‘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. 

Which Would You Rather?

I am currently on my General practice rotation. So I’ve been placed at a medical centre under a supervising doctor for two weeks now.

I’ll be honest, not the best two weeks. Not an extremely friendly supervisor or a particularly enjoyable task set for me. I seem to be doing more work as a nurse at this practice than a 5th year medical student. And not very well, I might add. I have no idea what half the wound dressings’ names even mean. So when the supervisor asks for a crêpe dressing, I pretty much go looking for maple syrup.

I’ve only just started seeing patients on my own. And I think my history taking and examination skills are a bit rusty.

But something interesting happened in the last couple of days. My supervisor approached me and said that she would like me to come in during my holidays to assist her on surgeries. She also said that should I choose General Practice as my specialisation, she would be more than happy to take me on as a registrar during my training.

I was more than surprised. I thought I wasn’t doing well at all. I asked her whether I was performing okay. To which she replied “You will be good as time goes on. But I’ve been hearing from patients about how lovely you are. Your manner is very good”

Now this is very interesting to me. Throughout med school I’ve been hearing how great my ’empathy’ is and how well I seem to interact with patients. I never really get compliments about my clinical knowledge or diagnostic skills. Not that I’m turning this into a negative thing or anything because of course it’s important to have a good manner towards patients and I’m grateful that I am able to make patients feel comfortable. But that’s something I tend to think should be rather natural for everyone. Not just doctors actually. Everyone should have a good manner towards everyone else right? So why then, is this particular feature of my practice always commended? It just seems ironic. Is it that rare for doctors to be kind and caring towards patients?

And also, does the fact that I’m nice enough take away the importance of being a good diagnostician? How important is that? It’s kind of like the popular TV show House where Dr. House doesn’t care at all about his patients and treats them in a pretty disrespectful way, but once he cures them, they tend to be so grateful and thank him profusely.

So. Which is better? To be nice and kind but not a great ‘doctor’ or to be a brilliant doctor but not so much with the people skills?

This isn’t to suggest that I’d rather be horrible towards patients as long as I’m good at what I do, because like I said, I treat everyone I interact with exactly the same. The way I would like to be treated. And that’s perfectly natural for me. But when it comes to reports and I see an excellence grade for empathy but a pass grade for clinical knowledge, while others have it the other way around, I really wonder if they feel disappointed in only achieving a pass for empathy or if they believe it’s enough to have the clinical knowledge to a higher level.

I must admit I feel a bit disappointed in having a less than adequate level of clinical knowledge but I think I’d be equally (if not more) disappointed if someone suggested that my manner towards someone else was poor.

So. Which would you rather be? I’d love to know.

 

You Know What’s Frustrating?

When your supervising doctor says “Listen to the patient’s chest for the murmur and characterise it for me” and you put your stethoscope on the patient’s chest,

But then the doctor starts up a conversation with the patient… So you can’t even hear the heart sounds.

Doctor: So, could you hear the murmur?

Yes. Unfortunately that’s all I can hear. All over the chest.

Sigh.

Sometimes I Wish I Had A Clone 

Wouldn’t that be nice? 

I could be in two places at once. My clone would stay here, do her duties, be with family, not disappoint anyone. 

While I could disappear. Live among the mountains. Or in a field. Or in a far away forest where I can throw my phone away because there wouldn’t be any signal.

I could travel the world and learn so much. I could heal and be happy. And I would do so knowing my absence isn’t hurting anyone.

Thanks to my clone.

Sometimes I want to drop everything and take a break from life. But I’m responsible for too many things and too many people to just do that. And life isn’t always just about you alone. 

But if I had a clone, she would be me. And she would be responsible, while I would be able to leave. Unless she wants a break too. Haha.

Wouldn’t it be nice to escape for a while. 

I wish I had a clone. Do you? 

Healthcare In The Digital Age

Introducing the iMoko! eHealthcare at your fingertips!

This was the topic Dr. Lance O’Sullivan, New Zealander of the year 2014 talked about to a room of aspiring doctors. Dr. Lance is a GP in a small rural city in the far north of NZ. He is also the inventor behind a new app known as iMoko. The app was developed to reduce the number of preventable hospital admissions by infectious diseases. Particularly skin conditions such as impetigo, infected eczema, etc.

The app is used in schools by volunteers-and this point was stressed quite clearly and repeatedly by Dr Lance- who are NOT medically trained. They are from different backgrounds eg. IT, accounting, teacher aids, etc. He told us that these volunteers receive a maximum of 30 minutes training on how to use the app, along with small clinical devices such as a thermometer, pulse oximeter. They then visit students at school that teachers are concerned about, to perform a ‘clinical assessment’. They proceed to take pictures of any skin lesions and a supporting video if necessary.

This information is then uploaded to a cloud where other volunteers assess the information, make a diagnosis, suggest a treatment and submit the case for approval. At the end of the line, a doctor either approves or disapproves the case. If it is approved, a referral is sent or a prescription is to be processed.

Dr. Lance moved on to say that many kids have been treated through this app and the consultation time for him was a mere 15-30 seconds as opposed to the 15 minutes you get with your general physician. He also added that the volunteers were practically at the level of ED triage nurses after a 30 minute training on how to use this app. Finally, he concluded with the statement that this is the future of healthcare. And that in a country of 15,000 doctors, we only really need 5000. And soon we won’t need any.

……..well I’m sure you’ve realised that I have some thoughts on this.

First off, Dr. Lance seemed like quite the salesman. He was very persuasive that his idea was revolutionary. Okay that’s a bit catty. But it’s true to a certain extent.

Secondly, I like the idea. No really, I do. The intent of the app was to reach children in places with difficult access to healthcare and easily curable (but potentially fatal) diseases. That, by all accounts is a good thing.

Where I have issues is this whole “volunteers who are not medically trained” business. Not because I think trained doctors are superior to others or anything like that. But come on. Dr. Lance was essentially suggesting that a 30 minute app tutorial > 6 year medical degree. I’m sure I am not the only one who has issues with this. Would you be happy with someone with an IT background taking your temperature, looking at your skin lesion, taking photos of it to put on a web app and have other people with nor medical background diagnosing and suggesting medication for you? I wouldn’t.

And that’s another thing. Where does patient confidentiality fit into this app? Essentially, the volunteer doing the assessment and all the volunteers on the app have access to patient information. Including their NHI number (the index number that provides access to their entire medical record), name, etc. Patient confidentiality is an endlessly stressed topic at med school. You would get into all sorts of trouble if it is breached and if any confidential patient information is revealed. Who’s to say these volunteers have had training in confidentiality? How can we monitor that they are not showing this information to others (who are not volunteers) as part of their assessment?

Then there’s respect. Photos on this app can be of anything. Regardless of which part of the body the lesion is on. How comfortable would you be about having a bunch of pictures of different parts of your body (including your face, as there is generally an attached video of the patient) on a web app for many people to see. And you wouldn’t necessarily know who was viewing this info?

Another thing I was really iffy about was Dr. Lance’s nonchalance regarding these risks. During the talk, one of the other doctors present expressed her concerns about the possible risks of this app. To which, Dr. Lance smiled, said “good question”, and then turned to the rest of the audience and asked “How many of you believe our current health system is 100% risk free?”. That was a complete salesman response, in my opinion. Turn a question into another question to divert away attention from the fact that the person was unable to answer the question (or was reluctant to). Whether or not our current health system carries risks is in no way a justification for the risks posed by this new app. Because we should all be striving for a 100% risk free system. To say that yes we have flaws but atleast we’re better than, say, West Africa’s health system is really not a good comparison and is really nothing to boast about. I think it was pretty clear to everyone that Dr. Lance was not interested in addressing the risks of his app even though he may be aware of their existence. He seemed to be more interested in selling the idea that this is the future of healthcare and face-to-face consultations will become obsolete and we won’t need as many doctors anymore.

This is something that I really struggle with. You hear a lot about robots taking over human jobs and doing them better. But in a field such as healthcare I really fail to see how humans can become obsolete.

Yes you can have a machine dispense medication. But you can’t beat the important role of the pharmacist in recognising pitfalls and contraindications in the prescription based on the patient’s history.

Yes you can have a robot in the emergency room bringing water/food, checking temperature and asking patients their current level of pain out of 10. But you can’t substitute the nurse’s ability to recognise when a patient is in distress and provide the appropriate support and action.

Similarly, yes you could probably devise an algorithm to diagnose disease (I assume this is how the volunteers suggest diagnoses and treatment, as Dr. Lance failed to elaborate on this). But there’s no way you can beat a doctor’s ability to see a patient and rule out several possible diagnoses that carry the same symptoms for the correct one in that particular patient. As well as provide support, respect and that human touch in the doctor’s role that goes so much beyond just simply diagnosing and treating.

Does anyone out there have any views on this? Would like to know how others feel about this app.