That Which Disturbs Silence

Some days I wish I was born both mute and deaf.

Not to trivialise or insult anyone who is mute or deaf. But some days I wonder what it would be like to be born and never hear awful things being said. And as such never being capable of saying anything awful? 

Some things can’t be unheard. What would it be like to not hear terrible, harsh sounds being spoken about yourself or others. What would it be like not to be scared beyond belief of what you might open your mouth and say that sets something horrible in motion? 

I’ve complained about silence. But some days, I wish nothing more in the world. 

There was a movie about a fictitious illness that spreads by talking. So everyone in a village had to be mute for a certain period of time. Really interesting movie. Everyone would be forced to only convey what needs to be conveyed. You can’t yell at or insult another person or express your anger through speech. You can’t attempt to destroy another person with your words. Wouldn’t that be nice.

I’ve had a long day. Not a great one, and so these were the thoughts going through my head during an important med school test. Sigh. 

It did get better though. While I was standing in the rain getting drenched waiting for someone, all I could hear was the rain. 

And that’s when Buddha’s words came to me.  

Words to live by. 

Portfolio And Poetry

All medical students have to write a portfolio every year up to and including their 5th year. It’s a compilation of experiences that demonstrate your learning in 5 domains. Professionalism, ethics and law, health and well-being, cultural competence, and learning and teaching (which no one really gets. Something about doctors also being teachers?). It’s supposed to be an exercise in reflective writing and can be used for future employment if required.

I HATE this exercise.

Not only because it takes so damn long to write the required 2 entries for each topic in a reflective way that truly shows your “growth” over the last 6 months (let’s face it, you have to exaggerate. Because one person can only be so culturally competent). But also because for the last 3 years, I’ve slaved away trying to write this thing and I only ever get “pass” as opposed to the “distinction grade”. And the worst part is, the supposed “feedback” to help me improve for my next portfolio has always been from some lazy person, in the form of “Excellent reflection!”, “Good work!!” or my personal favourite, “I can see you really thought about this”.

……………. Then why the heck didn’t I get distinction?!

But anyway. It doesn’t stop me from spending the amount of time I do every year writing it. In fact this year I seem to be spending more time on each entry. But since this is our last year of doing these portfolio thingies, my friend and I decided to add some poetry into the entries. We heard from others that they are generally well-received. Plus they take much less time.

Now, I’m no poet. I think this is mainly because I’m not very good at conveying a lot of things in a concise manner (you know that from my blog anyway. xD). But I thought I’d give it a go.

This is a topic I am actually quite passionate about. Motivational interviewing. Telling patients simply to change their health behaviours (diet, exercise etc) without really understanding the challenges they face. I’ve mentioned this before on this blog, but I’ve actually seen how useless some people can be at advising patient about supposed “lifestyle changes”. So without further ado, here is a poem about patient perspective on lifestyle advice.

The Doctor says I’m fat
He says I eat too much
He says my blood sugar is too high
He says I need to go on a diet
He just doesn’t understand
I work all night
The grocery shop is half an hour away
And the KFC is just up the road
I know he wants to help
But the Doctor just doesn’t understand

The Doctor says I’m stressed
She says my blood pressure is too high
She says I might have a stroke
She says I need to take time off to relax
She just doesn’t understand
I work 2 jobs on contract
I have 3 kids
I am a single parent
I don’t have time to relax
I know she wants to help
But the Doctor just doesn’t understand

The Doctor says I drink too much
He says my liver is failing
He says if I don’t stop
I’ll die
He just doesn’t understand
My parents used to drink everyday
My mates drink at parties
My partner drinks with me
I don’t know how to stop
I know he wants to help
But the Doctor just doesn’t understand

The Doctor says I’ve been smoking too long
She says my cough isn’t going away
She says if I don’t quit
My cancer will kill me
She just doesn’t understand
I started smoking in school
I tried to quit
But I got horribly sick
People in my family smoke
All my mates smoke
I tried to quit
But it didn’t work
I know she wants to help
But the Doctor just doesn’t understand

The Doctor said I need to change my diet
He said I need to quit
He said I need to relax
He said he knows how difficult it is to change
He said we’d do it together
He said he won’t push me too hard
He said he’s been there
I know he wants to help

The Doctor really understands

Like I said, I’m not a poet. None of that even rhymes. But I think it kinda shows what I feel doctors are doing and what they should be doing. And it’s my first poem so it’s made it to this blog so I can remember it even after it’s marked by these silly portfolio people.

But hey, 1 entry down, 10 to go.

Better get back to it!

 

3 Eyes

I have 3 sets of eyes.

My own eyes, which are blurry most of the time and riddled with astigmatism.

My glasses which are quite old and do NOT give me a bookish look, but rather make me look like a clueless 2-year-old (much like Chuckie from rugrats ^^)

And my contacts which are hella expensive and have just become useless (my current pair anyway.)

2 days ago I developed an itchy, sticky, watery Eye (just the left one) with a foreign body sensation in it also. This was around the morning time on my last day at the GP practice. Which was not a good look because patients kept asking me if I was okay or if I was tired (as I kept rubbing my eye like a sleepy 3-year-old)

Embarrassing. But I am a well-read med student who had recently come off an ophthalmology rotation. I thus concluded the most likely, plausible, rational diagnosis for my eye.

Omg I have acanthamoeba keratitis!! I panicked for a bit because this is a disease that contact lens wearers get and you could lose your vision in one eye completely and I had seen a victim of acanthamoeba keratitis and it did NOT look pretty.

Fortunately, my GP calmed me down and said it’s very unlikely to be acanthamoeba keratitis and it’s more probable that there was some debris on my contact lens that had damaged it. And was thus causing said itchy/ watery/ irritating eye. But just to be sure, I had to get rid of them.

Unfortunately, I usually get a 3 month stock of lenses from my optometrist, and those were my last pair of the 3 month stock. Which means I have order new ones and rely on NZ post to bring them to me. Which essentially means I have to go 2 weeks without contacts. Not. Fun.

I don’t really hate my glasses or anything, but they do get frustrating sometimes. Like when I want to wear sunglasses, I have to awkwardly place them on top of my glasses (because I do not have the fancy photo-chromatic glasses). Or when it rains and suddenly I’ve got underwater vision (which is not a good thing by the way). Or when I have a nap-attack, I can’t just flop on my bed or couch unless I want a bruise on the bridge of my nose. Just so inconvenient.

First world problems, I know. And normally I wouldn’t complain, but I’m in a complaining mood at the moment. So it just must be done.

My eye is fine now from not wearing my contacts for the last 2 days. Which is good. But I’m still 2 weeks from getting a new pair.

I should just have laser eye surgery. But my mommy said no because she’s worried I will develop cataracts at the age of 40 from it. Apparently she read this somewhere. Does anyone out there know someone who has had laser eye surgery and is past the age of 40 who does not have cataracts? I want to know if I can prove my mum wrong and get my eyes zapped. And I’m too lazy to read the literature.

3 pairs of eyes are just so inconvenient.

Special 

On my last week of GP rotation, I am required to do a mini-cex. A GP consult with a supervising GP present. Everyone gets 2 tries at this.

My first try was not the best. My GP said I needed to improve in my second.

I studied as best as I could, going through notes I had made nearly 3 years ago now on history and examination. Which was beyond difficult. 

But it paid off. My GP awarded me a high grade for my mini-cex. She went so far as to tell me that I’m very on to it and I’ll make a great doctor.

Now, I don’t particularly handle compliments well. Mostly because I don’t receive them too often. I don’t usually get praise for being smart or on to it or at a high level with my clinical knowledge. I basically just work as hard as I can trying not to waste the opportunity given to me. And I have a sneaking suspicion my GP just has a soft spot for me. But it was lovely to hear anyway.

In that moment, I wanted to believe her. I wanted to believe that I can be someone who is “on to it” and “a great doctor” someday. 

Lately I’ve had trouble believing I’m anything other than an all around mess. So when someone suggests I can be better, I go through many levels of not really believing them and then kind of thinking maybe it’s okay to believe it. I liked being an “onto it” person. It’s not a feeling I often experience. 

Made me feel special. ^^

Who Is The Word?

So today, while on my GP run, I was just organising the store cupboard when the nurse asked me to come see a patient who didn’t have a appointment but had chest pain that was of concern to him and his mother.

Rehearsing SOCRATES for chest pain and the protocol for referral to hospital for heart attack in my head, I went to see the patient. This man was 48 and otherwise well. He presented a history that sounded like reflux/indigestion/heart burn/GORD (GERD for Americans).  I arrived at this conclusion because he described a pain radiating up his oesophagus, typically in the morning, with an acid taste in his mouth, and that the pain is relieved on burping. He has had this chest pain for 3-4 years and occasionally had tummy pain.

But this guy was anxious. He was terrified that this was coming from his heart. He had a family history of heart disease on his dad’s side who had passed away from a heart attack at the age of 60. He broke down at the clinic. I reassured him as best as I could that this pain did not sound cardiac and considering his risk factors, it is unlikely to be a heart attack. He had however, not completed any blood tests given to him in the past so technically, I was unaware of his cholesterol status, etc. I told him that the doctor would probably prescribe him omeprazole, and check his H. Pylori status, and order any blood tests to establish his CVD risk for future.

Anyway! He was super anxious and the nurse suggested that we carry out an ecg just incase. To ease his anxiety. She also thought that the history sounded much like reflux. So we hooked him up to an ecg machine and printed an ecg.

And that’s when the problem began. His ecg showed T inversions in lead 1 and what looked like ST depression (I couldn’t actually remember the exact number of squares the wave had to be below to confirm ST depression, but it looked like it to me anyway) in the rhythm strip. There was also evidence of Left ventricular hypertrophy (peaked R waves). Uh oh. Not good. Ran to the GP and showed her the ecg for a second opinion. She said the ecg definitely showed both these things and the patient needed an urgent troponin. She THEN asked me what his history was. I explained that it sounded like a history for reflux and his ecg abnormalities may be an incidental finding.

So the GP took her own history and the patient ended up being referred to hospital. What was interesting, was that the referral stated the findings as “chest pain + ecg changes”. And there didn’t seem to be much detail about the nature of the chest pain. Nothing about the acid taste or the burping relieving the pain.

Eugh.

The patient was discharged later that day. Diagnosis? Chest pain secondary to reflux. Omeprazole charted. Out-patient H. Pylori testing ordered. LVH changes on ecg noted; Echo clear, NAD. No evidence of significant hypertrophy. There was no mention of ST depressions.

I’ve been in hospital. In ED. And I could just see the registrars on acutes rolling their eyes or face-palming at this referral once the history was taken. And the further frustration of the house officer that would be required to type out the discharge summary within 3 hours of the patient arriving in ED.

The funny thing is, this is the second time this has happened while I’ve been on this run. I thought a patient had Bell’s palsy, my GP referred her to hospital for a possible stroke when her only symptom was a droopy lip and a BP of 180/100. Which is fair enough because the high BP means you can’t risk not sending her to hospital. But she was discharged with a diagnosis of Bell’s palsy and antivirals the same day.

What is the discrepancy here? Perhaps because I haven’t known these patients for years as my GP has, I don’t have any preset notions for diagnoses? A colleague presented a case on a discussion board about confirmation bias because the doctor had known the patient for a long time, and hence knows what their most likely diagnosis would be. I wonder if that is what pushed the GP to refer this patient to hospital where the doctors would make a diagnosis based on the patient they see then and there.

But then who’s right? I think one of the peculiar things about medicine as a field is how much variation there can be between doctors and how they practice the same medicine they all learnt. One doctor says stroke, another says oh please just take some prednisone. One doctor says it’s just reflux, another says omg it’s a heart attack! Go to hospital asap!! I mean, who’s practising the best medicine? Does it matter as long as the patient is okay? But then you hear stories of how a patient goes through a bunch of doctors who tell them they’re fine, but then one doctor provides the correct diagnosis that all the others missed. What happens then? Are the other doctors incompetent? I doubt it. Because I’m sure there were other cases that they would have diagnosed brilliantly.

So then, who is the Word?

It’s not like I didn’t know this before, but I’ve just been put in the middle of it I think. And it makes me a little insecure about what type of doctor I will become. Because obviously everyone wants to be that guy at the end of line that picked up on the right diagnosis, because obviously he’s the ‘best’ doctor. But is he? Really? Maybe he just got lucky. Lucky in a sense, anyway.

Thoughts?

Satisfaction

 Just finished my poster on this GP run. Apparently all students are required to contribute to their GP clinic in some way during their 4 weeks. This does NOT include cleaning and organising, apparently. Which stinks because I’ve done a HECK of a lot of that.

My GP asked me instead to educate the nurses at the rest home she manages. I was required to make a poster about the top mortality and morbidity causes in a rest home and how nurses can prevent these. And it was not easy. Apparently not many people are very aware of these issues and as such, research papers in this area were surprisingly scarce. 

But I did not give up. And so 3 weeks, long hours of googling, (specifically, google scholar-ing, Pubmed-ing and Medline-ing), challenging my computer’s RAM, and frantically digging up my poster making skills later, 

Voila! Isn’t it poifect? 

poster

It seems to have more info than an average poster. But my GP did say she liked how colourful it was and approved it (albeit with small edits) and this is the final draft! Onward to A3 printing and laminating. 

After which time it will be plastered on a wall in a hallway of the rest home where nurses will walk past it barely reading the whole thing. Because come on. I don’t believe it’s going to change much at the rest home, but hey. I tried!

The best part however, is the pure satisfaction I get from closing the -what seems like- millions of tabs I had open of the various website I took bits of info from and compiled together first on Word, then on pdf, then finally on PowerPoint. 

My goodness. My screen has never looked so cluttered. So happy the little X on the top right hand corner of the screen can be highlighted and clicked on! 

desktop 2
Farewell to these websites and thank you for helping put together this poster for whatever it’s worth on a wall somewhere in a small rest home. 

Ahh. The satisfaction of completion. 

Now I can get back to cramming for my mini-cex tomorrow. Since I pretty much screwed up the last one, tomorrow had better go well. But I haven’t been studying much due to this poster. Eugh. May some  odds be ever in my favour! 

Rain In Winter

I’ve been going on about June and winter a lot haven’t I? Well I enjoy season changes. And yet another thing that is great about July (as it is as of today)/winter are the intense rainy days that define winter of course.

Winter in New Zealand for everyone else in the world, means snow. And snow is amazing in New Zealand. Even a little bit of snow = days of excitement.

But I live in Auckland. To many people (myself included to a certain extent) is pretty useless. It’s just a city. There’s nothing you can say “omg Auckland has the best _____”. When friends come from overseas and ask me what there is to do in Auckland, they usually receive a very long “….ummmm” from me. Then some vague comments about the skytower and a beach. I mostly advise them to visit cities outside of Auckland where there is more charm.

But there is in fact two things that Auckland is famous notorious for.

  1. The weather
  2. The traffic

The latter I absolutely hate. Traffic in Auckland has the potential to turn what is usually a 15 minute drive, into up to 1.5 hours. Not exaggerating in the slightest.

The former, however, is something that never fails to stun me.

Today was a rainy/windy/cold day. It was the perfect day to stay indoors leaning against a window and listen to the forceful patter of rain on my window and the howling of the wind

The wind is howling like this swirling storm insi- yeah no. Let’s not go there. xD 

And incredibly, some time later, the rain would stop completely. Such that there’s complete silence outside. Then a soft wind with cloudy skies. As though threatening to open again to let the rain pour. I love this interim. Going for a walk in this climate is one of my most favourite things to do. And I did just that. Admiring the effect the rain has on everything. It seems to make everything softer. Trees, flowers, road, everything has a dewy hue that is much easier on the eyes. 

This is something you’d only get in Auckland. My old chemistry teacher once told someone that “if you don’t like the weather in Auckland, leave for two hours and come back”. Because that’s how quickly it changes. 

And in winter, it’s the best thing ever. I’ve developed a fondness for walking in the rain. And the wind, and the cloudy-ness. 

I would have liked to attach a photo to this post, but I love my camera too much to risk it in the rain. Maybe I shall attach one later, taken while indoors. 

For now, I have to complete a monster assignment for this GP run and studying for my test. While listening to the rain of course. It’s doing wonders in keeping me company and calming me down while I stress over this. 

Ahh. Rain. 

‘Neath Starry Skies

Yes I know it’s late. Yes I know it’s a school night. Yes I know tomorrow is an important day.

But another great thing about June are the rare sunny days that turn into clear nights. 

Nights that are perfect to venture atop a mountain (or a relatively large Hill in the city), lie on your back at stare at the sky. 

And enjoy the city scene of course. 

When you’re overloaded with thoughts and events, the perfect getaway is to look up at the stars. It seems to make everything else seem less important. 

Yes I could do this in the summer. But the great thing about June is the stillness that comes with a cool winter night. Just me and the city in the distance and the open sky.

Not trying to sound overly mystical or anything. But I just needed to switch off an not think about the day to come. And my goodness, did it work. 

Of course I wasn’t thinking straight when I packed for this “getaway” so you’ll have to forgive the poorly captured photo on my phone that can neither prevent noise in darkness, nor focus with even 1x zoom. 

Some day I shall take my canon, use the “bulb” feature overnight and capture the stars. Not just the city scene. But I suppose from where I was, the perspective at that distance made everything much lighter in my head. 

Great feeling to lie ‘neath the starry skies. 

Sunrise And The Day

sunrise with birds.jpg

I’m a pretty early riser. But lately I’ve been waking up earlier than usual. Don’t worry I’m not an insomniac (yet), something’s just been keeping me up.

But one of the perks of waking early is that you get to watch the sunrise. Especially in winter where the sun is also lazy and rises late and slowly such that there seems to be more vibrance and colour in the sky. 

Only in June in Auckland can you find a sunrise like this. Having an East facing house with a pretty good view is always a plus. And with a little bit of photographer’s luck, I was able to capture some migratory birds as they fly away to a warmer place right over the sun.

I’m actually very partial to sunsets. Sunsets in the West in Auckland – actually sunsets anywhere in New Zealand are pretty spectacular all year round. The multiple colours mixed together as the sun sinks over the horizon is something I could marvel everyday. But as I said, in June, from my house, the sunrise is worth appreciating. 

Pretty happy with this photo.

With a start like that, it’s kind of hard not to be motivated and hopeful for the rest of the day. 

Where I Failed

Today I had to take a history from a patient who needed a repeat on her prescriptions. During the consultation, I dutifully took an alcohol and smoking history. The patient stated that she drinks 1-2 bottles of wine every Friday and Saturday both because it would help her sleep (she has recently had trouble sleeping) and because she “liked to drink wine”.

Alarm bells went off in my head.

I asked her more about this. She said that it was her only vice. She didn’t do it any other night of the week and she stayed home and went to sleep promptly. Her boyfriend didn’t like that she had this drinking culture, but she knew she was in control. She was aware that this was more than the recommended limit for drinking alcohol in a week, but she wasn’t interested in stopping or decreasing this amount because she was sure she was in control.

I have been trained in my last few years of med school to discuss risky alcohol drinking with patients and offer proper advice. There were numerous role-playing teachings and lectures that endlessly talked about the risks of over drinking and how to approach this with a patient.

But in this situation, I failed to do all of those things.

What I did was listen, explore as best as I could whether the patient was aware that she was drinking above the limit, but then when it came to the part where I should have asked her about cutting down and offer advice, I didn’t.

I cannot explain why. I don’t know why. But I am embarrassed. This woman was binge drinking. It was a substantial risk to her health. But being me, the little 5th year student in a GP practice, just seeing patients for my own learning, I felt grossly inadequate. I didn’t feel like I had the right or ability to offer advice on such things. I really don’t know why I felt like this. But I felt I seriously failed the patient. I shied away from offering advice. I knew it wouldn’t have mattered exactly what I said. Because studies show that just very brief advice is enough to get patients thinking about their behaviours in order to change them.

Then why didn’t I do it?

I have no idea.

I should have. My own view of myself. The fact that I felt too low in some invisible hierarchy, stopped me from helping a patient. I can’t explain why I felt this way. I wonder if lately I’ve decided that my voice isn’t good enough to help change anyone or anything. But even if that were the case, it doesn’t matter because, by focusing on whether or not my voice will be helpful, I essentially stopped the patient from receiving necessary advice to benefit her health. And for that, I am disappointed in myself.

I informed my GP about the patient’s drinking after she left, because from her notes, I could see that the GP had not addressed this either. But then again, GPs don’t have enough time during consults to explore all aspects of the patient’s health. I was there. I could have done something about it. I know this is a health risk, one that may be harmful for the patient and one that probably wouldn’t be addressed at all atleast until the next time she decided to visit the GP. By then, who knows what could have happened?

I hate this feeling. I hate thinking I may have failed a patient. I hate knowing that I had failed them because of some ‘view’ I have of myself that isn’t even true. I didn’t feel like I was the best person to offer advice to this patient. I was wrong. I was the person to offer advice in that situation. I was possibly the only person who could have offered advice. And I had all the tools to do so.

It probably isn’t as bad as I’m making it out to be, but it probably is. I feel guilty.

I hope that I always remember this situation with this patient. I need to be mindful of where I let my weaknesses hold me back from helping a patient.

I’m sorry if this post is rather morbid. But in the absence of having people to talk to about my thoughts, this blog serves as good avenue to share my thoughts and keep as a reminder of this day and what I have learnt. I can only hope I rise to the challenge next time and actually do what I am capable of doing and what needs to be done by me. 

And I hope I have learnt my lesson.