Wow time flies! I am half way through my medicine term already and I have written very little. The pace is much faster and I have been busy.
A typical day:
Get to the hospital a bit before 8am, print the lists for the day, this can be quite daunting post take (the day after the consultant for our team was on call) check outstanding bloods/radiographs (x rays) and see how patients are going (on paper). By 8am the rest of the team has arrived, and doing similar things (except for the consultant who just turns up). We go see the critical/less stable and the new patients first.
The consultant walks in to the patients room first, followed closely by the registrar and resident (who is holding the chart) with the med student/s following in the rear usually holding charts for the few patients either before or after this one and they draw the curtains closed. The consultant is usually all smiles "Hi Mrs... how are we today?" while the patient is tell their story, the Reg is telling the key changes over the last 24hrs (the resident was the one who actually arranged the tests and chased up the results). The consultant seamlessly gets to the guts of the problem in less than 30 seconds and if there is an interesting sign, gets the students to elicit the sign. (if the student fails, he is shown and the patient is in awe of the consultant...he is the guru.. If the student finds it, the student is excited but it is assumed that anyone could elicit the sign, the patient is in awe of the consultant..he has taught them well...either way the consultant is revered). The consultant pimps the students for a differential diagnosis or the pathology of disease x (the med student now has homework...he had better know the next time this comes up!) and then asks the registrar for a management plan. Generally, the registrar nails it, but inevitably he forgot a key aspect, the consultant corrects him and the registrar or resident writes the plan up. The resident adds the tasks e.g. order a gastro consult, get psych referral or do an ABG to his ever going scut list. The team moves on.
By lunch time the Consultant is usually gone. The rounds are mostly done (anyone left is usually not urgent and the registrar and resident see them without the consultant). The consultant is off either doing paper work, attending a meeting or teaching the registrar and the resident is madly running around trying to get things done on his scut list plus writing up medication orders and fluid orders. The registrar is called if any curly questions need to be answered. The med students go to tutorials (often happen to coincide with a free lunch) and then go and see people on other wards who have interesting signs and practice exams.
Generally, I am loving this rotation. I enjoy the acuity of it (well at least compared to GP) and the time to think (compared to a 15 minute consultation in GP land) - You have time to look something up if you don't know (you are expected to know to a higher level than in GP and even though there are consults available form other services, they are your patients and you do most of the work). I love the team work - nurses, pharmacists and allied health (physios, speech pathologists, psychologists etc). I think I am very well suited to the hospital environment. However I like the Monday-Friday 8am to 5pm (with occasionally weekend shift) though. Naturally, I am an evening person but my current schedule dictates I function well in the early AM. I am a very sensitive sleeper (can't sleep in cars, public transport, with light, without ambient noise etc) and if I sleep in, even once, on the weekend, or do an evening shift at work (which often has me all wound up with the cool stuff I saw), it takes me most of the week to get settled back into the early morning routine. I am wondering how a career in anaesthetics will be possible? will I learn to be less fussy about my sleep? I hope so!!!
Sunday 28 June 2009
Monday 22 June 2009
Monday 8 June 2009
'Real' Medicine
I am one week into my first 'real' medicine rotation (I use this expression with tongue in cheek, because the undifferentiated patient and all their issues and concerns encountered in general practice is in many ways truly patient focused medicine). It is great though. It is interesting to see really sick patients and the accompanying end of life issues and to see someone improve or get worse so quickly. Pathology and treatments are discussed in much more depth, and because everyone is teaching and learning education is a high priority.
General impression of how things run...
Team work is the rule, however it is far from a democracy. For those who don't know the (medical) hospital hierarchy is as such:
A consultant has the final say, directs treatment and has ultimate responsibility. He (or she) is in the position most of us aspire to eventually be in. A registrar (equivalent to a senior resident in the US) is the consultant's right hand man and as they have chosen that specialty (in this case General Medicine) they stay for longer periods and know the service well and function with a reasonable degree of autonomy depending on seniority.
Next is the Resident. He is either a Junior House Officer (JHO), who is 1st year after an intern, or Senior House Officer (SHO), second and subsequent years. They are still trying to get clinical experience, pass exams and get into a training position. They rotate every 10-12 weeks and the standards vary greatly depending on their experience and amount of learning they have done (some are real slackers) and so their responsibility is varied and they tend to do the after hours cover, relieving rosters etc. The intern (if present) also rotates about every 10 weeks and as they need to impress to get signed off and get a good recommendation for a JHO job, do the scut work (otherwise the RMO has to do it).
Then finally comes the medical students. There are often too many of us per team (2 in mine) and we walk around and generally get under peoples feet. Sometimes it seems we are treated better than the interns, about on par with the RMOs. Perhaps because we are outsiders/visitors and the consultants want to give a good impression/sell their discipline to encourage the best applicants try for their team. But it is pretty clear that we are outsiders, have no responsibility and so low in the pecking order we are not really in it. Allied health plays an important role and without speech therapists, occupational therapists and physios a service wouldn't run smoothly at all. The nurses are very important. They interact with the patient and do a lot of the dirty work.
Now this is just an observation...please don't lynch me!!
Often there seems to be an unsaid power struggle between Allied Health and middle level doctors. It is subtle and usually not a problem in well run units, but seems quite real, just under the surface. As the nursing staff and allied health staff are assigned to the ward and often don't change for a long time they are often trying to assert themselves against the more frequently changing doctors. The consultants have absolute say, they are rarely challenged. The registrars although newer to the service often have a great deal of training and knowledge and mostly come out on top. The resident though are usually not game to argue with Allied health or nurses outright and smart Interns usually don't even put up a fight, knowing that they have to get things done for the consultant and if the other staff don't want to play nice, it will be very hard for them.
Maybe it is all in my head...not sure though
General impression of how things run...
Team work is the rule, however it is far from a democracy. For those who don't know the (medical) hospital hierarchy is as such:
- Specialist/Consultant
- Fellow - extra post fellowship training (1-2 yrs) Optional
- Registrar (training to specialize) OR Principle House Officer (not in training spot)
- Resident - Senior House Officer (PGY2+) then Junior House Officer (PGY2)
- Intern (PGY1)
- Med student
A consultant has the final say, directs treatment and has ultimate responsibility. He (or she) is in the position most of us aspire to eventually be in. A registrar (equivalent to a senior resident in the US) is the consultant's right hand man and as they have chosen that specialty (in this case General Medicine) they stay for longer periods and know the service well and function with a reasonable degree of autonomy depending on seniority.
Next is the Resident. He is either a Junior House Officer (JHO), who is 1st year after an intern, or Senior House Officer (SHO), second and subsequent years. They are still trying to get clinical experience, pass exams and get into a training position. They rotate every 10-12 weeks and the standards vary greatly depending on their experience and amount of learning they have done (some are real slackers) and so their responsibility is varied and they tend to do the after hours cover, relieving rosters etc. The intern (if present) also rotates about every 10 weeks and as they need to impress to get signed off and get a good recommendation for a JHO job, do the scut work (otherwise the RMO has to do it).
Then finally comes the medical students. There are often too many of us per team (2 in mine) and we walk around and generally get under peoples feet. Sometimes it seems we are treated better than the interns, about on par with the RMOs. Perhaps because we are outsiders/visitors and the consultants want to give a good impression/sell their discipline to encourage the best applicants try for their team. But it is pretty clear that we are outsiders, have no responsibility and so low in the pecking order we are not really in it. Allied health plays an important role and without speech therapists, occupational therapists and physios a service wouldn't run smoothly at all. The nurses are very important. They interact with the patient and do a lot of the dirty work.
Now this is just an observation...please don't lynch me!!
Often there seems to be an unsaid power struggle between Allied Health and middle level doctors. It is subtle and usually not a problem in well run units, but seems quite real, just under the surface. As the nursing staff and allied health staff are assigned to the ward and often don't change for a long time they are often trying to assert themselves against the more frequently changing doctors. The consultants have absolute say, they are rarely challenged. The registrars although newer to the service often have a great deal of training and knowledge and mostly come out on top. The resident though are usually not game to argue with Allied health or nurses outright and smart Interns usually don't even put up a fight, knowing that they have to get things done for the consultant and if the other staff don't want to play nice, it will be very hard for them.
Maybe it is all in my head...not sure though
A note of thanks to readers...
Hi All
I have noticed that the readership has increased a fair bit recently and some have even been making comments and giving encouragement. Thank you! It is great to know that others find the journey through my final years of medical school (and hopefully Junior training years) to be interesting enough to return.
Also, although this is in many ways a one way blog, I do welcome any constructive criticism or feedback or even the sharing of similar experiences. At this stage, I will keep the comments moderated to prevent unsolicited or offensive posts (not that I anticipate many), but that may change in the future.
Anyway, to summarize. Enjoy, feel free to say hi and Thanks for reading!
I have noticed that the readership has increased a fair bit recently and some have even been making comments and giving encouragement. Thank you! It is great to know that others find the journey through my final years of medical school (and hopefully Junior training years) to be interesting enough to return.
Also, although this is in many ways a one way blog, I do welcome any constructive criticism or feedback or even the sharing of similar experiences. At this stage, I will keep the comments moderated to prevent unsolicited or offensive posts (not that I anticipate many), but that may change in the future.
Anyway, to summarize. Enjoy, feel free to say hi and Thanks for reading!
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