Home Stretch

Oh boy Oh boy Oh boy

So today I had my final practical exam of medical school! In psychiatry!

Happy to say I got a “solid distinction” in the examiner’s words. They even asked me if I would consider a career in psychiatry! Hahaha I wouldn’t, but it’s good to know I’ll probably be a good psychiatry house officer when I start working in November!

I celebrated this victory with Ice cream and a walk on the beach.

And that’s what this post is about! With the ending of my final practical exam, I now only have 4 weeks of medical school left for the rest of my life!! :O

My final rotation starting on Monday will be Obstetrics and Gynaecology. Back to the land where there’s far too much oestrogen in the air. 

But I’m not bothered! There aren’t any major assessments as part of this rotation.

I do have my final exam of medical school, the progress test, towards the end of October. But I am so over these after 6 years, I’m happy to just pass.

So, I’m literally on the home stretch now. 4 weeks to finish medical school, 2 weeks vacation, then graduation!

AND THEN,

Worklife begins.

I’m just going to leave those words hanging there for a bit.

I can say I am already looking forward to starting to work. Actually, I’m looking forward to the next few years of working. Getting to where I need to go. Not that I know where that is, but I do feel it’s time to start looking that way.

Medical school has been a huge part of my life in many ways. So many things had changed where when I first got in, I thought the hard part of life was over. And everything was sorted. I can at least say I’m no longer so naive.

But yes. Let’s get the next 4 weeks done and just keep swimming! 😀

A view of Rangitoto from my ice cream celebration

Hectic Real Quick

I do apologise for my absence for the last two-ish weeks. Things got hectic real quick.

Let me outline it for you. Last I spoke, was about paediatrics. That’s over so yay! Made some good connections. I expressed my interest in pursuing gastroenterology as a specialty and one of the nice consultants took me on to do a project. Specifically,  a case report.

Good thing about a case report is that it’s likely to get published. Buuuut it’s not exactly a “research project” so I’ll probably have to do an actual project later on.

Yeah the requirement to join the gastroenterology program is to have done a research project in gastroeneterology. I’ve got time though. And a case report is still neat. So I’ve been working on that.

Straight after paediatrics, began Psychiatry. I am placed this year, not in Mason clinic, but in a community facility. Which is interesting enough. I do find psychiatry interesting, psychiatrists themselves are weird, as usual. One of my consultants is really nice, the other uses 3 different e-cigarettes constantly in a pattern I call, “chain-vaping”. I doubt it’s really much of a step up from actual cigarettes.

Anyway! Psychiatry this year is very stressful because I have a practical exam at the end of the rotation where I take a psychiatric history from an actor and present it according to the DSM 4. Good old DSM 4 with its pages and pages of criteria but still managing to make the conditions fluffy and not really any easier to distinguish between. Sigh. So I have been cramming as much A B C criteria for the diagnoses as possible. Not. Fun.

I was also given my rotations for my first house officer year in these past weeks. They will be as follows:

Psychiatry (oh my God when will it end)
Gen med (Good. Good learning, useful, mhmm)
Cardiology (Interesting, should be fun)
General Surgery (Not looking forward to. Lots of admin, but if I do it now, never have to do another surgical rotation again so yay!)

I didn’t really want this combination, but pretty much all the combinations were pretty lame and at least I don’t have to do any runs I really dislike like orthopaedics or geriatrics. So good stuff!

In other news, my mood has been quite low lately. No particular reason that I can mention. My right brain playing up maybe. But life seems a bit bleh these days.

I wonder if I have some watered down form of bipolar disorder. But where a person with bipolar disorder would have a mood pattern that looks a bit like this;

Sketch (1)

Mine, looks more like this:

Sketch (2)

Yes I’m a whiner at the moment. I don’t have bipolar disorder and frankly my problems are no where near that substantial. They have it hard. I’m just complaining about something that isn’t there. I should get over myself. I guess it’s just a first world thing.

So yes, that’s what has been keeping me busy lately. Blogging helps, as always. Hope everyone else has been doing great!

Psychiatry Review 

Well it’s time to wrap up this run and move on! It’s been a quick 6 weeks. But I think I’ve done more reflecting and pondering on this run than any other. Mostly because I had a heck of a lot of free time when my consultants were doing paperwork work for 4 hours of the day.

But anyways!

There’s a lot of philosophy that I’ve learnt on this rotation. My view of people with mental illness has changed. Especially in forensic psychiatry.

The great thing about people with mental illnesses is that they become a complete version of themselves. By that I mean, they can’t be anything else except them. They can’t put on a fake mask or pretend to be someone else. They’re authentically who they are. And I find that so much easier to work with than normal people. xD

Especially in forensic psychiatry where it’s so easy to assume that a criminal is a criminal because they were born a criminal. But only when you see people who have mental illnesses and are treated appropriately, do you realise just how vulnerable many of these “criminals” are. When treated, the patients I have seen are the sweetest, most thoughtful people. There’s nothing really wrong with them. But outside, they’re considered evil, disgraces and are shunned from society without receiving the help they needed early on in life. And a few of them, particularly those considered “antisocial” were those who attacked others and showed no remorse. But when you find out about the people they had assaulted, many of them frankly, had it coming. They were horrible people who said and did horrible things. Many times in my life, I have had the overwhelming urge to punch someone in the face. Multiple times. But I have the inhibitions and the ability to stop my hand from shooting out and catching Mr. Stuck-up in the face, more than once. Even though he would have deserved it. Or how often have you read in the news about a horrible dictator or politician who treated others in a horrific way and thought to yourself “someone ought to teach him a lesson”? Sadly, both you, and those people are “normal” and free to be around in society, where the individuals who actually act on these feelings are locked up and labelled “criminals”, “psychopaths”, “sociopaths”, etc.

Not all of them fit this category of course, but for a while, I was under the impression that none of them fit that category. I thought all of them were fundamentally flawed. They’re normal people just like us if they received the help they needed. I reflected a lot about the circumstances of a person’s environment that predisposed them to ending up with a mental illness. If I had a dollar for every traumatic childhood case I had heard in the Mason clinic, I’d be pretty happy with the amount. It’s quite sad. It’s not really your fault someone bullied you to the point where you began hearing them in your head continuously telling you what a loser you are. And that makes you lash out. At yourself and others. And that means you’re locked up while the bully is probably still out there somewhere.

Whew. So that was pretty philosophical. In terms of this field of medicine, I’m not cut out for it. I can definitely see that. I think I’d like something a bit more fast-paced and with less paperwork. I also think that psychiatrists have a “trait” that I don’t really possess. It’s this detached trait. One of my consultants is actually quite shady. He told me off for laughing at a joke He made in a patient interview. He told me that I must be more self-aware and careful about laughing during patient interviews as it might upset the patient…………… I nodded politely. He also told me that he cannot give me an excellence grade for ‘professionalism and boundaries’ because I expressed some sadness that my patient Mr. PH left back to prison abruptly. I believe my exact words to my other consultant was “aww I didn’t know he had left”. She told my shady consultant I had said this, and so it was decided that I have boundary issues. He then proceeded to lecture me on “Empathy vs Sympathy” and the importance of “do not feel what the patient is feeling“. Eye-opening lecture, that. It was then that I learnt that the real “professionalism” is making sure you don’t say anything at all to your consultant that is not work related. The best part was when he later told me that my performance is great because I have such a great manner towards patients and I make them feel comfortable. By this point I adopted an emotionless face. Determined not to respond to anything he would say anymore. Yeah I definitely do not have the psychiatrist trait. That sounds like I’m being a bit bitter. But truly, I respect all the psychiatrists. Their job is in no way easy at all. They’re all super qualified and brilliant doctors. I just don’t think I can be one of them.

Anyways! It’s time now, finally, to move on to my last rotation! Hopefully it will be a good way to end the year!

The Blogger’s MSE

Mental State Examination:

Appearance/ Behaviour: The blogger is a man/woman aged between 20s and 30s of medium height and normal build. They are dressed in casual clothing and are frequently dishevelled. The blogger establishes good rapport and maintains intense eye contact with their computer or mobile device. They tend to smile stupidly or frown intensely at the screen when blogging 

Speech: Speech is minimal to non-existent when blogging although occasionally seen muttering phrases to themselves with normal rate but low volume. 

Mood: The mood of the blogger is often subjectively variable before blogging and is objectively euphoric following blogging. 

Affect: The affect is expansive and labile ranging from irritable to blunted to euphoric, and changes frequently depending on the subject of the blog

Thought Form: The Blogger’s thought form is not linear or goal directed. There is often signs of thought disorder including tangentiality and circumstantial writing. There is also frequent flight of ideas evident in the blog posted.

Thought Content: Thoughts consist of grandiose delusions regarding popularity of blog. They also believe they will become a famous author. The blogger is preoccupied with obsessive thoughts regarding their next post and have a compulsive need to log on to WordPress frequently. 

Perception: Blogger has occasional auditory hallucinations of sentences in their next post. Blogger does not report visual hallucinations and is not observed to be responding to non-apparent stimuli.

Cognition: Blogger is alert and oriented to time, place and person. Good recall of previous posts.

Insight & Judgement: Both insight and judgement is impaired as the blogger believes their delusions are reality based and do not believe they need help with their obsession with blogging. 

Risk: The Blogger’s risk of harm to self is deemed moderate and is mostly in the form of procrastination by blogging and hindering their progress and completion of school work. Their risk of harm to others is deemed moderate by causing them to procrastinate also when reading the blogger’s post, and also possibly causing harm by boring them. 

ECT facts

Abracadabra here, to tell you that electro-convulsive therapy (ECT), or more commonly known as “shock treatment”, is grossly over-dramatised in movies, books, media etc. Emphasis on grossly. 

As part of my psychiatry rotation I get to observe ECT being administered to patients with treatment resistant depression, psychotic depression, etc etc. 

It is NOTHING like they show in the movies. It is not done in a dark dingy room where the patient is forced into the room and strapped down into a chair or table with multiple wires stuck to their head. There is no giant dial that the cruel doctor turns up to increase the amount of voltage entering the patient and watches them scream in pain as they convulse while the nurses and doctors look on with a sadistic satisfaction on their faces. 

Seriously. It’s about as exciting as static electricity. 

What really happens is that the patient is brought into the procedure room and asked by multiple people multiple times if they’re happy to be there and go through with the procedure. Everyone is smiling as they explain the procedure again, the patient gets onto the bed and is given general anaesthesia! Yaay!! They’re also given muscle relaxants which means there’s no horrific flopping about. The machine that delivers the shock is about the size of a shoebox and just as complex. Two dials to set the amount of electricity and one button to turn it on. When the patient is asleep, the button is pressed. 

Oh this is the best part. Because I actually missed the “seizure” the first time. The patient looks like they’re squeezing their eyes tight. And their toes curl slightly. I didn’t even notice this until my consultant pointed it out. And this lasted a grand total if 8 seconds. After this, the machine is turned off and then everyone watches as the patient twitches. Not even great big twitches. Just little finger movement. This lasts for about 20-40seconds. And that’s all folks! Wires come off, patient is woken up and wheeled out of the room, still smiling. 

That was definitely not what I was expecting. xD I, like a lot of people had a hugely distorted idea of what ECT was and what it does to people. The stigma around it alone, has prevented patients with treatment resistant conditions from receiving a treatment that’s actually proven to be extremely effective for such conditions. It’s sad, really. This is a pretty good example of how media distorts real facts and stops many advances in medicine and other fields. 

Because of these ideas, even doctors don’t offer ECT as a first-line treatment for many patients who it would be very effective for. Hopefully more people will realise that ECT is not really as bad as movies make it out to be. I actually got a bit bored. 

Unexpected Loss

Today I spent the morning in another hospital for tutorials on psychiatry. When I returned to the Mason clinic where I am based, I saw one of the patients there leaving, surrounded by police. I waved and said hi to him as I usually do. He smiled back at me. I wondered where he was going and resolved to ask him later. I assumed he was leaving to a court hearing. 

Later while I was updating myself on the patient’s notes, I found that the patient (Mr. PH) had been discharged from the Mason clinic back to prison. 

I was shocked and upset. 

Mr. PH was the first patient I had met in the Mason clinic. He introduced himself to me on the first day when I seemed a bit clueless and told me that I would learn a lot there. He was the first patient I had taken a psychiatric history from. He knew it was my first history taking session and was patient and cooperative throughout the 1h it took me to take the entire history. Mr. PH shared many of his life stories and we found we had a few things in common. 

From then on he had always greeted me and asked how I was. He offered to teach me how to play jazz style on the guitar and wanted to have a jam session together. 

Mr. PH has bipolar disorder and had committed a theft during one of his manic episodes. He was facing 7 years in prison. He told me of how scared he was of returning to prison and his worries that he may not get the bail he was moving towards. I had tried to encourage him to keep positive. 

He was a really sweet person who I became quite fond of. So much so that seeing him around everyday was almost comforting. I had no idea he would be sent back to prison so quickly. Apparently, neither did he. He was the reason I first realised how vulnerable patients at the Mason clinic were. Sure, they were big scary criminals to the outside world, but this was mostly due to their mental illness. When treated, they were all just very simple, regular people who had talents and hopes for the future. 

If I had known I had been walking past Mr. PH as he was leaving, I probably would have said goodbye or wished him all the best. I am sad that I wasn’t able to do this.

Every so often, you’ll lose contact with someone you know abruptly. And when that happens, you’ll feel a pang of loss. And a regret. That you didn’t get a chance to tell them you’re grateful to have known them, and for all they had taught you and that you’ll miss them. Well, that’s how I feel anyway. 

I didn’t get a chance to say thanks and goodbye to Mr. PH and I didn’t get to have a guitar jam with him. Both of which I’m deeply upset about. I wish Mr. PH all the best. I hope he gets bail. I hope his life is happier from now on. And I’ll miss seeing him around. 

Sigh. 

The Voices 

“you’re pathetic” said Jona as he loomed over me in the corner behind the dumpster at the back of the school. I could smell the chocolate and chips on his breath. He shoved his hand in my pocket and pulled out my 3 cookies I had for lunch. I tried to grab his arm and take them back, but Jona’s other arm came crashing into my chest and knocked the wind out of me as I fell back onto the concrete. My back aching from the force and my arms burning from where they scraped the ground. I looked up. I couldn’t see Jona as my eyes filled with tears. But I heard his voice. “you’re a loser!”

“Do as you’re told. You stupid dickhead” said the man that was my new dad. I looked up at him. His clothes had the stink of cigarettes and vinegary smell of alcohol. “eat it” he said. Shoving the orange ends of his smoked cigarettes into my small mouth. I turned my head away and squirmed to run. But his hand was holding my thin arm with a grip that was as strong as a vice and just as deadly. “eat it!” he repeated, successfully stuffing a handful of the cigarette butts into my mouth. They tasted of ash and poison. I choked and spat them out, feeling a warmth spread in my pants where I had peed myself. “you pathetic mess! Look at the mess you’ve made!!” said the man as he raised his hand above my head. I couldn’t see him as my eyes filled with tears. “you’re nothing but a loser” his voice rang in my ears.

“you loser. Why don’t you just go kill yourself?” I woke with a start from my bed. I sat up and saw only darkness. As my eyes adjusted to the dim flickering tubelight in the hallway, I saw that I was alone. “you stupid useless idiot” the Voice rang in my ears and I pressed my hands to the side of my head. I told myself It’s in my head. The doctor with the kind eyes told me it’s just Voices in my head. Before he gave me the pills to put me to sleep. Now I’m awake. “yeah you’re awake, dickhead”. I can still hear their Voices…. Then what’s real? “you’re crazy. That’s what’s real. Loser.” I looked down at my arms. Even in the dark I could see the linear gashes and scars criss-crossing all the way down on my forearm. Some still raw, bandaged by the doctor. Marks I had given myself. “see that? Loser scars.” I smiled to myself. They’re not. I slid my hand under the pillow of my bed and extracted the lone object that lay there. The paperclip that Steve from the room opposite my own had given me. The one that I had bent out of shape until it was a thin rod and sharpened on one end by the dinner cutlery. I pulled off the bandage that was wrapped just below my elbow. I felt the air touch the still healing wound. I pressed the sharp end of the paperclip at the top of the wound and ran it down the length of the old cut. I savoured the burning pain that shot through my arm. The sound of my heart in my chest as it began to beat rapidly. The cool sensation of the blood leaking out of the wound. I did it again and again. As I did, the Voices got quieter and quieter. And then they stopped. 

Pain is good. I don’t know what’s real. But atleast I know I’m alive. 

What’s Your Drug?

You learn some weird things in psychiatry. In any other specialty, you learn anatomy and physiology and pharmacology. In psychiatry… you have to learn the different ways people can kill themselves. You need to learn the different possible things people can hear or see. You need to learn the different types of thoughts people can have.

And, you need to know about all the drugs out there. The illegal ones. You gotta speak their language.

I had to take a drug and alcohol history from a patient today with my consultant. In every other specialty I’ve taken this history in the past 4 years, the results are always the same. “Have you ever been a smoker?” “How much would you smoke in a day, when did you start, etc.” “Do you drink alcohol?” “How much in a week, etc.” And the “do you use any other drugs” question generally results in pretty mundane response of either “no” or “smoked cannabis once when I was 15”.

But in this particular specialty, all patients are on every drug you can think of, and all the ones you can’t think of. As you can imagine, my knowledge on the subject was very minimal.

Me: So Mr. S, how much cannabis were you smoking a day?

Patient: Oh just a tinny’s worth aye

Me: Oh okay, how long have you been smoking for?

…….

Me: How much methamphetamine were you smoking daily?

Patient: Oh about half a gram

Me: Oh okay. When did you start smoking the meth?

Later, my consultant asked me how much a ‘tinny’s’ worth of cannabis was. I blinked for 10 seconds and replied with “ummmm”.

He then asked me if 0.5g of methamphetamine was a large amount. I blinked for 30 seconds this time and offered a very quiet “no”.

Both were very wrong answers. A “tinny” is a word used only in NZ apparently. It amounts to 1g of cannabis. It’s the standard amount you can buy on the market. And it’s a pretty substantial amount to smoke in a day. With methamphetamine, the standard amount you can buy is called a “point” which is 0.1g of methamphetamine. Mr. S was smoking the equivalent of 5 ‘points’. This was a very high amount of methamphetamine. Apparently.

I did not know any of this. My consultant expected me to know that he was smoking quite high amounts of both drugs and to have asked him about his thoughts regarding this high amount and the possibility of cutting down.

For the first time in my life, I felt that not knowing about illegal drugs was a bad thing. And it really was. My consultant definitely gave me the ‘look’. I’m used to getting the ‘look’ from consultants for not being able to answer questions in courseguides and textbooks about medicine. It was the funniest thing to get the ‘look’ for something like this. Only in psychiatry would this be the case.

The problem is, when I get a question wrong in other specialties, I can go read the textbook or do research to learn about the thing I got wrong. But in this case, how on Earth do I learn more about illegal drugs?! Seriously. Google ‘illegal drugs in NZ’? I actually did do this, but I ended up on the government website with details about offences. Which is interesting, but not exactly what I’m looking for. Sigh. I’m just not Street enough for this. What a strange feeling of being ‘too’ normal.

Man. Psychiatry is weird.

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.