Apple Humble and Custard

I have been thinking about where I am in the training pathway. In terms of seniority, I’m at the bottom of the pyramid. These thoughts may well linger until I’m a consultant, which is at least a decade away and it seems soooo far. I knew this well before applying to medical schools, but at that time I was more concerned with getting one of my ancient bunion feet through their well guarded, reinforced doors.

Being mature medical students, we may have achieved other things in life but in the eyes of the healthcare system we are still simply medical students. Previous accomplishments on our CVs might have granted a small sense of pride and demonstrated ability but might now be irrelevant. Regardless of whether we were once CEOs, engineering post-doctorate geniuses, professional sportspeople or stay at home mums/dads, it almost doesn’t matter and as mature medical students we have to swallow the same helpings of humble pie as our younger classmates. I suppose I could say force fed as there’s not much that can be done about the situation – it’s just how it is. Many skills, particularly interpersonal, management and organisational skills are definitely transferrable but knowing the inlet angles for turbine blades of a specific jet engine probably is not.

Being older often helps with patients, but not always with staff. When meeting any new staff there is always a familiar eye dart” from face down to name badge – searching for the words that denote one’s grade and thereafter how to behave towards the badge-wearer. Everyone does it and at all grades, due simply to the hierarchical structure.

Different members of hospital staff have widely differing opinions about medical students. We may be seen as being: useful, helpful, eager or sometimes useless, lazy, hindrances. Last week, a consultant said to me: “Hey you medical student, I’m too busy, go with Dr Smith”. In her eyes I was nameless even though she’d just done the eye dart thing and my name didn’t matter because I was “only” a medical student. Another time I was dismissed with a: “Shoo-shoo medical student, I need to use that computer” They need to remember that not so long ago, they were also “Hey you, shoo-shoo medical students.” I have no issues with those younger than me telling me what to do and don’t need or deserve special treatment, but good manners are fundamental and rudeness is unnecessary.

In military terms I’m an ageing cadet in basic training, no tours of duty under my belt, no medals. I’m still hoping just to make it to the passing out parade with proud family watching. Already in my 4th year of training but not yet even a private. I’m in the meat grinder again, somewhere near the beginning, being obediently churned through but this time hopefully emerging as well trained mincemeat (mutton dressed as lamb?) ready for action in the NHS.

Frozen meat grinder GW 300 – Seydelmann. Source. CC BY-SA 3.0

Sometimes I think about my previous job, a job that had little wrong with it, paid the bills and allowed me to live a decent comfortable life. A perfectly good and even enviable job. When I gave it up, I told myself “There may will come a time in the future when you’ll miss this job, the job in which you worked hard to reach a senior position, the job which surrounded you with great people and which you may regret giving up.” I told myself that, I did. But I also told myself I’ll regret it even more if I don’t try – so I thought “f*%k it” and hit “Send”

So, in truth I do miss being in a position of seniority that roughly correlates with my age, my ex-colleagues, the relative flexibility of my previous career (oh the flexibility!) and having a salary!

But (and a very big butt): aside from the odd crass ignoramus, I love what I am doing. Everyday I’m seeing and learning fascinating things that few others can or will ever see. The new born whose first breath I witnessed, the young man who walked right out of hospital but who only a few days earlier was unconscious and critically ill, the lady who can see clearly again, the caretaker who walks pain free after his hip replacement. It’s not always a happy ending but just to meet these people and catch a glimpse into their lives is a huge privilege. Also being taught by those rare breeds of doctors and consultants who know exactly how to teach and genuinely care whether medical students are learning or not.

So my medical student colleagues old and young; persevere with cultivating that thick skin, we are bottom of the pile – munching humble pie, but on top of the world and there are infinite helpings of great custard.

Night Time Needlestick

Even as students we are required to work “on-call” or night shifts. It means working quite closely with a doctor through the night and therefore there’s a good chance of receiving good ‘1 to 1′ bedside teaching, doing useful jobs and not feeling as inept as medical students usually do.

I paged the registrar on duty, who called me back. “It’s MSL, one of the medical students on Dr Bigwig Consultant’s team, I’m joining you on call tonight if that’s OK?”  

“Come on up MSL” came the reply. It was Dr Helpful, who I’d met before and who was always friendly. I made my way over to the respiratory ward accompanied by my footsteps clicking on the polished floors and the faces of eminent doctors looking down at me from their portraits. (With few people around, parts of the hospital can be spooky at night-time.)

“Let’s get you clerking Mr A. Don’t look at his notes, take a history, perform an examination, then page me when you’re done and we’ll compare your findings”

Mr A was in a single patient room, his infection status clearly indicated by the big sign on his door and confirmed by the boxes of protective equipment outside. ‘What has this patient got?’ I wondered and if there had been a rack of military grade biohazard suits hanging up, I would have gladly jumped into one. Instead, I put on a (slightly less protective) paper face-mask, plastic apron and some rubber gloves – and stepped in.

I saw a man in his fifties propped up in bed, emaciated and perhaps breathing faster than he should have been. A quick history revealed that Mr A was having a long run of bad luck, separated from his wife, jobless and sleeping on the streets. He was falling asleep during the history, waking up with a start at each new question. At least the lack of chit-chat made the examination easy. He was so thin that the diaphragm of my stethoscope bridged the hollow spaces between his ribs. He was also feverish and sweaty with a raspy cough.

‘Night sweats, fever, weight loss? That could be malignancy or TB… oh wait, TB?!’ I thought, suddenly even more glad of the mask. When I finished I thanked Mr A and went to present my findings back to Dr Helpful “…and erm, my preferred differential diagnosis is pulmonary tuberculosis” I said hopefully.

We checked his notes and pulled up the chest x-rays and there it was, a “small cavitating lesion with infiltrates” – apparently, at the top of his right lung. To me it resembled a white wispy circle, darker in the middle almost as if a smoker had blown a little smoke ring that had settled over the computer screen, right where the image of the lung was getting white and patchy.

It feels contradictory to hope that a patient has the diagnosis you suspect, particularly if it is serious, but as a medical student and if you get it right, it also feels reassuring to have proof that you do (sometimes) ‘know your stuff’.

Dr Helpful decided Mr A needed an ABG (arterial blood gas test). It involves taking blood by inserting a needle into the radial artery in the wrist, is quite painful and can be hit and miss. I’ve performed a few ABG’s before, but it needs practice and I was hoping to be given the chance so I was disappointed that Dr Helpful decided to do it.

*         *         *

“Sharp scratch coming up” explained Dr Helpful.

As the needle pierced Mr A’s skin, he suddenly reacted by jolting his hand back, knocking the needle out of his own wrist and a split second later into Dr Helpful’s glove. Our eyes met over our face masks, a look which said “Oh F&*k!” We both knew the implications. Ripping off the glove, there was a superficial but visible needlestick puncture in the skin of the thumb.

We scrambled outside, Dr Helpful went to deal with the needlestick and I carried on with my list of tasks. The electronic records showed that whoever admitted Mr A had correctly sent his blood to be tested for HIV, Hepatitis and other blood-borne diseases already. The results were not yet on the system although due anytime. I continued to check in the morning. At lunchtime I spotted Dr Helpful at the other end of the ward. Before I’d got to within speaking distance, the patient’s HIV & hepatitis status were obvious.

Thumbs up, an eye-roll and look of relief as Dr Helpful turned to deal with another patient.

In hindsight, I think I can rename Dr Helpful to Dr Fortunate, I think I was also fortunate since it could have easily been me. Lesson learnt.

Family & Friends

During revision and in the run up to exams I see exponentially less and less of anyone and eventually become a hibernating hermit hedgehog. It becomes awkward to continually turn down invitations to go out but it would be “frivolous” to chuck my books in the air whenever such an opportunity arises. Petrified of the consequences, I make my excuses.

The friends I do see are fellow classmates at the hospital. “What is the dosage of that drug again? Should the patient hold in inspiration or expiration when listening to a certain heart valve? Which cranial nerves are we likely to be examined on? This is what we discuss as we dash between clinics and bedside teaching sessions and everyone else except me seems to know all the answers. Dare I say it – I’m turning into an old bore, like really old bore.

I’m unsure if there is less time because of medical school or because there are more “chores” to do as we get older but unfortunately whatever the case, I’ve generally seen less family and friends since starting medical school. In the meantime, they’re getting new jobs, buying houses, giving birth or visiting exciting places around the world – whilst I admire from a Facebook distance.

So my dear family and friends, I’m sorry I sometimes can’t join you and I hope you are having a great time. I’m sorry for my enthusiasm when I recount what I see in surgery and clinics and not talking about anything else (mainly because I haven’t done anything else worth talking about); for recalling obscure and gruesome medical facts that won’t affect you; for complaining about the speed with which I hurtle towards exams and for worrying about how much I feel I still don’t know.

I’ll be back to normal shortly, I just have to get through this medical degree…

Halfway There

Halfway to Doctor Motorway Sign

Just passed this roadsign on my journey…

Halfway through another rotation and it all seems to be going well. We are now actually halfway through medical school  – at least from a time point of view and I’m surprised to feel that it’s gone so fast, although there is still a ton of continued learning for years to come. I certainly don’t feel as if I’ve travelled far enough along this journey or know enough to have reached the destination of half a foundation (F1) doctor. According to good old Wikipedia, I’m currently at the stage of “consciously incompetent“.

Although I’m confident using my stethoscope, it may be some time before I wield it with the same precision as Jedi consultants and can detach it from my neck without tangling it up in my ID badge neckstrap. It doesn’t inspire confidence in patients when your ID badge somehow ends up in their mashed potatoes.

I’ve met all kinds of patients with interesting jobs including a footballer, an athlete, an actor, an airline pilot, several doctors and even a professional clown. It has been pretty awesome.

Perhaps, my classmates and I are stressing too much about not knowing enough to be helpful and should just enjoy this stage where we can absorb and see a massive variety of specialties without being tied down to any of them – or be expected to carry out jobs or endure any huge responsibilities yet.

The “Medical Student” ID badge (when freed of potato) grants us “Access to All Areas” in the hospital and observe pretty much anything we’re interested in. Clinics and operating theatres may need prior arrangement but by asking nicely, I’ve often been able to show up ad-hoc even to these and watch procedures, get a bit of teaching and see conditions that we’d only previously read about in textbooks.

So we are not VIPs, but we do have backstage passes. Roll on the next 2.5 years – if all goes well.

Learning from Doctors & Patients

Amount-Learned-blackboard

Starting clinical rotations has been a really satisfying experience so far and I’m learning a lot. However, I think I could be learning more and this is mainly due to i) different kinds of doctors and ii) opportunities to see patients.

i) Types of Doctors:
We rely a lot on feedback and teaching from the doctors but there seems to be two categories of doctors on the wards.

The first are always: “busy and have no time to teach at the moment.” I never bother doctors who look stressed or busy but some consistently have no time to teach or completely ignore students during ward rounds – so I no longer feel comfortable asking. They are great doctors apparently and I’d learn a lot from them – but not being able to engage them, I won’t know.

Luckily, most doctors are in a second category; a different class who are really cooperative, sometimes actively seeking out students and recommending interesting patients for us to take histories from and perform examinations on – in addition to letting us present our findings back to them. Sometimes, we’re given the chance to be the first in the team to see the patient, write up the notes and present to the consultant. A small step but it’s a massive boost and a great feeling to be useful!

If you’re a doctor in this second category, I’m grateful and will try to follow in your footsteps!

“Want to see a patient with: a pan-systolic murmur / suspected appendicitis / a replacement mitral valve / Dupuytren’s contracture……?

Yes please.

ii) Seeing Patients:
The second factor that determines how much we learn is the amount of patients we see. This unfortunately involves good timing, luck and being in the right place at the right time. I have to add that patients are amazing, even though the majority of them are really sick, they still give us consent to practice on and learn from them.

Unless our team is on call, the earliest we can usually see patients is after the morning wash and breakfast. The race to examine and take histories begins – until the air fills with the unmistakable aroma of overcooked food and boiled to death vegetables signifying the imminent lunch trolley and protected mealtime when patients have to be left alone.

Other things to factor in are doctors on ward rounds, nurses, physiotherapists, pharmacists and phlebotomists who obviously get priority. Then of course there are fellow students who might reach the patient beforehand. So, an interesting patient who we can actually see is like gold dust!

After lunch – we squeeze in a few more hours seeing patients before visiting time when friends and relatives appear in the corridors, troop into the wards and fill patient bays, huddling around each bed.

The end result is that although we spend all day in a hospital jammed full of patients, there are only a few opportunities to actually see them!

As we students are the ones hanging around looking the least busy, we’re usually the ones who get asked the questions:

“Can I talk to you about my Mum/Dad/Husband/Wife……? How is he/she doing then Doc?”

“Erm… I’ll ask one of the doctors as they know more than me about your Mum/Dad/Husband/Wife

Cue, friend/relatives’ downward glance at my name badge. “Oh you’re only a student?”

Scrub Nurse Angel

Surgical_gloves_19Observed a prostate biopsy today. After the patient was wheeled in from anaesthesia, the consultant told his surgical registrars to do a digital rectal examination on the patient to feel the prostate’s size and its nodules.

An orderly queue formed at the foot of the table, index fingers held up as though testing wind direction. He then motioned to me that I should also become familiar with what a prostate with pathology felt like.

Accepting the fate of my finger, I donned the gloves and joined the line. I shuffled forward to take my turn and just as I reached the patient, someone shouted that the patient had not yet been ‘taped’. I stepped aside to avoid the scrub nurse as she sprang into action, taping certain appendages out of the way and then immediately afterwards the surgeon moved in to start the procedure. I was saved – thank you scrub nurse!

Clinical Week 1

Beilinson_Hospital_ward_1950I’ve survived the first clinical week. After two years incarceration in mostly lectures and the recent week of back to back induction talks, my patient hungry classmates and I were released into hospital wards.

However, the new found freedom we’ve been craving has sometimes left many of us feeling like spare parts, trailing behind junior (F1) doctors and not knowing enough to help properly yet. We’re dressed as doctors, reinforced by shiny new stethoscopes around our necks but with little experience of using them.

I’m not beating myself up as it’s only the first week and we’re still discovering hospital protocols but so far a good recipe has been to i) find a cooperative doctor ii) be nice to nurses and iii) find friendly looking patients who will consent to histories and examinations.

Me: “Hello Mr X, my name is MSL and I’m a medical student. Could I talk to you about why you’re in hospital?”
Patient: “Sure doctor”
Me: “I’m actually still a medical student”
Patient: “Oh, OK”
Me: “So Mr X, why are you here today”
Patient: “Well I’ve had this pain for 3 days now doctor”
Me: “I’m a medical student
Patient: “OK doctor”

My initial concern about being mistaken for a qualified doctor is semi valid for some patients but is wasted on staff who look me up and down and spot my “Medical Student” ID badge, Oxford Handbook of Clinical Medicine (aka cheese and onion) or notice me waiting around awkwardly. Actual doctors have a pager clipped to their belt/handbag and hurry around efficiently with patient lists in their hands. The pager is like a little time bomb except nobody knows when it is going to go off. Consultants walk around in expensive shoes and suits – no pager.

So far so good, not many pointy questions and no humiliation in front of patients yet but I did hear a rumour that a consultant made one of the doctors cry.