A Week In Melbourne

Greetings from Melbourne!

Apologies for not updating sooner but it’s been a challenging week for me on my first week of selective. And it’s been really full-on with highs and lows. That I shall now recount.

It’s my first week of living in an apartment with two flatmates. Both of whom are super organised but have been very nice and accommodating. It’s taking a while to get used to. When you live in an apartment you appreciate the value of hot water and electricity. You can’t have the heater on all day, you can’t take a shower for any longer than 15 minutes, you have to wait your turn to use the bathroom in general. You have to get used to the fact that everyone has a different sleep schedule and because you live in such close quarters someone is bound to be disturbed. One of my flatmates has crazy work hours and basically comes crashing in past midnight now and then. However, the following day, I crash around trying to make a cup of tea while he tries to sleep. And you’ve got to preserve electricity for when you need it.

That’ll be for the heaters.

Melbourne is 9 times colder than Auckland. It’s ridiculously windy and I haven’t seen sunlight in 5 days. And my apartment is lacking in insulation so things get extra chilly at night.

But otherwise, I’m super grateful for my little flat. My flatmates are great and I’m finding this new change quite endearing. Hopefully I’m a good flatmate too.

In terms of my selective, I’ve had an interesting week. The Alfred hospital is where I’m based and it’s pretty huge. But the medical school (as all medical schools seem to be), is completely useless.

I walked up to the clinical school on Monday, earlier than I was expected, and waited a full hour to be oriented. The selective coordinator I had been in contact with told me my “supervisor will come to collect me”. Instead, another doctor showed and took me through the basics of being in hospital. Avoid infections, wash your hands, patient confidentiality, don’t kill anyone, etc. After that he left me with the registrar on the gastroenterology team for a ward round.  After which, I still hadn’t met my supervisor. So I went down to his office, and he wasn’t at his desk. So I returned to the gastro department and asked my registrar where I could find him. A lady nearby said “oh he’s on leave for 3 weeks”

……..seriously? I have to have a pre-selective catch up, a midway catch up and an end of run catch up at which point my supervisor fills in my final report. I can’t do any of that if he’s away for 3 weeks!! And the most annoying thing was, I had told the lady I was in contact with all of this. So when I emailed her asking if she knew this, she said she had no idea and that I should ask my registrar who the “acting” director was and he/she would be my new supervisor. Eugh.

My registrar didn’t know who the acting director was. Double eugh. But she finally introduced me to a consultant who agreed to be my supervisor but could only meet me for 10 mins at the end of the week. Eugh eughh eughhhh.

So until then, I was stuck following the registrar around on ward rounds. It ended okay. I caught up with the other consultant, he was nice enough, gave me a project to do over the next 5 weeks, so that’s good.

But omg the ward rounds.

The ward rounds on gastroenterology are a minimum of 4 hours. I haven’t been on ward rounds since OBGYN. And those were pretty straight forward. All the women were either pregnant or had tummy pain. So I wasn’t used to the burning pain in my legs and feet as I trudged up to the 7th floor to see more patients after 2 hours and counting. But the horrific part wasn’t even the pain. It was the fact that everything about these ward rounds reminded me of my gen med rotation last year.

The rounds where you have no idea what the patient’s backgrounds were but you have to stand awkwardly in the room, turn the lights on, draw the curtains, and listen as your reg talks to the patient about their ongoing care. And they’re moving at a pace such that asking what this particular patient came in with would be the last thing they want to answer. The house officers are feverishly writing notes, so they’re no good either. So as the most junior person, you stand around and think about how you’re not learning anything.

But I am no longer a lowly 4th year student, traumatised and vulnerable, pushed around by superiors, and intimidated by everyone for no good reason. Crippled by the fear of appearing incompetent that I actually come across as less competent than I am. Yeah nah. That’s sooo last year. If I learnt anything from last year, it’s that you are the only person responsible for your learning. And that means ditch the ward round if you’re not learning anything. Find somewhere else to be. If your time is better spent studying, go for it. Better spent in clinic? Go there. Endoscopy? Hell yeah. Don’t force yourself to be in a situation where you’re not gaining anything just because you’re “expected” to be there. I showed up to all of 2 ward rounds this week. I went to clinic where the one-on-one time with consultants is the best to learn about gastro diseases. I went to endoscopy where I saw some pretty cool stuff, but left early when it was a couple of mild reflux oesophagitis cases being scoped. Time better spent reading up on IBD. Of course someone will always try to undercut you, like a consultant who decides you’d learn more about “acute management” on a ward round on the 4th day where the list hasn’t changed, than go to a liver clinic, but even then, don’t be upset. When I’m on that ward round, I do ask my registrar questions and I do persist in learning. And even if I don’t, in useless situations, even if you don’t learn how to practice medicine, you’ll definitely atleast learn how not to practice medicine, And even that, is good learning.

Taking responsibility for your own learning means that you can’t expect anyone else to care or take an interest etc. But it does give you the freedom to do the things to learn the most you can. And it means you don’t have to care too much about them either. Just make your learning work for you. I’ve been following this. And it felt good. I’m more excited to learn on gastro than I have been on previous runs.

But anyway. I shall make another post about the merits of Melbourne as a city. Not just hospital related stuff. Because this place is huuuge.

And in a big city, when you’re having a tough week, the best way to blow off some steam is go exploring at night in the rain and capture some pretty lights.

Melbourne state library

This is the Melbourne state library at night. Finally a picture with my canon. It’s been a while. Very good effect with the rain by the way. Even though I was freezing.

 

 

Passion 

Some days are hard. You can’t go through a 6 year degree without stopping somewhere and wondering if you’re really cut out for this and if the decision you made in choosing your career path was the right one.

For me, it’s on long days. The dreaded 8am-10(sometimes 11)pm shift spent following a registrar around on their long day that they’re getting paid for, that they really look like they’re enjoying. I’m the little student following them around, counting the hours down ’till they say “hey why don’t you head home?”. I am low on sleep and food, having missed dinner because the nurse on the other side of the hospital was in a predicament that needed immediate attention (a signature from the registrar). 

I am envious of my registrar who has all the energy in the world, and I am annoyed at myself for not having that passion for my job. Granted, being a student is not much of a job, but at the time I wouldn’t have wanted to be my registrar either. I was fantasising about my bed at home and whatever food was left over to eat. At this point, I realised that this is what my life will consist of from next year onwards. I didn’t know if I was up for it. I began to wonder why I hadn’t taken accounting or business as my subjects in highschool… (Probably because I was no good at statistics, but you know.)

It was heading up to the end of the shift. 15 minutes to handover. If I leave now, I would miss out on the pointless half an hour that a group of doctors and nurses share going through the list if patients. In which I have no part at all, so will most likely be falling asleep. 

But I never got to leave. 

There was a phone call about a new admission. An interesting/difficult patient to manage. The registrar asked me to accompany her, and I did. As the history was being taken, I was impressed. The registrar diagnosed the patient with a condition I had never heard of. And started her on the appropriate treatment. The patient was so grateful. Suddenly, I was full of curiosity and fully awake. I asked my registrar lots of questions about the disease and its management, etc. I was no longer hungry or tired. I suddenly had the energy to write notes, chase the nurse down to explain the diagnosis and treatment, and order tests she needed. 

By then, we had both missed handover, and she finally told me to go home. But it didn’t matter to me. It was super late, but I was buzzing with excitement. I was glad to be there. 

I may not always have the energy or the enthusiasm within me for my job, but I think I know that I atleast have the passion. The passion to learn something new and help someone in need. The passion that makes me forget about being tired/hungry or any other difficulties I was having. That’s what my life will consist of in the years to come.

Thank goodness for that. 

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?

OBGYN Rant..

Eugh. Okay I am very frustrated at the moment. This rotation has been less than ideal. I’m not sure why this run out of all the others I have been through thus far is annoying me, but it just is. And it’s also one of the shorter rotations. (5 weeks as opposed to the gruelling and usual 6). But into week 4, I am well and truly over it and would like to move on.

Why, you may ask. Well we could be here for days. But it is a realisation I have come to having spent my sick day off, pouring over online resources, the “highly recommended” textbook, notes from presentations my colleagues had put together, and my own feeble attempts at taking notes over the last 3 weeks, trying to put something together in my head for my osce (observed clinical exam – or something like that) next week. And all they have is contradicting info! Eugh!!

And remember, I’m sick. So much so that I have taken a day off from hospital which is usually a big no-no for me. I hate being absent. So this should be a pretty good indication of how bad I’m actually feeling. But having said that, I have tried to make my day very productive because the only thing that offers a better motivation to study over the motivation to sleep the day away to recover from an illness, is STRESS. And I’ve got a lot of it right now. So here is a list of things I dislike about this run:

  1. There are too many screaming women around. (And I’m not talking only about the pregnant women). Not a day has passed on this run where I’ve not heard a consultant/registrar/house officer use a string of colourful words to describe the uselessness of another health professional (nurse/GP referral/anaesthetists not showing up/ surgeons hogging theatres/ private obstetricians strutting about as though they own the hospital and the rest of the staff serve them) and then breathe deeply in and out a couple of times before telling each other to calm down….. -_-  Jeez why so much negativity la?
  2.  The freaking abbreviations on every page of every note of every piece of paper ever written on. Goddamn the APHs, PPH, TAH, IUA, TOA, OP, AP, NBF, EBM, etc etc etc. Why am I spending most of my time staring at notes with a train of abbreviations instead of words and trying to figure out what the HECK the last doctor even had to say about this patient. Doesn’t anyone write in words anymore? I remember parents yelling at kids for the overuse of text language. Though I have never been fully guilty of this, I understand their frustration now.
  3. Then there’s surgery. During which you are pretty much part of the wallpaper. I don’t know what to do with myself. The general surgeons were frankly more friendly during theatre than the obstetricians/gynaecologists. I don’t learn anything and basically just trying hard not to fall asleep. (Have to be subtle about this, I have learnt. People are apparently very quick to assume you are asleep even if you’re just tired or thinking really hard about life. >__>)
  4. The male consultants who seem very aloof and cold towards patients. I kind of mentioned the whole male/female dynamic in this specialty right? Well it’s rather obvious with the male consultants. They almost seem bored with their job. It’s like they chose this specialty just to prove a point. To prove their dominance. Again, it might just be the consultants on my team, but I sat through the most cringe-worthy situation where a male consultant told a woman she had endometrial cancer in the coldest way possible. In one sentence. “Yes Mrs. X come in, we’ve received the referral from your GP that your last smear was abnormal. The results have come. You have endometrial cancer.” Verbatim.
    He then sat in his chair, said nothing for 2 minutes straight while the woman cried. Before finally adding “I’m sorry about that” in the most un-sorry way imaginable. It was beyond frustrating and extremely useless. Obviously I couldn’t get up and comfort the woman, though I wanted to, very much. Sigh.
  5. Pregnancy is a mess. Scarred for life by all the bizarre things that happen to the body of a pregnant woman. Why do women do this to themselves?
  6. The tutorials… I feel stupid. I dislike feeling dumb and stupid. In a room full of “colleagues” and someone who I desperately want to think differently of me, I just feel stupid. And it does NOT help when the consultant who is supposed to teach, asks you a question, purely to “catch you out”. And ofourse, being me, I fell for it. I just don’t see what she was gaining from that. But I guess it’s my fault. I should not have let myself be “caught out”.

Whew. Well, as you can see, studying has made me very frustrated. But in the interest of not making this post too one-sided, I shall attempt to mention some positive things about this run.

The doctors are good. Like really good. Their diagnostic skills are amazing. And there is so much I’m able to learn from them. A registrar saw a patient and diagnosed one of the rarest phenomena in pregnancy. “Pregnancy- related intercostal neuralgia”. Never heard of it, purely clinical diagnosis, she called it, treated it, and fixed the young, pregnant woman and sent her home in 24 hours. This after several other specialties had diagnosed her with gall bladder disease.

The patients appreciate. Big time. It’s a sensitive subject. The problems are both horribly difficult to talk about, but also extremely horribly difficult to live with. And if you’re understanding, and make them feel comfortable, and fix them, their happiness and relief, is worth it.

And with that, I return to osce study.

Dress to…..Unimpressed

I live in a part of the world where the Doctor’s white coat is no longer worn because it spreads more disease than it helps cure (because most doctors do not wash their coats as often as they should – being a clean freak myself, this fact scared me very much). And because it induces white coat anxiety and tends to widen the gap between patients and doctors making empathy and cooperation difficult to achieve. Which I am told is very important in the clinical arena.

And while all of that is great, it does mean that students like myself no longer have the freedom of wearing whatever they want (other than crop tops and shorts, of course) with the confidence that it will go unnoticed under the very professional looking white coat. This means I have to wear formal clothes all day every day in hospital. And that means 2 things:

  1. In order to look formal, I must trade off the most important thing I think of when I buy clothes – comfort. Straight pencil skirts, stiff blazers that scrunch at the elbows when you bend them, dresses with no pockets, etc. Definitely not like my ideal choice of clothing which, although unimaginative (jeans and a top), allows me to do everything I need to do without sparing a thought to my elbows or knees from where my skirt is riding up.

 

  1. I need to get a whole new wardrobe because I don’t have a shred of formal clothing available for the hospital setting. And I know what you’re thinking: shopping spree! What could be wrong with that?! Well I’ll tell you. I stink at shopping. I am one of those people that only ever goes shopping if I lack one item of clothing. Or any object for that matter. I then proceed to go “shopping” whereby I walk into one shop and find this ONE item I need, buy it, and walk out without giving a second thought to anything else in the store. So if you tell me I need 50 items of clothing and they all have to match and they all have to look presentable, you’d see me implode. (well you wouldn’t see it, but you know.) I also do not consider myself very fashionable. I do not bother to keep up with trends or anything of the sort. As I said, my major intent in clothes is comfort and practicality. Which means I’m never seen in particularly trendy clothing or anything very out there. So you can see where I’d have trouble with this new lifestyle in hospital.

 

Formal clothes can be a good thing though! They make people look so professional and much older than they are. Which in my case, isn’t always a bad thing because with my small size and innocent expression, if I was in my casual attire, people in hospital would think that I am visiting a patient instead of seeing one and they would probably ask me where my mommy is. But if was wearing a very severe looking blazer, they’d know I was actually someone kind of important. Right?

So I did it. I went “shopping”. Turns out, if I actually pay attention to the other things being sold at stores, I’d find that there were lots of different types of formal clothes! Skirts, dresses, pants, blouses, shirts, and in all shapes and colours! Err… almost too many. The problem soon became deciding what exactly to buy. I found that another reason I only buy one thing at a time is because otherwise I become very indecisive and come back empty-handed. There were far too many options! It made me wish I was a boy meaning all I would need was a shirt and trousers which would be a nice adaptation of my regular jeans and top! But no, it just isn’t that simple for a girl. I’m still going mainly for comfort even among the formal clothes though! And practicality – by casually doing jumping jacks in the dressing room to make sure what I’m wearing allows full range of movement. (I’m not kidding) Otherwise it’s no good. Because I would need my elbows and arms if an emergency situation comes up and I’m the only person able to save a patient by commencing CPR! (I am kidding.) So far it’s working out pretty well. I still have a lot more clothes to acquire, but I’ve got almost a month left before hospital time begins, so hopefully I’ll be all set by then! And hopefully people will take me seriously in hospital.