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!!