Well things are still going ahead as planned

I have completed my internship and my junior house year. Great years at a regional hospital with ample hands on and development as a junior doctor
I am glad I chose the hospital I did and not the Really Big and Wonderful Hospital - which is our local tertiary centre. A lot of juniors were unhappy there and I don't think there was any advantage compared to where I was. We were a relatively tight bunch of doctors (as almost all who did internship stayed on as JHOs) and were on first name basis with each other, many of the nursing and allied health as well as some of the consultants!

Anyway, as is the trend in my state at the moment, there is a surplus of students graduating - not overall, but for the number of adequate training positions. As such, we are getting into specialty training spots earlier - 2nd and 3rd year out (becoming like the American system), or we are unemployed. Long gone are the days of graduating and working as a house officer for 3-4yrs getting broad experience. I know a few of my graduating cohort that are in career progression limbo right now. There are pros and cons of the situation that I won't go into now, but there are not always enough Specialist jobs at the end of training. I know specialists (with their fellowship) that are working as senior registrars until a job comes up.

My goal is, and has always been toward a career in critical care (hence the blog's name). Not that I wasn't open to suggestion or a change in path - but my heart was always in this . Luckily for me I am on that path and coming along nicely. As I have listed in my section "Specialty training - Registrar years". I am aiming for dual training in both intensive care - a specialty in its own right and anaesthesia. If I don't get side tracked, It will take me 9 years, with 3 major exam hurdles (1 primary, 2 fellowship - each >$4000 and taking >1 yr of solid preparation). So I need to treat it as a marathon, not a sprint (1 will be 40yrs old before I finish!). The good news is that I am on a training pathway already, the ball is rolling and I am having so much fun. Also, the pay is nicer as a registrar. It is not about the money, hell there are MUCH easier ways to make it, but it helps to be able to enjoy the days off and know that I can help provide for my family.

I have started my training as an ICU registrar and already I have some interesting stories. I try to blend them together and tell them some time after the event to maintain some confidentially, but by then some of the details are hazy and some impact may be lost.

Wow, Has time flown. I am probably one of the least active bloggers on the internet.

Lets see.. 4th yr. At the time it seemed so important, but now it is difficult to remember most of my rotation experiences (good reason to regularly update the blog hey ;) )

After Medical Specialties...

Surgical specialties:
Really a mix-mash of "left over bits" to fit in to the course. A whole 4 weeks (half) was dedicated to critical care. One week Emergency Medicine, one week ICU, and one week anaesthetics. The 4th week was a lottery of one of those 3. to be honest, I can't even remember which I did, I think anaesthetics. Heaps of online models, no time for serious learning or testing. The other half was further divided into 2 weeks of ophthalmology and 2 weeks of either max facs, ortho, ENT or cardiac surgery - I did cardiac surgery.

O&G:
Actually a fantastic rotation. half my time at a tertiary hostipal, a lot of weird and wonderful surgery, heaps of tutes and very little patient contact. It seems the bigger the hospital, the more they love to promote their own greatness, but hide the medical students (and interns to a point) in the back rooms. "test them, speak down to them, let them know how great we are....but don't let them near patients..." - > wanky ivory tower medicine. The other half was at a regional hospital was fantastic. I spent a lot of time in clinics, seeing patients, in theatre. Assisting (or at least scrubbed in) in many "bread and butter" O&G operations. In the rotations I had to "catch" at least 4 babies - ie deliver. Easily done at regional hospital. there was a very senior O&G consultant there who was a wealth of information, had a plethora of stories, very reflective on how medicine "used to be" - over all probably the best clinical rotation I did

Paeds:
A good but terrible rotation. I did the majority of my rotation at a (different) regional hospital. The consultants/registrars were very approachable. The exam at the end of the rotation was a very comprehensive, practical exam with about 10 stations including EBM. It was actually at the tertiary centre and although my training was regional, we had weekly video link tutorials (students at hospitals all around the state) and very clear guidelines. My hat off to a fantastic Paeds director. what was horrible was the patient load. A lot of paeds is dealt with by ED or their GP. Those that made it as patients (minimal paediatric surgery in regional hospital) were developmental or behavioural issues. Also a lot of child abuse and neglect. - you were forever suspicious of parents. when a child comes from such a dysfunctional environment, what you do medically is of minimal benefit. Even with the "normal" parents, they are often overbearing and protective, or quite thick. I realize, even as I write this now, how jaded that sounds; but it was a horrible environment and at this hospital it would not be out of place for a mother and her barely legal pregnant child to be in the labour ward together - having had minimal antenatal care and to later return under paediatrics for numerous "preventable" issues. Not to mention the premature neonates of these mothers: under birth-weight, foetal alcohol syndrome etc.

Elective
4 weeks ED at the tertiary ED. After tossing up wether to go to a large trauma centre in Melbourne or stay up here (rumoured to be a close second in volume of trauma), the decision came down to finances, not being away from family and trying to experience a potential destination as an intern here in my state.
- not too bad, the professor who supervised us (a few elective students) was very helpful. A bit of a Zoo though and we were very much supernumerary, and were constantly reminded. Often go sent to the library, it was a constant challenge to stay involved.

My last 4wks were at a private ICU with some anaethetics. Not to different to the 1st year elective, except I was treated with a lot more respect, felt very welcome and as the first student at the hospital, everyone was very keen to teach. I love the efficiencies of private land. One disadvantage though was as all the patients were private, I couldn't just go around and examine anyone without that doctors permission (unlike in the public hospitals - of course with their consent!). I was madly trying to study for my final clinical exam so was trying to practice when I could

MSAT
To finish the degree, we had to have done all the rotations of 3rd and 4th yr - including exams (clinical and written), case reports, assignments and research/literature evaluation and hand in a long of observed clinical competencies over the 2yrs. We then had to successfully pass a Multi-Station Assessment Task - basically a mini viva. We had stations such as a few cardinal diseases - clinical reasoning, ethical stations, clinical examinations, procedural skills and resus scenarios. - basically minimum standard. If you couldn't pass, you really weren't safe as an intern. Very few didn't pass first go. I passed and later that year I graduated!!... First major hurdle down, now the REAL learning takes place

Medical Spec (week 2)

Having a lot of fun at the moment. The 8 week term is divided into 2 x 4 week blocks in two different core specialties. The assessment for this rotation consists of a consultant mark at the end of each block and a 100 question MCQ test on anything in medicine (and knowing my uni - will be completely random) at the end of the eight weeks. Reportedly one of the easier rotations of the course, I am not too worried at this stage.

I am practically halfway through my 1st block. I am enjoying it more than last year (3rd year - Medicine) as far as I don't have the pressure to learn how to do short or long cases like in third year and that I am getting the opportunity to consolidate my knowledge, and feel more respected by my team now that I am in my final year. I am starting to see the light at the end of the tunnel. I also enjoy being the only student on the team, as much as I do like having someone to bounce ideas off, I didn't like the competition that sometimes went with both trying to do (or see) a procedure and making sure I looked at least as good a student as my fellow 3rd year student who was also being marked by the same consultant.

I am starting to feel like I am ready to handle the job of an intern and the concept of "being out-there" in the workforce as a doctor isn't as scary. It is only the start of the year though, I guess we will see how I feel when I am doing my O & G or paeds terms!

I'm back finally...

Hi All

Well I have finally returned after a long, well needed holiday from the virtual world of blogging, facebook and non-essential emails. I really enjoyed my surgery rotation (I will write of more later this week) but by the end of the year, I was less elated and more exhausted. For the first time since starting my medical studies (in fact since well before) my end of year break involved nothing medical. No study (the occasional rash or spot here and there from concerned friends/relatives - which ended with the similar speal of "See your GP, having your GP in the loop is the best thing I can recommend...") but otherwise a med free period. I didn't let my brain go to mush though - I am still doing some research on a part-time basis, and work always managed to evoke thoughtful discussions with the consultants at work on treatment options etc, but no dedicated study time for me. I also did a lot of reading on investment strategies, financial planning etc for when I finally do get some money, which was fun.

I guess as illustrated above, I will never truely get away from medical issues, but I don't want to (I do still have a passion for learning and helping) but the key thing is that I feel rested, recharged and ready for the new year. It looks to be an exciting yet hectic final year. Wow in less than 1 year, I will be a doctor!! A very green doctor, but a doctor nonetheless.

Surgery... loving it!

I am having a fantastic time in Surgery. As expected I enjoy it more in General surgery than Orthopaedic surg. I enjoy the diagnostic challenge, the ability to take a problem and deal with it. I like that learning anatomy, while hard, provides almost instant gratification when you know where something is in theatre. I like that just when you think you know the anatomy, a patient will have some rare varience or anomally that keeps you on your toes. I like the high pressure environment but still the degree of mastery required. I am loving it !!

Ortho...a great experience!

Well, I must say that my last two weeks in orthopaedics have been great. I saw many very common problems, a few not so common, I got to scrub in and assist numerous times. This leaves me a little confused, as out of all the specialties to do, I thought ortho would be my least favourite - I am not very sporty, never really had much sympathy for guys (or girls) who do stupid things and end up with impressive, yet completely preventable injuries.

Then again. I saw many average people just like me who really were in the wrong place at the wrong time. I saw how debilitating a musculoskeletal problem can be, how it is mostly amenable to surgery (the skeleton is remarkably resilient and partially self repairs) and how greatful (mostly) patients are when you intervene. I realised, it was no worse than the guy that keeps puting drugs in his veins, smoke on his lungs or alcohol in his liver - patients often have hang ups. What makes sports worse? If anything it is a negative outcome from a potentially less harmful activity. [I am still yet to find strong evidence that exercise is good for you (apart from a gentle stroll etc) - anything more intense often ends in fractures, arthritis, torn ligaments and so on...]

What I did learn is once you learn the anatomy (which is a LOT of work) surgery is fun, you get to fix problems with almost instant gratification and orthopods aren't all knuckle draggers as often portrayed. All in all a great experience!!

Surgery... an early start!

Since the blogs for my last two rotations have been few and far between, I thought I would get a head start for this one. I start 8 (supposedly grueling) weeks in surgery tomorrow. The first two weeks are in orthopaedics (Assessment = 1) consultant mark, 2) clinical case - complete following pre, peri and post op 3) random joint examinations and 4) a take home (for 24hrs) exam later in the term). I am doing my ortho with other students at a main tertiary hospital in the city.

The next 6 weeks are at a smaller hospital in general surgery where assessment = 1) 3 clinical cases (as in ortho), 2) consultant mark 3) surgical images paper 4) final paper. I am one of only a few students so hopefully I will get a bit of hands on experience.

At this stage, even though anaesthetics is on the top of my list, I haven't completely written off surgery as a choice. My background is physiology; it is where I feel comfortable whereas my anatomy knowledge is somewhat more rudimentary. But there is something about surgery which excites me. Surgery is sometimes seductive as a path and most books about the journey of becoming a doctor tend to be written by surgeons (probably says more about the personality types) and I can't help but wonder if anaesthetics was "sold" more actively would it be more or less popular?

In my elective rotation I saw both and I must say I was much more fascinated by anaesthetics. I like the idea of taking a problem and fixing it though...

At this stage I want to spend my elective in fourth year split (4 weeks each) between general surgery - hopefully trauma, and anaesthetics - again hopefully some trauma as well. I wonder if that will change after my surgery rotation??

Rural Med - that's a wrap

Well I have finished my rural med rotation already. Things generally went as predicted. It had many great moments; it was sometimes lonely, sometimes boring, but mostly relaxing (The lack of traffic, the country air, the generally slower pace of life was fantastic – to live I am not sure, but as a break from tertiary hospital life – awesome!) Unfortunately internet access was very difficult to get (except to quickly check an email or download a paper and was definitely not conducive towards blogging) and therefore my rotation passed by very quickly with no updates here.

Orientation week was busy, lectures and intro to rural medicine. Generally this week was helpful, but it did seem a bit dragged out. It also provided an opportunity to hang out with fellow students also on that rotation (about 40ish) which was great.

I spent weeks 2-7 at a small rural centre. I was welcomed and put to work straight away (Got there Sunday afternoon, called in to the hospital Sunday afternoon to assess patients about 1-2hrs later!) Sometimes, particularly after big sporting events (which saw people coming in from outside regions), the trauma workload was intense. We didn't have access to CT, an operating theatre or any obstetric services and any bloods needed to be flown a few hours away to a regional centre, taking >>6hrs for any results and so anything major involved stabilisation, finger crossing and flying out (Helicopter or small fixed wing plane with the RFDS) if the patient survived. This made you think about how essential advanced imaging/testing really is. Clinical judgment is more important than ever, and I think it help to really develop your clinical skills!

The hospital (About 10 beds) was staffed by Nurses and the town GPs (there were 2 doctors not 1 as previously thought) would take turns to cover the calls from the hospital. I was usually 1st call, I assessed the patient(s) and called the doctor on duty for advice/to attend. Sometimes I was scared, but a few slow breaths, a quick read of the therapeutic guidelines (similar to the BNF in the UK I think) or UptoDate and remembering to return to basics - Good history, comprehensive (but case specific) assessment - and things usually went pretty well.

A few of the things I learnt were...

• Common things present commonly! OMG how many people with a slight cough or obvious URTI did I see. Patients/Mothers who had made up their minds before attending that they required antibiotics.
• How to examine a eye and remove foreign bodies
• Venipuncture – lots of practice
• Stabilisation of trauma patients (particularly suspected neck trauma)
• Assessment and management of general orthopaedic trauma – rolled ankles, fractures, dislocations

Running in the back ground of all this was a rural health project where we had to design and carry out some sort of project that benefited the community medically, justifying in terms of current literature. This had to be written up by end of week 8.

The final week (week 8) consisted of exam revision, last minute lectures and study. The exam was only short (1hr) and was quite predictable (stabilisation of trauma, bush bugs e.g. Q fever and Brucellosis, aboriginal health, skin cancer, management of medical problems in a rural environment requiring transfer, referral etc) – the least stressed exam I think I have ever had. I'm really looking to the week off to catch up with my friends and family, do non-medical things (except maybe a little anatomy study for surgery rotation ;) )

Rural - an introduction

As I am in my "week off" I have been mentally preparing for my upcoming rural rotation. In case I forgot to mention previously, all my clinical rotations are 8 weeks long. The first week involves staying in a rural centre (in my case 8+ hrs drive away) and consists of an intensive orientation with lectures and procedural skills.

Weeks 2-7 are at another location (small rural town) where I stay at the local hospital and learn about rural med. From what I can tell will be a cross between general med and general practice without the luxuries of CT, Operating theatres etc. In Week 8 I go back to where I was for the first week and attend more lectures. The exam is on the Friday of week 8.

I am really looking forward to the rotation actually. The doctor (one doctor in this town) has to rely on his clinical acumen a lot (lack of access to many tests/pathology services). Of course anything major will be transported to a larger more metropolitan location or even back to a tertiary hospital, but we (him and I) will be there at the start. And while I appreciate that I still have a LOT to learn, I am not too nervous. I am, however, very glad that I have already done General Practice and have just gone through General Med. As I will be away from home and very homesick, I am sure I will update you much more frequently for this experience then I have previously (that is, if I can access the internet!!)

General Med - A wrap up (part 2)

On a More reflective note...

The rotation as a whole was draining, but fantastic. One of the key things it did was cement my clinical skills, which I must admit were lacking a bit having started this year with Psychiatry - where you DO NOT touch - and General practice - in which examination is very problem based and often sub-standard [done through shirts (limited exposure) and poor positioning for the sake of convenience and time].

There were days when I was totally enthused, and days when I felt exhausted and completely discouraged. But coming out at the end of it, I feel much more confident and I feel I'm clinically more efficient (and unfortunately perhaps a little more impatient with verbose patients).

In summary, I feel in this rotation I learned the most, but it took the most out of me...

General Med - A wrap up (part 1)

Well I apologize that I haven't written more for this general med term. I meant to. The term was very hectic and when I finally got a moment to think, I just didn't want to write.

The tone of the rotation dramatically changed toward the end. It went from being part of the med team, being part of rounds (generally experiencing life as a junior doc on general med) to one of, looking for long and short cases, trying to fit in study where you could around all the scheduled tutes and generally in exam prep mode. It was a necessary shift in focus (if we would hope to pass the exams) but after that the registrars/consultants seemed less inclined to involve you in the care of the patients.

The assessment (like all so far this year) consisted of 4 parts worth 25% of which one part was the consultant's mark. On this rotation the other 75% was from 2 short cases and 1 long case done on the last day.

The Long case was a patient on the ward. You were told the patient name/bed number and went straight to that patient. You had an hour alone with the patient (mostly uninterrupted, there is always morning or afternoon tea or the tv hirer or some physio/nurse interrupting which you have to quickly deal with) to take a detailed history, work out active problems (noting inactive ones) and taking a detailed social history intergrating all with a physical exam. You then have ten minutes to organise your thoughts then you have to formally present the problem to 2 examiners (one being the specialist looking after that patients presenting/main issue). You are then asked to list problems, investigations, and might have to interpret an ECG, blood gas analysis or chest xray. You are pimped for about 10mins by the two examiners. An example might be... Mr S is a 60 yr old man who presented with increasing SOB and productive cough of two weeks duration. This is on a backgroud of Chronic airway disease, Ischaemic Heart disease, Hypercholesterolaemia, Hypertention and poorly controlled Diabetes Mellitus. He has a cumulated 90 pack year smoking history, still smokes and has been on oral prednisolone (30mg) for 9 months now for frequent exacerbations of his COPD".
The problem list might constist of

1. Diagnostic and Management problem of Increasing SOB (DDX: Exacerbation of COPD or pneumonia, Lung cancer, Heart failure etc) - Including tapering steroids if possible (risk of osteoporosis, high glucose levels)
   
2. Management of his IHD (Incl. Cholesterol, HTN etc)
3. Management of His Diabetes Mellitus
4. Assist lifestyle modification (Stress reduction, wt loss, quiting smoking)
5. Assist with rehab to work or short-term financial aid (welfare etc)

The two short cases immediately follow where the examiners then take you to patients (often brought in especially for the exam) with nonurgent, but often interesting pathology. You have 10mins per patient to examine ("Mr x presents with increasing shortness of breath on exertion, please examine his cardiovascular system") Short cases took 10 minutes. Obviously, not all cases are cardiorespiratory in nature, they are very common however and these were the first I thought of as typical examples.

My Medicine term... half-time commentary

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!!!

GP --> Done

Results are out...I passed the G.P rotation yay!!!

'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:

• 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!

GP - a conclusion

Well I am finally all done. I sat the theory exam this morning. I was actually pleasantly surprised considering how random the exam was rumoured to be. I really ran out of time at the end though and I am (in the back of my mind) a bit stressed that when I very hastily transcribed my answers onto the electronic marking sheet (this exam comprised of MCQ) I may have made some errors. I hope they are not all out by one! If so, I will be in a world of hurt.

For the clinical exam I was not so lucky. Two cases: one diagnostic, the other management. The management one was a little different than what was expected, but I think I did OK (I definately left out a few things though), but I froze in the diagnostic. I forgot to be systematic and missed the diagnosis completely. In hindsight, It was staring me in the face! I hope the management case will pull me through - or I will have to do a resit. Now I have a pounder of a headache...and I am off to get my Age of Empires on.

Finishing up my general practice rotation

My last clinical session for the GP rotation was Friday. I think it all went pretty well. By the end, I was interviewing and examining patients and prescribing treatments (with Dr M's close supervision and signature on the scripts etc). I would like to think I did some good. Dr M slightly (in some cases) altered his choice of Antibiotics more in line with the current therapeutic guidelines (where there was any major difference) and some new protocols were established due to patient experiences while I was there.

The "First" major excision I did, turned out to be an SCC...I now find myself questioning...did I allow a 4mm margin? I think maybe a little less. The current recommendations require a 4 mm (SCC) and 3mm (BCC) clinical margin and at least 1mm microscopic margin. The pathology report indicates, I got it all. I guess I will always have times when I think back and wonder if I should have made a different decision. oh well. Dr F is very diligent, I am sure she will keep an eye out with him. No infection or ischaemia with the wound, just a nice fine scar without bunching or hatch marks, very impressive if I do say so ;) The excision from Dr F was benign, but at least it won't cause her concern anymore. Sometimes it is not worth the "wait and see" approach, esp when therapy is so simple and the consequences of delay are so disastrous.

Now, time to study. Less then 47hrs to my clinical exam. 71 hrs to my written (not that I am counting!)

Operation on Dr F

Wow three blogs in less than a week! I don't think that is sustainable (I will try to increase frequency though). Just a quick update on the removal of the skin lesion.

Dr F came straight in, I anaesthetised the area for excision. I "played" with the skin and told her my margins (no marker this time) she agreed and went to see another patient while I scrubbed up and prepared. She came in and sat on the bed, wrist on a pillow and I went ahead. Her skin was a lot thicker than the leg skin on the older gentleman from yesterday. I cut too softly, I was scared of hurting her. EVENTUALLY I got through and stitched it up , very carefully! Quite neat in the end, I was proud. I will find out for sure in about 10 days.

After my first 'real' patient for a skin excision...

Today was great as expected. I got to draw up and give a couple more injections, I am getting better at recognizing different sounds in the chest and I did my first 'real' excision.

I am much more confident with anaesthetising with local anaesthetics. Dr F showed me a few cool tricks and helped me redraw the margins for excision (you need to feel the skin - to determine the tension and therefore might avoid making the ellipse so big!). I cut the skin and as I peeled the skin back, dissected the skin from the underlying tissue. As I used 2% xylocaine with 1:80000 adrenaline, there wasn't too much bleeding, but still a fair bit...being quick helps! Using 3/0 monofilament non-absorbable sutures I set to work. I used a vertical mattress suture in the centre to pull the wound together (most of the way), then using the rule of halves, placed the rest of the sutures (simple, interrupted). I must say that human skin is much more resiliant than you would initally think, but much easier to handle than the pork trotters and bellies I have practiced on. Happy I was doing well, Dr F left me to finish up while she saw some patients. I tried my best to place even sutures tension wise (I put a few more in the middle as there was a bit more tension on the skin there). I removed that original holding suture and replaced it with a simple suture, tidied the ends and cleaned the wound site. I placed a few steri strips for extra hold (it was on the proximal anteriolater aspect of the leg) after I swabbed the site with betadine. I am paranoid about wound dehisence or infection, so after I was sure Dr F was satisfied, it was dressed and a water proof covering was added and the patient was instructed to leave them covered for at least two days and that they will need to be removed in two weeks. When tying I used 5 throws (2+1+1+1). I think they normally don't do the last, but as I said, I didn't want dehiscence. My only regret is that I think I may have actually tightened the sutures too much (too much tension) and considering, they will be left in for 2 weeks. I am hoping the tissue doesn't become necrotic, but I am expecting cross-hatch scarring. I hope not, but it probably will happen. I hope I am there in 2 weeks when he comes for the removal of stiches...I will give the verdict then.

Dr F asked me this afternoon if I could remove a small, but troubling lesion on her wrist for her tomorrow. She must have some confidence in me!

A great "hands on" experience

Yesterday I had another full day with the GP I have been with for the last week (my supervising GP is on two weeks holiday). She is fantastic, unlike my official doctor Dr M (M for male, F for female) who has been a GP for 20 or so years, Doctor F is a relatively recent graduate (FRACP for about 5-6yrs). She is very knowledgeable and is very good at mental health, antenatal care and technical procedures, though if doesn't know the answer to a question she looks it up straight away. I really appreciate how she involves me in the consult and asks my opinion. Rather than me just being a spectator, then asked a difficult question in front of the patient to make me look stupid (pimped to boost the doctors ego)

Anyway, yesterday I was giving a bunch of different injections in adults and kids. Apart from putting about half a varicella vaccine intradermally (forming a bleb under the skin) because an untrusting mother (who's baby cries at the doctor just listening to his chest or touching his ears), let her little boy squirm and the sub cut injection almost came out - needle stick city for sure - I did OK. And bless the elderly gent with numerous skin lesion (and multiple past excisions) who offered for me to cut out a rather large SCC from his right leg. He is booked in for Thursday when Dr F can supervise and guide me... awesome! He also had a benign, but large and irritating skin tag on his back which was causing him grief. Dr F explained it was harmless but it could be removed, but unfortunately she was too busy today. She did however say that if he was happy with it, I (Kaydon) could remove it now. He said it would do HIM a favour! So while Dr F was seeing patients, with the assistance of the practice nurse (I suppose it will pass, but at the moment I feel guilty with someone running around and setting things up for me and fetching things when I need them), I anaesthetised the skin and then cut of the tag. The wound was very shallow, so didn't need to suture it and the nurse put a dressing on it. I will review it on Thursday when I take out his SCC.

Afterward as I was about to leave, I popped in to talk to the nurse in the treatment room and there was a patient who had been waiting for a fluvax for 30mins but his doctor still hadn't checked it, so Dr F came and checked it and I quickly gave it to him (as the nurse was busy cleaning). I told him about potential side effect (local and systemic reactions) and he was very grateful that I could help him as he was in a hurry to get home. Wow I was actually useful! What a fantastic day.

My General Practice experiences

This post is actually a completely rewritten post that started along the lines of "So I am now two weeks into my GP rotation..." Well now I am about to start my fifth, I WILL actually complete it.

I have had highs and low with this rotation but overall I have enjoyed it. My psych rotation has come in handy like expected (I am not nearly as anxious about the concept of anxious/depressed patients or the schizophrenics and borderlines which tend to be more prevalent in the community than I once realized) but I sooo glad to be actually physically examining patients again.

So what have I been doing? Off the top of my head

• I have been giving injections - I have immunized a bunch of kids and a few adults,
• Syringed out a few ears and done basic physical exams.
• Frozen a few skin lesions (cryotherapy)
• Examined a few babies (youngest 15 days old) for hip problems etc - narrowly missed being peed on.
• I have observed a few excisions, and I have practiced excising and suturing on a pork belly and hopefully I will get to do one on a real patient soon.
• Learnt about how that sometime treatment require perseverance and ultimately good luck

I enjoy the fact that almost anything can come through the door. It keeps you on your toes. I really like the mix of counselling, reassurance, education, procedures encompassing follow-up, preventative medicine and immediate management.

Psych - A conclusion

I have finished my psychiatry rotation. I received excellent consultant and patient interview marks - though I am unsure about how I fared in the viva or the final exam. All in all it was a fantastic experience and I thought it was well run and gave me a pretty good peak into the world of mental illness. I enjoyed the luxury of being able to hypothesize/formulate how a person got to where they were in life. As I have eluded to previously, I definitely see how the skills I have learned will help me with patients from any background. I would like to do a psych term as a registrar in the future, but I doubt I will have the time...ohh well. Onward with my general Practice rotation..where I actually get to touch patients!

Work update

A bit of an update with work

I have, like most do, taken the "new job" in my stride and I quite enjoy it. I couldn't do it for a living but as a weekend reprieve, it is great. I am getting a lot of exposure to radiology (not literally!) which I otherwise wouldn't get. One of my favourite parts of the shift is when I take a patient to get a CT or radiograph, I get to not only see the indications for the scan and later follow up in how they were treated (at least in emergency) I actually get to see the imaging and pathology real-time.

A bit of a scandle a while back (if you are one to assume). A gent was brought in by his wife with a broken penis (that's right, penis) but he had been home 'alone' (wife was out somewhere when it happened) though he happened to be on viagra at the time. Coincidentally, his neighbour (who is about the same age), was also home alone...

Exam stress!

Just a quick note to say that I am really starting to feel the stress of exams now. Just a bit less than one week to go then I am expected to be at intern level in my psych formulation/diagnosis and management...no pressure!!

Clinical rotations are coming to a close tomorrow and I am partially scared, but also very glad. I feel that I have seen quite a variety of patients and as much as I hate to say it, I just need to polish up my book knowledge, seeing more of the same patients won't help me much.

I am Looking forward to the GP rotation coming up soon!

Still enjoying Psych

Well I have just finished my 5th week of Psychiatry and I fell that I now (as expected) have a much better picture about what it involves. I don't propose I have seen it all, but I am very fortunate that the program at my hospital allows for rotation into many different areas and (when the tutors show up) excellent tutorials. I have seen acute and frank Mania and Psychoses, many flavours of underlying personality disorders, mood disorders, schizophrenia and eating disorders plus many more... There have been times when the thought of doing psychiatry (as a specialty) is very unattractive, but there are other times when it is appealing. The ability to sit down and philosophize and delve into the underlying causes of disease not just in that patient, but the community in general which few clinical specialties could match and the humane hours are major draw cards.

But I think even more importantly, I now see how relevant mental health issues are in general med. How MANY patient's recovery or indeed, poor health to begin with, are strongly influenced by their mental health (often a delicate construct on a background of predispositions, genetic vulnerability and exposure/experiences in earlier life). I feel with a bit of psych awareness, patients can be treated more humanely (not just handled better) and that recovery can be enhanced. To sum up my current thoughts - which unfortunately can be a tad 'circumstantial' (psych term for circular thought formation) I think I will be a better doctor (in any field, including critical care) for my psych rotation and I am glad for the opportunity, and I might even try to fit in a 3-6mth term as a junior doctor before the specialisation begins.

Again..sorry for any redundant thoughts in my blogs - I am just addressing my current thoughts and perhaps that will decrease as I become a more experienced blogger

Psychiatry

I have approached my mental health rotation with a fair degree of cautious optimism, trying not to be too quick to judge (either positively or negatively), but now I am half way into my second week ( a long time I know ;) ) I feel comfortable enough to write on my experiences so far.

I must say I am pleasantly surprised by how the rotation is going. As is typical of my school, it is very poorly organised (numerous conflicting timetables given, very average orientation to the hospital and missing resources...end gripe) but the actual rotation is quite stimulating. Patients are fewer than in a typical medical ward, well at least a little harder to access - but this is balanced by the interesting presentation of symptoms and diseases.

In a little over a week, I have seen, many people with classical schizophrenia, depression as well as complete mania and catatonia (including a few "take downs" of those really psychotic), eating disorders and the personality disorders. Very commonly there is a typical history of troubled home life, mental problems in close family members, positive drug use (cannabis and amphetamines most commonly), florid alcohol abuse and smoking...everyone smokes. Not to tar everyone with the same brush, but the stories so far tend to go that way. If ever there was a good anti-drug message, teenagers should visit the wards - this of course is highly unethical and would further add to the stigma of mental health, and so mustn't happen.

One thing which strikes me is that mental illness is so debilitating if not adequately treated, cure is not really a possibility (life long control of symptoms, or at very least a life long vulnerability for relapse when life stressors occur is the best you can hope for). It is also a bit different from most other disciplines of medicine in that many of your patients don't want help (often no insight to their illness) and are not grateful - not that it is why you help someone, it just makes your efforts seem less futile. Also because the support network and environment outside the facility is SO crucial in helping the patient cope and get better, and many of those patients who need it have either lived in isolation or burnt too many bridges, it is disheartening to know they will almost certainly relapse.

The work hours of psych doctors are much more humane though. 8:30 to 5pm...occasional on call to 9pm for the registrars or a rare rostered weekend shift. If there are any real emergencies, a consultant may come in, but this isn't too often. Psychiatry also is much more cerebral, in that you see less patients (generally), but see them for longer, think holistically (biopsychosocial model that the medschool tries to drum into us ad nauseam is the model) and there is more time to reflect and read theory. Basically, read and discuss rather than be task oriented.

Overall, I am enjoying this rotation and I think it will help me in the future even though I am not intending to go into psychiatry

Words of wisdom

I was cleaning out my office last night, basically culling all my old notes. I had piles and piles of notes from all different years and subjects (depending on what I used to study for my last few exams) and I was completely disorganized. Anyway, I found a document from UCLA, San Diego - A Practical Guide to Clinical Medicine called 'A Few Thoughts Before You Go'. I thought it was good advice so I will share it.

A Few Thoughts Before You Go

The start of your clinical rotations provides you with an opportunity to finally get involved with patient care and begin in earnest the process of becoming a doctor. You'll be amazed at the speed with which you move from outsider to functioning participant amidst the swirl of activity that is clinical medicine. It is, unfortunately, quite easy to lose your sense of perspective while working in this very intense environment. In fact, you'll recognize this as a common problem among many in the medical field. A few things to think about before you get started (and perhaps refer back to as you make your journey):

1. Treat patients as you would want yourself or a family member to be cared for. This should cover not only the technical aspects of health care but also the quality and nature of your interpersonal interactions.
2. Try to avoid viewing the medical training process as a means to an end. As medical education is a life long undertaking, you've got to enjoy the journey. If not, stop and think why.
3. Do the right thing. This applies to patient care and your dealings with colleagues and other health care workers. If something feels wrong, it probably is! The rules, which govern your behavior in the world outside of medicine, still apply, regardless of what others say or how they might act! This can be challenging, particularly when you are fatigued, in a subordinate position or working with others who don't have the same interests.
4. Mistakes will happen. The oft referred to: "Primum Non Nocere (first do no harm)" probably sets an unreasonable expectation. You will all do harm to someone at various points in your careers. Those who claim otherwise have either not taken care of enough patients or are not being truthful. We are all human and thus all fallible. When errors occur, acknowledge them, discuss them with colleagues and the patient, make efforts to correct the fall out, and move on. Above all, try to learn from what happened and don't allow yourself to forget any relevant lessons (without at the same time torturing yourself unnecessarily). This should help you to maintain a healthy dose of humility and become a better doctor. Remember also that anyone can be a genius in retrospect. Using this information in a manner that promotes education and growth requires a sensitive touch.
5. Never be afraid to ask questions. If those that you are currently working with are unreceptive, make use of other resources (e.g. house staff, students, nurses, health care technicians, staff physicians). You can learn something from anyone.
6. There is no substitute for being thorough in your efforts to care for patients. Performing a good examination and obtaining an accurate history takes a certain amount of time, regardless of your level of experience or ability. In addition, get in the habit of checking the primary data yourself, obtaining hard copies of outside studies, mining the old records for information, re-questioning patients when the story is unclear, and in general being tenacious in your pursuit of clinically relevant material. While this dogged search for answers is not too sexy, it is the cornerstone of good care.
7. Learn from your patients. In particular, those with chronic or unusual diseases will likely know more about their illnesses then you. Find out how their diagnosis was made, therapies that have worked or failed, disease progression, reasons for frustration or gratitude with the health care system, etc. Realize also that patients and their stories are frequently more interesting then the diseases that inhabit their bodies.
8. Become involved (within reason) in all aspects of patient care. Look at the x-ray, examine the sputum, talk with the radiologist, watch the echo being performed. This will allow you to learn more and gain insight into a particular illness/disease state that would not be well conveyed by simply reading the formal report. It will also give you an appreciation for tests and their limitations. Caring for patients is not a spectator sport. As an active participant in the health care process (rather then simply a scribe who documents events as they occur) you will not only help deliver better medical care but will also find the process to be more rewarding and enjoyable.
9. Follow up on patients that you care for in the ER, are transferred to other services, seen by sub-specialists or discharged from the hospital. This should give you a better sense of the natural history of some disease processes and allow you to confirm (or adjust) your clinical suspicions. This is particularly relevant today as patients are shuttled through the system with great speed, affording us only snap shot views of what may be complex clinical courses.
10. Keep your eyes open for other interesting things that might be going on elsewhere in the hospital/clinic. If there is a patient on another service with an interesting finding, go over and investigate, assuming it doesn't interfere with your other responsibilities and is OK with the patient and their providers. This will give you the opportunity to expand your internal library of what is both normal and abnormal.
11. Pay particular attention when things don't seem to add up. Chances are someone (you, the patient, the consultant) is missing something, a clue that the matter needs further investigation. Challege yourself and those around you by continually asking "Why... ?"
12. Before deciding that another provider is an "idiot" for adopting what seems an unorthodox or inappropriate clinical approach, assume that it is you that are short some important historical data. Give others the benefit of the doubt until you've had an opportunity to fully explore all the relevant information. And in those instances when it becomes apparent that mismanagement has occurred, focus on communication and education rather then derision and condescension.
13. Become comfortable with the phrases, "I don't know" and "I need help."
14. Try to read something medical every day. This will help you to stay abreast of new developments and provide an opportunity to become reacquainted with things that you've learned and forgotten. Medicine is less about achieving mastery then it is about reinforcing old lessons. Our individual "knowledge tanks" leak information on a daily basis. There is no way to plug the hole. Instead, you must continually replenish by adding to the top.
15. Realize that, ultimately, you are responsible for you. The quality of care that you provide is a direct result of the time and effort that you invest in the process. The distinction between good and bad medicine is generally not a function of oversight by the patient, colleagues, or the legal system. For the most part, it's dependent on your willingness to push and police yourself.
16. You are not automatically endowed with the historical wisdom of a particular institution merely by walking through its doors. Nor does this knowledge necessarily arrive with your white coat, degree or other advanced title. Rather, this is something that's learned and earned, often on a daily basis.
17. Every once in a while, push yourself to become an expert in something. First hand knowledge is a powerful tool, one that is available to anyone willing to take the time to read through the primary data. Become informed by delving into the original literature pertaining to a particular subject. You may find that the data is robust and the rationale for a clinical approach or treatment well grounded. As frequently, I suspect you'll find instances where the data is rather shaky, and the best path not as clear as guidelines or expert opinion might suggest.
18. Be kind… to others and yourself.
19. Have fun! Remember why you went into medicine. Keep this first and foremost in your mind and periodically readjust your course so that this is always in your sights.

There is magic in medicine. It does not, however, derive solely from technology, testing, or diagnostic aptitude. Rather it more often comes from your interactions with patients, a touch on the sleeve, sitting at the bedside and treating them (if only for a few minutes) as a fellow human being and not as, "That guy with Lupus." You are all capable, right now, without additional training, of being magicians. The challenge lies in not losing track of this as you make your way in the coming years.

Nervous, but excited

With less than 2 weeks until my third year begins, I am starting to get a little nervous. This IS what I have been waiting for, to be part of the team (I am under no illusion that I will actually be of any use to the team I am with). But I am anxious, will I be able to handle the study load, I am not confident in by pharmacology or anatomy knowlege, what if I fail a rotation...arrgghhh!!

I am not the first student in my position to feel this way...and I certainly wont be the last. It is just the transition I am going through. Without challenges and new experiences, I won't be able to grow and learn to be come the confident, competent doctor I know I can be. I owe it to my self to push myself to be the best I can be. More importantly, I owe it to my future patients.

I want to do some study...scared I will never have enough time. I have done some pharmacology study (about a day or two in total) but I just can't get into it yet. I am also VERY conscious of pacing myself. In my first year, I started like a 'bat out of hell' and had lost steam after mid year exams. Second year, I was a bit better, but I worked bloody hard. Of the graduate med program I'm in the first two years consist of year long subjects (all inclusive, combination of all disciplines) which allows subjects such as anatomy to be clinically focused, rather than a subject in isolation. Which is great for judging relevance and basic learning (detail is lost though, but then - query the relevance). The problem is it is easy to look at the year of 38 weeks (of learning) as a daunting never ending journey. In the final two clinical years, the year is broken up into 5 x 8wk rotations.
1 week orientation/start of learning, six weeks of core learning (some assignments/tasks in some rotations) and the final week with small discipline specific examination. I think the 8 weeks will fly by, too quickly, but at least it should be easier to chunk the learning.

For third year, everyone will go through the same order of rotation - starting at different places
Surgery>>Mental Health>>GP and the Community>>Medicine>>Rural>>

I am starting with Mental Health (so I finish up with surgery) - so I definately need pace myself!

Work is great!

I had my first solo shift on Saturday. After a relatively quiet orientation (very sore feet though), Saturday was frantic. It was a manageable pace, but by 3:30pm (started at 7am) I was exhausted.

I like the mix of customer service, dealing with sick patients, some autonomy and not having the burden of any major responsibility. While I realise with increasing medical knowledge, increasing responsibility is essential for growth, but I am not in a huge hurry...I am enjoying my medical "childhood" of watching and even trying, but much less stress in patient care.

My 1st post - a test

About to start my new job as an Emergency Attendant tomorrow
A little nervous - Not used to these 7am starts!!