).
Why is this so?
Well, when this ’tilt’ happens (see the second image presented below, which is a screen capture at 0:23 from a YouTube video illustrating antalgic gait), the ratio of the perpendicular distance between the plane containing patient’s centre of mass and the femoral capital vertical plane, to the perpendicular distance between the femoral capital vertical plane and the plane containing the ‘average’ origin of the gluteus medius, is effectively reduced (i.e. less than ‘3’ instead of approximately 3). Consequently, this would lead to a reduction in the tension within the gluteus medius (i.e. T < 3F), which would result in the sum of the downward forces on the femoral head being reduced (i.e. Z < 3F + F ; Z < 4F), which would theoretically reduce the intensity of mechanical pain on the affected ipsilateral lower limb.
CONCLUSION
You can probably see why I enjoyed the tutorial so much to the extent that I might even want to write an entire post on it. People who have known me for a long time know that for a rather substantial period of time, I have always wanted to pursue something related to physics (e.g. obtaining a physics degree, becoming a physics teacher). Being able to work things out from first principles fascinates me, and physics is a field where this practice routinely abounds.
Simply put, I am absolutely enamoured with A/Prof Low’s explanation because it theoretically illustrated an experimentally confirmed relationship using fundamental first principles in physics in a manner that most people who have had even just prior secondary school-level instruction in Newtonian mechanics can comprehend.
I consider it a privilege to have had A/Prof Low teach my colleagues and I on Wednesday, and hope you have enjoyed reading this article as much as I have enjoyed writing this!
Nic 27 Nov 2022 (Sun)
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The animated film Tarzan (1999) by Disney is one of the many animated productions that I watched fondly as a kid. The film chronicles the tale of a man raised by apes and must decide where he really belongs when he learns that he is a human. Famous soundtrack from the film include You’ll Be In My Heart by Phil Collins. In the first half of Tarzan, we are shown a scene of monkeys starting to cry, to which Jane Porter the female protagonist responds: “No, no, don’t give me those crocodile tears.“
In common parlance, the term ‘crocodile tears’ is used to suggest that a person may not be sincere with respect to his tears or expressions of sorrow. An example sentence would be as follows: “They weep crocodile tears for the poor and disadvantaged, but are basically happy with things as they are” (obtained from Google Dictionary).
This expression which has wended its way into our language is apparently derived from the ancient belief that crocodiles shed tears after killing their victims.
While crocodiles can and do generate tears, there is a lack of evidence to suggest that such tears are linked to emotion. This runs in contrast to that of us humans, who can and do shed tears for a myriad of reasons. Classically, we shed tears as an overwhelming emotional response to a particular situation. This emotion could be that of joy (thus giving rise to the well-known expression “tears of joy”). This can occur when mothers hold their neonates for the first time shortly after birth, when athletes finally clinch the long-desired Olympic gold medal, when one achieves one’s desired academic performance in an exam. Of course, joy is not the only emotion that can give rise to tears. Immense sorrow resulting from receiving the news of the death of a loved one can also move someone to tears. Additionally, touching Thai advertisements, Korean dramas, and even movies such as ‘The Notebook’ that are highly popular with the fairer sex are also all known to move people to tears.
It is challenging to determine the precise origin of this particular belief on crocodile tears, but one can see why such a belief might have propagated and stood the test of time. According to Adam Britton, an Australian zoologist and a crocodile specialist, “for an apparently remorseless creature such as a crocodile to actually weep over its victims is a memorable irony which has inspired considerable prose“.
Let’s now see how the phenomenon has found its way within an alternative descriptive term of the eponymous Borogad syndrome, the medical condition in which one sheds ‘crocodile tears’.
Crocodile tears syndrome
Crocodile tears syndrome, also known as Borogad syndrome, is the shedding of tears while eating or drinking in patients recovering from Bell’s Palsy. It is also referred to as gustatory lacrimation.
The eponymous syndrome is named after Russian neurologist F. A. Bogorad, who described the condition in a case report entitled “Das syndrom der krokodilstränen” that was published in Vrach Delo in 1928. In the words of Austin Seckersen, who offered his translation of Bogorad’s article many decades later on New Year’s day of 1979 in an article published in the Journal of the History of Medicine and Allied Sciences, “Borogad’s paper is not of easy access” and “it was written in Russian and was published at a somewhat disturbed period in Soviet history“. As such, Seckersen thought “it might be of value to produce a translation of it“.
Pretty interesting, I must say. I wouldn’t have been able to learn about crocodile tears syndrome if not for Seckersen’s introduction and translation of Borogad’s work that was originally published a few decades earlier.
Bell’s palsy is basically idiopathic facial nerve palsy. For a previous blog post where I discussed Justin Bieber’s relatively recent journey with facial nerve palsy, click here.
Many in society repeat ad nauseam how it’s a person’s personality that truly matters, perhaps in an attempt by their holier-than-thou attitude to demonstrate that they transcend the reality of the ‘superficiality’ of physical features. What’s funny is that it’s almost never the people who are conventionally unattractive that say that ‘looks don’t matter’. Rather, it’s physically attractive people, or even people whose looks are average that publicly declare that ‘looks are secondary’. The reason that conventionally unattractive people are practically never the ones to say that “looks don’t matter” is that they know what it’s like firsthand to be an unattractive person. Newsflash. It isn’t pleasant. They know that looks matter.
Take the typical obese person who is deemed conventionally unattractive for example. It doesn’t matter if the obesity was trigged by dietary indiscretion secondary to Prader-Willi syndrome, medications, or circumstances that are not reasonably within his control. Society would still stereotype him as a ill-disciplined gluttonous sloth. After all, why would anyone talk to him further to have a more holistic assessment of him when he already looks a certain way? First impressions matter a lot, and in my opinion, have particularly weighted influence on all subsequent decisions that people make.
I urge you, dear reader, to not just pay attention to what people say, but pay attention to what people do (eg consider the basis on which people select their romantic partners, and how they actually interact with others). You may be surprised that, upon closer inspection, people don’t really practise what they preach.
It is well established that good-looking people are treated by others better, ceteris paribus. People are more forgiving towards the misdemeanours of good-looking people. Good-looking people are shown more favours and are treated better across every domain of life. And perhaps it might frighten you to know that in many instances, those who treat good-looking people better don’t even do so consciously. People subconsciously treat good-looking people better. I would argue that this inclination to treat good-looking better is hard-wired into the human genetic code, and taps on our primal instincts.
In the spirit of the tagline of my blog (‘musings of guileless candour’), I’ll be frank and direct. Looks matter. Physical attraction, particularly involving the face, matters in all kinds of relationships: whether at work, in one’s friendships, or one’s romantic pursuits. Anyone who says otherwise should probably snap out of his naivety.
Furthermore, as much some people would so desparately like to believe that beauty is subjective, I am unfortunately the bearer of some discouraging news. Beauty is rather objective. The human mind, in a matter of seconds, is able to discern between the photographs of two individuals and determine whom the more attractive person is, even if one is not able to articulate preciselywhy one is more attractive than the other.
Do you doubt me? Try the following: take a raw photograph each of any two randomly selected men or women (ideally of the same age, sex, and ethnicity) under similar circumstances (eg similar posture, angle, and lighting). Ask fifty randomly selected people whom they find more attractive. If beauty standards were truly subjective and indeed in the ‘eye of the beholder’, one would expect an even split among the respondents regarding whom the more attractive person is. Of course, that result would never occur in reality.
So, what exactly makes a particular face objectively more attractive than another face? This question greatly piqued my curiosity when I first pondered on it a while back. In today’s post, I would like to share what I learnt regarding what objectively determines the physical attractiveness of faces (for the sake of this blog post, I’d be talking about a male face).
From mere inspection of a man’s face, one can tease out a myriad of facial features. All sorts of measurements can be made: lengths, widths, shapes, ratios, angles, symmetry. However, some features are more important than others. Very important facial features include the eyes, jaw, midface, face shape, and eyebrows. Features which are not as important include the lips, nose, forehead, and eye colour.
Once an assessment of the man’s facial features is done, consider the ‘category’ of men the evaluated man falls under. Is his face considered slightly feminine, regular, or hypermasculine? Lastly, consider the overall facial harmony of the person. At this point, you may then proceed with your attempt in devising a ‘score’ for the candidate (conventionally, people’s physical attractiveness are rated on a 1-10 scale, with 10 being absolute perfection).
Jaw analysis
One of the first features about a man’s face that people would note is his jawline (or lack thereof). The following illustrates a good, chiseled, and well-defined jawline. These photographs constitute the front and side profiles of none other than Henry Cavill.
In Cavill’s side profile, we note the presence of a lengthy ramus, which is a desirable facial feature. The term ‘ramus’ is a Latin anatomical term and may be alternatively rendered as ‘a projecting part, elongated process, or branch’. In the context of the mandible (ie the lower jawbone), the ramus refers to the posterior and partially vertical part that articulates with the temporal bone (one of the bones which constitute the skull).
Consider the original photograph of Cavill on the left, while the photo on the right is an edited version with a shortened ramus. No prizes for guessing which photo would be perceived as more attractive.
A lengthy ramus adds bulk and fullness to the jaw. Period. Besides one’s ramus, another facial feature of attraction is the tightness of the skin overlying the hyoid.
In obese people who are conventionally unattractive, the excess subcutaneous fat at the hyoid area would effectively conceal the definition of the body of the mandible and cause the face to look round. On the other hand, having tightness of the skin overlying the hyoid which is seen in the above photo of Cavill demonstrates the beauty associated with having the body of the mandible well-defined.
Next, a protruding chin is another jawline sub-feature that is attractive. The following images of Cavill best illustrate the difference been having a protruding chin and not, and this difference is night and day.
I’ve only shared a limited selection of jaw sub-features that can be considered. The following image shows other jaw sub-features that can be considered. And this is just all under the ‘jaw’. We’ve not even covered all the important facial features!
Midface analysis
Let’s now move on to the important sub-features of midface:
Allow me to elaborate on some of the points mentioned in the above image regarding desirable features in a male midface. The ‘cheekbones’ constitute the layperson’s term for the zygomatic bones.
You may frequently hear the term “high cheekbones” tossed around in magazine beauty articles and television shows. Typically, having high cheekbones means that the widest part of the face is just beneath the eyes, causing the cheek to dip in slightly beneath the bone. Particularly in people with a low body fat percentage, this dip causes a slight shadow, which further accentuates this midface sub-feature. If you go back to the earlier image of Henry Cavill, you’d see exactly this. You’d see the hollow caved-in cheekbones.
As for the nose, it should not be too wide. Ideally, the beautiful nose is approximately a fifth of the width of the face. The following image illustrates the proportions in a female face, but the same ratios apply to men as well. In addition to the width ratios, the partitioning of the face in three different vertical segments of equal length is notable too. The distance from the trichion (the point on the skin which coincides with the intersection of the sagittal plane and the normal anterior hairline) to the glabella should be equal to the distance from the glabella to the subnasale (the point on the facial skin which represents the most inferior part of the nose), which in turn should be equal to the distance between the subnasale and the menton (the most inferior point in the sagittal plane of the chin). A picture tells a thousand words, so review the following images if you didn’t quite get what I just said!
In fact, even for the segment bounded by the subnasale and the menton, another ideal proportion exists within it. In the image directly above, we see that the distance from the subnasale to the stomion (which represents the most superficial point of contact between the upper and lower lip along the median plane) should be half the distance between the stomion and the menton.
Eye analysis
An attractive eye would not have scleral show (i.e. you wouldn’t be able to see the bulbar conjunctiva beneath the inferior portion of the corneal limbus). Moreover, a positive canthal tilt is attractive. The following image illustrates what I mean (note that the person’s left eye is shown here):
The distance between the medial canthus of both eyes should be approximately the width of one eye:
Eyebrows analysis
For maximal attractiveness, eyebrows should be thick and full. They should also have a positive tilt, just as we have seen with the eyes. The eyebrows should also be close to the eyes.
The golden ratio
Golden ratio calculations can be used to supplement the above-mentioned analyses of different facial features in order to be as comprehensive as possible.
For example, the ratio of the length to the width of your face should correspond to the golden ratio (= (1+sqrt5)/2 = 1.618…) for maximal attractiveness. For even more calculations regarding the golden ratio, consider the following image as a guide. For a particular face you select, plug the raw values into the provided formulae and churn out the answers (expressed as a percentage). A score as close to 100% as possible would suggest higher attractiveness.
Conclusion
A person’s facial attractiveness is more objective than most people think. If you find yourself not having some or many of the aforementioned desirable features, do not despair. The whole point of all these objective markers is to guide you in letting you know where you can improve. For instance, when you are aware of your particular face shape, you can get a particular haircut to suit it. In nearly all people, fat loss can bring out many attractive facial features (eg having a more chiseled jawline, having more prominent cheekbones with a visible inferior hollow formed by the lateral aspect of the maxillae). The countless sets of before/after images of people’s incredible weight loss journies online are a testament to this phenomenon. For those willing to undergo invasive therapy, even more options are available: hair transplant surgery, blepharoplasties, rhinoplasties.
Some people might say that learning about all of this is so vain and that we shouldn’t even discuss these supposedly superficial things. However, in the spirit of my previous post on aesthetic medicine, I would argue yet again that learning about what constitutes an attractive face and then taking actionable steps (eg balanced diet, regular exercise) towards achieving a more conventionally attractive visage suggests that a person is committed to improving himself. This involves him putting his best foot forward in a society which is rather judgemental and unforgiving when it comes to a person’s external appearance.
If one can take steps to make a positive tangible difference in virtually all aspects in one’s life, why not? It’s a no-brainer. Such a commitment to personal development is laudable, and should be encouraged insofar as it doesn’t adversely affect one’s mental health.
Personally, it would be Japanese (Western is a joint favourite). My love for Japanese food began at the tender age of nine, when I was granted even more daily pocket money upon advancing to being a Primary Three student at Pei Hwa Presbyterian Primary School (PHPPS). A photograph of the primary school is attached below. When I was in Primary One or Two, school sessions would occur in the afternoon, and there would be lunch and dinner at home. As for my classmates and I, we would just talk to one another and play catching in the school field.
However, from Primary Three through Six, school sessions would occur in the morning, and it became pretty popular for my fellow classmates and I to consume food during recess time (most likely due to my peers and I now indulging in our newly-acquired increased purchasing power), in addition to the breakfast and lunch many of my peers and I would enjoy at home.
Favourite meal at the primary schoolcanteen
One of my fondest memories of primary school would be that of consistently buying a particular set meal from the Japanese food stall of the school canteen during the half-an-hour recess time. The meal consisted of the following: rice, some dark brown sauce, egg, and three pieces of yakitori (Japanese skewered chicken; the Japanese words ‘yakitori’ literally translate to ‘grilled bird’). There would also be seaweed strips sprinkled over the rice and other ingredients. All of this would be presented on a translucent rectangular tray, from which I would partake of the scrumptious food.
Sushi
Since that first exposure to Japanese food (at worst, a simulacrum of it), I have gone on to try other aspects of Japanese cuisine as the years passed. In particular, I stumbled upon sushi, a huge component of Japanese cuisine that is responsible for the cuisine’s widespread appeal. Sushi is an element of Japanese cuisine that I deeply relish, and it is precisely what I will talk about more in this post.
At least in the local context, authentic Japanese sushi is rather pricey as proper ingredients which are as fresh as reasonably possible, of excellent quality, often have to be imported directly from Japan. This contributes to the steep price of authentic Japanese sushi.
The overwhelming ubiquity of ‘fake’ wasabi
Just take wasabi as an example of the sheer value of ‘proper’ ingredients in the art of making sushi.
The overwhelming majority of so-called ‘wasabi’ served in restaurants does not contain any real wasabi. Such ‘fake’ wasabi is manufactured from a blend of Western horseradish, mustard flour, cornstarch, and green food colouring (the green colouring is required to convince people into thinking they’re consuming ‘real’ wasabi, which is actually green in colour). Many who think they know what wasabi tastes like have never actually tasted the real stuff, unless they have gone to top-of-the-line omakase restaurants such as Shoukouwa, or other places which serve real wasabi.
Unlike ‘fake’ wasabi, ‘real’ wasabi paste is obtained by grating the rootstalk (the technical term in botany for this would be ‘rhizome’) of the wasabi. When one grates real wasabi, the volatile compounds that confer the real wasabi its distinguished taste begin to disintegrate within minutes. That’s why real wasabi paste tastes best when it’s freshly grated. Wasabi is also considered challenging to grow, and this characteristic contributes to the vegetable’s high price. On the other hand, ‘fake’ wasabi is cheap and has a long expiration date.
Fake wasabi has a strong taste that overwhelms any delicate fish taste on the sushi. It delivers a strong blast of spiciness that comes from the mustard flour (recall the few basic ingredients that I mentioned above regarding what constitutes ‘fake’ wasabi). On the other hand, ‘real’ wasabi accentuates the delicate taste of fish in the sushi we consume. Real wasabi is not spicy. Rather, the taste of real wasabi is more like the aroma of spiciness but without the pungent punch of the mustard flour in the fake wasabi.
Sushi (cont.)
It’s not just the ingredients which are considered in the art of making authentic sushi. The expertise required for making authentic sushi needs to be considered too. Proper sushi-making is an art where knowledge is possessed only by a limited number of highly skilled sushi chefs. They have skills which are rare (even rarer outside of Japan). Coupled with the high demand for authentic sushi, anyone who has undergone an introductory economics class can tell you that the potent combination of a ‘low supply and high demand’ would result in the partaking of authentic sushi being a costly activity.
As a mere college student who isn’t swimming in multigenerational wealth, the hope of being able to enjoy authentic sushi regularly is but a distant dream. The fiscally prudent option, and what seems to be a reasonable compromise between quality and price, would be to settle for much more affordable mainstream sushi restaurants. While the experience at mainstream restaurants can never rival that of top omakase restaurants, it allows many Singaporeans the opportunity to still enjoy sushi at reasonable prices, which in my opinion, is still a great thing overall.
Moderately inauthentic sushi is still better than not having any sushi at all.
When this well-known piece of classical music finally comes to a halt in the documentary, we hear the first words of the legendary sushi master, Jiro Ono.
“Once you decide on your occupation, you must immerse yourself in your work. You have to fall in love with your work. Never complain about your job. You must dedicate your life to mastering your skill. That’s the secret of success and is the key to being regarded honorably.”
Jiro Ono, 96-year-old sushi chef
Jiro Ono is the Japanese chef and owner of Sukiyabashi Jiro, arguably the best sushi restaurant in the world. The restaurant can only seat up to ten people at any given time, and had earned three Michelin stars every year since 2007 until the year where it stopped receiving reservations from members of the public. Reservations are now only available to previous regulars, people with special connections, or people who book their reservations through the concierge of a luxury hotel. Sukiyabashi Jiro is no longer officially a three Michelin star restaurant because one of the guiding principles in how Michelin stars are awarded is that the eatery must be available to members of the general public.
In the documentary, we hear from Jiro’s older son:
“The techniques we use are no big secret. It’s just about making an effort and repeating the same thing every day. There are some who are born with a natural gift. Some have a sensitive palate and sense of smell. That’s what you call “natural talent”. In this line of business, if you take it seriously, you’ll become skilled. But if you want to make a mark in the world, you have to have talent. The rest depends on how hard you work.”
Yoshikazu Ono, the older son of Jiro Ono
One of the most well-known food critics in Japan speaks of Jiro, “He repeats the same routine every day. He even gets on the train from the same position. He has said that he dislikes holidays. The holidays are too long for him. He wants to get back to work right away. It’s unthinkable for most people.”
The food critic later goes on to say (the bolded text in this paragraph and the following three paragraphs all constitute quotes by this food critic), “A great chef has the following…attributes: first, they take their work very seriously and consistently perform on the highest level; second, they aspire to improve their skills; third is cleanliness…; the fourth attribute is impatience; they are not prone to collaboration; they’re stubborn and insist on having things their own way…”
“In France, the first Michelin guide was published in 1900. Michelin inspectors look first for quality. Next they look for originality, and finally they look for consistency. Jiro’s restaurant easily meets their standards. A perfect three-star Michelin rating means it is worth making a trip to that country just to eat at that restaurant.”
“When Jiro got three stars, everyone was astonished. There are only 10 seats there! The restroom is outside the premises. There’s not another three-star restaurant in the world like that. But the Michelin investigators say, “No matter how many times you eat at Jiro’s, the sushi there is incredible.” They said that three stars is the only rating adequate for the restaurant.”
“Always look beyond and above yourself. Always try to improve on yourself. Always strive to elevate your craft”.
The climax of the documentary occurs towards the end of the documentary when it is revealed in the words of the food critic that during the first year that the restaurant was checked by Michelin, Jiro Ono didn’t make sushi for Michelin even once. Yoshikazu was the one who made sushi for them. Clearly, if Jiro permitted, Yoshikazu was skilled enough to take over the restaurant if circumstances called for it.
Lessons for us
Jiro Ono’s life is simply fascinating. I’ll quote him again:
“Once you decide on your occupation, you must immerse yourself in your work. You have to fall in love with your work. Never complain about your job. You must dedicate your life to mastering your skill. That’s the secret of success and is the key to being regarded honorably.”
His words are applicable beyond the domain of making sushi, and are incredibly inspiring.
In my case, the question of whether medicine is the field I should have chosen to come to with the benefit of hindsight is no longer an important or relevant one. The reality is that I decided to apply for medical school with the best available information to me at the time, and here I am. I had decided that I wanted to graduate with a medical degree and procure gainful employment which would ideally capitalise on the skills I would have acquired over the course of the undergraduate degree programme.
According to the advice of Ono, I should now immerse myself in medicine and what it takes to be a successful medical student. I have to fall in love with being a medical student. What Ono may be trying to drive across is that such passion and love for what one does comes with becoming better at what one does in the context of a positive feedback loop. This ties in well with the advice given by Cal Newport in his influential career advice book, So Good They Can’t Ignore You.
Moreover, regarding Ono’s advice on not complaining about one’s job, though I have not graduated from medical school and started working as a doctor, I can identify moments in which I have lamented about certain aspects of being a medical student. Often, such lamentations are not constructive. A more meaningful thing to do is working diligently and humbly at improving my skills. Hopefully and ideally, this would manifest as me becoming more competent with each passing day.
I consider myself fortunate to have encountered such advice while still a student, even before I have entered the unforgiving working world. But even if you, dear reader, are already working, fret not. This advice is still highly relevant.
Whether we’re still in school or working, let’s focus on getting better at what we do. Don’t complain about our school or work.
As long as we do the above with consistency over the span of the many decades which we shall dedicate to mastering our craft, I’m confident that we will have a better shot at attaining success and being regarded honourably, just like Jiro Ono.
Yesterday, I went to get a haircut and while I was en-route to the barber, I encountered a sign which advertised the list of aesthetic services offered by a GP clinic, which itself was a member of a chain of GP clinics. Interestingly, aesthetic medicine isn’t recognised as a specialty or subspecialty in Singapore. Doctors who attempt to market themselves as an ‘aesthetic surgeon’, ‘aesthetic physician’, or a similar title will have to face various penalties as this would be deemed unethical by the Singapore Medical Council.
Anyway, on the topic of specialties, as a mere medical student, it’s still rather premature to hone in specifically on a single specialty. After all, this isn’t the US where medical students are required to pick their specialty early on. In Singapore, doctors have the flexibility to slowly discover where their interests and aptitude lie. In tandem with the advice given by senior medical students and doctors, I have decided to keep an open mind regarding what I might find myself doing in the future. Besides, as someone who is about to advance to Year 4 of medical school, there are still so many specialties that I have yet to gain exposure to in the form of clinical rotations.
As such, besides ophthalmology, I possess a broad interest in many other areas including, but not limited to: family medicine (including aesthetic medicine), internal medicine (cardiology, dermatology, endocrinology, infectious diseases, medical oncology, neurology, nuclear medicine), pathology, radiology, radiation oncology, and otorhinolaryngology.
In this blog post, I would like to talk specifically about aesthetic medicine. The perception of aesthetic medicine by the general public doesn’t seem to be a positive one. Most people seem to view aesthetic medicine as an exploitative field where practitioners are so fiscally oriented to the extent that it is borderline sickening.
A late doctor’s thoughts on life, wealth, success, and happiness
The thoughts of the late Dr Richard Teo Keng Siang (1972-2012) have amplified such a perception. You can read his thoughts on life, wealth, success, and happiness here, a webpage which offers a transcript of a speech he delivered a few months before his passing. The webpage also offers an embedded YouTube video of his speech, which was recorded eight months after he had been diagnosed with terminal lung cancer.
For those among us who have chosen not to read the entire transcript or watch the video, the essence of Dr Teo’s speech is as follows:
As a person from a below-average family background, he was told by the media and his peers that happiness is about success, and that success is about being wealthy. So, Dr Teo made it his goal to become wealthy. Dr Teo was a brilliant student who excelled academically, even in medical school. After graduating from medical school, he obtained a traineeship in ophthalmology, and was also awarded a research scholarship to develop lasers to treat the eye. In the process, he was able to obtain two patents: one for developing the relevant medical devices, and one for developing the lasers. Despite attaining various impressive academic accolades, he realised that these per se did not bring him any wealth. Once his MOHH bond was completed, he left for the private sector (specifically, to practise aesthetic medicine) because he decided that ophthalmology training was taking too long, and that there was much more money to be made in the private sector. He became very rich from practising aesthetic medicine. However, one day, he presented with back pain and approached his colleague at SGH for an MRI just to rule out spondylolisthesis and other ominous conditions. Unfortunately, the results of the MRI scan and subsequent investigations were not reassuring as Dr Teo had hoped. Dr Teo was eventually diagnosed with terminal lung cancer, and given a prognosis that many patients would deem highly unfavourable. He finally opines that true happiness doesn’t come from serving yourself, and that we ought not to let society tell us how to live. We ought not to let the media tell us what we’re supposed to do. We have to decide whether we are working solely for our own benefit, and/or whether you are going to make a difference in the lives of others.
This speech by Dr Richard Teo is so well-known that I have encountered his story on three separate occasions. I remember hearing about Dr Richard Teo for the first time when I was preparing for my GCE O Level exam in my final year at Maris Stella. That was in 2013. As for the second time, I encountered it via a link that a fellow friend who was a medical student shared on her Facebook profile (this was before I deleted my Facebook account for good). Lastly, I also remember hearing it for the third time during my church’s Watchnight service on 31 Dec 2019, where the pastor shared Dr Teo’s story in an attempt to emphasise the point that much of the material possessions that we can indulge in are truly ephemeral in the light of eternity.
With such a story to top it off, it is therefore no surprise that some people feel that aesthetic medicine is the epitome of unbridled capitalism, where people who are insecure about their physical appearance (particularly those of the fairer sex) are mere cash cows to be milked till their udders are sore. Some people even go to the extent to say that providing aesthetic services is not really medical practice. However, in my opinion, even after all that Dr Teo had said in his speech, such perceptions of aesthetic medicine are too harsh. They are too one-sided and fail to offer a balanced perspective of what aesthetic medicine has to offer.
A careful reading of the transcript of Dr Teo’s speech would allow one to realise that aesthetic medicine is neither evil nor exploitative per se. What’s more critical is your intention that undergirds your practice of aesthetic medicine, which will manifest in your attitude towards patients, and consequently, how you treat them.
Aesthetic medicine can offer individuals the opportunity to put their best foot forward in this society which places such an undue emphasis on one’s external appearance (like it or not). This can give patients greater self-confidence, allowing them to fulfill their potential even as they wend their way through society.
Thus, in this blog post on aesthetic medicine, I would like to take the opportunity to briefly introduce some examples of aesthetic services that may be offered in a GP clinic. This is in no way an attempt to promote any specific clinic. Rather, undergoing the process of writing this blog post would mean that I would need to acquire a basic understanding of each of the procedures that is advertised. Ultimately, I hope to have a better understanding of those aesthetic services as aesthetic medicine is a future area of practice that I’m considering. Additionally, as an inquisitive person, it brings me great joy to learn more about things that pique my curiosity. It brings me great joy to engage in writing, and sharing what I’ve learnt with you, dear reader.
The following image is a photograph I took of the sign:
I shall attempt to briefly describe how each procedure within Section 6 (highlighted in pink) works, based on the readings I have done for this blog post. Note that there’s going to be some overlap between the sections as the listed bullet points are not mutually exclusive.
Laser Hair Removal
Laser hair removal is a procedure which involves shining a laser on the region with the unwanted hair. The light is absorbed by the melanin (a dark pigment) in the hair. Within the melanin, the light energy is converted into heat, which damages the follicles that produce the hair. This in turn impairs future hair growth. The effect isn’t permanent, though such laser hair removal effectively delays hair growth for a long time. Any hair that grows out subsequently may be shorter and thinner than before.
Whitening & Pigmentation Treatment
Skin whitening can be achieved via chemical peels, or IPL (intense pulsed light therapy). Chemical skin peels will be discussed in a later section.
As for IPL therapy, which is also known as a photofacial, it is a non-surgical modality for one to improve the colour and the texture of the skin. IPL uses the energy from photons to target a certain coloured pigment on your skin. When the particular region of skin is heated, the body gets rid of the unwanted cells in that region, and that gets rid of the thing you’re being treated for. Unlike lasers, an IPL device sends out more than one wavelength of pulsating light. As such, IPL can treat a range of skin conditions at the same time.
Nevertheless, you can’t have your cake and eat it too. Due to the use of several wavelengths at a relatively gentle intensity on your skin, multiple sessions are normally required for the desired results to be achieved. After IPL, you may look younger because your skin tone is more even. And since the light doesn’t hurt other tissue, you can get better quickly.
As for pigmentation, the skin can either be hypopigmented or hyperpigmented. Hypopigmentation refers to having skin that is lighter than your overall skin tone. Conversely, hyperpigmentation refers to having skin that is darker than your overall skin tone.
There are many modalities that can be employed to treat hypo- or hyper-pigmentation. These include dermabrasion, chemical skin peels, laser skin peels, and IPL.
Laser Surgery for Moles/Warts/Lumps
Moles, warts, and lumps are typically harmless, and patients often want them removed or at least reduced in size for cosmetic reasons. One way of achieving this is via laser surgery. However, at least for moles, lasers (which are typically CO2 lasers) are only used for small moles. This is because for larger moles, the laser would not be able to penetrate deep enough to eliminate the pigmented cells that give rise to the moles.
Microdermabrasion
Remember how I mentioned ‘dermabrasion’ earlier? Well, that is different from microdermabrasion. Dermabrasion is an exfoliating technique that uses a rotating instrument to remove the outer layers of skin, and as you can imagine, this is most often requested for the facial region. Immediately following dermabrasion, treated skin will display some of the cardinal signs of inflammation such as rubor (reddening) and tumor (swelling). Note that I’m not actually suggesting that a neoplasm would form as a result from dermabrasion! It’s just that the Latin word ‘tumor’ is used to refer to ‘swelling; oedema’! The skin that grows back after dermabrasion is usually smoother.
As you may have guessed from the terms, microdermabrasion is a less aggressive form of dermabrasion. Microdermabrasion is a noninvasive cosmetic procedure which involves the doctor spraying or rubbing fine crystals onto the skin with a wand that gently exfoliates the surface, removing the top layer. The complications aren’t severe as that of dermabrasion (e.g. there’s no bleeding in microdermabrasion); however, the results of microdermabrasion unfortunately aren’t as spectacular as that of dermabrasion.
Chemical Skin Peel
Chemical peels work by having a chemical solution is applied to the skin to remove layers of the skin, revealing the underlying skin. There are three types of chemical skin peels: light, medium, and deep. As we go from light to deep, the thickness of the skin that is ‘peeled’ off increases. For the light skin peel, only the epidermal layer is peeled off. However, for the deep chemical skin peel, both the entirety of the epidermis and the dermis are peeled off. After the skin peel is done, the new skin underneath is often smoother, appears less wrinkled, and may have less damage.
Note that deep chemical skin peels are really rather invasive and nowadays, they are increasingly done less in favour of laser resurfacing, which we shall soon cover in the next section.
Laser Skin Peel & Resurfacing
Laser resurfacing treatment involves the emission of beams of light (this is basically what a laser is) to penetrate the skin and target either pigment, haemoglobin, or water in the skin. Depending on what is targeted, different skin abnormalities can be addressed. When pigment is targeted, age spots, sun spots, and dark spots can be reduced. When intradermal haemoglobin is targeted, erythema (reddening), scars, and stretch marks can be reduced. When intradermal water is targeted, wrinkles and fine lines can be reduced.
Radiofrequency
Radiofrequency skin tightening involves the doctor using a handheld device that is connected to a machine that creates radio waves. They will pass the device over your body to apply radio waves to your skin. The radio waves are exothermic, and this stimulates the production of more intradermal collagen and elastin. This treatment also speeds up cell turnover, and as such, the skin gets firmer and thicker over time. The process can take about an hour, depending on how much skin you are having treated. The treatment will leave you with minimal discomfort. You may see these treatments called by the brand names Thermi, Exilis, Profound RF, and Thermage, among others. The ‘Therm-‘ prefix that you see in some of these brand names should remind you that the radio waves are exothermic!
Botox & Skin Fillers
We have come to what is arguably one of the most famous aesthetic services: Botox.
Botox is the brand name for botulinum toxin, which is a substance that is produced by the bacterium Clostridium botulinum and a few other related organisms. As the name suggests, this toxin is toxic! Specifically, the toxin is toxic to the nerves. It prevents the release of the neurotransmitter acetylcholine (ACh) from axon endings at the NMJ (neuromuscular junction), thus causing flaccid paralysis. When people are infected by this organism, and experience flaccid paralysis, the disease they are said to have is botulism. It’s similar to how when people are infected by a related organism, Clostridum tetani, they are said to have tetanus.
Unlike the experience in botulism, where the infective bacterium is rampant in the body and affecting all sorts of nerves via the unbridled spread of the botulinum toxin, Botox treatment is administered meticulously by the doctor. In Botox treatment, small amounts of the toxin are carefully delivered to specific regions via fine-needle injections.
Based on the pathophysiology of botulism, it’s not hard to see how Botox treatment can reduce wrinkles. With the administration of Botox on the face, signals (the neurotransmitter ACh) that cause the facial muscles to contract are blocked. Temporarily, at least, this would reduce the wrinkles around the eyes and on the forehead.
Fractional CO2 & Resurfacing Laser
See the above point on Laser Skin Peel and Resurfacing.
Antioxidant Treatment
Antioxidant treatment can entail a process known as iontophoresis, which is a process of transdermal drug delivery by use of a voltage gradient on the skin. Molecules are transported across the stratum corneum (the most superficial layer within the epidermis) by electrophoresis and electro-osmosis and the electric field can also increase the permeability of the skin.
Think of iontophoresis as basically priming the skin for receiving the antioxidant (the increased skin permeability would mean increased absorption of the antioxidant). This is one solution to the perennial challenge that cosmeceutical companies face, which is to develop products that can penetrate well enough into the human skin.
Let’s talk specifically about Vitamin C (ascorbic acid), a well-known antioxidant. When iontophoresis is used in combination with vitamin C, absorption is effectively expedited (once again, due to the iontophoresis-induced increased skin permeability). Transdermal delivery of vitamin C via iontophoresis would improve superficial pigmentation issues such as freckles, spots, and acne.
Conclusion
There is a wide variety of aesthetic services that are available at many GP clinics. It is intellectual sloth to simply paint broad strokes of aesthetic medicine as an arena in which the udders of insecure cash cow patients are milked in the name of unfettered profit maximisation. Doctors who provide aesthetic services are often unfairly stereotyped as greedy and exploitative.
At least through the lens of a member of the general public who is also a medical student, I opine that aesthetic medicine appears to possess tremendous potential as a means by which people can heighten their self-confidence, and allow them to put their best foot forward in a world which can be rather critical of people’s external appearances.
Moreover, the practice of aesthetic medicine isn’t confined within the four walls of a physical clinic. Excellent patient management is anchored in good patient education, which in the context of aesthetic medicine would include educating the patient on the importance of having, as a baseline, a skincare routine. I challenge you to find me a single doctor who doesn’t think that consistent application of moisturiser and sunblock (even for patients without any known dermatological conditions) is good practice.
Let’s be more open-minded and remember that health, as defined by the World Health Organisation, is ‘a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’.
During my first week of the IM (Internal Medicine) rotation almost a year ago, I remember being asked by a doctor to perform an examination of a particular patient’s cranial nerves. The patient had been diagnosed with Ramsay-Hunt syndrome. That encounter left an impact on me.
Now, whenever I encounter the eponymous syndrome or read about facial nerve palsies in my medical studies, I never fail to be reminded of that patient.
In this article, I share how I was recently reminded of that patient yet again.
This morning, I entered my school’s medical library for my own self-study and decided to do some quick casual browsing through today’s copy of “The Straits Times” to start the day. I chanced upon a headline that caught my attention: “Justin Bieber recovering from virus, says surgeon“, as seen by the photograph I have taken of the print article I read:
Justin Bieber? Who?
Bieber rose to fame in the late 2000s, where uploaded YouTube videos of the precocious teenager doing some casual singing went viral and allowed him to jump-start his singing career. He is most well-known for the song ‘Baby’ which become a global hit. Whilst a secondary school student at Maris Stella, I remember that song being played nearly everywhere – in malls, etc. The song was also a means by which Bieber received a seemingly substantial amount of criticism by all sorts of people. I’m not sure whether it’s still the case, but I believe that the official music video for ‘Baby’ was the most disliked video on YouTube by absolute dislike count metrics (before YouTube officially removed videos’ public dislike count).
The matters of Bieber don’t particularly concern me and I am neutral about his life and craft. He neither appeals to me nor attracts my disdain. In terms of music, I am simply interested in other genres of music: classical, and movie soundtrack, for example. However, it’s easy to understand why Bieber has become a target of a significant amount of online vitriol.
Bieber is a classic example of someone leveraging online fame to cement financial success. This perhaps stokes jealousy in the hearts of many young men throughout the world who secretly aspire to achieve what he has: fame and fortune. Some people are of the view that Bieber has supposedly attained such fame and fortune because of his sheer luck and that he doesn’t actually possess the raw talent to warrant the success that he has attained.
I don’t think Bieber’s station in life is particularly admirable, and I wouldn’t want to be in his shoes if given the choice, but the reasons for this view will not be elaborated in this article. I merely wish to introduce Bieber to readers who may not be familiar with him. He shall be the subject of our brief study on facial nerve palsies and basic neurolocalisation.
Understanding facial nerve palsies, and a simple exercise on neurolocalisation
The published photograph, along with a short video uploaded by Bieber himself, suggests that he has right-sided facial paralysis. This is evident from the fact that in the published photograph, Bieber is unable to close his right eyelid, suggesting the likely failure of the right orbicularis oculi muscle (the muscle responsible for allowing you to close your eyelid voluntarily) to contract. We also note a mildly asymmetrical smile that is raised on the left side of Bieber’s face, and the loss of the horizontal creases on his right forehead. These are classic features of an ipsilateral facial nerve (CN VII) palsy. In this case, Bieber has a right-sided facial nerve palsy.
In fact, we can go one step further and determine more precisely where along the neuroaxis the lesion is located. One of the first few questions we can ask ourselves in the process of neurolocalisation is whether the lesion is an upper or lower motor neuron lesion.
In the case of Bieber, since there is forehead involvement, his facial nerve palsy is likely due to a lower motor neuron lesion (i.e. anywhere including the facial nucleus, and the entirety of the course of the facial nerve). This is because the upper division of the facial nucleus receives bilateral upper motor neuron innervation (i.e. in a typical focal upper motor neuron lesion resulting in a CN VII palsy, the forehead muscle function would remain intact because it receives bilateral UMN innervation).
Aetiology of Bieber’s right-sided facial nerve palsy
In a useful set of slides I was shown by one of my clinical tutors for my Internal Medicine posting, two questions were posed to the reader regarding the approach to neurolocalisation: – 1) Where is the lesion? – 2) What is the lesion?
Now that we seem to have reached the limits of precision regarding the level of the lesion responsible for Bieber’s clinical presentation at the present time, the next natural step in our journey of arriving at a provisional diagnosis is determining the aetiology of the lesion. This can be achieved by considering the remainder of the history that was taken of Bieber, and the findings of any physical examination that was performed on Bieber.
Given that Bieber seems to have been diagnosed with Ramsay-Hunt syndrome (as stated in the print article), also known as herpes zoster oticus, it is not unreasonable to assume that he may have also presented with right-sided hearing loss, and/or a painful vesicular erythematous rash in and/or around his right ear.
Note that herpes zoster oticus is different from herpes zoster ophthalmicus, a condition I mentioned in a previous blog post last year. As you might imagine, both conditions are subtypes of herpes zoster, the technical term for shingles, which in turn is a disease caused by the reactivation of the varicella-zoster virus (VZV) that would have previously infected the patient. Shingles is known for manifesting as a painful vesicular erythematous rash. In herpes zoster oticus and herpes zoster ophthalmicus, such a rash may appear on the ear, or the nose respectively.
Let’s explore what Ramsay-Hunt syndrome entails a bit more. While the zoster rash and the facial nerve palsy are classic features of Ramsay-Hunt syndrome, other symptoms and signs may be present in a patient that has been diagnosed with Ramsay-Hunt syndrome. These include, but are certainly not limited to: vertigo, hearing impairment, change in taste, dry eyes, and dry mouth.
I’m not able to confidently explain why a CN VII lesion leads to vertigo and hearing impairment as the affected corresponding functions correspond to CN VIII – the vestibulocochlear nerve. Nevertheless, if I were to hazard a guess, manifestations of vertigo and hearing impairment could be due to some focal lesion affecting both CN VII and CN VIII under circumstances where either both cranial nerves are in particularly close anatomic proximity or the threshold for the precipitation/formation of a space-occupying lesion that compresses both nerves is reduced.
What I find easier to account for are the symptoms of dry mouth and dry eyes. It is known that taste to the anterior two-thirds of the tongue is achieved through the nervous innervation by the chorda tympani, a branch of the facial nerve. Thus, ageusia secondary to facial nerve palsy is certainly a possibility in Ramsay-Hunt syndrome. Moreover, CN VII is associated with parasympathetic fibres which are responsible for the stimulation of the sublingual and submandibular glands. So, I can imagine how a CN VII lesion might result in a patient having dry mouth. A similar mechanism exists for how these parasympathetic fibres which are associated with the facial nerve also innervate the lacrimal gland. As such, in a facial nerve palsy, I can also imagine how a patient might experience dry eyes.
Of course, as a disclaimer, please don’t take what I have said in the preceding paragraphs as gospel truth. My knowledge of neuroanatomy and physiology will pale in comparison to what you’ll find in proper textbooks and the words of senior doctors and researchers. I’m merely voicing out my thought process and sharing how I think about certain conditions with the limited contextual knowledge I currently possess. There is no paucity of researchers out there who have devised hypotheses and proposed mechanisms for the above signs and symptoms – sophisticated hypotheses and mechanisms that are grounded in a more holistic, comprehensive, and nuanced understanding of neuroanatomy and physiology than what a mere medical student can possibly recall off the top of his head.
Concluding message
It’s been a while since I made a blog post. I hope to post more frequently and regularly. Anyway, I hope this short and simple case study involving a recent example of a celebrity’s circumstances has allowed us to learn about medical content in a more interesting way. This would probably be most helpful for medical students who are also fans of Bieber (though I’m sure they would be disappointed that Bieber has found himself in this predicament).
**Scroll to the bottom of this post for a tl;dr summary if you’d rather not read the details!**
In perhaps the first quarter of 2021, I encountered a fellow Singaporean medical student’s retweet on Twitter. The retweet promoted an online event, specifically a global competition for medical students, that had been organized by one of the world’s pre-eminent academic publishing companies – Elsevier. The event was entitled “ClinicalKey Student Global Challenge (CKSGC)”. In addition to publishing an entire array of journals, which is the core business of what Elsevier does, Elsevier has also ventured into other areas, and has developed products which facilitate medical education for medical students, doctors, and researchers.
In an article I had gotten published in SMA News in July 2021, I talked about how I had used the ‘Complete Anatomy’ app for iOS as a primary learning resource for anatomy. The ‘Complete Anatomy’ app had been developed and successfully marketed with the help of Elsevier, and this app is just one of many innovative products that Elsevier has developed. ClinicalKey, like Complete Anatomy, is an innovative product and constitutes a clinical resource for medical students and doctors that had been developed by Elsevier. CKSGC is essentially a marketing campaign for the ClinicalKey product.
A few weeks after that medical student’s retweet, my medical school sent an email to its current students: telling us of the existence of a competition for medical students. As it turned out, this was the same event which that same medical student had promoted. Given that I had now heard about this competition from two independent sources, I couldn’t help but feel that I was on to something legitimate and that I needed to check this out to satiate my curiosity.
Some of you may be wondering who that fellow Singaporean medical student is. Well, at least at the time the retweet was posted, he was a student. He is now a junior doctor (given that he was a member of the class of 2021 at NTU LKCSoM). This person is none other than Aaron Goh. Aaron and I are similar in that he was born in the same year as me and as such, we had taken our final high school-equivalent exams in the same year. He didn’t do the GCE ‘A’ Level though. He was an alumnus of Anglo-Chinese School (Independent), better known as ACS(I) locally, and he had done the International Baccalaureate Diploma Programme. We had actually connected with each other on Twitter back then (this was way before I permanently deleted my Twitter account) due to our shared interest in ophthalmology.
To the best of our knowledge, we were the only two students from Singapore who were engaging with medical students, doctors, and researchers from all around the world (though mainly from North America) on ophthalmology-related stuff on social media.
But perhaps most notable is the fact that he had actually participated in CKSGC’s inaugural run in 2019. I’ll give the details soon, but in essence, Aaron had cleared the initial stages of the global challenge, and was a finalist, which meant that he earned the right to participate in the global finale which was held in London in 2019. He ended up going on to be a member of the winning team (named “Happy Red Blood Cells”; presumably due to the colour of the scrubs they were issued for the event) of the entire global challenge, So, it was also an interesting coincidence that for the second run of the event (the finale of this second run was supposed to be held in November 2021; however, it was postponed due to the unforeseen developments in the COVID-19 pandemic) which I participated in, my team was issued scrubs of the same colour – fuchsia. We also coincidentally named our team after a type of cell (though the previous winners’ team name had no influence on our decision to name our team after a type of cell). However, instead of naming our team after erythrocytes, we called ourselves “The Astrocytes”. Like Aaron’s team, our team then went on to win the global challenge.
What exactly is Elsevier CKSGC ’21 and how were the 16 finale participants selected?
The structure of the Elsevier CKSGC is as follows: four question rounds (Rounds 1-4), one video submission round (Round 5), and the finale where finalists, Elsevier staff, and panel of content experts come together at some location in the world where Elsevier has a major presence.
How it works for the initial question rounds is that to be eligible for the next round, you need to either score full marks on the current round, or score at least 10% more than your previous round’s score. Each round has 25 questions which vary in difficulty level and are written in the style of USMLE (United States Medical Licensing Examination) questions. As you might imagine, the latter criterion is easier to achieve than the former. Each round needs to be completed within 40 minutes. According to the official rules, everyone clears Round 1 successfully and advance to take Round 2 by default.
The four question rounds commenced on 17 April 2021, and lasted for four weeks. When each new round commenced each week, the questions went live for three days, and students were able to access results and additional learning materials as they progressed.
People who clear round 3 successfully are known as quarter-finalists. People who clear round 4 successfully are known as semi-finalists.
For the relatively low proportion of students who clear all four question rounds, they would get the opportunity to undergo a video round, where these semi-finalists would submit a four-minute video recording of themselves in which they would answer three questions on the topic of leadership in medicine. All the semi-finalists who submit their videos would have their videos reviewed by an expert panel.
For the Elsevier CKSGC ’21, the expert panel consists of, in no particular order, Dr Ted O’Connell, Dr Ryan Pedigo, Dr Hao-Hua Wu. It may consist of other people that I’m not aware of, but these are the people whom I know for sure are on the panel.
In each video, CKSGC participants need to provide their responses to three questions pertaining to leadership in a medical scenario. Each member of the expert panel judges each participant’s response to the questions, giving a numeric score for each prompt. The mean of all the panel members’ assigned numeric scores for the prompt is then calculated. Lastly, a candidate’s final ‘numeric score’ for the video round is determined via some form of average of the average numeric scores obtained for each of the three prompts. Participants are ranked in order of their final ‘numeric score’ for the video, and the top students with the highest scores would be selected as finalists.
In total, 15 finalists were chosen from among the pool of 7,500+ medical students from 100+ countries who had participated in the Elsevier CKSGC ’21. A similar challenge that was specific to India had been held, and the winner for that country-specific challenge was Ms Mitul Suhane. She had won the Grand Prize of the ClinicalKey Student India National Challenge 2021. Though she hadn’t participated in the CKSGC to become a finalist in the traditional manner, the fact that she was the Grand Prize winner of her country-specific challenge meant that she received a ‘Golden Ticket’ and this automatically qualified her for the CKSGC finals. As such, with the inclusion of Mitul, there would be 16 participants for the Elsevier CKSGC ’21 finale.
London– Day 1 of 5 – 21 April 2022– Thursday
I departed Singapore on 20 April 2022, 2330 hrs and arrived in London at Heathrow Airport on 21 April 2022, 0555 hrs. It was great. Thursday was a day to ease in into things. Elsevier had actually allowed me to fly in to London one day earlier than most other participants given that I was coming from Singapore via a long 14-hour flight, given that the first official component for the finale would be the meet-and-greet at a bar that would occur at 2:45 pm on 22 April 2022.
I was picked up by a driver from Heathrow Airport and fetched to Travelodge London City. During non-peak hours, the journey would take around 30 mins. However, at the time we actually made the journey, the roads were congested and the navigation app predicted that we would take over 1.5 hours to get there. As it turned out, when I tried to give my details to the counter at the lobby of Travelodge London City, I realised that I had arrived at the wrong Travelodge branch. However, by the time I went outside of the Travelodge building to notify the driver in an attempt to get him to drive me to the correct location, I realised that he already vanished. The correct Travelodge branch was an 18-min walk away. Although I was advised to just book a cab there (I was promised reimbursement) by the point of contact, I figured that I’d just walk the distance. It was good exercise anyway. I didn’t have much stuff with me too. All I had to carry was just my simple carry-on bag and my check-in luggage that weighed about 8 kg.
When I reached the correct Travelodge, it was still too early for checking into my room (the standard check-in time was 3 pm). So, I decided to deposit my luggage with the counter and headed off for lunch at Dishoom Shoreditch, which had been recommended by someone who had been to London and enjoyed the food there. At Dishoom, I ordered the Garlic Naan + Mutton Pepper Fry (which came with three types of spices as seen in the saucers in the image below) + Chocolate Chai (which to my pleasant surprise, is refillable).
For the rest of the afternoon, all I did was sightseeing. I didn’t use public transport and instead got around purely on foot and ended up walking 20k steps (according to the ‘Health’ app on iOS).
For this first day, I visited some landmarks. The first place I decided to head to Tower Hill, followed by Tower of London. Then, I saw the beautiful Tower Bridge, which I learnt was not London Bridge!
I saw the actual London Bridge later that day, and found it quite underwhelming. It’s the former bridge that’s more iconic! We can only blame the popular nursery rhyme (‘London Bridge is Falling Down’) for this highly prevalent misconception. Later on, I visited the ‘All Hallows By The Tower’ church, the oldest church in the ‘City of London’.
I signed in the church’s visitor book on 21 April 2022, Thursday. Be sure to also do so if you’re gonna visit London too!
I then walked to St. Paul’s Cathedral, the venue of the wedding of Prince Charles and the late Princess Diana. They had gotten married in St. Paul’s instead of the more traditional Westminster Abbey because the former could accommodate a greater number of guests that they wished to invite. Isn’t the dome of the church simply magnificent?
Once I was done visiting St. Paul’s, I walked back to the vicinity of London Bridge. Look at the following photograph – a panaromic shot of London Bridge with The Shard (tallest building in the UK, standing at just above 300 m) in the background. Wouldn’t you agree that it’s underwhelming compared to Tower Bridge?
It was at point that I decided that I had done enough and that I wanted to rest for the day. So, I made my way back to Travelodge London Central City Road. I passed by the Bank of England along the way. I had dinner at Travelodge, and took the rest of the night off.
London – Day 2 of 5 – 22 April 2022– Friday
I woke up early. I had a buffet breakfast at my accommodation, and began my morning walk to King’s Cross Station (3 km away). I mostly walked along City Road, and passed a number of notable locations. Early on in my journey, I passed by the residence of John Wesley. Wesley was the leader of the Methodist movement, which ultimately gave rise to the Methodist denomination of Christianity. In fact, the largest and oldest Methodist church in Singapore is named after him: Wesley Methodist Church. Futher along my way on City Road, I soon encountered Moorfields Eye Hospital.
It would be a dream come true if I could work or conduct research here in some capacity in the future given my current interest in ophthalmology. Moorfields Eye Hospital, together with the UCL Institute of Ophthalmology, is the oldest and largest centre for ophthalmic treatment, teaching, and research in Europe. According to the hospital’s Wikipedia article page, the hospital will apparently be relocating to a new location near King’s Cross railway station and that the present building has been sold to private developers.
Dr Vivian Balakrishnan, Singapore’s Minister for Foreign Affairs since 2015, had worked here from 1993 to 1995 as a senior ophthalmology registrar, where he had subspecialised in paediatric ophthalmology. It was after he completed his stint here that he returned to Singapore and was appointed a consultant ophthalmologist at SNEC and NUH. Many well-known people in ophthalmology are associated with Moorfields in one way or another. Another example I can cite is that of the late Dr Robert Marcus Gunn, who had worked as a house officer at Moorfields. He was a Scottish ophthalmologist after whom the eponymous Marcus Gunn pupil (a clinical sign that may be seen in patients with multiple sclerosis or severe retinal disease) is termed.
Soon, I arrived at the famous London King’s Cross station.
London’s King’s Cross station is one of the busiest train stations in the whole of the UK, and is also well-known for being the filming location of the first of the Harry Potter movie series, where the ‘Platform 9 3/4″ had been featured. Adjacent to King’s Cross is St. Pancras International Station (see the following image), the London terminus for the international high-speed railway service to continental Europe.
I walked a bit within St. Pancras International Station and found two public pianos. I tried playing both of them but unfortunately, the keys’ action on both pianos were in a pretty terrible state. It’s this way probably due to the lack of maintainance and the fact that it is subject to the wide variation in temperature and humidity on all days throughout the year. The fact that London has four seasons does not help at all.
Soon, I left St. Pancras and headed to the nearby British Library.
Then, I walked to Great Ormond Street Hospital (formerly known as the Hospital for Sick Children). One of the reasons I had decided to visit this place was that my mentor (who has had a significant impact and influence on my life) had undergone specialty training here many decades ago. The hospital is closely associated with University College London (UCL) and in partnership with the UCL Great Ormond Street Institute of Child Health, which is adjacent to it, is the largest centre for research and postgraduate teaching in children’s health in Europe. Think of it as the Moorfields of the paediatric realm.
From what I had seen at the entrance of the hospital, I learnt a number of things: 1) that Elizabeth II had visited the hospital in 2002 to commemorate the hospital’s 150th anniversary as part of the Golden Jubilee celebration of her accession (she was coronated in 1952 after all).
NB: As a brief summary to those who aren’t familiar with the concepts of jubilees, a golden jubilee is a celebration of a 50th anniversary. Silver, ruby, diamond, sapphire, and platinum jubilees correspond to 25th, 40th, 60th, 65th, and 70th anniversaries respectively. Elizabeth II is the first British monarch to have had a sapphire and platinum jubilee.
Moreover, did you know that Sir James Barrie, the novelist and playwright best known for the creation of Peter Pan, actually donated the copyright of Peter Pan to the hospital? It is thus not totally surprising that Peter Pan-related statues can be found at the hospital entrance.
After this, I walked to the British Museum, the world’s oldest national public museum. It was established in 1753, 23 years prior to the ratification of the US Declaration of Independence.
Following the stop at the British Museum, I walked to Piccadilly Circus (this hyperlinked website mistakenly writes that the statue that surmounts the Shaftesbury Memorial Fountain is that of Eros, when the statue is actually that of Anteros). Here is a photograph is of me at the fountain. Piccadilly Circus is basically the London-equivalent of Times Square. Pretty cool.
After Piccadilly Circus, I walked to nearby Trafalgar Square, a public square in central London.
Also within Trafalgar square is the National Gallery that was founded in 1824. Majestic, isn’t it?
After this, I decided to walk towards Buckingham Palace and had a photo taken at Admiralty Arch. Its construction had been commissioned by Edward VII in memory of his mother, Queen Victoria. The Latin inscription says: In the tenth year of King Edward VII, to Queen Victoria, from most grateful citizens, 1910.
Then, as I was en-route to Buckingham Palace, I spectated the Changing of Guard which was happening.
The photograph is that of me and both Buckingham Palace and Victoria Memorial in the background.
Look at the crowd! I’m sure it was worse than this pre-COVID. And this isn’t even the peak period! And this was on a Friday – not even a weekend!
One of the things I appreciate about having learnt basic Latin previously is that I can make out random neat inscriptions. The inscription reads: Lord Jesus, King and Redeemer: by your blood, save us! Do you see the Latin word ‘sanguinem’ there? It’s whence we get our English words ‘sanguine’ and ‘exsanguinate’.
It’s important not to confuse Westminster Cathedral with Westminster Abbey. One church is Roman Catholic, and the other is Anglican! After the former, I walked to the latter. Westminster Abbey is one of the UK’s most notable religious buildings and the traditional place of coronation and a burial site for English and British monarchs. Since the coronation of William the Conqueror in 1066, all subsequent monarchs have had their coronation at Westminster Abbey.
After Westminster Abbey, I walked towards Elizabeth Tower (commonly known to the general public as ‘Big Ben’). In my readings, I learnt that the tower had actually been originally named simply as ‘Clock Tower’ and had been renamed ‘Elizabeth Tower’ in 2012 as part of the Queen’s Diamond Jubilee Celebrations (do you remember that little mini tip on jubilees I gave earlier? hahaha). Strictly speaking, the term ‘Big Ben’ is a nickname for the large central bell at the top of the tower that chimes on the hour. Big Ben is surrounded by four smaller bells which chime every 15 minutes.
I was very fortunate to be visiting London in end-April 2022 as the renovation for Elizabeth Tower is almost complete. For the past five years, it has actually been undergoing significant maintainance, which meant that for most of the past five years, a significant proportion of the exterior of the building, and the clock mechanism was shrouded in scaffolding. Thus, I am grateful for the present opportunity to view the entirety of Elizabeth Tower in all its splendour. To protect the hearing of the on-site workers and for practicality’s sake, the routine chiming of the bells has also been halted except on special events such as New Year’s Eve.
It’s such an iconic symbol of London, and I would argue that it’s even more well known than Tower Bridge. Show anyone an image of Elizabeth Tower, and he’ll know it’s London.
Here’s me crossing Westminster Bridge and having a photograph of me and Elizabeth Tower taken from another angle.
From Westminster Bridge, one can see the London Eye.
This was my last stop on my sightseeing journey for Friday morning. I had walked so much (25k steps on the whole of Friday according to my ‘Health’ app; I hadn’t used any form of public transport in the UK by this point as I had not been issued my Oyster card with 10 pounds of stored value by the Elsevier staff). After this, I headed to a nearby Japanese restaurant where I enjoyed delicious Osaka street food at OKAN South Bank. Specifically, I opted to partake of the ‘Okan Special Okonomiyaki’.
After the main course, I decided to have the Matcha Basque Cheesecake for dessert. It was absolutely delicious and satiating – both the main course and the dessert.
Finally, it was time to attend the first official event of the leadership summit, the main reason I had come to London. It was a meet-and-greet session at a pub – Smiths of Smithsfield. The following photo is that of me and the other participants in the finale.
What a great day this was. Simply unforgettable.
London – Day 3 of 5 – 23 April 2022– Saturday
The participants and I walked from our accommodation to Elsevier’s London office at 125 London Wall. Here is a photograph of us checking in at the lobby of the office.
They had prepared for us a wonderful breakfast. Incredible.
Just look at that wall. How often is it the case that one’s name can be found on a wall?
After breakfast, we had an ice-breaker activity, followed by a short break, where we were all offered decadent chocolate and vanilla cupcakes. There were other miscellaneous activities, and the day ended with an ‘Amazing Race’ where each group of four would go to various landmarks within London based on certain clues…
At the end of the Amazing Race, my team walked the Millennium Bridge (as seen in this photo). Straight ahead in the photo is St. Paul’s Cathedral. Millennium Bridge is so named because it opened in June 2020. According to its Wikipedia article, “Londoners nicknamed it the “Wobbly Bridge” after pedestrians experienced an alarming swaying motion on its opening day. The bridge was closed later that day and, after two days of limited access, it was closed again for almost two years so that modifications and repairs could be made to keep the bridge stable and stop the swaying motion. It reopened in February 2002”
My team didn’t win the Amazing Race. Nevertheless, I still had a highly enjoyable time in the evening as all gathered back at a pub. As someone who abstains from alcohol, I would either only consume cold water or apple juice at most. I did help myself to the canapes, the fries, and other food though. Absolutely sumptuous dinner.
London – Day 4 of 5 – 24 April 2022– Sunday
This was the day of the finale. Exciting. Early in the morning, we were transported by bus to a location somewhat far away – the University of Greenwich! Please note how ‘Greenwich’ is pronounced. Many people pronounce it wrongly!
In the following photograph, the scrubs I am wearing were issued by the Elsevier team. Each team of four had its own corresponding colour of scrubs. My team happened to be assigned scrubs of the fuchsia colour. And yes, look how large that wall is. It’s just incredible.
This is my team of four (we named our team “The Astrocytes” because of some of the team members’ interest in neurology and how we “reach for the stars”).
This photograph is that of me and Aaron (the person from whom I had first heard about this event):
After the finale, we were transported back to London where we had an early dinner at a pub. This was where it was announced that my team had won the finale.
I was pretty ecstatic as I wasn’t expecting the win at all. In fact, just making it to London on a fully-sponsored trip had already fully exceeded my expectations. Anyway, allow me to share some of the few photographs that I had taken.
The following is that of me talking to Dhruv Tuteja (a medical student from India) and George Garratt (a medical student from the UK; he’s studying at the University of Leicester).
A photo of George and I. I enjoyed talking to him a lot throughout on this trip.
This is Mitul Suhane. She’s a medical student from AIIMS (All India Institutes of Medical Sciences) Raipur, one of the top medical schools in India. She topped the entire Elsevier CK Student National Challenge in India in 2020.
A photo of Dhruv, George, Mitul, and I:
Lastly, I managed to have a photo taken of me and Dr. Hao-Hua Wu, a final year orthopaedic surgery resident at UCSF, and one of the members of the expert panel that had assessed the video submissions (if you remember what I had said earlier). He had gone to Penn (an Ivy League school) for medical school. Really brilliant person. It was actually on this fateful Sunday afternoon/evening, from talking to him, that I learnt more about the book publishing process and his journey of co-authoring multiple books. In fact, he’s currently working on coauthoring a book on leadership in medicine with this year’s ClinicalKey mentors: Aaron and Maria (another person who was on the same team as Aaron in CKSGC ’19).
On that evening, I met with my parents for dinner at a Vietnamese restaurant. And yes, my parents were in London at that point. They had arrived in London a day after I did and departed a day after I did.
London – Day 5 of 5 – 25 April 2022– Monday
Well, all good things come to an end. Finally, the day had come for me to depart London.
For lunch, I went to Flat Iron (a dining venue that had been recommended to me by someone who had been to London some years back), a steakhouse near my lodging. I took a direct bus there with my parents because they simply refuse to walk there! I had lunch with my parents, and I must say that I enjoyed the experience a lot. Over there, I ordered the ‘Flat Iron Steak’, not that there were many alternatives LOL.
What made the dining experience unique was that at the conclusion of our meal, we were handed these mini metal cleaver trinkets, similar to the ones that you would play with at a game of Monopoly. I’ll leave you to read for yourself how it works in the following image.
The ice cream was amazing! The original plan was actually to head to a ‘Greedy Goat Ice Cream‘ shop, an independent stall within Borough Market that sells ice cream made with goat’s milk. Well, as it turned out, Greedy Goat was closed on that Monday. It all worked out in the end.
After the ice cream, I got the opportunity to further experience the London public transport system for what it is. Having been born and raised in Singapore, I was quick to notice many aspects of the underground rail system that were pretty lacklustre compared to what I was accustomed to. However, it would not be totally fair to criticise the London rail system because it is after all the world’s oldest rail network. They have had to modernise and work from infrastructure that is pretty old. On the other hand, in the city-state, we have had the opportunity to learn from the mistakes made by other countries and construct a world-class transport system in the modern era with the assistance of the latest technology. This reminds me of the opening paragraphs of Francis Scott Fitzgerald‘s magnum opus, The Great Gatsby, where the narrator recounts the advice that he had been given by his father: that whenever he feels like criticising anyone, he should remember all the people in the world that haven’t had the advantages he has had.
Eventually, I boarded an arranged transport vehicle (along with a fellow member of “The Astrocytes” who also had to be at the airport at around the same time as me) opposite Travelodge at 4:30 pm. My flight’s departure from Heathrow was scheduled to occur at 8:50 pm.
We both sat in the rear passenger seats and had an enjoyable 1.5-hour conversation as we travelled to the airport. This was the final photograph I took in London. After this photo, we parted ways as she headed to Terminal Three while I remained in Terminal Two.
My short stay in London has been a highly memorable one, and I will certainly cherish all that I’ve learnt and experienced here for the remainder of my life!
Nic 2 May 2022
Tl;dr – A summary ofmy 5D4N experience in London
I had chanced upon information on an event entitled “Elsevier ClinicalKey Student Global Challenge” that was being promoted on Twitter by a friend. A few weeks later, I received an email from my medical school which informed its medical students of the existence of that same event. So, given that I had obtained information about the event from two independent sources, I decided to satiate my curiosity by visiting the event’s website. The event was essentially a competition amongst current medical students from all around the globe. The first run had occurred in 2019, and is expected to run annually. However, last year’s run was the second run instead of the third because the 2020 run was suspended in view of the pandemic. I decided to participate in the competition, and made it through all four multiple-choice-question rounds, and successfully cleared the video round, which earned me a ticket to the world finale, which would be held in London in April 2022. The finale took place over a weekend. There were four teams consisting of four people each. My team was named “The Astrocytes” given some of our team members’ interest in neurology and how we ‘reach for the stars’. Our team turned out to be champions!
I had departed Singapore on 20 April at 2330 hours, arrived in London on 21 April at 0600 hours. I then departed London on 25 April at 2050 hours, and arrived in Singapore on 26 April at 1655 hours. In addition to the official leadership summit that had occurred over the weekend, I did some sightseeing as it was my first time in the UK. I visited many famous attractions and had an enjoyable time. In sum, the Elsevier CKSGC 2021 provided me the opportunity to network with many brilliant medical students, mentors, and doctors from all around the world. They shared stories of their incredible journeys and their insights, which I deeply appreciate. To say that some of their stories was inspiring is such a sheer understatement. They make me want to become the most successful person I can be, a person who can be a significant positive influence in whatever domain he finds himself in.
This has been an incredibly fulfilling experience, and I hope to stay in touch with the people I met at this leadership summit, even as we go about attaining professional success in our separate ways.
The main body’s text was originally published on 27 April 2022. However, my views on social media yet again and with respect to that, I published an update (on 1 May 2022) that can be found at the bottom of this post.
Frequent visitors to my site would notice that just a few days ago, I updated my website’s main page to include a number of icons which are essentially hyperlinks to my profile on various social media platforms. This is almost a complete departure from my previous stance which I held for a relatively decent amount of time (about 14 months), where I had been highly sceptical of the utility of social media platforms. Why the sudden change, you may ask?
Background
I’m on a journey of being intentional about my use of these platforms in view of my desire to engage in deep work as part of the ongoing pursuit of the deep life. To better comprehend the aforementioned italicised terms, check out two books by Cal Newport: Deep Work and Digital Minimalism. Both books have significantly shaped my views on how we ought to lead our digital lives, and work in a world where constant distraction and fragmented attention spans are the norm.
I had first gotten to know about Cal Newport’s views in December 2020 through a YouTube video where he had given a TED talk entitled “Quit social media”. I found his arguments so convincing that I made a radical decision to permanently delete my accounts on many social networking sites. At that point in time, I had never made an Instagram account; so, there was nothing to delete. I permanently deleted my decade-old Facebook account, and my Twitter account. Since I took those actions, I’ve remained sceptical of the utility of social media, given the widely-known adverse effects that it can have on individuals’ mental health and productivity at work and school. I was simply of the opinion that the drawbacks associated with social media use far outweighed their benefits.
An epiphany that I had after attending a leadership summit
However, my experience at a leadership summit in April 2022 has caused my views on this matter to evolve. I realised that I might have blindly taken Cal’s words as gospel truth and that trying to replicate what Cal does in his own life to a tee isn’t something I should necessarily do; we both lead rather different lives after all. At the summit, I had conversations with the other participants on this matter. I have also learnt of their journeys more broadly, and how social media played a part in their professional success. Strategies for professional success should be personalised. It was incredibly inspirational. As such, my views on social media platforms have now become more balanced and nuanced. Does this mean that I regret espousing certain views in the past or executing certain actions? No. The actions of the past have contributed to the person I am today. If anything, this just demonstrates that the process of learning and growing is a journey. For the sake of enhancing my ability to network, seize opportunities, and attain professional success, I now opine that social media can (but whether it should ought to depend on one’s specific circumstances) be used in a manner that allows me to capitalise on its benefits while minimising its drawbacks.
The only reason I even participated in the leadership summit in the first place was that I first encountered information pertaining to it on Twitter. If I hadn’t possessed a Twitter account at that point in time, it is likely that I would have missed out on the opportunity of participating in the event that ultimately enabled me to attend the leadership summit. In my next blog post, I will elaborate on the specific details on how this occurred.
The key to taking advantage of the benefits of social media while avoiding its downsides lies in intentionality, self-awareness, and discipline. For instance, two people can have an Instagram account but use it in absolutely different ways. One person could be responding instantly to virtually every minor notification and squandering his time on scrolling through news feeds mindlessly. On the other hand, another person could carefully curate the list of pages he follows and remain intentional and disciplined when using the platform.
As such, since the conclusion of the leadership summit, I have decided to re-establish my long-foregone social media presence (e.g. creating an Instagram page and recreating a Twitter account a few days ago) as I now firmly believe that judicious and intentional use of social media platforms can allow me to put my best foot forward and help me maximise my professional success by establishing my personal brand. With that said, I’m not sure how active I’d be on these other platforms though. For now, I mostly use those platforms as a way of redirecting people back to my personal website, which is my hub for my CV, blogging, and other information pertaining to me.
My views on social media will likely continue to evolve, but for now, I’m happy with what it’s currently at. I’m constantly learning. Please reach out to me if you have other perspectives that you would like to share.
Nic 27 April 2022
[UPDATE on 1 May 2022: Well, it’s been almost a week since I decided to start maintaining accounts on Facebook, Instagram, and Twitter. Today, I decided to permanently delete/deactivate my accounts on these three platforms. If all goes smoothly, then my accounts on these three platforms will be permanently deleted with effect from 31 May 2022. I think I’m going to revert to my initial stance after all.
The great thing about having had this week of experimenting with social media is that I am able to more objectively assess first-hand the benefits and disadvantages associated with social media use, as the initial hype associated with the weekend when the leadership summit had occurred would have dissipated.
So far, these platforms have not been able to persuade me to use them for the long-term. Perhaps, my mind will change for good some time in the future, but now is certainly not that time. These social networking sites have to be able to convince me that the benefits they offer significantly outweigh their current baseline stance as sources of mindless entertainment before I decide to turn to them again.
Some people might ask, “But Nic, what about the example you gave regarding being able to participate in the leadership summit in the first place because you encountered the information on Twitter first?” Well, the thing about that is that in reality, my medical school still reached out to me with information pertaining to that event. So, strictly speaking, I would have still heard about that event even without having a Twitter account. But even if my medical school hadn’t circulated such information, I would argue that I would still be be better off without Twitter and social media in general in the long run. This is because we must be wary of the any-benefit mindset (a concept I elaborated on in a previous blog post where I shared my favourite snippets from Cal Newport’s Digital Minimalism) that is becoming increasingly prevalent in today’s society.]
Last night, I completed my re-reading of Cal Newport‘s “Digital Minimalism”. The book is incredibly relevant to practically every soul whose life involves the use of, to any extent, devices such as smartphones, computers, etc.
I realised that when I had read the book for the first time last July, I failed to note down some of my favourite snippets of text along the way for the entirety of the book. I had stopped halfway. As such, I recently decided to commit to reading the book again, and this time, I would note the snippets I found to be the most interesting and insightful (note that any bolded text and the capitalisation of whole words constitute emphasis which are mine), which I hope you can benefit immensely from:
PART 1: Foundations
1-1. A Lopsided Arms Race
Seemingly small environmental factors create large changes in behaviour: – Wearing a red shirt on a dating profile will lead to significantly more interest than any other colour. – If your name is easier to pronounce, you’d advance faster in the legal profession.
Tech companies encourage behavioural addiction via two ways:
Intermittent positive reinforcement
As Harris notes, the notification symbol for Facebook was originally blue, to match the palette of the rest of the site, “but no one used it.” So they changed the color to red—an alarm color—and clicking skyrocketed.
2. Drive for social approval
1-2. Digital Minimalism
Digital minimalism may be defined as “a philosophy of technology use in which you focus your online time on a small number of carefully selected and optimized activities that strongly support things you value, and then happily miss out on everything else.”
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The so-called digital minimalists who follow this philosophy constantly perform implicit cost-benefit analyses. If a new technology offers little more than a minor diversion or trivial convenience, the minimalist will ignore it.
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Notice, this minimalist philosophy contrasts starkly with the maximalist philosophy that most people deploy by default—a mind-set in which any potential for benefit is enough to start using a technology that catches your attention. A maximalist is very uncomfortable with the idea that anyone might miss out on something that’s the least bit interesting or valuable.
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…the best digital life is formed by carefully curating their tools to deliver massive and unambiguous benefits. They tend to be incredibly wary of low-value activities that can clutter up their time and attention and end up hurting more than they help. Put another way: minimalists don’t mind missing out on small things; what worries them much more is diminishing the large things they already know for sure make a good life good.
Digital minimalism works because of its three core principles:
Principle 1: Clutter is costly.
Digital minimalists recognize that cluttering their time and attention with too many devices, apps, and services creates an overall negative cost that can swamp the small benefits that each individual item provides in isolation.
When people consider specific tools or behaviors in their digital lives, they tend to focus only on the value each produces.
More often than not, the cumulative cost of the noncrucial things we clutter our lives with can far outweigh the small benefits each individual piece of clutter promises.
Principle 2: Optimization is important.
An argument for Principle #2: The return curve
Principle 3: Intentionality is satisfying.
The Amish, it turns out, do something that’s both shockingly radical and simple in our age of impulsive and complicated consumerism: they start with the things they value most, then work backward to ask whether a given new technology performs more harm than good with respect to these values.
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What Laura describes modestly as smugness is almost certainly something more fundamental to human flourishing: the sense of meaning that comes from acting with intention.
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Pulling together these pieces, we arrive at a strong justification for the third principle of minimalism. Part of what makes this philosophy so effective is that the VERY ACT OF BEING SELECTIVE about your tools will bring you satisfaction, typically much more than what is lost from the tools you decide to avoid.
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The sugar high of convenience is fleeting and the sting of missing out dulls rapidly, but the meaningful glow that comes from taking charge of what claims your time and attention is something that persists.
1-3. The Digital Declutter
A nontrivial number of people ended up aborting this process before the full thirty days were done. Interestingly, most of these early exits had little to do with insufficient willpower—this was an audience who was self-selected based on their drive to improve. More common were subtle mistakes in implementation. A typical culprit, for example, was technology restriction rules that were either too vague or too strict. Another mistake was not planning what to replace these technologies with during the declutter period—leading to anxiety and boredom. Those who treated this experiment purely as a detox, where the goal was to simply take a break from their digital life before returning to business as usual, also struggled. A temporary detox is a much weaker resolution than trying to permanently change your life, and therefore much easier for your mind to subvert when the going gets tough.
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The three steps of the digital declutter process:
Step 1. Define your technology rules
Step 2: Take a 30-day break
– With this in mind, you have duties during the declutter beyond following your technology rules. For this process to succeed, you must also spend this period trying to rediscover what’s important to you and what you enjoy outside the world of the always-on, shiny digital. Figuring this out before you begin reintroducing technology at the end of this declutter process is crucial. An argument I’ll elaborate on in part 2 of this book is that you’re more likely to succeed in reducing the role of digital tools in your life if you cultivate high-quality alternatives to the easy distraction they provide.
– For many people, their compulsive phone use papers over a void created by a lack of a well-developed leisure life.
Step 3: Reintroduce technology
– …for each optional technology that you’re considering reintroducing into your life, you must first ask: Does this technology directly support something that I deeply value? This is the only condition on which you should let one of these tools into your life. The fact that it offers some value is irrelevant—the digital minimalist deploys technology to serve the things they find most important in their life, and is happy missing out on everything else.
– Once a technology passes this first screening question, it must then face a more difficult standard: Is this technology the best way to support this value? We justify many of the technologies that tyrannize our time and attention with some tangential connection to something we care about. The minimalist, by contrast, measures the value of these connections and is unimpressed by all but the most robust.
– If a technology makes it through both of these screening questions, there’s one last question you must ask yourself before it’s allowed back into your life: How am I going to use this technology going forward to maximize its value and minimize its harms?
– …many attention economy companies want you to think about their services in a binary way: either you use it, or you don’t. This allows them to entice you into their ecosystem with some feature you find important, and then, once you’re a “user,” deploy attention engineering to overwhelm you with integrated options, trying to keep you engaging with their service well beyond your original purpose
PART 2: Practices
2-1. Spend Time Alone
…solitude is about what’s happening in your brain, not the environment around you. Accordingly, they define it to be a subjective state in which your mind is free from input from other minds.
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Solitude requires you to move past reacting to information created by other people and focus instead on your own thoughts and experiences—wherever you happen to be.
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Kethledge and Erwin detail many benefits, most of which concern the insight and emotional balance that comes from unhurried self-reflection.
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“All of humanity’s problems stem from man’s inability to sit quietly in a room alone,” Blaise Pascal famously wrote in the late seventeenth century.
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Harris is concerned that new technologies help create a culture that undermines time alone with your thoughts, noting that “it matters enormously when that resource is under attack.” His survey of the relevant literature then points to three crucial benefits provided by solitude: “new ideas; an understanding of the self; and closeness to others.”
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Harris argues, perhaps counterintuitively, that “the ability to be alone . . . is anything but a rejection of close bonds,” and can instead affirm them. Calmly experiencing separation, he argues, builds your appreciation for interpersonal connections when they do occur.
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Even though iPods became ubiquitous, there were still moments in which it was either too much trouble to slip in the earbuds (think: waiting to be called into a meeting), or it might be socially awkward to do so (think: sitting bored during a slow hymn at a church service). The smartphone provided a new technique to banish these remaining slivers of solitude: the quick glance.
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Solitude Deprivation: A state in which you spend close to zero time alone with your own thoughts and free from input from other minds.
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For one thing, when you avoid solitude, you miss out on the positive things it brings you: the ability to clarify hard problems, to regulate your emotions, to build moral courage, and to strengthen relationships. —
Three practices that you can engage in to spend more time alone: 1) Leave your phone at home; 2) Take long walks; 3) Write a letter to yourself
– The key is the act of writing itself. This behavior necessarily shifts you into a state of productive solitude— wrenching you away from the appealing digital baubles and addictive content waiting to distract you, and providing you with a structured way to make sense of whatever important things are happening in your life at the moment.
2-2. Don’t Click Like
He now believes “we are interested in the social world because we are built to turn on the default network during our free time.”
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The problem, then, is not that using social media directly makes us unhappy. The key issue is that using social media tends to take people away from the real-world socializing that’s massively more valuable.
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PRACTICE: Don’t click “Like” – Finally, it’s worth noting that refusing to use social media icons and comments to interact means that some people will inevitably fall out of your social orbit—in particular, those whose relationship with you exists only over social media. Here’s my tough love reassurance: let them go.
PRACTICE: Consolidate texting. – This practice suggests that you keep your phone in Do Not Disturb mode by default. – When you’re in this mode, text messages become like emails: if you want to see if anyone has sent you something, you must turn on your phone and open the app. – There are two major motivations for this practice. The first is that it allows you to be more present when you’re not texting. Once you no longer treat text interactions as an ongoing conversation that you must continually tend, it’s much easier to concentrate fully on the activity before you. This will increase the value you get out of these real-world interactions. The second motivation for this practice is that it can upgrade the nature of your relationships. When your friends and family are able to instigate meandering pseudo-conversations with you over text at any time, it’s easy for them to become complacent about your relationship. These interactions give the appearance of close connection (even though, in reality, they’re far from this standard), providing a disincentive to invest more time in more meaningful engagement.
PRACTICE: Hold conversation office hours
2-3. Reclaim Leisure
As the MIT philosopher Kieran Setiya expands in his modern interpretation of the Ethics, if your life consists only of actions whose “worth depends on the existence of problems, difficulties, needs, which these activities aim to solve,” you’re vulnerable to the existential despair that blooms in response to the inevitable question, Is this all there is to life? One solution to this despair, he notes, is to follow Aristotle’s lead and embrace pursuits that provide you a “source of inward joy.”
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The value you receive from a pursuit is often proportional to the energy invested.
Leisure Lesson #1: Prioritize demanding activity over passive consumption.
In a culture where screens replace craft, Crawford argues, people lose the outlet for self-worth established through unambiguous demonstrations of skill. One way to understand the exploding popularity of social media platforms in recent years is that they offer a substitute source of aggrandizement.
In the absence of a well-built wood bench or applause at a musical performance to point toward, you can instead post a photo of your latest visit to a hip restaurant, hoping for likes, or desperately check for retweets of a clever quip.
Leisure Lesson #2: Use skills to produce valuable things in the physical world.
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Leisure Lesson #3: Seek activities that require real-world, structured social interactions.
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PRACTICE: Fix or build something every week.
PRACTICE: Schedule your low-quality leisure.
– …schedule in advance the time you spend on lowquality leisure. That is, work out the specific time periods during which you’ll indulge in web surfing, social media checking, and entertainment streaming. When you get to these periods, anything goes. If you want to binge-watch Netflix while live-streaming yourself browsing Twitter: go for it. But outside these periods, stay offline.
– There are two reasons why this strategy works well. First, by confining your use of attention-capturing services to well-defined periods, your remaining leisure time is left protected for more substantial activities. Without access to your standard screens, the best remaining option to fill this time will be quality activities. The second reason this strategy works well is that it doesn’t ask you to completely abandon low-quality diversions.
This year, the 73rd NUS Medical Society Arts & Culture Directorate has put together the 2022 HeARTbuzz Art Exhibition and its theme is “Pneuma: Breath of life”.
The Ancient Greek word πνεῦμα (‘pneuma’) means “wind, breath, spirit” and wends its way into our modern lexicon, manifesting itself in terms such as pneumonia or even more esoteric medical terms such as pneumoperitoneum, pneumothorax, and the ludicrously bombastic synonym for silicosis which I’m not even going to bother attempting to spell. It’d be an experience more catastrophic than the volcanic eruption that the word vaguely alludes to.
As set out by the organisers of “Pneuma: Breath of life”, the art exhibition aims to “construct an exhibition of our joys, our angst, our tenacity, our motives, our zeal and our empathy.” It encourages us to look “through the lens of the protagonists of it all – people”.
I have found this academic year challenging in various aspects (the academic workload; losing the once-held autonomy associated with independent living – something that I had enjoyed for a whole 3.5 years whilst residing in Adelaide; I have fond memories of Adelaide – the reduced population density, the weather, a more close-knit environment, and would love to return one day). As such, I appreciate having such outlets of expression which provide me with the occasional quantum of solace amid the arduous curriculum.
I was glad to learn that my work entitled “From a Distance” was accepted and featured by the Arts & Culture Directorate for this exhibition, along with the various works by seven other medical students. The works will be on public display this week and tomorrow will be the last day of public display at the foyer of MD6 – Centre for Translational Medicine.
There will apparently be prizes for the crowd-favourite works. If you are there in person and enjoy my work, you are welcome to vote for it via the QR code found there. Voting closes on Saturday.
What a pleasant surprise to receive this in my inbox (see the following attached screenshot of the email correspondence that has been partially redacted).
Yishun Health (consisting of Khoo Teck Puat Hospital 邱德拔醫院, 90 Yishun Central and Yishun Community Hospital) had their Teachers’ Appreciation Day on 1 March to demonstrate their thanks for the indispensable role that the medical, nursing, and allied health faculty play in the clinical education of our nation’s future doctors, nurses, and allied health professionals. These events are useful reminders to never take our clinical educators for granted.
On a personal note, I am grateful for the many senior medical students and doctors I have encountered along my medical journey who have pointed out the gaps in my medical knowledge. Many encounters were uncomfortable and unpleasant. Nevertheless, is it not only through at least some degree of discomfort that one can grow?
Comfort and growth cannot coexist.
Isn’t that what the notion of “leaving one’s comfort zone” alludes to?
Anyway, just being able to play on the ivories for the event was a double reward unto itself. I am glad I could be a part of the event.
To the Teachers’ Appreciation Day Organisation Committee, thank you once again for the kind words. I look forward to being involved in similar events in the future!
NB: This was adapted (mainly refinements on grammar, sentence structure, and a few additions to content) from a physical diary entry I made today. — Today, I experienced a renewed urge to become truly disciplined again with respect to my academic work – to work on my Anki reviews (ensuring that they are completed promptly every single day). The number of review cards I had to do today was actually higher than the typical daily amount because I had let the reviews pile up over the past few days (not a good habit). Nevertheless, I’m glad I got it done once and for all earlier this afternoon.
It’s incredible how positive habits can quickly morph into an unrecognisable mess if one does not continuously reflect on and examine one’s life, one’s goals, and if one is not intentional and true to oneself in all that one does. In my experience, the inability to maintain the positive habit that was previously established isn’t typically due to a hero-to-zero descent into chaos. The decline is typically gradual and progressive. Think of a cancer that is slow-growing and typically presents in the terminal stages (e.g. pancreatic cancer).
It begins with the subtle lies you tell yourself. If I were to broadcast on a loudspeaker to a crowd of 5,000 of your peers the kind of internal monologue you have in your mind consistently, I’m sure it would be incredibly embarrassing. “Cringe” is the word that teenagers would employ to describe the scene. This is precisely why the author of the bestseller Atomic Habits, James Clear, advocates actually voicing out a significant action you’re about to do before actually doing it.
When applied in the context of a bad habit, you will begin to realise how ridiculous it sounds. For example, suppose you’ve just finished dinner. Let’s suppose that you’re in my shoes and you have to lose 2 kg to get back into the ‘normal’ Asian BMI range (i.e. <23.0) but at the same time, you’re craving for some Häagen-Dazs Rum & Raisin-flavoured ice cream. In this scenario, imagine having to say the following out loud with everyone else at the table being able to hear you: ‘I am going to eat ice cream I am craving for right now even though I don’t like how it makes me feel 30 minutes after eating and even though I am trying to lose weight‘. Only after saying this aloud will you be granted permission to partake of the ice cream.
You’d feel like a complete imbecile!
That’s the whole point. This is one of the strategies that can be used to eliminate bad habits.
So, what happens instead when you choose not to voice things out loud but choose instead to host an internal dialogue?
I say ‘dialogue’ instead of ‘monologue’ because the image that I have conjured in my mind is something similar to that of the characters in the show Tom and Jerry, where it’s quite common to have an ‘angel’ and a ‘devil’ version of the character positioned on either side of the character. These imaginary versions of the character would give the actual character conflicting advice (which is for simplicity’s sake, often dichotomised as ‘good’ and ‘bad’).
“It’s ok if you do XYZ. Doing this on one occasion wouldn’t hurt”. Then, on the second day, you tell yourself, “You already broke the streak, you might as well indulge in the bad habit today too”. Thus begins the downward spiral into the abyss.
It’s so easy to deceive yourself. I remember how on one particular day in the past, I would just disable the Review Heatmap add-on in Anki to avoid having to see the soul-crushing work that I needed to do in the midst of the other things that were going on in my life. I used to be so proud of the streak when life was more smooth-sailing.
However, halfway through my General Surgery posting, I got so discouraged with all the stuff I needed to deal with that I think I basically lapsed in my habit of making Anki cards for newly encountered content. I also lapsed in my habit of diligently and consistently completing my Anki review cards every single day. Having encountered this, it was not a surprise that my Anki review streak eventually came to an end. Although the streak came to an end, I think it’s good that I at least had enough decency to not do a token ‘one review card’ on days where I would choose to skip the reviews just so that I could superficially maintain a theoretical streak.
I’ve been using Anki since June 2019, when my then-senior in medical school (who’s now a doctor), first introduced me to how I could use Anki seriously.
For too long, I’ve been procrastinating and letting things snowball intermittently (mostly because the streak had been broken a while back and I would deceive myself by telling myself it was alright that I break a new ongoing X-day streak because the previous 702-day streak was broken anyway). I have had too many days where I’ve not done the reviews I was supposed to do.
Today is the day this garbage stops.
So, the question you may have is: what makes you so confident that today will be any different from the other days in which you lapsed, Nic?
That is a fair question, given that after all, I have lapsed in my commitment do working diligently multiple times (my inability to reliably continue the 702-day Anki review streak is just one of a few manifestations of the lapse in the focus intensity and engagement duration dedicated to my pursuits). For that fair question, I have the following response:
This sudden urge to start becoming disciplined arose from seriously and deeply contemplating my long-term life goals (in terms of my health, my relationships, my future family plans, my crafts, and my academic performance as a student which will significantly influence my career trajectory) during a dedicated focused session this afternoon where I was just alone in my air-conditioned room without my phone or any form of digital technology. I decided to engage in this reflective exercise after having watched a few video clips from the recently-established YouTube channel of Cal Newport over the past week. During the reflective exercise, I was thinking about the vision of the deep life that I envision for myself.
I’m not sure if Cal is indeed the first person to devise the term ‘deep life’, but he is certainly the first and only person I know who uses it so extensively. The deep life is a concept that requires a lot of unpacking. I’m not able to do that over here, but I encourage you to click on the above hyperlink. That linked blog post made in 2015 is one of many blog posts made by Cal on the concept of the ‘deep life’. To read more elaboration on what is meant by the deep life, just do a simple Google search ‘Cal Newport deep life’. There are plenty of articles on his blog which has been running continually since the mid-2000s for your perusal.
It’s quite exhilarating, really.
As I envisioned the Nic I wanted to become years from now, I could not help but brim with excitement. Attaining the deep life at that state and living the deep life to get tothat state look indeed promising.
After that wonder of a reflective exercise, I decided to commit to completing the day’s Anki reviews with the utmost concentration. Overcoming the initial inertia to even start completing this catch-up review session was brutal. The whole session was mentally exhausting, but fulfilling nevertheless. This is what active learning is supposed to be like. Cognitively demanding. Like a muscle getting trained.
The feeling you get when you realise you’ve reviewed the final card in the review pile is similar to the post-run high associated with all-out sprinting the last 100 m of the IPPT 2.4 km run. The sheer intensity with which I worked this afternoon on my Anki reviews and on the reflection exercise was reminiscent of the 2012-2013 period, when I was an Upper Sec student in Maris Stella.
The two years that I spent in Maris Stella from 2012-2013 as an Upper Sec student were some of the most fulfilling and enjoyable years of my life. It was one of the most productive periods of my life. It was when I most diligent and focused in all that would help me attain excellence in the GCE ‘O’ Levels. It was a pity that the momentum didn’t carry on to my time in JC.
You would imagine that upon transferring to NUS Medicine Year 3 in May 2021, I might make a firm commitment that I would give my very best from that point on, right? It’s a natural transition point after all. Such a huge transition – flying all the way back to my homeland in the midst of a pandemic – transferring medical schools.
Things are easier said than done though. When I first started my clinical postings (Internal Medicine at SGH), I felt so overwhelmed and lost, and this was probably exacerbated by the fact that I was a transfer student. I didn’t have the same background as the other fresh Year 3 students. I was used to different conventions. Even overseas medical students who had transferred into NUS Year 2 at least got to spend a year integrating into the local system before starting clinical postings. Most importantly, they got to undergo the CSFP (Clinical Skills Foundation Programme), something that I totally didn’t get to undergo.
To be quite frank, I still feel lost (thankfully to a reduced extent compared to that of the start of the academic year as a Year 3 student). It is precisely this feeling of being lost and the lack of a cohort-wide consensus on a specific effective study strategy on how to overcome all the various components of the clinical phase of medical school that made me feel overwhelmed and discouraged. One frustrating component is the process of learning physical exam manoeuvres, particularly for the sake of school tests. Broad outlines may be similar, but there are essentially limitless variations to how physical exams can be done. I’ve even heard conflicting information and advice dispensed by senior doctors.
My view on the disgruntling variation in the physical exam manoeuvres has evolved to the point where I opine that the most practical approach for us time-limited students is just to settle on a reasonable initial template and just stick with it relatively firmly, and only modifying it or value-adding to it if there is a relatively compelling reason to do so. You don’t have to necessarily incorporate any minor change that some random doctor tells you to (unless that doctor will be supervising you for assessments over a period of time). I suspect that most of the time, such recommendations on the minor changes are made on the sole basis that the suggested revised version is simply what that particular random doctor is accustomed to.
Virtually the same sequence of steps and the same format for doing things should consistently be used in order to get those proper practice hours up. Note the emphasis on same. This is important because if there are always constant minor adjustments to the sequence, then there will never be one particular sequence which one is truly confident in executing. Can it also then be really considered true deliberate practice if there’s always some variation beyond random error?
Well, enough on physical exam manoeuvres .
In sum, as I reflect on the short video clips and various blog posts by Cal Newport concerning the deep life and my specific vision for what I want to achieve in my projected version of the deep life, I have experienced this strong renewed urge to give my best in the various domains (which I have personally defined for my specific circumstances and future; you are also free to define what and how many domains are important to you) of life I want to excel in.
This post has largely focused on the domain of being a current medical student and a future doctor as it is in this domain that I most strongly feel this renewed urge after this afternoon’s reflective exercise. Fortunately, there are also some spillover effects on the domains that I’ve defined for myself: my health, my relationships, my future family plans, the musical domain, and the domain of writing).
The rest of medical school isn’t going to be easy at all. In fact, I will be facing some rather daunting exams pretty soon, but the sheer thought of getting better progressively, day after day, from periods of intense focused studying is deeply appealing. Being able to and choosing to dedicate a significant proportion of one’s time to deliberately hone one’s skill at a particular craft and then being able to eventually perform at an increasingly greater level seems incredibly exciting and fulfilling.
For many, this is precisely what injects a ton of meaning into their lives. I see this in my journey of going from a beginner-level pianist to an ATCL-level pianist. Being able to reach a certain level of competency in piano playing over the years has given me immense satisfaction. It manifests when I am able to play piano pieces that I absolutely would not be able to play if I had not put in all the time and effort over the years. Words cannot describe the joy I feel when I learn the final bar of a challenging piano piece. The same could be said of athletes (e.g. when you see your personal best run timings slowly improve as you put in the hours of focused training). The same could also be said of students who dedicate the time and effort into a particular extra-curricular activity over the years, and getting familiar with and competent enough to be involved in the international arena (e.g. representing Singapore in the Odyssey of the Mind World Finals).
If my writing has failed to relay a tone of optimism and elation for what the future holds, then I shall state it here explicitly:
I’m absolutely bubbling with exuberance for what the future has in store for me.
I am you from the future, specifically 24-year-old Nic. It must be freaky and overwhelming to receive this letter. In fact, the contents of this letter may be a little challenging to understand at your age, so don’t be afraid to ask Dad and Mom to help explain some of its contents to you. It’s the first time I’m writing a letter to my past self, and despite it only working on the first paragraph so far, I can’t help but feel what a cathartic experience it’s going to be.
24 years old. Yes. Can you believe it? You do actually become an adult eventually – taller, bespectacled, and certainly not as chubby as you currently are.
A full-fledged adult (though you’d not have started working yet as you would still be in medical school). I know how much you are looking forward to becoming an adult – having greater autonomy, being taller, etc. People aren’t kidding when they tell you to enjoy yourself while you were in primary school though. You’d eventually progress to secondary school, junior college, enlistment, and university. At all these stages, numerous people would tell you to enjoy and be appreciative of where you are currently at, and there’s a reason for it.
While we adults do finally possess the things we so looked forward to as a child, we also do end up having to adopt responsibilities and deal with matters that are entirely foreign to your current world. It’s not something you simply could have fathomed. I’m sure you have heard of adults use terms such as “DSA, university, portfolio, CV, resume, BTO, marriage, citizenship status, insurance, and migration” in their conversations. Dad and Mom may have explained to you roughly what these terms mean, but they are still probably too abstract.
At this point, the burning question you have is probably a general “So how would I be like 18 years from now?” Let me jump straight to it. You are very privileged to be born in the family that you are born in. 18 years later, assuming things proceed as normal and that you do not sincerely apply what you will learn from the contents of this letter, then you will at least find yourself as a third-year medical student in NUS (as a 6yo boy reading this in 2004, it might feel superfluous to have the state the name of the university given that medicine can only be done locally at NUS; nevertheless, there will eventually be two other local medical schools in Singapore).
I know you are starting to hear the words of countless people who are older than you: they constantly ask you to study hard for the sake of your future. It must feel annoying to constantly have to hear that, and this is before primary school has even started for you. All you want to do is go to the playground to play catching, and you wonder why there is a need to be so caught up with this notion of ‘studying’ that adults keep talking about. Trust me, you’ll keep hearing such advice, and it’s only going to get more prevalent as the PSLE draws near (the examination might feel distant but it will come soon enough). I used to find such advice annoying too (you are me after all hahaha), but it was only as I got older that I realised that it was indeed so critical all this while. Grades truly are so paramount in this society which places such a great emphasis on one’s academic history.
If you really do receive this letter, please take it seriously. This isn’t Uncle Ronson, or Uncle Eric. This is not a random adult who is giving you the same old generic advice. This is me – Nic. You. You from the future. I know how you felt at 6yo. I know all the thoughts that you had (and will soon come to have).
As I reflect on my life and where I’m at, I can’t help but feel there was just so much unrealised potential. So I’m writing this letter to you from a position of “here’s all the things you can do so that you would become so much more than what you would be if you just let things course the way they would”.
And if (and when, hopefully) you do take my words in this letter seriously, do continuously re-read this letter as you trudge through the arduous journey of life. Read this before each major exam in primary school (CA1, SA1, CA2, SA2). Read it two months before the PSLE. Read it after the death of your maternal grandmother in 2006. Read it before each piano exam.
With all this being said, let me launch into the advice that can be categorised as general, specific dos, and specific don’ts:
GENERAL
Be grateful for your background. Nic, you have no idea how fortunate you are to be born in Singapore. Seriously. Of all the regions in the world that you could have born in (e.g. South Sudan, India, Sri Lanka, Indonesia, Afghanistan, Pakistan, North Korea), God has mercifully and graciously allowed you to be born in Singapore as a Singapore citizen, into a family with wonderful parents. Dad and Mom are both intelligent, educated, fiscally comfortable, and enjoy a good marriage. Unfortunately, this is not the norm at all for families worldwide. Our parents and their circle of friends do not constitute a representative sample of society. You are also ethnic Chinese, the majority ethnicity in this city-state. Fortunately or unfortunately (depending on whose perspective you’re adopting), this is a privilege that you have, and it would be a shame if you did not capitalise on it. Statistically, and based on historical data, your family background allows you to take advantage of many opportunities that some of your peers simply will not have. Be grateful.
Take your academic performance seriously. Amount of studying done = Time spent studying * Intensity of Focus. In all that you do regarding your academic work, you can work on those two components – time spent, and focus intensity. The former is self-evident. You need to put in the hours on something that is cognitively demanding and involves deliberate practice. What’s more tricky is the latter component. To focus intensely on something means to avoid distractions and concentrate solely on the task as much as possible for the duration of focus. This means working alone, and not even leaving your seat to grab a glass of water at an extreme. Do not have distracting toys, games, or other items on your study table when you are trying to focus. You most certainly shouldn’t try to do your homework while trying to watch television at the same time. One concept that I’ll emphasise over and over again is how we as human beings simply aren’t wired to multitask and still deliver at peak cognitive performance. Whenever we are distracted and do something else, we suffer a decrease in cognitive performance, and it takes a while for us to recover from such context-switching. When this happens multiple times (e.g. checking one’s phone or email every six minutes, even if it’s just for 10-15 seconds each time) over what would otherwise be a study/learning session of intense focus, the value of the session is lower than what it would otherwise be. People drastically underestimate the adverse effects of multitasking on one’s cognitive performance. If you are able to do this consistently: getting your study duration up, and having intense focus on an activity that is cognitively demanding and involves deliberate practice, you will then be one of the top performers in primary school and beyond.
Have proper eyecare habits. Go outdoors more and get more sunlight! If you have to do near work, ensure that the time spent is purposeful and that you still have good practices such as adhering to the 20-20-20 rule (i.e. every twenty minutes, glance at something twenty feet away for about twenty seconds). Work on the modifiable risk factors of myopia. If you are fortunate enough, you may not have to wear glasses if everything goes alright. Nevertheless, given that our parents have myopia, and that myopia is partially hereditary, some degree of myopia is to be expected. At the very least, change what you can, and I’m almost certain that the severity of your myopia can be minimised.
Start exercising! If all the benefits of an arbitrary duration of exercise could somehow be replicated by the consumption of a single drug, a single pill, a chemical substance, I have no doubt that it will go on to be the best-selling pill of all time. It’s good to start exercising early. Start training for the 5-station NAPFA tests that you will start to undergo in P3 (I think). It would be fantastic if you could consistently get ‘Gold’ each time you do the test.
Be kind to others. There is a difference between being assertive and being unkind. Appreciate the difference, and you will go further in life.
SPECIFIC DOs
Take learning of the piano seriously. Seriously, Nic, you don’t know how fortunate and blessed you are to have Teacher Helen as your piano teacher. For goodness’ sake, she has two grands in her house – a Steinway and a Kawai. Piano lessons with her aren’t cheap. Dad and Mom have done their part in accepting your initial request to begin piano lessons and have gone the extra mile to engage such a fantastic piano teacher. Do your part by practising diligently. You could become a concert pianist if you start taking piano seriously.
Take the learning of Mandarin Chinese seriously. You are disadvantaged in the sense that none of your family members communicate via Mandarin Chinese at home. The only exposure you have will therefore be your Mandarin classes in school and the Chinese tuition classes that your parents will make you undergo. During the limited time you have in these classes, focus on the material and ensure that you do any required pre-reading, preparation, and homework to get the most out of the learning opportunity.
Read The Straits Times and more books (especially Chinese literature). Books, in theory, represent the accumulated wisdom of the author, and everyone who has preceded him. A book is an incredible source of knowledge. For something to be published in the form of a book, you can be sure that it would need to add (at least from the perspective of the author) value to the lives of its reader. It would have to undergo many iterations of edits and revisions before the published work finally ends up in your hand. Books are wonderful. As you read books, you can potentially avoid making the same painful mistakes as others by reading about others’ lessons and what they learnt from it. You can learn about what to do and what to avoid. But most importantly, as an incoming primary school student, reading the newspapers and books enable you to have a firmer grasp of language. Your vocabulary will become more sophisticated. With the positive effects of reading compounded over a long stretch of time, you will be glad you started this. You vocabulary will become incredibly robust and versatile, and you will become far more articulate than I even currently am. A fantastic English teacher, Mrs Ivy Lee, will start recommending you to read the papers in Primary Six. Her advice is great. But you don’t have to wait till P6 starts to begin it. Start now. Read the books at home. Don’t just leave them on the bookshelf.
Ask Dad to make a Gmail account for you in a few months. Gmail is going to be open to the general public on 1 April 2004, a few months after you start primary school. Get Dad to teach you how to access the Internet, and make a Gmail account for you, and ask him to register “nicholas@gmail.com”, or “nicholasloh@gmail.com” ASAP. If you don’t make the email accounts fast enough, these emails are just going to be registered by other people around the world. If those two emails aren’t available for registration, then just do “nicholascloh@gmail.com”.
Start establishing positive daily habits. Wake up early in the morning and do not engage in any kind of alarm-snoozing. Sleep early. Be consistent with your morning and evening routine.
Take CCA in primary school seriously. Try to get involved in a CCA where you can represent the school in competitions and events. Attain some kind of award or do some kind of volunteering activity so that you can have something to show for the time and effort that you have put into the CCA. If the achievements are significant enough, it might even help in getting into certain choice secondary schools via the DSA if your PSLE score isn’t good enough (but of course, this shouldn’t be an issue if you seriously take the advice of studying).
Have excellent conduct and try to get the gold ‘Model Student’ badge consistently. Seriously. It’s all part of that quest to be that ideal student – one who excels academically, excels in conduct, and excels in physical fitness. Do everything well. One of the ways I suspect people are able to get the gold ‘Model Student’ badge is by having a track record of leadership appointments in primary school. So whenever an opportunity arises, do express your interest to be a class monitor, carry books to the staff room, and be a prefect. Pick the front row seats and be engaged in the class activity as much as possible. Yeah, you will soon come to realise that there will be primary school students who will wear neck ties. They are prefects.
Treat Aunty Yati, your current domestic helper, and all subsequently employed domestic helpers with respect. They are human beings too, not your personal servants. Get a glass of water yourself. Have meaningful conversations with them, and you might even be able to pick up the basics of Bahasa Indonesia.
Ask Dad to help you create a fresh Word document on a piece of software known as Microsoft Word. Start documenting all your achievements and accomplishments (to come). It will be useful when you need to submit applications for various scholarships, awards, appointments, bursaries throughout your education journey.
Make extensive use of the homework diary or the daily planner that is issued by the school at the start of each academic year. They are incredibly helpful for keeping track of things.
Make use of the tennis racquets and tennis balls we have at home; use the tennis courts at the condominium, and learn it well. It’s good to have at least one sport that one engages in. Tennis is a great way to socialise with one’s peers and keep fit.
Make use of the swimming pools we have at home. Get good at swimming. Don’t just play in the pool and have fun in the water. Practise the swimming strokes that you will be taught by Uncle Jimmy and Uncle Francis, who are swimming teachers that Dad will soon engage.
Whatever you do, put your mind to it, and focus intensely. As a follow up to the earlier point on academic performance, this advice of focussing intensely applies not just to academic work, but virtually any activity you engage in. The way to get the most out of something is to focus on it intensely.
SPECIFIC DON’Ts
Don’t ask your parents to get you a phone just because many of your peers will start having one in P3-P5. There’s simply no good reason for a primary school student to have a phone in the mid-2000s. Life was much simpler then. Delay getting a phone as much as possible. Why sign yourself up for a great potential source of distraction after all? Once again, focus on your studies.
Avoid the television (except the evening news on Channel Five) as if it were the plague. Watching television is such a passive activity, and there is little learning value in that, particularly if one is watching cartoons for entertainment. In time to come, Mrs Ivy Lee (if you do get her as your English teacher) will ask you to watch the evening news on Channel Five. This should be the only time you watch television. For this specific news programme, pay attention to how the news anchor pronounces and enunciates his words. Use the news anchor as your role model for how you should speak in your everyday conversations. This will all pay off at the PSLE English and beyond. Apart from this English evening news programme, please avoid watching the television.
Don’t create a Facebook account when you are P5 even though it will seem like a cool thing to do. At P5, you technically aren’t allowed to make a Facebook account anyway. For most people, the cons associated with social media use far outweigh the benefits. Even if you do find yourself having to use it eventually, please ensure that you use it intentionally (e.g. for communicating on a class group page) instead of squandering your time on Facebook games such as Mafia Wars, Backyard Monsters, etc.
Do not associate with the negative influences in your class. It is commonly said that you will be the average of the five people you most associate yourself with. Choose the people whom you associate with judiciously.
Do not do silly and foolish things in class. Don’t make those paper pellets to be shot with rubber bands, catapults, ‘G2 guns’, stapled erasers, or even those satay sticks that can be shot dangerously with a stapler. Don’t participate in the activity of passing chain letters around. It’s not going to do you any good. You’re just asking for trouble. Pay attention in class, focus on learning the content well, and excelling in your studies.
Don’t make fun of or bully anyone.
Don’t play video games. Don’t even start! They are not a productive use of your time. Practise the piano, do tennis, swimming, running, read books, or study instead.
Don’t slouch in your seat. Adopt a good posture as much as possible.
Don’t read books in a dimly-lit environment. This would likely accelerate any myopia progression.
Don’t bother with the various Chicken Essence and Bird’s Nest concoctions. Tell Dad and Mom to save their money. You will see advertisements of these products at the various bus stops: with top students posing with these substances. There will be these words in a huge font: “My Choice!” In retrospect, these advertisements were so predatory and certainly preyed on many parents’ insecurities regarding their children’s academic performance to the extent it must have compelled these parents to purchase such products. Singaporeans would do the most ridiculous of things – anything which superficially seems to offer a glimmer of hope of getting their children’s grades up. I’m glad such advertisements eventually disappeared for good.
Avoid unhealthy food and drinks. It’s unhealthy to munch on Sour Cream & Onion potato chips straight from the packet while watching ‘Cartoon Network’ and lying sideways on the sofa like a sloth. Please don’t let that become you. Also, don’t ever start the daily routine of getting 500-ml sugared drinks at the end of each recess period in school. Never consume those 500-ml POKKA Green Tea, Ice Lemon Tea, and Chrysanthemum Tea bottled drinks.
Well, I suppose that’s a decent amount of stuff for now.
I wonder how you are feeling right now, Nic. Perhaps a little bit of assurance that despite all the uncertainty that you’re imagining (two, three, or even four years from now), you would still end up as a student – in a course which society happily labels as safe, stable, and prestigious? You have no idea how willing I am to seize an opportunity to relive my life from the start of primary school given what I currently know. I don’t have that opportunity. However, if this letter somehow reaches you, then you do. Though you don’t have my vivid experiences and memories of the events that occurred from 6yo onwards, you nevertheless have the next best thing – the opportunity to vicariously experience what I did through the words of this letter.
Do not let the knowledge that you will be a third-year medical student at NUS at the age of 24 make you complacent. This is not a get-out-of-jail-free card for you to neglect doing your homework or neglect your responsibilities in primary school and the years to come. On the contrary, I urge you to consider how much more you could be if you would just internalise all the general and specific points of advice I have listed. Superficially, just letting things go as normal (as though you’ve never encountered this letter) and constantly succumbing to instant gratification seems to be a reasonable alternative given that you know where you’d be in about 18 years. However, there have been many bends, kinks, and painful moments, and consequences, and I wouldn’t want you to have to undergo what I did.
If you follow my advice in this letter down to a T, I am certain that when you actually turn 24, you will be absolutely superior to me in every conceivable way – a more filial son, a more proficient musician, a healthier individual, a better runner, a more academically brilliant individual, a more articulate person, a kinder person, a person who gets along more easily with others.
For now, you have the benefit of youth. Please don’t lend further credence to the notion that youth is wasted on the young. You have the opportunity to change things, and I hope to be your beacon. You are at the age where people still ask, “What do you want to be when you grow up?” I suspect that’s why people love interacting with children so much, and why I am quite keen on having children of my own in the future, God willing. Children represent potential and possibilities – a mould that can be shaped, a malleable metal. It’s almost like having a second shot at life – a chance to restart a game that wasn’t well played the first time.
I’d probably write another letter to an older you soon (perhaps to 12-year-old Nicholas who has just received his PSLE results). But either way, if you do receive this letter, please know that I’ve put so much thought into crafting this, and I hope you would live each day meaningfully, intentionally, and purposefully in order to maximise your potential.
Yours sincerely, 24-year-old Nic from the future 🙂
How the quote ‘Comparison is the thief of joy’ originated
“Comparison is the thief of joy”. This well-known quote is attributed to the 26th US President Theodore Roosevelt (1858-1919). Attached below is an image of him (taken from Wikipedia [1]).
Variations of this advice are common as well. In the US, a particularly well-regarded place to hike is the Appalachian trail – where the Appalachian Mountains are. Hikers on that trail apparently have the motto, “Hike your own hike”.
Even within secondary school, I remember how the teacher for my Physical Education classes would tell us that whenever we enter the gym, we should “leave our ego at the door”. His main objective in putting such advice forth is that safety issues are more likely to crop up if people leave their egos unchecked in the gym. For example, a man may injure himself at one of the stations within the gym in an attempt to impress other people when trying to do something beyond what his current physical capabilities can bear.
After all, in the gym, comparisons are certainly more objective. Dumbbells all have a specific weight associated with them. With all the numerical figures or size of objects being prominently displayed (e.g. heavier dumbbells are larger in size) for many of the stations within the gym, making comparisons with that other people is simply too easy. While easier said that done, individual users of the gym should indeed “leave their egos at the door” and focus on how they can become better than the person they were yesterday, and not compare with other people unproductively.
With that said, comparing oneself with others is not always a bad thing. It is appropriate in at least the following circumstances: I once came across a video online (the last time I checked it on YouTube, it was entitled “A Little Girls [sic] Lesson In Fairness”). It was a segment from a movie where a father gives advice to his daughter.
The most memorable line of that short segment of the movie was when the father says to his daughter that the only time we should look into our neighbour’s bowl is to determine if they have enough, not to see if we have as as much or less than them. In the direct form, here is the quote, at least from a cursory Google search:
“The only time you look in your neighbor’s bowl is to make sure that they have enough. You don’t look in your neighbor’s bowl to see if you have as much as them.” – Louis C. K.
Such a fantastic quote.
How I was recently reminded of it by my Clinical Group EnRICH mentor
I’m not sure if this is a new initiative but on my first clinical rotation as a third-year medical student at YLL, my clinical group was assigned an EnRiCH mentor. According to the NUS website [2], “EnRICH is a longitudinal mentorship program which aims to complement the students’ five-year medical curriculum by supporting the students’ professional development through:
Fostering personal and professional relationships with peers and mentors
Nurturing the NUS values of Respect, Integrity, Compassion, and Humility (Thus forming the RICH)
Developing self-mastery and resilience”
My EnRICH mentor is a paediatric emergencies consultant at NUH. When asked by one of our CG mates if she had any advice for us, the quote “Comparison is the thief of joy” was what she told us. How apt.
This is medical school after all. Medical school in Singapore. Medical students here are generally ambitious, diligent, possess type A personalities, and engage in many CV-enhancing/portfolio-enhancing side projects (e.g. volunteering, a side business, research) in addition to their main role of training to become safe and competent junior doctors.
Listening to the various student presentations at Saturday’s WHBS Research Day event
Despite only having been in YLL for about seven months, I have found myself making comparisons with many of my peers: not to see if they “have enough in their bowl”, but comparing to see if “I have as much as them” on numerous occasions.
While I rationally am aware that such a mindset and approach is unproductive, I still succumb to it anyway. I wonder if it’s because the tendency to compare oneself with others is an inherent characteristic in human beings that is virtually impossible to eradicate.
Anyway, I would like to share a specific example of how I had to deal with these comparisons that I made in my mind.
On Saturday morning (29 Jan 2022), we had the Research Day by the Wong Hock Boon Society (WHBS), where various medical students had the opportunity to present their research to panellists of judges which consisted of established medical doctors and/or scientists. The event took place from 0830-1330 over Zoom.
There were multiple breakout rooms, and each breakout room had multiple groups presenting their projects. For each project presentation, a panel of judges in the breakout room would evaluate the project on a points system.
Dealing with feelings of inadequacy and combatting negative thoughts
One thing that should be understood by the general public (or anyone that wishes to know more about how medical school works) is that engaging in research is generally not mandatory in most medical schools (particularly undergraduate medical schools). My perspective is that, at least in the context of Singapore, the goal of medical school is to produce functioning junior doctors at the end of the half-a-decade factory production line in order to ensure that our healthcare system is kept functioning.
Even at Flinders (a graduate-level medical school), where students had to complete a mandatory ‘Advanced Studies’ component as part of the medical curriculum, students still had the choice between a research project and coursework. I had chosen the former (specifically: I had embarked on ophthalmology-related research given my interest in ophthalmology); however, I could also have chosen the latter option.
In the context of medical school, engaging in research is something students can do to enhance their portfolio. You can imagine how having co-authored several peer-reviewed articles would make one stand out more as an impressive applicant to various residency programme selection committees. After all, when virtually all applicants possess a basic medical qualification (e.g. MBBS), you need other elements to sieve through applicants. Truly, with respect to research, the sky is the limit. I know about someone who is currently an HO (house officer) and has absolutely off-the-charts publication metrics. His h-index on Google Scholar as of the time of writing is 23 despite being only two years older than me. He’s only 26!
Anyway, as for the WHBS Research Day event, I didn’t participate in the event for the full duration but I did still managed to attend a significant proportion of it. I did see many familiar names over there. As I heard the various students present their research to the judges, I couldn’t help but feel a combination of awe and regret.
I wondered, “These presentations are amazing. I’m so happy for all these medical students – that despite the normal workload of medical school, they worked on meaningful research, and got to present their findings to these esteemed doctors and researchers.”
I was impressed by many of the presentations I heard. It was evident that the students who worked on their project had put in significant effort to their project. On top of the actual research work, they still needed to spend time to prepare appropriate PowerPoint slides for the group presentation on Research Day.
As I heard all these presentations, I couldn’t help but feel disappointed that I had not achieved anything like any of those students. It didn’t feel totally great as a participant, particularly as I watched medical students in my cohort or even in relatively junior cohorts (e.g. Phase II) present research findings that they were proud of. I couldn’t help but wonder, “What am I doing wrong? Why am I lacking? All these brilliant people are all ahead of me in this aspect.”
I didn’t have a significant publication to my name.
Thoughts of “if I had made many small but consistently good decisions over the years, things would have been different for me today” coursed through my veins. It’s not just such a thought of making generic good decisions.
I can recall specific branch points in my earlier years, and I wonder how my life would have been different if I had chosen different paths. This probably deserves its own blog post but in essence, with my ‘O’ level score (a perfect net L1R5 of 2) as a Singaporean citizen, I was guaranteed admission into any JC via the JAE. One question that I ask (and asked) myself and people have always asked me was, “Why Hwa Chong? Why not Raffles?”
Even within Hwa Chong, I did not make full use of the opportunities available which would have enabled me to get the most out of the Hwa Chong experience:
I wasn’t as hardworking as I could be.
I didn’t fully leverage on my abilities to participate in certain special programmes within the school.
I didn’t leverage on my abilities to join a CCA in which I knew I could confidently excel in at a starting baseline (thus resulting in a missed opportunity to truly shine in terms of CCA performance and one’s perceived potential for taking on a leadership role within the CCA).
I didn’t make use of the numerous advertised/promoted internship and attachment opportunities on the school portal. I recall this instance where even when I had actually, on the rare occasion, applied to go on an OCIP trip to Nepal, I was successful in my application (there were many students competing for limited spots)! However, I had not followed up regularly to check the outcome of my application status. By the time I found out that I had actually been accepted initially for the Nepal OCIP, it was too late. My spot had gone to someone else.
I didn’t aggressively apply for all the miscellaneous awards and scholarships that I could have.
I didn’t network as effectively as I could have.
I could have chosen Geography instead of Economics (though my H2 Economics subject was ultimately computed as a H1-level subject for the UAP calculation, I nevertheless only attained a ”C” grade for it, which is unfortunate) for my A-level contrasting subject. The reason I chose Economics was that it was the most popular contrasting subject choice in the student cohort, and I just went with the flow. It’s quite unfortunate because at the O-levels, I did enjoy Geography a lot and excelled in it. Who knows what my A-level result would have been if I had chosen Geography instead of Economics.
Even for one of Hwa Chong’s special science research programmes which I was a part of, I could have been more strategic to choose a project with a high likelihood of leading to a tangible outcome: a journal publication, or being able to present some significant finding. Instead, I had chosen a project where getting some meaningful tangible result was much more challenging.
It hurts just thinking about what could have been if I had been more serious, mature, and competitive at that age.
Even beyond Raffles and Hwa Chong, I also wonder how things could have turned out if I had gone to ACS(I) instead. I recently had lunch with a friend who did the IB, and she explained to me in detail how the IB works. It did sound quite meaningful and I wonder if I would have been able to achieve a better equivalent score in the IB than I did at the A-levels. We could even go one step further. If I had truly excelled at the A-levels, and had gotten into local medical school ASAP, I would be working as an HO now.
In an alternate universe, I could have been one of these students delivering a presentation on the WHBS Research Day on Saturday.
As for dealing with the issue of regrets, I simply don’t think it’s productive to dwell on one’s regrets. Though easier said than done, I know that I should let bygones be bygones. The past cannot be changed. We have knowledge of the past, and we are living in the present. We should use that past experience to our advantage.
Conclusion
As I have quoted previously in my other writings, there is a well-known Chinese proverb that goes, “The best time to plant a tree was 20 years ago; the next best time is now”.
I recall watching an inspiring video on YouTube once, where the speaker talks about how one’s absolute position is not necessarily the most important. Rather, it’s one’s trajectory that is more important!
Armed with the lessons I have learnt, I know that I can start making good decisions from today so as to maximise the likelihood of attaining meaningful long-term success in various domains: academic performance, future work performance, relationships, and health.
If you meet me about a year from now, ask me how my life has changed since I made this blog post today. I hope to give a positive report.
It isn’t challenging to appreciate the sheer number of beauty, skincare, and facial products that are marketed primarily towards the female demographic in society. It’s everywhere: physical advertisements at bus stops, MRTs, shopping malls; advertisements along the side of the page as you surf the web. Beyond advertisements, the depiction of the ‘ideal’ attractive woman in various forms of the mass media: movies, animated short films, games, popular profiles on various social media platforms, only help to further cement the notion of the sheer emphasis that society generally places on female beauty. This emphasis is surely felt to at least some extent by all women, but particularly so for impressionable adolescent females, who at that age are also especially concerned with how they are perceived by their peers.
In view of this, just visit any typical mall in Singapore (or any other country for the matter of fact). Various components of make-up (e.g. lipstick, mascara, blush), skincare, and beauty products abound. From the perspective of many of these for-profit corporations, there is a lot of profit to be made in exploiting women’s general desire to look, or at least feel, as physically attractive as possible. This is not surprising because men are generally attracted to the physical beauty of women. Being physically attractive as a woman can generally be considered to be an asset. Attractive women are generally more desirable, not just from the direct perspective of engaging them as sexual or romantic partners, but also in a myriad of arenas: in the workplace, or any other conceivable situation with some level of social interaction between men and women. To simply put it, it is advantageous to be an attractive woman. I’m sure my female readers can appreciate this truth even more than me.
While women generally also desire their potential partners to be physically attractive, it is generally not as highly prioritised as that of the male perspective of women. Women generally assess romantic or sexual partners more holistically. Things associated with a man’s ability to provide for and protect her (physically and financially) and any potential children are considered equally (if not even more) prized by women: wealth, income, and physical fitness. Men and women ultimately prioritise different attributes in the opposite sex when looking for a romantic or sexual partner. At least based on this brief discussion on the differences between men and women, it should thus come as no surprise that an overwhelming proportion of beauty and skincare products target the female demographic primarily.
Conventionally, men do not wear makeup, but they can still certainly benefit from having a separate skincare routine that is independent of makeup. With a proper skincare routine, one can develop a smooth (or at least smoother) complexion, and reduce the risk of developing skin cancer, undesirable clinical features and complications of acne, and more.
As such, it is my wish to outline my journey of how I started my skincare routine recently so as to particularly encourage you (particularly if you are male) to consider starting a routine or resume a routine (if you had begun one previously but failed to be consistent with it).
How I decided to establish a skincare routinerecently
On one of the last few days of last year – 29 December 2021, I had a productive and meaningful chat with a friend regarding skincare. This conversation with her occurred after I had gone for a run with her on that Wednesday morning. We started talking about skincare when she made a remark about the mild facial acne I had.
You should have been there in person – to see how she was left mouth agape when she learnt that I did not even use facial cleanser or any skincare product. She was the polar opposite of me at that point in terms of her commitment to skincare. She used multiple products. In addition to the products she ultimately convinced me to use, she also used serum, eye cream and face oil (see the image below for reference [1])!
She is diligent and consistent with her skincare routine and has been doing it for years. So, it came as no surprise that her complexion is great. In fact, she told me how her peers in secondary school (she came from an all-girls’ secondary school) would comment on how great her complexion was. Unfortunately, she did develop some mild peribinocular freckles after going to Australia to study briefly. According to her at least, it’s irreversible. ☹️
What I appreciated about the dialogue I had with her was that she was sincere about explaining to me what a basic routine consisted of and how I could get started despite being a complete beginner. She was patient, encouraging, and explained to me the rationale of certain components of the skincare routine and how I could use them properly.
In the end, it took a girl around my age 1.5 hours to convince me to establish a routine. She accomplished what my parents had attempted to do for about the past 11 years (well, since my first onset of acne, at least).
I suspect that I was more inclined to adhere to my friend’s advice for the following reasons:
My friend was gentle, knowledgeable, and specific in her advice. She actually knew how to use a product properly, and how to use each component of the skincare routine in conjunction with the other components. It was way beyond merely buying “alcohol-free toner” and asking someone to “just use it”. She had years of experience in using this stuff. She was also quite enthusiastic about skincare. She had watched many videos and read many articles on it. It was great just talking to someone who had so much zeal for anything skincare-related; some of that contagious zeal must have ignited my internal spark for skincare! As for my parents, while I’m not sure about their level of knowledge of skincare, what I can say is that over the years, I’ve just been told to “use” skincare products which were already in the house. Boo…
Perhaps I am just more willing to listen to people around the same age as me. I wonder if this has anything to do with how a part of rebellious teenage Nicholas still resides within me, that I intentionally go against the well-intentioned advice of my parents. “Nicholas, go do XYZ” would be met with thoughts of “Why do I need to do XYZ? How does XYZ work; and exactly do I benefit from doing XYZ?”
When a person of the opposite sex (particularly a person who is also one’s peer) gives advice pertaining to things which affects one’s physical attractiveness, one is generally inclined to take it seriously. Such advice has significant weight. What are the factors which women consider when assessing the physical attractiveness of a potential male partner? The following factors, in no particular order of ranking, are what I can think of at the moment: 1) height; 2) presence of facial acne and abnormal facial skin changes (or lack thereof); 3) habitus; 4) dress sense; 5) haircut; 6) general facial appearance. It goes without saying that men without facial acne or any other abnormal facial skin finding would be perceived as being more physically attractive than men with those skin findings.
Anyway, after that conversation with my friend, which happened to also conclude our meeting that morning, I ran home (literally) to shower before joining my parents for lunch. Immediately after my shower, I enquired about the skincare products that my friend had convinced me to start using.
My parents were so delighted when they heard me asking about the skincare products. You could see the glee and exuberance written all over my mother’s face, in particular. For all these years, they had attempted to convince me to use these products regularly but to no avail. Their constant advice would be resisted by equally persistent reluctance. However, 29 December 2021 was the day when all that would change.
Enthusiastically, my mother handed me the products I could use!
There had always been an abundance of such products in the house. It’s just that I would never use it. In the following section, I will talk about my current established routine.
My daily skincare routine within the broader contexts of my morning and evening routines
I currently use the following components: facial cleanser, toner, moisturiser, sunblock, and topical benzoyl peroxide.
Every morning, I awaken at the sound of my alarm on my iPhone. After stopping the alarm, I do 60 push-ups and proceed to brush my teeth with my electronic toothbrush that has been programmed to run for exactly two minutes at the simple push of a button. Then, I grab the towel from the yard, hang it along the top edge of the full-length glass pane in the bathroom, step into the shower, and begin rinsing myself. During the rinse, I would use the facial cleanser (see image below). I would pump a small amount of cleanser onto the ventral surface of my left ring finger, and apply it to my face.
Then, I would dry myself with the towel, drying all regions of the body except the face. I would go to my bedroom, and get changed into my attire for the day. I would then head to the kitchen, where I would partially fill a hemispherical bowl with muesli and fresh white full-cream milk. I then partake of the food with just a spoon in my left hand (NB: in order to train ambidexterity, I do this, just as I hold my toothbrush with my left hand).
My right hand would be on my iPhone or my iPad. In either case, I would likely be reading email or doing my daily Anki review flashcards on my iPhone or iPad. By the end of it all (the breakfast and work), my face would usually be sufficiently dry. As such, I would begin applying the alcohol-free toner.
After application of the toner, I then apply the moisturiser. The moisturiser is quite a unique component of my routine in that I will always strive to apply it twice a day regardless of the number of times I have showered on that day. One of the things that my friend kept emphasising to me was that moisturiser use is so important, and that I should strive to apply it twice a day, rain or shine.
As for the other products, I just use them at least once (if I only happen to shower once that day), though I still generally use them all twice (except topical benzoyl peroxide) daily.
The last thing I apply (after the moisturiser) is sunblock, though I would wait for some time to elapse after applying the moisturiser before applying the sunblock, if possible, in order to let the moisturiser be effectively absorbed into the deeper layers of the skin.
NB: Did you know what sunscreen and sunblock are two technically distinct terms that mean entirely different things? I only learnt there was a difference when I was reading some articles while working on this blog post. I’ll probably discuss the difference and its implications in a future blog post, but in essence, the product as shown in the image above is sunblock because one of its active ingredients is titanium dioxide, which is an active ingredient that is commonly found in sunblock.
Sunblock is also known as physical or mineral sunscreen. This is different from chemical sunscreen.
The distinction between sunblock and chemical sunscreen is important because sunblock should be applied after moisturiser while chemical sunscreen should be applied before moisturiser use. As such, sunblock is the last thing I apply in my post-shower skincare ritual.
The last component that I use which is not part of my immediate post-shower skincare ritual is the topical benzoyl peroxide. For that, I apply it just once a day – before my nocturnal slumber. I exercise care and caution such that I only apply it to the specific regions which are adversely affected by facial acne. This has two benefits. Firstly, it allows me to conserve the acne cream, and allows us to use the product for as long as possible. Secondly, it minimises the side effects associated with the topical application of benzoyl peroxide, which is known for inducing localised skin irritation, skin reddening, and increased photosensitivity. Fortunately, I have not been afflicted with any significant adverse effect thus far, and I expect things to remain this way.
Topical benzoyl peroxide comes in a number of concentrations. The above contains 5% benzoyl peroxide. The lowest and highest concentration of benzoyl peroxide I have seen are 2.5% and 10% respectively.
Although it has only been about three weeks since I started, I am already seeing some improvement, much to my surprise. Hopefully, there is room for even more improvement the longer I adhere to the skincare routine.
Conclusion
I think my skincare routine, at least for a male, is pretty decent the way it is. I doubt I will be including even more products to make my skincare routine more elaborate but if I ever do in the future, it’s going to be yet another investment of time and money required.
If you’ve gotten to this point, dear reader, then I urge you yet again to consider assessing the state of your facial complexion and your current skincare habits (or lack thereof). For most people, there will be some area for improvement. Work on it. Talk to people who are more experienced for advice.
There is a famous Chinese proverb which goes, “The best time to plant a tree was 20 years ago; the next best time is now”.
What are you waiting for? Get started!
Disclaimer
I am not sponsored by any of the companies whose products I have featured in this blog post. I am still a beginner, when it comes to anything skin-related. This is also a learning journey for me. Always do your due diligence and cross-check what I have published.
The information in this blog post is general and informational in nature. For your specific health concerns, you are advised to talk to a qualified healthcare provider who can address your personal concerns.
On a humid afternoon a few days ago, I was seated in my black swivel chair at my study table. My mind was just wandering as I pondered the events that had occurred in the entirety of 2021 and the first week and a half of 2022. What an adventure it has been. As I sat down and glanced around my bedroom, I noticed my glasses lying on the surface of the table. It is one of the few items I absolutely cannot live without.
My journey with glasses began when I was a Primary Three student. Despite being positioned at one of the first few rows in the classroom, I needed to squint to accurately note the fine details that lay on the whiteboard. It did not help that sometimes, the teachers’ handwriting would be quite tiny.
My dad realised that I needed glasses, and I had my first ever pair of prescription glasses made when I was Primary Three. I was officially diagnosed with myopia.
Myopia is better known as short-sightedness. Its pathophysiology is characterised by abnormally increased ocular axial length, or less commonly, by actual increased refractive power (either at the level of the cornea, or the natural lens embedded within the eye). In either case, the resulting focal point becomes anterior to the retina. For human beings to see a clear image, the resulting focal point should correspond nicely to the retina’s surface. Even if the focal point is just a little too anterior or posterior, the resulting image will be visually distorted. The extent of the distortion will depend on the extent to which the focal point is displaced from the level of the retinal surface. The clinical features of myopia are that of the patient reporting clear vision for near objects, and relatively blurred vision for far objects. On general observation of the patient, it is common to see patients having to squint when trying to focus on details that are far. How does this work?
Well, when one is squinting, one effectively reduces the effective surface area for which light rays are incident on the lens. The effect of this is that only a small amount of focused central light rays are incident on the eye. Pinhole glasses work on this same principle. By shielding our eyes from the unfocused peripheral light rays, less of such unfocused light rays reaches the retina, resulting in better vision. But of course, there is a downside to this. The consequence of squinting or using pinhole glasses is that peripheral vision is hindered (you are effectively preventing unfocused peripheral light rays from reaching the retina after all). The brightness will also be lower (due to having fewer light rays reach the retina). As such, caution should be exercised when using devices such as pinhole glasses. It certainly should not be used when one is driving, due to the dramatic effect it has on one’s peripheral vision. The benefit associated with the mild alleviation of one’s myopia likely doesn’t outweigh the harms associated with the decreased peripheral vision and the decreased brightness.
The poorer the patient’s visual acuity, (visual acuity needs to be assessed independently for each eye), the greater the functional limitation on the patient, resulting in a greater reduction in the quality of life of the patient. It is thus important to address the disease entity – myopia. Survey after survey has found that of all the five senses, people consistently rate sight as the most important. Sight is something that is so easy to take for granted. Just try walking with your eyes closed in your very own humble abode!
The most common way of managing myopia is via prescription lenses. This is not surprising given that it is non-invasive and doesn’t involve the use of topical drugs or invasive refractive surgery which both have their adverse effects and associated risks. As such, the most common first-line treatment of myopia involves one trying a diverging lens with refractive power such that it would diverge the incoming rays of light. This effectively weakens the overall refractive power of the eye and causes the resulting focal point to move posteriorly, back to the retinal surface where it should belong. And of course, a natural question would be – how do we know the strength of the diverging lens to use by determining how much to move the focal point posteriorly by?
For that, we need to go back to the pathophysiology of myopia. The answer is that we can first determine the current focal point for each eye of the patient, and we in turn accomplish that by having the patient undergo a visual acuity test for each eye. That’s how we figure out the corresponding prescription lens to use for each eye. One thing I should just quickly say is that if you (for those of us who have our prescription) look at your prescription, you may see something presented in the same format as this (this is my latest prescription, for those of you who are wondering):
OD: -2.75 -1.75 10 OS: -3.00 -2.25 155
‘OD’ and ‘OS’ are short forms for ‘oculus dextra’ and ‘oculus sinistra’, which are Latin terms for right eye and left eye respectively. As for the numbers in the three columns, ignore the second and third columns for the purposes of this article. Let’s just focus on the first column.
The number in the first column denotes the spherical error. If the number is a negative number, that means the patient needs a lens which weakens the refractive power of the eye (i.e. a diverging prescription lens). You can hence infer from this that the patient is myopic. In this case, the patient’s right eye requires a diverging lens of -2.75 D (D stands for dioptres). Colloquially, at least in Singapore, laymen don’t know and don’t use the term ‘dioptres’. They always talk about ‘degrees’, which is essentially just the magnitude of the spherical error multiplied by a factor of 100. So, if we use the data from the example I have given above, then most people in the local context would say that their right eye is 275 ‘degrees’.
Over the years, as I progressed from Primary Three through Six, secondary school, and even through junior college, I have had to update the lenses on my prescription glasses every two to three years on average. This was because my visual acuity for both eyes deteriorated gradually, albeit at slightly different rates. Normally, when the lenses were changed, I would also take the opportunity to change the frames. However, recently I have decided to maintain the same frames because I truly relish my current pair of glasses.
Allow me to give some background.
I enlisted for full-time national service (a local euphemism for military training lol) in January 2016. In view of that, I decided to update my prescription lenses a month prior to that. So, in December 2015, I went to the optometrists whose services my family has used for the longest of time (Mee Mee Optics, the branch at Bukit Timah Plaza). On that occasion, in addition to updating my prescription lenses, I decided to have these updated prescription lenses in two totally new frames. One frame would have to be a black full-rimmed one in order to comply with the military regulations. For the entire duration of my full-time national service, I would have to don this particular frame. However, I also made another pair of glasses (the MYKITA ‘Rafael’ glasses), which I would wear whenever I was not in camp. In fact, I enjoyed the look of the Rafael so much that I would bring the Rafael to camp, despite having to wear the black full-rimmed glasses most of the time while in the military camp. Nevertheless, whenever I left the camp in civilian attire, I would don the Rafael!
NB: The ‘Rafael’ glasses of the MYKITA No. 1 collection is no longer being manufactured. Its successor is the ‘Dennis’. So I guess you could say that my ‘Rafael’ glasses are limited edition! The images below are taken directly from the MYKITA website, and they show the ‘Dennis’ glasses, which bears an uncanny resemblance to its predecessor (trust me on this one).
For this second pair of glasses, it was specifically a pair of navy blue MYKITA No. 1 ‘Rafael’ glasses which were specially handmade in Berlin. According to the MYKITA website, “Collection NO1 laid the foundation for MYKITA. Fashioned from stainless steel sheets, the frames are made into a three-dimensional structure through a series of bending and folding steps, similar to the Japanese art of origami. The modern principle behind the openly displayed spiral hinge represents the design approach that has informed all subsequent MYKITA collections: the technical solution must also be an aesthetic one.
All the tinted lenses of the NO1 collection come with an antireflective coating on the reverse side and offer total defence from UVA and UVB rays as well as maximum glare protection.”
The ‘Rafael’ model is half-rimmed, and I just think that this lightweight pair of glasses looks incredibly sophisticated. The generally rectangular shape of the lenses complements my face shape a lot. Having a dark colour for the rims and temples of the glasses also complements my dark hair. So, although this purchase was on the relatively pricey end, I was and remain absolutely satisfied by the purchase. Price is what we pay, but value is what we get. I enjoyed it so much that even when I decided to update my prescription lenses in June last year (shortly after I had returned to Singapore for good upon acceptance of the offer to transfer to NUS Medicine), I decided to retain this frame. For now at least, I intend to use these frames indefinitely. I have no intention of changing these frames.
Another relatively piece of good news is that my myopia progression seems to have somewhat stabilised, which is good, considering that my visual acuity could be considered to be at the threshold between mild and moderate myopia. Classifying myopia by severity is clinically significant because it is well known that one’s risk for a retinal detachment is much greater if one’s myopia is severe!
At this juncture, some of you might be wondering what happened to the black full-rimmed glasses. Well, given that I finished my full-time military service obligation for good in November 2017, and that I have not had to go back for military duties, I have not worn those glasses for a long time… Also, unlike my current MYKITA glasses, those black full-rimmed glasses do not have transition lenses, which is something I do appreciate a lot!
In essence, all is well, and I am still wearing the same frame for my glasses even after 6 years! On many occasions, I can’t help but marvel at how technology that has been refined over several millennia has enabled us to develop corrective lenses to treat myopia. I am so grateful that such a treatment option exists. With these corrective prescription lenses, I, along with millions of other people worldwide with varying severity of myopia, have been granted the ability to see normally, and function at our best in contemporary society. Engaging in healthy eye care practices and habits is so underrated.
Take care of your vision (speak to your doctor, optometrist, or ophthalmologist for personalised medical advice), and stay safe even as we get battle the Omicron variant of SARS-CoV-2!
I had been sleeping and just woke up (1:23 am) from a vivid and bizarre dream. I’m going to document/type what I can remember before the details are quickly forgotten.
In the dream, I was with five other medical students (donning our white coats) working as assistants for a cardiologist (this person is someone who is an actual MBBS-PhD clinician-scientist who works in Adelaide; I know him personally) who was the lead investigator of multiple projects in a seven-storey research facility. Overall, the research facility was well-lit. Everything was running quite good. There were many doctors employed and working in the research facility.
In addition to the doctors and students, there were some other supporting staff. For some reason, there were prison inmates in the building too. I don’t even know what they were doing in the building. Were we conducting unethical experiments on prison inmates? I don’t know. I can’t remember. Maybe they were just there to help out as a cheap/free source of labour.
But one afternoon, just after lunch, the building-wide alarm bell was rung, and all of us (medical students + the lead investigator) rushed to the seventh-floor cafeteria, and we found many chairs and tables overturned. The place was in a mess. The person (the manager) responsible for the tidiness of this particular place was quite furious. We saw one of the prison inmates (who was decked in full orange) running away. The manager told us medical students that we needed to catch up to the guy. So we ran after him. We managed to catch a glimpse of his face initially. I asked the lead investigator, “I saw his face, but do not know about him. What about you, Doctor? Do you know his name?” “No”, he replied.
The lead investigator was visibly disgruntled by the entire nuisance. Based on past events, he was going to have to submit some kind of incident report. I offered to help draft a paragraph or two of the report that he needed to submit. He then replied saying that he would really appreciate such a gesture.
Eventually, we did catch up to the person who ran away. And here’s the part I don’t get. Due to what had happened, he was condemned by the building management, and was made to die. If he wasn’t proactive and simply acted very passively, then he would be put to death by a lethal injection of a fatal amount of IV KCl, WITHOUT first sedating him! Some of the doctors working there would put ECG leads on the inmates who were strapped down for the lethal injection, and used the opportunity (opportunity for students to witness the characteristic ECG patterns live, along with the obvious real-time clinical correlation) to teach medical students (obviously unethical on so many levels) about death by unstable hyperkalaemia which induces a fatal arrhythmia (characterised by certain morphological changes on ECG (listed in order of onset of appearance with increasing concentration of serum potassium: peaked T waves, flattening of P waves, PRI prolongation, increased QRS duration, and eventually sine wave appearances, and asystole).
ECG morphological changes that are characteristic of unstable hyperkalaemia
The inmate had heard stories about this terrifying experience, and so, he decided to be more active to avoid this fate. He decided to commit suicide by hanging, which was permitted within the facility as an alternative to the lethal KCl injection. He opted for ‘the red room’ at the corner of one of the floors in the facility (I only remember that it wasn’t the seventh floor). This is the part of the dream that was most vivid. A guard and I accompanied him to the location. When he reached the final door, he unlocked a metallic mechanism at the top of the door, which effectively unlocked the door. He then opened the door.
He pressed a red button, and a buzzing sound was audible while a square-shaped opening formed at the top of the ceiling and a noose was lowered gradually while suspended from the ceiling. The loop also somehow got larger as it was lowered down (so that the inmate decked in orange could put his neck within the loop easily from a normal standing position). The noose was not of the typical beige rope-like material. Instead, the noose was a black loop created by material similar to that of bicycle chain locks: the ones which are virtually impossible to cut if one doesn’t have the relevant professional cutting tools.
Once his neck was in place, he pressed the red button again. Alas, his fate was sealed. The noose loop then became smaller by a certain percentage (such that his neck could no longer spontaneously fall out). The noose was also then raised, which caused the inmate to be lifted off the ground. He was quite calm about it, and decided to position his arms such that his upper arms were flexed to 90 degrees bilaterally, and that his forearms were then also flexed 90 degrees bilaterally about the elbow joints, but with hands pronated bilaterally.
In the initial phase of the asphyxiation, I saw him starting to struggle. His hands started becoming more tense and then it looked like he was shivering. I then saw spontaneous mallet-finger formation on his ring fingers bilaterally. He looked uncomfortable. So, when he was first being smothered, he struggled and I could hear attempted gasps that were weak. However, it got to the point where you could see his body starting to physically resign and accept its fate. The intensity of the struggle lessened, and his hands could no longer maintain the position he initially adopted. What I noticed first was how the flexion of his upper arm bilaterally was lessened, followed by the more rapid homeostatic extension of his forearms bilaterally. Simply put, he could not sustain the position of his arms as doing so required active effort.
I didn’t get to the point of his death because it was at this moment during the hanging process that I awakened. I noted palmar tingling on my hands bilaterally, and immediately checked what the time was on my iPhone. I was hoping it would be around 4+ am, but it was only 1:23 am… I’m about to finish typing this account, and as I’m finalising this blog post, it’s 3 am. I’m not sure what to make of that dream, but I’m glad that it’s a Saturday morning. And I think I’ll just consider this a rather early start to my Saturday.
What a ride it has been. I just concluded the penultimate week of the Year 3 Family Medicine (FM) posting. Specifically, I just completed the second of two weeks of the GP component of the FM posting, and I must say that the fortnight that I have spent here at this clinic has been the most meaningful fortnight I have encountered yet in this academic year.
For GP attachments, students are posted to doctors in pairs. My clinical group partner and I were fortunate to have been posted to this particular GP clinic in Sengkang, which relishes a decent patient load. The doctor possesses an excellent reputation, and it is not hard to see why. After sitting in just the first few consultations that he had with his patients, I realise that he goes the extra mile to get patients personally involved in their care. The advice he gives patients is also personalised (giving specific personalised weight loss targets) and appreciated by many patients. Allow me to elaborate on what I mean.
The GP keeps his handy physical copy of the eighth edition of Dr John Murtagh’s Patient Education in his clinic. Towards the end of each consultation session, with respect to patient advice, he would flip to the relevant pages in the book, and ask them to take a photo of the relevant page(s) with their phone so that they can benefit from further reading even after the consultation has ended. This arrangement is beneficial for multiple reasons. Firstly, the amount of time available for the doctor to provide personalised patient education is limited in the typical GP clinic. This is unlike the case in polyclinics, where there may be an advanced practice nurse who dispenses patient education advice. Providing patient education via an esteemed book such as Murtagh’s Patient Education is a reasonable alternative. For the time saved by this arrangement, the doctor is able to see more patients, solve more issues for more people in the same limited amount of time, and also generate more revenue for the clinic.
In addition to allowing his patients to take a photograph of relevant pages in Patient Education, this GP also has his own leaflets of patient education that he personally prepares beforehand: leaflets that he would hand to the patients. He prepares these leaflets via Microsoft Word, and prints multiple copies to be stored in the clinics. He has a leaflet for every commonly encountered problem in the primary care setting (e.g. fever in children, diarrhoea, constipation, gastro-oesophageal reflux disease, gastritis). These leaflets provide a short definition of the disease entity, common aetiologies, clinical features, and advice on how the patient can do his part in the management of the condition. For example, in one such leaflet on gastro-oesophageal reflux disease, I remember seeing under one section how patients are advised to sleep in a left lateral decubitus position with their head elevated, while also avoiding triggers such as chocolate, caffeine, tea, spicy foods in general, and food and liquid consumption in the hours just preceding nocturnal slumber. Having a section on Dos and Don’ts for patients is practical and useful because it directly assures patients on practical steps they can take to manage their condition in conjunction with their doctor. By extension, patients may feel that they play an important part in their recuperative journey, and this can have positive downstream effects on future patient adherence.
Hopefully, the above has provided sufficient background and context for what I have undergone the past fortnight.
During the afternoon session of the clinic on Thursday, a Chinese male middle-aged smoker came in for an initial consult with the doctor. While the GP was conversing with his patient for an unrelated matter, I noticed a Hutchinson’s sign of the nail on the patient’s right third toe, which was accompanied by ulceration and partial nail plate destruction. Imagine if the patient had worn closed-toe shoes. I would not have picked it up. Thank God I happened to be observant. So, what is Hutchinson’s sign of the nail?
As discussed in an earlier blog post on eponyms, eponyms are ubiquitous in medicine. It particularly doesn’t help when the same eponym is used to refer to different phenomena within medicine, thus necessitating the use of additional clarifying identifiers. In the case of this specific “Hutchinson’s sign”, we require the additional “of the nail” to distinguish it from the following:
Hutchinson‘s sign of the pupil
A mydriatic and unreactive pupil on the same side of the body as an ipsilateral intracranial mass
Hutchinson‘s sign of the nose
Vesicles on the nasal tip, the lateral aspects of the nose, both of which may precede the development of herpes zoster ophthalmicus, also known as ophthalmic zoster or ophthalmic shingles
NB: herpes zoster ophthalmicus is different from herpes zoster oticus, which is the entity perhaps better known by the eponymous ‘Ramsay-Hunt syndrome’)
Hutchinson triad, a triad pathognomonic of congenital syphilis which consists of interstitial keratitis (NB: keratitis refers to inflammation of the cornea; the word “interstitial” reminds us that it is specifically the stromal layer, the thickest of the five layers of the cornea, which is inflammed), malformed teeth (which includes Hutchinson incisors and Mulberry molars), and sensorineural hearing loss
We have the late Sir Jonathan Hutchinson to thank for all the above eponyms. Anyway, a positive Hutchinson’s sign of the nail should raise one’s suspicions for a subungual (‘ungium‘ is the Latin word for ‘nail’; by extension, ‘subungual‘ refers to ‘underneath the nail‘) melanoma, a subtype of acral lentiginous melanoma, which itself is a type of malignant melanoma.
For readers who are not in the medical field, this can all sound like Greek. So, for the sake of accessibility, let’s first establish a basic mental model about skin cancers. When we talk about skin cancers, we can categorise them as non-melanomas (NMSC; cancers grouped under this term are considered benign simplistically because they are much less likely than malignant melanomas to spread and have serious adverse effects on the patient) or malignant melanomas. There are many different types of malignant melanoma, of which the more common ones include superficially spreading melanoma, nodular melanoma, lentigo maligna, and acral lentiginous melanoma. While homing in on the acral lentiginous type of melanoma, let’s try to understand some of the big words here.
The word ‘acral’ is defined as ‘of or belonging to the extremities of peripheral body parts’. The word ‘lentiginous’ comes from the word ‘lentigo’, which is a dermatological term used to describe a small pigmented lesion that is clearly demarcated from surrounding healthy skin. I find the following elaboration on ‘lentiginous’ from Wikipedia quite helpful and educational:
It is a harmless (benign) hyperplasia of melanocytes which is linear in its spread. This means the hyperplasia of melanocytes is restricted to the cell layer directly above the basement membrane of the epidermis where melanocytes normally reside. This is in contrast to the “nests” of multi-layer melanocytes found in moles (melanocytic nevi). Because of this characteristic feature, the adjective “lentiginous” is used to describe other skin lesions that similarly proliferate linearly within the basal cell layer.
Wikipedia
Acral lentiginous melanoma accounts for about 5% of all melanomas, and is more common in Asians and dark-skinned populations. Predilection sites in acral lentiginous melanoma include unsurprisingly (as the word ‘acral’ suggests) the palms, soles, the nail bed, and the mucous membranes. The following image is an example of Hutchinson’s sign of the nail, which constitutes the classic clinical appearance of the subungual subtype of acral lentiginous melanoma. According to the AMBOSS Knowledge library, Hutchinson’s sign of the nail is a dark linear patch, which arises from the proximal base of the nail bed and widens with time. Although this clinical sign isn’t an infallible predictor of a subungual melanoma, this is sufficiently concerning to me to warrant a referral to the dermatologist.
The above is similar to what I saw on Thursday afternoon. This concerned me, and thus I notified the GP about it. When he saw it, he confirmed my suspicion that this was indeed likely to be Hutchinson’s sign of the nail. He then promptly told the patient that he needed to consult a dermatologist to further manage this possibility of a subungual melanoma. There is a chance that what the patient has isn’t subungual melanoma, and I hope it isn’t but if it is indeed subungual melanoma, then at least having it promptly seen and managed by the dermatologist should render the prognosis more favourable.
“Good call”, the GP remarked to me.
I have never been more proud of myself. This encounter has reaffirmed my decision that was made more than three years ago to embark on a journey to become a medical doctor.
I hope my contribution as a medical student on Thursday potentially saved someone’s son, husband, and father.
Today is the last day of the 1-week-long ICOPE (Integrated Care of Older Persons) component of my Family Medicine posting. While I spent my time at the community hospital (specifically at St. Andrew Community Hospital from Monday through Thursday), today was spent entirely at home, where I participated in the following lectures virtually via Zoom:
Intro to Rehabilitation Medicine (0900-0930)
Deconditioning and Orthopaedic Rehabilitation (0930-1030)
Pretty long day of just being in front of the screen.
As you might guess from the title, I would like to share my thoughts on the ‘Exercise Prescription’ lecture I had the privilege of attending. Though it was only half an hour, I felt that it was such a great and practical lecture. The lecturer, Dr Yen Jia Min, introduced us to how exercise can be classified into four types. It was fascinating to hear of the theory and evidence that underlie exercise recommendations for adults. In this blog post, I would like to share my main takeaways from that lecture.
We are all quite familiar with the general non-pharmacological management of countless chronic conditions. Such non-pharmacological management also plays a significant role in, by extension, the promotion of good health. When the management is non-pharmacological, the principle is invariably to modify one’s lifestyle, and that manifests in multiple ways: engaging in exercise, cessation of smoking and alcohol (the protective effect of moderate amounts of alcohol consumption against cardiovascular disease incidence is deemed by some to be dubious), and ensuring good nutrition. In this blog post, I will be focusing on the specific lifestyle modification of exercising.
Doctors, allied health professionals, and well-meaning peers often tell patients that they have to “just exercise more” to be healthier. In my opinion, telling people to just exercise more without supplementing such vague advice with personalised details on how one should go about doing it is problematic because is not constructive. It is 2021, and virtually every human being in any given developed country would know that exercising is beneficial to one’s health. It’s been drilled into our heads by countless health promotion campaigns. So, to tell patients (or even one’s friends who are generally healthy) that they just need to exercise more risks triggering the perception that they are being infantilised.
Imagine being good-intentioned and then being met with: “Duh! Everyone knows that exercise is good. You don’t have to tell me that. I know that. Do you think I’m a little child who doesn’t know that?”
When the person on the receiving end of such vague advice feels that he is being infantilised, this could make him resist the idea of exercising even more. This is because transitioning from a state of not exercising enough to commencing an exercise routine (or exercising more) after hearing that vague advice to “just exercise more” would superficially lend credence to the notion that one didn’t know that earlier. Yes, I know. In such a scenario, it would indeed be objectively better to start exercising, but do bear in mind that human beings aren’t totally rational. They have feelings too, and I’m sure the typical person doesn’t like being infantilised, or being on the receiving end of vague ‘common sense’ advice, particularly if it’s unsolicited.
With that being said, it is thus important to ensure that the person who requires such advice is receptive to hearing advice regarding lifestyle modification in the first place. Then, to ensure that the advice is personalised and contains the relevant details, it is important to elaborate on the nature of the exercise. This is where today’s 30-min lecture has been rather helpful. Let me share with you what I learnt.
Incorporating the FITTP acronym in the context of establishing an exercise prescription
This is so important precisely because systematically incorporating the FITTP acronym would allow one to elaborate on the nature of the exercise. This allows a goal to be much more clearly-defined, and allows one to know if one has met the goal or not. It also allows the goal to be tweaked as needed.
The FITTP is: Frequency (number of days in a week), Intensity (mild, moderate, and severe), Time (how long is each session going to be?), Type (what type of exercise is this), Progression.
Something that I quite liked was when Dr Yen shared that there are generally four types of exercise. I did not know this previously. The four types of exercise are:
endurance (aerobic) exercise
resistance or strength exercise
stretching exercise
balancing exercise
I have heard of aerobic exercises and resistance exercises previously but I did not know that exercise could be neatly classified into four categories. This is a useful structured framework for both doctors and patients to think about exercise. During the lecture, Dr Yen remarked, “If you can only remember one thing, but forget everything else about this lecture, please remember this table”. Here is the table:
Please pay particular attention to the first two rows of the table! The recommendations for aerobic and resistance exercises apply to the typical adult and it would behove us to try to adhere to it as much as possible (good for you if you can exceed the minimum recommendations)! At least currently in medical school, everyone seems to know about the 150 minutes of moderate-intensity aerobic exercise per week recommendation. However, what doesn’t seem to be as well known is the recommendation on resistance training: moderate-intensity resistance exercise involving all major muscle groups for at least two days a week.
Both aerobic exercise and resistance exercise are important components of the physical activity guidelines for adults. This table outlines the physical activity guidelines for adults in the United States. Nevertheless, the recommendations are highly similar for that of Singapore.
Another useful learning point from this second table is how the 150 minutes of moderate-intensity exercise is equivalent to 75 minutes of high-intensity exercise. Recall earlier the ‘I’ in the FITTP acronym. The intensity of exercise can be graded as mild, moderate, or high/vigorous.
In making exercise prescriptions, one of the most common questions that we would likely face is, “How do we gauge the exercise intensity?” That’s a good question, and a good rule of thumb we can use is as follows:
Mild-intensity exercise = can sing and talk
Moderate-intensity exercise = cannot sing, but able to talk
High-intensity exercise = cannot talk, let alone sing (if you can still talk, try harder lol; you’re not there yet)
It’s also important to remember that the guidelines as given above are appropriate for the typical healthy adult. If one, for example, has a chronic disease such as osteoarthritis, then the recommendations may have to be tweaked slightly and personalised for the individual. In a patient whose knees are implicated in osteoarthritis, it is important to still engage in aerobic exercise. However, running would not likely be recommended. Instead, activities which do not result in much mechanical impact on the knee (e.g. cycling, swimming) could be recommended.
One last thing that I want to talk about is the issue of ‘exercise progression’ (c.f. the ‘P’ in FITTP).
The above is one of the slides in the lecture and I think it’s useful. Important points include how in the case of resistance exercise, increasing repetitions is preferred to increasing load. It’s also important to note that progression in exercise isn’t just about the frequency of the exercise. The intensity and duration of each session can also be varied.
In sum, I enjoyed this afternoon’s lecture on exercise prescription thoroughly. It taught me a lot about exercise and as such, I now have a much clearer mental framework about exercise that would prove beneficial not just in my own personal life, but also in interactions with my patients, friends, and colleagues where elaborating on the nature of exercise is both solicited and warranted.
On Friday, I concluded my three-week stint at Queenstown Polyclinic as part of the ten-week Family Medicine (FM) posting of the third year of the NUS MBBS undergraduate curriculum (i.e. Phase III). There were various assessment components associated with this three-week stint, one of which was the ‘patient care plan’ that each medical student was expected to complete.
I decided to craft a care plan for an 86-year-old woman whom I had the privilege of encountering during the polyclinic attachment. I could spend time talking about all the various aspects of her care but for the purposes of this post, I would like to talk about how I have witnessed first-hand the importance of managing chronic diseases, and knowing the various nuances in the current guidelines so that we can deliver evidence-based care for the good of our patients.
Singapore’s population is ageing, and it is indeed staggering to see for myself the sheer proportion of patients who visit the polyclinic (particularly for chronic consults) who present with a personal medical history of the common chronic diseases: hypertension, diabetes mellitus, hyperlipidaemia, osteoarthritis. Unfortunately, the statistics on the predicted trends on the prevalence and incidence of these diseases paint a bleak picture.
As the average life expectancy increases (age is a classic non-modifiable risk factor for many chronic diseases) and the proliferation of the modern diet (which is generally unhealthy, processed, and laden with added sugar, particularly high fructose corn syrup) continues without bounds, both the prevalence and incidence of these chronic diseases are going to rise.
Why is this a concern? Let’s take one of the chronic diseases, diabetes mellitus (DM), for example. In the case of DM, complications can be classified as acute (hyperglycaemia symptoms, and hypoglycaemia symptoms secondary to DM therapy) and chronic. Chronic complications can be classified as microvascular (e.g. diabetic retinopathy, diabetic neuropathy, diabetic nephropathy) and macrovascular (stroke, acute coronary syndrome, peripheral vascular disease). In addition to the decreased quality of life experienced by the individual in view of all the potential complications, there is a real tangible cost to society: the cost of the medical services and resources deployed to diagnose DM, manage DM, etc. How can we keep healthcare costs reasonably low without compromising on accessibility and quality? This problem is exacerbated by the fact that Singaporeans aren’t keen on having children (c.f. data from Singapore’s 2020 census). So, where exactly are we going to find the means to pay for the increasing healthcare expenditure associated with an ageing population?
I have heard a lot about how prevention is better than cure, and that we need to win the war on diabetes, etc. These concepts are great. However, they can be rather abstract if one is not affected by these chronic diseases or personally knows loved ones, peers, friends, and colleagues who are affected by these chronic diseases. Having seen so many patients and their journey with chronic diseases has made me come to the realization that indeed, prevention truly is better than cure. It’s much more cost-effective too. But even if one has been diagnosed with a chronic disease, all hope is not lost. This is because chronic diseases can be managed!
In the specific case of the 86-year-old patient I had encountered, I had the following takeaways:
1) There is a lot more to target control than just adhering to the doctor’s management plan. Positive health outcomes are not guaranteed even if patients adhere to the plan established by their doctors, and this is because there are other factors that are (at least in 2021) beyond the control of both the patient and the doctor. Despite being 86yo, and having reported dietary indiscretion, her glycaemic and lipid control are excellent. She isn’t exactly on intense drugs, and she doesn’t even do home blood pressure monitoring (HBPM). In stark contrast, I have seen many patients who are younger than her. These patients may be more disciplined in their lifestyle habits, adhere more to the doctor’s management plan, are on stronger drugs, and still do not achieve values as good as her. As such, genetics plays a huge role. As with virtually all major diseases, the interplay between genetics and environmental factors is significant and we must always bear that in mind. If patients have sincerely tried their best and are still unable to meet certain health targets, we should graciously accept the situation for what it is and not fault them for things beyond their control. On the other hand, having favourable genetic disposition is not an excuse for poor adherence to the prescribed management plan.
2) I have learnt the importance of personalised targets for particular subset of patients. For example, in patients who are aged 80 years or older, the blood pressure target is no longer as strict and becomes 150/90. The age-associated BP target change takes precedence.
Screenshot of page 16 from the summary card of MOH Clinical Practice Guidelines on Hypertension
As for the hypothetical patient’s ideal HbA1c target, although we like to throw the 7% number around a lot out of convenience, the reality is that the ideal HbA1c target should be individualised to the patient’s biodata, DM history, and comorbidities. As such, with the 86-year-old patient’s profile, an appropriate target would be an HbA1c% target of 7.5%. The HbA1c% target may be as low as 6.5% in young and healthy patients while it may be 8.0% in very old patients with highly advanced DM. So, chronic management of DM requires a multidisciplinary holistic management centred around patient education to meet individualised glycaemic targets with non-pharmacological and pharmacological means while simultaneously managing complications and comorbidities. The same reasoning (i.e. in the previous sentence of this paragraph) could be applied to other chronic diseases; just change the phrase ‘individualised glycaemic targets’ to something relevant for the chronic disease in question.
In summary, this case, and the process of putting together the care plan for the 86-year-old patient as a practice exercise have constituted an excellent opportunity for me to understand first-hand the reality of chronic disease management in Singapore. It is certainly not easy at all, particularly if one truly wants to ensure that the management plan is personalised in the name of evidence-based practice. As mentioned earlier, the trends on diabetes prevalence (and similarly for other chronic diseases) don’t look particularly promising. As such, for most of us who will be doctors in the primary care setting, we need to be mentally prepared to manage an ever-increasing proportion of patients with chronic diseases.
This blog post is my translation attempt on the fifth chapter of LLPSI FR. If you wish to learn Latin, all you have to do is just follow me from chapter 01. The Latin text is designed such that you can learn Latin from scratch just by reading the text itself without any external aid. Such is the power of context. For my translation attempt on the fourth chapter, please check out an earlier post: 02(10).
I am making this translation to actively consolidate my knowledge of Latin. As for how to use the text, I would advise that you read the original Latin text, and refrain from consulting my translation attempt unless you need to!
The villa and the garden Here is the villa and the garden of Julius. Julius lives in the large villa. The father, mother, and the three children live in the villa. Julius and Aemilia have three children: two sons and one daughter – not two sons.
Many servants live in the villa. Their master is Julius: he has many servants. Many maids also live in the villa. Their lady-boss is Aemilia: she has many maids.
Julius lives in his villa with a large family. Father and Mother live with Marcus, Quintus, and Julia. Julius and Aemilia live in the villa with children, servants, and maids.
The villa of Julius is in a large garden. In Italy, there are many villas with large gardens. In the garden are roses and lilies. Julius has many roses and many lilies in his garden. Julius’ garden is beautiful, because in it are many beautiful roses and lilies.
Aemilia is a beautiful woman. Syra is not a beautiful woman, and her nose is not beautiful, but is ugly.
Syra, who is a good maid, has a large and ugly nose. Julius is the husband of Aemilia, a beautiful woman. Julius loves Aemilia because she is a beautiful and good woman. Aemilia loves her husband Julius and lives with him. The father and mother love their children. Julius does not live alone, but lives with Aemilia and the large family in the villa.
There are two doors in the villa: a large door and a small door. The villa has two doors and many windows.
In Julius’ villa, there is a large hall and a large water basin. What is in the water basin? There is water in it. There are no windows in the atrium.
In the villa, there is also a large and beautiful peristyle (an inner courtyard surrounded by columns). ‘Peristylum’ is a Greek word. In Greek and Roman villas, there are large and beautiful peristyles. Is the water basin in the peristyle? The water basin is not in the peristyle, but in the hall. In the peristyle is a small garden.
There are many bedrooms in the villa. Quintus sleeps in a small bedroom. Is the bedroom of Marcus large? It is also small. Julius and Aemilia sleep in a large bedroom. Where do the servants sleep? The servants also sleep in bedrooms. Are their bedrooms large? The bedrooms are not large, and many servants sleep in one bedroom. It is also the case that many maids sleep in one bedroom, and they do not have large bedrooms.
Aemilia is in the peristyle. Is she alone? Aemilia is not alone: she is with her children in the peristyle. Julius is absent. Aemilia is in the villa without her husband Julius. Where is Julius? Julius is in the town of Tusculum without Aemilia, but with four servants.
Aemilia, along with Marcus, Quintus, and Julia, is in the villa. Julia sees the beautiful roses in the garden and leaves Aemilia’s presence. Now, Julia is now in Aemilia’s presence. Aemilia does not see her. The girl is in the garden.
Aemilia commands: “Marcus and Quintus! Call for Julia!” Marcus and Quintus call for Julia: “Julia! Come!” but Julia neither hears them nor comes. Julia calls the boys: “Marcus and Quintus! Come! There are many roses here.” The boys hear Julia, and the boys do not leave Aemilia’s presence. Quintus: “Gather the roses, Julia!” Julia gathers the roses and comes from the garden with five roses.
Julia: “Look, Mother! Look, boys! Look at my roses!” Julia is happy; the roses delight her. Aemilia: “Here is my beautiful daughter with beautiful roses!” The words of Aemilia pleased Julia. Marcus: “The roses are beautiful; the girl is not beautiful without the roses!” The words of Marcus does not please Julia! Aemilia (angry): “Silence, bad boy! Julia is a beautiful girl – with roses and without roses”.
Julia: “Listen, Marcus and Quintus!” Marcus: “Mother does not see your ugly nose!” Marcus and Quintus laugh: “Hahaha!” Julia: “Listen, Mother: and now the boys are laughing at me!” Julia cries and leaves the boys with one rose. Aemilia: “Silence, bad boys! Julia’s nose is not ugly. Leave the peristyle! Take the other roses and put them in the water!”
The boys take the other four roses and leave with them.
Aemilia, who is now alone in the peristyle, calls for the maids: “Delia and Syra! Come!” Delia and Syra come from the hall. Aemilia asks them: “Are the boys in the hall?” Delia responds: “In the hall.” Aemilia: “What are Marcus and Quintus doing?” Delia: “The boys are taking water from the water basin…” Syra: “…and putting the roses in the water.”
Here, the lady-boss and maids can hear the boys from the atrium: Quintus cries and Marcus laughs. Aemilia: “What are the boys doing now? Go, Delia! Leave and ask them!” Delia leaves the presence of Aemilia and Syra. Aemilia asks Syra: “Where is Davus?” Syra responds: “In the town with Master.” Delia comes from the hall and calls the lady-boss: “Come, Lady-boss! Come!” Aemilia: “What is it, Delia?”
Delia: “Quintus is in the water basin!” Aemilia: “In the water basin? What is the boy doing in the water basin?” Delia: “Beating the water and calling you.” Aemilia: “What is Marcus doing?” Delia: “He is laughing because Quintus is in the water!” Aemilia: “O, what a bad boy Marcus is! Go! Call for Julius, maid!” Syra: “But Master is in town.” Aemilia: “O, Julius is away again!” Delia: “Go! Come, lady-boss, and beat Marcus!” What does the lady-boss do? The angry lady-boss leaves the peristyle with the maids.
A translation attempt by yours truly NL 3 July 2020
This blog post is my translation attempt on the fourth chapter of LLPSI FR. If you wish to learn Latin, all you have to do is just follow me from Chapter 01. The Latin text is designed such that you can learn Latin from scratch just by reading the text itself without any external aid. Such is the power of context. For my translation attempt on the capitulum tertium, please check 02(09).
I am making this translation as a way for me to actively consolidate my knowledge of Latin. As for how to use the text, I would advise that you read the original Latin text, and avoid consulting my translation attempt unless you need to!
The master and the servants
Scene One People: Julius, Aemilia, Medus.
The purse of Julius is not small. There is money in his purse. Julius has money in the purse.
Aemilia sees the purse and asks Julius: “How many coins are there in your purse?” Julius answers: “A hundred.” Aemilia: “There are not a hundred coins here, are there?” Julius counts the money: “One, two, three, four, five, six, seven, eight, nine, ten. What? Only ten?”
Julius counts the money again: “One, two, three, four… nine, ten.” The number of coins is not one hundred, but only ten.
Julius: “What? In my purse, there aren’t one hundred, but only ten coins! Where are the other coins? Where are my servants?”
Medus: “Your servant Medus is here.” Julius sees his servant Medus, but does not see Davus. Medus is present. Davus is not present, but away from here. Julius, Aemilia, and Medus are here. Davus and the other servants are absent.
Julius: “What? Only one servant is present! Where is Davus? Call for Davus!” Medus calls for Davus: “Davus!” but Davus neither hears Medus nor comes. Medus calls for Davus again: “Da-a-vus! Come!” Davus comes. Now, two servants are present.
Scene Two People: Julius, Aemilia, Medus, Davus.
Davus, who does not see his master, asks Medus: “What is it, Medus?” Medus: “Shush! Master is here. Salute Master!” The servant salutes the master: “Hello, Master!” The master salutes the servant: “Hello, servant!” Davus: “What is it, Master?” Julius: “Shush! Be silent, servant! Be silent and listen!” The servant is silent. Julius: “There are only ten coins in my purse. Where are my other coins?” Davus is silent, and does not respond. Aemilia: “Respond, Davus! Master is questioning you.” Davus responds: “Your money is not here. Ask Medus!”
Julius asks Medus: “Where are my coins, Medus?” Medus does not say a single word. Julius asks him again: “Where is my money? Respond, servant!” Medus accuses Davus: “Your money is in the purse of Davus. Davus has your money.” Aemilia: “Hear, Davus! Medus accuses you.” Davus: “Whom does Medus accuse? Me?” Julius: “Silence, Medus! A servant who accuses a servant is not good!” Medus is silent. Julius does not accuse Davus, but asks him: “Is my money in your purse, Davus?” Davus: “In my purse is not your money, Master.” Julius: “Where is your purse?” Davus: “It is here. Here is my purse.” Julius: “Put your purse on the table!”
Davus puts his purse on the table. Now, his purse is on the table. Julius puts his stick. The master’s stick is on the table.
Davus: “Look: there is no money in my purse.” Julius sees no money in the purse. There are no coins in the purse of Davus. His purse is empty. Davus does not have the Master’s money.
Julius: “O! Davus is a good servant: [he] does not have my money. Here are your coins, Davus!” Julius puts one coin in the purse of Davus. Now, the purse of Davus
is not empty: in his purse is one coin. Davus is happy.
Julius: “Take your purse and leave, good servant!” Davus takes his purse and leaves.
Medus sees the stick which is on the table. Medus also leaves! Why does Medus leave? Medus leaves because he has the master’s coins in his purse!
Davus and Medus are absent.
Scene Three People: Julius, Aemilia.
Julius: “Davus is a good servant. He does not have my money. – But where is my money, Medus? Who has my money?” Medus does not respond. Julius: “Where is Medus? Why does he not respond?” Aemilia: “Medus does not respond because he is away. No servant is present.” Julius calls for Medus: “Medus! Come” but Medus, who is away, neither hears him nor comes. Julius calls again: “Medus! Come, bad servant!” Medus does not come. Julius: “Why does Medus not come?” Aemilia: “Medus does not come because he has your money! His purse is not empty!” Aemilia laughs. Julius is angry – he laughs not!
Julius: “Where is my stick?” Julius does not see the stick which is on the table.
Aemilia: “Here, the stick is on the table.” Julius takes his stick and leaves.
This blog post is my translation attempt on the third chapter of LLPSI FR. If you wish to learn Latin, all you have to do is just follow me from chapter 1. The Latin text is designed such that you can learn Latinfrom scratch just by reading the text itself without any external aid. Such is the power of context. For my translation attempt on the capitulum secundum, please check out an earlier post: 02(08).
I am making this translation as a way for me to actively consolidate my knowledge of Latin. As for how to use the text, I would advise that you read the original Latin text, and refrain from consulting my translation attempt unless you need to! —
The Shameless Boy
Scene One People: Julia, Marcus, Quintus.
Julia sings: “Lalla.” Julia is happy. Marcus: “Stop!” Marcus is not happy. Julia sings: “Lalla, lalla.” Marcus: “Ssst!” Marcus is angry. Julia sings: “Lalla, lalla, lalla.” Marcus hits Julia. Now Julia does not sing, but cries: “Uhuhu!” Marcus laughs: “Hahaha!”
Quintus sees Marcus. Marcus does not see Quintus. Quintus: “What? Marcus hits a girl – and laughs!”
Quintus is angry and Marcus strikes! Now, Marcus is not laughing. The angry Marcus hits Quintus. Julia: “Where is Mother?” Julia does not see Aemilia. Julia says to Aemilia: “Mother! Marcus hits Quintus!” Marcus (angry): “Shush!” Marcus strikes Julia. Julia cries and calls for Aemilia: “Mamma! Mamma! Marcus hits me!” Aemilia comes.
Scene Two People: Aemilia, Julia, Marcus, Quintus
Aemilia asks: “Who calls me?” Quintus responds: “Julia calls you.” Aemilia asks Quintus: “Why does Julia cry?” Quintus responds: “Julia cries, because Marcus hit her.” Aemilia: “What? The boy hits the little girl? Fu! Why does Marcus hit Julia?” Quintus: “Because Julia sings.” Aemilia: “O Julia, my little girl! Marcus is not a good boy; Marcus is a bad boy!”
Quintus: “Julia is a good girl.” Aemilia asks Quintus: “Where is Julius? Why has he not come?” Aemilia does not see Julius. Marcus responds: “Father sleeps.” Quintus: “Mother did not ask you, but asked me!” Aemilia: “Shush, boys! Where is Father?” Quintus: “Father is not here, but Marcus is here.” Quintus calls for Julius: “Father! Father!”
Julius does not hear Quintus, and does not come. Why does Julius not hear Quintus? Julius does not hear him, because Julius is sleeping. Marcus: “Haha! Father is sleeping and does not hear you.” Aemilia: “Fu, boy!” Aemilia is angry. Mother beats the boy: tuxtax, tuxtax… Marcus cries: “Uhuhu!” Julius hears him. Now, Father is not sleeping.
Scene Three People: Julius, Aemilia, Julia, Marcus, Quintus
Quintus: “Father comes.” Aemilia does not hear Quintus, because Marcus cries. Julius sees Quintus and asks him: “Why does Marcus cry?” Quintus responds: “Marcus cries, because Mother beats him.” Julius: “But why does Mother beat Marcus?” Quintus: “Marcus is beaten because he is a bad boy. Marcus strikes the little girl!” Julia: “Mamma! Father is here.” Aemilia sees Julius. Aemilia: “Your Marcus is a bad boy!” Julius: “Fu, boy! A good boy does not beat a girl. A boy who hits a little girl is bad!” The angry Julius beats the bad boy: tuxtax, tuxtax, tuxtax…
Marcus cries. Quintus is happy and laughs. Julia is not happy and does not laugh. Why is Julia not happy? Julia is not happy, because Marcus cries. Julia is a good girl!
A boy laughs. A girl cries. Who is the boy who laughs? The boy who laughs is Marcus. Who is the girl who cries? The girl who cries is Julia.
Marcus, who hits a girl, is a bad boy. The girl who Marcus hits is Julia. Julia calls for Aemilia. Aemilia, whom Julia calls, is the mother of the children. Aemilia beats the boy. The boy whom Aemilia beats is Marcus.
Whom does Quintus call? Quintus calls Julius. Julius, whom Quintus calls, is the father of the children. Julius does not hear Quintus. Whom does Julius hear. Julius hears Marcus. The boy whom Julius hears is Marcus.
The girl who sings is happy. The girl who cries is not happy. A boy who hits a girl is bad!
Translation attempt of Capitulum Tertium of LLPSI Familia Romana by yours truly on 30 June 2020.
This blog post is my translation attempt on the second chapter of LLPSI FR. If you wish to learn Latin, all you have to do is just follow me from chapter 1. The Latin text is designed such that you can learn Latin just by reading the text itself without any external aid. Such is the power of context. For my translation attempt on the capitulum primum, please check out an earlier post: 02(07). —
Julius is a Roman man. Aemilia is a Roman woman. Marcus is a Roman boy. Quintus is also a Roman boy. Julia is a Roman girl.
Marcus and Quintus are not men, but are boys. The men are Julius, Medus, and Davus. Aemilia, Delia, and Syra are women. Is Julia a woman? Julia is not a woman, but a little girl.
Julius, Aemilia, Marcus, Quintus, Julia, Syra, Davus, Delia, and Medus are a Roman family. Julius is the father. Aemilia is the mother. Julius is the father of Marcus and Quintus. Julius is also the father of Julia. Aemilia is the mother of Marcus, Quintus, and Julia. Marcus is the son of Julius. Marcus is the son of Aemilia. Quintus is also the son of Julius and Aemilia. Julia is the daughter of Julius and Aemilia.
Who is Marcus? Marcus is a Roman boy. Who is the father of Marcus? Julius is the father of Marcus. Who is the mother
of Marcus? The mother of Marcus is Aemilia. Who is Julia? Julia is a Roman girl. Who is the mother of Julia? Aemilia is the mother of Julia. The father of Julia is Julius. Julia is the daughter of Julius. Who are the sons of Julius? The sons of Julius are Marcus and Quintus. The three children are Marcus, Quintus, and Julia. The children are sons and daughters. Marcus, Quintus, and Julia are children of Julius and Aemilia. In the family of Julius are three children: two sons and one daughter.
Is Medus a son of Julius? Medus is not a son of Julius; Medus is a servant of Julius. Julius is the master of Medus. Julius is the master of the servant. Davus is also a servant. The two servants are Medus and Davus. Julius is the master of Medus and Davus. Julius is the master of the servants and the father of the children.
Is Delia the daughter of Aemilia? Delia is not the daughter of Aemilia; Delia is a maid of Aemilia. Aemilia is the lady-boss of the maid. Syra is also a maid. The two maids are Delia and Syra. Aemilia is the lady-boss of the maids.
Whose servant is Davus? Davus is the servant of Julius. Whose maid is Syra? Syra is the maid of Aemilia.
How many children are in the family? There are three children in the family of Julius. How many sons and daughters are there? There are two sons and one daughter. How many servants are there in the family? There are a hundred servants in the family. In the family of Julius, there are many servants, and few children. Julius is the master of many servants.
‘2’ and ‘3’ are numbers. ‘100’ is also a number. The number of servants is 100. The number of children
is 3. 100 is a large number. 3 is a small number. The number of servants is large. The number of children is small. In the family of Julius, there is a large number of servants, [but] a small number of servants.
Medus is a Greek servant. Delia is a Greek maid. In Julius’ family, there are many Greek servants and Greek maids. Is Aemilia a Greek woman? Aemilia is not a Greek woman, but [a] Roman [woman]. Julius is not a Greek, but a Roman [man].
Sparta is a Greek town. There are three towns: Sparta, Delphi, and Tusculum. Of these, there are two Greek towns and one Roman town. In Greece and in Italy, there is a large number of towns. There is a large number of rivers in Gall. The rivers of Gall are large. Are the rivers of Africa large? In Africa, there is one large river: the Nile; the other rivers of Africa are small. Are there large Greek islands? The two islands, Creta and Euboea, are large; the other Greek islands are small.
Who is Cornelius? Cornelius is a Roman master. The two Roman masters are Julius and Cornelius. Medus is not a servant of Cornelius. Medus is a servant of Julius.
Cornelius: “Whose servant is Medus?” Julius: “Medus is my servant.” Cornelius: “Is Davus your servant?” Julius: “Davus is also my servant. My servants are Medus, Davus, and many more…” Cornelius: “Is Delia your maid?”
Julius: “Delia is my maid, and Syra is also my maid. My maids are Delia, Syra, and many others. My family is large.” Cornelius: “How many servants are there in your family?” Julius: “There are 100 servants in my family.” Cornelius: “What?” Julius: “The number of my servants if 100.” Cornelius: “A 100 servants! The number of your servant is large!”
Your Latin book Here are two Latin books: an old book and a new book. Lingua Latina is your first Latin book. The title of your book is ‘Lingua Latina’. Your book is not old, but is new. In Lingua Latina, there are many pages and many chapters: the first, second, third chapters, and more. ‘Imperium Romanum’ is the title of the first chapter. The title of the second chapter is ‘Familia Romana’. In the second chapter, there are six pages. On the first page of the second chapter, there are many new words: vir, femina, puer, puella, familia, and more. The number of Latin words is large!
The diagram shows an island (insula), town (oppidum), and river (fluvius).
Rome is in Italy. Italy is in Europe. Greece is in Europe. Italy and Greece are in Europe. Spain is also in Europe. Spain, Italy, and Greece are in Europe.
Egypt is not in Europe; Egypt is in Africa. Gall is not in Africa; Gall is in Europe. Syria is not in Europe, but in Asia. Arabia is also in Asia. Syria and Arabia are in Asia. Germany is not in Asia, but is in Europe. Britain is also in Europe. Germany and Britain are in Europe.
Is Gall in Europe? Gall is in Europe. Is Rome in Gall? Rome is not in Gall. Where is Rome? Rome is in Italy. Where is Italy? Italy is in Europe. Where are Gall and Spain? Gall and Spain are in Europe.
Is the Nile in Europe? The Nile is not in Europe. Where is the Nile? The Nile is in Africa. Where is the Rhine? The Rhine is in Germany. The Nile is a river. The Rhine is a river.
The Nile and Rhine are rivers. The Danube is also a river. The Rhine and Danube are rivers in Germany. The Tiber river is in Italy.
The Nile is a large river. The Tiber is not a large river, the river Tiber is small. The Rhine is not a large river, but a large river. The Nile and Rhine are not small rivers, but are large rivers. The Danube is also a large river.
Corsica is an island. Corsica, Sardinia, and Sicily are islands. Britain is also an island. Italy is not an island. Sicily is a large island. Melita is a small island. Britain is not a small island, but a large island. Sicily and Sardinia are not small islands, but large islands.
Brundisium is a town. Brundisium and Tusculum are towns. Sparta is also a town. Brundisium is a large town. Tusculum is a small town. Delphi is also a small town. Tusculum and Delphi are not large towns, but small town.
Where is Sparta? Sparta is in Greece. Sparta is a Greek town. Sparta and Delphi are towns of Greece. Tusculum is not a Greek town, but a Roman town. Tusculum and Brundisium are Roman towns. The island of Sardinia is Roman. Creta, Rhodus, Naxus, Samos, Chios, Lesbos, Lemnos, Euboea are all islands of Greece. In Greece, there are many islands. In Italy and in Greece are many towns. In Gall and in Ger-
-many, there are many rivers. Are there many rivers and many towns in Arabia? In Arabia, there are not many, but few rivers and few towns.
Creta isn’t a town, is it? No, Creta is not a town! What is Creta? Creta is an island. Sparta isn’t an island, is it? Sparta is not an island! What is Sparta? Sparta is a town. What is the ‘Rhine’? The Rhine is a large river. The Atlantic Ocean isn’t small, is it? It is not small, but a large ocean.
Where is the Roman Empire? The Roman Empire is in Europe, in Asia, and in Africa. Spain, Syria, and Egypt are Roman provinces. Germany is not a Roman province: Germany is not in the Roman Empire. But Gall and Britain are Roman provinces. In the Roman Empire, there are many provinces. The Roman Empire is great!
Letters and Numbers
I and II are numerals. III is also a numeral. I, II, and III are Roman numerals. I and II are small numerals. CIↃ is a large numeral.
A and B are letters. C is also a letter. A, B, and C are three letters. A is the first letter; B is the second letter.
C is the third letter. Γ is a Greek letter. C is a Latin letter. C and D are Latin letters. Γ and Δ are Greek letters.
Fluvius and oppidum are Latin words. Ubi is also a Latin word. In the word ubi, there are three letters. In the first chapter, there are a thousand words.
In the word insula, there are six letters and three syllables: first syllable in-, second -su-, third -la. In the word non, there are three letters and one syllable.
What is III? III is a Roman numeral. What is Γ? Γ is a Greek letter. C isn’t a Greek letter, is it? It is not a Greek letter, but a Latin letter. Is B the first letter? B is not the first letter, but the second. What is non? Non is a Latin word. Non, sed, magnus, numerus are Latin words. Vocabulum is also a Latin word!
A few years ago, I decided to start learning Latin for various reasons.
Firstly, I thought that it was and still do think it is a majestic and beautiful language. Its words just have that accompanying gravitas. It had so much weight. Somehow, the mere fact that something is written in Latin seems to lend it greater credence. This could explain why so many mottos and well-known sayings are in Latin. It doesn’t sound as grand in English.
Secondly, many of the difficult words in the English language, which includes but is not limited to medical and scientific jargon, often make use of Latin and Greek roots by combining them to yield esoteric language. I had the idea that if I went about learning Latin, I would have a much better shot at deciphering a lot of medical jargon (particularly in anatomy), and many challenging English words that I encounter as I read the literary classics, medical textbooks, and other texts.
Thirdly, I thought it would be cool to be able to read the Bible in another language. I think it is quite interesting to read Scripture in Latin, a language known for its beauty. I particularly like how some expressions are rather concise in Latin. For example, consider this: Dixitque Deus : Fiat lux. Et facta est lux.
This is Genesis 1:3, and the KJV reads: ‘And God said, Let there be light: and there was light’.
As I read the original Latin, several things jump out at me. Allow me to walk you through my train of thought. The first is the word ‘Dixitque’. The suffix -que just means ‘and’. ‘Dixit’ refers to how somebody said something in the third person. All we know from ‘dixit’ is that a third person spoke it. It could be a he or a she. We don’t know. This third person is of course clarified by the word following ‘Dixitque’: Deus. The ‘third person’ who did the speaking is none other than God Himself.
I am reminded of the puzzle game called ‘Dixit’.
I wonder how many people know that ‘dixit’ is an actual Latin word. It’s subtle, isn’t it? The root word for ‘dixit’ is dico, dicere, dixi, dictum and from this root springs words such as ‘diction’, ‘dictionary’, dictation’, ‘contradict’, ‘dictator’, ‘predict’, ‘benediction’ (‘bene’ means good’; so go figure what Benedict as a name means), and ‘verdict’. ‘Verdict’ is interesting. We know what -dict in ‘verdict’ stands for by now. What about ‘ver-’? We see this in words such as ‘verify’ and ‘veracity’. The Latin word ‘ver’ means ‘truth’ or ‘true’?
Do you know what Harvard’s motto is?
Perhaps you could have figured it out from the logo. Veritas, which means ‘truth’. Unsurprisingly, in Roman mythology, Veritas is a goddess. No prizes for guessing what she is a goddess of.
Most people should recognize that ‘Deus’ refers to ‘God’. From this word, we have words such as ‘deity’, and phrases such as ‘deus ex machina’.
What is Mozart’s middle name? Most people should know this one. Yes.
Amadeus. It can be split into ama- and -deus.
The prefix ama- means ‘love’ (I’m sure you have heard of ‘amore’). So ‘Amadeus’ can be rendered as ‘one who loves God’. Amadeus is not a name that you would hear nowadays. However, its feminine form ‘Amanda’ is alive and well. In a similar vein, the Latinized form of my name is Nicolaus, which is quite uncommon. However, the feminine form ‘Nicola’ is alive and well. I suppose the equivalent feminine form of ‘Nicholas’ would then be ‘Nicole’, which is also rather common.
We have deviated quite a bit. I’ll just make two more short points. Consider the word ‘et’. That means ‘and’. In fact, can you think of a symbol or character that looks like ‘et’ and shares its meaning?
&. Yes, the ampersand, &! The ampersand actually originated as a ligature of the letters ‘e’ and ‘t’ in ‘et’. According to the Wikipedia article, the word ‘ampersand’ is a corruption of the phrase “and per se & (and)”, meaning “and by itself and (represented by the symbol &)”. Marvellous, isn’t it?
Lastly, we have the word ‘lux’. Not that interesting. From this Latin word springs words such as ‘luminosity’, ‘elucidate’, ‘luminate’, and ‘translucent’.
See the sheer number of connections one can make just from that short Genesis 1:3.
For a very long time, the Bible was only available in Latin. Latin was the language of the educated. For century after century in Europe, various regions all had their local languages. The Bible as we know it has the Old Testament and the New Testament. The original language of the OT is Hebrew with some bits of Aramaic. The original language of the NT, on the other hand, is Koine Greek (or common Greek). Perhaps due to the influence of the Catholic Church for much of medieval times, Latin earned its place as the language of the elite. It probably also helped that by the time the biblical canon was well-established, the Roman Empire that we associate with Caesar and Augustus had faded. I do not know the relevant history well enough to be able to make a definitive comment but what I will say is that the languages spoken by the masses, at least from the time of Christ onwards, slowly morphed from the classical Latin that has survived in the form of the works of classic writers such as Caesar. Latin was preserved in writing. However, regarding the spoken form of Latin, Vulgar Latin, according to the relevant Wikipedia article, ‘is a blanket term covering vernacular dialects of the Latin language spoken from earliest times in Italy until the latest dialects of the Western Roman Empire, diverging still further, evolved into the early Romance languages – whose writings began to appear about the 9th century’. Many factors reinforced one another to give rise to the sheer influence of a Latin translation of the Bible.
What happened in the 4th century was that Pope Damasus I commissioned Jerome to revise various Latin manuscripts for the Gospels that were used by the church at the time. Presumably, things would be neater and more organized if there were just one standardized manuscript that the church could use. It seems that Jerome was quite spontaneous, as he decided to go the extra mile. Jerome extended his task to that of most of the Bible, essentially making his own Latin translation of the Bible, which would be known as the Vulgate. Once published, the Vulgate was widely used and it was basically the same text used by the Catholic Church from that point on for the next 1,500 years (from around the year 400 (note that Jerome was commissioned by Damasus I in AD 381) to the year 1979, when the Catholic Church decided to use a new Latin translation, the Nova Vulgata). This is what Wikipedia has to say on the influence of the Vulgate on Western culture:
For over a thousand years (c. AD 400–1530), the Vulgate was the most commonly used edition of the most influential text in Western European society. Indeed, for most medieval Western Christians, it was the only version of the Bible ever encountered. The Vulgate’s influence on Latin culture throughout the Middle Ages and the Renaissance into the Early Modern Period is even greater than that of the King James Version in English. For Christians during these times, the phraseology and wording of the Vulgate permeated all areas of culture.
These constitute some of my thoughts that had prompted me to want to learn Latin a few years ago. However, I gave it up after a while. I did self-study it to the extent that I can dissect Genesis 1:3 and various other bits of the Bible. However, I am not at the proficiency where I can read the Bible comfortably in Latin without needing to consistently consult a dictionary. I do intend to resume learning Latin again for good though.
You might be asking at this point? So Nicholas, how did you actually start learning Latin? Allow me to introduce you to LLPSI, or Lingua Latina Per Se Illustrata (which could be rendered ‘The Latin Language Intrinsically Illustrated’). This is a series which comes in two parts: 1) Pars I Familia Romana; 2) Pars II Roma Aeterna. I used this series when I first started learning Latin on my own a few years ago.
It employs the ‘natural method’, which is a rather interesting concept. Basically, the entire LLPSI series doesn’t contain a single word of English. The entire book is in Latin. The learner learns by context, visual cues, and gradual acquisition. It starts off very easy. For instance, Its first sentence is ‘Roma in Italia est’. I am confident that every decent speaker of English or a Romance language will be able to know instantly what that means.
What I intend to do is that I’ll post screenshots of the text in my blog posts. You will be able to learn Latin by reading them. I will also post my translation attempt of the text, which I think is helpful for my learning. You may also find it helpful to consult it.
I need to ensure the question to which I am giving my response is the same as the question that another party might be asking. It is easy to take for granted that both the former and the latter are always equivalent. They are not always the same, given the different lenses through which people view the world, and I opine that this constitutes the basis for countless misunderstandings that have occurred since time immemorial. It is probably impossible to absolutely reconcile the subjective differences in our understanding of the question, but we can do what we can by clarifying the keywords.
The thing that we need to define here is what is meant by ‘intelligence’. Intelligence is an interesting concept, to me at least, and this concept is certainly rather controversial. In relatively recent times, psychologists seem to have discovered new types of intelligence. This is not unreasonable, particularly if one imagines intelligence as a thing which helps one “move forward successfully” in the world. There are definitely phenomena that would reasonably fulfil such a description. The next few paragraphs outline some “forms of intelligence” that some psychologists have proposed to account for this.
One prominent psychologist who is a proponent of different kinds of intelligence is Robert Sternberg, who is known for his triarchic model of intelligence. As the term ‘triarchic’ suggests, Sternberg’s theory posits that there are three types of intelligence:
1) analytical intelligence (being able to complete academic-style and typical questions that one might encounter on IQ tests; it is often the case that these tasks are fairly well-defined problems with a single correct answer);
2) synthetic/creative intelligence (being able to deal with novel problems by relying on one’s existing set of skills; this may manifest in an individual giving a ‘wrong’ answer because he sees things through a different lens);
3) practical intelligence (“street-smarts”; the way I interpret this is that this is a bit similar to synthetic intelligence, but as the term ‘practical’ suggests, this proposed kind of intelligence pertains to everyday life instead of novel problems; the similarity manifests as requiring the individual to draw on an existing set of skills).
Another prominent psychologist who is perhaps even more well-known as a proponent of different kinds of intelligence is none other than Howard Gardner, who devised his theory of multiple intelligences. This theory of multiple intelligences had a dramatic effect on educational psychology when it was first proposed.
Unfortunately, this supposed dramatic effect does not actually tell us much because educational psychology, among all fields, is arguably the most susceptible to fads. We have heard about the different learning styles, etc. The incorporation of these trends, one after another, may not necessarily be a good thing at all. Gardner’s theory, which was outlined in his 1983 book Frames of Mind: The Theory of Multiple Intelligences, categorically states that there are eight different types of intelligence [1]:
As we have seen earlier, Sternberg proposed the idea of a practical intelligence. We also know how people promulgate the idea of EQ, which is supposedly a measure of the extent of emotional intelligence. From my experience in the equatorial city-state, some people, when referring to a highly sociable person, make statements such as “Waah, look at him sia, he really high EQ leh; vely good people skills sia”, or “Aiya, your studies not so good one, never mind lah, with your high EQ, people will like you at work no matter wat”. There exists a view that such arbitrary categorization of intelligence is absolutely meaningless, and constitutes an entire pile of garbage, and such a view is underpinned by philosophical and technical justification.
Firstly, one cannot just frivolously introduce any old random adjective to qualify a noun. The whole point of having a word is so that it establishes a boundary between what the word describes, and what the word does not describe.
Ok, let me walk you through this. Suppose we can make the word ‘intelligence’ mean whatever we want initially, which does not actually sound entirely unreasonable. The meaning of words at a given moment, after all, depends on what the majority of people at that particular moment who use the word refer to. Such is the dichotomy of descriptivism and prescriptivism in linguistics. For example, the word ‘meme’ is hardly even new at all. It actually has more than one meaning (most people are probably only aware of the one meaning) and has been in use for a long time. Apart from the common meaning which has dominated popular culture for the last decade or so, the word ‘meme’ can also refer to ‘an element of a culture or system of behaviour passed from one individual to another by imitation or other non-genetic means’ [2]. The word ‘meme’, as such, can also be used as a technical word in anthropology, as we can see from this alternate definition.
Anyway, let us consider the issue of ‘intelligence’. Hypothetically, let us suppose that the ability to cook very well is a form of intelligence. It then follows that one may designate another form of intelligence “cooking intelligence”. Unfortunately, the problem with this construct is that the word ‘intelligence’ is now so blasphemed that one cannot even tell what ‘intelligence’ means anymore. So, why is such use of adjectives to qualify intelligence even necessary? Some would argue that such categorization is not necessary at all. English, as it is in 2020, is an extremely rich language, and we have precisely a word to designate what is meant by the ability to cook very well:
Talent (side note: and just like ‘meme’, even ‘talent’ technically has more than one meaning).
We have two separate words: ‘intelligence’ and ‘talent’. The question that the skeptic would then pose is, “How do you determine the difference between intelligence and talent?” That is certainly a valid question because these two concepts are certainly similar to a certain extent. This is where the process of construct validity shines [3].
To illustrate what I mean: suppose we randomly select 1,000 people in Singapore, Australia, or anywhere in the world, and can somehow objectively rank the 1,000 people on their cooking ability. In addition to this, you can rank this same group of people on their ability to multiply two two-digit numbers mentally quickly (e.g. 67 x 54). If these two abilities were intelligences, then the people who could cook well would also be able to multiply two two-digit numbers more quickly mentally on average. If intelligence were the right term to encompass both these abilities, we would be seeing a relatively high correlation between cooking ability and the multiplication ability. However, the actual correlation between the two abilities simply does not meet this criterion (i.e. there is no relatively strong positive correlation).
For intelligence to mean intelligence, every manifestation or form of intelligence that is subsumed by intelligence (i.e. intelligence qualified by whatever adjective you want to slap on it) needs to demonstrate a relatively high degree of correlation with another form of intelligence. Otherwise, they are not the same thing, or at least similar, statistically speaking!
Now, maybe you see where I am going with this.
In order to investigate intelligence (i.e. What is intelligence?), there are perhaps two sub-questions to contend with:
1) If and how does intelligence manifest in the world in which we live? 2) What do we mean by intelligence?
So there is quite clearly an empirical and a definitional issue to be worked out here. People have been studying IQ and intelligence since at least the 1920s. IQ, is a rather unique construct. This is because IQ is the most rigorous concept to have ever arisen from the social sciences. If you think IQ is a load of garbage, you might as well as toss out the field of psychology. This is because the psychologists who first developed intelligence testing were the ones who established the statistical techniques that all subsequent psychologists used to test their hypotheses. IQ is the most stringently and accurately defined construct in psychology. Do you remember the concept of practical intelligence as proposed by Sternberg? Well, according to Professor Jordan Peterson, interest in “practical intelligence” has fallen dramatically since the 90s because when “practical intelligence” is matched head-to-head with standard IQ intelligence, IQ convincingly accounts for the variability in terms of the explanatory power for various phenomena which are associated with success in a particular domain.
IQ is the single best predictor of a person’s success in life. The second-best predictor is the trait conscientiousness, one of the Big Five traits. This could be because unlike IQ, we have not developed a very valid way to measure conscientiousness. Conscientiousness is currently measured by self-report (or even peer reports) on personality tests, which can be easily manipulated to yield extremes because it is so easy to predict what response will yield a higher conscientiousness score. On the other hand, it is statistically impossible for one to be able to just churn out correct answers on an IQ test at a proportion which is beyond one’s threshold of intelligence.
Regarding prediction of life success, conscientiousness yields about r = 0.4 (which is considered a high-end estimate for conscientiousness), whereas IQ yields about r = 0.5 to 0.6. Both correspond to a variance (need to square the r value) of about 16% and 25% (if we are using the low end of r = 0.5 for IQ). So, even low-end estimates of the predictability of IQ of long-term success are superior to what we currently know of conscientiousness by a factor of 25/16= 1.5truncated (i.e. IQ has about 1.5 times the predictive power of long-term life success than the second-best predictor we have: conscientiousness, even by conservative standards). Now you can see why intelligent people who are also highly conscientious are so potent in their ability to just destroy the competition. I think this is somewhat rare though (not only because the extremes of traits are rare), because intelligent people may become complacent and essentially choose to be unconscientious, thinking that their intelligence alone is enough to carry them through life. On the other hand, less intelligent people try to be more conscientious to compensate for their lack of intelligence. This concept is concisely expressed in the Chinese idiom:
勤能补拙, which literally means that diligence can mend one’s stupidity. How candid.
Now that we have talked about IQ, let us consider the “different forms” of intelligence again. What does it mean to have different form of intelligence? Suppose we have Form A and Form B, how highly correlated do these forms of intelligence have to be before we can say that they are the same thing? In other words, how uncorrelated do two different forms need to be before they are deemed to be essentially different? The answer to these questions lie in the practical utility of these different forms of intelligence.
Imagine that I am trying to figure out how well Sally will do in university. I measure some metric “a”, which is correlated at r = 0.7 with “b”. These two forms are pretty well-correlated. So, is there any point in measuring both things? The way to figure this out is by doing a statistical analysis: use some sort of dependent variable or target (e.g. Sally’s university GPA), and establish a regression equation. We then need to ask ourselves: can we predict Sally’s GPA better if we use one variable, or two variables? In addition to using different variables in a regression equation, the weights given to the different variables can also be different, and this is reflected by the different coefficients of each variable (e.g. GPA = 2.4a + 1.3b).
So, back to the original question: are there multiple types of intelligence? The first thing we need to ask is “what do we mean by ‘are there’”? The answer to that would be to specify the question.
Step 1: We can try to predict people’s performance in university (as a proxy for long-term success in life), as we have done with Sally. To start, we need to assume that “if intelligence is not associated with university success, then you are probably not talking about intelligence”. In other words, is it reasonable to assume that intelligence and university success share something in common? This is a definitional issue that needs to be settled. Most people would respond affirmatively, although you could technically choose not to (e.g. adopting the view that intelligence plays absolutely no role in university success; rather, other factors such as socioeconomic status, wealth; and of course, these other factors do indeed influence success, which is why IQ and personality traits cannot fully explain the variance in success).
Step 2: So, once we have established this basic proposition, the next thing that we do is to consider each of the supposed different types of intelligence that were outlined above. A measure needs to be made for each of these different types, and the measure needs to be able to measure the same thing (of course within the limits of acceptable experimental error) across multiple instances in the same person. This is absolutely critical because what use is a ruler if it can stretch and change in length (i.e. the actual distance between the marked intervals fluctuate)? The same thing needs to be measured multiple times, and yield a reliable and accurate result, ideally speaking.
Step 3: The next step is to determine the extent of correlation between all these “different types of intelligence”. If we determine that two types of intelligence have basically perfect correlation, then those two types are one or the same type of intelligence. A factor analysis can be done to determine the thing that is common between all the different types of intelligence, which is unsurprisingly: intelligence. It is important to note that this is a proposition, not a fact. If someone were more likely to be musically inclined if he were also inclined in mathematical ability, then the hypothesis would be that there is a single factor that is responsible for all the different manifestations of intelligence.
Step 4: You can also do the same thing not just with Sally’s university GPA as the dependent variable, but also with her PSLE results (end-of-elementary school barrier exam in Singapore), her GCE O-level results, her GCE A-level results, her job performance, and other proxies of success as the dependent variable. Then, what you can say is that the thing that is common between all those supposedly different types of intelligence which predicts Sally’s success across her entire life is called intelligence. THAT common thing, my friends, is how you end up with IQ.
In other words, IQ, which measures g (that you can see in that huge circle at the top of the above diagram), is what is common among all possible intelligence tests. Of course, people are going to debate this because “what constitutes a test?” Psychometricians have managed this by essentially saying that not everything that is measured is called intelligence.
For example, extraverted people are more socially adept. Are we going to call that intelligence? Of course not! We going to call that personality, specifically extraversion.
Are people who can tolerate more stress deemed more intelligent? No! That is yet another component of personality: low neuroticism.
Are people who are more co-operative more “emotionally intelligent”? No again! Are people who are more competitive less intelligent? As such, this is also yet again another component of personality: agreeableness/disagreeableness. Females are more agreeable than males, and this certainly contributes to the manifestation of how many managerial, leadership roles, and what society deems as “positions of authority and power” are predominantly occupied by men.
The final question then is, once IQ and personality traits have been factored in, are there any differences between the “different types of intelligence”?
Once IQ and personality traits have been considered, there are NO differences between the so-called different types of intelligence.
I think the only thing responsible for the actual variation in the manifestation of “different types of intelligence” that we observe over time in a particular person is domain-specific deliberate practice (e.g. engaging in more deliberate practice on the piano would yield better performance ceteris paribus), which of course cannot be due to inherent intelligence as we have already controlled for IQ.
The reason that many people are proponents for “different types of intelligence” lies in the fact that people are uncomfortable with the fact that there are real tangible differences between individuals. The idea that someone is naturally predisposed to be able to solve problems cross-domain and across time better than another person is frightening to some. Moreover, I suspect that many are uncomfortable discussing intelligence because an individual’s intelligence has been erroneously conflated with his intrinsic worth as a human being. Intelligence is an issue which warrants more discussion in society but the reality is that many people in the world are insufficiently mature to discuss the implications of our current understanding of intelligence on social and educational policy.
NL 2 June 2020
References: Peterson, JB (2016). “2016 Personality Lecture 13: Openness and Intelligence”. Date published: 30 March 2016. Date accessed: 2 June 2020. https://www.youtube.com/watch?v=qRFxulvRC7I Peterson, JB (2017). “2017 Personality 18: Biology & Traits: Openness/Intelligence/Creativity I”. Date Published: 19 April 2017. Date accessed: 2 June 2020. https://www.youtube.com/watch?v=D7Kn5p7TP_Y
[1] Slavin, Robert (2009), Educational Psychology, p. 117, ISBN 0-205-59200-7 [2] Google Dictionary (2020). Meaning of ‘meme’. Accessed online: 2 June 2020. [3] Trochim, W (2020). Construct Validity. Accessed online: 2 June 2020. https://conjointly.com/kb/construct-validity/
In this post, I will be introducing the question bank of AMBOSS. Before diving straight into that, I think it helps to establish some essential background information so that we can at least understand slightly better AMBOSS’s role in medical education today.
My earliest encounter with AMBOSS was probably late in 2018, where I chanced upon a few advertisements on AMBOSS on my Facebook News Feed. At the time, I was quite curious because I had not heard of it. An introduction of AMBOSS’s global expansion beyond the borders of Germany in relatively recent times would be incomplete without introducing the USMLE and why it is a significant issue of most discussions regarding medical school online (hint: a lot of content on the Internet focuses on issues pertaining to the US).
Back then, I was only familiar with UWorld, Rx, and Kaplan’s Qbank. These three question banks were and still remain pretty well-known among the medical student community online for allowing students to consolidate preclinical knowledge (apply their knowledge to solve questions which often require multiple orders of thinking). Many online resources for medical school focus on preparation for the USMLE, a series of high-stakes examinations which dictate whether and how exam candidates can practise medicine in the US.
For those unfamiliar, the USMLE consists of a series of “step” exams: Step 1 (preclinical knowledge), Step 2 CK (clinical knowledge), Step 2 CS (clinical skills), and Step 3. With these high-stakes examinations that are mandatory in order to be licensed to practise medicine in the US, an entire “Step-prep” industry spawned over the years to cater to the needs of students who wish to prepare for these exams. In addition to the three question banks i have listed, there are comprehensive and highly innovative video resources such as Dr Jason Ryan’s Boards and Beyond, Dr Hussain Sattar’s Pathoma, SketchyMedical (SketchyMicro, SketchyPharm, SketchyPath), Physeo, Pixorize, and Dr Najeeb Lectures.
Anki (Japanese for ‘memorize’), an open-source flashcard platform which originally catered to learners of the Japanese language, has also become highly popular in recent times for medical students around the world. In fact, an entire subreddit “r/medicalschoolanki” even emerged. Students on that platform share premade medical school decks (eg Zanki, LY, Duke, and Dope) based on various resources (including the ones I have listed and more).
If you are reading this post, and do not intend to take the USMLE, you might be thinking: “What has this got to do with me? How will these resources even be relevant to what my medical school requires of me?”
Fret not. The good thing about medicine is that the curriculum is roughly the same wherever you learn it in the world. I think medical students nowadays are very blessed. Although the three question banks and various resources I have listed above have largely been designed to help students prepare for the USMLE (particularly the USMLE step 1), I would argue that the required content knowledge for the USMLE Step 1 has a pretty substantial overlap with preclinical curriculum in medical schools all around the world to the extent that even students who do not intend to sit the USMLE can benefit immensely from using USMLE-prep resources in their medical studies.
NB: I am putting a focus on preclinical knowledge because that is largely what I am involved in right now. All of what I say is also largely applicable to clinical knowledge and skills as AMBOSS and many question banks also have questions regarding those.
In my experience, USMLE-step prep requires not just breadth, but also depth. I think that the nature of USMLE-step prep resources will allow you to understand medicine at a greater depth than what is required by many medical schools. While some may think that deeper knowledge is just a waste of time and has little clinical relevance, I would argue that it can allow you to understand many concepts more fundamentally. This can enable you to explain why certain things are the way there are, while your peers may be unable to.
Now that I have established some context regarding the USMLE, I will now talk about how medical students can use AMBOSS to take their learning to the next level. AMBOSS has entered the Step-prep market recently (previously, it was only largely used by medical students in Germany; it has since expanded worldwide), positioning itself as a highly competitive alternative to the other question banks/resources that have been in the Step-prep industry for a longer period of time. It is becoming more popular with each passing day with its far-reaching promotional efforts. If you were to visit its website at amboss.com, you would be greeted with this:
AMBOSS prides itself as ushering in a “new era of medical education”, That’s sounds like a pretty bold claim, doesn’t it? Well, I think they are fairly justified to say that though. In recent years, AMBOSS has been expanding rapidly. More students and clinicians have begun to see the utility of AMBOSS. It has a nice ecosystem which reminds me of how Apple also its own ecosystem for its products. Most notably, AMBOSS has its renowned question bank, AMBOSS library, and its AMBOSS addon. As I have mentioned earlier, I will proceed to talk about these aspects of AMBOSS in separate posts. In this post, I will focus on the AMBOSS Qbank. Here is a video I would highly recommend to get a broad overview of AMBOSS:
Introducing: AMBOSS Question bank
Although the video that I have embedded above is nine months old, I think that it is still largely relevant. When you first login to AMBOSS, you will be greeted with a sleek interface:
The sidebar allows you a variety of options: from creating a study plan, to studying from the AMBOSS library, and setting up a question session. You can also opt to review past question sessions. In particular for the question bank, it is rather customizable. When you click “Qbank” on the left sidebar, you are taken to this page:
You can essentially tailor the question bank to your specific needs. The slider at the bottom allows you to choose how many questions you wish to do for your created question session. You can filter the question selection by system (eg cardiovascular, endocrine, reproductive, nervous system), by discipline (eg biochemistry, embryology, reproductive), by symptoms, by learning cards (which demonstrates the integration between the AMBOSS Qbank and its learning library).
You can also filter questions by difficulty (ranging from 1 ‘hammer’ questions to 5 ‘hammer’ questions). The more ‘hammers’ a particular question is tagged with, the more difficult the question is deemed (probably judged by the percentage of people who chose the correct answer, and the overall option selection distribution).
Most importantly, you are able to filter questions by status (include/exclude unseen questions, incorrect questions, correct questions, and questions answered correctly with “Attending Tip”). Such incredible flexibility allows your specific needs to be met! Let’s move on to the interface once you have begun a Qbank session.
Study mode means that you are presented with this interface during the Qbank session:
Clicking Key Info would automatically highlight relevant information in the question stem. Clicking Labs would allow standard lab values to pop up on the right, which you can consult while attempting questions. Clicking Attending Tip gives a hint, which makes you more likely to arrive at the correct answer.
After clicking on an answer, you would automatically be told whether you got it correct or wrong since this is Study Mode. Note that in Exam mode, this feature is absent. This is what it looks like after selecting an option for the above question in Study mode:
I think this question is great because it requires the student to possess strong fundamentals in biochemistry regarding how mRNA interacts tRNA in the context of protein translation. To solve this question, one needs to know the sequence for methionine’s mRNA codon (i.e. AUG) and stop codons (UGA, UAA, UAG). What medical students can use to learn what the stop codons are is the following:
UGo Away, U Are Away, UAre Gone.
Logical reasoning is required. The kind of question cannot be tackled by just memorizing one’s way through. This demands critical thinking: something that I think all patients expect their doctors to be able to engage in. In my opinion, it is these questions that truly make AMBOSS shine as a QBank, and provide abundant learning opportunity for medical students. It doesn’t take long to find out that AMBOSS’s question bank is arguably the most challenging of the question banks.
I have done nearly 1k questions on AMBOSS and what I can tell you is that for many questions, you have to really understand how something works to get full credit for the question. Both factual recall and critical reasoning are necessary. Sure, some of the questions can be quite picky but that’s how some tough questions are. For this reason, I have personally found AMBOSS quite challenging, more challenging than other question bank I have attempted. Don’t expect questions in AMBOSS to explicitly and frequently mention buzzwords such as “Auer rods” or “hair-like projections” in the context of AML or hairy cell leukemia respectively. Expect instead creative phrasing such as perhaps “large crystalline cytoplasmic inclusion bodies” or “radial cytoplasmic projections”.
Note that clicking on the underlined words within the explanation would cause a popup of the relevant learning card in the AMBOSS library, allowing you to see both the question and the library on the same screen simultaneously. Here is the new view after clicking the underlined ‘tRNA‘ in the explanation for option C:
On a lighter note, I was joking with a friend and I told him how I thought this question would have even be more brutal (maybe even a 6 ‘hammer’ question if such a classification existed) if the answer options presented with just letters and without the 3′ and 5′ markers (because by convention the 5′ end is on the left). As you might have guessed based on the answer statistics, this was a pretty tough question. Only 29% selected the correct answer. Not the worst I have seen though. I think I saw one AMBOSS question with only 18% correct. Really tough. It just makes the success sweeter when you know that a question you get correct was quite tough. On the other hand, if you get such questions wrong, you can take comfort in the fact that many people also got it wrong.
Takeaway: Treat every question as a learning opportunity and do not get discouraged if you get questions wrong.
This following question is an example of that. I incorrectly chose option E but the correct answer was option B!
Well, that is what I have for this post. I hope you have found it useful. AMBOSS offers a 5-day free trial, which you can make use of to test the waters without any financial commitment. There are also many useful videos on YouTube which you can view to learn more about AMBOSS. Please do not hesitate to contact me should you wish to find out more about AMBOSS or need any help.
NL 5 May 2020
I am ethically obliged to divulge that I am affiliated with AMBOSS GmBH, and that I am compensated for my role as a representative and promoter for AMBOSS. Nevertheless, I decided to become a part of its AMBOSSador programme because I have genuinely found it helpful for my learning. I had used AMBOSS a fair bit before deciding to join its student ambassador programme.
Today, I was playing the piano (indulging in the majestic opening chords of Tchaikovsky’s first piano concerto and some soundtrack pieces from The Phantom of the Opera) and as I also played other pieces I was familiar with, I reminisced about the past.
Specifically, I recalled how someone had written me a note when I was in my second year of junior college. I wonder how the writer of the note is doing now. Thinking about this prompted me to write this post. In fact, I had previously scanned an image of the small note she left me. I am confident that the person who wrote me this note is female as such gestures tend to be more associated with females; the penmanship and the note’s contents further lend credence to this assumption.
This was nearly 4.5 years ago. 12 October 2015 to be exact. I had scanned both sides of the note she left me because I had thought that it was something worth remembering. After all, it’s not every day that someone gives you a handwritten note which compliments your piano playing.
Here is the note she left me. I found it placed on top of my school bag that I had left on one of the seats in the front row of the auditorium.
I had also scanned the opposite side of the note (is this supposed to be some cartoon character?):
In junior college, I would arrive early in school on some days so that I could have the opportunity to play on the grand piano before morning assembly. At the time, my house didn’t have a grand piano, so the mornings were a rare opportunity to play on a grand. The “Audi” refers to one of the main auditoriums in Hwa Chong: Cheng Yi Auditorium.
Here are some images that show the interior of the auditorium:
I cannot remember the other pieces I was playing that morning on the Yamaha grand found backstage in the auditorium but what I do remember is playing Bach’s fugue in C major from the Well-tempered Clavier, Book I. The learning process for this four-voice fugue was tedious. I had to grind it out bar by bar. This wasn’t like the first movement of Sonata facile where you have a nice Alberti bass on the left hand while the right hand plays a charming melody. No. This fugue is enriched with interleaving harmonies. Such is the highly contrapuntal music of Bach.
Today is March 14, which can be written as 3/14, and these digits correspond to the first 3 digits of the mathematical constant which is defined as the ratio of the circumference of a circle to its diameter, at least in the decimal system that we human beings have arbitrarily chosen to adopt.
π is one of the first mathematical constants to whom an elementary learner of mathematics would be introduced. Most people should be able to at least recall that it has something to do with a circle, and most probably would at least know the first three digits of this constant.
π is an irrational number, and what that implies is that cannot be expressed as a ratio of two integers. That’s why it is called “ir-rational” (i.e. no ratio). What this means is that you can’t find a nice recurring pattern in its decimal expansion. This is contrasted with a popular approximation of π: 22/7, whose decimal expansion is 3. 142857 142857…
Notice how the group of digits ‘142857’ repeat.
In an article published exactly five years ago (Hickey 2015), a ‘SurveyMonkey Audience’ was asked to put a poll to see how far people could get reciting the infinite digits of pi. Of 941 respondents, 836 attempted to name the digits after the decimal point. Here is an extract from that article:
That’s what I can recall from memory. 40 decimal places. I chose this number of digits to memorise a long time ago because with this number of digits, one can calculate the circumference of the observable universe to an accuracy of a hydrogen atom. Of course, when I decided to learn it, I didn’t expect to have to use it at all. It was mostly just for fun.
The unbelievable thing was that two years ago, when I participated in a freshman orientation activity, I remember that one of the station activities required that our somebody within our group recite the first 20 elements of the Periodic Table and write the first 12 decimal places of π with our short-term memory after trying to memorise it. It goes without saying that I certainly helped my group out in the latter exercise!
What a long time that has elapsed since my last post in September 2019. Five months have passed and now here I finally am, again, with yet another (long-awaited?) blog post.
Earlier this morning, I attended a session from 9-11 am where the movie “Wit” (2001) was streamed in the lecture theatre. It was the introductory session for the ‘Law’ module which falls under the theme of “Health, Professions, and Society”, better known here as HPS.
Just before the movie was screened, the course co-ordinators did warn that it would be rather graphic, particularly for people who have had to vicariously experience the gruelling nature of cancer as their loved ones receive treatment.
The school actually managed to stream the entire duration of the movie within the two-hour time slot. While it should be said that there were certainly many elements and depicted behaviour by certain health professionals within the film that could be considered rather outrageous and could perhaps be dismissed as mere hyperbole for the sake of dramatic effect, the movie contains many valuable lessons for everyone, particularly health professionals.
These few paragraphs are from a review of the movie by a nurse (Mclean 2014):
There was a scene near the beginning of the movie which I perceived to be rather thought-provoking. The scene encapsulated the sheer difference that the presence of both punctuation and capitalisation or lack thereof could have on the meaning of how certain content. English Language teachers may like to cite the classic example of the difference that the presence or absence of a comma can make on the strict meaning of a sentence as in: “Let’s eat, Grandma!” and “Let’s eat Grandma”. However, this scene takes this idea to another level entirely. This idea is worthy of serious contemplation, and can have a significant impact on one’s life, particularly as one is going through aggressive chemotherapy for stage IV ovarian carcinoma. Given that a picture can tell a thousand words, what more a video? The scene which I am referring to can be viewed here:
What a powerful scene this is.
The icing on the cake kicks in when the main theme of the movie starts to play, and we realise that even after all those years, Bearing and Ashford are able to continue their discussions on Donne’s works. The main theme has a simple melody, but this haunting melody pierces into the soul. It is none other than ‘Spiegel im Spiegel’ composed by Arvo Pärt. The piece is a duet for piano and viola. In this piece, the viola breathes, and the piano’s heart beats peacefully.
Notice how that between the flashbacks, the relationship between Bearing and Ashford may be presumed to have strengthened over the years, to the extent that Crawford now refers to Vivian by her first name instead of “Ms. Bearing” when Vivian was a student.
What a stark contrast we are presented. According to the Wikipedia article on Donne, “John Donne is considered the pre-eminent representative of the metaphysical poets. is poetical works are noted for their metaphorical and sensual style and include sonnets, love poems, religious poems, Latin translations, epigrams, elegies, songs, satires.“
Here we have Dr. Vivian Bearing, who earned a PhD in English Literature, specialising in the Holy Sonnets of Donne. She is a renowned academic on the issues of life and death, at least as put forth by Donne in his sonnets. Now, she is no longer contemplating these issues as if they were abstract. No. She is now living it second by second, minute by minute, day by day in the hospital.
Once again, I’m quoting Mclean (2014) because I think she wrote in an absolutely sublime manner regarding the above scene and how it relates to the entire plot of the movie and beyond:
‘In a flashback to Bearing’s graduate school days, Ashford points out the deficiency in her student’s thinking by calling attention to punctuation in one of John Donne’s metaphysical poems. An advocate for the poet, Ashford wisely observes that Bearing has relied on an inferior translation that uses incorrect punctuation in the stanza “Death be not proud, though some have called thee mighty and dreadful, for thou art not so. … Death shall be no more, death thou shalt die.” Instead of using a comma in the last sentence, which would have preserved the poet’s intent to communicate that death is just a pause between this life and the next, the editor of the specious translation has inserted a semicolon, which changes the meaning completely.
A semicolon is too dramatic, Ashford explains. A semicolon communicates that death is a struggle that one can defeat with intelligence. The semicolon is too hysterical in its portrayal of death. It makes the act of dying a spectacle, a Code Blue. A comma, on the other hand, reduces death to a simple, inevitable truth, just a pause between this life and eternal life. Death, suggests the comma, is not an insurmountable barrier to overcome, but a transition separated by a breath. The comma is natural death, facilitated by the DNR.‘
Indeed, I would concur with the notion that death should not be viewed as an insurmountable barrier. In fact, just as one would never experience the satisfaction of having one’s thirst quenched were it not for the physiological necessity for water, I think that it is precisely because death exists that life, as defined by the limited time we have on this physical earth which shall one day pass away, is rendered meaningful.
‘If you want drama, a metaphor for resuscitation with the ACLS (advanced cardiovascular life support) team, study Shakespeare. If you want art, a metaphor for physiologic death, choose the holy sonnets of John Donne. And to learn about life and death, the mentor advises her protégé, visit friends rather than the library. The audience learns that this important life lesson is lost on Bearing when she, as a young student, forgoes developing relationships by returning to the library stacks.
Bearing’s lesson is not learned until, near the end of her battle with cancer, she learns to appreciate humanity and kindness through nurse Monahan. Although Monahan doesn’t know the definition of soporific and doesn’t hold an academic title, she emerges as the movie’s most powerful force.
Modeling values taught in nursing school—respect, dignity, rights, and advocacy—she provides tissues when Bearing cries and advocates for a patient-controlled analgesia pump. When the patient is in a morphine-induced coma, Monahan puts lotion on her hand. In juxtaposition stands young doctor Posner, who regards the patient as a vessel for his cancer cells. Bearing remarks that she is nothing but a petri dish in his important experiment. To Posner, talking to the patient is an inconvenient annoyance that interferes with his research. He is the least likely person to initiate a DNR.
In the dehumanizing environment of a teaching hospital, nurse Monahan provides perspective, finishing the life lessons that Professor Ashford started so many years before. In telling her patient how simple life and death can be, Monahan reminds the audience that death is simply the stopping of your heart, or your last breath. For the first time, Bearing understands that her death does not have to play itself out as a chaotic Shakespearian drama, but rather as a pause in a holy sonnet. Between licks on a Popsicle, she agrees to a DNR order. This is a beautiful scene. The compassion and kindness that Monahan shows while caring for her patient build the relationship that allows the nurse to broach the delicate subject of initiating a DNR.‘
As I have said earlier, I will repeat it. This movie contains many scenes where certain health professionals, particularly the doctors, have in many instances displayed outrageous conduct and behaviour which I deem absolutely unprofessional. As Summers (2003) puts it, this movie does not make any attempt at trying to glorify doctors. We already have enough of that from the mainstream medical TV shows. In this movie, we have these highly intelligent doctors who are MD-PhD clinician-scientists. However, they have demonstrated blatant disregard for patient well-being.
While many doctors in reality fortunately do not act with such disregard to the extent as that seen in the movie, the movie highlights the importance of being professional as a doctor, displaying empathy, and always keeping patient well-being as a priority.
Meanwhile, in stark contrast, we have the nurse who emerges as perhaps the only person in the movie who actually cares for Vivian. According to Summers (2003), “Susie, who is not an intellectual, simply wants to provide Vivian with health care that is consistent with her professional obligations and with basic human decency, a goal which brings her into increasing conflict with the physicians pushing Vivian’s chemotherapy.“
For some reason, the full movie can be found on YouTube (albeit segmented). You can watch it here:
I thoroughly enjoyed this movie, and would recommend it to everyone, particularly nursing students, medical students and health professionals.
Which is the “correct” term: Alzheimer’s disease, Alzheimer disease? Should the eponym be replaced entirely?
According to the Wikipedia article on medical eponyms, “medical eponyms are terms used in medicine which are named after people (and occasionally places or things). In 1975, the Canadian National Institutes of Health held a conference that discussed the naming of diseases and conditions. This was reported in The Lancet where the conclusion was summarized as: “The possessive use of an eponym should be discontinued, since the author neither had nor owned the disorder”. New discoveries are often attached to the people who made the discovery because of the nature of the history of medicine.”
The existence of multiple terms to refer to the same concept/disease in medicine, or conversely, the same word being used to mean absolutely unrelated concepts, creates an inconvenience in medicine. This is most evident in database probes. If a person were to do a database probe on a particular disease or concept, he would need to incorporate all the different terms used to refer to that particular concept (e.g. searching for McArdle’s disease, you would probably have to include the term “glycogen storage disease type V” too for a truly rigorous and comprehensive search).
As the search results roll out, he would then need to be cautious not to waste time on the search results which have mainly incorporated the alternative meanings of the desired term (e.g. Purkinje fibres associated with the cardiac conduction system are absolutely different from the Purkinje neurons in the cerebellum).
Let’s not even get started on the differences in American English and British English (oestrogen vs. oestrogen) and the arbitrary use/lack of use (e.g. Type V vs. Type 5) of Roman numerals which create even more hassle in rigorous database searches. Furthermore, generic names for drugs/hormones may be different from the US and that of the rest of the world (e.g. paracetamol vs. acetaminophen; salbutamol vs. albuterol; adrenaline vs. epinephrine). Here is the skeletal formula of paracetamol:
Fun fact: Paracetamol and acetaminophen both derive from the systematic chemical name for the drug: N-acetyl-para-aminophenol. To get either term, different parts of the chemical name were taken and compounded to yield a new generic drug term!
In my first semester last year, I had a physiology assignment which consisted of several questions, the first of which pertained to the pathophysiology of Tay-Sachs disease, a lysosomal storage disease. As with the names of many diseases/syndromes/disorders, this was yet another eponym. Usually, when we come across diseases with eponyms, we often think that eponyms are perhaps the surname(s) of the men who have been the first to document the said disease. In most cases, this would be true.
However, in some cases, the eponym is associated with the patient who suffered from the disease (e.g. Christmas disease, Hartnup disease), or even a location (e.g. Lyme disease, Marburg virus). Lyme disease was named after its namesake, a small coastal town in Connecticut, a state in the US, where in 1975, a woman brought an unusual cluster of paediatric arthritis cases to the attention of Yale researchers. In 1977, the Yale researchers identified and named the clusters Lyme arthritis.
As I studied the glycogen storage diseases and lysosomal storage diseases a few months ago, I couldn’t help but notice that virtually all the diseases had medical eponyms.
Off the cuff, at least for the more prominent lysosomal storage disorders, all but one I can think of are all eponyms. Consider this diagram:
And the above is only for the diseases implicating sphingolipids (i.e. sphingolipidoses). Another category of lysosomal storage diseases would be the mucopolysaccharidoses, the most prominent of which are Hurler’s syndrome and Hunter’s syndrome. Only metachromatic leukodystrophy isn’t an eponym! Here is another useful image I found that shows you how deficiencies of various enzymes in sphingolipid metabolism result in the accumulation of various sphingolipid derivatives:
In fact, a few months ago, I had a chat with my friend who is a doctor. I told her something along the lines of “many diseases are due to deficiencies in particular enzymes. Instead of having these eponyms, wouldn’t it be easier if the common name for all these diseases took the form: “[enzyme name] + deficiency”? The name would then provide functionally useful information. What use is knowing that two men with surnames Tay and Sachs helped document Tay-Sachs disease? Its alternative names: Hexosaminidase A deficiency, and GM2 gangliosidosis tell us so much more!”
We just laughed, and chuckled at such a quixotic notion. After all, one does not simply just go about and casually dictate the conventions and traditions to which the medical fraternity chooses to adhere.
For the glycogen storage diseases, which have many types, types I, II, III, IV, V, VI, VII are von Gierke’s, Pompe’s, Cori’s, Andersen’s, McArdle’s, Hers’, and Tarui’s, respectively. There are also sub-types and other types which are rarer. Today, at least 15 types of GSDs have been documented.
One possible explanation for the survival of some eponyms despite the existence of functionally useful alternative terms is that the eponyms are coined before the pathophysiology of the disease could be worked out. This is not surprising because usually, one would expect that the clinical signs and symptoms are documented first. It is only thereafter that research is conducted to find out more. In the case of Tay-Sachs, the root cause of Hexosaminidase A deficiency was only discovered in 1969, long after British ophthalmologist Dr Warren Tay initially described the characteristic cherry-red spots seen on one of his patients’ retina in 1881.
NB: Cherry-red spots on the macula are also seen in Niemann-Pick’s disease; the way to differentiate between the two diseases is via the presence/absence of hepatosplenomegaly in Niemann-Pick and Tay-Sachs, respectively.
That’s the way medicine is. The medical fraternity appears to relish its long-standing traditions. Anecdotally, I think many senior physicians would be more comfortable with the use of eponyms. This is in contrast with the recent trend of not favouring eponyms. People who discourage the use of eponyms have the following arguments:
1. “They don’t reflect the pathophysiology”. I have already covered this with the example of Tay-Sachs disease above. In many cases, there is simply little you can do about it. For many eponyms, especially for those of common diseases, the eponyms are so widely used that using the alternative terms would do you inconvenience and a disservice to yourself and your peers. You would probably be asked to clarify yourself if you insist on using a term that is not commonly used. This is a major reason I suspect that the US would likely never use the metric in practice. The economic cost simply doesn’t justify it, and even if there were economic aspect of the problem were resolved, people are simply too accustomed to the status quo. In the case of the imperial units which the US uses, whole institutions in that vast country have been established and worked on the premise of the imperial units. Enforcing a change of units would likely cause unbelievably great inconvenience to many people. Likewise, we see a similar phenomenon with medical eponyms. Even if an alternative term makes “more sense” to you, there is no point using it if your peers are just going to seek clarification all the time.
2. They may stigmatise certain groups of people. Did you know that syphilis used to be termed the “French disease”? According to its Wikipedia article, the first written records of an outbreak of syphilis in Europe occurred in 1494 or 1495 in Naples, Italy, during a French invasion (Italian War of 1494-8). Since it was claimed to have been spread by French troops, it was initially called the French disease by the people of Naples. The French should be glad that syphilis no longer adopts its former name as it would only add to the list of stereotypes that people have of them!
3. They may glorify people associated with undesirable and shunned ideologies. Believe it or not, there is actually a Wikipedia page on medical eponyms associated with the Nazis (see reference [4]). Of this subset of medical eponyms, Asperger’s syndrome is probably the most well-known. The syndrome is named after Hans Asperger who apparently “managed to accommodate himself to the Nazi regime and was rewarded for his affirmations of loyalty with career opportunities.” He “joined several organisations affiliated with the Nazi party, though not with the Nazi party itself, and publicly legitimized race hygiene policies including forced sterilizations and, on several occasions, actively cooperated with the child ‘euthanasia’ program.” Despite this history, Asperger remains honoured in the form of the eponym partially because his involvements with the Nazis were not so direct and notable, in stark contrast with some other physicians (you’ll never hear Mengele getting honoured with an eponym).
While learning respiratory physiology and histology, I chanced upon Club cells (formerly known as Clara cells):
Club/Clara cells are nonciliated cells, as you can see from the above illustration. Clara cells are located in bronchioles and the functions of these cells include: 1) degrading toxins, 2) secreting a component of the pulmonary surfactant, 3) acting as reserve cells.
This “Clara” wasn’t the name of a woman. It was the surname of Dr Max Clara, who according to the relevant Wikipedia article: “was an active member of the Nazi Party and used tissue taken from executed victims of the Third Reich for his research—including the work that led to his discovery of Clara cells. In May 2012, the editorial boards of most of the major respiratory journals (including the journals of the American Thoracic Society, the European Respiratory Society and the American College of Chest Physicians) concluded that the continued use of Clara’s eponym would be equivalent to honoring him; they therefore introduced a name-change policy, which went into effect beginning January 1, 2013. The term “Clara” was used parenthetically after “club cell” for a 2-year period, after which “Clara cell” and “Clara cell secretory protein” were conclusively replaced with “club cell” and “club cell secretory protein”, respectively.
Who knew that such innocent terms would have such a backstory? I once mentioned this to a friend whose name is Clara. Maybe she’ll discover something else and have something named after her!
As we have seen above, there are various reasons that people wish to stop using medical eponyms in certain scenarios. Nevertheless, I am personally in favour of eponyms, as I opine that the merit warranted by the following factors outweigh the disadvantages associated with eponyms.
1. They favour communication, and are definitely more succinct than equivalent descriptive terms, which are usually longer. It could also potentially be the case that there isn’t any satisfactory alternative descriptive term because the symptoms may be too broad, or not enough is known about the disease, etc.
2. They distinguish between different forms of a particular symptom/concept, thus allowing for more accurate description (e.g. Sydenham’s chorea vs. Huntington’s chorea).
3. They may commemorate the achievements of hardworking doctors, patients, and other medical staff whose contribution may otherwise be lost to posterity. They also give recognition to otherwise relatively unknown places (e.g. Lyme disease, Marburg virus).
4. This is an important counterargument to the earlier point on how eponyms may stigmatise certain groups of people. In fact, one classic example of how eponyms help people reduce stigmatisation is the case of leprosy. The general public would be well-acquainted with leprosy, but its eponym is much less familiar to the layperson: Hansen’s disease. Eponyms can also help preserve patient dignity (e.g. Angelman’s syndrome vs. Happy Puppet Syndrome) and avoid racism (e.g. Down’s syndrome vs. Mongolism).
5. Eponyms pique the curiosity of those who are interested in the history of a disease or a concept. They teach us about medical history and culture: the noble work that our forefathers have done to give us the immense cumulative wealth of medical knowledge that we have today. In some cases, the eponyms tell us an amusing story! For instance, Professor Sir Edwin Southern (who is still alive) invented the Southern blot procedure in 1975, a procedure that is commonly used in laboratories today for detection of a specific DNA sequence in DNA samples. Following this invention, the Northern and Western blots were developed as blotting procedures which involved RNA and proteins, respectively. Clearly, you can see the play on words! This naming convention on directionality wouldn’t have happened if not for the initial Southern eponym and at least one other biologist’s sense of humour!
NB: A helpful mnemonic for the various blots and the substances is: SNoW DRoP, where S, N, and W are Southern, Northern, Western, and D, R, and P are DNA, RNA, and Protein respectively!
In fact, what do you think a Southwestern blot entails? If you guessed that it’s something that involves both DNA and proteins, then congratulations! You’ve just demonstrated how marvellous eponyms can be! Southwestern blots identify DNA-binding proteins!
6. If we’re being honest with ourselves, these eponyms often make us sound more sophisticated. Which is more sophisticated – noting the four symptoms: pulmonary infundibular stenosis, right ventricular hypertrophy, overriding aorta, ventricular septal defect, or elegantly presenting it simply as “Tetralogy of Fallot”? Evidently, the latter is more succinct.
What do you think of eponyms? Let me know your thoughts!
In a previous blog post, 01(15), I discussed my musical journey from its very beginning. I highly recommend that you read it if you want an exposition on my musical journey. That blog post is a must-read if you are a frequent visitor to my blog!
In this post, I would like to expound on why I chose the pieces I did for my most recent piano examination: the ATCL diploma (Piano Performance) examination. To summarise a portion of the previous blog post, I cleared my Grade 8 in August 2014. For the years following that exam, I would intermittently toy with the idea of doing a piano performance diploma. However, I would always dismiss the thought for one or more reasons: 1) I didn’t have a teacher; 2) the pieces on the diploma syllabus were significantly more challenging than that of ABRSM Grade 8 pieces; and more.
Despite all the hurdles and discouraging factors, I finally made the decision to register for the piano diploma exam in early July 2018, to have the exam scheduled for Nov/Dec 2018. Today, I look back and find it incredible that I was so bold to decide to do it. The circumstances just suggested that I was going to fail the exam and that I would be throwing a thousand dollars in exam registration fees down the drain.
To cut the long story short, I had a friend who told me once that anything worthwhile doing will often be difficult, but doing the difficult is often worthwhile. I heeded this advice of his. Over time, I had learnt more pieces, and I increasingly felt that this new milestone was a more accurate representation of my musical abilities. I reckoned that it would also be a nice pat-on-the-back.
The sheer sense of adventure was exhilarating.
One of the major reasons that I felt sufficiently motivated to register for the diploma exam was that some of my favourite pieces were on the syllabus list. As you would see in 01(15), I chose four pieces for my piano diploma exam:
1. Bach – Prelude & Fugue in A-flat Major, The Well-tempered Clavier, Book I, BWV 862
My first real experience with the music of Bach was around the time when I was a Sec 3 student in 2012. That year, I attended the Founders’ Day ceremony (a ceremony which commemorates the anniversary of the founding of Maris Stella High School, my secondary school), and musical performances were included as part of the programme. There were performances by various performance arts CCAs (e.g. symphonic band). I remember that the string ensemble of the primary school side played the first movement of Vivaldi’s Spring. That was very memorable!
The one musical performance that stood out to me was that of a solo piano piece. A Primary 3 or 4 student played the grand piano on the stage (just a few weeks before the ceremony, the school had replaced the old Ibach grand with a brand-new Yamaha grand). The piece he played was relatively simple but it etched a memory that I shall never forget. He performed Invention No. 14 in B-flat major by J. S. Bach. You can listen Gould’s recording of it here:
The piece is simple in the sense that it only has two voices: one voice per hand. It is quite simple to hear the dialogue between both hands. You can hear the rhythm of one hand echoing that of the other. Despite being such a simple piece with few notes, Bach has constructed such a musical masterpiece. Hearing that live performance of a Bach work motivated me to learn other piano works by Bach. From that day, I went on to learn the other two-part inventions, pieces from the French Suites, Partitas, Well-Tempered Clavier, and just over a third of all variations from the Goldberg Variations. As of the time of writing, most of my repertoire consists of Bach. Just take a look at my YouTube channel. Most of my uploaded videos are performances of Bach works.
About a month after my A-levels ended in 2015, my family went on a holiday to New Zealand, and on that trip, I would listen to the recordings by the pianist Ms Kimiko Ishizaka. She is a renowned interpreter of Bach (in fact, the embedded video above of the prelude and fugue in A-flat major is that of her performing)! Whilst travelling from place to place via a coach (we were on a tour group), I would listen to her recordings of Bach, and admire the amazing scenery of New Zealand. I had her complete album consisting of all the preludes and fugues from the first book of the WTC on my phone.
One particular prelude and fugue set stood out to me. It was Prelude and Fugue in A-flat Major, BWV 862. I would set it on Repeat-One, and listen to it over and over again. I enjoyed it so much that the moment I returned to Singapore, I immediately set out to learn the prelude. Before I knew it, I was done learning it. The fugue was something I learnt only after I had committed to learning the set for my piano diploma exam.
I completed learning the A-flat major prelude within a few days of returning to Singapore, and uploaded a video of my performance of it directly to Facebook on New Year’s Day of 2016. I remember distinctly that I had made a post (simultaneously paired the video upload) which discussed the relevance of SG50, and what the next 50 years would be like for Singapore. I also talked about how I was inspired by Ms Kimiko Ishizaka to learn that prelude. In fact, I tagged her Facebook page in my post, and to my great surprise, she responded to my post and said that I played well!
It was a humbling experience. She even shared my post and video to her own Facebook page and my video ended up getting more than 1.3k views. That’s a lot, considering I was, and still am, an unknown pianist (as competent as Kimiko is, she isn’t that well-known in the classical piano arena either), and that very few people are interested in classical music in the first place!
2. Beethoven – Piano Sonata No. 8 in C Minor, Op. 13 – ‘Pathétique’
This piano sonata by Beethoven is well-known. My first encounter with this sonata occurred while I was in junior college. There was this guy who would often play on the upright piano that could be found just outside the main auditorium of the junior college. One of the pieces that he would frequently play is the third movement of the Pathétique sonata. Its opening notes is very well-known. I talked to this guy and he told me that this third movement was one of his chosen ABRSM Grade 8 Piano exam pieces!
The second movement of the Pathétique is arguably the most famous of the three movements. I loved the haunting melody of the second movement and when I saw the Pathétique on the diploma syllabus list, I strongly considered it. Seeing that I liked all three movements, I ultimately chose this sonata as one of my performance pieces.
3. Chopin – Nocturne Op. 48 No. 2
I’ll be honest with you. I don’t have much to say about this Chopin nocturne. Firstly, it was Chopin, which meant that the harmonies and melodies were bound to be very pleasing to the ears.
This piece isn’t technically challenging too, and it simply blended well with my other pieces (notice how the four chosen pieces are in chronological order in terms of when they were composed?). The ending of this nocturne is phenomenal and majestic though. I didn’t think too much of this piece overall, as I chose it to make up the time requirement (for the ATCL, the total duration of pieces need to be within 32-38 minutes excluding breaks between pieces).
I mean, there were other pieces I liked much better which could have been chosen to make up the time requirement. However, I felt that I did not possess the technical competence to do these pieces justice. One such piece was Liszt’s Liebesträume No. 3.
In Liebesträume No. 3, we have runs like this:
Achieving the level of precision required to execute those runs would simply not be feasible, given the limitations of time I had as a full-time student, and the sheer amount of time that I would need to practise in order to play those runs satisfactorily. Hence, I ultimately chose to learn the Chopin nocturne.
4. Rachmaninoff/Kreisler – Liebesleid (from Piano Compositions No. 2)
This is the most interesting one. This is quite special in that the piece is Rachmaninoff’s piano transcription of a work for violin and piano that was originally composed by the violinist, Fritz Kreisler. The melody of Liebesleid is very well-known. Just hum the first two bars and just see how the average Joe on the street is able to hum the succeeding bar effortlessly.
Of course, as with anything Rachmaninoff, this piece is probably bound to be technically challenging. Rachmaninoff is notorious for having large intervals in his compositions (e.g. tenths just scattered here and there throughout his virtuosic compositions). Well, that shouldn’t be too surprising considering that Rachmaninoff had a handspan of a 13th! That perhaps explains the monstrous opening chords of his second piano concerto. For a detailed exposition on pianists and their handspans, read an earlier post I made: 01(24).
Fortunately, while this Rachmaninoff transcription is challenging enough to find its way onto an ATCL syllabus list, it isn’t AS challenging as many of Rach’s other pieces, as it’s “only” at an ATCL level. Many Rach pieces require musical maturity far beyond an ATCL level for a performance that one can be proud of. Nevertheless, this piece was challenging enough that I ended up the devoting the greatest proportion of my time to learning and mastering this piece for the performance exam. And as you might have guessed: among the pieces I ultimately selected, this was the most technically challenging one.
I am very fortunate to have an above-average handspan. This has enabled me to stay faithful to Rach’s original composition in that I am able to, in many instances, play the originally-written block chords (I personally rather have all notes of a chord sound simultaneously than having them roll). This is contrasted by the act of “rolling chords”. Pianists usually “roll” chords when their span is not large enough to play the chord as a block. For those of us who read sheet music, just watch the above video and you’ll know what I mean.
My first encounter with this piece was quite unusual. I no longer watch Japanese cartoons/anime but back then, I used to watch Japanese animation, along with other movies during my free time. Around October 2014, A-1 Pictures, a Japanese animation studio, began airing an anime television series that was an adaptation of a Japanese manga series written and illustrated by Naoshi Arakawa.
The Japanese name of the series was Shigatsu wa Kimi no Uso, which translates to “Your Lie in April”. The animation series was quite popular. I don’t have time to talk about the plot in detail but basically, the plot revolves around two main characters: Kousei Arima, a prodigious pianist, and Kaori Miyazono, a violinist. Some time in the show, Kousei performs Liebesleid on stage and personally, it is a way for him to have proper closure regarding the death of his mother, whose death had a great psychological impact on him.
Liebesleid (which is German for “Love’s Sorrow”), as originally composed by Kreisler, is actually part of a set of works known as Alt Wiener Tanzweisen (German for “Old Viennese Melodies”). This set consists of three works: Liebesfreud (Love’s Joy), Liebesleid (Love’s Sorrow), and Schön Rosmarin (Lovely Rosemary). The three works are usually heard or performed separately. Rachmaninoff composed a set of virtuosic transcriptions on the first two works: Liebesfreud, and Liebesleid.
In the anime, Kousei’s piano teacher was his mom, and she would only ever play Liebesleid, and not Liebesfreud. The curious Kousei then recalls mid-performance how he asked his mother when he was younger, and when she was still alive, why she would only play Liebesleid.
In the ‘subbed’ version of the anime, Kousei’s mom replies “So that you’ll get used to sorrow”. In the ‘dubbed’ version of the anime, she replies instead “I play it, so that sorrow won’t be as scary”. Either way, there is something we can learn from her response.
Rachmaninoff is a true master at taking the simplest of melodies and creating complex sequences of dissonant chords, and interwoven melodies. Though the learning process for Liebesleid was most challenging among all my pieces, I also found it to be the most rewarding. To date, Rachmaninoff’s transcription of Kreisler’s Liebesleid remains one of my favourite pieces for piano.
In 01(15), I talked about how as expected, the examiner felt that my best-performed piece was the first piece: the piece by Bach. I was not surprised by this as Bach is my favourite composer and an overwhelming majority of the pieces that I have learnt are by Bach. So, one mistake is that I didn’t focus on my strengths. The piece by Bach was the shortest piece among the four pieces and it only accounted for slightly more than 10% of the total performance duration (excluding breaks).
In hindsight, I could definitely have chosen my pieces such that Baroque pieces (specifically those by Bach) took up the greatest proportion of the performance duration. I definitely could have chosen to perform something like Bach’s French Suite No. 5 in G Major (I do in fact, already know how to play two movements from that suite!). That whole suite on its own would already take up around half the performance duration! Who knows? I just might have gotten that elusive distinction for my piano performance diploma exam if I had chosen to focus on my strengths instead!
Well, that’s all I have for this post. For more details, please, once again, check out 01(15), as it truly is the most comprehensive post I have at the moment on my musical journey. If you have any questions for me, please feel free to contact me on Telegram or via my e-mail. Thanks!
What comes to your mind when you think of people swimming in warm freshwater lakes and rivers? For me, this thought conjures pleasant images of people relaxing in these water bodies. Some might even relax in natural hot springs. Usually, all is well and people are just enjoying their time away from work: the rat race that plagues the lives of many Singaporeans. Such people would probably have gone overseas to partake in such an experience.
Recently, I was learning about parasites as they piqued my curiosity. Parasitology is the study of parasites and is a category within microbiology, a basic medical science that is learnt in the pre-clinical phase of medical school. Other categories within microbiology include mycology (study of fungi, especially microscopic fungi), bacteriology (study of bacteria), and virology (study of viruses). This is a neat classification as microbiology is after all, the study of very small (micro-; at the scale of the micrometre) organisms, or if we want to be extremely precise: agents or entities (since viruses are not typically considered to be organisms).
Within parasitology, there are further sub-categories: protozoa (unicellular eukaryotes), nematodes (roundworms), cestodes (tapeworms), trematodes (flukes), and ectoparasites (parasites which live on the outside of the host).
The parasite that I wish to discuss in this post comes from the subcategory: protozoa. Even within the subcategory of protozoa, there are further categories! One way of classifying infectious protozoa would be the nature of their infections. For example, some protozoa can cause 1) GI (gastrointestinal) infections, some cause 2)CNS (central nervous system) infections, some cause 3)hematologic infections (the well-known malaria is caused by Plasmodium), while some protozoa cause 4)visceral infections and sexually transmitted infections.
The organism that I wish to discuss today belongs to the group of protozoa which causes CNS infections. You might have heard about it or seen it being mentioned in newspaper articles. Its colloquial name is “brain-eating amoeba“, better known among the medical and scientific community as Naegleria fowleri, which was first identified in Australia, but is thought to have evolved in the US.
N. fowleri can be found in warm lakes, ponds, rock pits, mud puddles, slow-flowing rivers. It can also be found in swimming pools, spas, wells, and municipal water which are all untreated. It can even be found in aquariums, and soil. There is currently no evidence that suggests that N. fowleri is able to survive in salt water. That is probably why it can usually only be found in freshwater. There are several species under the genus Naegleria but only the fowleri species (all known fowleri subtypes are believed to be equally dangerous) are known to be anthropopathogenic (causing human disease). This is a computer-simulated representation of the trophozoite form of the parasite:
Like many other amoebae (unicellular eukaryotes), N. fowleri exists as a cyst (inactive form) when environmental conditions are not favourable. However, when conditions are favourable, N. fowleri transforms into a trophozoite, its active and feeding form which is pathogenic.
Mechanism of infection by Naegleria fowleri
The colloquial name for N. fowleri suggests that the microbe is just like an undead entity which munches and chews on your brain tissue as its primary source of nutrition. However, our brain tissue wouldn’t be their first choice. Think of how children wouldn’t usually prioritize the consumption of their greens! N. fowleri normally consumes bacteria. However, when N. fowleri infects us, it feeds on our brain tissue. The reason that N. fowleri infection is so associated with freshwater contact is that the parasite enters via the nose, and then to the cribriform plate. This means that infection occurs mostly from activities involving freshwater contact where water finds its way into the nose. Such activities would include swimming, and many water sports.
Unfortunately, cases of such infection by N. fowleri have even been reported (though very rare) in people who dunk (sounds absolutely silly but that which Homo sapiens is capable of ironically knows no bounds) their heads in hot springs and people who irrigate their nostrils with neti pots that contain untreated tap water.
As a consolation, there is no known evidence to suggest that N. fowleri can be transmitted between human beings.
Current evidence suggests that the parasites are attracted to the chemicals that our neurons use for intercellular communication. Once in the nose, N. fowleri travels to the frontal lobe via the olfactory nerve. Look at this image below:
When swimming in fresh water, the water makes its way into the nasal cavity and there, N. fowleri penetrates the mucus layer, and probably enters the cilia of olfactory receptor cells. As such, it is able to penetrate the cribriform plate and enter the olfactory nerve (responsible for our sense of smell). Note that for basal cells, and supporting cells, they do not have any passages which penetrate the cribriform plate. Only the olfactory receptor cells have axons which penetrate the cribriform plate on their way to the CNS.
The olfactory nerve is known as the first cranial nerve (CN I), and it is the shortest of all 12 cranial nerves. After the cribriform plate, the olfactory nerves pass upward to several areas of the brain, such as the hypothalamus and amygdala, However, for the purposes of our discussion, the olfactory nerves terminate on the undersurface of the frontal cortex.
In essence, after penetrating the nasal mucosa, the trophozoite migrates along mesaxonal (the mes- prefix comes from the Greek word ‘mesos’ which means middle/intermediate, and -axonal just refers to the axon/nerve fibre of the neuron) spaces of unmyelinated olfactory nerves which terminate at the olfactory bulb in the subarachnoid space, among many other terminal destinations. I imagine that one reason this particular parasitic infection is so deadly is that the subarachnoid space is quite vascularized and is a route of transmission of N. fowleri trophozoites to many other areas of the CNS. So it is not surprising that after the initial incubation period, N. fowleri infection is characterized by an abrupt onset of headache, fever, nausea, vomiting, encephalitis (inflammation of the brain).
After the typical signs of a CNS infection, progression to seizures and then, coma, is rapid (usually over 3-7 days).
The disease that is caused by this parasitic infection is officially known as Primary Amoebic Meningoencephalitis (PAM or PAME). The prognosis of PAM is extremely bleak as a vast majority of cases (>95%) end in death, which occurs an average of just 1 week after the initial onset of symptoms. PAM/PAME caused by N. fowleri has a worldwide distribution, and occurs most frequently in tropical areas and during hot summer months. Most cases of PAM due to N. fowleri infection have occurred in the US. However, this might be due to underreporting in other countries, and not simply due to a higher prevalence of PAM in the US. In many countries, autopsy is not standard.
Diagnosis of PAM is so problematic because:
Firstly, early in the course of PAM, PAM often resembles purulent bacterial meningitis (PBM), and cannot be easily distinguished from PBM.
Secondly, PAM progresses incredibly quickly, and rapid diagnostics must be developed for early detection. Must of the diagnosis is based on patient history (e.g. whether the patient has recently swum in warm fresh water, along with associated symptoms). The gold standard (for now) is not achieved until the trophozoites are isolated and identified from cerebrospinal fluid (CSF) or brain tissue. While N. fowleri does grow easily in culture, this can nevertheless still take a few days. For a disease like PAM where an infection will kill in about a week, a few days is just simply too long, and often this means the difference between life and death.
Treatment for PAM secondary to Naegleria fowleri infection
Intravenous amphotericin B is the current standard of care. Amphotericin B works by disrupting the selective permeability of plasma membranes. It works by binding to ergosterol (the sterol in fungi cell membranes). Though not a fungi, N. fowleri has ergosterol in its cell membrane. Hence, Amphotericin B, which is normally an antifungal medication, can also be used as an antiprotozoal medication for otherwise-untreatable diseases caused by certain protozoa.
In this case, Amphotericin B binds to ergosterol in the cell membrane of N. fowleri, giving rise to a pore which allows potassium ions and other small molecules to leak out from the cell, ultimately leading to cytolysis. Unfortunately, having great results in the lab doesn’t always necessarily translate to a similar level of success in actual patients.
Amphotericin B is a ‘last-resort’ drug as it has high toxicity, and its use in actual patients are not as successful in actual patients compared to what initial lab experiments predict.
So, just bear this all of the above in mind before you decide to venture out into warm ponds, freshwater rivers and lakes for a swim, especially during the hot summer months.
Well, I’m kidding. The odds are that you’re probably going to be fine. Nevertheless, take caution. Don’t dunk your head in the water at a natural hot spring for goodness’ sake.
There have only been a few hundred cases of Naegleria fowleri infection worldwide since the parasite was documented from the 1960s. Naegleria fowleri is actually quite common, but its infection is rare. However, if you are infected, then the prognosis isn’t particularly optimistic (>95% death).
I hope you have learnt more about this interesting parasite from reading this article!
Yesterday, I was watching a video where the teacher had asked his students a question. He had just discussed how penicillins and cephalosporins can be used against certain bacteria, right after talking about Mycoplasma.
The teacher then asked the class: “Which is Mycoplasma more sensitive to: penicillins or cephalosporins?” One student raised his hand and answered, “Penicillin”. To this, the teacher replied, “That is wrong.” Immediately, the teacher asked another student, “So, what do you think Mycoplasma is more sensitive to: penicillins or cephalosporins?” Seeing that the first student was wrong when he had answered the question, the second student was perhaps quite confident that he would get it correct if he answered cephalosporins, and that was exactly what the second student did. Unfortunately, he was wrong! I absolutely saw it coming though, as this teacher is known to ask such trick questions to test students’ concepts. The teacher was visibly lamenting that they both got it wrong.
This was obviously a trick question. Mycoplasma has an equal sensitivity (better seen as an equal lack of sensitivity) to both penicillin and cephalosporins because while both classes of drugs work on bacterial cell walls,it has to be understood that Mycoplasma does not have a cell wall, and specifically, a cell wall with peptidoglycan! Consider this similar scenario. A person has no ears, and cannot effectively listen or hear anything. Which would give him a more enjoyable music-listening experience: earbuds or headphones? Hahaha!
The teacher’s original question is good because it reinforces the concepts which students are taught. This is how students actively learn: by seeing how the dots connect. A student can learn these three things separately: 1) the mechanism of action of cephalosporins; 2) the mechanism of action of penicillins; 3) the characteristics of Mycoplasma. Questions like the one asked by the teacher are effective in getting students to integrate the knowledge that they have learnt separately, at least from anecdotal experience.
As of the time of writing, Mycoplasma is arguably the smallest known living organism. What defines life? What defines a living organism? While there isn’t a unanimous consensus within the scientific community regarding the definition of life, a majority within the scientific community agree that prions, plasmids, transposons, bacteriophages, viruses all do not constitute life. As such, bacteria would generally constitute the smallest and “simplest” life forms. They are prokaryotes and are unicellular.
Most bacteria have cell walls. Why do they need a cell wall? Well, they need cell walls to prevent osmotic burst as their cell membranes are unstable due to a lack of sterols, which confer stability to the cell membrane. Recall that the cell membrane consists of mostly consists a lipid bilayer. The difference between a phospholipid and a triglyceride is that instead of having 3 fatty acid chains attached to a glycerol backbone in triacylglycerols, there are only 2 fatty acid chains attached to a glycerol backbone in phospholipids. A polar negatively-charged phosphate group takes the place of where the third fatty acid would have been connected. As such, the phosphate group, along with the carboxylic esters formed between the glycerol backbone and the two fatty acids constitute the hydrophilic head of the phospholipid while the tails of the two fatty acid constitute the hydrophobic tails of the phospholipid. What I have explained is beautifully illustrated in the diagram below.
With the hydrophilic heads of phospholipids facing the extracellular fluid and the cytosol, polar and charged substances are not able to diffuse through the cell membrane. However, despite being a polar molecule, water is able to diffuse through the cell membrane because it is a very small molecule.
As such, if not for the cell wall, bacteria would undergo osmotic burst or cytolysis due to excess water diffusing into the cell (we have just previously established that water is able to diffuse through the lipid bilayer despite being a polar molecule), and that the cell membrane is not large enough to accommodate the excess fluid.
This is where the cell wall comes in to help the bacteria resist cytolysis. But before we discuss how the cell wall, let us first discuss which living organisms have cell walls and their variations.
For the sake of our discussion, let us ignore plants and non-infectious agents since I am interested in infectious agents. For eukaryotic infectious agents, we have fungi, protozoa, helminths, and ectoparasites. Of these eukaryotic infectious agents, only fungi have cell walls. As for prokaryotes, we basically only have bacteria, and most bacteria have cell walls. Here is a diagram showing the structure of a fungi cell wall.
The difference between the cell walls in fungi and in bacteria is in the composition. Fungi cell walls consist of chitin, a polymer of N-acetylglucosamine, which is a glucose derivative. On the other hand, bacteria cell walls consist of peptidoglycan. The first step to understanding peptidoglycan is simply looking at its name. Consider “peptido-” and “-glycan”. This tells us that peptide bonds and sugar or sugar derivatives are involved in peptidoglycan’s structure. Consider this excellent diagram below which illustrates the structure of peptidoglycan beautifully:
With a cell wall, bacteria are able to resist cytolysis.
The answer is that Mycoplasma has sterols within its cell membrane for stability. This presence of sterols within the cell membrane is unique among prokaryotes and it strongly suggests that sterols function as regulators of membrane fluidity.
The most well-known sterol that probably all of us have heard of is none other than cholesterol. The prefix “chole-” means bile or gall, which is a fluid produced in the liver. Bile consists mainly of water (97%), bile salts (0.7%), other substances, and of course, cholesterol.
Let’s take a look at the diagram involving peptidoglycan again. Do you see those pentaglycine cross-links? As the term suggests, these cross-links consist of 5 (penta) glycine residues linked together, with one terminal glycine joined to L-Lysine while another terminal glycine is joined to D-Alanine.
Penicillin works by binding to penicillin-binding proteins, which ultimately leads to cytolysis. One such protein is transpeptidase, the enzyme which catalyses the pentaglycine cross-links that connect the amino group on one N-Acetylmuramic acid to the amino group on another N-Acetylmuramic acid. When penicillin binds to transpeptidase, penicillin inhibits transpeptidase.
As such, with penicillin, these pentaglycine cross-links do not form, and the cell wall is not as sturdy as it should be, causing the bacterium to be more susceptible to cytolysis.
In the above image, we have the core structures of penicillin above (1), and the cephalosporins below (2). The part highlighted in red is known as the beta-lactam ring. It is named as such because a lactam is a cyclic amide (which is evident from C=O and the C-N bonds within the red 4-membered ring), and it is a beta-lactam because if the peptide bond were hydrolysed, then the nitrogen atom would be attached to the beta-carbon. The takeaway is that both penicillins and cephalosporins both belong to a broader category of antibiotics known as beta-lactams.
In all 20 standard naturally occuring amino acids, the amino group is bonded to the alpha-carbon, which is defined as the carbon immediately adjacent to the carboxylic acid group. It then follows that the beta-carbon would be immediately adjacent to the alpha-carbon and so on.
NB: This is why the most common ketone body in our bodies, 3-hydroxybutyrate, is also called beta-hydroxybutyrate (not technically a ketone). In beta-hydroxybutyrate, the hydroxyl group is attached to the beta-carbon. This is also why mitochondrial lipolysis is also known as beta-oxidation.
Some bacteria contain enzymes known as beta-lactamases, and as its name suggests, they degrade and thus inactivate beta-lactams. Such enzymes can be thought of as bacteria’s defence against our antibiotics. Bacteria which are capable of producing beta-lactamases include Staphylococcus, Neisseria gonorrheae, Mycobacterium tuberculosis, etc.
In response, to these beta-lactamases, we stubborn human beings who refuse to succumb to bacteria have developed what is known as beta-lactamase inhibitors. This is our strategy of combating the resistance put forth by the bacteria in the form beta-lactamases which break down our beta-lactam antibiotics. So, we developed a weapon against their weapon which worked against our initial weapon.
It wouldn’t be surprising if bacteria develop an enzyme which inactivates our synthetic beta-lactamase inhibitors. Then perhaps, we need to come up with something called the beta-lactamase inhibitor-inactivator inhibitor. This is a vicious cycle that may just carry on: beta-lactamase (inhibitor-inactivator) (inhibitor-inactivator) (inhibitor-inactivator) (inhibitor-inactivator) ad infinitum!
NOTE: To make this blog post more educational, I have decided to come up with some questions throughout this blog post which you can contemplate to reinforce your understanding. My suggested answers can be found at the bottom of the post, just above the references. Feel free to give me feedback so that I can improve these questions and/or answers.
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For a long time, I thought that the (-) in blood type labels represents the lack of an antigen while the (+) represents the presence of that same antigen. I thought that the Rh system worked just like the ABO blood group system. So, I had always thought that the truly universal blood was O(-), and not O(+). My understanding was incomplete as the ABO system and the Rh system are not that similar. Even within the ABO system, O is not truly universal as individuals of the Bombay blood type cannot receive type O blood. Surprised? Allow me to explain.
There are many red blood cells (RBCs) in our body. These red blood cells are also called erythrocytes (“erythro-” comes from the Ancient Greek word ἐρυθρός or ‘eruthros’ which means ‘red’; “-cyte” comes from the Latin cyta, which in turn comes from Ancient Greek word κύτος or kutos which means ‘vessel or jar’). In most scenarios, the suffix “-cyte” just means “cell”.
NB: Not all substances with the -cyte suffix are cells. For example, platelets are called thrombocytes. Just looking at prefix and suffix of this word suggests that platelets are cells that lead to the formation of a thrombus. This is only partially right because while platelets help in the formation of a thrombus, platelets are not cells. Platelets are large fragments which are produced and released by megakaryocytes, which are basically large cells in the bone marrow. Platelets are not considered cells because they lack a nucleus and hence, lack nuclear genes. They do however have mitochondrial DNA, and nearly every other feature of a normal cell.
All of us have heard of blood donation. Some of us have even gone for blood tests or donated blood. The first time I went for a blood donation drive, all was fine until the last moment, where the volunteer was unable to find a suitable vein to draw blood from. Such an anticlimax. How does this all work? Historically, when blood transfusions were first attempted, immediate or delayed agglutination and subsequent hemolysis often occurred, and this often led to death.
As you might imagine, doctors were curious as to why this was happening. It was soon discovered that the bloods of different people have different antigenic and immune properties. Hence, what happened in those adverse transfusion cases was that the agglutinins present in the plasma of one person binded with the agglutinogens present on the RBCs of a different blood type. The antigens were treated as foreign invaders and this triggered a severe immune reaction. Fortunately, what this also meant was that if one can predict ahead of time the blood types of individuals, one could also thus predict if an adverse reaction would occur.
It should also be said that there are many other types of antigens on the outer surface of RBCs (about 30 which are common and hundreds of other rare antigens), which can all trigger antigen-antibody reactions. However, most of these reactions are weak. So, these other antigens are mainly used for studying the inheritance of genes to establish genealogy. Two particular types of antigens are much more likely to cause blood transfusion reactions, so we will be discussing those two types today: 1) the O-A-B system of antigens, and 2) the Rh system.
Firstly, within the O-A-B system, people typically have one of four blood types: O, A, B, AB. Whether one’s blood type is O, A, B, or AB is determined by the presence or absence of the two agglutinogens: the A and B agglutinogens, which are glycoproteins. What this means is that if your RBCs have neither the A or B, you are blood type O. If you have the A but no B, you are blood type A. If you have the B but no A, you are blood type B. If you have both the A and B, then you are type AB.
The type of agglutinogen you have depends on your genes. The genetic locus for the ABO blood group has three alleles (i.e. three variations of the same gene). For simplicity’s sake, we’ll call the alleles A, B, and O. To be extremely precise, Allele O technically results in the production of agglutinogen H, which is the precursor for for agglutinogens A and B (I’ll talk more about this antigen H later; for now just know that antigen H is also expressed on people blood types A, B, and AB). The diagram below is an excellent visual aid. You can clearly see that to get antigen A from antigen H, N-acetylgalactosamine needs to be added to the distal galactose group on antigen H. You can also see that to get antigen B from antigen H, a galactose group is added to the distal galactose group on antigen H.
Antigen h forms instead of Antigen H when the terminal fucose group is missing. People who lack antigen H and have antigen h instead are known to have the Bombay blood type or hh blood type. But of course, you will almost never hear of this Bombay blood type being mentioned online or in any textbook because of its sheer rarity (4 per million worldwide). Hence, even the production of the H antigen itself is often ignored because it is often deemed the baseline which almost everyone already has.
On the other hand, the alleles A and B result in strong agglutinogens on the cells. Thus, the O allele is recessive to both the A and B alleles, both of which demonstrate codominance.
However, each person only has two sets of chromosomes (one set from your mother and one set from your father). While a person with blood type AB may have all three antigens A, B, H, he can only have a maximum of two of the three alleles (i.e. A and B). Since there are 3 different alleles and 2 chromosomes, then 3 * 2 = 6 genotypes are possible: OO, OA, AA, OB, BB, AB. OO will give rise to type O blood, OA and AA will give rise to type A blood, while OB and BB will give rise to type B blood. Since the A and B alleles demonstrate codominance, having both the A and B alleles will give rise to type AB blood.
When a person doesn’t have a particular agglutinogen on the surface of his red blood cells, he develops the corresponding anti-agglutinogen antibodies which are known as agglutinins. For example, if my blood type were B, then I would develop anti-A agglutinins. If my blood type were O, then I would have both anti-A and anti-B agglutinins.
Qn 1: a) If my blood type were A, what agglutinins (if any) would I have in my plasma? b) If my blood type were AB, what agglutinins (if any) would I have in my plasma?
Earlier, I mentioned that when blood transfusions were first attempted, agglutination and hemolysis often occurred. How does this happen? Well, this is because agglutinins are immunoglobulins and they are either IgG (immunoglobulin G with 2 binding sites) or IgM (immunoglobulin M with 10 binding sites). Hence, a single agglutinin can bind 2 or more RBCs at the same time, thereby causing RBCs to be bound together by agglutinin. Such binding causes many RBCs to clump together, which is the process of ‘agglutination‘. These clumps then plug all the small blood vessels throughout the circulatory circulation. While stuck in these small vessels, the RBCs in these clumps either undergo physical distortion or phagocytotic attack which destroys the membranes of the agglutinated cells. This releases hemoglobin into the plasma, which is called hemolysis of the RBCs.
Qn 2: Apart from blood transfusion, how are agglutinins produced within the blood of people who do not have the corresponding agglutinogens on their RBCs?
Well, that was a lot of text. Secondly, there is also this thing called the Rh system. There are 6 common types of Rh antigens, each of which is called an Rh factor. They are C, D, E, c, d, e. A person with the C antigen will not have the c antigen, while a person with the c antigen will not have the C antigen. The same works for D-d and E-e. Because of the manner of inheritance of these factors, we all have one antigen from each of these 3 pairs of antigens. The type D antigen is widely prevalent in the population and is way more antigenic than the other Rh antigens. It is precisely the presence and absence of this type D antigen which is responsible for the (+) and (-) you see in blood group type labels respectively. So a person with antigen “D” would be Rh-positive, while a person with antigen “d” (i.e. does not have antigen “D”) would be Rh-negative.
Qn 3: We normally hear of people having (+), a Rh-positive, in their blood types way more frequently than (-), Rh-negative. From a simplified perspective, do you think that the gene that codes for antigen D is autosomal dominant, or do you think that it is autosomal recessive?
The major difference between the earlier discussed O-A-B system and the Rh system is that in the latter, spontaneous agglutinins almost never occur. Instead, the person must first be exposed to large amounts of the Rh antigen before enough agglutinins develop to cause a significant transfusion reaction.
Qn 4: Given the info in Qn 3 and your response to it, why do you think it can be problematic when a Rh-negative woman is pregnant? (Hint: her husband is likely to be Rh-positive; what does this mean for her fetus?)
Having given a pretty decent overview (hopefully) of the two main blood type systems, I want to share with you a piece of amazing news I read which prompted me to write this article in the first place. Just a few days ago, researchers analysing bacteria in the human gut published an article in Nature, a leading peer-reviewed journal, where they discussed how they discovered that microbes there produce two enzymes which can convert type A blood to type O blood. If all goes well, this could revolutionize blood donation and transfusion.
As we have discussed above, type O blood has no A or B agglutinogen, and this makes type O donor blood ideal as it is virtually universal. Scientists have tried transforming the second-most common blood type, type A, into type O by snipping off the terminal N-acetylgalactosamine from antigen A. Recall this excellent diagram:
This has had limited success because currently known enzymes which can catalyse the conversion of antigen A to antigen H are not efficient enough to make the process economically feasible.
After 4 years of trying to improve on those enzymes, a team led by Stephen Withers, a chemical biologist at the University of British Columbia (UBC) in Vancouver, Canada, decided to look for a more efficient enzyme produced by bacteria in the human gut. Some of these microbes latch onto the gut wall, where they digest the mucins. Mucins’ sugar groups are similar to that which are found on the antigens on RBCs.
So, UBC postdoc Peter Rahfeld collected a human stool sample and isolated its DNA, which in theory would contain genes that encode the bacterial enzymes that digest mucins. Chopping this DNA up and loading different pieces into copies of the commonly used lab bacterium Escherichia coli, the researchers monitored whether any of the microbes subsequently produced proteins with the ability to transform agglutinogen A into agglutinogen H (its exclusive expression in the absence of antigens A and B defines blood type O).
At first, nothing promising was found. However, when two of the resulting enzymes from the obligate anaerobe Flavonifractor plautii were tested simultaneously, the N-acetylgalactosamine could be removed from antigen A. This worked because the two enzymes worked together in a pathway. First, N-acetylgalactosamine is deacetylated to galactosamine in a reaction catalyzed by N-acetylgalactosamine deacetylase.
With the second enzyme, the galactosamine linkage was cleaved. The cleavage would not have occurred unless antigen A was first deacetylated. The necessity of having both enzymes is illustrated in the image below:
The most remarkable thing about this pair of enzymes is their ability to completely convert antigen A to antigen H on RBCs of the same rhesus type at very low enzyme concentrations. If this finding can be replicated, then this could indeed simplify their incorporation into blood transfusion practice, increasing the amount of “universal donor” blood.
Qn 5) Explain why people with the hh/Bombay blood type cannot receive supposedly “universal donor” type O blood.
Answers
Ans 1a) Anti-B agglutinins; Ans 1b) Neither the anti-A nor the anti-B agglutinins
Ans 2) Small amounts of A and B agglutinogens enter the bloodstream via food, and via bacteria, and these agglutinogens initiate the development of the corresponding anti-A and anti-B agglutinins.
Ans 3) The gene that codes for antigen D on the surface of red blood cells is autosomal dominant.
Ans 4) The fetus is affected by the pathological Erythroblastosis Fetalis, aka: “Hemolytic Disease of the Newborn” (HDN). Since the gene that codes for Rh-positive is autosomal dominant, a Rh-negative woman is statistically more likely to have Rh-positive man than a Rh-negative man. This also means that the fetus is statistically more likely to Rh-positive. When the fetus is Rh-positive, the fetus has antigen D on its RBCs. The mother develops anti-Dantibodies due to exposure to the fetus’ RBCs which express antigen D. Now, this is fine for the mother since she doesn’t have the antigen D. However, the synthesised anti-D agglutinins diffuse through the placenta into the fetus, and cause RBC agglutination. Good luck to the fetus. The agglutination leads to fetus RBC hemolysis and the released hemoglobin is broken down to bilirubin by the fetus’ macrophages. Bilirubin is a yellow substance and it is this that causes the baby’s skin to become yellow (jaundice). The anti-D agglutinins circulate for another 1-2 months after birth, destroying even more RBCs.
Ans 5) People with the Bombay blood type lack the terminal fucose group that is found on agglutinogen H. Hence, they have antigen h instead and thus produce anti-H agglutinins. When a person with Bombay blood receives type O donor blood, the anti-H agglutinins in the plasma will bind with antigen H found on the RBCs of type O blood. This will trigger the adverse blood transfusion reaction.
“Hey bro, do you have this thing called G6PD? What is this G6PD?” What do the title and the preceding sentence have in common? These are perhaps the words of full-time national servicemen, both 30 years ago and now respectively, to their fellow soldiers as they are left perplexed by the medical questionnaires they are tasked to complete.
Whilst serving in the SAF as a full-time national serviceman, I had the opportunity to go on overseas military training exercises. Before embarking on these overseas training trips, servicemen would need to ensure that they are certified to be medically fit for the relevant training. This would often entail getting the required vaccinations at the camp, declaring one’s vaccination history, and declaring any medical conditions to the senior medics or the medical officers at the medical centre of the army camp, either verbally or through the completion of forms.
I remember filling in some of these questionnaires and one of the points on these questionnaires would be:
“2. G6PD: Yes/No”.
I’m not even kidding. It was just this, word for word. Allow me to explain why such wording can technically be misinterpreted. Servicemen have to fill in these forms individually. A few weeks prior to leaving for training in Australia, my entire company was given such a form to fill in. In the company office, someone from another platoon asked one of the platoon commanders, “Sir, how do we fill this in? I’m not sure what G6PD is”. The lieutenant replied, “If you are not sure what it is, you probably don’t have it.”
On the surface, this seems to be a reasonable position to adopt. After all, if you have gotten through life this far without doctors ever having diagnosed you with G6PD (glucose 6-phosphate dehydrogenase) deficiency, you probably do not have the said condition. Here is an image of a patch that a soldier can put on his ILBV to indicate his G6PD deficiency:
Most students who have learnt of G6P (glucose 6-phosphate) first studied it in the context of glycolysis, gluconeogenesis, and glycogenolysis. However, the G6PD enzyme is relevant in neither of these pathways. Instead, it is an enzyme that is relevant to the pentose phosphate pathway/HMP (hexose monophosphate) shunt, which occurs in the cytosol. Now, this HMP shunt is quite important because it provides a source of NADPH from the available G6P. NADPH is used in reductive reactions such as glutathione reduction inside RBCs (red blood cells), fatty acid and cholesterol synthesis. Additionally, the shunt also yields ribose for nucleotide (those ATCGs in DNA) synthesis and glycolytic intermediates (fructose 6-phosphate and glyceraldehyde 3-phosphate). This is particularly important in RBCs because NADPH is needed to keep glutathione reduced, which in turn detoxifies free radicals and peroxides.
In other words, here are the pairs of redox reactions. Firstly, G6PD catalyses the irreversible oxidation of G6P to 6-phosphogluconolactone, which reduces NADP+ to NADPH.
NB: 6PGL (6-phosphogluconolactonase) then catalyses the oxidative hydrolysis of 6-phosphogluconolactone to give 6-phosphogluconate.
Next, NADPH is oxidised back to NADP+ when glutathione reductase catalyses the reduction of GSSG (glutathione disulfide) to 2 GSH (glutathione). NB: The ‘S’ and ‘H’ in GSSG and GSH represent sulfur and hydrogen atoms respectively. Lastly, 2 GSH is oxidised back to GSSG when glutathione peroxidase catalyses the reduction of H2O2 to 2 H2O.
I’m sure you can now clearly see the problem with having G6PD deficiency. When there is deficiency in G6PD, all the above reactions are inhibited. There won’t be as much NADPH produced, because there isn’t as much dehydrogenation from G6P to 6-phosphogluconolactone. Consequently, there would be hemolytic anaemia due to poor RBC defence against oxidising agents (remember the last step in the chain in the above paragraph where H2O2 is reduced to water; that now doesn’t occur as much). H2O2 is a reactive oxygen species that can be converted to hydroxyl radicals, which can attack the proteins in the cell.
Consider this quote from reference [4]:
“Protein oxidation is defined as the covalent modification of a protein induced either by the direct reactions with reactive oxygen species (ROS) or indirect reactions with secondary by-products of oxidative stress. ROS can cause oxidation in both amino acid side chains and protein backbones, resulting in protein fragmentation or protein-protein cross-linkages. Although all amino acids can be modified by ROS, cysteine, and methionine that are the most susceptible to oxidative changes due to high reaction susceptibility of the sulfur group in those amino acids. Oxidative modifications of proteins can change their physical and chemical properties, including conformation, structure, solubility, susceptibility to proteolysis, and enzyme activities.“
As the quote above says, amino acids with sulfur-containing R-groups are most susceptible to oxidative attack due to the relatively high reactivity of sulfur. Hence, it isn’t a surprise to learn that the hydroxyl radicals can attack haemoglobin in RBCs, causing a cross-linking of sulfhydryl groups on globin chains, which in turn causes haemoglobin to be denatured and precipitate. And what happens when oxidised haemoglobin precipitates?
Heinz bodies.
Look at this image above. That damaged haemoglobin coloured in blue represents a Heinz body. That pink Pac-man thing represents a splenic macrophage, which comes and “eats” the Heinz body. Bite cells, represented by the cell below the cell with the damaged haemoglobin, thus result from the phagocytic removal of Heinz bodies by splenic macrophages. Such original and creative naming. Lol.
G6PD deficiency is an X-linked recessive disorder, and is the most common human enzyme deficiency.
If we were to be quite pedantic, then the construct “2. G6PD: Yes/No” is, strictly speaking, problematic because it is people who are deficient in the enzyme G6PD that have the condition known as G6PD deficiency. In other words, people who havesufficient G6PD are fine and do not have G6PD deficiency. So, since normal people have G6PD, would it be wrong for people to circle “Yes”? On the other hand, the form is probably asking people whether they have the deficiency.
My recommendation to the SAF is to unambiguously alter the construct in the medical questionnaire to “G6PD deficiency: Yes/No”.
Personally, I wouldn’t be surprised if some people think that the “D” in G6PD means “deficiency”. After all, it doesn’t help that there is a practice where people repeat the full word of the last letter of acronyms (e.g. POP parade, IPPT test, PSLE exam, GUI interface, PIN number, ATM machine, D-Day, HIV virus, DC Comics, LCD display, OPEC countries).
Ironically, such a practice is known as RAS syndrome, where RAS stands for “redundant acronym syndrome”. What a term! For all who design invitation cards. please take note. Please don’t put “Please RSVP” on invitations!
The world’s tiniest motor, ATP synthase, or F1FO-ATPase, stands at about 20 nm in height and 10 nm in diameter.
Look at the above artist’s impression of ATP synthase. What a beautiful image. This protein complex is something that many biology, biochemistry, health sciences students are required to learn about. Today, I wish to talk about ATP synthase as I find it quite fascinating.
To begin, let us resolve some issues regarding its nomenclature. ATP synthase belongs to a broader group known as ATPases. This might leave you wondering, as it did for me: “why does ATP synthase fall under this category? From its name alone, don’t ATPases couple the hydrolysis of ATP with endergonic reactions? In other words, don’t ATPases catalyse the dephosphorylation from ATP to ADP which would generate energy that would be harnessed by the ATPase to drive reactions which would otherwise not occur? ATP synthase isn’t hydrolysing ATP; it’s making ATP” It turns out that for most ATPases, ATP is hydrolysed; however, ATPases also include the inverse reaction to ATP hydrolysis, to wit, the phosphorylation of ADP with inorganic phosphate to give ATP.
It’s just like how the oxidation of succinyl-CoA to succinate is catalysed by succinyl-CoA synthetase. Even though succinyl-CoA isn’t the product in the forward reaction, the same enzyme is being used in both the forward and reverse reaction.
Under the umbrella term of ATPases, there are sub-categories: F-, V-, A-, P-, and E-ATPases. I will focus on F-ATPases (aka F1FO-ATPases), the most notable of which is ATP synthase. Unlike most of the other sub-categories of ATPases, F-ATPases catalyse the synthesis of ATP. A-ATPases work like F-ATPases too; it’s just that A-ATPases are found in Archaea. ATP synthase is sometimes known as Complex V.
“Nicholas, why is the F-ATPase called F1FO-ATPase? Shouldn’t it be named F1F0-ATPase? After all, isn’t the preceding number to 1 is obviously 0?” Let me explain. Oligomycin is an antibiotic that inhibits ATP synthase by blocking its proton channel through the Fo subunit. In my opinion, F0 has become commonly adopted by many authoritative textbooks and peer-reviewed articles for the following reasons:
1) The letter ‘o’ is visually similar to ‘0’. In classrooms or lecture theatres, where teachers and professors write about the Fo sub-unit by hand on the whiteboard, it might be impossible to determine if an ‘o’ or ‘0’ was written.
2) This is probably the biggest factor: ‘0’ precedes ‘1’. Meanwhile, ‘o’ is a letter while ‘1’ is a number.
3) There are many more symbols where ‘0’ is the subscript instead of ‘o’.
4) Many authoritative texts and teachers use F0 instead of Fo and when other people read or listen to them, they also do the same and adopt the convention. As such, the use of F0 is rapidly adopted.
5) There is little mention about this historical development in various resources.
This two-paragraph extract from a paper by McCarty (1992) elaborates on the situation.
Also of note is the fact that some older texts refer to ATP synthase as ATP synthetase.
According to the JCBN (Joint Commission on Biochemical Nomenclature)/NCIUBMB (Nomenclature Committee of the International Union of Biochemistry and Molecular Biology) newsletter in 1984, the word synthase can now be added to the name of any substance to signify an enzyme that catalyses a reaction producing that substance, i.e. its range is extended to include enzymes catalysing reactions that involve hydrolysis of a nucleoside triphosphate, which previously could not be called synthases. In addition, “synthetase” is now synonymous with “ligase”.
In view of this update, it is thus more precise to refer to Complex V as ATP synthase instead of ATP synthetase. I also want to talk about the theoretical or experimentally-determined values regarding how many ATPs are produced for each molecule of NADH or FADH2 that enters the mitochondrial electron transport chain. The oldest values are: each NADH and FADH2 molecule leads to the production of 3 ATP and 2 ATP respectively.
However, we also see values such as 2.5 ATP and 1.5 ATP for each molecule of NADH or FADH2 respectively. Some modern texts even state that each NADH leads to 2.7 ATP being produced and 1.6 ATP/FADH2. Which is it?
To understand how we got into this mess, we must understand the relevant historical development. In the 1960s, ATP was known to be the energy currency of life, but the mechanism by which ATP was generated in the mitochondrial matrix was assumed to be substrate-level phosphorylation. After all, substrate-level phosphorylation was seen in glycolysis, and the Krebs cycle where succinyl-CoA is oxidised to succinate, while dephosphorylating GTP to GDP, which in turn phosphorylates ADP to ATP.
A scientist named Peter D. Mitchell realised that the movement of ions across an electrochemical potential difference could provide the energy needed to produce ATP. His hypothesis was actually derived from information that was already well known in the 1960s. He knew that living cells had a membrane potential; interior negative to the environment. The movement of charged ions across a membrane is thus affected by the electrical forces (the attraction of positive to negative charges). Their movement is also affected by the chemical potential, where substances diffuse from regions of higher concentration. He went on to show that ATP synthesis was coupled to this electrochemical gradient.
But of course, as with many great scientists who came up with seemingly absurd hypotheses, I’m sure he was mocked and ridiculed for this. Here is a quote from a biography of Mitchell: “It is a striking fact that, at the time Mitchell proposed his theory, there was not a shred of experimental evidence in its favour.” When Mitchell died in 1992, the following obituaries were published:
FromThe Times, a British daily national newspaper, on 15 April 1992: “His hypothesis met, initially, with an almost derisory reception. Few of the workers in the field had the necessary background knowledge of electrochemistry to appreciate the proposals and they spent many years searching for a chemical intermediate, which Mitchell argued did not exist.”
From The Independent, established in 1986 as a politically independent national morning newspaper published in London, on 16 April 1992: ‘For 20 years Mitchell was ridiculed, and Jennifer Moyle was his only professional supporter’.
Mitchell’s contemporaries have been criticised for their hostility towards Mitchell’s chemiosmotic hypothesis. Such criticism may be misplaced, though. For example, the elegance of the hypothesis was immediately recognised by some. In a review published in 1962, Lehninger (yes, this is the same Lehninger as the one who authored the renowned biochemistry textbook) gave a sympathetic summary of the chemiosmotic hypothesis, and Mitchell was invited by his peers to present his hypothesis in seminars at various European universities.
Anyway, the chemiosmotic hypothesis eventually became the leading hypothesis. The brilliance of the chemiosmotic coupling was that it allows nonintegral stoichiometries of oxygen consumption and ATP synthesis. Let me explain.
Before the chemiosmotic model for oxidative phosphorylation was accepted, the assumption was that the overall reaction equation would take the following form because everyone thought that it would be substrate-level phosphorylation:
where the value of ‘x’ would be an integer. When intact mitochondria are suspended in solution with a oxidisable substrate such as NADH or succinate, along with addition of oxygen, ATP synthesis is readily measurable, as is the decrease in oxygen. In theory, this should allow ‘x’ to be calculated. However, measurement of ‘x’ is complicated by the fact that 1) in intact mitochondria, any ATP that is produced is used by the mitochondria in other reactions in the matrix. Also, 2) oxygen is also used in reactions unrelated to oxidative phosphorylation. Hence the discrepancy due to these two factors need to be taken into account. Most experiments, after the necessary corrections, have determined x to be between 2 and 3 when 1 mole of NADH is used as the oxidisable substrate.
Given the assumption that x was to be an integer, most experimenters agreed that the x should be 3 and 2 for NADH and succinate respectively. Just like that, these values have been used for years in peer-reviewed articles and textbooks.
With the chemiosmotic model involving the coupling of ATP synthesis (involving phosphorylation) and electron transfer (involving oxidation), there was no longer a theoretical requirement for x to be an integer. The measurement of proton fluxes (how many protons are pumped through the various complexes) is quite complicated but basically, the experimental consensus is that for each pair of electrons, 10 protons and 6 protons are pumped into the intermembrane space for one molecule of NADH and succinate respectively. For flow back into the matrix from the IMS, the most widely accepted value is that 4 protons are required to drive the synthesis of 1 ATP.
Since 1 NADH leads to 10 protons being pumped from the matrix into the IMS, and 4 protons are required for synthesis of 1 ATP, it follows that x = 10/4 = 2.5 for NADH. Thus, 1 NADH leads to the production of 2.5 ATP. It also follows that since 1 succinate molecule leads to 6 protons being pumped from the matrix into the IMS, then x = 6/4 = 1.5 for succinate. Thus, 1 succinate leads to the production of 1.5 ATP.
Since 1 NADH leads to 10 protons being pumped from the matrix into the IMS, and 4 protons are required for synthesis of 1 ATP, it follows that x = 10/4 = 2.5 for NADH. Thus, 1 NADH leads to the production of 2.5 ATP. It also follows that since 1 succinate molecule leads to 6 protons being pumped from the matrix into the IMS, then x = 6/4 = 1.5 for succinate. Thus, 1 succinate leads to the production of 1.5 ATP.
You might have noticed that I talked so much about succinate. What happened to FADH2? Here’s the brilliance of the mitochondrion. The TCA Cycle takes place in the matrix, and recall that one of the steps of the TCA involves the oxidation of succinate to fumarate. Now, this oxidation actually occurs at Complex II of the mETC. The oxidation of succinate to fumarate simultaneously reduces FAD to FADH2. FAD is a prosthetic group, a covalently-attached cofactor that is found within Complex II. FADH2 is then oxidised back to FAD when it reduces Q to QH2. QH2 then shuttles to Complex III. This is how electrons are carried from the TCA, through II to III, etc! Amazing, isn’t it? Thus, it could be alternatively said that 1 FADH2 leads to 1.5 ATP.
We could use the same logic and apply it to NADH, but then NADH could come from so many places. Just imagine. 1 isocitrate produces 2.5 ATP; 1 α-ketoglutarate produces 2.5 ATP; 1 malate produces 2.5 ATP. This isn’t practical at all. From the TCA cycle alone, NADH is produced in 3 instances:
1) the oxidation of isocitrate to α-ketoglutarate simultaneously reduces NAD+ to NADH 2) the oxidation of α-ketoglutarate to succinyl-CoA simultaneously reduces NAD+ to NADH 3) the oxidation of malate to oxaloacetate simultaneously reduces NAD+ to NADH
NADH can also come from another reaction within the mitochondrial matrix which is not, strictly speaking, part of the TCA. Firstly, consider the earlier oxidation of α-ketoglutarate to succinyl-CoA, where this reaction is catalysed by α-ketoglutarate dehydrogenase complex. α-ketoglutarate (5 carbons) is oxidised to succinyl-CoA (4 carbons). What happened to that one carbon? Well, it escaped as CO2. Look at the product of the reaction too. A “CoA” is added. Also, an NADH is produced. The enzyme is a dehydrogenase complex.
Does this ring a bell?
If you thought of the oxidation of pyruvate to Acetyl-CoA, then CONGRATULATIONS, you got it!
The thing you must understand is this: α-ketoglutarate dehydrogenase complex is virtually identical to pyruvate dehydrogenase complex. Within the matrix, the oxidation of pyruvate (3 carbons) to Acetyl-CoA (2 carbons) produce CO2, brings about the addition of a “CoA”, and lastly, reduces NAD+ toNADH.
In addition, NADH can be shuttled from the cytosol into the matrix to be used as substrate at Complex I.
Let’s go back and talk about the proton flux where protons move from the IMS into the matrix. How does it work? ATP synthase consists of two parts: Fo and F1. Fo has a number of sub-units and the number of sub-units is equal to the number of protons that move through Fo. In animal mitochondria, n = 8 (it varies, depending on the organism; in E. coli, n = 10). This means that 8 protons move through Fo in one revolution of Fo. Also consider the F1 portion, where one revolution of F1 produces 3 ATP. Since the synthesis of each ATP molecule requires the transfer of 1 Pi into the matrix, at a cost of 1 proton for each Pi transfer, that means that 3 additional protons are required for the synthesis of 3 ATP. This means that 8 + 3 = 11 protons are needed for the synthesis of 3 ATP. Remember that this is animal mitochondria that we are talking about. 11/3 gives 3.7 protons/ATP for ATP synthesis in animals. When we use the values of 10 protons/NADH and 6 protons/succinate or FADH2, we get: 10/3.7 = 2.7 ATP/NADH and 6/3.7 = 1.6 ATP/succinate or FADH2 in animals.
Then you might be wondering: how does this relate to 2.5 ATP/NADH and 1.5 ATP/NADH respectively? Recall that the experimental consensus was 4 protons/ATP. Now, what organisms were used to obtain that value? That is the crux of the matter. In the previous paragraph, I mentioned that the number of Fo sub-units vary depending on the organism. This totally changes everything. For example, in the case of E. coli andyeast, where n = 10, the values you get will be 2.3 ATP/NADH and 1.4 ATP/succinate or FADH2, if you follow the same calculation process in the previous paragraph.
These above calculated values of x (aka P/O ratio) define a range that includes the experimental values of 2.5 ATP/NADH and 1.5 ATP/FADH2. Thus, 2.5 and 1.5 are ubiquitous in biochemistry textbooks. Yet, for simplicity, some still choose to use 3 ATP/NADH and 2 ATP/FADH2.
I hope this blog post has perhaps allow you to understand why I find ATP synthase so fascinating. It is a pity that a lot of the above background information which includes highly interesting historical development isn’t discussed enough in textbooks, classrooms, and lecture theatres because of a lack of time, resources, etc.
Ask any kid what he thinks of when he comes across the word “scientist”. It is not surprising to hear scientists being described as weird, introverted, bespectacled old men with grey hair in white lab coats who do crazy stuff involving explosive chemical reactions in the laboratory. This stereotypical portrayal is perpetuated by the abundance of children’s books, cartoons and the mass media. Sometimes, these scientists go to extreme lengths to prove a particular point. For example, they might use their own bodies as experimental vessels to test their hypotheses simply because ethics committees wouldn’t allow them to test their hypotheses on the bodies of others as it would be “unethical”. Would you knowingly infect yourself with dangerous bacteria to test a hypothesis?
I thought so.
Neither would I. Yet, this is exactly what Dr Barry Marshall did. The Australian doctor infected himself with bacteria. Due to what he did, he demonstrated that most stomach ulcers are actually an infectious disease. This valuable information has helped save many lives.
Peptic ulcers are open sores found in the endothelial lining of the stomach and/or the upper portion of the small intestine. The most common symptom associated with these ulcers is abdominal pain. If things get bad enough, one can start bleeding, or even have one’s stomach burst.
Back in the 1970s, ulcers were most common in middle-aged men who smoked and drank alcohol. Having ulcers seemed to run in the family. As such, doctors assumed that ulcers occurred when there was overproduction of acid in the stomach, and the ulcers were a result of stress, and perhaps some genetic defect. As such, the typical advice was for the patient to relax, watch what he consumes, and take some antacids.
Most notably, it was assumed that the stomach was sterile (ie completely bacteria-free). It is understandable to see why people thought that. After all, the pH of the stomach lumen is around 2-2.5, indicating its high acidity. What organism could possibly survive such an acidic environment?
Then, in 1979, an Australian doctor, Dr Robin Warren began to have his doubts. This was because the pathologist began to regularly see comma-shaped bacteria in the samples from patients who had gastritis. In that same year, Dr Barry Marshall was appointed as “Registrar in Medicine” at the Royal Perth Hospital (RPH). Dr Warren and Dr Marshall met in 1981 while Dr Marshall was doing his internal medicine fellowship training at the RPH.
In 1982, the duo established a formal study and found that a majority of all their ulcer patients had been infected with the bacteria too. They identified the bug as Helicobacter pylori, and suspected that its presence was the true reason for peptic ulcers and gastritis.
NB: At the time of the study, this bug wasn’t known as H. pylori. It was first known as Campylobacter pyloridis. However, in 1987, it was re-named Campylobacter pyloris. This was because ‘pylori’ is the genitive case of the Latin nominative ‘pylorus’, which is the circular opening leading from the stomach into the duodenum. As mentioned in the paper, ‘pyloridis’ is a linguistic error that had to be corrected. The Latin word ‘pylorus’ in turn comes from the Greek word ‘πυλωρός’, transliterated ‘puloros’, which means ‘gatekeeper’.
Then, when 16S rRNA (component of the 30S small subunit of a prokaryotic ribosome) gene sequencing and other research showed two years later (by October 1989) that the bacterium didn’t belong in the genus Campylobacter, the bacterium was placed in its own genus Helicobacter. As you might have guessed, the prefix of the new genus name ‘helico-‘ comes from the ancient Greek word helix.
Anyway, back to the study. The hypothesis was absurd for its time and I’m sure very few of the duo’s peers were convinced that anything useful could come out of it. How could anything survive the highly acidic environment of the stomach? If this were true, why hadn’t someone discovered it earlier? The odds seemed to be against Dr Warren and Dr Marshall.
By 1984, Marshall was convinced of his results and must have been exasperated that others were not convinced. This was because in 1983, the previous year, the duo had submitted their findings hitherto to the Gastroenterological Society of Australia. However, the reviewers turned the papers down, rating it in the bottom 10% of the papers received in 1983.
So, Marshall did something radical. After ensuring he had no H. pylori of his own, he became his own guinea pig, and in one gulp of meat broth at 10:00 am, he purposefully swallowed a whole load of the bacteria. Unsurprisingly, he began to experience indigestion, nausea, bad breath, and began vomiting in the coming days. Although he hadn’t developed an ulcer, it was close. It was gastritis. H. pylori penetrates the mucosa layer of the stomach lumen and exposes the submucosa epithelial cells to all that acid in the lumen.
The infection usually takes a while to cause a problem, and the symptoms can be exacerbated by things like smoking and stress. This could be why older men with less-than-stellar health records seemed the most susceptible. Nevertheless, correlation is not the same as causation. Without H. pylori, most people would never even get peptic ulcers. Marshall and Warren also went on to demonstrate that certain drugs could get rid of H. pylori. In recognition of this groundbreaking work, the Australian duo was awarded the 2005 Nobel Prize in Physiology or Medicine. Marshall is the younger of the two.
This disco-era discovery turned out to have an even bigger impact than anyone imagined. Today, the World Health Organization recognises H. pylori as a carcinogen. The same damage the bacteria does to the lining of the stomach with an ulcer also causes gastric cancer. As more people got antibiotics to cure their ulcers, gastric cancer incidence rates plummeted.
Yet, the situation turned out to be not that simple. While most ulcers are caused by H. pylori, most people with H. pylori don’t develop ulcers, and even fewer get gastric cancer. The presence of H. pylori might even help as it seems to protect people from developing heartburn, and protect people from getting cancer in the oesophagus. Unfortunately, we can’t get the best of both worlds. The strains of H. pylori that are the most dangerous to the stomach are also the most protective to the oesophagus. As such, the current consensus among doctors seems to be to keep the status quo unless H. pylori starts causing problems. If it does cause problems, then green lights to the most common initial treatment – a ‘triple therapy’ for one week:
1) Amoxicillin, a penicillin-type antibiotic, which means that it is similar to penicillin. So, if the patient is allergic to penicillin, he should avoid all drugs in the penicillin family and take something like metronidazole. 2) Clarithromycin, which is an acid-stable macrolide with a broad spectrum of antibacterial activity, well absorbed with a wide tissue distribution and with mild side effects. Clarithromycin has a low minimum inhibitory concentration (MIC50) for H. pylori and its effect is potentiated by acid inhibition. 3) Proton pump inhibitor (eg omeprazole). It works by irreversibly inhibiting H+/K+ ATPase on gastric parietal cells.
However, even this may not be sufficient. The main reasons for the eradication failure of the standard ‘triple therapy’ above include escalating antibiotic resistance, poor compliance, and rapid metabolism of proton pump inhibitor. Generally, resistance to clarithromycin and metronidazole has been on the rise. Interestingly, though amoxicillin is one of the most commonly used antibiotics, resistance to amoxicillin remains extremely low (<5%) in most countries. If the rates of clarithromycin resistance are known to be > 15%, then bismuth-based quadruple therapy can be tried.
You might still be wondering how H. pylori is able to survive the acidic environment of the stomach lumen. The answer lies in the specific adaptations that H. pylori has developed.
Do you see the things that look like tails? They are called flagella (plural of ‘flagellum’). The flagella confer H. pylori motility. With the flagella, H. pylori burrows into the gastric mucin gel to reach the epithelial cells, where it is less acidic. This is possible because of chemotaxis. H. pylori senses the pH gradient in the mucus and tends to move towards the region of lower acidity.
In addition to chemotaxis, H. pylori produces lots of an enzyme called urease. As its name suggests, the cytosolic urease catalyses the conversion of urea (found within the stomach) to ammonia and carbon dioxide:
(NH2)2CO + H2O → CO2 + 2NH3
The ammonia reacts with the strong acid in the vicinity of H. pylori to give rise to a relatively neutralised buffer zone that surrounds H. pylori. Thus, with these adaptations, H. pylori is able to endure the acidity of its environment.
In fact, the cytosolic urease in H. pylori is the very basis of the urea breath test: a rapid diagnostic procedure used to identify infections by H. pylori. For the test, patients swallow urea labelled with an uncommon isotope. The detection of isotope-labelled carbon dioxide in exhaled breath indicates that the urea was split, which in turn indicates that urease (the enzyme that H. pylori uses to metabolise urea) is present in the stomach) is present. This thus corresponds to the presence of H. pylori.
The handspan, or simply “span”, can be defined as the distance between the tip of one’s thumb and one’s pinky of the same hand. Understandably, a pianist is going to have a headache if his hand is not able to accommodate a particular series of notes as dictated on the sheet music. The hands are sometimes forced into awkward positions. How does he get around this? He has several options:
1) omit some notes or omit a single note 2) roll the chord (hence, all the notes of the block would not be played at the same time) 3) not even play the piece at all
That which needs to be done needs to be decided on a case-by-case basis.
In this post, I shall talk about some scenarios that I have encountered, some research that has been done regarding this issue, and the historical development that is partially responsible for this.
Let us start by considering one of the most well-known pieces that isn’t technically too challenging. The piece is Minuet in G Major.
NB: Contrary to popular belief, this piece is not written by Bach. Since 1970, it had been discovered that this piece was actually composed by another person: Petzold. Regardless of who composed this, its legendary status remains forevermore. Most people would recognise the piece just from the first bar alone! Nevertheless, it has been thought that it was composed by Bach for so long that it has its own catalogue number in Bach’s catalogue of works (i.e. BWV Anh. 114).
The minuet is a technically simple piece and it would not be uncommon for beginners to the piano to learn this piece. The largest harmonic interval that this piece demands (or requests) is a major sixth. This is found in the last bar of the piece.
This is highly manageable and virtually everyone who attempts this piece should be able to play a major sixth with his span. Even young children should be able to do a major sixth. Here are spans of some notable pianists and composers:
Move to the Romantic/20th century repertoire and you find that the pieces are more technically challenging. They make Petzold’s minuets look like child’s play (*shhh, they really are*). There are now huge runs which span multiple octaves with accidentals strewn everywhere. Here are the opening bars of one of Chopin’s etudes. How deceptive the first four bars are:
We have come to the age of the virtuoso, where humble harpsichords fade away. Keyboard instruments have become bigger. Thanks to the precedent established by performers such as Paganini and Liszt, performers would now play from memory. Audiences now constantly look forward to the “next big thing”.
I quote from the Wikipedia article on the piano: “In the period from about 1790 to 1860, the Mozart-era piano underwent tremendous changes that led to the modern form of the instrument. This revolution was in response to a preference by composers and pianists for a more powerful, sustained piano sound, and made possible by the ongoing Industrial Revolution with resources such as high-quality piano wire for strings, and precision casting for the production of massive iron frames that could withstand the tremendous tension of the strings. Over time, the tonal range of the piano was also increased from the five octaves of Mozart’s day to the seven octave (or more) range found on modern pianos.“
In many compositions, octave harmonic intervals on both the left and right hands are common. At the most extreme end of the spectrum, harmonic intervals of tenths are not unusual, particularly in works by Liszt and Rachmaninoff. After all, take a look at this:
This other infographic below is perhaps more useful for telling you how the handspan (in inches or centimeters) corresponds to the interval that you would be able to reach.
My 1-5 handspan measures 9.8 inches, and I’m an Asian male. Let’s see some interesting statistics from the literature review that was done in 2015 (Australian study of 473 pianists where 2/3 participants were Caucasian and 1/3 were Asian). See reference [4] for the link to the full literature review in PDF format.
Assuming a Gaussian distribution for the above data, then:
my 1-5 span would be at the 98.8 percentile among all 473 adult pianists.
my 1-5 span would be at the 94.6 percentile among all 159 male (73% Caucasian and 27% Asian) adult pianists. my 1-5 span would be at the 99.8 percentile among 37 adult Asian male pianists.
Not bad at all. Here is my 1-5 span for the right hand:
Both my left and right hands can do 11ths semi-comfortably. This has been so useful once, where I needed to play the final chord of a piano transcription of the Aria from Bach’s third orchestral suite, better known as “Air on the G String”. The ending chord for that piano transcription is what you see in the photograph above. In my opinion, rolling the chord would kill the majestic end of the piece as each note of the chord is so paramount in establishing the sheer character of the conclusion. They all needed to be heard simultaneously. The piano transcription I played from was highly faithful to the original parts of the string orchestra (see the four individual parts below). Essentially, the piano transcription covered all four voices from the four instruments accurately! Such are the benefits of being able to stretch an 11th!
If I really tried, I can do a 12th too, but that is not realistically achievable under performance circumstances at all.
Meanwhile, some modern Rachmaninoffs can do the infamous C-Eb-G-C-G. This is absolutely mind-blowing. With this kind of handspan, you can probably play some beginner pieces meant for both hands, with just one hand. This is the largest handspan I have ever seen. If anyone has seen an image/photograph of a handspan greater than that of the image below (online/real life), let me know!
Well, I’m contented with what I have. With my handspan of an 11th, I can play the opening block chords of Rach 2 comfortably (thank God these are semibreves and not crotchets). Personally, I feel that the full effect of the dissonance and the rising tension can only be exuded when all the chords are played as blocks. Of course, for pianists who do not have such large handspans…
Recently, I learnt a piece that I had actually wanted to learn for quite a long time. It is Animenz’s transcription of Departures, one of the ending songs for a Japanese animation series called “Guilty Crown”. I learnt an extract of the transcription, which you can view here:
I frankly don’t know if I could live with learning this piece if I had to do away with all the tenths that Animenz puts into his transcription. A harmonic tenth simply adds more flavour than an octave. Look at the following six bars. The highlighted chords are huge intervals.
Once again, look below. This must be rather discouraging for anyone who wants to play the tenths faithfully as blocks but is unable to.
The following six bars of music are one of the most beautiful and unique I have come across in a piano transcription. They actually motivated me to learn this piece! Observe how the melody is in the upper voice of the left hand. The lower portion of the left hand plays consistent rhythmic notes while the right hand drones up and down beautifully. Charming! At some points, such as the the first beat of bar 32, I could not realistically do that C-A-C-F# chord. Hence, I needed to use my right hand to play the F#. The more interesting point is the Bm7 chord in bar 35. For a while, I actually did the full chord in my left hand. However, accuracy was being compromised because the transition duration to the chord was short. So, I decided to play that top D with my right hand instead, and that turned out quite well.
I didn’t go on to learn the rest of the piece after bar 38 because I felt that it would take too much time and effort to learn the entire piece. So, we see that even though my handspan is pretty large, that alone isn’t enough to learn and master pieces. There must also be that technical ability that allows the pianist to navigate challenging pieces, along with a million other factors for him to consider. One must also be clever when choosing the fingering to adopt for a particular passage. The example regarding the Bm7 chord in bar 35 is classic.
Moreover, playing the opening block chords of Rach 2 doesn’t mean that I can play the entirety of Rach 2. On the other hand, there are internationally-acclaimed concert pianists who cannot play the block chords for the opening of Rach 2 but can play Rach 2 reasonably well.
In conclusion, I would say that being able to stretch large intervals certainly does help when learning more advanced piano repertoire. If you can do a tenth comfortably, virtually the entire repertoire is accessible, at least according to one of the infographic above. Nevertheless, don’t be complacent. One still has to work on technique, and put in deliberate effort when striving to perfect a piece. For those who cannot stretch large intervals, I would say: don’t fret! As I mentioned at the start of the post, there are many things you can do to work around it: omit some notes, roll the chord, use a different fingering, use the pedal, choose a different piece, etc. There is so much more to piano music than just being able to stretch and play some chords with big intervals (as much as I feel that playing block chords as written is quite important). In either scenario, the important thing is not to be complacent or discouraged respectively. One must work diligently and put in serious effort in order to become a competent pianist.
The content enclosed between the following two dividers is a direct quote from reference [1] which I found particularly interesting. It succinctly illustrates yet another aspect of the piano which has evolved over time, in addition to the increased dynamics and range. Modern pianos have wider keys than the pianos 200 years ago. This partially accounts for why certain pieces that were composed a long time ago have intervals that alienate a significant proportion of contemporary pianists when attempted on a modern piano. On the pianos of the past, these intervals wouldn’t have required the same extent of hand-stretching as that of today. A consequence of the widening of the piano keys over time has been that a smaller proportion of modern pianists is able to play octaves, ninths, tenths, etc. Well, the piano has historically revolved and been designed for the adult European male pianist. Go figure.
Given that Caucasians have larger hands on average than Asians, I’m not at all surprised that the widening of the piano keys over time has simply reinforced the perception that the piano is a challenging instrument, particularly in predominantly Asian societies such as Singapore.
“It’s worth noting that piano keyboards used to be smaller! The keys on so-called fortepianos – the early pianos that Haydn, Mozart and Beethoven played – were slightly narrower. Moreover, the keys were much lighter to play and only could be pressed about half as far as today’s grand pianos. This certainly affects pianists when we play music written for these older pianos on modern instruments with their much heavier keys that we also need to press further down. Beethoven wrote a pianistically novel passage in his second published piano sonata. The opening movement of the Sonata in A major, Op. 2, No. 2, has this passage:
“This is a rare example of Beethoven specifying fingering. However, even pianists with large hands are unable to play this passage using Beethoven’s fingering on a modern piano. (If you know of anyone who does so, please leave a comment below. I’ve never heard of any modern-day pianists using this fingering.) The keys on today’s pianos are simply too wide for this fingering to make any sense. Instead, the best solution in this case is to split the passage between the hands:”
One of my modules this semester is titled “Communication for Improved Patient Care”. Yesterday, we had a lecture from 1-2pm, followed by a workshop from 2-4pm. The theme for this week was “Creating the right therapeutic environment”.
When delving into the realm of medical ethics and the nature of the relationship between doctor and patient, it behooves us not to neglect the work of Beauchamp and Childress. I quote from reference [1]. They are American philosophers best known for their work in medical ethics. Their book Principles of Biomedical Ethics was first published in 1985, where it quickly became a must read for medical students, researchers, and academics. The book was written in the wake of some highly unethical biomedical experiments – most notably the Tuskegee Syphilis Study, where hundreds of rural black men, their partners, and subsequent children were infected or died from treatable syphilis. Beauchamp and Childress aimed to identify healthcare’s “common morality”.
The four principles that they established were: 1) Respect for autonomy; 2) Beneficence; 3) Non-maleficence; 4) Justice. With these principles, it is not difficult to see why the Tuskegee Syphilis study was deemed outrageously unethical. Some will claim that morality is subjective and that the weighing of these different ethical principles, which are often in tension with one another, is subjective. What I will talk about in this post is not about whether these principles are valid. Debating the innate fundamental validity of these principles, or even whether morality is subjective, is something probably best left to the devices of philosophers and theologians. In this post, I instead make the assumption that these four principles are all valid principles to be considered in the context of modern evidence-based medical practice.
During the tutorial, we were told to get into pairs or trios, as part of one of the initial activities, to discuss the question: “What is meant by patient-centred care?” I started by first sharing with my group partner how the term is somewhat self-explanatory. Patient-centred care would just mean placing the patient’s needs and welfare above all else to ensure optimal patient outcome. It’s so simple. What could possibly go wrong?
Reality is not so straightforward. The tutor voiced her disagreement regarding one of the points I made (I shall elaborate on this soon) in front of the entire tutorial group during the tutorial. The disagreement probably stemmed from misunderstanding as there wasn’t enough time for me to fully explain my views. Hence, I have written this post.
The impression I got from her was that she views patient autonomy as being the most important thing to consider in the context of “communication for improved patient care”. Understandably, she might feel this way due to the nature of the topic and perhaps, even some past experience where she feels that her autonomy should have been emphasised. I am not her and I cannot say with certainty what she thought, and so I’m merely speculating.
In the context of patient communication, we cannot directly control the minds of patients and influence their responses and behaviours. What we can change, however, is what we can do on our part (eg our diction, our tone, our body language, our holistic response). For example, you may encounter an unreasonable patient who raises his voice and shouts at you during the consultation. In such a scenario, it would be inappropriate to respond likewise. Raising your voice at the patient as a way to vent your frustration will likely land you in trouble. It will likely provoke an even more emotional response from the response, and this will not help in de-escalating the situation at all. The last thing you want is a letter of complaint from the patient which ultimately gets you berated from your superior, which might in turn cost you your job. What you can do, however, is to insist on behaving in a professional manner and adhere to a standard of decorum which is expected of a medical practitioner.
While optimal patient care requires both the patient and doctor to play their part, the sole focus tends to be on what the doctor can do, at least for this particular module I’m currently taking. After all, the patient tends to be passive while the doctor tends to be active. Some people talked about the power differential between the doctor and patient; some talked about the state of vulnerability of the patient.
I talked to my group partner about a hypothetical scenario where there are two treatment options for a patient’s condition. Let us suppose first that hypothetically, all options work equally well given the patient’s condition, and that treatment A and B cost $50 and $100 respectively. Patient-centered care in this context would mean explaining to the patient that both options work equally well and that treatment A costs less than B. The rational patient would likely choose the former option since it is more affordable and it works just as well as the more expensive option. Everyone lives happily ever after. Simple, right?
Let me now introduce you to something slightly more realistic. What if Treatment B works better, and that it improves the patient’s quality of life more than A? You explain how both treatments to the patient and the patient gives informed consent to proceed with a particular treatment. The patient’s autonomy is respected. Even if the patient rejects either treatment, the doctor accepts it and the patient’s autonomy is respected, and everyone still lives happily ever after. Still simple, right?
I talked about this issue with my group partner. Specifically, I talked about how certain medications can be administered to lower peripheral vascular resistance, so as to treat hypertension by lowering blood pressure. Blood pressure in our bodies is governed by the equation BP (Blood Pressure) = CO (Cardiac Output) * PVR (Peripheral Vascular Resistance), which can be further broken down to BP = SV (Stroke Volume) * HR (Heart Rate) * PVR. There are so many things you can do to influence blood pressure in the body. Let’s talk specifically about PVR (Peripheral Vascular Resistance).
With the equations above, you can lower BP by lowering the vascular resistance. There are at least three ways you can lower the PVR.
According to a doctor who knows well how hospitals in Singapore operate, treatment 1 is relatively affordable. Treatment 2 is moderately priced. Treatment 3 is relatively expensive. In Singapore, at least, Treatment 1 tends to be given more in public hospitals whereas Treatment 3 tends to be given more in the private hospitals. These treatments have different levels of effectiveness in people with different conditions. Do you see the different principles at play here? As much healthcare providers would like to provide quality patient care, there are other considerations, particularly so for public hospitals which have more red tape and standard operating procedures. Resources are scarce and subsidies are limited. Who gets to decide what constitutes an equitable distribution of resources? How much subsidy should a patient receive? Means-testing? How then is the criteria decided? There are endless questions one can ask. Many stakeholders are involved, and the ever-changing laws and advancements in medical technology just further complicate matters. These issues cannot be analysed as though they constitute a static cross-section in the moving tubular fabric of time.
Still manageable? Well, let me now bring you to murkier waters. I want to discuss informed consent, which is a sacred cow in healthcare. There is information asymmetry between a doctor and his patient, and this was the point of disagreement and contention between my tutor and me. I said that a doctor is likely to have a far better understanding of the patient’s condition than the patient, and objectively speaking, it is the doctor who has a much better chance of making the informed decision. After I raised this, she immediately said that she disagreed. She talked about how the patient also considers the non-medical aspects of his situation. For example, in deciding which treatment to get, or whether to even get treatment, a patient would also consider whether he would be able to cope with his work/daily activities as he would have to deal with the side effects of the treatment. Finances are involved too. Medicines can be quite expensive and insurance plays a huge part. Insurance policies are notorious for their fine print and it doesn’t help that there are so many types of insurance policies. The patient’s policy might not cover a particular treatment. In this aspect, I agree with the tutor regarding how the patient is and should able to make an informed decision because of two reasons:
1) There should be respect for patients’ autonomy. 2) The patient knows and understands the non-medical aspects of his life more than the doctor. In this sense, the patient can take into account the medical and non-medical aspects of his life when making a decision whereas the doctor will only have a superficial understanding of the patient’s non-medical aspects. Regarding the non-medical aspects, the doctor is limited by what the patient tells the doctor. However, the caveat is that the patient’s understanding of the medical aspect of his condition is limited by how much his doctor tells him about the condition and how much the patient understands what the doctor is telling him.
However, there is one factor that we cannot neglect in the above scenario:
Externalities.
If my tutor insists on the notion of giving utmost precedence to patient autonomy without carefully weighing the impact of these externalities, I would have to respectfully disagree with her stance. There are externalities associated with different treatment options or rejection thereof. These externalities can be positive or negative, and externalities bring us directly to the heart of the tension between the four principles. If patient autonomy were given utmost precedence under every circumstance, the issues of anti-vaccine groups, abortion, euthanasia would not even be controversial. In Singapore, it is compulsory for a child to be vaccinated against measles and diphtheria. If patient autonomy (in this case, the parent decides on behalf of the child) were to always take precedence, why is it then legally mandatory for children to be vaccinated against measles and diphtheria? After all, shouldn’t they have the right to reject the treatment? Haha.
These are highly contentious issues, and we need to remember that patients’ decisions regarding medical treatment often do not just affect themselves but also the people around them, the general public, and even another powerless entity whose life depends on the patient (in the case of abortion).
In addition to the issue of externalities, another thing for us to consider is the power differential between doctors and patients. When you go beyond the clinical setting and consider the big picture, saying that doctors are always in a position of power and authority over their patients is an oversimplification. Patients have ways of getting back at their healthcare providers in the form of complaints, litigation, etc. Allow me to quote from an article entitled “Things are looking up for the medical profession. Really.” written by Salma Khalik, Senior Health Correspondent, published on 21 March 2019 by The Straits Times (reference [4]), regarding the case involving a $100,000 fine:
In January, a doctor was fined $100,000 for not telling his patient about the side effects of a steroid jab, which is fairly common injection. The disciplinary tribunal said it was the correct treatment, but took exception to his not telling the patient about the possible side effects, which she suffered from. An expert witness during the hearing said that while it is good practice to do so, not all doctors do, since the side effects are both rare and transient.
The judgment and the size of the penalty upset doctors in both the public and private sectors. Some wrote in to the Forum pages, others signed a petition to the MOH, and the subject was also raised in Parliament.
In the light of the two recent cases in Singapore, we see that doctors don’t take that high-and-mighty role all the time. Even when they act reasonably in good faith, they can be subject to disciplinary tribunals, litigation, and can be meted out with unreasonably harsh penalties. Do we really want to see defensive medicine in Singapore, where doctors order excessive tests, create more paperwork and forms to sign, spell out the comprehensive list of side effects for even ubiquitous drugs such as paracetamol to avoid getting sued and avoid having to pay exorbitant sums of money? This will only bloat the healthcare sector, particularly the public sector, with more inefficiency, smother everyone with red tape, and ultimately cause healthcare costs to skyrocket.
In conclusion, while I do believe that patient-centered care is a noble objective that doctors must strive for, it is quixotic to take this to the extreme by insisting that the patient’s desires and views must be at the forefront at the expense of other factors that need to be considered. Respect for the patient’s autonomy is one thing, but what about beneficence, non-maleficence, and justice? The needs and limitations of other people, in addition to his patient, need to be considered carefully as well. These principles are often in tension with one another and drawing the line is not easy. Patients should acknowledge that the doctor does not have an easy time as the doctor needs to carefully weigh all these factors because he is not just accountable to his patient alone; he is also part of a network of healthcare providers which is responsible for the healthcare of an entire population.
Yours faithfully, Nicholas Loh 22 March 2019
P.S. (2019-03-22, 2:16pm, ACDT) One of the readers of this post, a medical student, has given valuable feedback. He talked about how in the context of Singapore’s healthcare, some older patients are more accustomed to medical paternalism, and I think it is good for medical students to be aware of this. Hence, they can be somewhat shocked when they are confronted with “choices”. They have grown used to having the physician as the authority figure who knows what is best for them. Hence, they can be taken by surprise. What is the physician then to do? Can there truly said to be “informed consent” in this scenario? I contemplated discussing in this post the Bolam and Montgomery tests. However, I decided against it as to do the issue justice would require a separate blog post!
“Don’t forget to complete questions 3 to 7a. We shall be going through them on Thursday! Remember this, I can’t help you if you choose not to help yourself. So please, be true to yourself!” reminded Mr Toh, our Physics teacher. As the school bell sounded like it always did on the hour, my classmates erupted into incessant chatter, likewise with the other classrooms adjacent to ours. Lorraine, who sat nearest the door, immediately faced towards the diagonally-opposite corner of the class, and tried to catch the attention of Jolene, her best friend. “Jo!” Lorraine beckoned. “What do you wanna do later?!”
Lorraine’s shrieks faded into the background as I made my way out of the classroom, trailing Mr Toh. With some effort, I jostled through the pairs and trios of students who were walking along the corridor. Disgruntled, I made my way to the ground floor. Surrounding me were class benches.
It was the same old sight every day. In their cliques, girls engaged in gossip. People charged their portable chargers at the wall sockets while they perused their lecture notes. The same people had their earbuds fitted nicely, with which they enjoyed what was supposedly their favourite music. Unattended laptops, phones and other valuables lay atop the class benches. And yes, I know, I know – how can we forget that group of people – the same old familiar faces masquerading around school. Though they didn’t hold hands (which they were certainly not allowed to), it was obvious to anyone with half a cerebrum that they were couples. In the evening, some of these couples even shared earbuds, that they might listen to the same music while “studying”. The sight went in stark contrast with what my father described to me when he himself was a student. When he was in my shoes thirty years ago, things were different. Back then, discipline and order were apparently upheld and championed with pride. Even girls were only allowed to have short hair. C’est la vie. As for whether the past could be coined “the good old times”, well, that’s ultimately up to our imagination, isn’t it?
At that moment, I couldn’t help but recall a picture I had chanced upon online. The picture was divided into four quadrants. Each quadrant contained one sentence. Strong men lead to good times. Good times lead to weak men. Weak men led to bad times. Bad times led to strong men. One-sided arrows connected the quadrants. Chuckling to myself, I made my way to the gate at the side of the school led me on my way to the nearby Starbucks joint.
As I opened the glass door to the Starbucks joint, the gush of cool air comforted my face. In its embrace, I was there and then relieved of the discomfort from the beads of perspiration that had been cascading down my forehead and cheeks.
Oh, thank God for the air-conditioner.
I headed towards one of the chairs and promptly set my brown leather sling bag on it. After glancing around, I then glanced at my watch at the flick of a wrist. Hmm. It was barely a quarter past one.
Shouldn’t there be more of a crowd? Well, in that situation, I wasn’t one to complain. This was a blessing.
“What you want today sir?” hissed the bespectacled woman who donned a sulk on her face. Well, there can never be enough negativity for one day huh.
“Do you do Trentas here?”
“Huh? Tlenta ah? That is what ah? Got such thing meh?” she replied, baffled.
“Never mind then. A Venti Iced Teavana Shaken Strawberry Green Tea Infusion Lemonade with sugar and caramel syrup.”
“Huh? Sorry can repeat again?”
That phrase bugged me. The word “again” is redundant, unless of course, I had already repeated myself, something I clearly had not done.
After successfully completing that unusually arduous task which seemed to take aeons, I proceeded to my seat and whipped out the tutorial questions that I had to complete by Thursday. While I don’t normally do schoolwork in places like Starbucks, this time was different. Somehow, I felt that I should just complete it before going home.
I opened the booklet containing the tutorial questions, while also laying beside it ruled paper. Just at that moment, the door swung open, initiating the chime of the miniature bells that adorned the top of the door frame. In walked a girl whose hair was neatly tied into a ponytail, with a black hairband holding it in its place. The badge on the left collar of her beige blouse was no strange sight. Though I knew not her name, I had seen her frequently, albeit from a distance, as I traversed the school premises. It must be something like the Baader-Meinhof at play here. Given her petite figure, I doubt she would even order half of what I ordered.
“A Short Iced Coffee please, and also, without sugar or syrup”, she remarked, with a smile plastered on her face. As expected – how predictable.
She soon returned to her seat which was three seats on my right. While sipping on her coffee, she glanced out of the window, looking at the vehicles zipping past along the road, all while maintaining her pleasant smile, as her visage basked in the glory of the majestic limpid sunlight that filtered through the speckless windows. Putting her cup of coffee down, she soon began to glance around the joint, just like I had done. Briefly, just so ever briefly, our curious eyes met.
I immediately darted away. It soon dawned on me how long I had spent gazing at her – from a distance. Oh dear. I certainly hope she didn’t think I was a creep. That was certainly not a first impression of myself that I intended to establish. What’s wrong with choosing to be more cognizant of one’s surroundings?
I started doing the tutorial questions. Yet, I yearned to talk to her. Who was she? I simply wanted to know the name of someone whose face I kept seeing. I could not focus on the questions that lay on the table. Though they were right before my very eyes, they were taunting me.
I glanced back at her.
With her left thumb holding a verso and a recto of a paperback apart, she gently sipped on her coffee once again. That was it. I was going to walk up and talk to her. Thoughts were running through my mind. “What if she just stares at me upon approaching her?” Anxiety coursed through my veins. “What if she just stands up and walks away without saying a word?” After overcoming the internal cognitive dissonance, I mustered whatever ounce of courage I had in me. With the faith of a mustard seed, I departed for her table (which was technically my table since all the seats shared a single long table). No sooner had I taken three steps than she glanced at me in surprise. However, upon arriving at her seat, whatever courage I had was now depleted.
“Hey, my name’s Nic. I couldn’t help but notice you when you walked in. You see, I somehow notice you a lot lately on campus, I mean…not that I actively look for you, but…”, I stuttered slightly in a way that was not representative of my usual coherence.
Mmmmm. Pretty sure she donned a Gucci Bloom – a rich floral scent that suits her so well. I was now close enough to her that I could see in full view her dark hazel iris and sharp gaze as though her eyes lined with shards of glass around the edges. The calculating coldness at the centre of her pupils drew me closer.
She put her book down, with the front cover against the cool surface of the pine table. The look of surprise soon morphed into one of serenity. And now, this time, though her lips were delicately against each other, she sat there smiling. Those few seconds of silence felt like an eternity. How was she going to reply? To say that I had mixed emotions was an understatement. There she sat, smiling at me. I wonder if she knew the effect that she was currently having on me. The dimples on her cheeks now further catalysed the melting of my heart. Yet. Yet, I could feel my heart palpitating with trepidation, as consternation and uncertainty engulfed my thoughts. Soon, she spoke with a delicate and mellifluous voice that caressed my earlobes like the petals of a rose.
“I was wondering when you would approach me”, she beamed.
My Primary One English teacher was addressed by us students as Mdm Siti. In secondary school, I had a Chemistry teacher who wished to be addressed as Ms Ngo. Then, when I was in Primary Four, I had a teacher who was to be addressed as Mrs Loh. On the other hand, addressing my male teachers was so much more straightforward. Women have it more complicated than men in many aspects of life. Of the many aspects, the aspects of titles is one. Before we discuss the distinctions between the various forms of social address that women have, permit me to first discuss social titles given to men.
Consider the name: Mr John Smith. The typical man would have the title “Mr”. This is the most common honorific for men under the rank of knighthood. “Mr” is an abbreviation of “Mister”; the title derives from earlier forms of “master”. On the other hand, men who are knighted are addressed with the honorific “Sir”. For example, after Mr András Schiff was knighted in 2014, he became known as Sir András Schiff.
There is another honorific for males, albeit highly traditional. You won’t ever hear it in Singapore, but you might still hear it within conservative circles in the UK. That honorific is “Master”, and it is used as an honorific for boys and young men. Typically, when you imagine a young boy being addressed as “Master”, you would conjure a typical movie scene of a butler in a wealthy household addressing the young son of the head of that household. I quote from the Wikipedia article for the honorific “Master”:
“Master” was used in England for men of some rank, especially “free masters” of a trade guild and by any manual worker or servant employee addressing his employer (his master), but also generally by those lower in status to gentlemen, priests, or scholars. In the Elizabethan period, it was used between equals, especially to a group (“My masters”), mainly by urban artisans and tradespeople. It was later extended to all respectable men and was the forerunner of Mister (Mr).
After its replacement in common speech by Mister (Mr), “Master” was retained as a form of address only for boys who have not yet entered society. By the late 19th century, etiquette dictated that men be addressed as Mister, and boys as Master.
In regions which abide by British tradition, abbreviated forms of social titles and degree titles generally do not contain periods between the letters (eg Mr/Dr/MD/PhD/BS/BA). On the other hand, it is customary in the US and places influenced by US tradition for there to be periods between the letters (eg Mr./Dr./M.D./Ph.D./B.S./B.A.). Singapore abides by the British tradition. Hence, we do not have periods after titles.
Having established what it is like for men, let’s talk about the titles that women need to deal with. To begin, the titles “Ms”, “Miss”, and “Mrs” all ultimately derive from the term “mistress”, which dates to the 15th century. Here are some example texts from the OED (Oxford English Dictionary):
1463 in S. Tymms Wills & Inventories Bury St. Edmunds (1850) 36, I … be qwethe to my maistresse Clopton a spoon of berell.
1471 J. Paston in Paston Lett. & Papers (2004) I. 443 Iff it come to Mestresse Elysabeȝ Hyggens … sche schall comveye it to me.
Today, the use of “mistress” to denote a married woman is now the least common meaning of the word.
“Miss” is an honorific for young women (typically under thirty years of age) who are unmarried. It can also be used as a form of address. This is increasingly uncommon, as “Ms” becomes increasingly popular. The distinction between “Miss” and “Mrs” became problematic with the rise of feminism and more opportunity for women as more women entered the white-collar workforce. Women who became famous before marriage often kept their birth names, stage names, pen-names, or pseudonyms.
“Mrs” is an honorific that is reserved for married women. Very traditionally, this is used along with the husband’s first and last name. For example, if John Smith were to marry Jane Doe, Jane Doe will be referred to as Mrs John Smith. However, it is now quite uncommon for a woman to be addressed by her husband’s first name. Typically, a woman is addressed by her husband’s first name only when they are addressed jointly. For example, “Mr and Mrs John Smith were invited to the gala”. Many married women now adopt only their husband’s last name after marriage. For example, Jane Doe would be referred to as Mrs Jane Smith after marriage. Here is a quote from the Wikipedia article which elaborates on the use of “Mrs”:
In several languages, the title for married women such as Madame, Señora, Signora, or Frau, is the direct feminine equivalent of the title used for men; the title for unmarried women is a diminutive: Mademoiselle, Señorita, Signorina, or Fräulein. For this reason, usage had shifted toward using the married title as the default for all women in professional usage. This had long been followed in the United Kingdom for some high-ranking household staff, such as housekeepers, cooks, and nannies, who were called Mrs as a mark of respect regardless of marital status. However, in the late 20th century the marital-neutral Ms became more common for women professionally and socially.
According to Wikipedia, “Ms” arose in the 1970s when this term started being used by those seeking to diminish the importance of marriage to a woman’s social identity. When in doubt, just use this title. You can’t go wrong because “Ms” is neutral and would be equivalent to the male “Mr” as it is not marriage-dependent.
Now, for the last one, we see the clash of cultures in Singapore. Singapore is in many aspects, the interface of the East and the West. This is where the term “Madam” or the abbreviated “Mdm” comes in. A variant of “Madam” is “Madame” and it comes from the French term “ma dame” which means “my lady”. In Southeast Asia, it is traditional for women to continue using their maiden name after marriage. It is not uncommon to see women being addressed by their maiden surname after “Madam”, while women would be addressed by their husband’s surname after “Mrs”. Women who use “Mrs” over here are typically more inclined to Western culture and influence. Of course, there are inconsistencies too. I know this particular woman whose maiden surname I know not. Hence, I address her as Mdm Tan (her late husband’s surname is Tan). Remember my Primary One English teacher I mentioned in the first paragraph? I’m pretty sure “Siti” is her given name and not her last name.
Take-home message: Aren’t you awed by the sheer amount of historical baggage that accompanies women’s honorifics? So many of these developments occurred because of societal norms which changed over the years. Some people (eg divorcees, single unwed mothers with children, older women who were unmarried) did not fit nicely into the categories which society had established. Furthermore, conventions from other languages have also influenced the use of these titles in English. The culture and history of a region does play a big role in how honorifics are used. As such, there have been inconsistencies regarding how the titles were used and are being used across the women, particularly for women.
Ultimately, a woman chooses a particular title for herself probably because she feels that it best reflects her values, beliefs, and current position.
Ask her how she wants to be addressed if you are unsure!
One of my topics this semester is Pathophysiology. According to the topic co-ordinator, the “purpose of this topic is to introduce you to the pathophysiology of the cardiovascular system with a special interest in Acute Coronary Syndrome (ACS) & ECG Interpretation. The cardiovascular system is an integral part of every patients’ [sic] presentation and understanding its function in health and disease is essential for optimal assessment and managment [sic] of your patients. This topic will briefly review cardiac A&P, then analyse the cardiac conduction system and what happens when it becomes pathological in cardiac emergencies such as ACS, STEMIs & cardiac failure.”
The content this week consisted of a review of cardiac anatomy and physiology. Allow me to share some stuff I found interesting.
1. Below is an image that depicts some of the main branches of the aorta.
What I wish to talk about is the brachiocephalic artery. Did you know that apart from its alternative name, brachiocephalic trunk, it has yet another name? The brachiocephalic trunk is also known as the innominate artery. How ironic. Yet, it is interesting to note that “brachiocephalic artery/trunk” started getting coined earlier than “innominate artery”. Why then is this trunk described as “brachiocephalic”? As I discussed in a previous post, a lot of medical jargon consists of Greek and Latin roots cobbled together. In this case, the term “brachiocephalic” can be broken down into “brachio-” and “-cephalic”. The former and latter terms mean “arm” and “head” respectively. It is easy to see how in many cases, the name of something gives a clue as to its function. It is thus not surprising to learn that the innominate artery supplies blood to the right arm, head, and neck.
2. Another thing I found interesting was the word coronary. Why are the coronary vessels described as “coronary”? For a long time, I thought this adjective came from the Latin word for heart – “cor”. However, the true etymology is such that the word comes the Latin word “corona”, which means “wreath” or “crown” (cf Elizabeth II’s coronation in 1952).
In the image above, the green line is the interface of contact between the crown and the person’s head. The way the right and left coronary arteries encircle the heart makes the term “coronary” an apt descriptor.
3. What do you know about the coronary dominance of hearts?
As I watched the video, this diagram came up. What is depicted above is the most typical form of the heart. Here, the posterior interventricular artery branches from the right coronary artery. However, as I saw this diagram, I thought to myself: “Wow, the end of the right coronary artery is so close to the end of the circumflex artery. I wonder if they join together, in some people, to produce a true “crown” that encircles the heart.”
Regarding coronary dominance, according to the video at least, dominance of the coronary arterial system is defined by which artery gives rise to the posterior descending artery (PDA)/posterior interventricular artery. Apparently, the PDA arises from the RCA (see image below) 60-80% of the time. Hence, we don’t normally talk about a “right dominant heart” because that is usually the assumption.
In a minority of people, the PDA arises from the circumflex artery, which ultimately comes from the left coronary artery. The hearts of such people would be termed “left dominant”.
In an EVEN smaller minority of people, the PDA would arise from both the circumflex artery and the right coronary artery. Such people are said to have co-dominant hearts.
Interesting, isn’t it? It turned out my intuition was right after all. Haha.
Have you ever wondered how the digits and letters within your NRIC relate to one another? The most recent news shrouding the NRIC concerns the nature of its collection, use, and disclosure. According to a Straits Times article published last August, it will be illegal for organisations to collect, use, or disclose NRIC numbers or make copies of the identity card, under stricter rules spelt out by the PDPC (Personal Data Protection Commission), from 1 September 2019.
Why are NRICs treated more highly than other personal particulars? Well, that’s because the NRIC number is a “permanent and irreplaceable identifier which can be used to unlock large amounts of information relating to an individual” (quoted from the Channel NewsAsia article).
The structure of the NRIC number is as follows: there is a prefix (which can be either S, T, F, G), followed by 7 digits (each ranging from 0-9), and a suffix (which can be one of many possible letters, as we shall we shortly). The following information regarding the structure of the NRIC number has been adapted from the relevant Wikipedia article:
The structure of the NRIC number/FIN is #0000000@, where:
A. # is a letter, the prefix, that can be “S”, “T”, “F” or “G” depending on the status of the holder.
1) Singapore citizens and permanent residents born before 1 January 2000 are assigned the letter “S“. 2) Singapore citizens and permanent residents born on or after 1 January 2000 are assigned the letter “T”. 3) Foreigners holding long-term passes issued before 1 January 2000 are assigned the letter “F”. 4) Foreigners holding long-term passes issued on or after 1 January 2000 are assigned the letter “G”.
Fun fact: Before 1 January 2000, it was commonly thought that “S” stood for Singapore” and “F” for Foreign. In 2000, the “T” and “G” ranges (which are one letter after “S” and “F” respectively) were introduced to avoid conflicts with previously issued numbers. As “S” is the 19th letter of the alphabet, it was reinterpreted as denoting that the person was born or registered in the 1900s (1900–1999), “T” is the 20th letter of the alphabet, denoting that the person was born in the years 2000 to 2099.
B. 0000000 is a 7-digit serial number assigned to the document holder.
For Singapore citizens and permanent residents born on or after 1 January 1968, their NRIC number will start with their year of birth e.g. 71xxxxx#. For those born on or before 31 December 1967, the NRIC number does not relate to year of birth, and commonly begins with 0 or 1. Non-native Singaporeans who were born before 1 January 1967 are assigned the heading numbers 2 or 3 upon attaining permanent residency or citizenship. They are randomly assigned according to the issuance number. Subsequent numbers are only for people attaining permanent residency or citizenship after 2008 (“4” or “5”).
C. @ is the checksum letter calculated with respect to # and 0000000.
Fun fact: Special NRIC numbers that are numerically significant have been issued to notable people:
S0000001I (Yusof bin Ishak, first President of Singapore, deceased November 1970) S0000002G (first Chief Justice of Singapore Wee Chong Jin, deceased June 2005) S0000003E (first Prime Minister of Singapore Lee Kuan Yew, deceased March 2015) S0000004C (Kwa Geok Choo, wife of Lee Kuan Yew, deceased October 2010) S0000005A (first Deputy Prime Minister of Singapore Toh Chin Chye, deceased February 2012) S0000006Z (second Deputy Prime Minister of Singapore Goh Keng Swee, deceased May 2010) S0000007H (first Minister for Culture S Rajaratnam, deceased February 2006)
I quote from the Channel NewsAsia article yet again: “The NRIC algorithm was never meant to be an impenetrable cipher, but a check for input errors,” Mr Lee said. “With a large enough data set, any budding cryptoanalyst would be able to solve this algorithm.”
Indeed, some people have reverse-engineered the algorithm. See references [5] and [6] for more information. All information below has been obtained from reference [6]. Now, we get to the part which you have been waiting for.
Consider the following random IC: S1234567@, where @ is the valid letter that we shall determine.
Step 1) You take the 1st number and multiply it by 9, then take the 2nd number and multiply it by 4, take the 3rd number and multiply it by 5, take the 4th number and multiply it by 6, and carry on until you take the 7th number and multiply it by 9. Now, take the sum of all these products. In the case of our example, the number will be 202.
Step 2) Divide the sum by 11 and determine the remainder. In other words, 202 mod 11 = 4. This remainder value is known as the checksum.
The above two steps are illustrated in the image below:
Step 3) Look-up the corresponding suffix letter from the following checksum table.
Since the original NRIC (S1234567@) has a prefix letter of ‘S’, we shall consider the first row of values. We see that the checksum value of 4 corresponds to the suffix letter of D. Hence, given the prefix and seven digits of S1234567, we can deduce that the valid NRIC must be S1234567D.
In Singapore, we drive on the left side of the road. As such, people use the right lanes for overtaking, and so, it is natural for expressway exits to branch out from the left-most lane on the highway, so that cars on the right lanes can continue on their journey without let. However, not every expressway exit in Singapore branches from the left lane. There is still one left that has the exit on the right. I present to you:
Having previously lived in the vicinity after the exit, I am familiar with this road. For people unfamiliar though, this must certainly be a source of momentary confusion. There are so many problems with this design.
The main problem with this layout is that all the buses and trucks which need to use that exit have to filter from left side of the expressway all the way to the right. This is a safety hazard for the road users. This is particularly challenging for the trucks and buses (they also not allowed to exceed certain speeds) because they normally have a nice exit on the left to just follow. It certainly isn’t the case here.
Moreover, it certainly doesn’t help that the right lane will have many speeding motorists. It is quite common for there to be cars which travel around 100-110 km/h in this region. Imagine having to change your lane and/or halve your speed for buses which are filtering lanes to get to this exit.
What a mess.
As such, the LTA has decided to do something about this situation and made the following announcement last April:
“The Land Transport Authority (LTA) has awarded a contract to Megastone Holdings Pte Ltd for the construction of a vehicular underpass at PIE. The new underpass will replace the existing PIE Exit 26A leading towards Clementi Road.
When completed, motorists will be able to exit the expressway via the left lane leading towards Clementi Road, improving overall traffic flow for this stretch of the PIE. As part of the works, part of Hua Guan Avenue will be realigned and widened to a standard dual-1 lane road.
Works are expected to commence in the second quarter of 2018 and scheduled to complete in the fourth quarter of 2021.“
In order to have an exit on the left at this region, there will need to be an underpass. See this map for a clearer view of how this is exactly going to play out.
What image is conjured in your mind when you encounter the word “Latin”? You would probably think of a bunch of old priests in parishes chanting in an esoteric language, and indeed – you would be right. As I type this, I am reminded of James Joyce’s phenomenal encyclopaedic novel, Ulysses. I shall first talk about this book and one of its passages before I talk about the legacy of Latin in general.
According to its Wikipedia article, Ulysses is a modernist novel and since its publication, the book has attracted controversy and scrutiny due to its anti-Christian rhetoric. The novel’s stream-of-consciousness technique, careful structuring, and experimental prose – replete with puns, parodies, and allusions – as well as its rich characterisation and broad humour, have led it to be regarded as one of the greatest literary works in history. The book even has its day of celebration (known as Bloomsday) – June 16! This is because the events as chronicled in the book all take place within a single day: 16 June 1904!
This is a quote from the author himself: “I’ve put in so many enigmas and puzzles that it will keep the professors busy for centuries arguing over what I meant, and that’s the only way of insuring one’s immortality.”
This book certainly appeals to those who are very well-read. When I say “very”, I mean “very“. To fully appreciate the book would require one to be well-acquainted with the Bible, classical works in various fields (philosophy, literature, history), practices of the Roman Catholic church, Greek and Roman culture and mythology, etc. Fully appreciating even just the title of the book requires familiarity with Greek mythology. It requires one to recognise that “Ulysses” is the Latin variant of “Odysseus”, the name of an entity in Greek mythology. Unsurprisingly, the events of the book resemble the events that Homer’s Odysseus undergoes. This is but one of the many examples of the contextual knowledge required to appreciate this monstrous work.
On a relevant Wikibooks page of the book, it is stated that the book’s encyclopaedic nature and voluminous display of erudition have proved to be stumbling blocks for many readers. The reader’s initial enthusiasm for the book is whittled away at the expense of a growing sense of bewilderment, as a mass of unexplained references and quotations piles up. Bewilderment inevitably gives rise to frustration, and this frustration provides the reader with an excuse to give up.
I would argue that it is precisely because this book is so challenging to the casual reader, that many people would strive to understand all the puns, parodies, and allusions. Moreover, there is much that can be learnt if one goes to the extent of probing into why Joyce writes about a particular thing or why Joyce writes in a certain way. Learning new information this way is certainly more accessible than doing what Joyce did to procure all of the knowledge he needed to produce this work.
The book opens with the following passage:
Meanwhile, here are the annotations to the above passage:
Mind-boggling, isn’t it? This is madness. God bless the soul of any student of English Literature who dares attempt to trudge through this labyrinth of a novel on his own.
The reason I gave such an extensive introduction to Joyce’s work is that I ultimately wanted to talk about the Latin phrase which is used just on the first page alone.
“Introibo ad Altare Dei”. I self-studied some basic Latin previously, so allow me to help in dissecting this phrase for you so that you too, can understand its meaning. 1) Perhaps the most challenging word for most people in this phrase would be the first-word “Introibo”. Doesn’t this bear resemblance to the word “Introit” that we see during church services? It shares the same root prefix as the word “introduce”. Indeed, the word “introibo” is an inflection of the word “introeo” – specifically, the first-person singular future active indicative (Latin is a highly-inflected language). The ending “-o” in “introibo” tells us that it is the first-person. Hence, the word “introibo” has the meaning “I will enter”.
2) The word “ad” should be fairly easy to understand. It is a preposition in Latin and usually means “at”. It can also mean “to; for; on”. In fact, “ad” and “at” are cognates. It is seen within set phrases such as “ad hominem”, “ad nauseam”. “ad infinitum”.
3) The Latin word “altare” should be pretty self-explanatory. It bears much resemblance to the English word “altar” and is unsurprisingly, the word from which the word “altar” is derived.
4) The Latin word “Dei” is the genitive form of the nominative “Deus”, which is Latin for “God”. When we say that the word X is in the genitive form, it is helpful to think of it as “of X”. Hence, “Dei” means “of God”. It is from “Deus” that we get words such as “deity”, “deus ex machina” (this plot device literally means “god from the machine”). As I was typing this, I suspected that the word “Deus” might have come from the Greek word “theos” which also means “God”. It is where we have words such as “theology”. Surprisingly, despite the superficial similarity in form and meaning, “Deus” and “theos” are not related as the two come from different roots. Kudos to Wiktionary for that piece of information.
Hence, we can piece everything to decipher the meaning of “Introibo ad Altare Dei”. It thus means: “I will go in to the altar of God”. I will now quote the relevant portions in the above-mentioned annotations.
Consider that first sentence once again: “Stately, plump Buck Mulligan came from the stairhead, bearing a bowl of lather on which a mirror and a razor lay crossed”. By the way, this first sentence in Ulysses is rated by The Guardian the top 10 best first lines in fiction. A stairhead is a level space at the top of a flight of steps. Buck Mulligan, in mockery of the Catholic ceremony of the Tridentine Mass, has just ascended the steps in imitation of a Roman Catholic priest ascending the steps to the altar.
Moreover, the shaving bowl which Mulligan carries is a mockery of the chalice that a Roman Catholic priest would hold (the chalice holds the wine). Interestingly, Roman Catholicism adheres to the doctrine of transubstantiation (they hold the view that the wine transforms into the actual blood of Christ upon consecration). Such audacity – that the shaving bowl is being compared to a chalice that holds the blood of Christ. Outrageous indeed.
Within the practices of the Roman Catholic Church, the Latin Tridentine Mass (Traditional Latin Mass) opens with the Prayers at the Foot of the Altar. After making the Sign of the Cross, the priest and his servers intone an antiphon (a short sentence sung or recited before or after a psalm) based on Psalm 43:4 (Psalm 42:4 in the Vulgate), Iudica Me, Deus (Latin for “Judge Me, O God“), which Buck Mulligan quotes. By intoning these words after he had ascended the steps, Mulligan has perverted the order of the liturgy.
Interesting, isn’t it?
At the risk of an oversimplification, Latin should have died totally when the Western Roman Empire ultimately fell. Of course, Latin didn’t totally die. It didn’t because of the world’s continuously functioning institution – the Roman Catholic Church. Since time immemorial, Latin has been the official language employed by the Church. In the medieval ages, the papacy was highly influential and there was always a tension between the monarchs and the Pope: who wielded more influence? On one hand, the monarchs were the ones with direct control over the troops, but on the other, the monarchs had their positions only by the grace of God (note that the Roman Catholic Church affirms that the Pope is the Vicar of Christ; hence, the “divine right of monarchs” would not be valid without the Pope’s approval). The Church was a dominant influence on Western civilization from Late Antiquity (fall of the Western Roman Empire) to the dawn of the modern age (Renaissance).
I briefly mentioned the Vulgate earlier. For those who are unfamiliar with the term, it refers to the late 4th-century Latin translation of the Bible. It was basically the only Bible translation that people ever knew for over a thousand years (AD 400-1530). It was, unsurprisingly, the invention of the printing press that led to the widespread dissemination of translations of the Bible in other languages. The printing press made it much tougher for the Church to curb the dissemination of alternative translations (basically anything other than the Vulgate). Prior to the printing press’ invention, Bibles were painstakingly produced by manual copying, and virtually all these Bibles were Vulgates. How laborious indeed. Latin was the language of the Church, the educated, the elite, and the whole system just ensured its continued usage.
The Vulgate had a large influence on the development of the English language, especially in matters of religion. Many Latin words were taken from the Vulgate into English nearly unchanged in meaning or spelling: creatio, salvatio, justificatio, testamentum,sanctificatio, regeneratio, and raptura. The word “publican” comes from the Latin publicanus (cf Mt 10:3), and the phrase “be it far” is a translation of the Latin expression absit (cf Mt 16:22). Other examples include apostolus, ecclesia, evangelium, Pascha, and angelus.
Regarding the English language, borrowing from Latin occurred from ecclesiastical usage established by Augustine of Canterbury, and indirectly after the Norman Conquest in 1066 through the Anglo-Norman language. During the Renaissance and beyond, as the term suggests, many writers “re-discovered” the works of classical antiquity. As such, English writers cobbled together huge numbers of new words from Latin and Greek words, dubbed “inkhorn terms”. The title of my first blog post is a partial example of an inkhorn term: “Blogogenesis”!
The influence of Roman governance and Roman technology on the less-developed nations under Roman dominion led to the adoption of Latin phraseology in some specialized areas, such as science, technology, medicine, and law. For example, the Linnaean system of plant and animal classification was heavily influenced by Historia Naturalis, an encyclopedia of people, places, plants, animals, and things published by Pliny the Elder. We have terms such as Homo sapiens (literally Latin for ‘wise man’) to describe our species. Binomial nomenclature characterises the Linnaean system.
Roman medicine, recorded in the works of such physicians as Galen, established that today’s medical terminology (e.g. atherosclerosis, hypoglycaemia, ophthalmology) would be primarily derived from Latin and Greek words, the Greek being filtered through the Latin. Roman engineering had the same effect on scientific terminology as a whole. Latin law principles have survived partly in a long list of Latin legal terms (e.g. mens rea, in absentia, ex post facto, habeas corpus).
Basically, in any technical field, Latin and Greek roots will be used to come up with new terms to describe a particular phenomena or object. It certainly sounds fancy and certainly makes the people who use such jargon to appear more sophisticated.
Now, I shall talk about Latin’s legacy in some words and contractions that I find interesting. You may be surprised by some of the words’ history.
AD/BC: As a child, I knew that the Gregorian calendar uses Jesus’ life as a reference point that demarcates the two eras: the era before Jesus’ birth and the era after Jesus’ birth. I knew that BC meant “Before Christ”. So, I had just thought that AD meant ‘After Death’ without giving it much thought. Of course, 10 seconds of thinking about it seriously would tell you that this didn’t make any sense at all since Jesus didn’t die the year he was born. AD is short for the Latin “Anno Domini” which translates to “In the year of the Lord”. People sometimes erroneously translate it as “In the year of our Lord”. While that would still be factual, that isn’t strictly what “Anno Domini” says. For the translation “In the year of our Lord” to be valid, the phrase would need to be “Anno Domini Nostri”. The word “Nostri” is what gives the meaning “our”. We see this somewhere else too. The Romans would call the Mediterranean “Mare Nostrum”, which literally translates to “Our Sea”. At its peak, the Roman Empire occupied all the territory that surrounded the Mediterranean Sea.
You might notice how some people use CE/BCE (Common Era/Before Common Era) instead of the AD/BC system respectively. The change is simply one of semantics—that is, AD 100 is the same as 100 CE; all that changes is the label. The advocates of the switch from BC/AD to BCE/CE say that the newer designations are better in that they are devoid of religious connotation and thus prevent offending other cultures and religions who may not see Jesus as “Lord”. The irony, of course, is that what distinguishes BCE from CE is still the life and times of Jesus Christ.
Auspicium Melioris Aevi: Rafflesians should recognise this. The word ‘auspicium’ comes from the word ‘auspex’ which means ‘augur or priest’. ‘Auspicium’ can mean ‘sign or indication’. It is where we get the English words “auspicious”, “auspice”, The word “melioris’ comes from the nominative “melior”. It means “better” and this is where we get words such as “ameliorate” – a fancy word for “improve”. The word ‘aevi’ comes from the nominative ‘aevum’ and means ‘time; eternity; age’. Both ‘Melioris’ and ‘Aevi’ are in the genitive case. “Melioris” is an adjective, and it describes “Aevi”. Thus, one rendering of this motto is “Hope of a Better Age”.
am/pm: We use these contractions all the time. They stand for “ante meridiem” and “post meridiem”, which literally mean “before the mid-day” and “after the mid-day” respectively. Fascinating, isn’t it?
Dominus illuminatio mea: This is Oxford’s motto and it means: “The Lord is my light”. Not too tough, right?
eg/ie: These are among the most frequently used Latin contractions. They stand for the Latin “exempli gratia” and “id est”, which mean “for the sake of example” and “that is” respectively. Many people use them wrongly. The use of the former is self-explanatory, hopefully. The latter is used when when you are re-phrasing something (ie using other words). See what I did there?
etc: This is short for the Latin “et cetera”, which means “and others”.
ibid: You might see this in research papers and academic writing. This is short for the Latin “ibidem” and means “in the same place”
LLB/LLM: These mean “Bachelor of Laws” and “Master of Laws”, which come from the Latin “Legum Baccalaureus” and “Legum Magister” respectively. You might now ask: why then are there two letter ‘l’s in LLB/LLM? Well, that is because ‘legum’ is the plural of ‘lex’, the Latin singular for the word ‘law’. Latin plurals often abbreviate by doubling the first letter (eg ‘pp’ for pages).
NB: When you use BC, ensure that you put the year before the term BC (i.e. 37 BC), whereas the year comes after the term AD (i.e. AD 2019). Were you wondering what NB means? Well, it is short for the Latin “Nota Bene” which literally means “good note”. It is from the Latin word “bene” that we get words such as benevolence, benediction (literally means “good words”) and of course, the name Benedict.
Nil Sine Labore: This is VJC’s motto. The word “sine” here means ‘without’ and this word also appears in the phrase “sine qua non”. As you might easily guess, the motto means “nothing without labour”.
PhD/DPhil: Some people have told me jokingly that a ‘PhD’ stands for ‘Permanent Head Damage’. Well, see that lowercase ‘h’ over there? That means that ‘Ph’ is a contraction of a single word. The term ‘PhD’ stands for ‘Doctor of Philosophy’, which comes from the Latin ‘Philosophiae Doctor’. Do you see that ‘-ae’ ending in ‘Philosophiae’? Well, that is the genitive for you right there. ‘Philosophiae’ thus means ‘of Philosophy’, just as ‘Dei’ means ‘of God’ as we discussed earlier.
PS: This is short for “Post Scriptum”. Traditionally, it is used when you realise that you forgot to write something but you unfortunately, you already signed off on your letter. Given that digital communication is increasingly ubiquitous, using PS doesn’t make sense anymore, strictly speaking.
QED: Some people erroneously think that this means “Quite Easily Done”. This is actually a contraction of the Latin “Quod Erat Demonstandum”, which loosely translates to “that which was to be demonstrated”. It is often found at the conclusion of mathematical proofs.
Veritas: This is Harvard University’s motto. It is Latin for ‘truth’. Veritas is the goddess of truth in Roman mythology. It is where we get words such as ‘verify’ and ‘veracity’. It also follows that we are not using the word ‘very’ correctly.
viz: This is short for the Latin “videlicet”, which means “namely”. This is another one of those terms you will encounter in academic writing. This belongs to the realm of words with “et al”, “ibid”, etc.
As I hopped on to my computer to conduct a search on Google this morning, I noticed that today’s doodle featured lanterns. Did you notice that there is a pig in lieu of what would be the second letter ‘o’? Hahaha. In Singapore, people are busy with their work and school and oftentimes, if there isn’t a public holiday associated with a particular event or festival, it gets overlooked, and nobody knows about it.
According to the relevant Wikipedia article, the Lantern Festival, also known as the Spring Lantern Festival, is a Chinese festival celebrated on the fifteenth day of the first month of the lunisolar Chinese calendar. It marks the final day of the traditional CNY celebrations. It is the Chinese equivalent of Valentine’s Day. Since the Chinese calendar is lunisolar (read my previous posts for more details), the day of the Lantern Festival would thus not fall on the same day from year to year in the Gregorian calendar. Likewise, the first day of CNY varies from year to year.
I know what you’re thinking: are there years where the Lantern Festival falls on February 14, Valentine’s Day?
Indeed, such years exist. However, they are uncommon. The last year in which the coincidence occured was 2014, and the coincidence occurs every 19 years. Hence, the next year where such a coincidence occurs again would be 2033.
Today, 19 February 2019, marks the day of the Lantern Festival. As early as the Western Han Dynasty (206 BC-AD 25), it had become a festival with great significance. During the Lantern Festival, children go out at night carrying paper lanterns and solve riddles on the lanterns (simplified Chinese: 猜灯谜; traditional Chinese: 猜燈謎).
In ancient times, the lanterns were fairly simple, and only the emperor and noblemen had large ornate ones. In modern times, lanterns have been embellished with many complex designs. For example, lanterns are now often made in the shape of animals. The lanterns can symbolize the people letting go of their past selves and getting new ones, which they will let go of the next year. The lanterns are almost always red to symbolize good fortune.
It should not to be confused with the Mid-Autumn Festival; which is sometimes also unhelpfully also known as the “Lantern Festival” in locations such as Singapore and Malaysia. The MAF celebrations are significant, particularly in my alma mater, Hwa Chong Institution, where it serves as one of the significant celebratory events of the year!
I can still remember exactly how I started learning the piano. My family had paid a visit to Plaza Singapura and as a boy at the tender age of six, I marvelled at the majesty of the grand pianos that were showcased at one of the top levels of the mall. For those who are familiar with Plaza Singapura, the store which showcased the pianos was, and still is, the flagship branch of Yamaha. I enjoyed visiting malls as a child because of the sheer myriad of products that would be displayed. Hitherto, I was intrigued with music. This first-time visit to Plaza Singapura was my first time in real-life seeing grand pianos displayed in their full grandeur.
Previously, I had known that pianos were common instruments used for music-making, and that pianos were perhaps among the most versatile instruments. One of my favourite shows as a child was “Tom and Jerry” and I remember one episode to this day. It was entitled “Cat Concerto”. As you might guess from its name, that episode has something to do with music. Basically, it featured Tom playing the well-known Hungarian Rhapsody No. 2 by Franz Liszt. A single sentence summarises the narrative of the episode: “Tom fights off Jerry as he tries to disrupt his concert without missing a note on his piano.”
Here is a video of someone trying to synchronise her actual playing with the chronology of the episode!
As typical of Liszt, this piece is a somewhat show-off piece and is appropriate indeed for this episode. One thing I greatly enjoyed about the piano (or keyboard instruments in general) was its ability to allow the pianist to play more than one voice at once. Potentially, up to ten notes could be played in a single instant. The bass and the treble are covered. Thus, a piano is a “complete instrument” in its own right. I once learnt a piano transcription of Bach’s famous aria from his third orchestra suite in D Major, BWV 1068, better known as “Air on the G String”. This is one of my favourite pieces of music. The piano transcription was comprehensive in that it basically covered all the voices that would be played by the various stringed instruments. The ability to play multiple voices on the piano allowed me to cover the parts of the first and second violins, violas, and cellos.
So, as a six-year-old, I stood rooted to the ground as I appreciated the beauty of the pianos within the store and soon enough, I found myself sheepishly imploring my parents if I could learn how to play the piano. They replied in the affirmative. It wasn’t an immediate decision, though.
My parents had no formal musical training and they must have been surprised at my question. I constantly look back and am grateful that my parents had faith in me that I would learn it well, despite knowing that they were treading unknown territory. After all, I was the oldest child and I was almost always the guinea pig. I essentially served as a precedent to guide the path for my younger siblings to follow. It wasn’t an entirely smooth-sailing journey, but I am glad with where I am today. My situation is quite unusual in that usually, it is the other way around. In a society such as Singapore where many parents have a “kiasu” mentality (a fear of “losing out” to other people) and want the best for their kids, music lessons are authoritatively inflicted upon their children. The harsh reality is that many parents live vicariously through their children. They want their children to achieve their dreams because they were not able to do it themselves while they were younger.
I suppose a major factor that made my parents decide to support my endeavour was the fact that there was a well-known pianist who lived just a few floors above us in our block. She had students who would come from as far as Woodlands to her house for 1-hour piano lessons. She was a concert pianist who had studied music at university. Her fees were somewhat high, as you can imagine. Nevertheless, her students’ parents must have felt that it was worth it, given her impeccable qualifications.
What truly astounded me was what I saw when I first walked into her penthouse. It was my first time seeing a grand piano in a house. She had not one, but two grand pianos! Who in the world has two grand pianos in his house? It is already amazing that a house can have a grand piano. Most homes only have an upright! What was even more incredible that one of them was a Steinway! Of course, I did not know that I was playing on such an exquisite and fine piano when I first started lessons as I did not know about Steinway’s reputation then. Before I played on the Steinway each lesson, she would make it a point that I use the hand-sanitizer!
One of the first songs I learnt which involved playing both hands was a simplified rendition of the hymn “As The Deer”. It was a simple two-part piece (with each hand playing once voice). The hymn is based on Psalm 42:1-2 which reads from the Authorized Version:
1 As the hart panteth after the water brooks, so panteth my soul after thee, O God. 2 My soul thirsteth for God, for the living God: when shall I come and appear before God?
Fun fact: The word “hart” is a more specific word than the generic word “deer” as “hart” refers specifically to an adult male deer. You might then ask, “What is the word for a female deer then?” Well, I think the first line of a famous song from the musical “Sound of Music” is instructive. After all, “Doe, a deer, a female deer…”.
I enjoyed playing the piano initially but somewhat lost interest as I progressed through primary school. This can be attributed to various reasons. However, I opine that the most significant factor was that the popularity of computer games was experiencing burgeoning growth. My classmates introduced it to me while I was Primary 2. Naturally, I was intrigued by how computer games work. I was most fascinated with the fact that you could communicate with someone from another part of the world by simply transmitting information across the “Internet”, which was novel to us primary school students then.
It also didn’t help that progression in piano learning was marked by the milestones of passing the grade examinations of music boards (for ABRSM, the most well-known music board in Singapore, the grades range from 1 through 8). I suspect that many music students have their interest in music waned because a huge component of the ABRSM grade examinations is the “Set Pieces” section. Students are required to present three set pieces (each of which has a maximum mark of 30; the grade examination has a total mark of 150). Hence, the set pieces account for 90 of the maximum 150 marks. Parents who are results-oriented (*cough cough* basically the typical parent in Singapore) would thus encourage their children to practise the same three pieces over and over again. Each of the three pieces has its own category (A, B, C). For the grade examinations, there would be a range of pieces to choose from within each category. A huge factor that goes into the decision-making process for choosing which piece to prepare for the exam is its technical difficulty. Once again, it goes back to the marks. Whether the student enjoys the chosen piece is secondary to the technical difficulty of the piece. After all, to us, the ends justify the means, doesn’t it?
As such, I would imagine that in many cases, teachers choose the pieces which they think their students can score the highest marks in. Often, this is a piece which presents the least technical challenge. After all, for a teacher to continue attracting students, it is certainly helpful if he can speak of how his students have achieved stellar results in the music examinations. Of course, I was quite fortunate in that this concert-pianist teacher of mine was not like that. She allowed me to choose the pieces I wanted to play for the examination. Nevertheless, the monotony associated with practising the same three pieces incessantly for an examination got to me. When coupled with the increasing popularity of video games, other time-consuming activities, and increasing academic rigour, it is not difficult to see why so many students today abandon their initial musical endeavours. Many parents’ desires are insatiable. Their children must go for swimming lessons, ballet classes, tuition, taekwondo classes, and in some cases, even abacus classes for better mental calculation. Wow.
My first-ever piano exam was an ABRSM Grade 2 (2005), followed by a Grade 5 (2008). I think the reason I stopped lessons with my first piano teacher was that I was preparing for the PSLE. Furthermore, I no longer had much interest in piano. As such, the high fees were not justified, and lessons were stopped.
Shortly after I completed the PSLE, my parents got me to learn under another teacher within the same condominium complex. However, the arrangement was ephemeral. We changed piano teachers yet again and alas, I started attending a music school near my house. The teacher under whom I learnt piano would be my last piano teacher. I wasn’t a serious student. Nevertheless, I just did things for the sake of doing things, went with the flow, and managed to get my Grade 6 (2011), and Grade 7 (2013) exams under her tutelage.
On a fine afternoon while I was attending the music school, everything changed. On that day, while waiting for my turn to enter the room within the music school for my piano lesson, I listened intently to the piece that the student before me was playing. I liked it so much, but I did not know what it was called. I was determined to find out what it was called so that I could learn it. Eventually, the door opened and out walked the girl who had been playing that piece (which turned out to be one of her three set pieces for her Grade 6 exam). It was that day that I learnt about Dussek’s Sonatina in E-flat, Op. 19, No. 6: Rondo Allegretto (A2 of the 2013-2014 Grade 6 Piano Syllabus). It is a charming piece. I highly recommend you to listen to it!
Soon enough, I looked at music through a different lens and started learning all the pieces I liked, and re-learnt past exam pieces that I enjoyed thoroughly. Most importantly, I spontaneously learnt pieces that were beyond the examination repertoire of the grade examinations. I flipped through the music books that I had, and learnt one of Mozart’s most endearing piano sonatas: Piano Sonata in C Major, K545. I also learnt transcriptions of soundtrack from film, animation, and even games. This was done by actively scavenging the Internet for sheet music that other musicians had painstakingly transcribed.
However, one of the most serendipitous events that motivated me to aim for even greater musical heights occurred while I was a Secondary Three student in 2012, perhaps a few months after I had heard the rondo in the music school. At that time, I had already completed my Grade 6 and was preparing for my Grade 7 exam. One day, I was walking along the backstage of the school hall when I chanced upon my classmate playing on the piano. I knew that he was a bassoonist in the school’s symphonic band, but I never knew that he could play the piano. I found out that he was an accomplished pianist, percussionist, and violinist, in addition to being a bassoonist. This was a student who truly embraced music. I played my Grade 7 exam pieces for him and I was encouraged by his particularly kind remarks of my performance of the piece from the A category, a piece by Scarlatti:
When I encountered him in the school hall, before I performed my piece, he was playing Scherzo No. 2 by Chopin. It is a very famous piece. In fact, in the established general repertoire, it is over-played.
We became quite close and we would share our musical insights with each other. In fact, I am very grateful to him for introducing IMSLP to me. That platform has been useful in allowing me to obtain even the most obscure sheet music. All sheet music and resources on IMSLP are public domain! That helps many people because published music books in music stores are often expensive. Often, one is faced with the scenario where one is only interested in a particular piece among a set of pieces. However, music stores often will not sell the sheet music of a single piece that is part of a larger set on its own, unless the single piece is so famous to the extent that it gets its own product (e.g. the Pathétique sonata by Beethoven). As such, if one were to get sheet music from music stores exclusively, one would have to pay a lot.
Eventually, I passed the Grade 7 exam in 2013, which also happened to be the year I took my GCE ‘O’ Level exam. Due to the fact that I wanted to focus on preparing for the ‘O’ Level and that I had attained a milestone, I decided to stop lessons. Who could have known that that would be the last time I would have a piano teacher? From that point on, I self-learnt and prepared for all subsequent music examinations all on my own.
I actually did not want obtain my Grade 8 Piano initially, at least so soon after my Grade 7 exam. However, a few months before the GCE ‘O’ Level exam, in September 2013, I met another person in yet another moment of serendipity and inspired him to take up music again. He learnt the violin from a young age and attained Grade 8 when he was Primary 5 (c. 2008). However, from what he related to me, he did not enjoy it one bit. He saw it as a chore and had the mentality of “Good riddance” when he finally obtained the Grade 8 Certificate. He told me that ever since he passed the Grade 8 Violin exam, his violin case had been left dormant in his cupboard, untouched for half a decade. I am glad I managed to play a role in helping him rekindle his passion for music, because he is currently undergoing a Music Performance diploma at NAFA (Nanyang Academy of Fine Arts), majoring in violin. I think life would be very different for him if I had not met him on my way back home from school one fine afternoon.
This person was also somewhat decent at the piano. He was self-taught as I knew that he had never gone for formal piano lessons. Apparently, his older brother learnt piano but stopped at Grade 6, if I remember correctly. So, he had a piano in his house. It must have been after the ‘O’ Level, sometime in December 2013, that I went to house and was surprised to see that he had purchased the Grade 8 Piano Exam Pieces book. I was impressed by his ambition and so I thought: if a self-taught person dared to attempt the Grade 8 exam on his own without having had any formal piano lessons ever, surely I, a Grade 7 holder, could?
My first day in junior college was 6 February 2014. There had been approximately a three-month interim period between the conclusion of my last paper of the GCE ‘O’ Level and the start of JC. It was during this three-month period that I chose which pieces I would want to play, based on what I felt was the most musically enjoyable. Remember that I was on my own. I had to learn the scales, arpeggios, and all the pieces on my own without the help of a teacher. It was daunting.
By that time, I had grown to like the music of Bach, Mozart, and Chopin (for sheer majesty of musicality, Bach’s music reigns supreme; however, Mozart’s melodies are unparalleled). Hence, my choice pieces were quite easily selected (for the Grade 8 Piano 2013-2014 syllabus):
I chose the following three pieces: A5: J. S. Bach – Praeambulum, 1st movt from Partita V in G, BWV 829
B6: Mozart – Rondo in D, K. 485
C9: Chopin – Waltz in F, Op. 34 No. 3.
These are all such charming pieces. Even though I practised the pieces repeatedly, I never felt that they were stale. Somehow, now that my learning and preparation was entirely self-motivated, everything was different. I yearned to quench my thirst for musical prowess and perfection.
Eventually, I sat for my Grade 8 Piano exam. I still remember how that morning went vividly. It was around 9:30 am on 19 August 2014, Tuesday. I was having an Economics lesson and when it was appropriate, I told my teacher that I needed to take my leave to attend the exam. I then proceeded to the area outside one of the school’s auditoriums to have my last-minute practice on the piano while waiting for my father to come to the school to fetch me to the venue: Regent Music Centre Pte Ltd (Schubert) at Peninsula Shopping Centre. My exam timing was 11:15 am.
I remember telling the examiner prior to the examination’s commencement that I was feeling anxious. He reassured me and told me to remain calm. I suppose I was quite encouraged by his gracious gesture. Then, the exam started. “Would you like to play the scales or pieces first?” he asked. “Scales”, I replied, heeding the advice by my previous teachers to always play the scales first because they served as a form of ‘warm-up’ for one’s fingers. I remember doing the sight-reading section better than I normally would. The rhythm and note accuracy was great. However, the tempo was just too slow. I also played the three pieces somewhat well. After the exam, my father drove me back to the school and all I could think about were the aspects of the exam that had not gone as well as I had expected. When I returned, it a Physics class.
Soon enough, I received the results of the Grade 8 Piano exam and…
I had obtained a distinction as icing on the cake!
I was ecstatic. I had never achieved this before. Also, I achieved this without a teacher’s help. The highest I had previously attained was a merit!. I was incredibly humbled by this result.
After receiving this result, I was glad that I had attained this milestone. Having their children attain a Grade 8 qualification is something that many Singaporean parents hope for. For many Singaporean parents, this milestone would mean a sigh of relief as they no longer have to fork out money for expensive piano lessons or having to endure listening to the same exam pieces over and over again. For the children of such parents,such an achievement would also warrant a sigh of relief because it would mean they no longer have to “waste time” on music-making. They could now spend the time on hanging out with their friends, or dedicating the time on their academic pursuits. What is the one thing we see in common in the most typical mindsets?
Music is not treated as an end unto itself. Rather, it is used as means for something else. Parents and their children may use it for superficial “bragging rights” when “comparing” with other parents’ children; some use it to boost their portfolio for admission into prestigious institutions. What happened to the intrinsic joy that music is supposed to fundamentally spark?
Do the learners use the skills they have acquired from their musical training to learn pieces outside the examination syllabi which they would genuinely enjoy? From what I have observed among my peers, that does not seem to be the case. Most of my peers whom I have observed were somewhat glad when the ordeal of music lessons came to an end (either when they hit a satisfactory milestone or they stop lessons due to commitment issues, financial burdens, reluctance to practise, etc.)
I did my two years of junior college from February 2014 to November 2015. I then did my two years of full-time NS from January 2016 to November 2017. Then, I started my medical studies February 2018. From the time I passed my Grade 8 in August 2014 till the end of my first semester of my first year in university in June 2018, I entertained the idea of doing a diploma. Although Grade 8 is still seen as the “standard” end-game milestone for most learners of music in Singapore, I nevertheless knew of friends who went beyond Grade 8. Perhaps they (or their parents, hmm) wanted more of a challenge.
After the grade examinations, there are what we call ‘Diploma’ examinations. For Trinity College London and ABRSM, they each award three levels of music diplomas. For simplicity’s sake, let us only consider performance diplomas, since these constitute the diplomas that the majority of learners would take. For Trinity College London, the three levels are: ATCL (Associate), LTCL (Licentiate), and FTCL (Fellowship). According to Trinity College London’s website, an ATCL award is equivalent in standard to the first year of an undergraduate degree; an LTCL award is equivalent in standard to the final year of an undergraduate degree; an FTCL award is equivalent in standard to a postgraduate course at a conservatoire or university. For ABRSM, its three diplomas are DipABRSM, LRSM, and FRSM. They are equivalent to the ATCL, LTCL, and FTCL diplomas respectively.
All but one of the people whom I know personally took the ATCL. Regarding that one person, she took the LTCL. I do not know anyone personally took the ABRSM diplomas. This could be because of the disparity in the assessment criteria for the ABRSM and TCL diplomas. ABRSM demands a more holistic assessment of the candidate’s musicianship. There are more regulations associated with the exam and there is just a lot more to deal with. On the other hand, TCL places an emphasis on the performance component. Here is some information pertaining to the DipABRSM syllabus (with effect from 2015):
Having considered all the above information, I made the pragmatic decision to do the ATCL instead of the DipABRSM for the following reasons:
1) In strict consideration of qualifications, an ATCL is equivalent to a DipABRSM. The general public would probably not even know that there are three different diploma levels, let alone the differences between the music boards regarding assessment criteria for performance diplomas.
2) The presence of additional components of Viva Voce and Quick Study in the DipABRSM requirements strongly suggests that the weighting of the performance component is lower in the DipABRSM (60% performance; 25% Viva Voce; 15% Quick Study) than in the ATCL (90% before 2019 syllabus revamp; 10% Programme Notes). Considering that most people associate a Performance diploma with one’s ability to perform music, I feel that giving the performance component as high a weighting as possible is desirable. After all, we are not dealing with a general musicianship diploma, but a performance diploma.
3) I felt that I could excel more in the performance component than the Viva Voce and Quick Study. Hence, I felt that I had a much better chance of overcoming the hurdle of meeting the assessment requirements. It is easy to see why many people would be somewhat more uncomfortable with the requirements of the DipABRSM. There is so much more uncertainty associated with the non-performance aspects of the diploma. The fees for the diploma are certainly not cheap. I doubt anyone has the intention of failing when registering for the diploma examination!
4) Performing ability was, and is, ultimately what I, and probably many others, deem to be the most important element of being a musician.
Apparently, the ATCL examination I took turned out to the be one of the last of its kind as the Trinity College London diploma syllabus had undergone a revamp that would be valid from 1 August 2019. Among some of the changes include detailed programme notes no longer being required for the ATCL and LTCL, and that there would be increased mark weighting for performance. This would mean that candidates can be sure that their result fully reflects their performance standard.
By June 2018, nearly four years after passing my Grade 8 in August 2014, probably no fewer than a dozen people had asked me if I were going to take a performance diploma after finding out that I was a Grade 8 Distinction holder. My answer had been that I had no intention of pursuing a diploma as there were many things that deterred me from doing so. However, as time went on, I learnt more pieces and I felt that perhaps this next milestone would be a better reflection of my musical abilities and that it would certainly be a nice pat-on-the-back. Furthermore, as the wise words of a friend’s motto go: “Anything worthwhile doing will often be difficult, but doing the difficult is often worthwhile.”
Nevertheless, here were the issues that discouraged me from deciding to get a diploma in end-June 2018.
I only had short time frame to decide whether to register for the diploma examination. TCL Diploma examinations are held twice a year in two periods: mid-May through June and mid-November through December. The former option would not be feasible since I would still be studying in Australia during that time. I have only two major breaks as a university student every year (a winter break of around three weeks in July, and the much longer summer break of around three months from late November to late February).
Since the mid-year exam period was not an option for me, I could decide to do the examination either in November/December 2018 or November/December 2019. Remember the syllabus revamp I talked about that would be effective from 1 August 2019? Well, I considered the syllabus changes when I contemplated the two options.
At the time of decision-making (end-June 2018), I was of the view that the Programme Notes would offer easy marks, at least relative to the performance component. Seeing that the latter option had a decrease in weighting, I felt that I would have a much better chance of doing better in the old syllabus. Hence, being more inclined with the examination being in November/December 2018 period, I would have had to deal with full-time university commitments during my second semester of 2018 while preparing for the ATCL from scratch in only 4.5-6 months. 4.5 months would be the worst-case scenario (if I had gotten an exam date which marked the start of the examination period). Hence, when booking the exam date, I requested to be given a date which was as late as possible, since I would only be back in Singapore on 23 November 2018 (imagine the horror of getting an exam date before you fly back; they are very strict about exam dates and one can only change the dates without penalty under very limited circumstances).
I had no teacher to guide me. It had been five years, since 2013, that I had a formal piano lesson. I was treading on unknown territory as this was nothing like the grade examinations I had taken previously. There were so many more requirements, and the pieces were much more challenging. Anybody who thinks that an ATCL is a linear step-up from Grade 8 like the step-up from Grade 7 to 8 should reconsider his perspective. Doing the ATCL without any guidance from a teacherwas unheard of since even the syllabus explicitly recommends the following:
I had absolutely 0 of the suggested 54 guided learning hours, and if one were to consider 900 hours over a 5-month period, that would work out to be an average of 6 learning hours a day every day just to prepare for this exam. That is excluding the fact that some of the hours are supposed to be guided. It is because of such proscribed requirements that it is quite common to take around 1-1.5 years to prepare for the ATCL (54 guided learning hours would be 54 weeks of weekly 1-hour lessons). The stakes were high as the examination fees were nearly 1k SGD.
Everything seemed to suggest this was a suicide mission.
Yet, the sheer sense of adventure was exhilarating. It also helped that I truly liked all the pieces I chose for the exam (more on that in another blog post).
So, the ambitious and perhaps over-confident Nicholas registered for the exam in early July 2018, while he was in Singapore for his winter break of a few weeks. In that short time in Singapore, I put in the effort in obtaining the currently-published music books which contained the pieces that I was going to perform. I had the choice of performing pieces absent from the syllabus list. However, I already had a full plate and I did not want to add another element of uncertainty. Besides, self-selected pieces were subject to prior approval. I had inspected the syllabus, and after much contemplation, I decided to perform the following four pieces:
1. Bach – Prelude & Fugue in A-flat Major, The Well-tempered Clavier, Book I, BWV 862
2. Beethoven – Piano Sonata No. 8 in C Minor, Op. 13 – ‘Pathétique’
3. Chopin – Nocturne Op. 48 No. 2
4. Rachmaninoff/Kreisler – Liebesleid (from Piano Compositions No. 2)
The examination had strict regulations regarding music protected by copyright. For the examination, I was required to present the examiner with photocopies of the sheet music of the music that I would be performing. To ensure that the music was not illegally obtained, I had to bring the original sources, and that meant having to bring legitimate music books.
Strictly speaking, I could have used music from IMSLP, since resources from that website are public-domain. However, I wanted to play it “safe”.
The pieces by Bach and Chopin were not an issue since I already owned reputable editions of The Well-tempered Clavier, Book I and Chopin’s Nocturnes. Hence, I needed to purchase books for the pieces by Beethoven and Rachmaninoff/Kreisler. Astute readers would remember that I mentioned how single pieces get published alone despite being part of a well-known larger set of works only if these single pieces are very famous. The Pathétique sonata was the perfect example. I managed to find a seller on Carousell who was selling a second-hand ABRSM edition of the sonata for only $4. How happy I was when she agreed to sell it to me for that price! Music books are typically very expensive and I was glad that I could a well-maintained second-hand copy which contained just the piece I needed.
On the other hand, attempting to procure the Rachmaninoff/Kreisler piece was an absolute nightmare. The piece is not that well-known because it is a piano transcription by Rachmaninoff of a piece for violin by Kreisler. The transcription is part of the second volume of Rachminoff’s “Piano Compositions” (the second of three volumes).
I called up stores. “Out of stock”, and “Check the other branch” were all I got over these phone calls. Time was tight and I had less than a week at that time before I flew back to Australia. There was no way I could wait for shops to re-stock. Over the course of a few days, I checked out Synwin’s two branches at Tanjong Katong Complex and Marina Square, a music store at the Esplanade, and music shops at Bras Basah Complex and Serangoon NEX which sold piano books, all to no avail. It was absolutely futile.
Can you imagine how ridiculous this situation was? Many music shops I visited were within the CBD area. I remember one afternoon where I walked from one location to another, under the unforgiving rays of the Sun. It was ruthless. It was a cycle of finding temporary solace in the air-conditioned music shops and trudging in vain to yet another location in the sweltering heat.
Then finally, as a last stand for one of the days, I decided to go to Yamaha’s flagship branch at Plaza Singapura, the place where my musical journey had begun nearly a decade and a half ago. It was a long walk from Marina Square. I was so disheartened when I realised that the store did not have the book. Before the leaving the store, I decided to ask the counter staff if they could help me probe their database to check if they had any other branch which had it.
Words fail to describe the joy I felt when I was told there was one last copy at Yamaha’s Tampines Mall branch. It was the only one of two copies left across all of Yamaha’s branches in Singapore (I was told there was another copy at Yamaha’s Thomson Plaza branch). However, I had already made plans to visit a friend briefly to collect some stuff from him that afternoon. So, that was what I did. I left for my friend’s house after leaving Yamaha’s flagship branch. After collecting the stuff, I made my way for the Tampines Mall branch. I chose the Tampines Mall branch instead of the Thomson Plaza nranch as it was more convenient for me. At my friend’s house, I gave the Tampines branch a call, asking if I could reserve the book. They told me that I would need to come by tomorrow, and if not, the reservation would be forfeited. To their statement I replied, “I’ll be there in 40 minutes”.
I gave them my phone number and off to the Tampines branch I went. I was unfamiliar with the region of Tampines and confused Tampines 1 (another mall) for Tampines Mall. No sooner did I arrive in the Yamaha store at Tampines Mall than I headed straight for the counter, telling them that I had a reservation. The counter staff opened one of the drawers at the counters and revealed a book. Yes, that was the book. I did a final check by flipping to the sheet music for the examination piece within the book.
By the time I purchased the book, it was 8pm – one hour to the store’s closing time. I had not eaten my dinner; yet I was satisfied beyond that which words could describe. The bus ride was unpleasant. It was raining and the roads were congested. The bus was packed. However, that didn’t matter. I finally obtained the book.
How apt that the name of the piece within this book was Liebesleid, which is German for “Love’s Sorrow”.
With the four books that I now had which contained the pieces that I would perform for the ATCL, I headed back to Australia for my second semester. I knew that I had to master all four pieces before I came back to Singapore to sit for the ATCL exam.
While in Australia, I learnt of this app called forScore. It is a paid app, and is used by many professional musicians. How it works is that instead of learning from the physical music books, you can instead learn from the digital sheet music. So, I scanned the relevant pieces from the four books and imported them as PDFs to the app. In retrospect, getting the app was an excellent decision. I should have gotten the app much earlier. This app offered me the following advantages:
1) I would not have to deal with the physical weight and space that is associated with the books. The app is on my iPad and the display is just perfect. The Apple Pencil truly allowed for a realistic experience of annotating the music just as I would with normal book-and-pencil.
2) I wouldn’t mind annotating the book as I deem fit to aid my learning. Personally, I treat books with a lot respect and the most I am willing to do to physical books is to put a faint mark with a pencil!
3) Since my iPad would usually be with me (I use it for a lot of my work), I could access the scores readily and study them with much flexibility.
To cut the long story short (well, this blog post has been quite long), I managed to finish learning the pieces in the short time I had. I was very glad when the administrators of the exam told me that they had given me one of the latest dates within the examination period: 19 December 2018. I was so grateful for this as I had nearly a month to practise even after arriving in Singapore on 23 November 2018.
Finally, the day had come. My examination time was 10:10 am. I had not tickled the ivories for two days leading up to the exam because I had been attending my church’s youth fellowship camp.
I was the second candidate for the day. I sat outside the examination room, thinking, while hearing the magnificent playing of the candidate before me: “It has been two full days since I touched the piano, four years since my last piano exam, and five years since a piano lesson“.
What could go wrong, right?
There were so many things that could go wrong.
Here was my examiner’s profile:
The piano was a Kawai grand. I sat down on the bench, and the examiner’s bench was on my right.
Before I knew it, the examination was over. I headed back to church immediately after the examination to continue my participation in the camp.
Then came the dreaded wait for the examination results.
On my registration form, I had indicated that I wanted to collect the certificate and results from Parkway Parade branch (the main branch) since that was where I took my examination. However, a few weeks after the examination, I requested for a change in collection venue to the Paragon branch. I was quite surprised when that request was granted.
On Wednesday, 13 February 2019, during my visit to National Gallery Singapore with a friend, I received an e-mail which I knew also had the scanned copy of the mark sheet attached to it. I did not check it immediately, for I feared that seeing a fail mark would kill the mood of what would be a highly enjoyable afternoon.
At some point during the visit, I was alone in the toilet and I had an internal debate: “Should I check the results only after I get home?” “I’m going to regret checking this if it turns out that I failed.” Eventually, I decided to check it after about thinking for about half a minute. Though it was only about 30 seconds, those 30 seconds felt like an eternity. I decided to do the rational thing. If I had failed the exam, then so be it.
I clicked on the blue-and-white Mail app icon on my Home Screen.
I clicked on the second e-mail under “All Inboxes”.
I flicked up and clicked on the attachment entitled “Loh Chieh, Nicholas.pdf“.
A chunk of text appeared – revealing the examiner’s detailed comments. My eyes darted straight for the lower right-hand corner of the screen.
“Total: 66/100”
I had PASSED!! What a relief! So many thoughts ran through my mind. I shared the news with my family and thanked God. I also shared the wonderful news with my friend. It was a joyous occasion indeed!
When I got back home that evening, I arranged for a lunch meeting with the doctor with whom I had done a clinical attachment. Since I intended to go to Paragon the next day to collect the result, I figured I might as well pay him a visit. After all, his clinic was one of the private suites in Mount Elizabeth Hospital Orchard (just opposite Paragon). It had also been a month since I had finished the fortnight-long clinical attachment with him.
Everything fell perfectly into place. I reached the music school at Paragon at 11am (as stated in the e-mail, it was the earliest I could go to collect the certificate and results). It was a painless process. There was this other lady who was a piano teacher collecting the results on her student’s behalf. She thought I was a piano teacher who was collecting the exam results on his students’ behalf. HAHAHA. After the collection of the certificate, I went for lunch with the doctor and other students who were doing their clinical attachment with him. We had an enjoyable time together at a Japanese restaurant.
For the ATCL, the pass mark is 60, and the minimum mark for a distinction is 80. I was slightly disappointed that I did not achieve a distinction, but oh well, I guess one cannot have his cake and eat it too. As I reviewed the examiner’s comments, I managed to draw some precious insights. First of all, what was most jarring was that I had actually fared worse for the non-performance component (10% allocated to the Programme Notes) than the performance component! How ironic. I had assumed the opposite initially!
Also, as expected, she felt that my best-performed piece was the first piece: the piece by Bach. I was not surprised by this as Bach is my favourite composer and an overwhelming majority of the pieces that I have learnt are by Bach. So, one mistake is that I didn’t focus on my strengths. The piece by Bach was the shortest piece among the four pieces and it only accounted for slightly more than 10% of the total performance duration (excluding breaks).
In retrospect, I might have gotten a distinction if I had 1) chosen to take the examination in 2019 instead of 2018 (having essentially an extra year to prepare), and if I 2) had chosen to focus more on Baroque pieces. Besides, 3) year-end 2019 is also when the new syllabus takes effect (where the performance component accounts for 96% instead of 90% of the marks). Who knows? Hindsight is 20/20 after all.
I definitely will take these learning points into account if I ever do try for the LTCL. Haha. With all that has been said, I nevertheless still remain grateful for the result I obtained.
To conclude this lengthy blog post, my final word to all aspiring musicians and current learners of music would be to seek the intrinsic joy that music can bring to the table. Music transcends languages, cultures, and time. Cultivate your musical ability and use it to learn music that is beyond that which is established within the music examination syllabi. If you attend a church, learn some hymns and edify the brethren! You could also learn how to play soundtrack from a particular film or game. Make your own transcriptions and covers. The list is endless! Don’t let a piece of paper or the prospect of getting a piece of paper extinguish the flames of passion for music. If it has, then, well, rekindle it.
‘His Robes For Mine’ is a hymn consisting of text by Chris Anderson and tune by Greg Habegger. I first heard of this hymn at the conclusion of my church’s youth fellowship camp last December. This hymn was used as the background music of the church camp’s montage. The montage was shown at the end of the camp and yet again during the combined anniversary service of the Youth Fellowship and Young Adults’ Fellowship on New Year’s Eve – which took place prior to the Watchnight Service (a late-night service which commemorates God’s faithfulness in the past year and prepares us for the coming year).
When I first heard the hymn, I was amazed not just by the majesty of the melody and harmony of the tune, but also the sheer theological depth of the hymn’s text. This hymn has had an indelible impact on me, to the extent that I feel much compelled to write this post.
With much gratitude to reference [1], here is the lyrics for ‘His Robes For Mine’, along with my insights from the lyrics:
1. His robes for mine: O wonderful exchange! Clothed in my sin, Christ suffered ‘neath God’s rage. Draped in His righteousness, I’m justified. In Christ I live, for in my place He died.
Ask a typical ‘Christian’ in contemporary Singapore, who is only Christian because of his parents’ religion status: what the effect of Christ’s death on the cross at Calvary was. Most will only say that Christ has forgiven them of their sins as our sins have been imputed unto Christ. Their explanation stops there. They fail to address what the sins were exchanged for. This is haply the consequence of an anthropocentric culture that pervades modern liberal Christianity. The first line of this stanza tells us that this is not all. An exchange has taken place, and how wonderful it is! An exchange is two-way. On one hand, our sins have been imputed unto Christ, the sacrificial Agnus Dei. On the other, his righteousness was imputed unto us (cf 2 Cor 5:21; Rom 3:19-4:8; Phil 3:9). Such is the essence of an exchange. The imagery of ‘robes’ in this hymn is supported by Scripture (Isa 61:10; Zech 3; Matt 22:1-14; Rev 7:9-14), as the doctrine of imputed righteousness and unrighteousness is often pictured by the exchange of garments. Kudos to reference [1] once again for the valuable verse references.
This counters people, particularly those whom are fed the heretical ‘Hyper-Grace’ messages in certain churches in Singapore and around the world, who treat the Son’s expiation as a total farce. They go to the extent of even saying that they can continue indulging in sin because Christ has forgiven them and would forgive them of their sins as long as they ‘believe’ in Him. In sum, hyper-grace teachers turn ‘the grace of our God into lasciviousness‘ (Jude 4), and into a license for immorality. They and their followers flirt with antinomianism (the false belief that there are no moral laws God expects Christians to obey; see reference [3] for more information). It is indeed unfortunate that such people have been imbibed with a spurious understanding of the work of Christ at Golgotha. The rest of the stanza elaborates on the mechanism of substitutionary atonement.
I truly appreciate the structure in this hymn because the latter part of the second line in this stanza alludes to its analogue in the refrain. The idea of Christ suffering underneath God’s rage baffled even the earliest of theologians at the Council at Nicaea. Are not both God? How can God exist as three distinct persons, where the Son is subordinate but not inferior to the Father? The core of this statement is the doctrine of the holy triune God, better known as the Trinity.
The last line reminds me of Galatians 2:20, which was coincidentally the theme verse for the youth fellowship camp last year. Many years ago, I was given a gift of memory verse cards which, as you might easily guess, aid in memorising verses. One of the first verses I worked on was Galatians 2:20. Time and time again, this verse has cropped up. When I was still in Adelaide last September, I attended the church’s Integrated Fellowship Retreat, and its theme was “Not I, But Christ” (no prizes for guessing the theme verse). The hymn of the same name (which was also used as the theme hymn in the youth fellowship camp) has its roots in *surprise surprise* Galatians 2:20.
Refrain: I cling to Christ, and marvel at the cost: Jesus forsaken, God estranged from God. Bought by such love, my life is not my own. My praise-my all-shall be for Christ alone.
I did not think much of the words of this hymn until a friend told me about how she was so amazed by the words of this hymn’s refrain: ‘God estranged from God’. To quote her, ‘Who can comprehend such love? The Trinity, which has always been in perfect union since the beginning, had to be broken in order to redeem Man from his sinful state and become the sons of God’. Indeed, for Christians, our existence and entire being should be centered on Christ and the Godhead. The first point the Westminster Shorter Catechism addresses this issue: What is Man’s chief end? Man’s chief end is to glorify God, and enjoy him forever.
2. His robes for mine: what cause have I for dread? God’s daunting Law Christ mastered in my stead. Faultless I stand with righteous works not mine, Saved by my Lord’s vicarious death and life.
The word ‘vicarious’ is a big word and those unfamiliar with the faith might not know it. One definition of this adjective is as such: ‘acting or done for another’. Hence, Christ’s death can be described as a ‘vicarious atonement’. The word comes from the Latin word ‘vicarius’, which means ‘substitute’. Basically, this is a fancy word for ‘substitutionary’. Similarly, we have the English word ‘vicar’. According to Wikipedia, a vicar is a representative, deputy or substitute for a superior.
Fun fact: Linguistically, the word ‘vicar’ is cognate with the English prefix ‘vice’ (cf Vice-President = Deputy President).
3. His robes for mine: God’s justice is appeased. Jesus is crushed, and thus the Father’s pleased. Christ drank God’s wrath on sin, then cried “‘Tis done!” Sin’s wage is paid; propitiation won.
The cry of “‘Tis done!” brings to mind John 19:30, which reads ‘When Jesus therefore had received the vinegar, he said, It is finished: and he bowed his head, and gave up the ghost.‘ The wages of sin is death (cf Rom 6:23). However, instead of us who rightfully deserved such a death, Jesus received the wages on his sheep’s behalf. Such is the essence of vicarious atonement. What stark contrast – the Word incarnate who was absolutely free of sin, and at the other end of the spectrum: a group of depraved wretches. The word “propitiation” is yet another one of those theological terms which can confuse those who are unfamiliar with such jargon. According to Google Dictionary, the “propitiation” is “the action of propitiating or appeasing a god, spirit, or person; atonement, especially that of Jesus Christ”.
4. His robes for mine: such anguish none can know. Christ, God’s beloved, condemned as though His foe. He, as though I, accursed and left alone; I, as though He, embraced and welcomed home!
The word “accursed” just means the state of being under a curse. This is similar to the word “athirst”, which describes the state of being thirsty.
Congratulations if you have read this far. I hope this hymn and my insights on it have blessed you.
On the evening of the first day of the Lunar New Year, my family paid my maternal grandparents a visit. In the living room of their residence sat an upright, and it was the piano with which I had grown up. In fact, my earliest videos on my Youtube channel feature that Christofori upright. That upright was the first piano that I used and it was the piano that my home would ever know until late 2017, when my family moved to a larger apartment. The upright was then moved to my maternal grandparents’ place while we procured a grand for our new residence. Since then, I have been playing on the grand while the upright has been lying dormant within the confines of my grandparents’ house.
After dinner at my grandparents’, I approached the upright and opened the lid that I was supposed to be familiar with. Yet, it felt foreign. What a peculiar feeling indeed. I had played on this upright for more than a decade. Yet, merely after a year of not playing on it, even the mere act of opening its lid was strange.
I started playing it and I was shocked. Compared to the grand which I had become accustomed to, this was so…bright. The notes lacked depth, and the sound wasn’t as rich and full as the grand back home. What exactly makes a grand piano better than an upright piano?
The development of the piano goes all the way back to Europe. Originally, all pianos had the shape of the modern grand piano. There were no uprights. Uprights were devised because people either had issues with space and/or cost.
Despite the title, grands don’t necessarily always sound better than uprights. In a holistic assessment, one would consider the material quality, craftsmanship, string length, soundboard size, etc. However, uprights are usually better than grands in somewhat ‘extreme’ cases. For example, the tallest uprights will have longer strings and larger soundboards than the smallest grand pianos (around 5 feet or even shorter). Nevertheless, generally speaking, people who get uprights don’t get the tallest ones, and people who get grands don’t get the smallest grands. Larger soundboards and longer strings will lead to greater tonal quality and volume, ceteris paribus. It goes without saying that a Steinway D-274 would absolutely destroy a 45″ upright any day.
With that being said, why would people not just get the tallest uprights to save on space? After all, they do sound as good as the smallest grand pianos and moreover, space would be less of an issue. The answer lies in the action of grand pianos. Kudos to reference [2], for allowing me to learn the information that I am about to present.
The mechanical components that start with the keys that your fingers depress and end with the hammer that strikes the strings creating the sound constitute the action. In a grand piano, most of the components move up and down, and take advantage of gravity to reset them to the resting position, ready to be played again. From one end of the keyboard to the other, gravity acts uniformly. In an upright piano, many of the parts move in a horizontal direction, and since gravity does not work in that direction, springs are used to move these components back into the rest position. The key takeaway is that while these springs can be regulated to be uniform, they can never bring the same degree of uniformity as gravity!
Springs succumb to wear and tear over time, thus leading to unevenness from one note to the next throughout the keyboard. Moreover, in order to repeat a note on an upright, the key must be allowed to come all the way back to the top of the stroke before it can be played again. In a grand, a note can be repeated after the key has come up about a third of the way to the top. This means that a grand’s action gives the player more control. There is also thus a greater limit to the number of times the same note can be played per unit time when a grand is used.
For most beginning pianists, who deal with incorrect rhythm and notes when playing elementary pieces such as ‘Twinkle Twinkle Little Star’, what I have discussed is far beyond what they need to consider. In most cases where the sound comes out uneven from an upright, the pianist’s inability to depress the notes evenly is the main culprit, rather than the variation in spring tuning. In such cases, the pianist ought to work on finger independence in order to cultivate a tone which is even. However, for seasoned pianists who have mostly overcome these elementary hurdles, the differences between the average grand and upright are magnified when playing pieces which test the limits of the piano.
I used to wonder why the train ride between Caldecott (CC17) and Botanic Gardens (CC19) was unusually long (5-min) while taking the train home from school. I looked at the MRT network map and then realised that there was a skip from CC17 to CC19! Usually, train rides are 2-3 minutes. Sometimes, they can be as short as 1 minute (e.g. ride between Potong Pasir station and Woodleigh station).
Public transport is the most common form of transport in our land-scarce city-state. Singapore’s public transport consists of buses and trains. For the train network, the following lines have been established (when they commenced operation chronologically): North-South Line (red), East-West Line (green), North-East Line (purple), the Circle Line (yellow), and most recently, the Downtown Line (blue).
Fun fact 1: The red, green, and yellow lines are operated by SMRT, while the purple and blue lines are operated by SBS Transit.
It turns out that there is, after all, a CC18 station – Bukit Brown. The station is located in the Novena planning area. It is non-operational due to a lack of development in the area. Being a ‘shell’ station, its facilities are only used as emergency escape shafts. As you might guess, the station sits on the former Bukit Brown Cemetery.
There are stations that were once in Bukit Brown station’s shoes. Two such stations are Woodleigh (NE11) and Buangkok (NE15). Woodleigh MRT station was opened on 20 June 2011. When the North-East (purple) line first commenced operations, Woodleigh and Buangkok were non-operational due to low development in their vicinities then.
Readers who use the North-South line frequently might notice that, similarly, NS6 and NS12 are not present on the list of currently operational stations. Let us talk about NS12 first. For this station, it is set to open this year!
The new station is Canberra and is located between Sembawang (NS11) and Yishun (NS13) MRT stations. According to the LTA website, the Canberra MRT station will ‘serve commuters living in nearby estates such as Sembawang Springs, as well as a mix of upcoming public and private residential developments in the neighbourhood’. With a direct connection to the MRT network, the new station will reduce travelling time towards Jurong East or the city centre by about ten minutes.
Fun fact 2: Canberra is Australia’s capital, NOT Sydney. Basically, it was because Australians couldn’t agree between having either Sydney or Melbourne as their capital that they compromised and decided that a region geographically between the two cities would constitute their capital!
For NS6, it is likely to be named ‘Sungei Kadut’, if it ever does become operational. Similar to the case involving Caldecott and Botanic Gardens, the train ride between Yew Tee (NS5) and Kranji (NS7) is about five minutes!
Likewise, DT4 is missing from Downtown Line. It is probably going to be called ‘Hume’. However, just like the case of ‘Woodleigh’ and ‘Bukit Brown’, DT4 is not operational because there is not enough development in the region to justify its operation.
I hope you have found this article interesting! Stay tuned!
People in their early twenties will remember Disney’s High School Musical series. The first of the existing HSM trilogy was released on 20 January 2006 as a Disney Channel Original Movie (DCOM). It has been the most successful DCOM yet. Songs from its soundtrack such as ‘Breaking Free’ and ‘We’re All In This Together’ became highly popular. When Youtube first became popular, ‘Breaking Free’ was one of the first few videos I looked up then! HSM 2 had songs such as ‘Gotta Go My Own Way’ and ‘Everyday’.
Why did ‘Everyday’ leave me somewhat puzzled? When HSM 2 had been recently released, I was still in elementary school and naturally, I was relatively impressionable then. It was this song’s title and lyrics that gave the erroneous lasting impression that ‘everyday’ and ‘every day’ were interchangeable. The reality is that they are not!
In fact, before this blog post, some of you might not realise that there is a difference between the two terms. Allow me to elaborate. According to my trusty Oxford Advanced Learner’s Dictionary (7e), which I was gifted to me whilst studying in elementary school, the single word ‘everyday’ is an adjective; as such, the word is used only before a noun. In addition to the self-explanatory meaning, it can also mean ‘ordinary’. Here are some example sentences.
1. ‘The Internet has become part of everyday life’. 2. ‘This is a small dictionary for everyday use’.
The adjective runs in contrast with the adverbial phrase ‘every day’. Since it is being used as an adverb, every day (two words) will be modifying adjectives, verbs, or other adverbs, but not nouns. Only adjectives modify nouns.
Here are two stanzas from ‘Everyday’ (the lyrics are quoted directly from azlyrics.com):
Everyday of our lives Wanna find you there, wanna hold on tight Gonna run while we’re young And keep the faith
Everyday from right now Gonna use our voices and scream out loud Take my hand Together we will celebrate
Interestingly, the most popular video of this song on Youtube actually has the grammatically correct forms in the lyrics etched onto the video. Kudos to the person who was responsible for editing the video. Perhaps the people in charge of the HSM 2 soundtrack felt that a single word song title (‘Everyday’) would be more appealing than a two-word song title (‘Every Day’).
As a child, I visited my grandmother weekly and one thing that caught my attention was a calendar with which I was not familiar. Compared to the calendar I was accustomed to, this one had more ‘annotations’ and peculiar symbols. It looked something like this:
This calendar has many names; it is known as the Rural Calendar/Former Calendar/Traditional Calendar/Lunar Calendar. It is a lunisolar calendar (a calendar whose date indicates both the moon phase and the time of the solar year).
The Chinese calendar is based on observations of astronomical cycles, whereas our Gregorian calendar uses set dates that approximate astronomical cycles. The Gregorian calendar is a solar calendar because it is based on the Earth’s revolution of the Sun and the progression of seasons. Consequently, every Gregorian year is the same (except in the case of leap years).
On the other hand, the Chinese calendar tracks time according to the cycle of the moon’s phases as well as the progress of the Sun. Each month begins with the occurrence of a new moon. This results in the Chinese calendar sometimes having an extra month included in the year, and from one year to the next, a variable number of days to make up the length of a year.
Since the months of the Chinese calendar are derived from the lunar cycle, which lasts 29.53 days on average, Its months are either 29 or 30 days long. Like the Western Calendar, the Chinese calendar’s ordinary year has 12 months. However, there will be a leap month every leap year (occurs every two or three years). The ordinary year in the Chinese calendar runs between 353 and 355 days, while a leap year has between 383 and 385 days. The system of having leap months helps ensure that the average duration of a year in the Chinese calendar is reasonably close to that of a solar year.
Unlike some lunisolar calendars, the Chinese calendar does not mark its years chronologically. Rather, the Chinese calendar names its years with two components. The first component denotes an element (e.g. metal, fire, or earth), while the second component denotes an animal (e.g. dragon, ox, monkey). For example, 2019 is the year of the Earth Pig, and it lasts from 5 February 2019 to 24 January 2020. As there are five elements and twelve animals, it follows that there are 60 different combinations (i.e. the next Earth Pig year will occur in 60 years). The following paragraph is a near-direct quote from reference [4]:
Also named the sexagenary cycle or the stem-branch cycle, the Chinese 60-year calendar cycle is based on the combinations of a cycle of ten heavenly stems and twelve earthly branches, as espoused by traditional Chinese myths. Each year is named by a pair of one stem and one branch. The Year of Jia Zi (Jia from the heavenly stems and Zi from the earthly branches) is the beginning of the sexagenary cycle. The next Jia Zi Year will come 60 years later. Jia Zi has had a figurative meaning a full lifespan in ancient times (cf ‘threescore years and ten’ in the Bible (Psalm 90:10)). People would be obviously blessed if they can meet the second Jia Zi in life. Therefore, a 60-year cycle is also called a Jia Zi.
You might be wondering: in combinations, why use a pair of one stem instead of not using a pair of one stem (i.e. a lone stem; one of the ten stems)? With 10 stems and 12 branches, shouldn’t there be 120 combinations? Apparently, the pair comes from the fact that for each of the five elements, there is a ‘yin’ and a ‘yang’. They go together and are always paired up. Hence, we have 60 combinations instead of 120.
Fun fact: Singapore’s prime minister, Mr Lee Hsien Loong, was named with a ‘dragon’ character in his name probably because he was born in the year of the dragon (1952)!
The tenth and twelfth month in our calendar are October and December respectively. Yet, the prefixes of these months suggest otherwise. Has this ever puzzled you? The prefixes ‘oct-‘ and ‘dec-‘ come derive from Greek and they mean eight and ten respectively.
With the prefix ‘oct-‘, you have words such as ‘octagon’ (an eight-sided polygon), ‘octane’ (an alkane with eight carbon atoms), ‘octopus’ (an eight-limbed mollusc). For those of you who are musically inclined, consider the word ‘octave’. Its symbol is ‘8va’ and this is no coincidence as it is a shortened form of the word ‘octava’ (why an octave is divided into 12 semitones should be given a separate blogs post!).
With the prefix ‘dec-‘, you have words such as ‘decimal’, ‘decade’ (period of ten years), ‘decibel’, ‘decagon’ (ten-sided polygon), and ‘Decalogue’ (another term for the Ten Commandments).
Given that December should then be the tenth month by virtue of its name, you might have guessed that the first month of the year might have been March at some point in history, and you would be right! The modern calendar that we use can be traced to the Romans.
Before we go on, it helps to talk about the following terms: ‘equinox’ and ‘solstice’, as some readers might not be familiar with them. Let’s consider the term ‘equinox’ first. The term literally means ‘equal night’ (derived from Latin ‘aequinoctium’), and refers to the instant of time where the plane of the Earth’s equator passes through the centre of the Sun (i.e. the centre of the visible Sun is directly above the Equator). On the vernal (spring) and autumnal equinoxes, the duration for day and night are nearly the same throughout the entirety of Earth, which makes sense, when you think about it.
Let’s consider the term ‘solstice’ next. A Google search defines it as ‘either of the two times in the year, the summer solstice and the winter solstice, when the sun reaches its highest or lowest point in the sky at noon, marked by the longest and shortest days. This should also be quite intuitive.
We have all the above phenomena because the Earth is tilted on its axis by about 23.5 degrees. If not for the tilt, the plane of the Equator would pass through the Sun’s centre throughout Earth’s solar revolution, and there would not be any seasons. There are seasons because in different time periods of the solar year, each location on Earth gets a different daily (as in every day and during the day time) exposure to the Sun’s warmth. This explains why a country such as Singapore (near the Equator) will not experience the four seasons. This is because throughout the year, the Sun strikes equatorial regions at approximately the same angle, and so, these regions have an approximately equal amount of day and night throughout the year.
N.B. Some incorrectly believe that the four seasons are due to the fact that Earth’s solar orbit is elliptical (leading to points at which the Earth is closest to and farthest away from the Sun – perihelion and aphelion respectively). The difference in distances between the perihelion and aphelion (about 3.2 million miles) is not THAT significant, and has a negligible impact on the Earth’s climate.
The time between the equinoxes and solstices, and the duration of a solar year were calculated accurately by ancient astronomers. However, with Mother Nature providing such a prominently displayed Moon in the night sky, many cultures preferred to have their calendars based on the lunar cycle. The original Roman calendar (753 BC; the calendar was adopted by the Romans from the Greeks) had ten months:
1. Martius – March (named after Mars, the god of war in Roman mythology; apart from being the god of war, Mars was also deemed the god of agriculture; the beginning of March corresponds to the transition from Winter to Spring) 2. Aprilis – April (the word April is a variant of ‘Avril’ as in ‘Avril Lavigne’; yes, that singer) 3. Maius – May 4. Junius – June (named after Juno, Jupiter’s wife) 5. Quintilis – July 6. Sextilis – August 7. September 8. October 9. November 10. December
This ten-month did create problems though. As established earlier, many societies liked basing their calendars on the lunar cycle because it was easily observable (the lunar cycle is about 29.53 days long). Each of the ten months would have either 30 or 31 days, and the original ten-month year had a total of 304 days, around 61 days short of the actual solar year (325.242 days).
You might be asking: what happened to January and February? Well, those months correspond to the months during winter. Winter was a pretty harsh time for everyone, and so, people just simply took the new moon before the vernal equinox (aka spring equinox) as the start of the next year. Surprisingly, this arrangement worked relatively well (as long as you didn’t need to figure out the day in the interim 61.25 days)!
One day, Numa Pompilius, who may or may not have existed, felt that even numbers would only bring about bring about misfortune. Hence, he removed one day from all the months with 30 days. As such, Aprilis, Junius, Sextilis, September, November, and December all had 29 days, thereby reducing the total number of days to 298 days.
Numa wanted to have 12 lunar cycles in his calendar, with 56 days being added to the 298, thus bringing the new total to 354 days. This is gonna sound ridiculous (bear with me), but Numa felt that having 354 days would bring bad luck! So, he decided to have an extra day, in addition to the 56 days to be added. The 57 days were divided between two months and just dumped at the end of the year. As you might guess, the two months were Januarius (29 days), and Februarius (28 days), and THAT is how February ended up with 28 days!
I know what you’re thinking. 28 is an even number. How did they accept that? Apparently, February was the month of spiritual purification, so they closed one eye (Februarius derives from the Latin ‘Februum’, which means ‘purification’).
Although this new calendar (355 days) was a massive improvement from the original calendar (304 days), it nevertheless still fell short of the solar year (365.242 days)! As you might imagine, it was only a matter of time before all the seasons did not correspond to certain months, and the whole system was messed up.
Here’s where it starts to get confusing. February actually consisted of two parts: the first 23 days, and the rest. Every year, Numa’s calendar would be out of line with seasons by about 10 days (cf 355 vs 365.242). Hence, every other year (usually two), the ‘rest of February’ (the part after the 23 days) would be ignored and replaced by a 27-day leap month called mensis intercalaris. With this new arrangement, the new calendar would have 366.25 days on average (2 years with leap months and 2 years without leap months would give a total of 1465 days; 1465/4 = 366.25). That is about one day more than what we need, but hey, this is a massive improvement.
This could have worked, in theory, because every 19 solar years correspond to 235 lunar months (with a difference of about two hours). So, as long as there is due diligence in adding the leap months appropriately, things will be fine……except when there ISN’T due diligence.
Politicians would ask for leap months to extend their terms, or ‘forget’ them to get their opponents out of office. Things were worse when Rome was at war. Under such circumstances, the leap month might be forgotten for several years. By the time Julius came to power, things had gotten quite confusing. So, he reformed the calendar!
As we all know, Julius had a thing with *cough* Cleopatra. He spent some time in Egypt, which was a highly sophisticated region. They were perhaps the only culture that used a solar calendar with 365 days then. So, in 46 BC, Julius gave us the Julian calendar, a solar calendar which rendered the lunar calendar that had been used hitherto obsolete. January and February had been moved to the beginning of the year.
Remember how the lunar calendar (355 days) was still about 10 days short of the solar year? Julius resolved this by adding ten days to ten different months (without touching February).
Lastly, to account for the nearly extra average quarter-day difference (since the tropical year was 365.242 days), a leap day would be added to February every four years. This would bring the average Julian year to be 365.25 days long!
Of course, we are not using the Julian Calendar at the moment. There was one more calendar reform that took place. That reform took place to bring the average year from 365.25 days to 365.2425 days (much closer to the actual year). That reform was the Gregorian reform. To learn more about that reform, check out an earlier blog post I made.
I hope you have greatly enjoyed reading this post!
Yours faithfully, Nicholas Loh 3 February 2019
P.S. Quintilis and Sextilis were renamed July and August after Julius Caesar and Augustus Caesar (Julius’ successor) respectively.
We deal with them all the time. ‘Arrghh, I hate Mondays; Monday blues!’ is something that is commonly heard. ‘Let’s have lunch on Saturday’. ‘I have dinner with my family on Sunday’. ‘I have a dental appointment on Wednesday’. These sentences are not unusual, and we do not give the days’ names a second thought even as we cite them throughout our lives.
As with basically anything fancy, it can probably be traced back to the Greeks and Romans. The names of the days of the week are derived from the names of the then-contemporary deities; the planets were, and still are, associated with deities. What the Greeks did with the days of the week was highly influential. After them, the Romans adopted it. Soon enough, the whole world adopted a seven-day week. However, if we dig deeper, we learn that it didn’t begin with the Greeks. It goes all the way back to the ancient Babylonians.
Before the rise of the Greeks, it was the ancient Babylonians who were living in the cradle of civilisation. They were formidable astronomers and they devised their calendars to predict the movements of heavenly bodies. Unlike the year which closely corresponds to the period of Earth’s revolution around the Sun, and the month, which closely corresponds to the Moon’s revolution around the Earth, the week has no analogue. The week came to have seven days because the Mesopotamian astrologers designated one day for each of the seven most prominent objects in the sky: the Sun, the Moon, Mars, Mercury, Jupiter, Venus, and Saturn. Do you see something familiar with the way I listed the seven celestial bodies?
After the ancient Babylonians, in came the Greeks with their extensive mythology, which had been around since 1800 BC. As we said earlier, the planets are associated with deities in Greek.
Between the 1st and 3rd centuries, the Roman Empire gradually replaced the eight-day Roman nundinal cycle (the nundinal cycle, market week, or 8-day week was the cycle of days preceding and including each nundinae) with the seven-day week. Our earliest evidence for this new system is a Pompeiian graffito referring to 6 February AD 60 as dies solis (literally Latin for ‘day of the Sun’). The Latin word for the Sun is ‘sol’. You see the suffix ‘-is’ as in ‘solis’ because the genitive case is being used (i.e. indicating possession; ‘of the Sun’). The word ‘sol’ is where we get words such as ‘solar’.
Another early witness is a reference to a lost treatise by Plutarch (a Greco-Roman biographer), written in about AD 100, which addressed the question of ‘Why are the days named after the planets reckoned in a different order from the actual order?’ I bet this must have been the question in your mind as I told you about the celestial bodies four paragraphs earlier. Well, you’re nearly two millennia late.
Anyway, let’s not get distracted. The days were named after the planets of Hellenistic astrology, in the order Sun, Moon, Mars (Ares), Mercury (Hermes), Jupiter (Zeus), Venus (Aphrodite) and Saturn (Chronos). Yes, that’s the same way the fashion brand is spelt – Hermes. The seven-day week spread throughout the Roman Empire during Late Antiquity. By the fourth century, it was used throughout the empire, and it had also reached India and China.
Let us dissect each day. Before we move on, we should note that people back then had the practice where gods across different mythologies would be one and the same. For example, the Roman goddess of the Moon (Luna) would be taken to be the same entity as the Greek goddess of the Moon (Selene). The Germanic people adapted the system introduced by the Romans by substituting the Germanic deities for the Roman ones (with the exception of Saturday).
Sunday
The Greek word for Sun ‘helios’ is where we get the word ‘heliocentric’ (cf the historical dispute between the geocentric and heliocentric model for the solar system; the phrase ‘solar system’ gives a hint as to what the correct model is; haha).
In OE (Old English) Sunnandæg, meaning “sun’s day”. That strange symbol in that word is called a digraph (a combination of two letters representing one sound). This is a translation of the Latin phrase dies Solis. English. Like most of the Germanic languages, it preserves the day’s association with the Sun. Many other European languages, including all of the Romance languages, have changed its name to the equivalent of “the Lord’s day” (based on Ecclesiastical Latin dies Dominica). In both West Germanic and North Germanic mythology, the Sun is personified as Sunna/Sól. Hence, we see that in Romance languages such as French and Italian, Sunday has become dimanche and domenica respectively. ‘Domenica’ is a Christian reference to Jesus.
In Russian,the word for Sunday is voskresen’je (воскресенье), and it means ‘resurrection’ (cf Christ was crucified on a Friday, which Good Friday commemorates, and resurrected on a Sunday, which Easter Sunday commemorates).
This change to a reference to Christ probably never happened in English because of a division in language between different classes after the Norman invasion of 1066. While the official Norman-French language in use among the lordly elite switched effortlessly into official Latin and used the ‘Lord’s Day’, Anglo-Saxon remained the vernacular of ordinary folk.
It should be noted that Emperor Constantine the Great had converted Rome to Christianity and standardised the seven-day week across the Empire. According to Dr Matthew Nicholls, senior lecturer in Classics at the University of Reading: ‘The Roman context of the spread of Christianity meant that Rome contributed a lot to the structure and calendar of the new faith.’ Rome may initially have acquired the seven-day week from the mystical beliefs of Babylonian astrologers, but it was the biblical story of creation, God’s creation of the heaven and the earth, and resting on the seventh day that would have led the first Christian emperor of Rome to ensure that the seven-day week endures to this day.
Monday
Monday is a shortened form of ‘Day of the Moon’. It shouldn’t be too difficult to see how ‘Luna’ relates to Monday. It is from the Roman goddess that we get words such as ‘lunar’, ‘lunatic’ and ‘lunacy’ – a condition which has been associated with the lunar cycle. In Roman mythology, Diana, the twin of Apollo the Sun-god, is the goddess of the moon, the hunt, and child birth. Diana is considered to be the same as Luna and Selene.
Tuesday
In Greek and Latin, we see that Tuesday is the ‘Day of Ares’ and the ‘Day of Mars’ respectively. As I said earlier, they were considered to be the same entity. Mars is known as the Roman god of war. It is where we get words such as ‘martial’ as in ‘court-martial’ and ‘martial arts’. The English word Tuesday is also derived from OE and from the Norse god of war Tiw (or Týr). Consider the historical development of Tuesday (ME tewesday, OE tiwesdaeg, OHG ziestac). By the way, ME and OHG refer to Middle English and Old High German respectively.
Wednesday
The following chunk regarding Wednesday is a direct quote from reference [1]:
Wednesday comes from ‘Woden’, the Old German and English name for the Norse god Odin. Odin is father and ruler of the gods and mortals, often called ‘the all father’. He is also the god of war, learning, poetry and the dead. He had only one eye, having traded his second for a drink from the Well of Wisdom. Odin was considered to be one and the same with Mercury. He is the ruler of Asgard, the home of the gods, and is able to shift and change into different forms. In contrast, Mercury, the Roman god for whom dies Mercurii is named, is a messenger god. While Woden survives in English, he disappeared from the days of the week in German. This dates from the time Christianity was displacing pagan beliefs in the centuries following the collapse of the Roman Empire. “In Germany they found themselves the heirs to classical Rome as the Carolingian leaders of the Holy Roman Empire, so along with Christianisation went a willingness to embrace all that that new title meant” explains archaeologist Iain Sodden. In German, Wednesday or Woden’s day was replaced with Mittwoch or ‘mid-week’.
Thursday
Thor, Jupiter, and Zeus were all gods of thunder. Thursday comes from ‘Thor’s Day’. Nothing much here.
Friday
Friday is linked with Venus. This day is unique because it is the only day named after a woman. Friday comes from OE/ME Frigedaeg or ‘Frigga’s day’. Frigg was the wife of Odin, and the goddess of love and beauty. Venus was the goddess of sex, love and fertility. She is also associated with marriage and fertility. Venus can outshine any of the other planets, and was the Roman goddess of love, beauty, sex, fertility, prosperity and victory. Venus was closely associated with the Greek goddess Aphrodite.
Saturday
This is an easy one. Saturday (cf OE Saternesdaeg) comes from ‘Day of Saturn’. This is in my opinion, the most interesting day. Saturday is the only day in English which is directly named after a Roman god. Its equivalent in Greek mythology is Chronos/Kronos, the ruler of the titans and the god of time. It is from the Greek word ‘chronos/kronos’ that we get words such as ‘chronometer’, ‘chronological’, ‘chronograph’, ‘synchronise’. Isn’t language fascinating? Saturn is the father of Jupiter, the chief Roman God. The following paragraph is a direct quote from reference [1]:
The association of Saturday with a Roman god in English helps date when the seven-day week came to Britain. According to Prof Mckinnell,, it suggests that the names of the days “may have arrived in the UK along with Latin learning – with or after the conversion to Christianity, between AD 597 and AD 685.” In the Romance languages of southern Europe which are largely derived from Latin, the word for Saturday was changed to mirror Church Latin. For example the Spanish word sábado comes from Sabbath.
The word ‘Sabbath’ is where we get words such as ‘sabbatical’. The Sabbath is observed by adherents of Judaism and Seventh-day Adventists on Saturday as a day of rest and worship.
There are more interesting things that we could discuss: 1) Plutarch’s question: ‘Why are the days named after the planets reckoned in a different order from the actual order?’ 2) Why modern Mandarin only has numbered days (with the exception of Sunday 星期日)? 3) Should Sunday or Monday, or even Saturday be the start of the week?
However, this blog post would be too long. In fact, as it is, this is my longest blog post yet. Thank you for reading!
I first heard the hymn during a church service a few months ago. It was the closing hymn for the service, and I could not help but feel how apt the hymn is as a choice for the closing hymn. Its melody is truly grand and majestic. Do you remember my post regarding the hymn ‘Great Is Thy Faithfulness’? Well, the composer for that hymn, Thomas O. Chisholm, also composed the hymn ‘Living for Jesus’. In case you were wondering, Chisholm’s middle name is Obadiah.
Fun facts: The name ‘Obadiah’ is Modern Hebrew for ‘slave of God’. It is a theophorical name, meaning ‘servant of God’ or ‘worshipper of Yahweh’. The book of Obadiah is the shortest book in the Old Testament; the text consists of a single chapter, divided into 21 verses. Hence, when citing a verse reference from Obadiah, the convention is to omit the chapter reference. For example, quoting from verse 7 would just be ‘Obadiah 7’, and not ‘Obadiah 1:7’. Can you imagine a scenario where someone asks everyone in the group to flip to Obadiah 7, and another person asks, ‘Which verse?’ Haha!
It is cognate to the Arabic name ‘Abdullah’, which is probably much more familiar to you. The suffix of Obadiah’s name (i.e. -iah) means ‘of God’. It thus should not surprise you that there are many names with this suffix in the Old Testament (e.g. Moriah, Josiah, Isaiah, Hezekiah, Jeremiah, Zephaniah, Zechariah; ok, I think you get my point). Interestingly, consider the name ‘Elijah’ too. The suffix ‘-jah’ is basically ‘-iah’, since the letters ‘i’ and ‘j’ are simply variants of each other.
The progression of Chisholm’s life was covered in a previous post, so I shall not be repeating it here. Additionally, you may check out the references for a more detailed exposition of Chisholm’s life. According to Dr Hawn’s article on the history of ‘Living For Jesus’, the late hymnologist William J. Reynolds noted that ‘Living For Jesus’ actually started with the tune. The words were only added later by Chisholm. The following paragraph is a direct quote from Dr Hawn’s article, which expresses the subject matter more succinctly than I could ever achieve:
“C. Harold Lowden [1883-1963] composed the tune about 1915, and it was first published under the title ‘Sunshine Song’ in a Children’s Day Service that he wrote. Early in 1917, while preparing a collection of hymns for publication, he came across this song and was impressed that the tune needed a stronger text. He substituted ‘Living for Jesus’ for the original title and sent the tune to Thomas O. Chisholm, then living at Winona Lake, Indiana for a new text.” Even though Chisholm protested that he had never written a text for a pre-existing tune, Lowden insisted, telling the author that he “believed God had led me to select him” to provide a text for this music. Within a short time, Chisholm returned the tune with four stanzas and a refrain. The hymn appeared as a separate song sheet in the spring of 1917, and was used at a number of youth conferences that summer. More than a million copies of the hymn were sold in this form.”
Once again, enable the annotations to view the lyrics while the video plays.
The three words describe the same thing – holiness. The first is self-explanatory as it is the most familiar to us. The second is more interesting. Where have you seen this word before? Most people would simply note in glee, ‘Halloween!’, and they would be right. According to the etymology as established on Wiktionary, the word ‘Halloween’ is a shortening of of ‘All-Hallow-even’ (i.e. All Hallows’ Eve – the name of the evening before All Saints’ Day). As you might infer, All Saints’ Day falls on 1 November, and as its name implies, it is a Christian festival celebrated in honour of all the saints, known and unknown. However, most people would associate the now-pagan festival of Halloween with children going door-to-door in costume and demanding candy with menaces (mainly in the UK, Canada, USA, and Ireland). Such is the influence of the mass media.
On the other hand, astute Christians would note that the word ‘hallow’ appears in the first petition of the Lord’s Prayer (cf Matthew 6:9), which reads: ‘Hallowed be thy name’. The 101st point of the Westminster Shorter Catechism discusses the first petition more concisely and accurately than I could ever hope to achieve. It is as follows:
Q101. What do we pray for in the first petition? A101. In the first petition, which is, Hallowed be thy name, we pray that God would enable us, and others, to glorify him in all that whereby he maketh himself known; and that he would dispose all things to his own glory.
I could talk extensively about the Lord’s Prayer, but that deserves its own blog post. In the Vulgate, the Latin Bible employed by the Roman Catholic Church for a long time, the first petition is rendered ‘sanctificetur nomen tuum‘. The extensively inflective nature of Latin allows the first petition to be expressed in merely three words, compared to that of four words in the KJV! The Latin word ‘sanctificetur’ is the third-person singular present passive subjunctive of the Latin word ‘sanctifico’. Yes, just let that sink in for a moment. Look how much inflection and conjugation there is in Latin. It puts modern English to shame. The word ‘sanctifico’ is comprised of ‘sanctus’ (holy) and ‘-fico’ (do, make). The verb ‘sanctifico’ thus means ‘to consecrate; make holy’. The legacy of ‘sanctus’ is seen in English words such as ‘sanctuary’, ‘sanctify’, and ‘sanctification’. The word ‘nomen’ is Latin for ‘name’ and is actually where we get our words ‘nomenclature’, ‘nominal’, and ‘nominate’. It should be no surprise that an overwhelming majority of the bombastic words in English have their roots in Latin.
In the spirit of the previous posts, I made a video with a relevant hymn. Some of you might have already seen this coming. The hymn is not ‘Holy, Hallow, Sanctus’, but ‘Holy, Holy, Holy’ (they are technically the same, but oh well, whatever). Haha.
Its lyrics was established by Reginald Heber in 1826 and the music was composed by John B. Dykes in 1861. The hymn is based on the latter part of Revelation 4:8, which reads: ‘…Holy, holy, holy, Lord God Almighty, which was, and is, and is to come.‘
The tune title was named NICAEA, and it was written specifically for ‘Holy, Holy, Holy’. The tune was aptly named after the Council of Nicaea, the 4th-century council at which the Trinity was upheld as an essential doctrine of Christianity. Like the hymns featured in the previous blog posts, this is also a well-known hymn. Once again, please enable annotations to view the lyrics while the video plays. I hope this hymn blesses you.
‘Great is Thy Faithfulness’ is one of the most recognisable hymns of all time. Its author and musician are Thomas O. Chisholm (1866-1960) and William M. Runyan (1870-1957) respectively. It is so popular that it is still sung even in most contemporary and liberal churches which have abandoned the traditional singing on hymns.
This endearing hymn has its roots in the biblical passage of Lamentations 3:22-24, which reads: 22It is of the LORD’s mercies that we are not consumed, because his compassions fail not. 23They are new every morning: great is thy faithfulness. 24The LORD is my portion, saith my soul; therefore will I hope in him.
The above text is a quotation from the Authorized Version, better known as the King James Version (KJV). The italicized words were added by the translators of the KJV to aid the reader because the translators wanted the translation to be clear and readable. However, to ensure that readers understood that these words were not in the manuscripts that they worked with, the translators set the additional words in italics.
According to an article on Gaither Music, Chisholm wrote “Great Is Thy Faithfulness” as a testament to God’s faithfulness through his ordinary life. Chisholm was born in a humble log cabin and became a Christian when he was 27. He entered the ministry when he was 36; however, poor health forced him to retire after just one year. For the rest of his life, Chisholm spent many years living in New Jersey and worked as a life insurance agent. Despite having a desk-bound job, he wrote nearly 1,200 poems throughout his life, including several published hymns. Chisholm explained towards the end of his life that his income had not been large at any time due to impaired health in his earlier years. His impaired health persisted throughout his life. He insisted that he would not fail to record the unfailing faithfulness of a covenant-keeping God, for God had given him many wonderful displays of His providing care. Chisholm had immense gratitude for what God had done in his life.
Like the previous blog post, I also made a video as ‘Great is Thy Faithfulness’ is also one of my favourite hymns. Once again, please enable annotations to view the lyrics. I hope you are blessed by this video!
Last September, my pastor gave a sermon entitled ‘Jesus led to Golgotha’. One learning point I had from that sermon was the meanings and etymologies of the words ‘Golgotha’ and ‘Calvary’. The word ‘Golgotha’ means ‘skull’ in Aramaic, one of the two languages of the Old Testament. Golgotha is also known as Calvary, which is derived from the Latin word ‘calvaria’, which in turn, unsurprisingly, also means ‘skull’. Hence, ‘Golgotha’ and ‘Calvary’ refer to the same thing.
Naturally, this made me wonder about the term used for soldiers who ride on horseback. Is the term ‘calvary’? No, it is not! The word that describes soldiers on horseback is ‘cavalry’. I then realised that I had erroneously conflated the two terms ‘Calvary’ and ‘cavalry’ all my life! It is easy to see why people can confuse the two terms though. They are rarely used in everyday speech and writing!
Fast forward a few months. During one of the services, a friend within the church was playing one of the most heartwarming melodies on the organ. He played it as the Lord’s Supper was being administered. As I was not familiar with the melody, I was eager to find out the name of the hymn which contained such a majestic melody. I then found out after the service that it was hymn number 555 in the hymnal that we used: Hymns of Grace and Glory. The hymn was ‘Lead me to Calvary’.
Since learning about that hymn, it has become one of my favourite hymns. Here is a video that I put together recently. I hope it blesses you (enable annotations for the lyrics)!
While learning about watches, I chanced upon the fancy feature of ‘perpetual calendars’. However, before talking about perpetual calendars in watches, I should also discuss annual calendars in watches and watches without either feature. In mechanical/automatic watches without either the annual or perpetual calendar feature, there is a date wheel that adjusts every 24 hours and runs from 1 to 31. The watch owner is expected to manually correct the date on the first of the month following any month that has fewer than 31 days (5 times a year: February, April, June, September, and November).
Annual calendars keep track of months with 30 or 31 days. This means that the owner needs to adjust the date on 1 March each year since annual calendars are unable to handle months with fewer than 30 days (*cough* February).
Perpetual calendars not only take into account that all months can have a different number of days (it is usually either 30 or 31 days in a month; however, there are usually 28 days in February), they are also able to take into account the fact that February has 29 days in leap years. So, this means the date on a watch with the ‘perpetual calendar’ feature will always been correct, right? After all, the word ‘perpetual’ suggests eternal adherence. To fully grasp this issue, we need to examine the history of our calendar.
The calendar that is ubiquitous in today’s world is known as the Gregorian calendar. It is named as such because the calendar is named after Pope Gregory XIII, who introduced it in October 1582. Before talking about the Gregorian calendar, let us discuss the calendar it replaced – the Julian calendar.
The Julian calendar got its name from Julius Caesar, who introduced it in 46 BC. It was a reform of the Roman calendar, and it took effect on 1 January 45 BC. The Julian calendar has two types of years: ‘normal’ years with 365 days and ‘leap’ years of 366 days. There exists a simple cycle of three ‘normal’ years followed by a leap year and this pattern continues forever without exception. The Julian year is therefore, on average, 365.25 solar days long.
At this point, some readers might be confused. ‘Isn’t this the way our calendar works?’ you might ask. What’s wrong with this? Why did we need to switch to the Gregorian calendar? Doesn’t the leap year every four years ensure that the average year is close enough to the actual tropical year? Strictly speaking, the tropical year is about 20 minutes shorter than the solar/sidereal year due to the seasonal cycle not remaining exactly synchronised with the position of the Earth in its orbit around the Sun resulting from the precession of the equinoxes. But, hey, let’s take the tropical year and solar year to be basically synonymous.
Surprise, surprise. One tropical year is 365.24217 solar days long, implying that the mean tropical year is approximately 365 days, 5 hours, 48 minutes, 45 seconds. To clarify, 1 solar day in this context is NOT 86,400 seconds (ie 24 hours). A day that lasts exactly 24 hours is known as an ephemeris day (which is not the kind of ‘day’ we are talking about).
As we established three paragraphs earlier, the Julian calendar is 365.25 solar days. 365.25 is not the same as 365.24217. Although this difference is miniscule over a matter of a few years, you can imagine how this error will accumulate over many centuries. Although Greek astronomers had known, at least since Hipparchus, a whole century before the Julian reform, that the tropical year was slightly shorter than 365.25 solar days, the Julian calendar did not compensate for this difference. As a result, the Julian calendar year gains about three days every four centuries compared to observed equinox times and the seasons.
So, how do you fix a discrepancy of three days over four centuries?
Something absolutely brilliant.
The difference between the Gregorian and Julian calendars is that in the Gregorian calendar, year numbers evenly divisible by 100 are not leap years, except that those evenly divisible by 400 remain leap years. What does this mean? That means 2000 was a leap year, whereas 2100, 2200, and 2300 will not be leap years!! The mean Gregorian year is thus 365.2425 days long, which is much closer to the tropical year (difference of 0.0008 solar days) than the Julian calendar (difference of 0.0083 solar days).
At the time of the Gregorian reform, there was a 10-day difference between the Julian and Gregorian calendar. To deal with the difference that this drift had already reached, the date was advanced so that 4 October 1582 was followed by 15 October 1582. There was no discontinuity in the cycle of weekdays (i.e. 4 October 1582 was a Thursday and 15 October 1582 was a Friday).
Of course, the Gregorian calendar isn’t perfect either. The Gregorian calendar diverges from astronomical observations by one day in 3,030 years. Perhaps we could consider every year that is a multiple of 3032 to not be a leap year? It shall be the Nicholasian calendar. HAHA,
What does this mean then for the ‘perpetual calendars’ in watches that I mentioned earlier? They are perpetual only in the Julian Calendar! Watches with ‘perpetual calendars’ will erroneously consider 2100, 2200, and 2300 to be leap years. Thus, such watches aren’t, strictly speaking, perpetual.
This is something I never noticed until I chanced upon an online article discussing this issue. Upon reading this, my eyes were immediately set upon the dial of my Longines. Indeed, ‘IIII’ is used instead of ‘IV’. I continued reading the article and found it to be intriguing. The link to the article I read can be found in the references. However, it is a rather long read (9-min read). So, I shall distil it to give you the essential takeaways. The most notable exception to the observation would be Big Ben of London. The Big Ben uses ‘IV’.
Big Ben of London
I) The first possible explanation for this is that ‘IIII’ was the earliest way to write ‘4’ in Roman numerals. Even though the most common way to represent ‘4’ in Roman numerals today is ‘IV’, it was not always the case. Perhaps watchmakers wanted to continue this tradition. The earliest timepiece models even used ‘VIIII’ instead of ‘IX’. However, this situation was problematic as the numerals ‘III’ and ‘VIII’ were confused for ‘IIII’ and ‘VIIII’. Interestingly, as I write this paragraph, the spellcheck function detects ‘IIII’ and ‘VIIII’ as spelling errors and thus flags them with a red squiggly line beneath them. This does not occur with ‘III’ and ‘VIII’. According to the article, the first mechanical clocks were created in Europe during the 13th century, and Roman numerals were still used extensively then. Most clocks were mounted on churches, and Latin was the official language of the Roman Catholic Church. It thus made sense to use Roman numerals instead of Arabic numerals on the dials of timepieces.
Longines Record Collection: COSC-certified; this image has been taken from the Longines website.
The article then goes on to mention a few other possible reasons that ‘IIII’ is used in lieu of ‘IV’. Here are some possible reasons:
II) ‘IV’ was avoided because it was deemed as an offence to Jupiter, a god in Roman mythology. Consider the word ‘Jupiter’. The letter ‘j’ was one of the last letters to be added to the Latin alphabet. For much of history, the letter ‘j’ did not exist. The letter ‘i’ was used where we would use the letter ‘j’ today. Consider the letter ‘y’ and some names such as ‘Johanna’. ‘Johanna’ would traditionally be pronounced with a ‘y’ sound at the start. Moreover, consider the sound of ‘y’ in words such as ‘gypsy’, ‘rhythm’, ‘fly’, and ‘by’. Also consider the letter ‘u’ in ‘Jupiter’. It was basically interchangeable with the letter ‘v’ in medieval times. In fact, the King James Bible, as originally published in 1611, is a classic example of this. The word ‘love’ would often be spelt ‘loue’, etc. Hence, coming back to what we were originally discussing, we see then that ‘Jupiter’ would have been written as IVPITER. What do you observe about the first two letters of the name?
This issue of not writing down the name of a god reminds me of a similar practice of adherents of Judaism. According to the Wikipedia article on the Tetragrammaton, the written tetragrammaton must be treated with special sanctity. Writing the tetragrammaton unnecessarily is prohibited, so as to avoid it treated disrespectfully. To guard the sanctity of God’s name, a letter within the tetragrammaton is substituted for another letter. Alternatively, a letter is substituted for a hyphen. This practice is applied to the English name ‘God’, which adherents of Judaism would write as ‘G-d’.
III) It was easier for the non-educated folk. The additive notation in ‘IIII’ would certainly have been easier for the majority of the illiterate and non-educated European population. The subtractive notation might have been confusing. When this is coupled with the fact that ‘IV’ and ‘IX’ can be confused for ‘VI’ and ‘XI’, it is easier to empathise with the people back then.
IIII) The ‘Lazy Clockmaker’ hypothesis. This is a hypothesis that is not taken seriously.
V) The Sun King, Louis XIV. One explanation is that like Jupiter, Louis XIV did not want to have part of his name on the dial. However, this theory is quite implausible because the practice of having ‘IIII’ instead of ‘IV’ on timepieces had been around a long time before the birth of Louis XIV.
VI) The visual balance. This reason is one of the most convincing. Consider watches which have ‘IIII’ and ‘IX’ to represent ‘4’ and ‘9’ respectively. The Roman numerals on the watch would be as follows: I, II, III, IIII, V, VI, VII, VIII, IX, X, XI, XII. The first third of the dial would have the ‘I’ type. The second third of the dial would have the ‘V’ type. The last third of the dial would have the ‘X’ type. When the dial has three distinct areas, it is perceived as more elegant and harmonious.
Conclusion: There is no definitive explanation for having ‘IIII’ instead of ‘IV’ in watches. It is likely to be a combination of some of the above reasons. I end the article with yet another exception to the trend:
H. Moser & Cie. is one of the few modern watchmakers to use IV on its dials.
Nic 21 January 2019
P.S. Did you notice that I used ‘IIII’ in the list numbering?
In the early days of digital self-expression, initiating a personal blog on ‘blogspot.com’ was a prevalent trend. Much like the Greek gods who dined on ambrosia, the youth of that era relished the opportunity to share their thoughts and experiences with the world. Over a decade later, the landscape has shifted, and active bloggers have become a rarity among my contemporaries.
Individuals create and maintain blogs for various reasons, such as engaging in online commerce or utilising the platform as a means of catharsis, hoping to find resonance among empathetic readers.
Socrates, in Plato’s Apology, posited that “the unexamined life is not worth living.” In numerous developed societies, individuals navigate their daily lives without introspection. This phenomenon could be attributed to an overwhelming focus on personal challenges, such as financial obligations and interpersonal relationships, thereby neglecting self-reflection. This issue merits our contemplation.
Throughout my personal journey, journaling has been a sporadic activity, akin to the waxing and waning of the moon. This inconsistent pattern parallels the annual ritual of declaring New Year resolutions, a fleeting commitment that often lacks perseverance. In my youth, my documentation of life’s events was equally scarce, leaving my memories enveloped in a metaphorical fog. Nonetheless, with renewed vigour, I embark on this digital journaling endeavour.
The impetus for this blog’s inception can be traced to an encounter with an erudite individual, a fervent advocate for the written word who laments the contemporary scarcity of such a form of expression. I could go on and on about the benefits of writing, but I believe that deserves its own post.
Anyway, this blog shall serve as a repository of my thoughts and personal experiences. The Sisyphean task of recounting lengthy narratives to diverse audiences can be mitigated by directing them to relevant blog posts, ensuring the transmission of accurate information. This written medium, unmarred by the potential distortions of oral communication, minimises the scope for misinterpretation and confusion resulting from divergent retellings. The blog post stands as a definitive testament to my narrative.
In sum, this digital chronicle shall provide a valuable resource for those seeking insight into my perspectives, or for those simply desirous of a deeper understanding of my persona. I invite you, dear reader, to partake in this intellectual journey as we explore the intricate depths of thought and experience. Stay tuned!
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