Pimped by Dr Angry

Hulk. Source: Erica Wittlieb

Consultant: “So what do you think the patient wants to do next?”

I dreaded this question, but he always asked it. I often had no idea what the answer was – or rather what he wanted me to say. What kind of infinitely open ended question was this? The answer could be anything, “go home?” “win the lottery?” “go to the spa?” “dress up as a cat?”  What did this consultant want me to say? Sometimes it was obvious, glaringly obvious but it was hard to figure out what of many possibilities he wanted to hear.

 *       *       *

I had finished my consultation with a patient by taking her history, examining her and I had made a provisional diagnosis and management plan which she seemed satisfied with. “So as I mentioned, because I’m not qualified yet, I’ll call the consultant in to review what we’ve talked about and the plan going forward – just to double check OK?”

Dr Angry had arrived and was loading the chambers of his guns with questions to fire at me in front of the patient. “Well?”

Me: “Well, this is Mrs Smith a 39 year old woman who presents with a 3 week history of a spontaneously bleeding mole…….”

Dr Angry was leaning on the examination couch, arms crossed and had already turned his head to the window, waiting for me to say something mildly interesting before he would turn it back.

I continued: “On examination there is an asymmetrical lesion on the dorsal surface of her left hand…..”

I concluded “Due to the nature of the mole, her sun exposure and family history of skin cancer, my impression is ……..” My voice faded as the consultant was shaking his head, frowning, red faced, exploding with rage. I wondered what on earth I had done – or not done, yet again.

“HOW BIG IS THE LESION?” he demanded

“Oh, it’s 6 x 10 mm…..”

“But you didn’t tell me that in the history DID YOU???”


The patient tried to help me by intervening and explaining that I had been very thorough and the diagnosis seemed reasonable. Apologetically, she looked at me. Dr Angry looked back to the window and at his nails. I didn’t know where to look and wished the consulting room would implode, disappearing into a tiny box with me in it and I’d wake up the next day and all of this would not have happened. If only Groundhog Day could be turned on and off at will. I felt absolutely demoralised and pretty stupid. Damn! There was a minor part of the history that I’d missed and I’d forgotten to mention the size of the mole whilst presenting the patient back.

Unfortunately this consultant wanted the history, examination and presenting of the patient to be done in a very particular way, his particular way and I’d messed up. He was one of those terrifying consultants that you heard about but hoped never to meet. Saying ‘I don’t know’ was unacceptable.

The first time, it really bothered me and I thought I had drawn the short straw to have been placed with him. I would tense up and feel my temperature rising. At the end of each day my jaw and temporal muscles would ache from clenching them together so hard. Every encounter with him was like sitting an examination with the examiner from hell.

Now, I just stop and I think. I take my time and I’m pretty calm. Sometimes too calm according to Dr Angry who still does his utmost to try and rattle me.

“you’d better have something bloody worth listening to”

I thought I had been progressing reasonably OK – until I met this consultant. Now I’m improving and learning (the hard way) how to present a patient’s history, examination and my diagnosis. It’s making me pause and think logically before I open my mouth, it’s stopping me blurting out the first thing that pops into my head only to instantaneously regret it as the words reach the consultants ears. Now, I make sure I have at least one plausible reason for every answer. In all fairness it has made me organise my thoughts before that dreaded knock on the door after which Angry marches in with a “you’d better have something bloody worth listening to” look on his face. I’ve been thoroughly pimped. But I’m better than I was before and I’m learning.

 *       *       *

Its got to be one of the obvious answers I thought:

“I think she would like me to tell her that we need to rule out skin cancer so I’m going to send her for a biopsy.” I said

Dr Angry smiled, “Well what are you waiting for?” turned and walked out. I don’t know whether to thank him or to loathe him.



Mid Life Crisis

When I was considering applying to medical school, a friend suggested I talk to his father, “Mr Goodstuff” who used to be a university admissions tutor. He wasn’t involved in admissions for medicine, but I jumped at the opportunity and spent time on the phone with him discussing how to stand out from the crowd (as if at my age I wouldn’t) and I emailed drafts to him to polish up my application.

I remember his exact words: “Don’t worry, we will get you into medical school” and I was genuinely reassured when he said them. It helped me gain the confidence to believe that at my stage in life it wasn’t such a crazy thing to do after all and I almost began believing that people were taking risks by quitting good jobs and applying to medicine all the time. Recently, my friend Goodstuff junior, told me that his father had actually been quite skeptical about my chances of success and was pleasantly surprised that I had got in! Insert facepalm here. I have yet to properly thank Mr Goodstuff for helping me so for now at least – thank you!

The other words I remember him saying were: “You’d better make it look like you’re not going through a mid-life crisis.” If I understand correctly, an applicant’s age is not shown on the application but if you’ve worked before and done other things, the medical schools could have a good guess from your previous experience and they’d certainly have more than an inkling at the interview stage when instead of a fresh-faced 18-year-old youngster, they would have homely me sitting in front of them.

I never realised that my application might be seen as a mid-life crisis and the phrase ‘middle-aged’ made me stop and think: “Wait, does that phrase actually apply to me?” What happened? Am I middle-aged? Well, perhaps not when I applied but now a little older, I suppose there’s no denying it. Like in the ER, when a patient receives the explanation that poor diet, lack of exercise and a gradual build up of cholesterol and plaque is causing them at that very moment to be having a heart attack – is medical school a manifestation of a mid-life crisis and I’m having one right now? Did I fail to recognise the biological signals telling me to shop for a new wardrobe, dye those grey hairs, find a lover 10-20 years younger and applied to medical school instead?

I don’t think so, but if this is a midlife crisis, it’s not too bad a crisis to have. I had my end of year examinations a few weeks ago, the results of which I found out recently. I passed the 4th year! So after the summer I’m on the home stretch. That impossible summit might just be reachable and I may actually become a doctor. Final year here I come!

Well, here I come, after perhaps: a blepharoplasty, a tummy-tuck, joining that gym…

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 lichenified 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”

Biohazard Sign Clipartbest.com
Source: http://www.clipartbest.com/clipart-jTx7AKbTE

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  glad of the mask despite being vaccinated. 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” said Dr Helpful, his finger circling the top of his right lung.  I leaned and squinted until I actually saw it. 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.