Gastroenterology Review

This is probably a bit preemptive considering I’m only 4 weeks into this rotation in Melbourne. But this rotation has been different to the others I have had this year. So I think now would be a good time to talk about my thoughts on gastroenterology.

I had mentioned how it must have been fate that I got accepted into gastroenterology over radiology. I think that was definitely true. It’s been a good run thus far.

Well. Kinda. Here’s the thing. I’ve had consultants here in Melbourne that ignore me and don’t acknowledge my presence (like back home). I’ve had registrars and team members that don’t really teach and don’t really care where I am or what I’m doing (also like back home). Then I’ve had consultants who are absolutely lovely and who teach and take an interest in me and my learning (this is also like back home). So the run in itself has been the same as all other things I have experienced in the last couple of years.

But I’ve been excited to go to hospital. I’ve been excited to go to endoscopes, clinics, ward rounds and to do my own studying. I actually enjoy what doctors do on a daily basis in gastro. Gastroenterology is one of those specialisations which has a good balance between medical management and procedures. And that’s something which I think is great 

I find the pathophysiology interesting and exciting. I find the medical management of patients intriguing. And I find the procedural side of endoscopies challenging and satisfying. I haven’t bad this kind of experience on any other rotation so far. I can actually see myself becoming a gastroenterologist.

And I am so grateful for that.

Now this isn’t 100% obviously. I’ve got a long time to definitely decide. But I am so glad that atleast one run (funnily, the final run of the year) has piqued my interest and has allowed me to visualise what kind of medical professional I would like to be.

And within gastroenterology, there are sub specialties. Liver, IBD, Oncology, etc. I’m not too sure which one of these I’d like. But I find liver pathology more interesting than IBD. So maybe I will specialise in hepatology. But hard to say.

It’s just exciting to ponder these options. To have something to hang off these ideas and consider them seriously. I am so glad. After a lot of rotations where I found out what I don’t like, it’s been nice to have a run I really do like.

Future gastroenterologist Abracadabra? Perhaps!

 

In other news, Melbourne is a huuuge city. But it’s a lot like back home. I went to Great Ocean Road today which has these big rocks on the shoreline. Great roadtrip with my flatmates and I took some photos! The weather was basically not great and we were all freezing and wet, but it was a good day overall!

12 apostles 412 apostles 512 apostles 6

I Am Not A Fish

4 weeks into this gastroenterology rotation, I’ve found that it’s quite specialised again.

I’ve found this on many rotations before and I’ve mentioned it on here. I don’t know what it is about being in a particular department that suddenly means you are wearing horse blinders and can only focus on one part of the body.

As in, you are admitted under gastro so therefore for the time that you are here, you are nothing except your liver and bowels.

One of the other med students and I admitted a patient together. As part of admission we completed the standard history and examination. This patient was being admitted for bowel preparation before a routine colonoscopy. While examining him, I found that his pulse was abnormal. The other med student confirmed this and we were concerned that he may have an arrhythmia. When we reported this back to our intern as part of the admission notes and said that we would like to request an ECG, she gave us a very pained look.

“…Really?” She said. “I mean. He’s just here for a colonoscopy. His pulse doesn’t really matter.. You can request an ECG if you want, but it’s just an extra thing to do…”

We were both a bit disappointed by this. Yes it probably isn’t relevant for a colonoscopy. But if it’s a heart rhythm that could descend into VF at any time during the anaesthetic administration for the colonoscopy, I would imagine the anaesthetist would question why the patient made it this far without anybody picking up his irregular heart beat. The chances of this happening are very low of  course as we did request the ECG and he had a benign RBBB. But the chance exists and I would hate to be the one to fall in that percentage. I wondered why my intern didn’t feel the same way.

Then today, a patient who had an endoscopy for a bleeding ulcer was found by the gastroenterologist to have something pressing on her stomach externally. He had ordered a CT scan to find out what this was. My gastro team received the result and it appeared that the patient had multiple large cysts in her abdomen. There were multiple cysts in her liver, and some pressing on her stomach. My registrar was satisfied with this finding and was glad that we found what was pressing on her stomach. I asked him what would have caused the cysts. He told me he had “no idea”. “Some people just have cysts. We just don’t touch them. We just need to know what was pressing on the stomach”.

I just…. Eugh.

What if those cysts were hydatid? Caused by parasites? What if they become infected? Again, super low chance of this happening. And I appreciate that. But no referral, no plan to monitor further, nothing really.

Ie. Let’s just wait ’till it becomes a gastro problem that needs fixing.

What is this mentality? I’m seeing this in all parts of medical practice that I have experienced. And it really bothers me. I appreciate that once you’ve confined yourself to a specialty, your priorities are the problems that come to that specialty. But surely that doesn’t mean you have to intentionally ignore the patient’s other problems? They bang on and on about ‘holistic’ patient care in med school. I wonder how people interpret this. I am still a student so obviously I’m trained to think about every possible issue a patient presents with. But I’d like to believe I’m not just trained that way for the heck of it.

For me, if you’re the sort of doctor that says “they’re only here for a colonoscopy, don’t worry about their heart”, you’re just not providing good enough care for the patient. Like it’s just not multi-dimensional.

Okay I understand that people are busy. I understand that you cannot possibly be expected to fix every problem someone comes in with. It would be super stressful and will probably shift focus from the problem you’re supposed to fix, but it’s just the attitude. It’s just the way you’re doing your job. Why would you tell the medical students to be just as uncaring about these things?

It’s broken as Seth Godin would say. This sort of thing would come under the “I am not a fish category” Whereby the person who designed the water exit for a fish placed it one foot above the water level. The fish can’t even get up there. Why did they guy design it that way? Because he’s not a fish. He just did what his job description said: To build an exit.

Really interesting talk if you’re interested:

 

Anyway. Point of this is. I want to know which field of medicine I need to be in for doctors to not shrug off certain problems just because it’s not part of the body that they are assigned to. I wonder if there even is such a field.

Maybe I just have to try to maintain my student training mentality.

I don’t know.

Specialize Why Don’t You

In ophthalmology clinic:

Ophthalmologist (who specialises in oculoplastics, particularly in cataract removal)Well Mr. Brown, I see you’ve been referred for cataract removal. But I really don’t want to remove these. They’re quite small. I don’t see why I should remove them.

Patient: Oh, well I also have double vision. Can you do anything about that? I’m not too sure what’s happening.

Ophthalmologist: …………..Well you see, I’m the cataract guy. So I have no idea what’s causing your double vision. You should really ask someone else about that.

Patient: Oh. Well my doctor said that if he wants to fix my double vision, my cataracts need to be removed?

Ophthalmologist: *Unimpressed look* Let me go discuss with my colleague

*disappears for 20minutes* *Patient’s wife stares at surgery consent form half filled out*

Ophthalmologist: Mr. Brown I’ve just talked to my colleague and he’s explained the practical aspects of doing the cataract surgery now! If I remove them, you’ll be able to have prisms placed on your glasses to fix your double vision it seems!

Patient: …Yes

Ophthalmologist: Well we can do the surgery then!

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Student: Mr. Jones also had a maculopathy in addition to his cataract. Could you tell me what caused it and how we would fix it?

Ophthalmologist: I didn’t notice his maculopathy. I’m going to remove his cataract so his macula doesn’t concern me at all. Someone else can fix that for him. I don’t know what’s going on there.

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Really? I mean, REALLY?

I’ve seen and heard that if you specialise, you acquire a kind of tunnel vision whereby you forget all the other aspects of medicine (eg: an orthopaedic surgeon wouldn’t know much about a patients’ gastrointestinal diseases). That’s reasonable. Acceptable almost.

But this, is pushing it. You can be specialised. But you shouldn’t be so specialised within your OWN specialty such that you no longer care about anything other than that one type of surgery you’re equipped to do, surely.

I just found this consultants’ attitude a bit shocking. What if he was in surgery and a patient has a cardiac arrest in the middle of the procedure. Would he be like “It’s okay! I’ve got the cataract out. Someone else deal with his heart please.” Eugh.

Let’s hope I don’t become so one-body-part focused.

How weird.