That’s Gen Med 

First week of gen med done! And it was very refreshing.

Good news is that my team still exists as we have a consultant covering the missing one. And my registrar is quite nice, and I’m the only house officer on my team. So yay that worked out.

And it’s wonderfully busy! I barely have any time to think or worry about anything else! Going on a ward round takes up half the day, then doing jobs takes up the other half! With a couple of late finishes too! 

Needless to say, I’m enjoying myself so far.

But this was a short week. I only worked Monday, Thursday and Friday. Because incase you didn’t know, (and you’re not likely to because this isn’t big news like Lady Gaga and Bradley Cooper possibly being in love or Taylor Swift hinting at new music) the junior doctors of New Zealand are on strike! 

We are on strike for safer hours. Basically we work 12 day stretches (including weekends) without breaks and are demanding that we should not work any more than 10 days continuously at a time. Which I am totally behind. A lot of the other house officers are strong advocates and unionists so I hear a lot of noise from them.

I’m not a big unionist. I do support the cause, but I feel like sometimes people take it overboard in a “Us vs them” concept. And people complain about a lot of things that I don’t think ought to be complained about. There’s a lot of “they don’t care about us!!” Talk from a lot of the other house officers but I think I can atleast be grateful that I have a job. 

But anyway. I am part of the union and so I have been going on strike!

In the midst of that however, yay gen med is good so far. It’s been an interesting week. I got shot down by the radiologist when trying to discuss my first case (he basically said your patient is 90. She’s done with life, what’s this investigation going to change), ordered a blood test for the wrong patient (I’m sure I’ll be screwing up a lot of these little things) did atleast 10 discharge summaries in 2 days, and worked late. Not too bad for the first week

Hopefully things stay manageable.

Hurdles Crossed 

Today was the last day of my first rotation of 2018! Never had I known Gen Med to be so tolerable as I had this year. Of course it may have had something to do with the fact that I am a final year medical student and as such I am a legitimate member of the team not just the awkward appendage that opens curtains and turns lights on as a 4th year student.

No more. I am needed. I am important! I am a Trainee Intern and I am second to the house officer.

It’s been really great actually. My house officer had been extremely helpful in teaching me how to be a house officer next year. I was doing jobs and learning the ways. My consultants were lovely and actually took an interest in me, making an effort to teach, etc. It was such a change to the experience in my 4th year.

But it’s been 6 weeks and it was time to end. I had my long case assessment which was entirely horrendous. Basically I had to take a history and do a focused examination on a patient with a long-term issue. These usually being medical issues like diabetes or heart failure or something along those lines. And these patients are supposed to know the drill and know quite a lot about their conditions. I however, got Mrs. Vague from Lost Town in Shadyville.

Me: So, what concerns you mainly about your health?

Patient: Well I had a fall 50 years ago. I hurt my back. And I haven’t been able to walk since.

Me: Oh I see. Could you tell me a little bit about that?

Patient: Well, I fell over and hurt my back. I had a surgery, and I haven’t been able to walk since.

Me: What surgery did you have?

Patient: A surgery on my back which took the pain away but left my legs feeling like lard. I couldn’t move them, couldn’t feel anything, and I had to have physiotherapy for 1 year.

Me: Oh so you’re able to walk now?

Patient: Yes I walk fine now. I don’t need supports or anything.

Me: Okay and how is the feeling in your legs now?

Patient: Oh much the same. They feel like lard. Like I can’t move them at all. And I have foot drop in both my legs. But I can walk fine. Everything is fine!

Horrendous. She kept talking in circles and I had no idea what her problem was. When I presented to the consultant, he told me that she actually had a failed spinal surgery where a few nerves were accidentally cut!! I never would have gotten that out of her. Meanwhile, the other students had garden variety patients with diabetes and atrial fibrillation.

I had this awful 10 minutes before presenting to the consultant where I was sure I had failed. Fortunately for me, both the examiner in the room, and the consultant I presented to recognised that I had a particularly difficult case and said I did well, and I passed!

Thank you Universe!

And then on my last day, my own consultant gave me a good report. She told me I had been a wonderful addition to the team and I would make a great doctor. Which was so nice to hear. It just gives you that boost of confidence. After two years of being unsure about everything, it made me feel good. That maybe I’m finally doing enough to come across as someone competent. Who does belong in medicine. But anyway, as I’ve mentioned before, I’m useless at receiving compliments still, so I just sort of smiled and said thank you. Hopefully she didn’t think I was being weird.

The Gen Med rotation and the long case are huge hurdles for this year. The long case is the major assessment 6th year students are expected to pass. I’m really grateful that I was able to get through it and feel competent doing so. 

But anyway. I’m properly exhausted now. Gen med is the most tiring rotation to be on. I’m moving on to rural GP starting Monday. So hopefully that’ll be a good change of pace and I can get some decent rest. Hopefully not famous last words. xD

 

On Gen Med I..

Wake up tired

Get to hospital way too early and tired

Go on 3 hour ward rounds getting progressively tired

Answer questions through the scrambled fog of tiredness in my brain and feel kinda good

Eat way too late and thus feel hungry and tired

Trudge up and down 5 floors of stairs to do ward jobs while still tired

Get home way too late to be motivated to study and do the things that need doing despite the tiredness

Fall asleep far too early 

And repeat.

Sighhhh. 

Admin Nightmares

Nothing says back to uni like a big admin stuff up.

I just cannot stand the admin people in universities. Medical universities in particular. They are the most frustrating people in the world.

Yesterday was my first day back at hospital. I showed up and had a little orientation meeting with one of the consultants, during which I and other gen med students were handed a pack of information about our run. Including the team we would be attached to.

I was assigned to the Black gen med team ( at Auckland hospital, the team names are colours. But even so, black shouldn’t really be a colour associated with healthcare. I don’t think they thought this through very much)

Anyway! I trotted up to the ward and asked the nurse where I could find the Black team (The first fail was that there were no contact details or names for any members of the Black team provided in my “information pack”).

The nurse looked at me and said “which one? We have 3 black teams”. I stared back in horror. My “pack” did not specify which black team, nor did it mention there was more than one. Useless. I told the nurse I didn’t know. She was kind enough to call the Black team that was currently on the ward to look after me.

The consultant asked me who I was meant to be with. I said I didn’t know. He then proceeded to call the consultant I had met with this morning to see if he would know. He apparently said that it  should have been printed as part of my “information pack”.

Oh for God’s sake.

After standing there awkwardly for a bit, the Black team consultant said he would take me on. And I spent the last two days with this team.

Today, I received an email from “admin” specifying that I should be attached to a registrar of another black team.

And this wasn’t just me. The other students also joined whoever was present at the time of their arrival to their respective wards and we were all collectively pissed off by this late email asking us to switch teams.

It cannot be that hard to have the tiniest bit of communication between the so-called “admin” department that are supposed to run the whole show, and the clinical teams. Like what is the problem?

And it’s not just my university. Admin people worldwide are crap at replying to emails, answering phone calls, and just generally getting things done that they are supposed to do.

I mean it’s not like anyone is asking them to move heaven and earth. We’re only asking what is part of their job description. Surely this isn’t mission impossible.

All the students on Gen med decided to ignore this admin person’s jumping team suggestion and to remain with our own chosen teams. It seemed so much less messy.

That’s how you do good administration to be honest.

Blech.

Well that’s my rant for the day. I shall talk about Gen med itself later on!

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?

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.

 

Gen med..Generally.

As I’ve already said, I’ve just finished my first rotation at hospital. That being general medicine. I thought now would be a good time to reflect on the past 6 weeks from a medical perspective.

So, general med. I’m not too sure what it’s called in your part of the world. Internal medicine? Family medicine? Well in my little corner it’s called general medicine. Why am I dwelling on the name? Because I feel it needs defining. With every other branch of medicine, cardiology, neurology etc, it’s pretty self-explanatory what that branch entails. General medicine is a bit different. So. Can I define it? Uhh not really. Basically it seems like this. If you’ve got heart failure, you’re a cardiology candidate. But if you’ve got heart failure in addition to lung abscess, liver metastases, diabetes, kidney failure, fluid overload, peripheral neuropathy aaand urinary symptoms, you’ve just won a free ticket to the general medicine ward! Welcome aboard!

The whole place seemed very disorganised. Everybody seemed to have a million and one problems: The million problems likely to have accumulated over many years (which I’m sorry, you’re just going to have to live with) and that one extra problem you’ve just acquired that we will now attempt to cure or bring to a stable enough condition for you to live with. Eugh. During med school, we were taught that a lot of conditions have no cure, etc. and I was okay with that. But seeing it in practice, was quite difficult to digest. The doctors don’t really make problems go away, they just make sure your treatment is good enough for you to go home and live with your problems. Now I realise this may not be exclusive to general medicine, but it was pretty much all I saw on this ward.

Another thing is that because these patients have a million and one problems, generally they stick around for a while. Statistics say that the average number of days a person stays in hospital is 3 days. I can tell you that only a quarter of the patients I saw in 6 weeks stayed for 3 days or less. There are patients on my ward that came in before I started and are still to remain for a few more weeks after I’ve finished. At least one of their problems causes issues for them every day. Leaving doctors clueless. There is a lot of standing around and thinking in general medicine. I can’t imagine any other speciality doing so. If you’re an orthopaedic surgeon, there’s no two ways about it. The knee needs to be worked on, the knee gets worked on. In general medicine, each of your million problems have to be considered separately and together before any of your medications are changed. Whew. That’s a lot of brain work. I can’t tell you how many times my registrar or consultant stare off blankly into space. Their agile minds sifting through thousands of resources of information on all the illnesses said patient has, and how best to treat them. You can see the sheer concentration on their face as they work to solve the puzzle. It’s quite cool really. But sadly, the solutions are not always so exciting. It generally consists of some small change in their current medication which, to be fair, does make them better and stable enough to go home, but not actually cure them of anything. Sighh. I think I might be too idealistic.

Also, if you stay in hospital for too long, bad things start to happen. Patients become boomerangs. Mr Brown came in with exacerbation of his heart failure which was complicated by his diabetes, liver abscesses, kidney failure and new onset diabetic neuropathy. He remained in hospital for 4 weeks during which time many doctors worked to stabilise him. At the end of 4 weeks on Friday, he was well enough to go home. The doctors cheered and celebrated his farewell for it was a job well done. Monday morning of the following week, he registrar received a call. Mr Brown was to return. He appears to have developed hospital acquired pneumonia. facepalm

Luckily for Mr Brown however, the pneumonia in addition to his lung abscess and pleural effusions qualified him to be in the care of the respiratory overlords. Mr Brown was lucky. Poor Mrs Smith however, returned with a new macular popular rash after being treated for her adenovirus. She is doomed to stay on the general medicine ward until the cause of her rash can be isolated.

As I’ve mentioned, in general medicine we get whoever doesn’t qualify for specialist care. Sometimes this can be extremely frustrating because the requirement for specialist care seems to be a bit too specific. And patients that just miss out seem to get sub-optimal care under general medicine. Mrs. Jones has had a long-standing rheumatological condition called behcet’s disease. She presented with abdominal pain and diarrhoea and was admitted under general medicine. Upon investigation, a colonoscopy was done which revealed ulcers in her intestines characteristic of her behcet’s disease. She requires immediate treatment of ulcers and further management of flares of her behcet’s. Both of which cannot be provided under general medicine. However, the rheumatology overlords refused to accept her as she presented with gastrointestinal type symptoms. Gastroenterology refused her as she has an underlying rheumatological condition. But both were happy to offer advice on her care for the minions in general medicine to carry out. Meanwhile, Mrs. Jones was still in pain.unimpressed

Not. Cool. But I’ve learnt that in hospital, everyone plays hard ball. My consultant knew the game. After several angry calls to both specialists, you’ll be happy to learn that Mrs Jones was referred to gastroenterology and is receiving the care she requires.

success-kid-300x166General medicine for the win.

I could go on and on and it seems as though I have. But I will say this. What I love most about general medicine is the patient centred care. The holistic approach to treatment of the patient as a whole. It’s all about the patient. What did they want? Were they well enough to go home? Did they understand what was happening to them? Who else did they want to involve? Etc etc. I think this is something unique to general medicine. One of my lecturers at medschool who is a bigshot neurosurgeon taught us that the more a doctor goes into a speciality, the less they see the whole patient. “An orthopaedic surgeon would basically just see a knee walking through the door” He would say. “Remember to look at the patient as a real person and treat them”. I was really able to appreciate this in general medicine. I could see that this made the patient feel that much better and safe. And I loved it. It’s what I would expect as a patient and it’s what I want to offer. I think I would really enjoy working in general medicine. But of course, it’s too soon to tell. Starting next week is my speciality medicine rotation and I’ve been allocated the most specialist subject there is: Stroke! I will be spending the next 3 weeks thinking and learning only about patients with stroke. I’m not too sure what to expect. But I’ll keep you posted!

NOTE: All names of patients given are not real names.