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.

 

 

I’m Over Psychiatry 

Yup. It’s been one week. And yup. I’m already tired of my new rotation. I kind of knew I didn’t want to be a psychiatrist but this feeling of being underwhelmed seems to be a recurrent theme for me. I’m worried I’m not going to find any specialisation that I really enjoy. Sigh.

But anyway back to psychiatry. I’ll tell you why I’m already over it on here so I can decide whether it’s just me jumping the gun and disliking a run straight away after one week or whether I’m justified in my unimpressed-ness on this rotation.

So. Reasons I’m ready to fast-forward the next 6 weeks:

1. Taking a psychiatric history has a minimum duration of 1 hour. This includes patients who are already admitted and whose progress needs to be monitored. And this is by the consultant. Not just an entry level house officer.

2. The pauses within the history taking.

Doctor: So how has your mood been?

Patient: …………………………………………………….. Yeah

Doctor:……………………………………………………………………………………………………………………………………………. How are the medications?

Patient:………………………………………………………………………………………………………..*shrugs*

I mean, come on! I admire the psychiatrist and their patience but as the observer, I was dying. Of sleep.

3. The 50 million unnecessary labels for conditions.

  • schizophrenia
  • Schizoaffective
  • Schizoid
  • Schizofreniform

Omg. And you know what the funniest part is? There was a patient whose regular psychiatrist had diagnosed him with bipolar disorder and who was being treated with Lithium. At the Mason clinic, another psychiatrist spent 1.5 hours with the patient taking a history (while I was falling asleep in the corner) and concluded that the patient had Schizoaffective disorder instead. I asked what that was. Apparently it is a combination of schizophrenia, bipolar disorder, AND depression. The psychiatrist spent a further 15 minutes explaining to me how to distinguish between schizoaffective and plain old bipolar.

I then asked her what the management was for this. She replied: “Oh there’s not difference. We just need to change a lithium to Sodium Valproate because Lithium isn’t working for him. Otherwise it’s just treating the bipolar”

-_____________________-

I felt like I had been trolled. The treatment is no different, yet it has a scary name distinguished only by “affect”.

Why.

Just why.

4. There are only about 5 treatment options for all psychiatric illnesses. You’re either on an antipsychotic, an antidepressant, a mood stabiliser, given cognitive behavioural therapy, or electroconvulsive therapy. For literally EVERY psychiatric condition. And it does not cure them, unfortunately. So then why is there so much hoopla about the psychiatric history. One of my consultants actually asks patients such specific questions like “Do you see spirits rising up out of the ground?” and “Do you believe that any of us here are working for the secret service and spying on you to pull the thoughts from your head?”. I failed to see how this was relevant. Because he had asked these questions after the patient had described the nature of his delusions/hallucinations. What exactly was the psychiatrist intending to do with the specifics of his hallucinations once it had been established that he was having hallucinations? Was the treatment going to be any different? Nope. Were we going to help change or rid him of the hallucinations? Nope. Then why these leading questions that may have in fact put such hallucinatory ideas in the patient’s head?? For their entertainment?

I just don’t get it.

And those are the reasons why I’m over psychiatry. I just don’t think I have the patience to be a psychiatrist. I admire them though. Such patient people with great listening skills. The consultants are actually lovely people which is great. But yeah I’m not really cut out for psychiatry I don’t think. I think psychiatry is really interesting and I’ll probably enjoy seeing a psych patient in ED (where it’ll be a short history with a quick referral. xD) but that’s about it.

Well. 1 week down. 5 to go. Hopefully it gets better. Or goes by quickly. Whichever. 

Forensic Psychiatry 

Day 1 of psychiatry. The first day of rotations are always really lame because it’s a new place with new people and there’s the awkward tour where you’re trying to remember everything you see but all the hallways look the same and you gotta introduce yourself 15 times to everyone you walk past, and and sigh.

Plus on the first day there’s never much to do. You just pretend to do some study or look mildly interested while thinking about the 6 weeks to come and the daunting assignments/assessments that need completing.

Today was no different in that respect. But this placement is very interesting for me. As the title suggests, I’ve been placed in forensic psychiatry. Where mental health meets the law. I’m in a relatively small practice known as Mason clinic in Auckland. It’s an extremely high security clinic for offenders with mental illnesses.

Apparently this is a scary place. When you google Mason clinic, some of the phrases that come up include “where the mentally insane killers are protected in the most secure mental clinic in Auckland” and that it is “home to some of the country’s most dangerous offenders”.

During orientation, the first thing the students received were these:

 
The rectangular thing on the left is a “personal alarm”. It is essentially a distress call that will have staff running your way in “about 10 seconds” in case you’re being attacked or held hostage or something. In addition, all hallways have reflective glass near doorways so you may see if someone is tracking behind you. Every door is swipe and fingerprint protected. I was also given a heavy iron key that opens certain doors in the high security areas. Oh and no lanyards as they pose a significant safety risk in case someone wanted to strangle you. No messing about in this place.

I knew I was placed in Mason clinic. The idea didn’t scare me much. But some of my colleagues were clearly spooked and were discussing ways to hide their ID cards and thinking up fake names to give to patients during history taking sessions. Oh and we’re also not allowed to carry out patient interviews alone. Always have a staff member present for your own safety.

Psychiatry has such a stigma. It’s kind of borderline funny for me. We always having teaching that tells us to position ourselves in the room with a psychiatry patient such that we are close to the door and can run away if any problems arise. Yes, I know,  safety first and all that but still. From the patient’s point of view, won’t that make them feel suspicious and as though we’re scared of them? Honestly these bulky personal alarms. I’m worried the patients will see them and think that we find them a significant threat. This is the 21st century people! Can’t we get smaller, more discreet alarms? How am I supposed to build rapport with a patient if I’m walking in going “yeah watch yourself pal, I’ve got an alarm and I’m not afraid to use it”. 

It can’t be easy having a mental illness as it is. But then with the added feeling that you’re a danger to others? That kind of thing might distress some people I think. 

But hey. They’ve been using these things for ages, so I might be the only one who thinks it might be weird for patients. I also wonder if they’ve ever had issues with patients with paranoid schizophrenia thinking that we’re using these personal alarms to spy on them or something. 

Okay now I’m just pushing it.

Oh and someone’s personal alarm went off today. It was a false alarm, but we’re supposed to treat every alarm call as genuine and go running. I’m so scared I’m going to accidentally set mine off. Eugh. They’re just too big and bulky. 

Well that’s day 1. I think psychiatry is going to be really challenging for me. We’ve had next to no teaching at all on this subject in the last 4 years. Except yesterday when a couple of psychiatrists attempted to conduct a crash course in psychiatry. Which was extremely overwhelming. Did you know that there’s a DSM 5 now?! These DSM people need to stop and take a breather. The criteria keeps getting thicker and thicker. And to be honest I feel like it’s including more and more normal people characteristics to diagnose a person with mental illness. 

It makes me question my own sanity. Sigh. This should be interesting. 

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.

 

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.

It’s all in your head

One of the lectures I had during formal learning week included a session on ‘Mind-Body Medicine’. This basically talked about how psychological stimulants can affect the body physically.

The lecturer that talked about this topic said how your body is a “metaphor” that conveys what your mind goes through. She provided a couple of case examples.

There was a woman who had recurrent mouth ulcers. Doctors were unable to ascertain a cause for these mysterious ulcers and were unable to cure the patient. Eventually she was seen by a psychiatrist who questioned her about the time of the onset of the ulcers. If anything significant happened in her life. The woman stated that she and her family were devout Catholics, but recently her daughter left the church. She was deeply affected by this. When asked what most bothered her about this situation, she said that it bothered her that “she couldn’t talk about it” with her daughter. The psychiatrist suggested that she try talking to her daughter. After the woman agreed and proceeded to do this, her mouth ulcers mysteriously disappeared as quickly as they came.

Another patient, an elderly woman living alone had once had a fall in her garden and hurt her foot. Traumatised by this incident, she retreated to her home and over a few months became agoraphobic and refused to go outside or interact with others. She developed scleroderma  (an autoimmune condition that causes hardening of skin). She did not respond to treatment and doctors were unable to find a cause for her condition. She was approached by a psychiatrist to address her condition and her agoraphobia. When discussing this, she mentioned that she had “retreated into her shell” and did not want to come out. The psychiatrist proceeded to work with her to help her “come out of her shell” and get on top of her phobia. After a few months, she was no longer agoraphobic and her scleroderma resolved in an unexplained way.

These were both very interesting cases for me. I have some belief in the idea that psychological conditions can manifest physically, but to know that – as the lecturer put it – “the physical symptoms tell the story of the patient’s mental state as they would”, was quite surprising. And I began to ponder to what extent this was true.

While in the lecture, these cases were surprising to me. But my friend next to me said she thought they were “scary”. She didn’t believe that psychological aspects can manifest physically. She told me she finds concepts like this “quite fluffy” and so they can’t really be true. I wondered why she thought that. I suppose it comes from an innate fear that this is something unknown and thus isn’t controllable. I mean, if I told you that you would get an infection because your friend Bob sneezed on you and tiny microscopic virus particles were expelled in droplets and you inhale them and they penetrate your nasal mucosa, activating your immune system and causing symptoms of the common cold, you would know to stay away from Bob, so as to prevent him sneezing on you and unleashing the nasty little virus on you. But what if I said – you would get an infection because last week you were asked to go to your uncle’s wedding but you really didn’t want to go and you just got really angry? How could you stop that? (well it would get you out of going to the wedding, but still). There’s no way you can prevent that. And there’s no clear cause for it, etc. It just happens?? Because of thoughts?? Scary. And as the doctor, you probably can’t treat this person normally by giving them a medication.

I can kind of see her apprehension. I was later telling my mum these stories and she was all-too-eager to believe this. She went on to tell me that 90% of all patients I will see in my clinical practice will definitely only have some underlying psychological issue that once fixed will fix the person entirely. Now, I thought this was a bit extreme. My mum was convinced, from her experiences that everything psychological manifests physically and no one really needs medical treatment.

Seriously, how far does this go, I wonder? I believe in things like psychoneuroimmunology. So much so that I did a research project on it. Basically it was based on the idea that social closeness leads to better skin healing. Ie. If you feel more supported and less stressed, your immune system works more effectively and leads to faster healing. But even so, there is clear evidence and a physiological flow diagram to explain this effect. Things like abstract thought affecting physical body in a particular way (no talking = mouth ulcers and “shell” = scleroderma) is a bit difficult for me to comprehend. Could it just be a coincidence? Or maybe there is an actual physiological relationship to explain these effects but haven’t been discovered yet?

But if so, can all illnesses be attributed to a psychological stimulant? How then would doctors treat patients? Exclusively Psychologically? Without medication?

Thoughts? How big a role do you think psychology plays in affecting the physical body?